Successful kidnapping of baby shows weakness in hospital security systems
High-tech devices fail hospital and child
Loyola University Medical Center in Chicago learned a tragic lesson recently when a woman kidnapped a premature baby from its nursery: Even a host of high-tech electronic devices may not stop someone from simply picking up a baby from the nursery and walking out the door.
The incident was shocking not only because the baby died, but also because the hospital appeared to have taken many sophisticated precautions to avoid such a crime. An elaborate alarm and door-locking system were not enough, says Anthony Barbato, MD, president and chief executive officer of Loyola University Health System and Loyola University Medical Center.
"This is the first incident of this type that Loyola University Medical Center has experienced in over 31 years of serving the community and delivering approximately 38,000 infants," he says. "We are determined that it will never occur again."
Other hospitals may be discouraged to learn that their precautions against baby kidnapping could prove equally ineffective.
Thirteen-day-old Zquan Wakefield was in the nursery at Loyola on May 1, but his mother, 21-year-old Zandra Wakefield of Maywood, IL, had been discharged already. The baby had been born April 18 at only seven months gestation and was still in the hospital because of low birth weight, only 4 lbs.
Cook County Sheriff’s Department officials and Loyola officials provide this account of what happened that day: On May 1 at about 10 p.m., a woman visiting the nursery apparently picked up the child and headed toward an exit. A transmitter on the baby’s wrist bracelet was supposed to activate alarms and "mantrap" doors that would trap the woman between two sets of locked doors. The alarms did sound, but for some reason the mantrap doors did not lock. The woman was able to leave the hospital without being stopped by anyone.
Police target a suspect
Hospital security personnel responded to the alarm and began searching the building, after the nurses’ head count revealed that the baby was missing. After about an hour, when there was no sign of the baby, the security officers called the sheriff’s department to report the kidnapping. Sheriff’s deputies reviewed the security videotapes from the nursery and saw that a woman had left with a coat draped over her arm. They now think the woman hid the baby under her coat.
By checking the list of approved visitors to the nursery, authorities quickly zeroed in on 24-year-old Vanecha Cooper of Chicago. Police say she was approved to visit the baby of a family member in the nursery. When police went to her home at 2 a.m., they took her and her boyfriend in for questioning. Five hours later, police went back to the apartment and searched for the baby. They found the baby under laundry in a hamper, apparently smothered.
Though the police wasted no time in finding the suspect, they have offered no reason they did not search for the child when first visiting the apartment, other than to say that the suspect was cooperative and they had no search warrant. Hospital officials have not said why they waited an hour to contact authorities.
Police say Cooper had told friends she was pregnant, but actually she was not. She has been charged with murder and kidnapping.
For Loyola, the crime was a dramatic revelation that its safety procedures were inadequate. An expert in hospital security says the Loyola incident is the best proof yet that technology is not the solution. Edward Flores, senior director of security at the New York University Medical Center and president of the International Association for Healthcare Security and Safety in Lombard, IL, says high-tech devices to prevent baby kidnapping have proliferated in recent years. But Flores says the incident shows that you have to depend more on an overall plan in the hospital.
"Technology is part of a good system, but it’s not a major part," he says. "Education of parents and staff are more important, and so is having a good plan in place for prevention and response. Electronics is always more of a backup, the same as with any other security in the building."
Flores cautions that it is easy for hospitals to rely too heavily on door sensors and transmitters on the baby, or other systems such as the doors that were supposed to lock the kidnapper in the Loyola nursery. All of those can be worthwhile, but if they fail, a baby can be lost.
"Never rely on just one thing," he says. "This crime can happen anywhere, no matter how much electronics and security you have, so you have to approach it with a well-rounded plan. Losing a baby like this is a black eye that is very, very hard to take care of, whether you are at fault or not, so you have to try to prevent it."
As for the door-locking system that failed at Loyola, Flores says such systems can be effective. "[A door-locking system is] not a bad idea, but the system has to be tested and it has to work," he says. "And you still have the question of what is that person going to do to the baby while they’re trapped in there, knowing they’ve been caught? I’d be happier with a system that just prevents the person from going through the first set of doors."
(See p. 77 for advice on how to structure a plan to prevent and respond to baby kidnappings.)
Hospital hit quickly with HCFA rebuke
The Health Care Financing Administration quickly issued a statement of deficiencies in response to the crime, requiring the hospital to explain how it plans to improve. The incident also qualifies as a sentinel event with the Joint Commission on Accreditation of Healthcare Organizations, so the hospital will have to conduct a root-cause analysis and report to that organization as well. Loyola already has provided a plan of correction to HCFA. (See p. 77 for a summary of the plan.)
"Loyola University Medical Center and all of its physicians, nurses, administrators and staff take extremely seriously the tragic incident which occurred on May 1, 2000," Barbato wrote to HCFA when submitting the plan. "Since May 1, 2000, I have convened a series of policy and procedure reviews with the nursing and security and administrative leadership from the hospital to be sure that our policies reflect everything we have learned from this incident. All revised policies are attached for your reference. We have also conducted joint in-service training for all Newborn Nursery/Maternity Unit/Labor and Delivery nursing personnel and all security personnel in these new policies and procedures."
