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Centinela Hospital Failed To Take Measures That Would Help Prevent Patient Deaths, State Report Finds
Supporters of Inglewood resident April Valentine, who died in childbirth, protest outside Centinela Hospital.
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Mariana Dale
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LAist
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State investigators found Centinela Hospital Medical Center put patient lives at risk by failing to meet some federal health care standards.
The California Department of Public Health reviewed hospital procedures weeks after an Inglewood woman died there while giving birth to her daughter.
The evaluation, obtained Friday by LAist, and first reported by Los Angeles Times on Thursday, was in response to a complaint and looked at whether the hospital met standards required for medical facilities that receive federal funding.
Among the findings: Centinela failed to take preventative measures to reduce the risk of blood clots, which could lead to serious injury or death. Investigators said that created an “immediate jeopardy” situation; regulators use this term to describe conditions that “caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.”
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April Valentine died at Centinela Hospital. Her daughter was born by emergency C-section. She'd gone into the pregnancy with a plan, knowing Black mothers like herself were at higher risk.
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Read LAist's investigation into Centinela Hospital.
Untreated clots that form deep in veins can break off, travel the lungs, and stop the flow of blood. The Centers For Disease Control and Prevention say these blockages, called pulmonary embolisms, are “one of the most common causes of pregnancy-related death in the United States.”
Blood clots are preventable — as are most pregnancy-related deaths, according to CDC data.
Investigation details
The Centinela evaluation is based on observations of a select number of patients over several days.
Investigators noted six of seven patients were not properly assessed for dangerous blood clots. The report also stated in some cases there were not enough registered nurses to meet patient needs.
Though the report does not name April Valentine, it describes a patient whose story aligns with the account shared by her family and partner, including the date she was admitted to the hospital, January 9, 2023.
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Valentine’s partner and her sister said the 31-year-old complained of pain, numbness, and swelling in her legs for hours before she died. They said Valentine’s doula was repeatedly denied access to the hospital by staff and her physician.
In California, Black people die from pregnancy complications at a rate nearly four times higher than the general population.
What's next?
Investigators removed the immediate jeopardy label after the hospital presented a plan to fix the problems outlined in the report. That plan included re-educating nursing staff about the risks of blood clots and implementing “preventative measures.”
A hospital spokesperson declined to provide additional details on its plan to correct deficiencies and said the hospital “immediately addressed and implemented all CDPH recommendations.” The hospital did not state whether employees were disciplined for not following proper procedures.
Family and supporters called for accountability in the days and months since her death.
“I'm grateful for what has been revealed, but it's definitely reinforcing the fact that this fight has literally just begun,” said Valentine’s cousin Mykesha Mack, who leads the Justice For April campaign.
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The Los Angeles Times reported the hospital faced no financial penalties.
The California Department of Public Health previously opened a separate investigation in the wake of Valentine’s death and said in a statement Friday that it cannot “discuss the details of an active investigation.”
Valentine’s partner Nigha Robertson is baby Aniya’s father and now sole provider. Mack said together with the family they celebrated what would have been Valentine’s 32nd birthday on April 26, with balloons and cake.
Read the full report
How to take action after a bad pregnancy experience
After a violation
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If you believe you’ve experienced a violation during pregnancy or labor, it can sometimes be challenging to know what course of action to take. In their resource on birth rights, Pregnancy Justice and Birth Rights Bar Association (BRBA) offer the following options as a place to start.
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There’s no one right approach, so it’s important to weigh the pros and cons of each of these strategies, and keep in mind that some come with risks or may not be realistic for everyone.
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- Talk about what happened. Find someone you trust to talk openly and freely about what happened. This process can help you understand what happened and decide what next steps you want to take.
- Write your narrative. It can be helpful to have a record of what happened, from your point of view, written as close to the time of violation as possible. Start by writing freeform, and ask others you trust and who were there to clarify details.
- Request your medical records: You have the right to see and get a copy of your medical records. These documents can help you understand what happened from the provider's point of view and could be a key source of evidence.
- Give direct feedback. You can write a formal letter to whoever was involved in the violation, which might help the person make a change in how they practice.
- File a formal complaint. Submit feedback to the official agency or agencies that oversee your providers. In California, the Medical Board licenses doctors and investigates complaints. The state’s Department of Public Health can investigate complaints against hospitals and other care facilities.
- Contact a state representative. Sharing your story with a representative can lead to an investigation by another agency or policy change. Find your California legislator.
- Contact the media. Media attention can help raise awareness and lead to others coming forward to help or share their stories.
- File a lawsuit. Legal action can bring new details to light and may lead to settlement negotiations and monetary compensation. How to find and afford a lawyer.
- Take direct action. Joining with others can bring attention to your issue, help build community, and can sometimes achieve outcomes that litigation cannot.
- Work the system, be creative. Understanding the system you’re in, you may have other ideas for how to get your story in front of key decision makers, through informal or artistic means.
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Birth and postpartum resources
Birth and Postpartum Resources
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These resources were recommended by California birth workers and families. Have a suggestion? Email sritoper@scpr.org.
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For more on specific topics, see LAist’s pregnancy guides.
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Mental Health
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- 988 Suicide and Crisis Lifeline - Free and confidential support for people in distress, prevention and crisis resources for you or your loved ones.
- National Maternal Mental Health Hotline - 24-Hour hotline for pregnant and new moms at 1-833-943-5746 (1-833-9-HELP4MOMS).
- Postpartum Support International (PSI) - Free, confidential support before, during, and after pregnancy. Responses within a few minutes 24/7 at 800-944-4PPD (4773).
