By Kerry Klein, KVPR NPR Radio Central California

September 14, 2022

https://www.kvpr.org/health/2022-09-14/bakersfield-hospitals-left-to-cl…

By the time OB-GYN Dr. Arthur Park surrendered his license in late 2021, all four of Bakersfield’s hospitals had been sued by patients of his, and at least two had paid out settlements. One, Mercy Hospital Southwest, was also found to have made errors in the days leading up to the death of one of his patients.

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

Demi Dominguez was 23 years old and vibrant, according to her mother Tracy Dominguez. She lit up a room, and had a way of setting people around her at ease.

“The most beautiful quality I can say she had is that she really loved you and she wanted the best for you and she always made you feel the most important person in her life,” Tracy said.

By spring 2019, Demi had so much ahead of her. She would be graduating soon from CSU Bakersfield with a degree in psychology. She wanted to work with kids with autism, an outgrowth of a college job she’d had with the Easter Seals counseling children with disabilities.

She was also pregnant.

Demi Dominguez and her baby boy, Malakhi De Leon, died in April 2019. The Medical Board of California alleged that her attending physician, Dr. Arthur Park, missed the signs of the blood pressure condition preeclampsia. She is pictured here with her fiance, Xavier De Leon.

Demi’s first two trimesters progressed normally. She was healthy. But in April 2019, when she was 32 weeks pregnant and still two months shy of her due date, something didn’t feel right. Her whole body was swollen. Her regular obstetrician couldn’t fit her in for an office appointment, according to Tracy, so she checked into Mercy Hospital Southwest in Bakersfield.

Nurses discovered her blood pressure was elevated, according to the state medical board. High blood pressure can be a sign of severe and potentially life-threatening pregnancy complications. Her providers told her they’d observe her for a day, according to Tracy, but a few hours short of that, Demi was back at her mom’s house. Medical Board of California records show she had been given medication to control her blood pressure at the hospital, and Tracy said she was told to keep taking it at home.

That was on Tuesday. On Friday, Demi’s fiancé woke up in the middle of the night as she was having a seizure. He called 9-1-1, but it was too late. She couldn’t be resuscitated. Doctors delivered their baby boy, Malakhi, via post-mortem C-section, but he too died just 18 hours later.

“It was horrible. Everybody was screaming,” said Tracy. “I was on the floor. I literally was on the floor.”

When Demi visited the hospital that Tuesday before her death, her attending physician was Dr. Arthur Park. Years earlier, the state medical board, which licenses and disciplines doctors, had already accused him of gross negligence in the deaths of two infants. Months after Demi’s death, the agency again accused him of gross negligence following the death of another young mother, Celeste Ortiz. In both cases, the medical board revoked his license but stayed the revocation and placed him on probation.

According to allegations from the medical board, Park provided grossly negligent care to Demi, too. He sent her home without the proper diagnosis or treatment, the agency found. What’s more, the medical board charged that there’s no record he ever actually physically examined her, though he disputed this, telling the agency he forgot to enter those details into her chart.

That accusation of gross negligence, which the medical board leveled in 2021, was the third in his 30-year career. Park surrendered his medical license nine months later.

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.

Hospitals have paid the price for Park’s missteps

According to the medical board, Park missed that Demi exhibited signs of the blood pressure condition preeclampsia. It’s one of the most common causes of pregnancy-related deaths, and research suggests more than half of those are preventable.

“One of the key aspects of avoiding deaths is to be aware of the complications as soon as possible,” said Dr. Emre Seli, chief scientific officer with the research and advocacy group March of Dimes. “At least in some cases, being aware of them early enough could help us address the issue in a timely manner.”

Along with the medical board, the California Department of Public Health also found deficiencies in the care Demi received from Mercy Hospital Southwest, where Park had had admitting privileges that day. The agency determined the hospital failed to follow its own preeclampsia protocols.

As a result, Mercy Southwest agreed to a corrective plan involving mandatory training for birthing center staff as well as regular chart reviews.

Consumer Watchdog patient advocate Michele Monserratt-Ramos, however, said the plan was just a slap on the wrist.

“Considering that they were not monitoring her in the most basic ways for an extended amount of time, it didn’t seem like enough,” she said.

In an emailed statement, a representative of Mercy Southwest did not answer specific questions about Demi’s case, but did say the hospital conducted a thorough investigation after her death and maintained that patient care is its highest priority.

