Deny, Defend, Death: A Newborn's Death and Salt in the Wound

How “deny and defend” tactics backfired on one hospital after the medical-error death of a newborn — and inspired a mother to take action.

After her newborn son, Michael, died as a result of medical error in 2003, all Beth Daley Ullem wanted was an investigation into what went wrong and actions to prevent those same errors from happening to someone else.

“I don’t want to sue you,” she told hospital administrators, “but I do want to know how you’re going to improve and protect families.”

Instead of answers and action, however, she said she was stonewalled with “complete deny and defend” — no investigation, no answers and no improvements. “They even hid [the event] from the quality department,” Daley Ullem says, “and to me, that was going from error to insult.”

Hospital leaders and lawyers hunkered down with what they knew best — deny-and-defend tactics.

Daley Ullem knew of the hospital’s record of medical errors and costly claims long before losing her son. As a claims processor for a major consulting firm years before, she recognized a pattern of claims against the hospital and thought, “God, I feel like I’ve seen the same claim over and over again. How do we get them to learn and stop these repeat claims?

Little did she know her son would become the subject of one of those claims.

“It was bad enough to lose a child … and then to find out [the same error] had happened before in exactly the same sequence, and then it happened again after you,” Daley Ullem says. “They had spent millions and millions of dollars settling suits without seeing the core problems, which in our case were fairly fixable or at least manageable.”

After burying her son, Daley Ullem approached the head of obstetrics with ideas and offers to help prevent repeat occurrences. Their response? “You know, sometimes bad things happen. We don’t know why God needed your angel, but now you have an angel.”

Beth Daley Ullem

“It was stunningly patriarchal and patronizing,” Daley Ullem recalls, and it only got worse over the next two years when the hospital kept sending bills for her $90,000 C-section.

Despite her ordeal, she believes patients aren’t asking for perfection, but they do expect competence, a commitment to care and honest communication. “Even if a mistake is made, I think people are remarkably forgiving if you say right away, ‘Here’s what happened, here’s what we’re going to do to improve, and we’re not going to hide from you,’” she says. “To me, this is about leadership and leadership commitment to become a highly reliable, learning organization — [that] you’re more committed to learning than protecting your pride.”

That was not her experience, however, so when the hospital did not act on her requests, she sued and — despite the hospital destroying her computer records and fetal monitoring strips, she says — she won the case and put the $4 million settlement into a philanthropic fund to be used for CRP-related projects and promotions.

“I want to see hope and that there is another way after harm,” Daley Ullem says. “I think a lot of organizations have made great strides. When errors happen, they have their review process, they do learning, they have safety huddles and there’s a higher-reliability and learning mindset, generally, in quality.”

“But there are still a lot of physicians looking for the joy in work, and this type of stuff can take away so much of their joy,” she continues. “To have the opportunity to do this in a way that doesn’t completely derail the love of their profession is something they need to think about, that’s worth some of those tradeoffs.”

Andy Smith is a staff writer for the American Association for Physician Leadership.