LONG BEACH — Closing out a controversial year for some Peninsula healthcare providers, a case pending for almost two years ended in late 2012 with at least four years of professional licensing probation for Long Beach midwife Tamra Roloff.

Also this year, a medical doctor voluntarily surrendered his license. And officials ordered suspension of an osteopathic physician and surgeon’s license.

In the most recent case, the Washington State Department of Health (DOH) case versus Roloff resulted from a complaint filed following the death of an Astoria woman’s baby in March 2010. Roloff eventually waived a hearing and agreed to professional probation. DOH did not disclose the Astoria patient’s name due to patient-confidentiality considerations.

Another of Roloff’s former patients, Peninsula resident Mindy Bizzell, conducted an active public campaign to achieve accountability for her baby’s death. Last Friday, she said regarding the DOH’s ruling, “My son Henry died a 100 percent preventable death under her care, as did baby ‘E’ in Astoria. No amount of sanctions against her license will bring our babies back from the dead.”

As in this case, it is the Chinook Observer’s policy to not report licensing complaints until they are formally concluded. This is in light of a desire to have all relevant facts on hand and the potentially harsh consequences on the reputations of the involved professionals.

A catalog of missteps

DOH’s order and statement of charges in the Roloff matter summarizes several ways in which her care for the Astoria mother and her baby “fell below the standard of care for a reasonably competent midwife in the state of Washington.”

The patient went into labor late in the afternoon of Feb. 27 and Roloff arrived to assist with the birth at 6:17 p.m. that evening. The expectant mother had previously arranged for Roloff to act as midwife for a home delivery.

The 39-year-old mother’s water broke — this is officially called spontaneous rupture of membranes or SROM — at about 11:45 p.m. and Roloff made a note on the patient’s chart of “SROM appears clear but.” This cryptic note “fell below the standard of care” expected of a reasonably competent midwife, DOH said.

Leading up to the labor, DOH also cites a failure by Roloff to follow up on birth-risk factors relating to the baby’s father.

Labor continued under Roloff’s supervision for more than 34 hours until March 1 at 5:27 a.m., when the woman suffered a seizure. She was then transported to the hospital by ambulance, suffering a second seizure en route.

According to DOH’s review of the case, the 39-week baby was delivered by c-section at Columbia Memorial Hospital (CMH) and had died 30 hours earlier of abruption. This is a complication that occurs in about 1 percent of pregnancies, requiring skilled medical intervention to ensure a good outcome. The mother then needed to be Life Flighted to Portland, suffering from eclampsia and acute respiratory distress. She was unresponsive on a ventilator but did survive.

Roloff said she urged her patient to go to the hospital earlier, but this assertion was disputed by the patient, her partner and two witnesses present at the failed delivery.

The case resulted from a complaint filed against Roloff by CMH’s Pheobe Reed, RN.

The case file

Care deficiencies highlighted by DOH include:

• The Washington standard of care requires that the mother’s vital signs be taken at least every four hours. Roloff took the mother’s five times during the long labor — on Feb. 27 at 6:30 p.m., on Feb. 28 at 3:20 p.m., and on Feb. 28 at 1:15 p.m., 3:15 p.m. and 9:45 p.m.

• The mother’s diastolic blood pressure at 3:15 p.m. on Feb. 28 “was close to 90, which is considered an abnormal maternal blood pressure reading.”

• During labor, the mother’s temperature exceeded 100 degrees more than once and reached 100.8 at about 4 a.m. on March 1. Roloff’s “failure to timely transfer [her adult patient] to a hospital each time [the patient’s] temperature exceeded 100 degrees Fahrenheit fell below the standard of care for a reasonably competent midwife,” DOH said.

• The failure of the labor to progress in a normal way and Roloff’s failure to transfer mother and baby to a hospital “caused — or was a contributing factor in the occurrence of” the mother’s first seizure.

• Although Roloff carries the anti-seizure drug magnesium sulfate in her birth supplies, she didn’t administer it following the patient’s first seizure. Failure to do so “fell below the standard of care” expected in Washington, DOH said.

• Washington’s standard of care requires midwives to monitor fetal heart tones every 30 minutes during the active phase of labor, and approximately every other contraction. Roloff’s failure to do so “fell below the standard of care,” DOH said.

• Although Roloff went to the hospital with her patient, she didn’t provide the hospital staff with the person’s health records and left, before later returning with them. This “fell below the standard of care,” DOH said.

• Taken together, all these instances of substandard care “resulted in injury … or created an unreasonable risk” to the patient and her baby, DOH concluded.

Legal consequences

There were previous complaints filed with DOH about Roloff, but she hasn’t faced any prior disciplinary measures. DOH considered aggravating factors, including the gravity of the misconduct, the age and vulnerability of the patients and the injury caused.

DOH placed Roloff on probation for at least four years. During this time, she has to take additional course-work on medical charting, assessment of vital signs and labor complications. Her practice has to be supervised by an obstetrician, certified nurse midwife or licensed midwife with at least five years of experience. DOH will conduct one or two unannounced practice reviews and/or record audits per year.

For the first two years of he probation, Roloff’s practice supervisors have to submit quarterly reports on her practice, and Roloff herself must also submit quarterly declarations about her professional activities.

Roloff has to pay all costs of complying with the order and faces a suspension of her midwife license for any violations of DOH’s order.

Doctor licensing

In other healthcare licensing news last year, Ryan Chamberlin, who worked at Ocean Beach Hospital between November 2010 and May 2011, was placed on indefinite suspension as an osteopathic physician and surgeon in Washington.

According to DOH’s Findings of Fact:

“As various times during his employment at the hospital, [Chamberlin] was observed engaging in concerning and problematic behaviors, which included the following:

“A. During his shifts, on multiple occasions, [Chamberlin] appeared to be sweating profusely, had shaky hands, and was red-faced.

“B. [Chamberlin] was often unable to complete his assigned shifts due to excessive fatigue, and could not be located during his assigned shift.

“C. [Chamberlin] appeared to frequently lose his train of thought.

“…During one occasion in December 2010, when [Chamberlin] was on call and responsible for responding to emergent medical issues, he was observed at a social function where he appeared to be intoxicated.

“On at least one occasion between January 2011 and October 2011, [Chamberlin] treated or attempted to treat [a patient] while he was apparently intoxicated.”

The DOH concluded Chamberlin “has committed unprofessional conduct” in violation of state law. He was ordered to obtain evaluation and monitoring by the Washington Physicians Health Program. Before he can resume work, WPHP has to first certify it is safe for him to do so.

Also in 2012, Brandon Adams voluntarily surrendered his physician’s license based on a diagnosis of Parkinson’s disease.

Adams, whose private practice in Long Beach centered on pain management, faced multiple allegations relating to “sexual misconduct and/or boundary violations, and … abandonment of or failure to maintain patient medical recordkeeping while prescribing large doses of pain medications.”

Adams agreed not to resume medical practice in the state of Washington in any capacity.

A third local physician is still in the midst of a DOH licensing proceeding, but details are not being reported here until such time as they are confirmed by an official state order.

Anyone can examine public medical licensing records by searching specific names at www.tinyurl.com/5pvjy2.

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