PHOENIX (3TV/CBS 5) - The incapacitated woman who police said was raped and gave birth at a long-term care facility in Phoenix was pregnant before, and workers missed vital warning signs, according to notice of claim against the State of Arizona.
The claim states that the Maricopa County Medical Center took an exam of the woman after she gave birth in late December. Officials said it appeared that the 29-year-old victim woman had been "violated repeatedly" and her giving birth was likely a "repeat parous event," meaning she may have been pregnant before that.
The victim has be in an incapacitated state since she was a child.
Arizona's Family was the first to report the exclusive story in early January.
The documents say the victim's mother requested years ago that the victim only be cared for by female staff members. That didn't happen, even though they said it was written into her individualized service plan or "ISP."
[ORIGINAL STORY: Woman in vegetative state gives birth at Hacienda HealthCare in Phoenix]
A former Hacienda employee, who asked to remain anonymous, said the fact this was ignored is a huge problem.
"If it's in her ISP, I mean that’s kind of a contract. You’re required to follow that ISP," she said. "It’s signed by the guardian, it’s signed by whoever oversees the facility, and it’s signed by one of the state workers."
Multiple sources told Arizona's Family the person who would have made sure the ISP was required was the person who oversaw ICF unit. That used to be Perry Petrilli, who is now the acting CEO of Hacienda.
In response to that, Hacienda said Petrilli was in charge of facilitating the ISP's, but did not see the medical personnel each day. Hacienda said the Director of Patient Care and the Director of Nursing were in charge of staff assignments day to day, including following ISP's. Both of those directors stepped down after this incident.
Authorities say Nathan Sutherland was a nurse at Hacienda HealthCare and raped her. He was arrested in late January and faces sexual assault charges.
An inside source says in 2018 alone, at least one other male nurse was caring for her too, in addition to Sutherland.
Investigators say Sutherland's DNA matched a sample from the woman's newborn, though Sutherland's attorney says there's no direct evidence linking Sutherland to the rape.
Sutherland pleaded not guilty to the charges and gave up his nursing license.
The victim gave birth to a healthy baby boy in late December.
The notice of claim states there were at least 83 opportunities that Hacienda HealthCare workers missed in diagnosing that the woman was pregnant. They include:
• Missed menstrual periods in months prior to delivery
• Staff noticing a "large and hard mass" in her abdomen three times
• Her abdomen was seen sticking out during 24 checks
• Staff noted her legs and feet were swollen 12 times between Dec. 12, 2018, and Dec. 29, 2018
Documents say staff documented signs or symptoms of pregnancy 73 times during her third trimester.
The report specifically highlights a paper trail of Dr. Thanh Nguyen's notes on the case.
The documents show Dr. Nguyen repeatedly noted a mass in her stomach, but prescribed her medication for weight loss and constipation.
But our source, who is very familiar with the victim's care routine, said gaining weight should have been an alert to something very wrong and unusual.
"Her diet was absolutely fixed. She was tube fed, she got the same amount of calories everyday," she said.
Then on December 28th, Dr. Nugyen noted it could be diverticulitis and that's when he ordered an ultrasound.
That was the day before she gave birth. The ultrasound was never done.
The notice of claim says the victim's family would settle all the claims with the state for $45 million.
[SPECIAL SECTION: Hacienda HealthCare pregnancy investigation]
The Arizona Governor's Office released the following statement:
"We’re reviewing the notice of claim. The details in this matter continue to be extremely disturbing — since day one, the governor has been clear that those responsible for this crime need to be held accountable to the fullest extent of the law. He’s called for the board to be terminated, a full criminal Investigation and an investigation to determine how this could have happened and for additional oversight at Hacienda to ensure something like this never happens again.
The Arizona Department of Health Services said it doesn't comment on pending or ongoing litigation.
The Arizona Attorney General's Office said the state is being represented by outside council in this case, and they had no further comment.