Seventeen-year-old Kathy Denise Murphy was the first to die in a facility that has changed its name and location multiple times.
To the best of my knowledge, Inglewood General Hospital, Inglewood Hospital, Inglewood Women’s Hospital, Inglewood Women’s Clinic, West Coast Medical Group, and West Coast Women’s Medical Group are all the same facility in different incarnations. Belous Medical Clinic seems to be a subsidiary, but might actually be the Inglewood entity. I think the Inglewood entity still exists, having been bought out by and put under the dirty umbrella of Family Planning Associates Medical Group — in which case, it’s now a National Abortion Federation member facility.
Some facilities have kept operating by just closing down and re-opening under another name — remember Dadeland. When shut down by the IRS for back taxes, it was simply reopened as Women’s Service Center. Same owner, same administration, same doctors, same problems, different name.
Here are the profiles of a few of the women who were victims of Inglewood in its various incarnations:
Seventeen-year-old Kathy Denise Murphy was the first to die. She went to “Inglewood Women’s Hospital” for an abortion on August 24, 1973. At that time, it was not unusual for abortions to be performed on an inpatient basis, and for patients to be kept for observation at least overnight. Evidently Kathy was kept at Inglewood for observation. During the days after her abortion, Kathy suffered breathing problems and became semi-conscious, so Inglewood staff transferred her by ambulance to Centinela Hospital on September 7. Later that night, Centinela transferred Kathy back to Inglewood, where John Dupont pronounced her dead at 1:20 on the morning of September 8. The autopsy found that Kathy had died of sepsis from the abortion; her cervix and uterus were infected, and her cervix covered with greenish-black pus. (LA County Coroner Report 73-14675, death certificate, LA Superior Court Case No. C555261)
The next woman to die was 22-year-old Lynette Wallace, who underwent an abortion at “Inglewood Women’s Hospital” on September 13, 1975, just a little over two years after Kathy Murphy’s death. Early on the morning of September 27, Lynette went to the emergency room reporting abdominal pain. Staff reported that she became agitated and “difficult to handle.” They put her in restraints, and she was pronounced dead of cardiopulmonary arrest at 10:53 AM. The autopsy revealed what the abortionist should have detected — the pregnancy had not been in Lynette’s uterus but in her fallopian tube. The tube had ruptured, spilling blood and a 10-week fetus into Lynette’s abdomen. (LA County Superior Court Case No. SWC34625)
Elizabeth Tsuji was the next to die. She had a saline abortion at a place identified as “Inglewood General Hospital” on February 2, 1978. Abortionist Morton Barke was somehow involved, although documents aren’t clear what his role was in her death. Barke also worked at the unsavory San Vicente Hospital. He is known to have been a partner at Inglewood and to have been involved in the deaths of Yvonne Tanner and Lynette Wallace. His involvement might have been that he served in a supervisory role.(Death Certificate 78-063811, Autopsy 78-1763)
The next to die was Cora Mae Lewis, age 23, following abortion under general anesthesia at “Inglewood Women’s Hospital.” Although the autopsy report describes necrotic endometrium and yellowish fibrinous exudate, indicates that Cora had thick vaginal discharge and gonorrhea at the time of the abortion, and notes possible therapeutic misadventure, no mention of these are made in the cause of death, nor is the fact that Cora had been placed under general anesthesia when the abortion was performed one month earlier. After the abortion, Cora developed fever and chills, and was admitted to a hospital on November 11. She was aggressively treated for pneumonia, but died December 3. The death was attributed to pneumonia and lung abscesses contributed to by the uterine and cervical inflammation, and was classified as both “Natural” and “Accident.” (LA County Coroner Report No. 83-15079)
Yvonne Tanner died next. The 22-year-old mother of one had an abortion performed by Stephen Pine and/or Morton Barke on July 10, 1984 at Inglewood; Yvonne went into a coma immediately after the abortion, and died August 14, 1984. Her death certificate indicates coma, hypertension, and urinary tract infection. (death certificate, LA Superior Court Case No. C555261)
The last known death at Inglewood was Belinda Ann Byrd, a 37-year-old mother of three. She underwent an abortion by Steven (Stephen?) Pine at Inglewood on January 24, 1987, when she was 19 weeks pregnant. According to the lawsuit, she was left unattended for three hours after her abortion, then detained another two hours prior to transfer to a better-equipped hospital. She went into a coma and died three days later due to bleeding from a punctured uterus. (Los Angeles Times 12-3-87, 8-12-89; Complaint No. 8-0001; Associated Press 7-15-89)
After Belinda Byrd’s death, an Inglewood attorney was quoted in newspaper coverage of the suit: “Had three doctors been standing there at the time, the chances of that woman surviving were practically nil.” However, Belinda was one of 74 women who had an abortion done in the single operating room that day, one of 24 operated on last 2 hours of day. State inspectors contended that no post anesthesia evaluation had been conducted. Paramedics reportedly found Belinda’s bed soaked with blood, consistent with the autopsy finding of a punctured uterus and hemorrhage.
