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.

[WATCH: Hacienda Healthcare rape victim's pregnancy likely a 'repeated' event]

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.

[WATCH: Hacienda HealthCare rape victim 'likely' pregnant before, notice of claim says]

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.

[RELATED: Nurse who witnessed incapacitated woman giving birth speaks for first time]

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.

[RELATED: Hacienda HealthCare rape suspect Nathan Sutherland pleads not guilty]

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.

[RELATED: Gov. Ducey issues order strengthening protections for people with disabilities]

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. 


Copyright 2019 KPHO/KTVK (KPHO Broadcasting Corporation). All rights reserved.



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(17) comments


So if she was pregnant before, the big question is what happened to the baby? Unfortunately this kind of thing happens in so-called care facilities, it's not just limited to Hacienda. I don't trust those places, even the high-rated ones.


And yet the real tragedy in ALL of this is that they were/are keeping a woman in a vegetative state pointlessly alive. A more selfish act I cannot imagine...


This whole issue begs the question, who was the physician in charge and why did he or she miss all of the signs of this pregnancy (or these pregnancies)? This sounds like a severe case of ongoing medical malpractice on the part of the attending physician(s) and the nursing staff at the facility. Perhaps this is grounds for yet another law suit.


$45 million! a bit much. $1-2 million? Sure. But not the STATE. Hacienda is responsible.


You bet the stinking state is responsible big time. They for probably good old boy reasons allowed this infested diseased institution to operate WITHOUT A LICENSE. Get it?

Rico Rush

Mister One Eye Jack sure blew the cover for the other guys, it safe to assume this has been going on for a very long time, and probably will continue to until someone gets caught or speaks up. I say cut the sausage on this dude, and drop him in the desert in a dooms day bunker and lock it shut, and let him die out of natural causes.


This place operated WITHOUT a license for years according to the news reports. Why? The state sanctioned this. Why? Why doesn't the otherwise worthless aclu look into this and determine who all profited from the NO license situation. Hopefully, the lawyers representing the family now suing these ah oles will bring this to light. Some in the state as well as the owners benefited from this and the public has the right to know.


Mormon Church

Uncle Leo

$45 mill.....heck yeaaa.....I'll let the dudes at Hacienda do what ever they want to me for that kind of dough!


Bad world, bad people. Dumb axx doctor and others in charge.[angry]


Support abortion.


I remember a news story about a quadriplegic teenage boy at a care facility in Glendale that had been repeatedly sexual abused by a guy who worked at the facility. Apparently the abuse had been going on for quite some time untill another staff member walked into the kid's room and caught the guy in the act. Is this some thing that is regularly occuring? These places clearly needed to be monitered far better than they currently are.


This is horrible. She was supposed to be cared for and protected not used for who knows how many people's disgusting perverted sexual gratification. Now I'm wondering why there's such a push to give the guy they arrested an HIV test. Is it because the woman or the baby tested positive for HIV? The depraved treacherous things people do to other people.


45 Million?????Yeah Right...


HOLY MOLY: that is SCARY; this woman was being regularly violated, and a birth or spontaneous abortion is a MESSY event; not something you'd not notice somehow. Further, since the woman was bed ridden for her to have pedal edema, it means she was most likely pre-ecclamptic as well; and that'd show in her blood pressure readings too. WHAT kind of "nurses" are working there that NONE of this was noted during routine care of the woman???? And HOW MANY others are being abused and it's not being "noticed" by the staff????

JF Conlon

Oh yes! And how about the claims that her baby is "doing well" in spite of the reports that the mother was on barbituates to control seizures during her entire pregnancy? This is, all of it, truly scary.


Oh oh

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