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.
With that in mind, leading hospitals and health networks, including UCLA, in recent years have designed ways to check and re-check medical decisions as they are made. They also have made a point of encouraging forthright discussion of mistakes with the aim of correcting faulty procedures.
In Delaney's case, UCLA doctors met with the Simi Valley family and explained what had gone wrong. But her parents say the hospital never took full responsibility for her death.
On her death certificate, a UCLA physician initially blamed an "airway obstruction" for causing a lethal loss of oxygen to the brain. After recalling the girl's body for an autopsy, the Los Angeles County coroner changed the cause to include the misplaced breathing tube.
"It's the result of having the intubation screwed up. They know that very well. They obviously misrepresented the facts," said Dr. John Cooper, an experienced forensic pathologist from Apple Valley who reviewed Delaney's death certificates and autopsy report at The Times' request.
Jodi Gonzalez, a 30-year-old registered nurse, and her husband, Danny, a 44-year-old business owner, have sued UCLA Medical Center and the University of California regents, alleging negligence in Delaney's care and failure to provide correct information on her death certificate.
UCLA declined to comment on any aspect of Delaney's care, citing pending litigation. The physicians who participated in her care did not return telephone calls or e-mails seeking comment.
UCLA released a statement, however, saying in part: "Everyone at the UCLA Medical Center, including its administrators, physicians and staff, are profoundly saddened by the death of Delaney Gonzalez. Our hearts go out to the Gonzalez family and to everyone touched by this tragedy."
The hospital also said it is working with the California Department of Health Services to address problems raised in its inspection report.
"As always, UCLA Medical Center's first priority is to provide the highest standard in quality patient care and safety," the statement said.
'Bring Her Back'
"Please bring her back," Jodi Gonzalez recalled telling the anesthesiologist who came to take Delaney to the operating room for her cleft-palate surgery on Feb. 4, 2002. "I will," the anesthesiologist replied.
The operation was successful, according to medical records. It was supposed to be the first of several to repair malformations on Delaney's head and face caused by Treacher Collins syndrome, a rare birth defect. The child's ears were not fully formed, her jaw was small and her cheekbones were underdeveloped.