Pregnancy lost due to Air Force base hospital error, lawsuit alleges
By Elizabeth Simpson | The Virginian-Pilot | Published: February 17, 2013
Heather Fergurson can't help but replay the mental tape of April 18, 2011, over and over in her head.
The Chesapeake woman had walked into Langley Air Force Base Hospital that day for a prenatal visit. Her husband and son were with her, excited by the idea of a new baby by Christmas.
But within hours, Fergurson was told she might instead have a mass of cancerous cells growing in her uterus. She was sent for a procedure called a suction dilation and curettage - typically done after a miscarriage to remove fetal tissue from the womb, or when there's an unwanted mass that needs to be excised.
Fergurson soldiered through the emotionally wrenching experience, believing the surgeon was removing cells that had gone haywire.
Little did she know the worst was to come two days later. That's when officials from the Langley hospital sat at a conference table and informed her that the tissue a surgeon removed had actually been a healthy fetus, about 11 weeks along.
Fergurson, 32, has been unable to conceive again. She often revisits the moments she spent on the operating table that day. And earlier this month, she filed a $1.7 million lawsuit against the federal government alleging malpractice.
She and her husband, Charles Fergurson, want answers.
"I've been deployed four times in combat zones," said Charles, a 56-year-old sergeant major in the Army. "We die in combat, we know that can happen. We accept that."
But he can't accept that his pregnant wife went into a military hospital for a prenatal exam and had a procedure that destroyed a healthy fetus.
"That's not supposed to happen," said Charles, who works for the military's Joint Staff in Suffolk. "That is unsatisfactory."
Scores of studies have been done over the years on medical mistakes, which are sometimes referred to as "never events." A study in the journal Surgery examined a federal database of medical malpractice claims to identify mistakes such as performing the wrong procedure, operating on the wrong patient or body part, or leaving foreign objects in a patient. The study, published in October, found 9,744 paid malpractice settlements and judgments for surgical "never events" between 1990 and 2010, resulting in $1.3 billion in payments.
Based on that data, the researchers estimate a rate of 4,082 "never events" annually in the United States.
Michael Martin, a public affairs specialist for the U.S. Air Force, declined to comment on the Fergurson case, citing pending litigation and privacy issues.
"However, I can say with confidence that Langley strives to provide the best healthcare possible and the well-being of our patients is very important to us," Martin wrote in an email response.
The following account is based on medical records, court documents and interviews with the Fergursons and their lawyers. A public spokesman for the Langley hospital would not comment on the Fergursons' description of events, and one of the doctors involved in the case also declined to comment.
Charles and Heather have been married eight years and have a 5-year-old son, Stone.
When Stone was 2, they decided they wanted another child.
Four months after they began trying to conceive, in July 2009, Heather became pregnant, but she had a miscarriage.
Charles was deployed in Africa for eight months after that, so they tried again upon his return. In October 2010, she was pregnant again.
This time she miscarried when the fetus was about eight weeks along.
Heather became pregnant a third time in February 2011. She found out through a home pregnancy test and had it confirmed by a urinalysis at Langley Air Force Base Hospital, where she planned to receive her prenatal care.
"We were elated," she said.
"It was going to be a Christmas baby, so we were excited about that," Charles said.
Heather attended a four-hour orientation at the Langley hospital for women at the same stage of pregnancy, then returned for her 12th-week visit in April.
She first met with a certified nurse midwife, who gave her an ultrasound in the exam room. The midwife couldn't hear a heartbeat or see a fetus and called for the help of an obstetrician-gynecologist. The ob-gyn, identified in the lawsuit as Dr. Beverly Reed, confirmed the midwife's findings with another ultrasound.
What they saw was a mass of tissue, something they described to Heather as looking like snow. It was noted in the records as "a cystic mass" with "no identifiable fetus."
They told her they thought she had a molar pregnancy - a rare mass or growth that forms inside the womb at the beginning of a pregnancy. It happens when there's an overproduction of tissue that is supposed to develop into the placenta, the organ that sustains the fetus during pregnancy.
Most molar pregnancy tissue masses are benign, but in some cases, they morph into a fast-growing cancer that can spread to other parts of the body.
The doctor recommended more blood work and a more comprehensive ultrasound. The ob-gyn also told her that if this ultrasound in the radiation lab also indicated a molar pregnancy, a chest X-ray would be performed to make sure cancerous cells had not spread to her lungs.
Heather was told that if it was a molar pregnancy, she'd need a procedure to remove the tissue and they would call a surgeon to see if it could be done that day.
By this time, Heather was reeling.
"We went into fight mode," she said. "I thought, 'OK, I'm not pregnant but I don't want to die, either.' "
Charles took their son to get something to eat while Heather had more blood drawn and went to the radiation department for the more comprehensive ultrasound. This one took much longer than the first two, and the technician took many images. At the end, the tech asked her why she needed the ultrasound, and Heather said the doctor thought she had a molar pregnancy. The tech told her they would not be doing a chest X-ray after all, and she needed to return to the obstetrician-gynecologist to find out the results of the ultrasound she had just completed.
"She looked me square in the face and smiled," Heather remembered. "I had this overwhelming feeling of 'What's going on?' - that everything was not what it was seeming to be."
Before they could see the obstetrician, a woman working in administration said that a surgeon would be able to do the suction D&C procedure during a period he normally would have his lunch.
Heather replied that she had been told to go over the ultrasound results with the ob-gyn.
The administrator said the surgeon, identified as James A. Reed in the lawsuit, would review the ultrasound and other tests before the procedure, but that she needed to go to his office because arrangements had been made for the D&C.
At the surgeon's office, Heather and Charles asked why the chest X-ray had been canceled and what the third ultrasound from radiology showed.
