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Baby mix-up raises questions about care


baby from A1


potential for harm to infants is minimal, federal authorities say the possible exposure to HIV or other infectious diseases should be treated just like an accidental exposure to other body fluids. The incidents also point to a


larger problem of accurate pa- tient identification — a major cause of health-care errors. That is a particular risk with new- borns, and experts say sleep-de- prived mothers are sometimes confused: It can be hard to recog- nize a swaddled infant brought by the nursing staff for feeding in the middle of the night. For the past few months, the Libbys say, they have asked hospi- tal officials to put in writing the verbal assurances they were giv- en. They want a list of tests and results, including a toxicology screening, that were performed on the woman who breast-fed their baby. The hospital has not provided them. Last month, the hospital’s risk-


management officer, Susan Rich- ardson, sent a lawyer hired by the Libbys a two-sentence letter that expressed regret and said: “Please know that after looking into the matter the Virginia Hos- pital Center has no knowledge of anything indicating that the woman who breast-fed Spencer Libby on Jan. 31, 2010, exposed him to any disease, toxin or other harmful substance.” In response to a reporter’s in-


quiry, Virginia Hospital Center said in a statement July 14 that one employee was fired after she “failed to follow standard proto- col.” The hospital also said that it had “conducted comprehensive laboratory tests and has no knowledge of anything indicating that the woman who mistakenly breast-fed the infant exposed the infant to any harm” and that it had “taken the necessary steps to ensure that this situation does not happen again.” Hospital officials declined to


elaborate, citing patient confi- dentiality. The Libbys are looking into le- gal options. “It was the worst moment of


my entire life,” Libby said, when she realized her son was missing and nurses didn’t know where he was. “On top of that, to find that another mother breast-fed him, without my knowledge, without my consent, was horrid. . . . He was exposed to someone else’s body fluid.” Her concern is that the mistake not be repeated, she said.


Identity checks Hospitals use information on a


newborn’s and mother’s ID bands to try to prevent such errors. Se- curity has increased since two baby girls in Virginia were dis- covered 15 years ago to have been switched at birth. Many hospi- tals, including several in the Washington area, say mothers are asked to say their name and


their baby’s name as an addition- al check before nurses hand over a baby. In profitable services such as labor and delivery, hospitals of- ten boast about security in their marketing materials. That was one reason the Libbys said they chose Virginia Hospital Center, a 334-bed community hospital that had 3,800 births last year. The hospital’s Web site prom- ised vigilant monitoring, saying that only nurses, doctors, the mother or someone she desig- nates are allowed to take a baby out of the mother’s room, the nursery or the neonatal intensive care unit. The employee who moved Spencer from the nursery was a patient-care assistant, the Libbys said. After being contacted by The


Washington Post, a hospital spokeswoman said the Web site information was incorrect, and it was changed to say that properly trained patient-care assistants can move infants. States typically don’t require hospitals to report breast-feeding mix-ups unless a patient is harmed. But the Virginia Depart- ment of Health is investigating the Virginia Hospital Center in- cident after receiving a com- plaint, said Chris Durrer, who oversees hospital licensure and certification. The Libbys said they filed the complaint.


‘You just got lucky’ At Sibley Memorial Hospital in


Northwest Washington, what hospital officials described as a “near miss” with a breast-feeding mother occurred last year, but the woman and a nurse realized the mistake before the infant ingest- ed breast milk. In addition to ver- ifying ID bands, hospital employ- ees transport only one crib at a time, a Sibley spokeswoman said. In April 2005, a newborn was put in the wrong bassinet by Georgetown University Hospital staff and was taken to the wrong woman, but the baby refused to feed, said the mother, who did not want to be identified. A hos- pital spokeswoman said that she couldn’t comment on specific cases but that employees are “continually trained and re- trained” on patient identifica- tion. Officials at Washington Hospi- tal Center, George Washington University Hospital, Shady Grove Adventist Hospital and Washing- ton Adventist Hospital said they were not aware of such incidents. Two systems that handle a high volume of births would not say whether they’ve had breast-feed- ing mix-ups: the Inova hospitals in Northern Virginia, which had 21,000 births last year, and Holy Cross Hospital in Silver Spring, which reported 9,000 births, the most in Maryland.