The years of bureaucratic delays in taking action to close the facility, and the lack of prosecution of the physician who had performed Belinda’s abortion added to the anguish her family felt over her death. Her mother, in desperation, finally wrote to a Los Angeles district attorney:
I am the mother of Belinda A. Byrd, victim of abortionists at 426 E. 99th Street in Inglewood. I am also the grandmother of her three young children who are left behind and motherless. I cry every day when I think how horrible her death was. She was slashed by them and then she bled to death…. She has been stone dead for two years now, and nobody cares. I know that other young black women are now dead after abortion at that address — Cora Mae Lewis and Yvonne Tanner. Where is [the abortionist] now? Has he been stopped? Has anything happened to him because of what he did to my Belinda? Has he served jail time for any of these cruel deaths? People tell me nothing has happened, that nothing ever happens to white abortionists who leave young black women dead. I’m hurting real bad and want some justice for Belinda and all other women who go like sheep to slaughter.
Sincerely,
Mrs. Mattie Byrd.”
Belinda Byrd’s mother has resorted to putting up posters in the neighborhood asking the women of Watts to urge the district attorney to take action against Inglewood’s abortionists.” (Amici Brief Webster v. Reproductive Health Services No. 88-605)
One month after Belinda Byrd’s death, Inglewood was closed for three days by the state. It immediately re-opened as West Coast Women’s Medical Group, a clinic. As a clinic, the new entity was not required to have state license. (Los Angeles Times 12-3-87, 8-12-89; California hospital license 4H00951, Ownership and Control Interest Disclosure Statement 3-24-83, Inglewood letter to health department 4-16-72, 4-22-75; Complaint No. 8-0001, Associated Press 7-15-89)
Were these deaths just instances of bad luck, “therapeutic misadventure,” the natural risk of any surgery? Or were they due to negligence, carelessness, recklessness, and slovenliness on the part of the Inglewood entity? Let’s look.
California is the home of the assembly-line abortion, and surely Inglewood had it down to an art form. Like a NASCAR pit crew, the Inglewood staff did fast work, getting the patient through the operating room as quickly as possible.
Belinda Byrd was one of 74 women who underwent abortions in Inglewood’s single operating room on January 24, 1987 — and one of 24 operated on in the last two hours of the work day. With 12 abortions being done each of the last two hours, that means that each patient spent an average of five minutes in the procedure room. That’s five minutes for staff to clean the room from the previous abortion, position the patient on the table, and start an IV if one was being used. Since Inglewood was using anesthesia, they were probably administering it intravenously. The patient had to be properly anesthetized.
While the staff prepared the patient, the doctor had some time to strip off the bloody gloves from the previous patient, wash his hands, and put on a new pair of gloves. Somebody in that room had to get rid of the soiled linens and instruments from the previous patient. Somebody should have been putting new tubing on the aspirator, collecting the fetal remains from the previous patient, and putting a fresh stockingette and collection jar on the aspirator.
Somebody should have been wiping and disinfecting the abortion table, mopping and disinfecting the operating room floor. Somebody should have been setting up a clean set of instruments.
At some point during this period, the doctor was supposed to review the patient’s medical history and discuss any concerns with the patient. He was supposed to perform an examination to verify the pregnancy, and the estimated gestational age. Since this was the first time the patient and the doctor would meet, this would also be the time to assess whether the patient’s informed consent had been properly obtained. All in that five minute window.