According to the couple, the doctor told them:
-- He had reviewed her tests, and her blood work showed high levels of human chorionic gonadotropin, a pregnancy hormone.
-- Her medical history of miscarriages and the blood work indicated she had a molar pregnancy, which he said needed to be removed.
-- A chest X-ray could be done after the D&C if needed.
"We were made to think it was so critical it needed to be done because these cells were going rampant," Charles said.
So Heather had the procedure.
She was put under "twilight anesthesia," a mixture of sedatives and other medications that leaves patients relaxed and sleepy but sometimes still aware.
"I have very clear memories of the procedure," Heather said. "I wish I didn't have those memories."
She remembers feeling a strong tugging inside her uterus and hearing the sound of the surgical instruments.
"I could feel what was going on."
It was over in about 40 minutes, and she was told she'd be informed of the pathology report after it was finished.
By 2 p.m., the Fergursons were on their way home to rest and to make phone calls telling family and friends they were not having a Christmas baby after all. They also explained to Stone, "Mommy is not pregnant anymore. The baby died in her tummy."
The day after the procedure, they received a phone call from the hospital asking them to return the next day for a conference with the surgeon and other officials about the pathology report.
The caller would not say why.
Charles remembers thinking, "It must really be bad. Maybe they found something cancerous. Whatever it is, we will get through it."
When the Fergursons arrived, they were escorted from the lobby to a conference room, where they saw the midwife, the ob-gyn, the surgeon, the head of the maternity department, a person from the hospital's legal department and a grief counselor.
"That made it really scary," Heather said.
The head of the maternity department wanted to establish a timeline of everything that had happened on April 18.
The midwife, ob-gyn and surgeon took turns telling their accounts of the case. Charles interrupted the surgeon. He asked all of them to stop using the big medical terms, stop the timeline, and tell him what happened and why they were there.
The director of the maternity department said the pathology report showed healthy tissue of a fetus that was 10.7 weeks in growth. The third ultrasound in radiology confirmed the existence of a live fetus, with a heart rate of 162 beats per minute.
"No complications are evident," the radiology record reads.
Heather was stunned: "I sat there frozen, like, 'What is going on?' "
She looked at her husband, a big, burly man, because she worried that "chairs would go flying and tables flipping."
That's not what happened.
He put his head in his hands and wept.
Then she looked around the table:
"Everybody else started crying, too. It sealed my worst fears. I started crying. I was done with the questions. I just wanted to leave."
The hospital officials said they would assist in grief counseling, in genetic testing and fertility treatments if that's what the couple wanted.
Charles asked that Heather's medical records be immediately transferred to Portsmouth Naval Medical Center.
At the end, when they all stood up to leave, Heather remembers doing something she later questioned herself about: She hugged the surgeon.
"I felt bad for everyone involved. It was a horrible thing for everybody."
According to the lawsuit, the medical records do not indicate that James Reed received the results of the third ultrasound, nor did he seek to find them. Before the records were transferred, he left a note in Fergurson's medical chart saying the midwife and ob-gyn told him of their ultrasound findings, but he knew nothing about the third ultrasound done in radiology.
The Fergursons said they specifically asked him about the results of that final ultrasound in radiology.
Dr. Beverly Reed declined to comment on the case, and attempts to reach Dr. James Reed were unsuccessful. The two are not related. According to the North Carolina Board of Medicine website, a Dr. James A. Reed who once was a major in the U.S. Air Force most recently practiced in an obstetric-gynecological practice in London, Ky. A person who answered the phone in that practice last week said he left the practice two weeks ago.
The Fergursons attend a Mormon church in Suffolk, and they immediately reached out to church members for support.
A couple of them were doctors, who advised them to talk with a lawyer, saying it was an important move to keep something like that from happening to someone else.
Charles said that when he was taking a phonebook out to the trash a few months later, it dropped and fell open to Ware Morrison, an attorney in Virginia Beach. In July, they contacted him.
Because Heather's care was in a military hospital, she first had to file a claim under the Federal Tort Claims Act, which Morrison helped the Fergursons do, asking for $1.7 million.
That claim was denied in a November letter: "As it is apparent we have different views on the merits of the case and your client has expressed her intention of filing suit, I must deny the claim," wrote Hildegarde Conte Perlstein, a chief of the medical law branch for the Air Force.
That freed Heather to file suit against the U.S. government in U.S. District Court, Eastern District of Virginia, on Feb. 5. A spokesman for the U.S. Attorney's Office declined to comment on the case.
Carlton Bennett, a trial lawyer working with Morrison on the case, said it should go to trial within six months.
The Fergursons, meanwhile, still want another child. They've been through fertility testing, and Heather had a cyst removed from one of her ovaries. They tried artificial insemination. The next step would be in vitro fertilization, in which eggs are retrieved from the woman and fertilized with the husband's sperm before being returned to the womb.
The couple are moving to California in April because Charles has orders to transfer to Moffett Federal Airfield, so they recently decided to shelve their hopes for another child at least until then.
"We need a break emotionally," Heather said.
They hope the lawsuit will bring some kind of closure, help with adoption fees if they decide to take that route, and ensure that something changes at the hospital for the better.
As a 26-year military man, Charles knows that if someone had been wrongly killed or injured in combat, someone would answer for it. He questions why the third ultrasound was ordered if the final results weren't reviewed before a procedure.
"We'd have a 2-year-old child right now if they did," he said.
And Heather goes over in her mind every small juncture of April 18, 2011. Should she have pressed the ultrasound tech for answers, even though she knew the tech wasn't supposed to reveal results? Should she have demanded to see the results of that third test before the procedure? Should she have doubted the surgeon when he insisted he had reviewed all the necessary tests?
"I trusted his knowledge over my own 'still small voice,' " Heather wrote in an email. "And I will regret that for the rest of my life."