Michelle Brantley holds a pillow belonging to her son, Isaiah, who died at John Muir Medical Center in Walnut Creek after developing a surgical site infection.
Brontë Wittpenn, photographer / The Chronicle
UPDATE: State bans Stanford-affiliated hospital from treating some of California’s sickest children after finding dozens of violations
California authorities have started an investigation into a prominent East Bay hospital system in response to a Chronicle report detailing four children’s potentially preventable deaths at John Muir Health’s medical center in Walnut Creek.
Anthony Cava, a spokesperson for the Department of Health Care Services, or DHCS, said the state agency met with county medical leaders last week to discuss their concerns about the hospital’s pediatric intensive care unit, or PICU.
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“DHCS takes the matter very seriously and intends to conduct a program review of John Muir,” Cava said in an email. “DHCS will continue to engage the counties in planning for that program review and will incorporate county assistance as appropriate.”
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Additionally, the federal Centers for Medicare and Medicaid Services contacted the California Department of Public Health, the agency it delegates to investigate complaints involving patient care.
A health department spokesperson confirmed Friday that the Centers for Medicare and Medicaid Services had been in touch about concerns at John Muir Health, but said the public health agency could not comment on “any potential or ongoing investigations.”
The potentially preventable deaths at John Muir Medical Center in Walnut Creek have prompted calls for an investigation.
Brontë Wittpenn, Staff photographer / The Chronicle
These actions came hours after the Chronicle reported that local, state and federal officials had requested that California investigate John Muir’s PICU, citing “grave concerns” about the deaths documented in the Dec. 1 Chronicle report.
The newspaper investigation examined patient care at the eight-bed PICU in the years after John Muir’s 2015 partnership with Stanford Medicine Children’s Health to open the unit for critically ill children. Leaders of both hospital systems said at the time that the alliance would allow John Muir to provide top-notch care to East Bay children with acute and complex conditions.
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In 2017, John Muir received approval from DHCS to care for youth who are part of California Children’s Services, or CCS, a publicly funded health program akin to Medicare for pediatric patients with serious chronic medical conditions. A large percentage of these children are also enrolled in Medi-Cal, the California arm of the federal Medicaid program.
The much-sought-after certification requires PICUs to adhere to strict quality standards pertaining to staffing, training and protocols. In turn, CCS approval allows hospitals to see more patients and receive additional compensation for their care. The program also mandates reviews of approved units “no less than every three years.”
The application to be part of CCS lists conditions that hospitals must meet “prior to submitting the PICU application,” according to new documents obtained by The Chronicle through a California Public Records Act request. The first condition listed — in bold — is that “there shall be a minimum of 350 admissions to the PICU per year.”
The first page of an application for California Children’s Services certification states that a pediatric intensive care unit must care for at least 350 patients each year. From 2016 to 2021, John Muir’s PICU failed to reach that threshold, yet still received state approval.
Jenny Kwon / The Chronicle
But The Chronicle’s investigation found that John Muir’s PICU, from 2016 through 2021, never once met this minimum annual patient volume that the state mandates to “maintain proficiency.” Cava previously told The Chronicle that the admissions threshold is one of several factors considered when approving units.
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More than a dozen medical experts who reviewed the four children’s medical records on behalf of The Chronicle and with consent from their families said their deaths appeared to be preventable and seemed to speak to John Muir’s inexperience treating extremely sick children, an issue further reflected in the PICU’s persistently low patient volumes.
Rep. Mark DeSaulnier, D-Concord, whose district includes Walnut Creek and the homes of two of the four children, said in an interview that he had encouraged CMS to look into the issues raised in the Chronicle investigation.
“We’re going to hold people accountable,” DeSaulnier said. “The goal here is safety and whether it should be operating.”
“We’re very concerned,” the congressman added. “Two of our constituents lost their lives.”
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State Assembly Member Rebecca Bauer-Kahan, D-Orinda, whose district includes John Muir’s Walnut Creek facility, also called for a state probe into the hospital’s PICU.
