Editor’s note: some of the events presented in this report may be difficult for some readers to read.
On September 5, 2023, eleven-year-old Jessie Limas died at El Paso Children’s Hospital about eighteen hours after arriving at the facility. El Paso News interviewed Jessie’s mother over the last few days via telephone, text messages and emails. The following events of what happened that day are directly from Jessie’s mother who was present throughout the ordeal. Readers should note that Nancy Limas, the mother of Jessie, is a Texas-licensed Registered Nurse. As such she is educated in the medical field and understands how medical staff perform their work, and how medical procedures are applied.
According to Limas, Jessie Limas arrived at the northeast facility of the University Medical Center of El Paso (UMC) at about 9:00 pm on September 4. Jessie was complaining of abdominal pain of about seven to ten in a medical pain scale. Jessie had “abdominal bloating” and was vomiting, her mother told us. At UMC, a CT scan, IV contrast and blood work were performed. After the procedures, doctors told Limas that Jessie had a volvulus, or “twisted intestine.” The mother was told that Jessie needed emergency surgery and the child was transferred to El Paso Children’s Hospital via an ambulance.
Limas told us that she insisted that the doctors re-evaluate her daughter and consider other options before subjecting her to surgery. The doctors insisted that if left untreated, the volvulus could lead to further complications, including killing her daughter.
At El Paso Children’s Hospital, Limas met with Dr. Sarah Walker, who assured her the surgery was needed and “that everything was going to be well.” Limas wrote that the surgery started at around 1:45 in the morning and waited in the waiting room until around six while her daughter was operated on. Limas added that “only two times” was she given updates about the surgery by a nurse named Dominique Wilson, who told her “everything was going well.”
At around six in the morning, the surgeon, Walker, and surgical resident Simon Yaguare met with the mother and told her that they were finished with the surgery and that Jessie was recovering well. However, Walker told Limas that she could find no signs of volvulus as was diagnosed originally, which is why Jessie was operated on. Walker told Limas that they removed “gastric content” from the stomach that decompressed it. Walker told Limas that Jessie “would recover well,” but “would more than likely remain that week in the hospital to fully recover.”
At about 7:30 in the morning Jessie was transferred to the Pediatric Intensive Care Unit (PICU).
New Nurse And PICU
At the PICU, Jessie was assigned to a new nurse, Diane Mena, who Limas described as “nervous like if she was a new nurse.” Limas confirmed that Mena was a new nurse who had just finished “her orientation.” Limas writes that PICU Nursing Director Kristine Tejeda was the one that confirmed that Mena was a new nurse.
Readers should remember that Nancy Limas is, herself, a registered nurse.
Limas explained that her daughter had a tube that required it to be flushed by the attending nurse at certain times. Limas observed that Mena, the nurse, did not know how to flush the tube and “kept bringing staff in to help her flush” it. Limas added that she was forced to “constantly be pushing” Mena “to attend to my daughter’s needs.”
The doctor assigned to Jessie at the PICU was Dr. Agarawal, who was accompanied by resident Santiago Lozano. Agarawal and Lozano saw Jessie when she arrived but did not return to check on her for the rest of the shift.
As Jessie started to emerge from the anesthesia she began complaining about pain and discomfort around her stomach area. As her daughter continued to emerge from the anesthesia, explains Limas, “she was able to verbalize more of her complaints of pain and discomfort in her” stomach. Limas writes that her daughter was getting worse, and after noting her daughter’s stomach “feeling tight,” she reported it to the nurse and medical resident Lozano. Lozano “palpated my daughter’s abdomen” and “said it was normal and expected from the surgery due to the inflammation.” Lozano told Limas that “what they did not want to see was an increase in the distention/tightness.” He then asked Mena, the nurse, if she had “taken a baseline abdominal circumference” to which she responded no. Lozano ordered that she measure it and continue to monitor it, which Limas writes “was never done.”
Limas wrote that “little by little I saw my daughter get more uncomfortable, restless, and with increasing abdominal pain and distention/tightness.” She kept pushing the call bell to report those signs and symptoms and nothing was done, she explained. Limas also added that no one had notified Walker, the surgeon, about Jessie’s condition.
Limas added that “my daughter started getting agitated and started yelling for help” as “she held my hand tight and pleaded for me to help her,” because “she knew something was not right and something was wrong.” Limas wrote that no one at the children’s hospital would “listen to her or my multiple reports!”
