This is the first I'd learned of a 2006 abortion death at the hands of Maryland abortionist Romeo A. Ferrer: Board to discipline doctor in abortion death
(Note, by the way, that as usual it's the prolifers calling for this guy to be held accountable. The prochoicers are, as always, eerily silent. If they do say anything after an abortion fatality, it tends to be along the lines of, "Oh, no no no no! Dead broad OFF the table!")
Operation Rescue West made a PDF of the medical board documents available here:
Like many abortion "clinics", Ferrer's private practice, Gynecare Center, would look to the untrained eye like an outpatient clinic. A patient making an appointment there would likely believe she was in a licensed clinic, not a doctor's office.
The board refers to the dead woman as "Patient A", which I find dehumanizing. I'll refer to her as "Peggy" Roe.
Peggy was 21 years old, mother of a 3-year-old son, when she went to Ferrer's clinic-looking office for an abortion on February 3, 2006. She was 16 weeks pregnant. Peggy was in good health, with a history of two "uncomplicated abortions" and a miscarriage. "On her health history form, it was noted that [Peggy's] reason for terminating her pregnancy was, 'can't afford it right now.'" Peggy was accompanied to her appointment by a friend, who was helping to keep the abortion a secret from Peggy's family.
Ferrer started the abortion, a D&E abortion, at about 1:00 p.m., using ultrasound to help him visualize the baby as he dismembered it. Twenty-five minutes later, Ferrer was still pulling fetal parts out of his patient, and administered 20 units of pitocin via an IV solution. Five minutes later, he added 125 mg of Demerol and 5 mg of midazolam (Versed, a short-acting sedative and amnesia-producing medication). Because "pt. was still reacting to pain", Ferrer administered additional doses of Demerol and midazolam. It wasn't until 1:45 that Ferrer completed the abortion.
Peggy was moved to the recovery room, where at 1:47 a "surgical assistant" noticed signs of cyanosis (blue coloring) in Peggy's fingernails. A nurse assistant was unable to get a blood pressure or pulse reading on Peggy, and told Ferrer. He gave a verbal order for 0.4 mg Narcan, which was administered by the nurse assistant. Narcan is a drug to counteract narcotics.
At 1:50, Ferrer began efforts to resuscitate Peggy, including performing CPR, and having an assistant perform CPR while he administered intracardiac epinephrine. Staff called 911 while Ferrer continued resuscitation efforts, maintaining an open airway with the non-professional method of head tilt and chin lift. Ferrer did not use an airway or endotracheal tube, as is customary with professionally-administered CPR.
The medics arrived to find Peggy still unresponsive and without a pulse. The medics used an oxygen mask and additional drugs as they transported Peggy to Anne Arundel Medical Center. There, emergency room staff continued the attempts to resuscitate Peggy, to no avail. She was pronounced dead at 2:57 p.m.
The autopsy found no underlying physical reason for Peggy's heart to have stopped. The cause of death was given as "Meperidine intoxication" (an overdose of Demerol).
The medical board faulted Ferrer in his care of Peggy:
1. Ferrer administered successive "push" dosages of medications. He should have titrated (gradually administered) the second dose. "[T]he second dosage was too large and administered too quickly."
2. Despite having had a written policy in place since 1994 to provide proper monitoring, Ferrer did not use a pulse oximeter to monitor Peggy's pulse and blood oxygen, nor were her pulse and blood pressure monitored every five minutes during the 45 minutes of surgery. Ferrer also failed to provide oxygen to Peggy during surgery. "[Ferrer's] failure to monitor [Peggy] appropirately during and after the abortion constitutes a violation of the standard of quality care."
3. During resuscitation, Ferrer did not use an airway and did not provide supplemental oxygen with an ambu-bag.
In short, Ferrer gave Peggy too much medication too quickly, causing her to stop breathing, and failed to monitor her closely enough to notice in a timely manner. He then failed to adequately resuscitate her.
UPDATE: The medical board did go through with suspending Ferrer's license. They learned of the incident when Peggy's family sued. You can read the suspension order here.