Series of Errors Led to Girl's Death, State Says

Just over a year ago, 16-month-old Delaney Lucille Gonzalez walked with her family into UCLA Medical Center for routine surgery to repair a cleft palate.

Three days later, she was disconnected from life support and died in her mother's arms.

"To bring a healthy child in there for surgery so minor," her mother, Jodi, said recently, clutching a headband she had made for Delaney, "you just don't accept that she's going to die."

The simple explanation is that a breathing tube had been misplaced and had pumped air into the child's stomach rather than her lungs, according to Delaney's medical and autopsy records. Because her body was deprived of oxygen, Delaney's heart stopped. She suffered irreversible brain damage.

But the misplaced tube was just the first in a series of errors leading to the child's death, according to state health inspectors who reviewed the case in response to a complaint from Delaney's mother.

According to their report, released last month, the radiology department waited hours before reviewing chest X-rays that would have pinpointed the problem because they were "too busy." In addition, staff members detached and did not replace a carbon-dioxide breathing monitor that they believed to be broken, gave the girl medications that ran counter to doctors' orders and failed to alert supervisors as her condition deteriorated, inspectors said.

"There is absolutely no question that ... these violations led to the baby's death," said Brenda Klutz, deputy director of licensing and certification at the California Department of Health Services.

Even in the most prestigious hospitals, medical errors sometimes kill patients. According to a landmark report in 1999, 44,000 to 98,000 people die annually in hospitals because of mistakes ranging from performing surgery on the wrong organ to prescribing the wrong type or dosage of medication.

Like Delaney, patients don't usually die from a single mistake. They die from a series of oversights, faulty assumptions and missed opportunities -- what some experts refer to as a systemic breakdown.

"One single problem is usually not sufficient.... It requires a chain reaction," said Dr. David G. Nichols, a professor of anesthesiology and critical care medicine and pediatrics at Johns Hopkins University School of Medicine.