Toddler Found Alive in Hospital Morgue

On Super Bowl Sunday in February, an 18-month-old boy was pulled from his family's pool in Gilbert, Arizona, and rushed to Mercy Gilbert Medical Center. He was pronounced dead at 6:20 p.m. At 11:52 p.m., staff from the medical examiner's office arrived to transport him. They found him breathing in the hospital morgue.

He was flown to Phoenix Children's Hospital. According to the ABC15 Investigators, who obtained the police report and body camera video, an MRI showed brain damage, and he's expected to need lifelong care.

That's horrible on its own. But the detail I keep thinking about is a conversation that happened a few minutes before the pronouncement.

What the police report says

According to the Gilbert Police report, the ambulance arrived at 6:03 p.m. About ten minutes later, an officer noted the doctor talking about measurements that were “incompatible with life.” The doctor then walked toward the room where the parents were waiting.

Then, according to the report, a nurse said, “I have a pulse.”

One of the officers went to tell the doctor. Here's what the officer wrote about that exchange, as reported by ABC15:

“[Dr.] Toosi arrogantly told me he was the doctor, he has the medical degree, he went to medical school for a reason, and to let him do his thing.”

The doctor is Aryan Toosi, DO. In fairness, the report also says he asked for another pulse check before he pronounced the boy dead at 6:20. “Arrogantly” is the officer's word, and we're hearing one side of it. Toosi's attorney told ABC15 there is much more to the case and that important medical facts haven't been reported. Public records show no disciplinary actions on his license.

Over the next hour, officers wrote that they saw and heard what looked like gasping and air releasing from the boy. One of those observations happened in the morgue, almost an hour after the pronouncement. ABC15 reported that family members and hospital security also described signs of life. Staff were alerted. According to the report, nurses described it as “agonal breathing,” and one nurse said the sounds could be a response to the resuscitation efforts.

The boy stayed in the morgue.

What we don't know

We haven't seen the medical records. Neither had Dr. Keith Zacher, a trauma surgeon ABC15 asked to review the public records. He raised a concern about hypothermia. The pool water was 57.2 degrees, and the report says the child's skin had a light blue color. Zacher explained that hypothermia can mimic death, and that a patient should be warmed before being pronounced dead. He said he didn't know whether a temperature was even taken.

There's an old saying in emergency medicine that you're not dead until you're warm and dead. I'm not a physician, and I'm not going to pretend I know whether the 6:20 decision was clinically defensible with the information in the room. The hospital says it reviewed the case and made changes. It won't discuss details.

So I'll stick to the part that doesn't require a medical degree.

How many times has this happened before?

My first reaction to the officer's quote was to wonder how many times this doctor has given a similar response to a nurse, a resident, or a family member.

I don't know. Nobody outside that hospital does. I'll admit my suspicion is that “I went to medical school for a reason” isn't a line someone comes up with for the first time that night. But that's a suspicion, and it's about one person I've never met.

Here's what bothers me more. The person who got that response was a police officer. The officer doesn't report to the doctor. The officer won't need him for a reference, won't work his next shift, and was wearing a body camera at the time.

If that's how someone outside the hierarchy gets treated, what happens to a new nurse who raises the same concern? She has a lot more to lose.

And I think the more important count isn't how many times someone got shut down. It's how many people learned from it and stopped speaking up. In my experience, people do this math quickly. One dismissive response, especially in front of others, teaches a whole team whether it's worth saying something next time. Leaders never see those concerns. They don't show up in incident reports or safety data. They just don't happen.

Once a decision is made, the system stops looking

What also stands out to me is what happened after 6:20.

Once the boy was pronounced dead, every later observation got interpreted through that decision. Agonal breathing is a real thing, and I'm sure that explanation is often correct. But multiple people reported signs of life over the next hour, including in the morgue, and he stayed there for hours.

That suggests a system where a pronouncement is very hard to reopen. Who had the authority to say, “Stop, let's check again”? Did anyone know how to escalate past the physician? Would a nurse feel comfortable doing that, knowing how the earlier concern was received?

In Lean, we talk about the andon cord. Anyone can stop the line when something looks wrong. But the cord isn't really what matters. What matters is how the leader responds when someone pulls it. If the response is “I went to school for this, let me do my thing,” people stop pulling the cord. The cord is still hanging there. It just doesn't get used.

Healthcare has tools for this. TeamSTEPPS teaches a “two-challenge rule,” where a concern that's voiced twice and dismissed gets escalated. Some hospitals let family members call a rapid response team directly. Those are good ideas. But they only work if people believe they'll be backed up when they use them, especially when the person they're challenging has the most status in the room.

If a nurse in your hospital said “I have a pulse” and the physician disagreed, what would happen next? And would she say it a second time?