The causes of the death of Ms. Temple were only recently made public and the investigation report indicates that over the two years preceding the death of Ms. Temple, 6 patients in labor at Woodhull Medical Center “suffered adverse outcomes related to the administration of anesthesia” and Dr Shlchkov was involved in most of them. The same errors of pushing the epidural needle too deep and mixing the anesthesia with cerebrospinal fluid as well as not proceeding to a test before administrating the full dose were reported. Despite the obvious pattern, the hospital did not take any measures to monitor the doctor who was finally stripped of his medical license in 2021.
Epidural complications are rare and while epidural complications started to occur regularly at Woodhull Medical Hospital, the system was so dysfunctional that cases went unreported. It took the death of a mother for the administrators of the hospital to notice the pattern.
Read more in the New York Times