[April 28, 2008: It was a little over two years ago that Beth Stover's daughter, Lehna Brewer, was stillborn at Kaiser Walnut Creek. We're spotlighting this post again this week to coincide with an article in USA Today about the alarming national trend of missing records in medical error cases, in which Beth's story is featured. Any new posts will appear below this one for the rest of the week.]
By Beth Stover
For a complete documentation of the events surrounding the death of My Baby at Kaiser Permanente, please read part one of my story.
One year ago today, March 4th 2006, My Beautiful Baby — Lehna Jordann Brewer — was stillborn at Kaiser Permanente in Walnut Creek, California. She didn’t have to die, but because Kaiser Permanente chose to withhold care and send me home, she died. This is a follow-up story documenting all of the challenges and roadblocks of the past year. It is not enough to be victimized only once at Kaiser. Kaiser chooses to continue victimizing by withholding critical medical information that the patient — EVERY PATIENT — has a right to as a U.S. Citizen. This is clearly stated in The Patient’s Bill of Rights.
ROADBLOCK Number 1: Destruction of Evidence
After Lehna died, apparently Kaiser felt that they had something hide. To date I have not been able to see the fetal heart monitor strip from the stress test done the morning before Lehna was stillborn. I have made several requests over the past year: in writing, and in person and by phone. According to Kaiser, the fetal heart monitor strip was “lost.” CONVENIENTLY LOST.
Only after I initiated an investigation by the California Department of Health, Licensing and Certification, did Kaiser begin to look for the missing fetal heart monitor strip. Ironically, the very same week that they were being investigated I received a phone call from the Kaiser ombudswoman telling me that they had found the missing strip in an envelope with my name on it. She told me, “Well, it doesn’t have a date or a time but we’re pretty sure it’s yours.” My response was, “Well, if it doesn’t have a date OR a time, OR a name OR a medical record number, then how can you be sure it’s mine?” And she replied, “We can’t.” She told me she would go ahead and put it in the mail. There is NOT ONE PIECE OF IDENTIFYING INFORMATION ON THIS STRIP THAT WOULD EVEN REMOTELY CONNECT IT TO ME. This is not even mine; it is a blatant attempt to commit fraud. This strip belongs to someone else and Kaiser knows it.
As a 40-year-old woman who has lost her Baby, most people would assume I would get some answers as to why my beloved Lehna died. This has been all but impossible with Kaiser. Instead of working with me to get some kind of closure or answer that makes any sense, they have withheld critical records and have put more effort into covering up the facts. At age 40 I was never classified as high-risk by Kaiser. I have educated myself since then and now I know that even 36-year-old women are normally considered high-risk outside of the Kaiser system. I have since learned that minimizing risks in general is standard operating procedure at this organization that proclaims that it is “setting the standard for health care delivery worldwide.” Be very afraid.
Never mind the fact that once I passed my due date of Feb. 23rd, a Kaiser doctor attempted to schedule me for an induction that would have put me at 15-days past my due date (not 13, as originally noted in Part One of my story). Does this seem like the standard of care that EVERY OB patient is entitled to? A 40-year-old woman, 15-days past her due date? I’m still trying to figure out how delaying necessary intervention equates with quality care. THIS, in and of itself, appears negligent.
ROADBLOCK Number 2: No Cause of Action for Spoliation of Evidence
This is ludicrous. Did you know that in California it is not against the law to “lose” important Medical records? How convenient for Kaiser. All they have to do is “lose” the medical records and they seem to be off the hook. This “No Cause of Action for Spoliation of Evidence” is in direct contradiction to the Patient Bill of Rights. It is AGAINST THE LAW to destroy a patient’s medical records, but if you conveniently “lose” them, then that seems to be OK. Just as in my case, I have heard that a lot of medical records get “lost” at Kaiser. Missing and/or tampered medical records make it very difficult to prove your case which works very well for Kaiser.