Jessie’s mother wrote that as Jessie’s pain continued to increase and her condition continued to worsen, the staff at the hospital “did nothing but let her deteriorate!!” Limas continues to explain that instead of calling the doctor that operated on Jessie, or bringing in the attending, Agarwal, the charge nurse, Stephanie Espinosa, “deeply sedate[d] my daughter because she was very agitated due to the unbearable pain, discomfort, and pressure she was feeling!!!”
Limas continued that “my daughter never aroused from” the sedation, “despite me trying to arouse her multiple times.” Limas adds that she was “very upset” that they sedated her so deeply, telling medical staff “not to give her any more sedatives.”
Jessie’s Condition Gets Critical
While Jessie was heavily sedated, Limas writes that she “noticed changes in my daughter’s vitals [sic] signs on the monitor,” that “her heart rate was in the 150s,” and her blood pressure “started to trend down all the way to 80/50,” after “being within normal ranges earlier that day.”
Limas wrote that when “I began to notice my daughter was getting pale and noticed a purplish tint in her lips I decided to further check her and when I lifted my daughter’s blanket I noted her legs all mottled (purplish discoloration of skin), blood was coming out her incision” and that “the pillow next to her was full of blood and I even noticed bloody discharge below her perianal area.”
Limas, who was “very scared” at this point, demanded that the resident, Lozano and the two nurses present bring an attending doctor to examine her daughter. Limas writes that Dr. Shahin, who she had not met before responded at “around 4:00” in the afternoon. “The moment he [Shahin] saw my daughter he said she was in ‘shock’” and started ordering immediate medical procedures.
Several medical staff started attending to Jessie with several medical procedures and Walker, the surgeon, was notified. By the time the surgeon arrived, Jessie was already “very deteriorated to the point of hypovolemic shock and abdominal compartment syndrome,” wrote Limas. Hypervolemic shock is severe blood loss that can lead to organ failure.
At around 5:00, in the afternoon, Jessie was taken to an operating room.
Mother Taken To Witness Resuscitation Efforts
When Jessie was taken to the operating room, the mother and the rest of the family went to the waiting room. About 20 minutes later, a hospital employee came to the waiting room and asked Limas to accompany her to the operating room. Limas and her mother followed the individual to the operating room where Jessie was being treated.
The individual, who “seemed very nervous,” kept asking Limas “what happened to your daughter,” as she escorted them to the operating room. The woman could not provide Limas with any details about what was happening to her daughter.
When Limas arrived at the operating room, she wrote that she saw that her daughter had coded. She describes how the medical staff were trying to resuscitate her. Limas goes on to describe the scene she witnessed, going into detail about what she saw. Limas wrote that “a lot of people were standing just watching others running like chickens without heads.”
Limas added that she believes that the doctors “already knew she was not going to make it,” but they just wanted us to see that they supposedly were doing ‘everything’ they could do bring her back.”
Limas continues, that this was “the most traumatizing experience, that the hospital staff “caused to my daughter, my mother, and myself to go through the worst!!” Limas adds that she is “very disappointed with this hospital and all the unethical, unprofessional, incompetent staff involved in my daughter’s ‘care’ that tragic day!”
Limas wrote that after they stopped their resuscitation efforts, the doctors came to talk to her. She wrote that “no one had the guts to look at me in the eyes, not even Dr. Spurbeck who assisted Dr. Walker that day and that I thought very highly-off [sic] as he had performed a surgery on my daughter when she was a toddler.” Limas continued that the doctors “gave me no explanation whatsoever, very unprofessional and inconsiderate.” Limas described that Walker had “her head down and looked very guilty as she approached me.” “The only thing she [Walker] was able to tell me was that my daughter had a ‘hole’ no further details or explanations were given to me.”
Eleven-year-old Jessie Limas arrived at El Paso Children’s Hospital in the early morning of September 5. By six in the evening, Jessie had died. From 7:30 am, to 5:00 pm in the children’ hospital PICU, Jessie deteriorated and although her mother implored the hospital staff to intervene for about nine and a half hours, the children’s medical staff did little to help Jessie, explained her mother, Nancy Limas.
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The trauma for Nancy Limas over the death of her daughter was not over. Limas wrote that El Paso Children’s Hospital did not provide support for the family. Limas added that hospital staff “were rushing us out that day,” as “we were praying and saying bye to my daughter.” Social worker, Adrian Rodriguez, “who is the supervisor told me he was going to speak to his team and get back to me the following day to guide me and help with this situation,” wrote Limas. She added that “I did not hear from him again,” although “he sent me a text days later,” after making multiple calls to him, letting her know that “he was out of the office until the following Tuesday!”