Once the prep was done, there was less than five minutes for what had to be done for the abortion itself. That meant less than five minutes to dilate the patient’s cervix — in Belinda’s case, dilating it enough to remove a 19-week fetus. That meant less than five minutes to reach in with forceps, dismember the fetus, and remove the larger parts. That meant less than five minutes to suction out the placenta and remaining tissues.
What time was left after the abortion itself would be used to rouse the patient from anesthesia and get her out of the operating room and off toward the recovery room so that the next patient could be brought in and aborted.
Also during that five minutes, somebody had to make the appropriate entries in the operating room log. The doctor was supposed to write the operative report in the patient’s chart. Notations to be made in that five-minute window include any drugs used, how they were administered, and how they were tolerated by the patient. Notes were to be made of how the patient was prepped for surgery. Notes on the surgery itself were to be entered, including an estimate of the amount of tissue removed. Notes of any suspected complications were to be made, along with notes of any measures taken to treat those suspected complications.
Five minutes for an entire second trimester abortion — a late second-trimester abortion — from bringing the patient into the room to removing the patient from the room.
Five minutes for surgery that can change a woman’s life, or end it.
Now we’ll look at what officials found in various inspections of the Inglewood entity over the years.
A March 1978 inspection found:
* no pulmonary function testing available
* missing radiology equipment
* required equipment not in recovery room
* no identification of infections evident at time of admission
Mind you, this was after the deaths of Kathy Murphy, Lynette Wallace, and Elizabeth Tsuji. Elizabeth Tsuji, in fact, had died only the month prior to this inspection.
The inspection also found no documentation that the physician director was coordinating respiratory care services, and respiratory care diagnostic and therapeutic procedures were not being provided. The facility was also conducting outpatient surgical services without having applied for a license to do so. The dietetic supervisor was not qualified to do the job, syringes and needles were not being rendered unusable in the recovery room, and the facility had an inadequate disaster plan. Although these are not scathing condemnations in and of themselves, together with the three patient deaths already to Inglewood’s discredit, they helped to paint a picture of a facility that could not be trusted to provide appropriate patient care. Yet Inglewood remained in business. (Statement of Deficiencies and Plan of Correction)
Inspector returned in November of 1978 — three days after the abortion that eventually killed Cora Lewis — and found:
* radiology equipment missing
* required equipment not in recovery room
* unqualified staff inserting laminaria and performing physicals
* no nursing care plans for 7 patients
* standing orders not signed
* medical records charting not all signed
Rather than correcting the lack of equipment in recovery room and the missing radiology equipment, Inglewood had slid further into noncompliance.
Although now the syringes and needles were lying openly about at the nurses’ station rather than in the recovery room. And a new area of noncompliance was noted: consent forms for sterilizations did not have physician signature, date, and time.
Cora Mae Lewis was hospitalized for post-abortion infection on November 11, and finally died on December 3, of 1978. And the Inglewood abortion mill ground on.
A year and a half later, in February 1980, thing were not much better. There was no documentation that a registered nurse was always available. In fact, there was not always an RN assigned to the recovery room. Two of the three nursing plans reviewed were identical, and had not been individualized for each patient.
There were more problems with the charts and documentation:
* notes not signed by the person making the observation
* irregularities of standing orders
* “surgery log had white out and a different procedure performed written over”
* “History and physican exams as recorded were less than adequate in a number of charts.”
And — are we surprised by this? — consent forms for sterilizations still did not have physician signature, date, and time. (Statement of Deficiencies and Plan of Correction 2/20/80)
Despite persistent problems, Inglewood continued to operate.
A year later, in February of 1981, inspectors returned and found:
* no documentation of pre- and post-anesthesia instructions
* only 1 crash cart available for both nursing and surgery
* cloth-wrapped sterile supplies marked with 6-month expiration date rather than 30-day expiration date indicated in policies
* ECG machine not on written preventive maintenance program
* electromedical equipment not tested as scheduled
* no control panel for nursing call station
Diet orders were also unclear. For example, saline patients were to be given “liquid diet,” but there were no written guidelines for that particular diet. The inspection team noted that “over use of pre-printed forms… lead to ambiguities and potential inadequacies.” An understatement, I’m sure, considering the four women who had already died at Inglewood, and the two that were going to lose their lives there later. (Statement of Deficiencies and Plan of Correction 2/9/81)
Inglewood’s string of disgusting inspections was far from over.
