Doctor Error Caused Christine Fields’ Death After Childbirth at Woodhull Medical Center

Investigators with the New York State Department of Health have concluded that a troubling lapse by a surgical team at a hospital in Brooklyn resulted in the recent death of a 30-year-old mother who gave birth by cesarean section, according to a document obtained by The New York Times.

It is the second known instance in recent years in which state health authorities have blamed doctors for a maternal death at Woodhull Medical Center, long regarded as one of the weaker hospitals in the city’s large public hospital system.

The death of the woman, Christine Fields, in November, brought renewed attention to the racial disparities around childbirth in New York City. Ms. Fields was Black. In New York City, Black women are nine times more likely to die during childbirth than white women. That disparity is far sharper than the national one, and a range of public officials, from Mayor Eric Adams to Gov. Kathy Hochul, have cast about for ways to reduce it.

Few details about what caused Ms. Fields’s death have emerged. She had been in labor at Woodhull when a change in the fetal heart rate prompted alarm. Doctors decided that an emergency C-section was necessary.

In the hours after her son was delivered, Ms. Fields bled to death, according to the medical examiner’s office. But Woodhull has yet to offer the family any explanation for why it was so slow to detect Ms. Fields’s deteriorating condition, according to her fiancé, Jose Perez.

A two-page State Health Department document obtained by The New York Times sheds some light on what happened. The document, dated Dec. 18, describes how a mishap at Woodhull resulted in a maternal death and violated federal health standards.

The document does not mention Ms. Fields by name. But a doctor at Woodhull said that it was clearly referring to Ms. Fields’s death. The details matched, according to the doctor, who insisted on anonymity because the doctor was not authorized to discuss the matter. In addition, the document’s date is just five weeks after Ms. Fields’s death.

The document states explicitly that an error by medical staff members “resulted” in her death. It describes a troubling communication breakdown in which the surgical team — a reference to the staff members who performed the C-section — did not alert others of complications that arose during surgery. The most serious of those was a “uterine arterial injury,” State Health Department investigators concluded, according to the report.

That injury also wasn’t mentioned in the initial medical records pertaining to the C-section.

Mr. Perez recalled that Ms. Fields quickly deteriorated after she was sent to a recovery room following the procedure. He kept trying to talk to her, but got little response. He searched for ice to put on her lips. He found a nurse and told her that there was something very wrong; Ms. Fields’s head had slumped to one side, Mr. Perez recalled. Soon medical staff members were performing CPR on her.

The medical workers caring for Ms. Fields did not detect her complications quickly, according to Mr. Perez, and seemed taken aback as she grew less responsive.

The lack of documentation and lack of communication about the uterine arterial injury “resulted in maternal death,” the report concluded.

“This should not be happening in this city to anyone,” a lawyer for the family, Sanford Rubenstein, said.

The document does not provide a detailed account of the C-section, the complications that arose or what care Ms. Fields received afterward. Rather it includes the initial findings of the Health Department’s investigators, who conducted an inspection of the labor and delivery floor at Woodhull. It focuses specifically on violations of safety and health regulations, such as the requirement that surgical complications be recorded in a report immediately after a procedure.

A spokesman for the city’s public hospital system, Chris Miller, declined to answer questions about Ms. Fields’s death, citing privacy laws. “Woodhull has revamped and enhanced its protocols across its obstetrics and anesthesiology departments, and recently hired two new clinical leaders in these areas,” he said in a statement.

The circumstances of Ms. Fields’s death so alarmed health inspectors that they required some Woodhull employees to review certain hospital policies or receive training in order for the labor and delivery floor to remain open, according to two employees at the hospital who were informed of what had happened to Ms. Fields, but who asked to remain anonymous because they were not authorized to discuss the case.

“There is need for immediate action for patients undergoing procedures to prevent serious adverse outcome,” the Health Department informed Woodhull’s top administrator, according to the document.

The Health Department’s investigation into the labor and delivery floor is not complete. The two employees at Woodhull said investigators were examining several other cases.

A spokeswoman for the Health Department said that because of the severity of the investigators’ initial findings they had put their broader inspection on hold to work with the hospital on a corrective plan.

“Once the immediacy for patient harm is removed, the survey team will resume the remainder of the survey,” the spokeswoman, Danielle De Souza, said.

Though Woodhull is a public hospital, its doctors are mostly staffed by NYU Langone Health, an arrangement the public hospital system has with a number of university health systems. A spokesman for NYU Langone, Steve Ritea, said that it had fired the doctor who performed the C-section on Ms. Fields.

Ms. Fields is not the first mother to die while giving birth at Woodhull because of a doctor’s error. In 2020, a 26-year-old first-time mother, Sha-Asia Semple, stopped breathing following a botched epidural. In addition to misplacing the epidural, the anesthesiologist inserted a breathing tube down Ms. Semple’s esophagus rather than her windpipe, the State Health Department concluded. Instead of delivering oxygen to her lungs, the ventilator pumped air into her stomach.

The anesthesiologist responsible, Dr. Dmitry Shelchkov, had a troubling track record even before Ms. Semple died in July 2020. Dr. Shelchkov was subsequently stripped of his medical license in New York, and he moved back to Russia where he had grown up.

There are typically between 20 and 30 maternal deaths in New York City each year, mainly from infections, embolisms, overdoses or a hemorrhage. Most of the deaths are deemed preventable. Under half occur during childbirth or within a week after.

About 1,200 to 1,500 babies are delivered each year at Woodhull, a large rust-colored structure that rises above the rumbling elevated tracks of the J and M trains where the Bedford-Stuyvesant neighborhood borders Bushwick and Williamsburg.

Because of the deaths of Ms. Semple and Ms. Fields — both of whom were Black — Woodhull has emerged as a symbol of sorts of New York’s maternal mortality crisis.

But for many expecting mothers in recent years, the hospital was regarded as an excellent place to give birth because of the strong role that midwives play on its labor and delivery floor.

A nurse-midwife who works at Woodhull and is also a researcher, Mimi Niles, said she considers the hospital “one of the safest places to give birth,” because of the midwives who attend most vaginal births there.

“I’m shaken to my core because I’ve always promoted the care at Woodhull as exemplary care of what a strong midwifery service can do” in a public hospital, she said.

Ms. Fields’s family had said she had hoped to have a vaginal birth, but that when the fetal heart rate began to drop, doctors had insisted on a C-section for the health of her baby.