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From the Los Angeles Times
'No one would listen'
Kaiser doctor is accused of negligence but remains on the jobBy Tracy Weber and Charles Ornstein
Los Angeles Times Staff Writers
Photographs by Carlos Chavez of The Los Angeles Times
October 16, 2007
Late one April night, the first of Sarah Valenzuela's twins arrived with little trouble, but the second stayed put.
Though the baby was not in distress, Kaiser Permanente perinatologist Hamid Safari attached a vacuum extractor to the boy's head to draw him out. Again and again he tugged, but still the baby would not come.
He vigorously shook the vacuum, up and down, side to side, according to government documents and hospital incident reports.
It took 90 minutes and six tries -- the last with Safari on his knees, pulling. Horrified staffers -- and the boy's father -- looked on as baby Devin finally emerged. His skin was a bloodless white, his neck elongated and floppy.
His spinal cord had been severed.
Safari lashed out at a nurse. "What did you do to that baby? I gave you a good baby," he said, according to a complaint letter the nurse sent to her union representative.
Staffers at the Fresno birthing center were devastated and angry -- and not just because of the twin lost that night in 2005.
Over the years, doctors and nurses repeatedly had complained to higher-ups -- including Kaiser's top medical officer in Northern and Central California -- about problems they saw in Safari's skills and behavior, according to interviews and documents.
This is a story not just of tragic medical outcomes, but of a health plan that did not prevent them.
A year before Devin's death, the doctor had waited more than three hours to do a Caesarean section even though the baby girl was in distress and her family said they had been pleading for the procedure, according to interviews and government records. She was severely deprived of oxygen and died months later.
As far back as 2002, a physician review committee at the hospital concluded that Safari provided "inappropriate" care and that his "conduct needed significant improvement," according to a lawsuit later filed by two of his peers.
Still, the doctor continues to work at Kaiser Fresno, practicing under restrictions that staffers say have not been explained to patients.
Regulators acted only recently. This July, the state Department of Managed Health Care fined Kaiser a record $3 million for its haphazard handling of complaints and physician errors throughout the state. Officials said in an interview that the Safari matter played a significant role in their decision to investigate the HMO's practices.
Late last month, the state medical board accused Safari of gross negligence, seeking to revoke or suspend his license.
The board also has faulted Kaiser, the nation's largest HMO with 6.5 million members in California. The health plan made the board's investigation of Safari "protracted and difficult" by providing incomplete medical records, a spokeswoman said.
Kaiser did not allow senior officials to be interviewed for this story -- and warned staffers at Kaiser Fresno not to talk, several said. In a statement, hospital administrator Susan Ryan said the HMO has cooperated with the medical board and is "committed to ensuring the safety of our patients."
In July 2005 -- three months after Devin's death -- Kaiser imposed its restrictions on Safari, barring him from performing vaginal deliveries and requiring him to be monitored by another physician or an advanced-practice nurse, Ryan said. The restrictions became permanent in April 2007. Kaiser and other hospitals typically do not notify patients of such actions, officials said.
Safari, 49, declined to comment. His lawyer, Stephen D. Schear, said the accusations are "completely unwarranted" and that Safari intends to challenge the medical board's action in a hearing. Safari, he said, has the support of many at the hospital and in his department.
"If you're doing thousands of high-risk deliveries over the years, it's almost inevitable that there's going to be some unfortunate cases where children die, where things don't go right," Schear said.
"You're talking about one minute maybe where he pulled too hard to try to extract this baby. . . . Just look at his whole record, 10 years."
But doctors and other staffers allege that Devin's death was the culmination of Safari's troubles, not a fluke.
"We do not feel that our perinatologist is competent," reads an August 2005 petition signed by eight of Safari's peers, about half of the ob-gyn department. "Over and over again he put our patients at risks and most recently with the undeniably terrible outcome."
Kaiser was "misleading our patients and the public" by advertising that it had a perinatalogist on staff even though his practice was restricted, said the petition, which was addressed to the hospital's medical director.
The petition, complaint letters, depositions and other documents used in preparation of this story are part of the ongoing lawsuit by the two doctors and arbitration cases against Kaiser, or have been provided to state regulators investigating Kaiser and Safari.
Dr. Gilbert Moran, one of the doctors who sued Kaiser and its affiliated Permanente Medical Group, alleges that they punished him and others who complained, rather than address their legitimate concerns.
"I've been telling these guys for years that he was going to kill someone," said Moran, the former ob-gyn chief. "And no one would listen."
In 1997, Kaiser's Fresno hospital needed more obstetricians but was having difficulty finding specialists willing to live and work in the Central Valley.
A staff physician recommended Safari, a former classmate from the Tehran University Faculty of Medicine in Iran, who had just completed a fellowship in perinatology at Los Angeles County-USC Medical Center. That training qualified him to treat high-risk pregnant women.
Without its own perinatologist, Kaiser had been forced to send such women to outside doctors and hospitals, often at enormous cost.
Safari arrived that August. Within months, staff members began to file complaints to Moran, alleging that Safari was rude and inappropriate.
