Fresno-area hospital fined for ‘avoidable death’ of mom six days after childbirth
Two hospitals that are part of the Central Valley’s largest healthcare provider were forced to pay nearly $200,000 in 2025 for penalties related to patient harm and death.
Clovis Community Medical Center was fined $100,000 on Feb. 24, 2025 for an “immediate jeopardy” related to the “avoidable death” of a mother one week after giving birth in 2022.
That same month, Community Regional Medical Center was fined $90,000 for an “immediate jeopardy” when staff wrongfully removing a Fallopian tube from a patient after a cesarean section birth, according to state records.
The U.S. Centers for Medicare & Medicaid Services define immediate jeopardy as noncompliance that “has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.” It is the most serious type of deficiency or violation. In California, citations for these violations can result in administrative fines between $25,000 to $125,000.
At least three other Fresno area healthcare facilities were also cited with seven immediate jeopardy penalties in 2025.
The penalty was the result of the death of a 26-year-old female patient at Clovis Community on Dec. 7, 2022, from a blood clot in her lungs six days after being discharged home after giving birth to a child, according to a California Department of Public Health investigation.
The hospital failed to identify the patient, based on her medical history, as at-risk for deep vein thrombosis before discharging her, the report concluded. DVT is a condition in which blood clots form in one or more deep veins in the body, usually the legs.
Discharging her home without ruling out the possibility of DVT may have contributed to the patient’s “avoidable death” six days after discharge, investigators concluded.
“We approach every unanticipated patient care outcome with deep concern for the patient and their family and certainly with a focus on learning,” Thomas Utecht, M.D., Senior Vice President and Chief Medical Officer for Community Health System said in a statement.
“Following this 2022 incident, we completed a comprehensive review, strengthened safety protocols and training, and shared those actions with CDPH,” he said. “Upon a follow-up inspection by CDPH, Clovis Community was found to be in full regulatory compliance.”
Numbness and weakness in leg post-delivery
The patient Clovis Community’s emergency department on Nov. 22, 2022 for a labor check at 38 weeks pregnant and delivered two days later.
According to a state inspection report, the patient was at risk for developing DVT due to her medical history, which included elevated blood sugar, hypertension (high blood pressure) and a Body Mass Index of 61; anything over 40 is considered “dangerously overweight” and puts a person at risk for severe heart disease and diabetes.
Following delivery, the patient experienced weakness and numbness in her right leg but was discharged home without ruling out the possibility of a DVT.
While at home, the patient continued to have numbness and weakness, according to a March 24, 2023, interview with the patient’s mother and another family member. She had the occasional pain in her right leg, but could wiggle her right toes. However, she was unable to lift her leg, which the family member described as “dead weight.”
The family member told state investigators that “the hospital did not tell (the patient) the cause of her right leg numbness and weakness.”
The patient then returned to the emergency department on Dec. 7 around 6 p.m. after experiencing calf pain and upper leg pain. She died within the hour as a result of cardiac arrest following a pulmonary embolism, a blood clot that blocks the vessels that send blood to the lungs.
In an interview with state investigators on March 23, 2023, an OB-GYN doctor that discharged the patient home said there was a concern that the numbness and weakness in her leg were due to the epidural anesthesia provided during childbirth.
However, the doctor didn’t order a doppler ultrasound to rule out DVT because the patient didn’t have other common symptoms associated with DVT, such as redness, swelling, tenderness and warmth. It’s not uncommon for patients to have delayed numbness after epidural anesthesia, and sometimes the position during delivery can cause nerve pain, he said.
Thre other OBGYNs interviewed by the state, including the Chief of OBGYN, agreed that the patient didn’t have the usual signs of DVT, such as pain and swelling, according to the report. One OBGYN concluded it was possible to have DVT without these signs and symptoms.
“Looking back, we could have done a doppler ultrasound to [the patient’s] leg to determine if she had DVT and administered enoxaparnin,” the generic medicine to prevent blood clots, the OBGYN chief said.
The state report concluded the hospital’s failture to recognize the patient was at risk of DVT,
This story was originally published January 12, 2026 at 11:52 AM with the headline "Fresno-area hospital fined for ‘avoidable death’ of mom six days after childbirth."
