Arizona family responds to Mesa birth center investigation

PHOENIX — A Valley family shared their reaction to a state investigation into a Mesa birth center. Daniel and Carson Neisess complained to the Arizona Department of Health Services after their newborn son died, following his traumatic delivery. 

The Neisess family filed their complaint about their labor and delivery care at Mesa’s Willow Birth Center, after 12News first aired the story investigating their son’s death. 

Their baby Winston died at a nearby hospital four days after his traumatic delivery, and now his parents are left with more questions for the health department. 

June 4th marks two years since Carson delivered her son Winston, at the Willow Birth Center in Mesa. As they reflected on his loss, Daniel and Carson Neisess tried to make sense of the Arizona Health Department’s investigation into the birth center.

“It was disappointing,” the Neisess family said. 

After the couple filed their complaint, ADHS filings showed the department found what it calls a deficiency during an unannounced complaint inspection at Mesa’s Willow Birth Center in February.

RELATED: Birth coalition calls for change to midwifery care in Arizona, more state oversight

The ADHS report showed Willow “failed to ensure fetal heart tones were assessed and documented per policy.”

“Which is in direct correlation with HIE, which was the cause of Winston’s death,” Carson Neisess said. 

Winston’s Death Certificate showed Hypoxic Ischemic Encephalopathy, a brain injury caused by lack of oxygen, caused his death. No autopsy was performed. 

Winston was not breathing when Carson delivered him at the Willow Center in June of 2023, according to fire reports. He was rushed to the hospital, where he died four days later. 

The parents said they learned about the findings in an email from ADHS.

“We lost our son, and I feel like that warranted a phone call and maybe a little bit of a conversation of explaining why, how they got to the resolution that they did,” Carson Neisess said. 

Carson Neisess was left with a lot of questions for the health department, and didn’t know who to ask. 

“When I did try to call, on several occasions, I was transferred so many times that I never actually got a hold of anybody,” she said. “So it was pretty frustrating that there was no there was no way to have a conversation about it.”

ADHS records showed a plan of correction was put in place at the Willow Center, including re-education, training and requirements for documentation during labor. There was a care policy review and prompts added for fetal heart tone checks. 

Their actions, these parents felt, fell short. 

“So at what point do you escalate that to being more than just like, what I feel like is a slap on the wrist,” she asked. “The thing that they failed to do is in direct correlation with his cause of death.”

An ADHS spokesperson declined an on-camera interview. In a statement, the department 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 Spokesperson declined to comment on the deficiency finding, but did comment on the Neisess family’s lawsuit which settled with the birth center in court. The Willow Center denied liability or responsibility in Winston’s death.

“So if you’re asking the person who said, ‘No, I don’t think I did anything wrong,’ to then have to punish themselves for the thing that they don’t think that they did anything wrong, then yeah, they’re probably going to go pretty easy on themselves,” Daniel Neisess said.

RELATED: Family’s heartbreak prompts birth center investigation in Arizona

Both Daniel and Carson think ADHS should do more. 

“They should be regulating it,” Carson Neisess said. “They should be watching them and making sure that they’re following this policy.”

In a statewide system where most health inspections begin with complaints, Daniel and Carson encouraged Arizonans to speak up if they think their medical care went wrong

“There’s nobody hand-holding you through any of it,” Carson Neisess said. “I think we’re grateful that 12News reached out to us and wanted to do an interview, because I don’t think we would have learned about a lot of these processes without going down that road telling our story.”

As the couple prepared to mark a second year without their son, Daniel and Carson said they plan to push for more state oversight.

“Do I think that nursing centers need to go away completely? No, I think that people should still have options,” Carson Neisess said. “But do I think that they need to follow policy and make sure that they’re practicing safe birthing.”

Another piece of midwife regulation in Arizona is through the State Nursing Board. The Neisess family made a complaint about the care their Certified Nurse Midwives gave. They said they’re still waiting to hear the results. 

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