A September 1982 inspection found even worse problems with record-keeping:
* post-anesthesia notes were dated later than the time the observation was supposedly made
* records face sheets were signed off by the physician with blank spaces later stamped with final diagnosis, surgery, and complications
* date and time of orders not documented
* patient records charted by aides but signed by RN
* improper documentation of IVs
* discrepancies between medications ordered and medications administered
There was only one registered nurse available for the pre- and post-operative surgical area for the 72 patients scheduled the day of the inspection. (Here we see the overloading of Inglewood’s single operating room; this would be seen again when inspectors discover that 74 patients were processed through Inglewood’s single operating room the day of Belinda Byrd’s fatal abortion in 1987.)
Patients were not provided with visual privacy. A plastic anesthesia face mask was washed and re-used. Multiple patients were given the same IV solution from the same container, using the same tubing. Staff were not changing scrub suits between patients. Linens were stored uncovered. An operating room technician washed hands for surgery, then opened the OR door, contaminating his hands. Solid waste bins were not covered and “had encrustations of putrescable material.” (Statement of Deficiencies and Plan of Correction 9/24/82)
In September of 1983, inspectors found:
* times for vital signs not recorded in recovery room
* sites of injections often not recorded
* one medication given 3 hours after ordered
* no infection control policy addressing scrub clothes
* inadequate documentation of “all possible infection possibly acquired during hospitalization and evident following discharge”
* addition to rear of OR not rodent-proof or sealed from the elements
* infection control in disposal of infectious waste not followed
There were other irregularies as well. Not all staff were documented as being tested for tuberculosis. A patient was ordered a particular diet, but there was no menu available to define the diet. A patient was put on a surgical liquid diet the day before that diet was ordered for her. And dishes were being towel-dried rather than air-dried; this could contaminate the dishes. Altough these other irregularities are not egregious, they’re part of a pattern of slipshod operations. Nevertheless, Inglewood continued to operate. (Statement of Deficiencies and Plan of Correction 9/23/83)
Despite worse and worse conditions found with successive inspections, Inglewood continued to operate.
Inspections were done in May and June of 1984 in response to a complaint. These inspections found:
* patient had complication, but “none” was listed in complication section of surgical log
* two patient surgical logs had no entries, just a blank under complications
* laminaria was inserted by unlicensed staff
* patient transferred to another hospital without proper documentation
* consent for laminaria insertions not always checked
* two patients’ physical exam forms and history forms contained different information
* unlicensed staff doing tentative gestational diagnosis
* no documentation that physician was notified of ruptured membranes
* one aide inserted laminaria, another was documented as doing it
* no documentation of observations of patient having seizures
* patient charted as in acute distress and unable to get blood pressure, but distress not described and no reason given for inability to get blood pressure
* entries in charts written over and/or not dated
* no stripchart EKG in post-anesthesia recovery room
* written policy for flash autoclave, used to sterilize instruments, not followed
Inspectors also noted that the facility was advertising outpatient and emergency services although it had not been licensed to provide those services.
The physical plant was hardly an encouraging picture: inspectors found the surgical suite shelving laden with dust and lint, and the surgical suite ceiling ventilation grid encrusted with grayish material.
The inspectors further noted: “Hospital does not have enough surgical equipment, nor does it appear that staff is properly sterilizing their equipment as evidenced by comparing the hospital’s surgical log with the number of surgical sets available.” They also noted that nurses, practitioner, and physician assistant lacked assignment of clinical privileges. (Statement of Deficiencies and Plan of Correction 5/18/84 , 6/21/84)
Yet Inglewood remained open. And the month following the second inspection, Yvonne Tanner died.