At least six other errors have


occurred at hospitals in Illinois, Massachusetts, New Hampshire and New York. There were no re- ports of physical harm to the


COURTESY OF LIBBY FAMILY


At left, Reed Libby cuddles his son, Spencer, who was born Jan. 30 at Virginia Hospital Center, above. The Libbys were told that a woman who breast-fed Spencer did not have HIV or hepatitis B or C, diseases that can be passed through breast milk.


on washingtonpost.com Anxiety at hospital


Go online to see more photos of the Libby family.


because he arrived a week early, his hospital wristbands called him “Libby Bb,” for “Libby baby boy.” Nurses put a blue knit cap on his head soon after he was born.


Libby knew she wanted to nurse as soon as possible. She breast-fed him two hours after the birth and several more times, recording the feedings on a clip- board hanging from his bassinet. The baby stayed in her room. By 4 the next afternoon, Libby


SARAH L. VOISIN/THE WASHINGTON POST


newborns. At least three cases in- volved nurse’s aides, according to media reports and documents. After a mix-up in 2003 at South Shore Hospital in Weymouth, Mass., the facility added a chime to ID bands so they ring when a baby is brought to the correct mother, a spokeswoman said. Lawrence, the breast-feeding


expert, played down the possible harm to infants, citing the use of wet nurses in many cultures. But others disagree. “HIV can be found in breast milk, as well as many drugs,” said Paul Hain, as- sociate chief of staff at Monroe Carell Jr. Children’s Hospital in


Nashville. The larger issue concerns er- rors in identifying patients, he said. In an initial audit, Hain found that 20 percent of his hos- pital’s patients had wristband ID errors, including illegible and in- accurate data. Such errors could result in the wrong treatment. In the Libbys’ case, he said, “you just got lucky.”


A moment of panic Suzanne Libby gave birth to a


healthy 7-pound, 3-ounce boy at 8:40 p.m. on Saturday, Jan. 30. Everyone remarked on his full head of dark hair. Not yet named


was exhausted. She and her hus- band decided that Spencer, who had been named that morning, could go to the nursery so she could rest. Reed couldn’t find their assigned nurse. But the pa- tient-care aide who had been as- sisting them offered to help. Reed asked her to take Spencer to the nursery, and then he went home. About two hours later, Libby went to the nursery to check on Spencer. Right away, she noticed something was wrong. Of the three babies there, only one had lots of dark hair. But he didn’t look like Spencer. A white hat was in the bassinet, not a blue one. She asked whether someone had changed Spencer’s hat. “No” was the reply. Libby panicked. “There’s no baby in there with a blue hat,” she remembered telling the nurses. As staff scrambled, someone yelled for the aide. Heart racing, Libby headed down the hall. All of a sudden, she saw Spencer, in his bassinet, wearing his blue hat, in another woman’s room. She overheard the aide saying “Libby, Libby” in a


confused manner, and an older woman say, “But he looks just like our baby.”


Libby became hysterical. “I’m thinking, ‘Oh, my God,


that’s my baby in there.’ I start screaming, ‘She has my baby, she has my baby.’ And I’m shaking and I’m crying.” She returned to her room, and someone brought Spencer back. She called her husband, who rushed back to the hospital. At 6:30 p.m., Libby tried to feed Spencer, but he wouldn’t eat. That’s when she noticed the feed- ing log had an entry of 5:43 p.m., in someone else’s handwriting. At 8 p.m., the hospital’s associate di- rector of patient relations con- firmed what Libby suspected: “Your baby was breast-fed by an- other woman,” Libby recalled her saying. Libby, a lawyer who works for a


government agency, said she started taking notes to keep track of what was happening. She still struggles to put into words how the incident has af- fected her. After watching a recent epi- sode of the TV series “The Office” in which Jim mistakenly hands the wrong baby to his wife, Pam, for nursing, Libby said the differ- ence was that it wasn’t “my goofy sitcom husband” who made the mistake: “It was the hospital staff who took my baby out of the nursery and gave it to someone else.”