"Dr. Safari let everybody know in no uncertain terms that since he was hired as the perinatologist that his intelligence level exceeded everybody's," said a nurse who, like several other staffers, insisted on anonymity because she feared for her job.
As time went by, staffers allege, they began to notice that the specialist also was making misjudgments and mistakes.
But Safari resisted criticism, they said. After the ob-gyn department's quality committee ordered him to work on his deficiencies in 2002, Safari "adamantly refused to follow the committee's plan, stating that general OBGYN's cannot tell a specialist, perinatologist, what to do," according to a pending lawsuit filed in May by Moran and a colleague, Dr. Robert Rusche.
The suit does not name Safari as a defendant but seeks damages from Kaiser and the Permanente Medical Group, alleging the HMO retaliated against them for drawing attention to Safari. In court papers, the defendants have denied the allegations.
The hospital called in Kaiser's regional chief of perinatology, who reviewed Safari's charts and sided with the committee, the suit said.
One of the cases involved a woman with possible pre-eclampsia -- characterized by high blood pressure and swelling that can lead to serious complications, according to Schear, Safari's attorney. A review by physician peers found that she should have been hospitalized, he said. In a second case, they cited Safari's failure to detect a potentially risky condition in which twins had markedly different weights, he said.
The review process was driven by Safari's enemies, principally Moran, and the cases cited did not involve harm to patients, Schear said. Even so, Safari followed the committee's instructions, he said.
"Peer review can be used in an unfair way to go after a doctor that people want to go after," he said. "No doctor is perfect."
Some of Safari's colleagues agreed.
"Dr. Safari has been scrutinized way beyond what a person in similar circumstances would have happen to them," said Dr. Thomas Kulterman, a Safari supporter.
Moran said Safari's performance made him a target, and it did not improve with time or scrutiny.
Repeatedly during 2002 and 2003, Moran and Rusche complained to Dr. Varoujan Altebarmakian, the hospital's chief physician, and others that Safari's "unsafe" treatment of patients "clearly fell below any accepted standard of care," according to the doctors' lawsuit.
Altebarmakian told them the situation "would be taken care of," the suit said.
Little need to question
Tanella Bessard knew nothing about Safari when she first saw him in October 2003.
She had grown up under the HMO's care. Her children were born at Kaiser hospitals, the second with a congenital heart defect. So when Bessard became pregnant with her third child, she heeded her Kaiser doctor'sadvice to consult Safari, the hospital's sole perinatalogist.
In mid-January, when she was about 32 weeks pregnant, Bessard was hospitalized for early contractions. Safari ordered shots to halt the labor and other steroid injections to develop her baby's lungs, then allowed her to return to work, she said.
"I didn't have a lot of reason to question him," said Bessard, now 33. "He seemed to stay in tune with me and what my concerns were."
On Jan. 28, when the baby was several weeks shy of full term, Bessard's contractions became unstoppable, according to interviews and deposition transcripts. She was admitted to the hospital, and by 10 p.m. Safari noted drops in the baby's heart rate after the contractions peaked. Such "late decelerations" can signal a reduced oxygen supply to the baby and, if prolonged, can cause critical harm.
Bessard's mother, Lanell Brown, said she was watching the fluctuating lines on the fetal monitor with growing concern. She and Bessard pushed Safari to do a Caesarean section, but he resisted, they alleged.
Bessard's baby, Paris, ultimately was delivered by C-section just past 1 a.m. -- more than three hours after the late decelerations began. By that time, the pH of Paris' umbilical cord -- an indicator of a baby's oxygen level before birth -- was 6.8.
This level is "almost incompatible with life, it is so bad," said Dr. Khalil Tabsh, chief of obstetrics at UCLA's medical school, who spoke generally and did not review Bessard's records. "Babies that are born with 6.8, they either are dead or they are in deep trouble."
In her first months, Paris required oxygen and had seizures. "She didn't do the normal things that children would do at her age," Brown said. Paris died that November, not yet 10 months old.
The county coroner attributed her death to chronic bronchitis and bronchiolitis -- respiratory diseases -- but did not address whether it was related to birth trauma.
Bessard filed an arbitration claim, which Kaiser settled for an undisclosed amount. The HMO requires arbitration in legal disputes, a mandate that keeps all legal filings and their resolution confidential and out of public view.
In a deposition reviewed by The Times, Safari testified that it was Bessard who resisted his recommendation for a C-section.
"He changed everything around," she said in an interview, "which really blew me out of the water."
A financial settlement with Kaiser, reached in October 2005, gave Bessard little solace, she said. That's why she asked her lawyer to refer her allegations to the state medical board.
Nearly two years later, when the board accused Safari of gross negligence, it cited his failure to do an "immediate Caesarean section." Instead, officials said, he waited more than two hours to call for one and then took "some 50 minutes to deliver the infant."
About the time of the Bessard birth, tensions within the birthing center were escalating, according to memos and interviews.
