HENRICO COUNTY, Va. — Matt Whitfield’s wife nearly died when she unexpectedly gave birth nine weeks early on October 29, 2024, at Henrico Doctors’ Hospital (HDH).
“There was a point in time where I thought I lost her and my daughter,” Whitfield recalled about that difficult time.
He had to split his time between his wife, who was recovering, and his daughter, who was in the Neonatal Intensive Care Unit (NICU) at the hospital. He said he implicitly trusted the staff at the NICU.
“We thought it was one of the best in the area, if not the state, and thought there was no safer place for our baby and my wife,” Whitfield said.
But, according to two new reports from the state, the hospital failed to implement actions to prevent abuse or to protect patients from abuse and neglect.
Read reports: State Licensure Complaint Inspection||Plan of Correction
Investigation Findings
The reports detail the results of an investigation that was launched after the Virginia Department of Health (VDH) learned that multiple babies had suffered broken bones in the NICU at HDH late last year.
The VDH Office of Licensure and Certification probe began this past December.
The day after Christmas, CBS 6 was first to report that the hospital had posted an alert on its website stating that NICU admissions were being paused and that safety measures were being updated due to “unexplainable fractures" in a number of infants.
Since that time, a nurse named Erin Strotman has been arrested and charged with multiple crimes against five premature babies, including abuse and malicious wounding.
Watch: Nurse accused of abusing premature babies at Henrico hospital
Whitfield said Strotman was the most consistent nurse tending to his baby during the first two weeks of her life.
“She was great,” he said. “Never would have thought it was Erin.”
Administrative Consequences
The state investigation confirms previous CBS 6 reporting that Strotman, referred to in the report as EMP11, was placed on administrative leave on September 10, 2023, because she was identified as having cared for four babies who had “unexplained fractures” in 2023.
CPS identified a second nurse as having contact with all four of the babies in 2023 as well, and they were placed on administrative leave on October 5 of that year.
The 2023 babies’ injuries were identified between August 5 and September 5 of that year but were not reported to Child Protective Services until September 20.
When the state investigator asked why CPS was not alerted within 24 hours about suspected abuse, which is required by law, another hospital employee “indicated that the facility conducted their own initial investigation and then determined the facility would report the possibility of abuse,” according to the report.
At that time, the hospital agreed to implement certain safety measures to ensure more babies would not be injured. They installed security cameras in NICU rooms and implemented daily head-to-toe assessments of all patients to look for any suspected signs of abuse.
Whitfield said it was actually Strotman who told him about the cameras.
“It was presented to us as a privilege to have this camera,” Whitfield said.
“You just thought the camera was a privilege to you to have the ability to watch your baby when you were not at the hospital?” CBS 6 investigative reporter Melissa Hipolit asked.
"That’s right. They never told us these cameras were there for security purposes or as part of a protocol to protect babies from what happened in 2023,” Whitfield replied.
Lack of Oversight
According to the latest VDH reports, inspectors found HDH did not review video from the cameras to audit or perform observations of care. Instead, they only reviewed the video to look at “hand hygiene” or if there was a complaint.
“Do you think that should have been in place from the beginning to have some sort of random review of footage?” Hipolit asked Whitfield.
“I think it would have been helpful for the hospital to be reviewing the footage of at least Erin if they knew that she was potentially a suspect for what happened in 2023. I don’t know why there wasn’t more oversight of her work,” Whitfield replied.
Inadequate Assessments
On top of that, another employee said the daily physician head-to-toe assessments that were implemented after 2023 were not routinely completed after late July or August 2024, and there was no evidence that discontinuing this intervention was discussed or approved by the Medical Executive Committee or the Board of Trustees.
Strotman and the other nurse were allowed to return to the NICU on September 17, 2024, after the CPS investigation found that abuse had taken place, but the abuser could not be identified.
The report states that upon returning to work, Strotman had to complete abuse and neglect training, safe handling, and heel stick education with the nurse educator and work alongside a supervisor called a preceptor. The other nurse did not have to conduct a preceptorship.
During an interview, another hospital employee told the state investigator that after three days with the preceptor, the hospital had “no concerns” with Strotman’s care.
“There were no stipulations, restrictions, or conditions for the nurses to return to work; they just had to complete the education. There was no documented plan in place to ensure and monitor the nurses’ provision of safe care upon returning to work at the facility in September and October 2024,” one HDH employee told state investigators.
