Arizona investigates Willow Birth Center after baby’s death

MESA, Ariz. — The Arizona Department of Health Services has taken some action against a midwife birth center after a family complained to the state about their care. 

The findings came after ADHS conducted an unannounced complaint inspection at the Willow Birth Center in Mesa in February 2025. That happened days after 12News first reported Carson and Daniel Neisess’ story and the family said they filed their complaint. 

Carson Neisess delivered her son, Winston, at the Willow Birth Center in June 2023. He was born pale and not breathing, according to first responders who rushed him to the hospital. 

Winston died four days later. The death certificate said Winston’s cause of death was hypoxic-ischaemic encephalopathy. It’s a brain injury caused by a lack of oxygen. No autopsy was performed. 

The state said they reviewed policy and procedure, medical records and staff interviews. They found Willow, “Failed to ensure fetal heart tones were assed and documented.” According to a care policy, ADHS said fetal heart tones should be checked every 10 to 15 minutes in the second stage of labor, but said the staff at Willow took too long at least five times. 

The Neisess family said they were surprised Winston wasn’t breathing when he was born. 

“I was fully expecting him to be totally fine,” Carson said. “They had reassured us over and over again that this is all normal, and baby looks good, mom looks good. They would go in with the Doppler and they’d be like, heart rate’s great. It was a surprise that things weren’t.” Daniel said. “It turned very quickly, as soon as he was out,” Carson added. “All of a sudden, things aren’t right,” Daniel said.

The state has put a plan of correction in place at the Willow Center. Under the plan, all clinical staff were re-educated on Willow’s Fetal Heart Tone Monitoring Policy. 

ADHS also added a checklist for labors, adding more requirements for documenting care, adding in prompts for timely reminders to check the fetal heartbeat, and mandatory training that was supposed to be completed in March. 

ADHS records also showed weekly chart audits would be conducted for all births, and results would be reviewed monthly, along with continuing education for staff. 

The Neisess family said they’re working to speak with ADHS about the findings. 

Will Humble, a former ADHS Director, gave insight into the findings process. 

“There’s no guarantee that any birth is going to have a good outcome, but the responsibility of the state is to ensure that their licensees are doing everything they possibly can to ensure that maximize the chances of a good outcome,” Humble said. 

ADHS declined an on-camera interview. A spokesperson released a statement which said in part, “When a facility is not in substantial compliance with the rules and regulations, ADHS may take enforcement action on that facility… Once accepted, a Notice of Final Enforcement Action and a request for a Plan of Correction is issued to the licensee. The plan of correction must be accepted by ADHS.”

A Willow Birth Center Spokesperson said they have no comment.

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