Several hospital officials, like Rodriguez, told Limas that they were there to help and would help her get the answers to the death of her daughter. For example, PICU director Kristine Tejeda told Limas that she would contact her the following day to “setup a meeting with the [hospital] directors” to investigate Jessie’s death, Limas tells us. Limas adds that she has been unable to speak to Tejeda, and others that offered to answer her questions.
Limas also explained that after she was able to get copies of the medical records, she “noted multiple discrepancies and incomplete notes, late entries from the nurse and doctors.” Limas wrote that she was present throughout the whole ordeal and the records, allegedly, contain additional “inaccurate things.” Limas wrote that the El Paso Children’s Hospital officials are “trying to cover up for each other and wash their hands” of the matter.
What The Medical Records Say
Jessie’s mother provided us with copies of Jessie’s medical records for that day. The original diagnosis at UMC Northeast was performed by a resident. This is where the diagnosis for a “twisted intestine” was made, although a supervising doctor confirmed the diagnosis. Jessie’s discharge record states that the “significant finding” in Jessie’s case was “abdominal compartment syndrome with a perforation at site of previous deserosalization that was repaired.”
Abdominal Compartment Syndrome is elevated “pressure in the abdominal cavity,” and is “associated with multiorgan dysfunction.” The failure to address the syndrome “contributes to its high rate of mortality,” according to the National Library of Medicine.
When Jessie arrived at the operating room from the PICU, she was “in extremis,” or at the “point of death.”
The report for the original surgery, performed by Walker, states that when the initial operation was completed on Jessie, there were no complications with the surgery. This is before Jessie was taken to PICU.
Hospital Official Investigation Delays
Nancy Limas, the mother, asked for the children’s hospital to investigate her daughter’s death the day after she passed. According to the medical notes, Medical Examiner Kathy Martinez told hospital officials that Medical Examiner, Mario Rascon, “had decided to release the body.” Hospital officials told Martinez that since the medical examiner “was releasing jurisdiction of the body” back to the children’s hospital that an autopsy would be performed at El Paso Children’s Hospital. This was on September 6. Nancy Limas had requested that an autopsy be performed.
Although Jessie’s funeral was held on September 11, hospital delays have stalled the body at the funeral home. It wasn’t until this past Monday, September 25, that the final paperwork to release her body for cremation was delivered to the funeral home. Limas told us that she made several telephone calls asking for the final paperwork so that her daughter could be laid to rest.
Limas shared with us a September 18 telephone recording between her and Flavia Diaz, the Quality of Life VP at the hospital. Diaz starts the conversation by telling Limas that she only has a “five-minute bathroom break” to speak to her. Diaz goes on to tell Limas that “Dr. Wilson has not completed the final portion of the autopsy” and that “unfortunately she is not at liberty to discuss with her what is discussed in those meetings.” Diaz was referring to the meetings at the hospital where the events leading up to the death are being investigated.
The hospital’s history of lack of transparency is important to note.
Hospital’s Lack Of Transparency
Although Limas has been insisting on an investigation into the death of her daughter at the facility, the Quality of Life point person refuses to provide Limas with an explanation of what is being discussed in the review meetings, telling Limas she must wait for a letter.
Important documents within the hospital about quality of care are not available and when they are available, the El Paso Children’s Hospital asks a judge to remove them from the public view.
Currently there is before the Texas Supreme Court the case of David Saucedo, whose three-year-old daughter also died at the children’s hospital on August 29, 2019. Saucedo is seeking the release to the public docket an affidavit that was part of the malpractice case but was removed by Judge Selena Solis after the lawyers for the children’s hospital and the doctors argued that the document had to be removed from the court docket.
The removal of the document and information on the docket took place over several hearings because the removal of documents from the public docket had not happened before and the judge needed to figure out how to remove certain paragraphs while keeping the complete docket in place.
One of the documents that was removed from the docket in the Saucedo case is the Mayes sworn affidavit. In his affidavit, Thomas Mayes, who is a doctor, explains that it was his job to screen doctors before they are allowed to work at the children’s hospital. Mayes refused to approve Dr. Roberto Canales. Nonetheless, hospital officials circumvented Mayes.
When arguing that the Mayes affidavit be removed from the public record, Diana Faust, an attorney for the defendants argued that the “factual matters” in the removed documents” are “issues that do not belong in the public view.”
El Paso Children’s Hospital officials are not arguing that what Mayes stated in his affidavit is wrong, but rather, that it does “not belong in the public view.”