ROADBLOCK Number 3: California’s MICRA and Kaiser’s own version of MICRA (Medical Injury Compensation Reform Act)
This is a BIG ROADBLOCK and one that works very well for Kaiser and any other healthcare provider that has adopted the practice of providing negligent care, or should I say “withholding care”. MICRA is a law enacted back in 1975. Yes, 1975! This puts a $250,000 cap on non-economic damages in medical malpractice cases in California. My Baby’s life is not worth enough money in California for a lawyer to be interested. It’s not a good business decision financially for lawyers to take on malpractice cases UNLESS the Baby/patient will need a lifetime of care. This brings us back to the missing fetal heart monitor in my case. Kind of makes us wonder if my Baby was left to die after discovering possible brain damage had already taken place. It is MUCH cheaper to let the Baby die instead of getting stuck with the economic damages that might have applied if Lehna had lived. This should have been my decision, NOT a financial decision made by Kaiser. I would have chosen to let Lehna live.
Not only do you have MICRA to go up against in California, but Kaiser saw how well MICRA prevented lawyers from going after them for medical malpractice that they decided to enforce a double whammy and put a $250,000 cap on any future Kaiser Members everywhere, who experienced medical malpractice within Kaiser. MICRA and Kaiser’s $250,000 cap is a LICENSE TO NOT PRACTICE MEDICINE since it prevents Kaiser from being pursued in the all too common event that medical malpractice has taken place. There seems to be no recourse for many Kaiser members and Californians due to the fact that finding a lawyer who will take these cases is next to impossible. ALL Kaiser members, not just in California, need to read the fine print in their agreement with Kaiser.
“In the cold calculations of medical malpractice, a brain-damaged baby is worth more than a dead baby. The brain-damaged baby will need a lifetime of specialized care.”
“Arbitrary caps on “non-economic” compensation unfairly discriminate against the suffering of women — who typically sustain injuries due to medical negligence, such as laceration of the uterus or loss of a new born during child birth, that do not carry high “economic” price tags but involve significant loss. Injuries sustained by homemakers are also unvalued, because they have no “wage loss.” Caps not only deny women victimized by medical malpractice fair compensation and legal representation for their injuries, but subject women to repeat offenders and have been undeterred.”
ROADBLOCK Number 4: Kaiser’s Ability to tamper with medical records
Not only does Kaiser destroy medical records, but they change medical records at will. In the original notes from the delivery room when Lehna was born it was first reported that I had a fever of 103. Later on in notes, the Dr. had gone in and “amended” the original notes. She dropped my fever from 103 to 101. Now, would someone please tell me how she would know this sort of thing after the fact? A fever is a fever and no one could not have possibly known hours after the fact what my fever was unless it was documented at the time, which it was. It was documented at 103. PERIOD. Why the need to go back and change it hours later?
ROADBLOCK Number 5: Kaiser’s Ability to Deny, Deny, Deny.
During the investigation by the California Department of Health, Licensing and Certification, back in Dec. 2006, the nurses and doctors at Kaiser were interviewed/investigated regarding my account of how I was treated at Walnut Creek Labor and Delivery the evening before Lehna died. One nurse in particular, whose initials are J.V. (and she knows who she is), completely denied everything to investigators. Once again, Kaiser is off the hook since it is her word against mine. Why, I ask, would I have a need to make this sort of thing up? I remember it all like it was yesterday. This is not something you ever forget. I will also add that there was a deficiency notice given to Kaiser for their lack of documentation surrounding the Death of My Baby. This comes as no surprise.
ROADBLOCK Number 6: My Baby was a “Non-Event.”
California law says that since Lehna died before she was born that she is considered a “Non-Event.” Please take a look at the photos of My Baby. Does She look like a Non-Event? The Birth of Lehna was the biggest and most important event of my life (along with the birth of my first Daughter). With no disrespect to Laci and Connor Peterson, the manner of death should not be a factor in determining whether or not My Baby is considered a Human Being, an “event.” Lehna was most certainly an event to us. A MUCH-LOVED, FULL-TERM, BEAUTIFUL BABY GIRL.
I will continue to document the chain of events as I go along. But today, my oldest Daughter and I will eat cake and remember our Little Lehna who would have turned one today. It’s a very quiet day in our home.
Happy 1st Birthday My Dear Little Lehna.