The mother of Alice Vitória, a one-year-old girl who passed away after undergoing several surgeries at Hospital Salvalus, expressed concern about the recurrence of mortality cases at the institution, which is under investigation due to a series of deaths in São Paulo.
Leticia Ferreira, a social worker, brought Alice to Hospital Salvalus, located in Mooca, East Zone of São Paulo, for a gastrostomy procedure. The child had a syndrome that made swallowing difficult and required the surgery to replace a nasoenteral tube used since birth with a long-term feeding access. Initially, the hospitalization was expected to last about a week.
However, the procedure was followed by a succession of complications, including new surgical interventions, infections, and cardiac arrests, culminating in Alice's death in April this year, three days after turning one. The death certificate indicated sepsis with pulmonary focus and acute respiratory failure as causes of death.
Investigation
In an interview with g1, Leticia detailed that after the first surgery, Alice could not be extubated due to bronchospasms and remained in the ICU. When signs of improvement appeared and the removal of the ventilator tube was planned, the gastrostomy suture ruptured, releasing abdominal fluid, which forced Alice back into the operating room.
During this second surgical procedure, the child suffered a cardiac arrest, and her clinical condition worsened. Alice had a congenital heart disease, specifically a ventricular septal defect (VSD), and the medical team attributed part of the complications to the effects of the cardiac procedures. After this operation, Leticia reported a considerable improvement, allowing her to hold her daughter again.
However, Alice developed wounds on the back of her head, one of them in the area of a valve implanted to treat hydrocephalus. Opening this area resulted in an infection that required another surgery and weeks of antibiotic use. Furthermore, Leticia mentioned that the girl contracted KPC and Clostridium, which deteriorated her health status, leading to two cardiac arrests the day before her death.
Leticia lamented the situation, stating that although a nursing colleague said some cases are normal, 'so many cases are not normal. It is not normal... It has something to do with some other issue of organization, of hygiene.'
Alice's case is part of an inquiry opened by the Civil Police to investigate a series of infant deaths at Hospital Salvalus. According to the Public Security Secretariat (SSP), six cases are being investigated at the 8th Police District, in the Mooca region. The victims, aged between zero and three years, died due to hospital infections, sepsis, and other complications. The events began at the beginning of the year and were reported to the authorities on Wednesday (21).
The Civil Police informed that the investigation involves testimonies from healthcare professionals and witnesses, as well as a complete analysis of medical records, aiming to clarify the causes of death. Eduarda Fragnan Gomes, a lawyer representing three mothers, stated that there are at least 19 families who have lost their children in surgeries performed at the hospital in the last six months.
In response, Hospital Salvalus, belonging to the Hapvida network of the NotreDame Intermédica group, declared that it had not received formal notification about the cited procedures and made itself available to the authorities. The institution also stated that its preliminary assessments indicated different clinical histories, without identifying a common infectious origin among the analyzed cases.
Hospitalization Timeline
The mother described the sequence of procedures and complications for Alice:
- Gastrostomy surgery: Hospitalization for insertion of a feeding tube into the stomach, replacing the nasoenteral tube, with an initial forecast of one week.
- Respiratory complication and ICU: After the surgery, bronchospasms prevented extubation, and she was transferred to the ICU.
- Suture opening and second surgery: While improving, the gastrostomy suture opened, leaking abdominal fluid, which required returning to the operating room.
- Cardiac arrest and clinical deterioration: During the second surgery, a cardiac arrest occurred, followed by weakness, drops in oxygen saturation and heart rate, in addition to pulmonary edema.
- Cardiac surgery: Due to VSD, the medical team informed that the heart condition was affected by the complications, requiring a lung patching surgery.
- Post-cardiac surgery improvement: After the operation, Alice stabilized, was extubated, and had a recovery that generated hope for discharge.
- Head wounds and valve opening: During hospitalization, wounds appeared on the nape of her neck, one of them in the area of a valve for hydrocephalus.
- New surgery for valve complication: The valve area opened, exposing the device and causing infection, which led to another procedure for external ventricular drain (EVD) installation.
- Antibiotic treatment and new infections: After the EVD, Alice spent weeks on antibiotics, contracting KPC and Clostridium, presenting with bleeding from the tube and severe swelling.
- Two cardiac arrests before death: Leticia reported that Alice suffered two episodes of cardiac arrest the day before passing away.
- Last cardiac arrest and death: The next day, there was another arrest. The family chose not to perform resuscitation, and she died on April 3rd, three days after turning one.
The social worker added that during the treatment, she had no idea of the extent of other mothers going through similar situations, and the lack of information from the hospital made understanding the facts difficult.
After the loss, Leticia felt a deep sense of guilt, a feeling shared by other mothers, of not having done enough. She emphasized that the lack of clarity about what happened during the hospitalization was a factor that hindered the understanding of the situation.
Eduarda Fragnan Gomes, the legal representative, demands that the circumstances of the deaths be fully clarified and that those responsible be identified. She contested the idea that the deaths would only be due to the children's clinical conditions, pleading for the authorities to seek out and hold doctors and the hospital accountable.
Official Statement from Hospital Salvalus
Hospital Salvalus reiterated its commitment to patient safety and quality of care. The institution treated the reports seriously but highlighted that distinct clinical situations cannot be attributed to a single cause without technical proof. The unit presents itself as a reference in high-risk maternity and complex pediatric care, attending children with serious conditions, such as extreme prematurity and genetic syndromes.
The hospital reported that more than a thousand children were assisted with individualized care this year. Internal evaluations pointed to diverse clinical histories, without evidence of a common infectious origin among the examined cases. The institution warned that allegations cannot be generalized to conclude about all care without technical support, and that statements without adequate context can increase the anguish of families.
Hospital Salvalus maintained its availability to provide clarifications to the competent authorities, preserving medical confidentiality and patient privacy, and confirmed not having received formal notification about the mentioned procedures.