Half a year after Yvonne’s death Inglewood was again inspected. Inspectors found:
* lab procedures performed without physician’s orders
* surgical log did not document complications charted elsewhere for 2 patients
* recovery room adequate for 2 patients was serving 4 patients
* only one cardiac monitor for 4 patients in recovery
* boxes of supplies stored on recovery room floor
* in two abortion patient records, verbal orders were documented from physician who was neither on premises nor contacted by phone
* some orders lacked dosage, frequency, or time
* medication administered without orders
* “policy and procedures manual contained conflicting temperatures and pressures for autoclaving”
* autoclaving documents not dated
* uncovered clean linen stored in patient room used as pre-op holding area
* linen stored on counter by recovery room sink
* disposable anesthesia masks re-used
* re-usable anesthesia masks rinsed but not sanitized between patients
* accumulation of dust and lint on OR suite shelving
* area of OR floor covering missing
* one recovery room gurney covered with dust
* sterile equipment with 12/24/84 expiration date seen on OR 1/17/85
* 2 of 8 employee records lacked documentation of health exams
* physician’s assistant practicing without privileges
Records-keeping had not improved. One patient had been discharged a month previously, but there was no medical history or physical examination record in her chart. Documentation on D&Cs were made by numerous staffers and not signed. One patient record had an undated examination form in it. A physician pre-signed blank physical examination forms for some patients.
But even more alarming was what inspectors observed about charting surgery: “It was common practice to record the time a surgical procedure began…before the patient actually entered the operating room. In one case, the patient’s record [documented] that the procedure had begun at 10:00 a.m., but this was observed at 11:30 a.m., and the patient had not yet entered the O.R.” In other words, we’ve solved the mystery of how staff could possibly prep a patient, perform an abortion, and properly document each patient’s care when the time devoted to each patient’s abortion was about five minutes: charting was done in advance, before the patient even entered the operating room.
On patient’s discharge summary indicated that vitals for that patient were taken every 15 minutes for 2 hours, then every 30 minutes for two hours, but failed to document that the patient’s vitals were actually taken. “Nursing and physician medical records forms documenting care in the recovery room are routinely filled in prior to the patient’s arrival in the recovery room. Neither the R.N., nor the M.D. signing these forms saw the patients prior to their discharge from the recovery room.”
Basic surgical hygiene procedures were blatantly ignored. “One physician did not wash his hands after going to the bathroom. He was observed going from the bathroom straight to the operating room to perform a surgical procedure.” Operating room staff did not wash hands “After returning from break and in between patients.” OR staff were also observed not following procedures for scrub gowning.
Inspectors also noted inadequate control of the pharmacy including:
* medication obseved on counter in utility rooms, accessible to unauthorized parsonnel
* backup supply of controled substances not adequately monitored
* single-dose vials of medications used for multiple doses
* medication dispensed contrary to manuracture recommendations
* no medication refrigerator on nursing unit
Inspectors also found medications charted as ordered but not charted as administered. One patient suffered heavy post-surgical bleeding, but nursing notes do not document adequate monitoring of her vitals. Another patient was noted to have temperature of 103.2 at 10 PM, but subsequent nursing note states physician was notified of fever at 7 PM — three hours before the fever was charted. Another patient’s vitals not documented as ordered. One patient was discharged without an assessment documented by the RN. And one chart documents in one place that IM medications were administered, and in another place documents that IM medications were refused by the patient, leaving it unclear whether the medications were administered or not. (Statement of Deficiencies and Plan of Correction January 17-18, 1985)
Yet Inglewood remained open.
Inglewood had been accumulating nasty inspection reports and dead patients since as early as 1978.