Serious Concerns Raised
“It is shocking to me that the hospital didn’t do more, that they let her come back, that they let this happen again. I don’t know how this happens twice,” Whitfield said.
Less than two months later, on November 10, surveillance video showed Strotman holding one of the babies without supporting the head and neck and also quickly twisting the infant’s head with one hand while the infant was lying on their back.
That same video showed Strotman “forcefully pushing the infant’s legs toward the abdomen, with the feet almost touching the infant’s face."
Three days later, according to the report, video captured Strotman “forcefully inserting a suction catheter into the baby’s nostril” and inserting it deeply.
Another employee told the investigator it was “the incorrect type of suction device for the nose.”
Watch: NICU nurse charged with crimes tried to watch their baby: 'We dodged a monster'
A staff member at the hospital who viewed the videos said, “We don’t know why she is doing anything she is doing.”
Somebody else who reviewed the videos said, "You can tell the baby is not tolerating that well when the nurse is holding the baby’s legs into the baby’s stomach,” because their heart rate and oxygen saturation were out of the normal range.
The state was unable to interview any of the NICU doctors because an attorney representing them refused to permit an interview.
Ultimately, the state investigation found that the hospital failed to prevent child abuse for seven NICU patients, although, as we have previously reported, Strotman is currently only charged with crimes against five children.
Official Response
While there is no evidence to suggest Whitfield’s baby was ever harmed, Whitfield said he is still haunted by what he described as a lack of communication from Henrico Doctors’ Hospital about what happened.
“We were in the NICU, we had her as a nurse; at any time, they could have told us what was going on, and they never did,” Whitfield said.
VDH spokeswoman Maria Reppas said the agency will conduct a site revisit to determine if Henrico Doctors’ Hospital is continuing to comply with a Plan of Correction they submitted after the state inspection.
In its Plan of Correction, the hospital said it has educated staff about the safe handling of babies, is now frequently reviewing video footage, and conducting daily physical exams to look for potential injuries.
We requested a response from HCA, which owns Henrico Doctors’ Hospital, to the reports.
Wes Hester, the Director of Media Relations for HCA, said “I want to clarify that our standard of care has always included a daily physical examination of our NICU babies by neonatologists."
“The CMS report identified some areas that did not meet the standard of care that we expect and that our patients deserve. We worked diligently to address the findings, and CMS has accepted our action plan.
We have been closely collaborating with regulators to further improve our NICU by increasing our training, implementing new security measures, and changing our reporting protocols.
We appreciate the regulators’ commitment to safety and the dedication of our colleagues who have helped our hospital care for our community for more than 50 years.”
Here is the full statement Reppas sent us from VDH:
“Today, the Virginia Department of Health’s (VDH) Office of Licensure and Certification (OLC) released two corrective action plans for Henrico Doctors’ Hospital (HCA) neonatal intensive care unit (NICU): a federal survey VDH completed on behalf of the Centers for Medicare and Medicaid Services (CMS) and a state licensure survey.
VDH’s OLC launched an investigation into the HDH NICU immediately after learning of fractures in two babies that occurred in November and December 2024. Since launching the investigation, OLC performed several on-site inspections and has been actively engaged in monitoring HDH’s plan of correction resulting from the investigation. In December 2024, VDH and HDH entered into a Consent Agreement that placed the provider’s license to operate as a Virginia hospital on conditional approval to operate subspecialty nursery level services. This Consent Agreement required the facility to follow the plan of correction which included the suspension of admissions into the NICU and instituting further safety controls until OLC was confident in the ability of the hospital to keep babies safe. Under conditional approval to operate subspecialty nursery level services, HDH NICU reopened to admissions on February 5, 2025.
VDH remains committed to ensuring that HDH is compliant with all federal and state regulatory requirements. VDH will maintain the Consent Agreement with conditional approval of its hospital license and will conduct a site revisit to determine if HDH is continuing to comply with the Plan of Correction and state and federal regulations.
The health, safety, and well-being of mothers and newborns remain a top priority for VDH, especially as they are some of Virginia’s most vulnerable populations. The public can be assured that VDH takes these incidents very seriously, and we are doing everything in our regulatory power to ensure quality of care and safety.”
This is a developing story. Email the CBS 6 Newsroom if you have additional information to share.
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