Special Report: Infant Abductions

Infant abduction yields lessons and warnings for risk managers

Some security measures worked, but woman posed as nurse

(Editor's note: This month's Healthcare Risk Management includes special coverage on the issue of infant abduction. The cover story focuses on lessons learned from a recent incident in Texas. Another article addresses the difficulties of allowing people to wear scrubs in the newborn unit, and we also include a feature on the potential liability from an abduction. Another article discusses an insurance rider that can help in these cases.)

A Texas hospital was recently involved in an infant abduction case that shows some strengths of the typical measures employed on many newborn units, but it also demonstrates the weaknesses that can make babies vulnerable if staff are not vigilant. Risk managers and experts on infant abduction say the case shows what can happen if a facility depends on high-tech security systems to the detriment of vigilance by the staff.

While the infant was not abducted on the hospital premises, the woman accused of kidnapping him apparently was able to pose as a nurse and ingratiate herself with the mother, explains Roy Bassett, a lieutenant with the Lubbock, TX, police department. The mother, Erica Ysasaga, gave birth to the child at University Medical Center in Lubbock in May and soon was visited in her hospital room by 33-year-old Stephanie Lynn Anderson Jones, Bassett says.

Ysasaga reported that Jones was friendly and interested in the newborn. She visited often and took the time to learn about the mother. Jones apparently never tried to take the baby from the newborn unit, Bassett says. He theorizes that she was discouraged by the security systems in place at the hospital, which include monitors on the children that set off alarms if they are taken past checkpoints at the exits.

After becoming friendly with the Ysasaga at the hospital, Jones visited the mother at her home, ostensibly to check on the baby's jaundice, Bassett explains. She took a walk with them, supposedly to get the baby some sun exposure for the jaundice, and when Ysasaga was distracted by her 2-year-old, Jones took the 4-day-old infant and ran, Bassett says. Police tracked Jones down about 36 hours later and charged her with kidnapping. They found the baby abandoned in a car seat under a condominium carport in 104-degree heat.

Scrubs prove key to abduction

Bassett says Ysasaga's report, along with information from the hospital staff, show that Jones was wearing scrubs each time she visited. That fact proved crucial in understanding how the woman was able to abduct the child, he explains. He says the nurses reported noticing Jones in scrubs but did not assume she was a nurse at the hospital or that she was trying to pose as one. Many people from other units of the hospital, or even from unrelated clinics in town, visit in their scrubs, the nurses reported, so they saw no reason to be suspicious.

Ysasaga, however, assumed that Jones was on staff at the hospital because she was wearing scrubs, Bassett says. That made her more receptive to Jones and her efforts to learn more about the mother and child, he says. Ysasaga did not question why Jones wore scrubs of a different color than the other nurses on the unit or why she had no hospital identification.

There was nothing that raised a red flag with the family; they believed Jones was part of the hospital staff, Bassett says. "The hospital staff knew she was not one of theirs; but at the same time, she was not doing anything at the hospital to draw their attention," he explains. "Whether by good planning or sheer dumb luck, she hit it just right so that the baby's family thought she was hospital staff and the hospital staff thought she was just a good friend or family member."

Bassett says police investigators now believe Jones' actions were an intentional effort to make Ysasaga comfortable with her and gain enough information to facilitate the kidnapping at the family's home. "It's safe to say that because of the hospital safeguards, she never really planned to take the baby at the hospital," he says. "I'm convinced that if she had tried to take the baby at the hospital, those security systems would have kicked in, and she would have been caught before she ever got out." A spokesman for the University Medical Center did not return calls from Healthcare Risk Management.

Bassett says Jones is being held on charges of kidnapping and endangering a child.

Case shows strengths, weaknesses

The Texas case highlights both the strengths and weaknesses of the systems typically employed to prevent infant abductions, says Barry Mangels, CPHRM, director of risk management and compliance at Good Samaritan Hospital in Los Angeles. He says the Lubbock incident is typical of many abduction scenarios in the way the woman is thought to have posed as a nurse to gain access to the infant.

Mangels says the Texas facility deserves praise for employing security systems that apparently discouraged the woman from kidnapping the baby at the hospital, and the incident underscores the need to have such systems in place for all newborn units. But at the same time, he says, the incident shows how risk managers must not rely too much on those systems.

"They appeared to have a human breakdown, a fault in how their staff monitored people coming on the unit," he says. "They had someone coming on to this unit in scrubs, looking like she could be a nurse, and no one ever challenged her about why she was wearing the wrong color scrubs and didn't have identification."

Mangels says the staff should have challenged Jones about her identity instead of assuming she was a family member or friend. A good infant abduction prevention system requires that the staff know more about who is visiting than would be the norm in most other units of the hospital, he says.

The problem with scrubs

The scrubs are a particularly difficult issue in this case, Mangels says. Scrubs are so common in hospitals that it is difficult to avoid having people wear them in the newborn unit, but this case shows that they can lead to confusion among family members, he says. At the very least, Mangels says, staff should be aware of this potential confusion and actively inform family members about who is and is not on staff. There is a question about whether the family was educated adequately about the hospital's procedures for keeping infants safe. Mangels points out that it is possible for a hospital's ultra-strict security measures to be thwarted when a family member doesn't understand them.

"One of the important things for obstetrical staff to do is to educate the family about the staff protocol — how the staff will be dressed, what identification to look for, how they will ask for the baby and so forth," Mangels says. "That probably was a breakdown in this situation in Texas."

Human factors still important

While the hospital was fortunate that the abduction did not take place on its property, there still is some potential liability and the negative media attention from having been involved. Mangels says the hospital's defense could hinge on what appears to be effective use of security systems on the unit.

But Mangels also says the Texas case shows that the high-tech measures are not enough. In fact, they can lead staff to let their guard down in some ways, he cautions. Staff should never put so much faith in the security devices that they fail to be alert and challenge unknown people on the newborn unit, he says.

"The electronic security measures, the policies and procedures, those are absolutely essential, and they can be very effective, as this case shows," Mangels says. However, human factors can never be underestimated, he says. "All the security devices in the world are not as good as having staff who are willing to question suspicious people and know who should and should not be on their unit," Mangels says.

Sources

For more information on the Texas infant abduction, contact:

  • Roy Bassett, Lieutenant, Lubbock Police Department, P.O. Box 2000, Lubbock, TX 79457. Telephone: (806) 775-2816.
  • Barry Mangels, CPHRM, Director of Risk Management and Compliance, Good Samaritan Hospital, 1225 Wilshire Blvd., Los Angeles, CA 90017. Telephone: (213) 977-2121. E-mail: bmangels@goodsam.org.