HOW WE REPORTED THIS STORY

San Francisco Chronicle reporters began investigating the pediatrics program at John Muir Health after reporting in April on a disturbing death: Two-year-old Ailee Jong had died on the operating table at the Walnut Creek medical center in 2019 after some staff members warned hospital officials that John Muir was not equipped to handle the complicated liver surgery. In conducting interviews and reviewing lawsuits, reporters learned that John Muir officials had flagged at least two other potentially preventable deaths since 2015, when the community hospital partnered with Stanford Medicine Children’s Health to create a pediatric intensive care unit, or PICU.

Reporters knew little about these two additional deaths. They knew one involved diabetes, the other asthma. But the deaths were significant, sources told them, because the PICU was seeing few patients — raising questions about whether the community hospital, in marketing itself as a Stanford partner, had taken on cases beyond its capabilities. To investigate further, reporters sent a dozen public records requests for data and documents; analyzed a data set of California hospital admissions over the last decade; reviewed internal hospital records; and contacted dozens of John Muir medical professionals and board members through calls, emails, letters and visits to their homes, ultimately interviewing 16.

John Muir’s Walnut Creek facility is located in Contra Costa County. There, neither the coroner’s office nor the county clerk can search autopsy reports, death notifications or death certificates by place of death. As a first step to find children who died at John Muir, reporters submitted a public records request to the California Department of Public Health for the state’s Public Use Death File from 2012 to 2021, a database of all deaths in California in those years. The files allowed reporters to search by place of death, date of death and age at death. Once reporters compiled a list of pediatric deaths since 2015 at John Muir, they filed additional public records requests with the county clerk for the corresponding death certificates, which provided causes of death. From there, they focused on two cases that appeared to be connected to diabetes and asthma. Reporters also examined a third death from a surgical site infection, which medical experts said was a potential indicator of questionable care.

Reporters then contacted the three children’s families, who talked at length with The Chronicle over the course of several months. They agreed to request their children’s complete medical records from John Muir, and gave The Chronicle permission to share those records with experts to get opinions about the care their children received. Chronicle reporters emailed more than 100 doctors specializing in medical fields associated with the three children’s deaths, and eventually consulted with more than two dozen medical experts about the cases, as well as how patient volumes impact outcomes in the PICU setting. Ten of these experts reviewed the children’s medical records — some several thousand pages long — and provided additional feedback specific to each child’s case. The experts spoke in their capacity as

individual specialists and not on behalf of their medical institutions.

Through a separate public records request, Chronicle reporters obtained annual PICU quality reports that are filed with the California Department of Health Care Services’ California Children’s Services program. These reports are intended to provide the state with “information regarding the quality of care, intensity of services, and risk adjusted outcomes” of units approved to care for some of the state’s most medically fragile children. In these Virtual Pediatric Systems, or VPS, reports, each hospital is identified by a unique letter. The Chronicle was able to identify John Muir in these reports by the year it started reporting data and its annual PICU patient volumes, among other factors. The state sets a minimum annual caseload of 350 to ensure approved PICUs are keeping up their skills. But The Chronicle’s reporting revealed that John Muir has never once met that important standard. The VPS reports also showed that John Muir’s PICU patient population, overall, is less critically ill than most of the other reporting PICUs and that, on average, the unit manages among the fewest number of intubated patients annually.

To further verify these findings and others, Chronicle data editor Dan Kopf analyzed a data set of all hospital admissions in California during the past decade. The data set, held by University of California researchers, contains a record of each patient who was admitted to a California-licensed hospital. The records are stripped of personally identifying information, but contain detailed information about patient diagnoses, case severity, procedures and outcomes.

As with the PICU-specific reports, The Chronicle found that John Muir’s Walnut Creek hospital had a low non-newborn pediatric population compared with nearby children’s hospitals, and performed relatively few unscheduled, or emergency, intubations in children. At the same time, a majority of John Muir’s pediatric patients did not have complications or comorbidities, an indicator that most of the hospital’s caseload was not severe. However, the percentage of cases with complications increased after the PICU opened. Health services researchers have documented an overall increase in the appearance of hospital patient complexity in recent years, a phenomenon that is, at least in part, attributed to the improved documentation of previous diagnoses in electronic health records. Still, The Chronicle found that the percentage of John Muir pediatric patients with complications or additional underlying diseases increased more significantly after its PICU opened than the increase in patient severity seen at surrounding children’s hospitals.

Reporters also obtained and reviewed internal records pertaining to concerns over the operations of John Muir’s PICU. These included a summary of an outside consultant’s risk assessment of the PICU, noting 10 areas for improvement, as well as confirmation of Stanford’s review of the unit. Reporters also obtained internal documents detailing early efforts to train John Muir employees on pediatric intubation and other airway management procedures.