Inspectors returned in May of 1985. They found (Statement of Deficiencies and Plan of Correction May 9-10, 1985):
* inpatient records charted primarily by nurses’ aides, co-signed by nurse
* two patients not reassessed as their condition changed
* patient chart entries not signed by person making entries
* medications not administered for several hours after ordered
* one patient’s chart did not show administration of ordered medication
* entries in charts written over
* patient’s allergic reaction documented in surgery but not in discharge summary
* emergency generator not tested as required
* expired medications noted in refrigerator
* no documentation of training for person disposing of infectious waste
* defective recording thermometer on OR autoclave
* outdated sterile supplies in utility room
* inadequately documented credentials for physician assistant and nurse practitioner
* drug administered to patient when she had had allergic reaction to that drug the previous day
* patient’s allergic reaction had not been documented
* CRNA documented as administering medication which interviews indicate had been administered by RN
* RN administered drug to treat allergic reaction without doctor order
* despite patient’s allergic reaction, CRNA indicated patient “tolerated anesthetic well without problems”
* numerous medical entries obliterated so as to be illegible
* physician orders documented, but not time
* one person functioned as circulating surgery nurse, another signed off
* physician observed documenting orders as if he had written them the previous day
* nurse signing off on charts written by aides, without assessing patients to ensure accuracy
* patient admitted with temperature of 100.6, no further documentation of patient’s temperature, later readmitted with high temperature
* nursing assessment not signed by RN
* chart documented positive skin test for medication sensitivity, but lacked documentation of further assessment
* drugs ordered to be administered for pain had been given to patient for fever
* improper documentation of autoclave temperatures
The physical plant remained unsavory:
* dust along ledge, ceiling, and fixtures in recovery room
* eroding plaster wall by handwash sink in OR
* peeling and/or chipped paint in OR
* torn and/or stained window curtains
* upholstery torn on OR surgical table and stool
And yet Inglewood remained open for business. And in January of 1987, Belinda Byrd died.
After Belinda Byrd’s death, there was press criticism of Inglewood and the state’s failure to take action despite the facility’s history. An October 12, 1988 article in the Wall Street Journal summarized inspection findings, with 33 violations cited in a 29-page report.
Since we’ve reviewed Inglewood’s previous inspections, none of what the Wall Street Journal complained about in the most recent inspection should come as a surprise.
Remember those five minute abortions? Remember how much the staff would have to do in that single operating room to clean it up after one patient and preparing it for the next?
The inspectors found that patients were rushed through abortions in a room with the table and floors stained with blood from previous patients. The OR table wiped with the same bloody towel between patients, with blood dripping from the table. Hands and equipment were not washed between abortions. Pre-anesthesia evaluations were being done while the patient was on the table being prepared for surgery. These pre-anesthesia evaluations consisted of asking the patient if she had allergies and if she had eaten that morning.
It was clear that records and medical histories were not being adequately reviewed prior to surgery. Health officials also alleged charts of patients weighing from 105 to 245 pounds all show same the dose of anesthesia was administered.
Inadequate monitoring of anesthesia and post-anesthesia status of patients was observed, including:
* post-anesthesia evaluations signed without observing patients
* five patients’ post-anesthesia evaluations consisted of an unsigned stamped entry
* patient Dana H.’s post-anesthesia evaluation for her February 25, 1987 abortion was signed already when she arrived in post-op
Poor care and falsified or shoddy records continued into the recovery room and through the discharge process. Inspectors observed:
* patients not examined by doctors after surgery and “encouraged to leave the facility before they felt comfortable doing so”
* post-recovery charts signed by physician without examining patients
* with inspectors present, “physician was observed entering the post-recovery area…she signed two patient records…did not go over and check the patients”
* with inspectors present, nurse-anesthetist entered recovery room and signed four charts without looking at the patients
* Dr. Zumwalt’s signature was noted on the pre-discharge evaluation at times when Zumwalt was in surgery attending to other patients
* three other patients have Zumwalt’s initials indicating performance of pre-discharge examinations that never took place
Inglewood owners allegedly asked for an extension to the deadline for response. The Attorney General sought revocation of Inglewood’s hospital license based on these violations. Allegations in the petition, in addition to those above, included: Patient Gail O.’s medical record, which disclosed her history of asthma, was not reviewed, and she was administered anesthesia; two patients experienced tachycardia without having their vital signs properly monitored; numerous abnormal blood test results apparently not called to the attention of physician or charge nurse; one LVN was observed adjusting and taping an IV needle on one patient without washing her hands after checking the perineal pad of another patient. (Wall Street Journal 10-12-88; Complaint No. 8-0001)
The state finally moved, though, and closed Inglewood. The facility stayed closed long enough to discharge those inpatients who were still being observed and/or treated. It then abandoned the inpatient model and reopened as an outpatient clinic, no longer subject to routine state inspections.
Now, presumably, Inglewood continues to operate under a new name with no more inspections. How many women are being maimed? How many are dying? With the poor state of complication reporting and lack of organizations gathering data, who knows?
Source: Christina Dunigan
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