Late one April night, the first of Sarah Valenzuela's twins arrived with little trouble, but the second stayed put.
Though the baby was not in distress, Kaiser Permanente perinatologist Hamid Safari attached a vacuum extractor to the boy's head to draw him out. Again and again he tugged, but still the baby would not come.
He vigorously shook the vacuum, up and down, side to side, according to government documents and hospital incident reports.
It took 90 minutes and six tries -- the last with Safari on his knees, pulling. Horrified staffers -- and the boy's father -- looked on as baby Devin finally emerged. His skin was a bloodless white, his neck elongated and floppy.
His spinal cord had been severed.
Safari lashed out at a nurse. "What did you do to that baby? I gave you a good baby," he said, according to a complaint letter the nurse sent to her union representative.
Staffers at the Fresno birthing center were devastated and angry -- and not just because of the twin lost that night in 2005.
Over the years, doctors and nurses repeatedly had complained to higher-ups -- including Kaiser's top medical officer in Northern and Central California -- about problems they saw in Safari's skills and behavior, according to interviews and documents.
This is a story not just of tragic medical outcomes, but of a health plan that did not prevent them.
A year before Devin's death, the doctor had waited more than three hours to do a Caesarean section even though the baby girl was in distress and her family said they had been pleading for the procedure, according to interviews and government records. She was severely deprived of oxygen and died months later.
As far back as 2002, a physician review committee at the hospital concluded that Safari provided "inappropriate" care and that his "conduct needed significant improvement," according to a lawsuit later filed by two of his peers.
Still, the doctor continues to work at Kaiser Fresno, practicing under restrictions that staffers say have not been explained to patients.
Regulators acted only recently. This July, the state Department of Managed Health Care fined Kaiser a record $3 million for its haphazard handling of complaints and physician errors throughout the state. Officials said in an interview that the Safari matter played a significant role in their decision to investigate the HMO's practices.
