By Kerry Klein, KVPR NPR Central California

September 15, 2022

https://www.kvpr.org/health/2022-09-15/a-bakersfield-family-lost-a-daug…

After her daughter and grandson died following what the Medical Board of California alleged to be negligent care from a Bakersfield OB-GYN, Tracy Dominguez embarked on a crusade to reform the agency and prevent other patients from experiencing similar tragedies.

This story is part of the series Moms and Babies at Risk.

In April 2019, 23-year-old Demi Dominguez and her baby boy, Malakhi, died at Mercy Southwest Hospital in Bakersfield.

Dr. Arthur Park, an on-call obstetrician, missed the signs of the severe condition preeclampsia, according to allegations from the Medical Board of California, the state agency that licenses and disciplines doctors. Preeclampsia is one of the most common causes of maternal deaths, though research suggests more than half of those deaths are preventable.

By the time Park saw Demi, the medical board had already investigated him for negligence following the deaths of two babies. After Demi’s death, the medical board accused him of negligence two more times. Following two of those accusations, the medical board revoked his license, then stayed the revocation and placed him on probation. He ultimately surrendered his medical license in late 2021.

KVPR attempted to talk with Dr. Park, reaching out to him by phone, email and certified letter, and although he submitted a statement by email he declined to be interviewed for this series. He did not respond to specific questions about Demi or any other patients.

Long before he surrendered his license, however, Demi’s mother, Tracy Dominguez, was struggling. Losing Demi and Malakhi on the same day was all too much.

“I was literally crawling, crawling to wash my face, crawling to get dressed,” she said. “I don’t think I even could get dressed the first week or two, I think my family members had to help me.”

She quit her job, and struggled to be present with her three other children and 10 grandkids.

What eventually helped Tracy off the floor was creating a memorial to Demi at her home in Bakersfield. A whole corner of her living room is devoted to photo albums, letters and bright display cases full of mementos from Demi’s life. Front and center is the blue, butterfly-shaped urn containing Demi and Malakhi’s ashes, as well as the coins, feathers and other tokens Tracy finds that remind her of them.

Tracy Dominguez’s living room features photos, mementos, feathers and other keepsakes to remind her of Demi. The blue butterfly on the top shelf of the display case is an urn containing Demi and Malakhi’s ashes.

What really got Tracy back on her feet, however, was the anger: anger at Park, and at the hospital where he’d had admitting privileges that day the medical board alleges he had missed Demi’s severe symptoms. She was also angry that the medical board, an agency tasked with disciplining doctors and protecting patients, allowed Park to stay in practice for decades.

Tracy turned all of this raw emotion into a thirst for change.

“It became how I survived, so it literally made me get up and deal with stuff because I could have just died in the bed,” she said.

Tracy’s advocacy work has made an impact

Tracy has never stopped moving since. There was a letter-writing campaign to revoke Park’s license. She hounded the medical board to investigate him, wrote to the media about her daughter, testified at legislative hearings about inadequacies at the medical board, and got involved in a campaign to increase the financial settlements patients can receive from malpractice lawsuits.

Since then, the state launched two investigations related to Demi’s death, resulting not just in a medical board accusation of Park’s negligence in 2021, but also a finding from the state public health department that the hospital where he had been practicing that day had failed to follow its own preeclampsia protocols.

Tracy also inspired at least one bill to reform the medical board. That bill, introduced in February by state Sen. Melissa Hurtado, aimed to improve the agency’s transparency to the public and the capabilities of its medical investigators. Though the bill ultimately died in the state Senate, Hurtado credits Tracy with first drawing her attention to the agency. Tracy had posted a video about her daughter’s death on Instagram and tagged the legislator.

“It just touched me,” Hurtado said, and within days she said she called up Tracy and opened up a line of communication. “Tracy really just opened up my eyes and a lot more people just started coming forward…about how many different challenges people have faced because of the medical board, or they don’t feel that the medical board is doing enough.”

The campaign to increase malpractice settlements also scored a victory. In May, Gov. Gavin Newsom signed into law a bill to reform the state law that had limited those settlements for more than 40 years.

In an emailed statement, a representative of Assembly Majority Leader Eloise Gómez Reyes, one of the lawmakers who introduced that bill, said that patient advocates like Tracy “served a vital role in bringing this piece of legislation forward…especially when testifying in committee about the significant importance of passing this legislation.”

Tracy also spurred Eserick “TJ” Watkins, who serves on the medical board, to speak out to other board leadership and the public about his beliefs that the agency doesn’t do enough to protect patients. He first heard Tracy’s testimony during a public meeting.

“Sometimes, it’s a way a mother speaks that doesn’t leave you, a mother that lost something,” he said. “Here she comes as a cautionary tale of what we are aiding and abetting in her hurt and her pain…It was very powerful.”

Tracy isn’t working alone

Tracy is too humble to take credit for her successes, but Michele Monserratt-Ramos is happy to give it to her.

“She's never said no. She's never said I can't. She's never said I don't have time,” said Monserratt-Ramos, a long-time patient advocate with the nonprofit Consumer Watchdog who spearheaded many of these advocacy efforts and helped Tracy to find her voice. “As I tell her all the time now, she is a healthcare leader in Kern County.”

Monserratt-Ramos, too, was pushed toward patient advocacy by medical tragedy. Two decades ago, her fiancé died following an operation from a surgeon who had a history of substance abuse.

Tracy and Monserratt-Ramos aren’t working alone. They’ve also partnered up with Demi’s fiancé, Xavier De Leon, and his mother, Monique Himes.

Together, their story also reached Kern County leadership. During a Board of Supervisors meeting, the four of them as well as the mother of another young woman who died during childbirth appeared alongside Supervisor Leticia Perez as she proclaimed May 2022 to be Latina Maternal Mortality Awareness Month.

“I want to say thank you for what you do to bring education, awareness and healthier homes to Kern County,” Perez said during a meeting on May 10, which is celebrated as Mother’s Day in Mexico and parts of Central America.

Kern County Supervisor Leticia Perez, right, wiped her eyes during a May 10 public meeting as Tracy, front left, described how Demi and Malakhi died. Perez proclaimed this May as Latina Maternal Mortality Awareness Month in Kern County.

Kern County has one of the highest infant mortality rates in California and mothers die at a higher rate during pregnancy and childbirth in the San Joaquin Valley than in any other region of the state.

Tracy and Demi inspired others to speak out

Angie Ortiz said Tracy has been an inspiration. Her daughter Celeste Ortiz, another one of Park’s patients, died of postpartum hemorrhage in 2016, according to medical board documents. The case prompted the medical board’s second accusation of gross negligence against Park and led the agency to revoke his license, then stay the revocation and place him on probation.

“She has always been so easy to share my story with,” Angie wrote in a text message. “I'm so grateful for her and all her hard work she has done going after Dr. Park.”

Additionally, a half a dozen current and former patients of Park reached out to KVPR after it published previous stories about the medical board’s investigation into Demi’s death. Several specifically cited Tracy’s advocacy as a motivating factor.

Despite her successes, Tracy’s work isn’t over. She, along with Himes and De Leon, founded a nonprofit to serve expecting moms called Save a Mom, Save a Family, and she’s hoping to create scholarships at the high school and university that Demi attended.

She’s also continuing her work to reform the system that allowed Park to stay in practice. State law allows him to reapply for his medical license in January 2025, and Tracy says she’ll do everything to prevent that from happening.

“He's not going to get rid of me. The medical board is not going to get rid of me,” she said. “I will speak her story till I die.”