“Our team of OB specialists and staff is dedicated to treating new mothers and their newborns in a safe, compassionate environment,” the statement reads.

Demi’s family sued both the hospital and Park. The case is ongoing.

In fact, all four of the hospitals that currently deliver babies in Bakersfield have faced lawsuits alleging patients either died or were injured in Park’s care.

Among those sued was Adventist Health Bakersfield, formerly San Joaquin Community Hospital, where a young mother named Celeste Ortiz died in 2016. The medical board alleged that Park had lacerated her uterus while removing her placenta, then failed to recognize she was in shock. According to medical board documents, she died of postpartum hemorrhage.

Park settled with Ortiz’s family, according to court records. In an emailed statement, an Adventist representative didn’t answer specific questions about Ortiz’s case, though a family member said the hospital was not required to pay anything.

At least two of Bakersfield’s birthing hospitals, Kern Medical and Bakersfield Memorial Hospital, have paid out settlements, according to court records and an attorney involved in one of the cases.

Park did not agree to an interview with KVPR. In an emailed statement, he didn’t respond to specific questions about Demi, Ortiz or any other patients. However, he alleged that many of his run-ins with the medical board and legal system stem from retaliation against him by Adventist, due to his involvement as a witness in a workers’ compensation suit against the hospital. An Adventist representative responded to say that Park’s claims “have no basis in fact.”

Park couldn’t practice at half of Bakersfield’s birthing hospitals, and patients didn’t know

By the time Park surrendered his license in late 2021, he wasn’t allowed to practice at two of Bakersfield’s four birthing hospitals, according to hospital representatives. At one, Kern Medical, the representative confirmed Park voluntarily resigned his privileges in 2005 but wouldn’t share any information about why.

Park stopped practicing at the other, Adventist, the day after Celeste Ortiz’s death in September 2016. In his statement to KVPR, he claimed the hospital had forced him to resign his privileges.

Adventist Health Bakersfield is one of many birthing hospitals that faced lawsuits alleging patients either died or were injured in Park’s care.

The hospital won’t confirm whether this is true or if his privileges were revoked, but in an emailed statement, a representative said that the hospital had followed its confidential peer review process laid out in hospital bylaws.

“While we cannot disclose details, we can assure our community that we have taken all steps to protect our patients and staff,” the statement reads.

Patients at his clinic or other birthing hospitals received no such protection, however, because there’s no requirement to share information about admitting privileges publicly – not at his office, nor on the medical board website, nor anywhere else.

According to Jackie Garmin, vice president for policy at the California Hospital Association, that’s because of restrictions laid out in the Medical Practice Act and other state code.

“In California, for example, we have extraordinarily strict laws that are designed to protect the confidentiality of the peer review process,” Garmin said, referring to the process by which hospital committees investigate doctors and decide whether or not to allow them to practice there. “That is thought necessary in order to encourage other physicians to engage in honest, candid peer review.”

The U.S. Department of Health and Human Services also has access to physician admitting privileges as part of the National Practitioner Data Bank. That database, however, is available only to a select few entities, like hospitals.

Patient advocate Dr. Sidney Wolfe with the watchdog group Public Citizen has been pushing to make that database more publicly available for years.

“The data bank is there, it is secret from patients…so it not only punishes patients but punishes physicians who would like to make evidence-based referrals,” Wolfe said.

Demi Dominguez never would have met Park if she had simply chosen a different hospital – one where he didn’t have admitting privileges. But according to her mother, she chose what she considered to be the nicest hospital in Bakersfield.

Now, Tracy Dominguez is doing her best to make sure Mercy Hospital Southwest is upholding the corrective plan it agreed to after Demi’s death, even calling up its labor and delivery unit to check on specific patients she knows are there.

“I want to know, are they keeping that up?…Are they actually doing it?” she said. “I don’t want anyone else to feel our pain.”

-----------------

Kerry Klein is an award-winning reporter whose coverage of public health, air pollution, drinking water access and wildfires in the San Joaquin Valley has been featured on NPR, KQED, Science Friday and Kaiser Health News. Her work has earned numerous regional Edward R. Murrow and Golden Mike Awards and has been recognized by the Association of Health Care Journalists and Society of Environmental Journalists. Her podcast Escape From Mammoth Pool was named a podcast “listeners couldn’t get enough of in 2021” by the radio aggregator NPR One.