- Maternal Mental Health NOW - Hosts a directory of providers and services in L.A. County and a self-help tool to help navigate the emotions of the transition to parenthood.
- Therapeutic Play Foundation - a Pasadena-based non-profit created by Black mental health professionals that provides mental health services, support for birthing people and community gatherings.
- All-Options talkline. Process how you feel or what to do next by talking to a volunteer peer-counselor about abortion, adoption, parenting, infertility or pregnancy loss.
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Breastfeeding
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- BreastfeedLA – Provides education and outreach to promote and support breastfeeding in Southern California. Find resources on their map of local breastfeeding resources.
- CinnaMoms – Support circles for Black birthing people hosted at WIC centers in the L.A. area, with the goal of breaking down barriers to breastfeeding.
- La Leche League – Peer support groups for breastfeeding. Find a local meeting.
- Kellymom – Breastfeeding information site run by international board certified lactation consultant Kelly Bonyata.
- National Women’s Health and Breastfeeding Helpline – Run by the US Department of Health’s Office of Women’s Health, breastfeeding peer counselors are available to talk between 9 a.m. to 6 p.m. ET at 800-994-9662.
- Soul Food For Your Baby – Black-led breastfeeding support groups.
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Doulas / Postpartum Support
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Doulas provide expecting and new mothers or birthing people with educational, emotional, and physical support before, during, and after a baby is born. Postpartum doulas’ services can include cooking, help around the house, and various healing modalities. Pro tip: many postpartum doulas are available pro-bono while they are seeking certification.
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- What Do Doulas Do? – LAist’s guide to doulas, including a list of resources to find a doula in Southern California.
- Birthworkers of Color Collective – A collective of birth workers of color providing trainings, workshops, and healing offerings for birthworkers, pregnant people, and their families.
- DONA International – Doula certifying organization that includes a search tool to find prenatal and postpartum doulas.
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Support Groups
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Many support groups and parent and me classes exist throughout Southern California, and the best way to find one is to search online for groups in your area. You might also find these groups through your hospital or places where you find breastfeeding gear. It sometimes helps to look for activities you enjoy (eg. yoga, swimming, dancing) and see if they have “baby and me” classes.
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A few places to start:
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- Kindred Space – A hub for midwifery care, doula support, lactation consulting and support groups.
- LOOM – Provides pregnancy, breastfeeding classes, and a doula directory.
- Lucie’s List – Map of local parent groups.
- Pump Station – Baby supply store that also offers parent and me classes.
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For Black Parents-to-Be
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- What Pregnant Black Women Need To Know To Have A 'Safe And Sacred Birth' – LAist’s guide for Black birthing people.
- AAIMM Doula Program – LA County Department of Public Health runs a program offering free birth doulas to Black birthing people.
- Black Emotional and Mental Health Collective (BEAM) – A national organization focused on Black emotional health care and healing that offers peer support groups, trainings, and grants.
- Black Infants & Families Los Angeles – A multifaceted Department of Public Health initiative that runs a program offering free doulas to Black birthing people. There are also Antelope Valley, South L.A./South Bay, San Gabriel Valley and San Fernando Valley/Santa Clarita- based groups that meet to discuss how to end Black infant and maternal deaths and share resources.
- Parenting For Liberation – a virtual community founded by an Orange County mom that “connects, inspires, and uplifts Black folks as they navigate and negotiate raising Black children within the social and political context of the U.S.”
- Sugar Heal Gang – A collection of Black healers who provides grants through their Black Maternal Health Fund to cover maternity care services.
- The Victoria Project – A fund for birth care outside of a hospital setting (home birth & birth center) to families within Los Angeles, Ventura, and Santa Barbara counties.
- Black Mental Health Task Force— a coalition of California mental health professionals, community organizations and residents focused on supporting “mental health wellness within the African American community.”
- Black Women For Wellness— An LA- and Stockton-based nonprofit focused on health education and advocacy
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For Partners / Fathers
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- Black Daddy Dialogues – Support group for dads raising Black children, every second Saturday of the month.
- Love Dad – Home visits to fathers and their children throughout L.A. County
- The Expecting Fathers Group for Black Dads – Support group for Black soon-to-be fathers and provides education, support and navigation tools for the prenatal, labor and delivery, postpartum, and early parenting.
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Loss / Grief
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- 'Just Try Again' And Other Things Not To Say - LAist reporting on miscarriage and loss, including a list of local and national support resources.
- Compassionate Friends – Support for parents dealing with loss.
- L.A. County Grief Support Resources – A list of resources for parents and families dealing with infant and fetal loss, service planning area (SPA).
- MISS Foundation – 24/7 online crisis support and long term aid to families after the death of a child from any cause.
- Open Path Collective – Sliding scale therapy.
- Our House Grief Support Center – Open to the community. Fee based on a sliding scale.
- Sisters in Loss – Doula Erica M. Freeman is dedicated to “replacing silence with storytelling around pregnancy and infant loss and infertility of Black women” and hosts a podcast and a virtual support community.
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Social Services
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- 211 – Information and referrals for all health and human services in LA County, including a query for “parent programs.”
- Home Visiting Programs – L.A. County has several free programs with home-based visits to support families with new babies, available depending on hospital, zip codes, and other criteria. First 5 LA gives an overview of the “Welcome Baby” program and participating hospitals. Look up which home visiting programs you might qualify for in the L.A. County home visiting program directory.
- PHFE WIC – Breastfeeding support, healthy foods, and connections to additional financial and social support services for low-income parents.
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