“To ensure the safety of our kids and our community we must see a full investigation of whether this system failed these children and whether it is safe for it to continue serving the community,” Bauer-Kahan said in a statement.
In a message to other county and state health leaders on Dec. 6, a former top state medical official raised questions about DHCS’s oversight of John Muir’s PICU, according to emails obtained through a separate public records request. Dr. Robert Dimand, the former chief medical officer of CCS, called the situation “clearly beyond comprehension.”
“State’s abdication of maintaining standards, certification, quality oversight,” said Dimand, who now consults for Kern County’s CCS program, in his email to a dozen health managers, including state officials tasked with providing PICU oversight. “Just so sad.”
Representatives with DHCS did not immediately respond Friday to questions about their oversight of John Muir’s pediatric intensive care unit and when it was last reviewed.
Reached for comment about these officials’ concerns, John Muir spokesperson Ben Drew said in a statement Thursday that the hospital “welcomes a review” and “proactively sent a communication to DHCS asking for a review to be conducted.”
“With very low PICU bed capacity across the state, it is important that parents have an objective assessment of the quality of care provided in the Walnut Creek Medical Center PICU,” Drew said. “An independent review will enable parents to make crucial medical decisions for their children.”
Emails obtained by The Chronicle through its public records request show that John Muir asked for the state review Thursday around noon — one day after The Chronicle informed the hospital that officials were calling for an investigation and sought comment for this article, and six minutes before Drew sent the statement to reporters.
In the statement, Drew also said that the PICU met the 350-patient benchmark for the first time this year, treating 365 children to date in 2022. He said the unit has had to turn down pediatric transfer requests from other hospitals in the region due to a lack of space.
“We believe that the PICU and pediatric beds we provide, supported by expert physicians, nurses and staff, are important to the community,” he said.
Elizabeth Valente, a spokesperson for Stanford Medicine Children’s Health, said in an email that Stanford would cooperate fully with any investigations, but could not comment on them.
“Stanford Medicine Children’s Health cares deeply about our patients and families, and we grieve when any child — especially one in our care — does not survive,” Valente said in the statement.
One day after the Chronicle investigation ran in the newspaper, county medical officials raised alarms in a series of emails obtained by reporters.
Michelle Brantley holds a photo of son Isaiah taken when he was 3 years old.
Brontë Wittpenn, photographer / The Chronicle
On Dec. 5, Dr. Louis Girling Jr., one of two CCS medical directors for Alameda County, sent a message to a dozen state and county health officials with the subject line, “Quality concerns in CCS PICU.”
“We have recently learned about tragic outcomes in the CCS-approved PICU at John Muir Hospital in Walnut Creek,” Girling wrote, attaching The Chronicle’s article to his email. “Perhaps you are already aware of this serious issue, but if not, I feel professionally compelled to bring the problem to your attention. It seems to me that a review by the PICU TAC and/or a CCS site visit is urgently warranted.”
The CCS PICU Technical Advisory Committee, or PICU TAC, includes the chief medical officer of the state CCS program and pediatric intensivists from around California who volunteer technical advice to the state and assist in facility reviews, according to documents obtained by The Chronicle.
Dr. Joanna Chin, the medical director of Contra Costa County CCS, responded to Girling’s email minutes later, seconding the call for an investigation.
“I agree completely with Dr. Girling’s grave concerns, and concur that further review is urgently needed,” Chin wrote. “I myself have had some concerns about the John Muir Medical Center PICU, though surely nothing as serious or tragic as the cases highlighted in the article.”
The following morning, Dr. Diana Obrinsky, the other CCS medical director for Alameda County, wrote to the group, “Dr. Girling and Dr. Chin have expressed my deep concern quite well. I join them in asking for an expedited review of the John Muir PICU, and perhaps a more comprehensive review of the entire hospital.”