In the case of Jessie’s death, hospital officials are asking her mother to wait for the final report while telling her that she is not allowed to know what is said in the meetings about her daughter’s death. Falvia Diaz told Limas she “is investigating the different areas…she just cannot discuss” with the mother what she has found.
Jessie’s Mother Wants Justice For Her Daughter
Nancy Limas told us that she witnessed her “daughter progressively deteriorated from 7:30 am to 5 pm in the PICU,” and their attempts to resuscitate her for one hour is “unjustifiable.” She adds:
“Due to all these negligent acts and incompetent decisions my daughter lost her precious life at only 11 years old full of dreams and hopes! El Paso Children’s Hospital needs to be responsible for the wrongful death of my daughter Jessie Limas and I will do anything it takes to get her the justice she deserves!!! I am her voice and that of many children that have lost their innocent lives there!!!”
We asked Nancy Limas what she wants readers to take from her ordeal after reading about it. In an email she wrote:
Nancy Limas asks that El Paso Children’s Hospital should “review their patient safety protocols and implement changes to improve the quality of care they deliver to be able to provide better safe and effective high quality patient care to our children to prevent this from happening again!”
County Commissioners Refuse Oversight Authority
El Paso Children’s Hospital is owned by UMC. Although it is a non-profit, UMC’s Board of Managers have full control of the children’s hospital by controlling board appointments, in addition to having control of the children’s hospital budget. More important is that the UMC Board of Managers has control of who is appointed as the El Paso Children’s Hospital’s Chief Operating Officer (CEO). Although the county commissioners argue that El Paso Children’s Hospital is a separate entity with its own board, the fact remains that the commissioners approve UMC’s budget. The Hospital District, which reports to the county commissioners, is comprised of UMC, the outpatient clinics, the primary care facilities and El Paso Children’s Hospital.
On August 28, the El Paso County Commissioners approved a controversial tax rate that includes a significant pay raise for the commissioners. In addition to approving the controversial 45.9 tax rate, the commissioners also approved a tax rate for UMC that funds the hospital’s operating budget for next year.
Included in UMC’s budget is the expansion of the eighth floor of El Paso Children’s Hospital.
When presenting UMC’s proposed budget to county commissioners for their approval, UMC’s CEO, Jacob Cintron, told them that the proposed budget will be “addressing some of the capacity constraints both UMC and El Paso Children’s Hospital have gone through.”
Because the county commissioners control the budget that UMC uses for El Paso Children’s Hospital means that the county commissioners ultimately have authority over it. Moreover, because the county commissioners use taxpayer funds to fund UMC, it will be taxpayers who will pay for any adverse court findings that exceed the insurance limits. In addition, adverse court findings can lead to the El Paso Children’s Hospital’s loss of accreditation that would stop Medicaid supplemental payments that keep the hospital solvent.
In 2015, El Paso Children’s Hospital declared bankruptcy. It emerged from bankruptcy after UMC forgave some of its debt and absorbed the hospital into the Hospital District.
We sent an email to the county judge and each commissioner on Tuesday asking for comment about the troubling aspects of Jessie Limas’ death and the pending David Saucedo malpractice case. We also included the Mayes affidavit in our request for comment.
Our request to the county commissioners was simple:
“Are you aware of the pending malpractice lawsuits and the latest death of Jessie Limas and the allegations that have been made? If so, do you plan on exercising your oversight authority over UMC to ensure that the taxpayers of the community are protected?”
None of the county commissioners responded to our request for comment.
However, at about 6 in the evening yesterday, we received an email from Laura Gallegos, the Communications Manager for the County of El Paso.
It states: “The County Commissioners Court has no detailed information regarding this matter, and it would be inappropriate to comment on any pending litigation involving separate entities such as Childrens and UMC.”
El Paso News is aware of three recent malpractice lawsuits that have been settled out of court. David Saucedo’s case remains in litigation and has a pending motion before the Texas Supreme Court. Nancy Limas told us she has retained an attorney and is weighing her options, while waiting for the hospital to explain what went wrong. Limas has also filed complaints with oversight agencies.
Author’s note: we spoke to Nancy Limas several times and exchanged several text messages and emails to produce this article. In addition, Limas provided us with voice recordings she took and extensive contemporaneous notes she compiled about the events leading to her daughter’s death. We also reviewed the medical records provided by Limas. Nancy Limas provided much more detail about her and her daughter’s ordeal, but because of the graphic nature of it we did not include all the details in this article.