She continued: “I know it


wasn’t my fault, but I feel like the first 24 hours of my baby’s life, I failed to protect him,” she said. “There was a period of time where I don’t know whose care he was in. . . . And every time I think about his birth, this is what I think about.”


sunl@washpost.com


Research editor Alice Crites contributed to this report.


ATF, police raids led to break in slayings of mother, daughter in Pr. George’s killings from A1


ble for a 2008 killing in which a Bowie woman was shot before her home was set ablaze and for other crimes as far away as Texas and Florida, police officials said. So far, Scott is charged only in


the Dewitt slayings. “Clearly, this was a gruesome double murder that really shocked the commu- nity,” said Prince George’s State’s Attorney Glenn Ivey. “I hope that this indictment will help bring some sense of calm to the com- munity.” Ivey declined to say whether


Scott would face charges in any other killings, citing ethics rules that prohibit him from talking about ongoing investigations. But Prince George’s Police


Chief Roberto Hylton did not back away from his characteriza- tion of Scott as a ruthless and de- ceptive serial killer. “This person was just a natu-


ral, hard-core criminal that just preyed on this community,” Hyl- ton said after the indictment. Hylton said investigators had been contacted by “a number of other police departments” won- dering whether Scott might be responsible for more killings. He declined to name those depart- ments, noting that investigators had to “compare notes” to see whether the cases are connected. He said his own investigators think that Scott might be respon- sible for “one or two” more slay- ings in Prince George’s as well. In almost every way possible,


law enforcement officials say, Scott was the worst kind of crimi- nal. Besides living under their ra- dar, he was computer savvy, re-


going guy” of “reasonable intelli- gence.” “That he would commit a crime of any nature, for me I don’t see it,” he said. “But I’ve been fooled.” Neighbors said they knew


PRINCE GEORGE’S STATE’S ATTORNEY’S OFFICE


Jason Scott read up on how evidence is collected so he could cover his trail, sources say.


ceiving a bachelor’s degree in in- formation systems management from the University of Maryland University College and using his access to a database at UPS, where he worked for nine years, to track his victims, law enforce- ment sources say. He also was crafty, reading up on evidence collection so he could learn how to clean his crime scenes, the sources say.


And he was depraved, they said, targeting complete stran- gers.


Peeping accusation Kobie Flowers, Scott’s attorney


on previously existing charges, declined to comment. No one re- turned a phone message or re- sponded to multiple handwritten notes seeking comment that were left at Scott’s family home. Richard Arnold, another law- yer who represented Scott in pre- vious cases, said Scott struck him as a “very mild-mannered, easy-


Scott as a pariah but never pegged him as a killer. One said that in 1997, she twice caught Scott peeping through her teen- age daughter’s window. One of those times, she called police but was told that no charges could be filed because she could not “posi- tively identify” Scott. She said she told her daughter to spread word of the incidents through the schools she and Scott attend- ed (first Kettering Middle School, then Largo High School) in hopes that it might deter him. It apparently did, she said, adding that it was a “total shock” to learn that police believe Scott is a killer. Law enforcement sources said


Scott read Internet articles and books on how evidence is gath- ered so he could learn to scrub his crime scenes and changed his methods to throw police off his trail. An FBI profiler had even concluded that the two mother- daughter killings were unrelated. The sources spoke on the condi- tion of anonymity because the in- vestigation is continuing. But Scott was a prolific crimi- nal, court records show. And as is usually the case with prolific criminals, they don’t stay under the radar for long. He has no criminal convictions on his adult record, but since his first arrest in 2009, police have charged him with several crimes dating to 2007.