In response, Dimand, the former chief medical officer of CCS, questioned whether DHCS had performed any onsite reviews of John Muir’s PICU, noting that in the past CCS has suspended approval and participated in corrective action plans for PICUs that have not met the program standards.
“Apparently no longer a function of DHCS/CCS.?? (sic)” Dimand wrote. “CCS Rules and oversight as (sic) functioned for decades vaporizing quickly. Site visits, adherence to quality monitoring, rapidly vaporizing.”
Cortney Maslyn, chief of the Integrated Systems of Care Division within DHCS, responded to these messages by offering to set up a time to meet with county officials.
“Thank you for bringing your concerns to our attention. We are committed to upholding the standards of the CCS program to ensure high quality care,” Maslyn wrote on Dec. 7. “DHCS will be taking timely action to address this issue.”
County medical officials declined to comment on their emails, referring questions to DHCS. Cava, the agency spokesperson, said that state officials met with county staff members on Dec. 9 “to discuss the information included in the article and next steps.”
Although the John Muir Health system is one of the largest in Northern California, and a key provider of adult trauma care in the East Bay, its critical care unit for children has struggled with low patient volumes.
While John Muir’s PICU failed to see 350 patients from 2016 to 2021, three nearby children’s hospitals saw between 870 and 2,100 children in their units every year, according to state reports.
The cases of the four children who died involved complex conditions — diabetes complications, breathing problems, severe infections and other medical issues requiring extensive surgeries — that John Muir and Stanford leaders said the new PICU could handle.
In the deaths of two patients — Katrina Daly, 13, and Caitlyn Gonzales, 16 — medical records show that doctors struggled to correctly place a breathing tube, a fundamental skill for doctors working in a PICU.
Isaiah Lofton died in May 2019 after the 16-year-old developed a deadly condition related to a surgical site infection that John Muir doctors waited a week to clean out. Later that year, 2-year-old Ailee Jong died on the operating table after John Muir moved forward with her complicated liver surgery despite warnings from staff members that the unit wasn’t prepared to perform its first-ever pediatric liver resection.
“They don’t have the numbers, so my hope would be that the funding would be pulled,” Katrina’s mother, Vikki Plumlee, told The Chronicle in an interview this week. “They weren’t ready to be what they thought they were. They weren’t ready to care for the types of children they thought they were entitled to take care of.”
In a lawsuit filed in April, Ailee’s parents alleged that the hospital misled them into thinking that it could provide Stanford-level care, prioritizing potential business growth over patient safety.
The Chronicle initially wrote about Ailee’s death and her parents’ lawsuit in an April report. In response to the article, the Medical Board of California, the state’s oversight agency for doctors, said it had opened an investigation into the case, which remains active.
Kristina Lawson, president of the Medical Board of California, served as mayor of Walnut Creek in 2014 when John Muir first announced its new PICU. Lawson recalled her initial excitement to The Chronicle, saying that all three of her children had been born at the hospital. But upon reading about the four deaths, she said, she wanted to see further investigations by her agency and others.
“My heart is broken for the families who have lost their children, and the circumstances of those tragic deaths must be reviewed by the appropriate state and federal government agencies,” Lawson said. “The Medical Board of California will conduct a thorough review and take appropriate action to ensure patients are protected and have access to safe, quality health care. I urge other government agencies with jurisdiction over this matter to do the same.”
For Isaiah’s mother, Michelle Brantley, the concerns with oversight and transparency hit particularly close to home. Her son died at John Muir after the family was referred through the CCS program to the hospital for a complicated spinal fusion surgery. Brantley said she was happy to hear calls for a state probe.
“CCS sold me on John Muir,” Brantley said in an interview this week. “We don’t take our kids to the hospital thinking about, ‘Do they have enough patients?’ We are already assuming that the doctors, the medical professionals, know what they are doing.”
Cynthia Dizikes and Matthias Gafni are San Francisco Chronicle staff writers. Email: [email protected], [email protected] Twitter: @cdizikes, @mgafni
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