Profile of the suspect
Barbato’s letter says the hospital’s internal review of the incident revealed the following circumstances:
• "The person now accused of the abduction was attending to her family member in the nursery. This individual was an adult family member approved to participate in the care of another infant in the nursery by that infant’s 14-year-old mother. Our records confirm that these visits were authorized in accordance with previous hospital policy. At least one Registered Nurse was in the nursery during her visits. All of our nurses are oriented to infant safety issues, including the conduct of visitors in the nursery. The suspect was never observed violating any of the policies of the nursery, including the restriction that she could only have contact with her relative.
• "Nothing she did on May 1, or on the prior occasions in which she was in the nursery caring for her nephew, caused any staff member to be suspicious of her activities. She left the nursery on May 1 in apparently normal fashion. Nothing alerted the staff to a possible abduction until the alarm was triggered by the wrist transponder bracelet.
• "Unfortunately, while the infant alarm sounded, the mantrap doors outside the unit that were designed to close and lock with the triggering of the alarm failed to do so. That allowed the suspect to leave the building before the security officers could detain her. These doors were working properly on April 22, 2000, and worked properly during prior occasions when they were inadvertently activated, e.g., if a staff member had a sensor bracelet in his/her pocket and walked between the sensor panels.
• "Immediately following this incident, the unit alarm and mantrap door-locking system were completely checked. We believe that the door-locking system failed because of a wiring problem. It is now tested daily and we are maintaining records of those tests."
In addition to correcting the wiring problem, Barbato says the hospital added an override button to provide a backup for the mechanism that closes and locks the alarm-activated security doors. The hospital also posted security personnel to ensure 24-hour, seven-day-a-week security coverage for the nursery.
System required visitors to have permission
Trisha Cassidy, senior vice president for system development and strategy with the Loyola University Health System, says the system already in place on May 1 was considered a sophisticated deterrent to kidnapping. When visitors come to the unit to visit a baby, they walk down a hallway and stand behind a yellow line so they can be seen through locked glass doors by the receptionist, who sits in a reception area outside the locked nursery, she says.
If the receptionist allows visitors to enter the reception area, they must sign in. Visitors will be allowed further into the unit only if a baby’s parent has given them approved access. The receptionist then will allow them to pass through another set of locked doors. At this point, visitors still will be outside of the secure nursery area. The only way to gain entry to the nursery is for the nurse in the unit to unlock and open the door.
Loyola has a wristband alarm system for the newborns. Each baby admitted to the nursery receives a band, which contains an electronic sensor. That sensor works in conjunction with other devices just outside the entryway to the reception area and will cause an alarm to sound if the bracelet passes between the sensor plates located in the hallway walls. The system is designed to close security doors at the far end of the hallway and lock those doors electromagnetically. Simultaneously, an alarm sounds in the Security Command Center, and security officers are dispatched to the nursery and to the primary hospital exits.
"When the alarm sounded, the nursing staff began a physical count of the infants, some of whom were rooming-in’ with their mothers," Cassidy says. "Although the initial count did not reveal a missing infant, this count was immediately repeated, and our staff determined that an infant was missing."
Loyola reports that it was contacted within days by attorneys representing both the mother and the father of the infant. Information from the National Center for Missing and Exploited Children (NCMEC), which closely monitors infant abductions from health care facilities, indicates that the previous success of prevention efforts has increased the risk for hospitals that fail to enact them successfully.
The hospital is more likely to be sued in cases where the abductor impersonated a hospital employee than in those cases in which the abductor used another method to obtain the child, the NCMEC reports. Lawsuits became more common in the 1990s, it says.
Infant abductions rank as one of those problems that is not statistically likely to hit your facility, but the enormity of the tragedy makes it necessary to prepare for the possibility nonetheless. The best estimate for the frequency of infant abductions by nonfamily members comes from the NCMEC, which says 12 to 18 infants are abducted from hospitals each year. If you add abductions by family members, which usually occur when they hear the child will be turned over to child protective services, the number rises.
The NCMEC reports that 88 infants were abducted from hospitals between 1983 and 1995. Five of the infants were never recovered. The International Association for Healthcare Security and Safety, the professional group for hospital security directors, reports a slightly higher number of infant abductions that includes the last few years — 94 abductions from health care facilities since 1983. Last year was the first since 1983 without a baby kidnapped from a hospital.
Infants can be abducted from any hospital or birthing facility, according to NCMEC data. Eight percent of the abductions have occurred in facilities with no more than 200 beds, 45% in facilities with between 201 and 400 beds, 21% in facilities with 401 to 600 beds, and 26% in facilities with more than 600 beds. Fortunately, 94% of the babies were located and safely returned within a few days to two weeks of the abduction.
Fifty-seven percent of the infants were taken from the mother’s room, 15% from the nursery, 17% from the pediatric area, and 11% were taken while outside the hospital but still on hospital property.