In June 2009, according to fed-


eral court records, Scott drew the attention of the Bureau of Alco- hol, Tobacco, Firearms and Ex- plosives when a confidential in- formant told agents that a UPS employee named Jason and an- other man named Marcus were selling stolen guns in the Land- over area. Already investigating a burglary at a gun shop in Wood- bine, the ATF now had suspects. For $1,000, the informant agreed to cooperate with ATF agents by trying to buy guns from Jason and Marcus. Author- ities had identified the pair as Scott and Marcus D. Hunter, 24, court records show. Later that month, the undercover operation came to fruition. For $3,000, the informant bought four guns from Scott. Three had been sto- len from the gun shop in Wood- bine, court records show.


The big break On July 1, 2009, the agents


raided Scott’s family home, court records show. A dozen guns were taken out of the house that day, along with a bulletproof vest, a police scanner and a silencer, the records say. Agents also found what appeared to be a burglar’s kit — a crowbar, Gerber tool gloves and a ski cap — and some of his loot, including computer equipment and a set of BMW car keys, court records show. They contacted Prince George’s police. That, police now say, was their big break in the mother-daugh- ter slayings. Prince George’s police searched Scott’s house again and found evidence connecting him to several break-ins in the area.


Court records say a stolen hand- gun connected him to a Decem- ber 2007 burglary on Albert Drive in Mitchellville. A com- puter tower connected him to a June 2008 burglary on West Branch Drive in the Kettering area. An Xbox and two spare keys to a BMW connected him to a burglary on Dunwood Valley Drive in Bowie in May 2009. Computer equipment connected him to another burglary that month on Aventine Lane. Two camera lenses connected him to a theft from a fire investigator’s car in May 2009. He was charged in each of those cases, but the charges were dropped in favor of federal charges in a separate case. Hunter told police that he and


Scott were also involved in two home invasions: one on March 14, 2009, on Pickering Circle in Largo, the other Oct. 4, 2008, on Medinah Ridge Road in Acco- keek, court records show. In the October home invasion, the two were forced to run when the homeowner wrestled one of their guns away; in the March home invasion, they made off in a woman’s 2002 Cadillac SLS, the records show.


But perhaps the most telling item was a computer flash drive containing pictures of a naked, young-looking female with a pil- lowcase over her head and a but- terfly tattoo on her left hand, court records show. That young woman had returned to her Fort Washington home with her mother on June 13, 2009, to find a man holding her younger sister at gunpoint, the records show. The man ordered her into a sep-


arate bedroom, made her strip, took nude photos of her and sex- ually assaulted her, the records show. Police now think the man was Scott, and he was charged in that incident. It is unclear whether the raids


in July produced any evidence to link Scott directly to the Dewitt or Lofton killings. Police have said the ATF search was a break in the case, although they have declined to discuss the evidence they have. Sources said the evi- dence is largely circumstantial and relies heavily on computer forensics and Scott’s access to a UPS database with names and addresses. Hylton previously said the evi- dence is “overwhelming” and places Scott at the “crime scene.” He said Tuesday that experts in anthropology and botany from the University of Maryland assis- ted with a sweeping investiga- tion. “While I don’t want to glorify his intellectual capacity, I will tell you he is a challenge to us,” Hylton said. Scott was arrested after the


July 1 raid. Police have subse- quently dropped and added vari- ous charges to keep him behind bars while they investigate the slayings. Court records show that he has given statements to au- thorities at least three times. At the time of Tuesday’s indictment, he was being held on federal car- jacking, weapons and sex charg- es, court records state. zapotoskym@washpost.com


Staff researcher Meg Smith and staff writer Maria Glod contributed to this report.


WEDNESDAY, JULY 28, 2010


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