In early 2004, Safari's "behavior became irrational and included threatening to starve himself, light himself on fire, and to call CNN to witness his plight," said Moran's suit, which refers to Safari as "Dr. X."
Schear, Safari's attorney, said his client never said he would burn himself, but did threaten to go on a hunger strike to protest harassment by his boss, Moran. Other physicians complained that Moran played favorites, he said.
In May 2004, medical director Altebarmakian removed Moran as ob-gyn chief, citing his arrogance and his department's dysfunction in a follow-up letter. At the time of his removal, Moran contends in his suit, he warned Altebarmakian that if something wasn't done, Safari "would again permanently harm one of Kaiser's patients."
In December of that year, Moran had his meeting with Dr. Robbie Pearl, Permanente's top physician for Northern and Central California, to discuss Moran's concerns about Altebarmakian. According to his notes made at the time, Moran said he warned Pearl about Safari, and Pearl said he was "well aware" of the situation, including Safari's threats to harm himself.
Devin, the twin boy, died in the delivery room four months later, and the case is now key to the medical board's complaint against Safari.
Tabsh, UCLA's obstetric chief, said that in his 35 years of practice he'd never heard of a full-term baby's spinal cord being severed during a vacuum procedure.
"Everybody that was involved in it was literally sick," said one nurse, who also spoke on condition of anonymity. "She was begging for a C-section."
Another nurse, the one allegedly blamed by Safari for Devin's death, questioned why no one had investigated whether Safari was threatening his colleagues. In her July 2005 letter of concern given to her union representative, she described him as repeatedly "harassing" her about the event.
"Those of us who did the right thing and came forward to speak up against Dr. Safari when he was in the wrong feel very threatened," the veteran nurse wrote.
Schear said Safari threatened no one and had safely performed about 200 vacuum deliveries.
"It stinks. It just stinks. You're looking at one minute of this guy's career and you're going to cream him. It's very dramatic-sounding, 'Oh, the poor baby broke his neck.' It's not something where you want to destroy a good and excellent perinatalogist's reputation."
Today, Valenzuela and her husband, Randy Ramirez, both 37, decline to say much about what happened. Valenzuela said she can't discuss her arbitration settlement, and that they are afraid talking about Devin will make life unbearable again.
"Words can't even describe it," Ramirez said.
Sarah's sister, Helen Valenzuela, recalled that Sarah "cried for a year" after Devin's death.
Helen still remembers a nurse emerging from the delivery room, crying. Later, she said, she confronted Safari in the hallway: "You murdered my nephew!"
"He told me to 'Calm down, or we're going to have you removed,' " she said.
Near dawn, hours after Devin's death, Helen said she was in the room when Safari sat on the side of Sarah's bed and unburdened himself.
" 'Nothing like this has ever happened to me before,' " she recalled him saying.
Futile to complain
As staffers traded details about the case, Moran and Rusche recall wondering why it hadn't been promptly discussed by the hospital's ob-gyn quality review committee -- a practice they called routine in serious cases.
Thedoctors separately looked at Valenzuela's medical records and Rusche brought his concerns to his supervisors.
In July, hospital officials took action by limiting Safari's scope of practice. But they also took aim at the messengers, Moran and Rusche, for violating patient privacy restrictions by reviewing the records.
Moran was suspended for two weeks without pay, had his salary cut by $20,000 a year and was denied a year-end bonus, while Rusche was suspended for one week without pay and denied a bonus, according to their disciplinary letters.
Both men challenged the discipline but got nowhere, their suit alleges. It was their right to view the records, they contend, as quality committee members. And Moran said he had treated Valenzuela after her delivery.
In the months that followed, the hospital administration chastised the eight obstetricians who submitted the petition warning administrators about Safari in August 2005.In a staff memo, Altebarmakian wrote that a petition "targeting an individual practitioner is counterproductive and discourages the cooperative, harmonious and respectful work environment that the medical group expects and encourages."
Several staffers began to sense that it was futile -- not to mention risky -- to complain.
"It looks like nothing changes," said one veteran nurse. "I don't know who protected him. I don't know who came to bat for him. But he's still there."
Rusche recalls the moment he decided he'd had enough. A new patient had come in, and Rusche deemed her high-risk -- a decision that ensured she would be sent to Safari.
"To me, I had crossed the line there," he said. "It all of a sudden hit me what the heck I had just done."
In January 2006, he and Moran gave up on resolving matters internally. They took their complaints to the medical board, just as Bessard's lawyer had done earlier.
Rusche retired last year and has traveled the country in a motor home.
Moran now works for Kaiser in Bakersfield, 100 miles from his home, and sees his family on his days off.
Safari is a "really good physician" with a lengthy track record of doing "very difficult deliveries," said Dr. Daryoush Razi, a fellow student from the Tehran medical school who now heads the ob-gyn department's quality committee. "I trust him with treating my family."
Earlier this year, he and 10 other doctors signed a letter of support for Safari. Several were new to the department, but three had apparently changed their minds after signing the protest petition in 2005.
He is "an asset to our department," the letter said.