The mistake that sent two stillborn babies from the Regions Hospital morgue in St. Paul to a Red Wing laundry appears to be the result of inadequate labeling of fetal remains.
Employees at Crothall Laundry Services discovered the first stillborn baby earlier this month. The baby had been delivered at 22 weeks. Regions Hospital then checked its records and realized another fetus, delivered at 19 weeks, was missing. The remains of the second baby have not been found.
Regions Hospital's chief nursing officer Christine Boese said the incidents were a "tragic human error" during a conference call with reporters on April 19. She said an internal review at the hospital found "both sets of the remains were mistaken as empty linens and placed in the laundry at the same time by a hospital employee." The review did not determine which employee made the error.
There's no indication the mix-up was intentional, and St. Paul police do not expect anyone at the hospital will face criminal charges. However, at two of the state's largest hospitals, just a few miles away, it's not that easy to mistake a dead body for laundry.
Stillborn remains at Hennepin County Medical Center and Abbott Northwestern Hospital are clearly labeled and placed in plastic bags or containers. Every step of the process from the delivery room to the morgue is carefully tracked in paper and electronic records.
"With the process that we have in place, I think it would be very difficult for that kind of situation to occur," said Michelle Smith, director of Abbott Northwestern Hospital's Mother Baby Center.
Although there are no specific state or federal regulations on the labeling of fetal remains, hospitals that receive Medicare dollars are required to have policies for all services to ensure consistent and appropriate care. Those services include the handling of stillborn babies, according to the Centers for Medicare and Medicaid Services. Regions Hospital did not respond to an MPR News request for a copy of its policy.
Regulators at the Minnesota Department of Health declined to say whether the department was investigating the facility for any licensing violations. A spokesperson said state law classifies that information as private.
However, in the conference call with reporters earlier this month, Regions Hospital CEO Brock Nelson said the facility is "cooperating fully with the regulatory inquiries by the Minnesota Department of Health."
How hospitals handle fetal deaths
Stillbirths are relatively rare in Minnesota. Last year, the Minnesota Department of Health recorded 413 fetal deaths and 69,193 live births. The low numbers mean that even at the state's busiest labor and delivery centers, nurses may work for months without encountering a fetal death.
When it happens, nurses need extra help to make sure they know what to do, said Smith, of Abbott Northwestern Hospital. The facility has its own step-by-step instruction packet and checklist that nurses must follow.
"Without having very specific laid out processes, it makes it very difficult for staff to remember, 'How do I label this baby? Who do I call to transport this baby to the morgue? What's our process again?'" she said.
Nurses at Abbott Northwestern attach two identification tags to a stillborn baby's wrist or ankle. They wrap the body in a blanket and attach another identification tag to the blanket with a safety pin. Then nurses place the wrapped remains in a clearly marked red bag. Additional paperwork goes in a pocket on the outside of the bag.
Nurses then take the bag to a special "loss room" on the labor and delivery unit. The locked room is used only for the temporary storage of fetal remains. Once the remains are logged into the hospital's database, a transport aide takes the red bag to the hospital morgue, where it stays while the family decides whether to call a funeral home or ask the hospital for cremation.
At Hennepin County Medical Center, fetal remains are sent to the Hennepin County Medical Examiner's office, which is connected to the hospital via tunnel. Stillborn babies are kept in clearly labeled plastic containers or bags. Separate records systems for the hospital and the medical examiner keep track of the remains.
Questions remain about what went wrong at Regions
Regions Hospital did not use body bags. Nurses wrapped stillborn babies in linens, and the tiny bundles were kept on a shelf in the hospital morgue, an area that was accessible to some non-morgue employees.
"I think what the problem was, is it was wrapped in linen, which can easily be mistaken as soiled linen," said Regions Hospital spokesperson Kristen Kaufmann.
It remains unclear why the hospital relied on a method that it now acknowledges could "easily" lead to devastating errors.
"I'm not sure why they were wrapped in linen. I'm honestly not," Kaufmann said. "I've seen speculations out there, but I can't attest to why it has been done that way."
Prompted by the incidents, the hospital has decided to switch to storing fetal remains in body bags. Administrators have vowed to improve tracking and identification of stillbirths and provide more security and supervision in the morgue.
All other fetuses have been accounted for, Regions Hospital officials said.