On January 16, in the waning days of the Biden administration, the US Department of Health & Human Services (HHS) announced a significant enforcement agreement with Cedars Sinai Medical Center concerning the tragic death of Kira Johnson., a 39-yeard old Black woman, after successfully giving birth to her son. The agreement is the final enforcement resolution reached by the Biden administration pursuant to by Title VI of the 1964 Civil Rights Act and Section 1557 of the Affordable Care Act.
Cedars-Sinai is an academic healthcare organization serving more than 1 million people each year in over 40 locations, including Los Angeles, California. Cedars-Sinai has over 4,500 physicians and nurses and trains medical professionals through 15 accredited residency programs and 89 fellowship programs. Cedars-Sinai also provides technology and facilities to physicians and scientists conducting research projects and clinical trials and is a grantee of the HHS National Institutes of Health.
Ms. Johnson’s treatment and death after childbirth were linked to racial discrimination by medical staff, even though Cedars-Sinai had previously implemented training to alleviate biased and discriminatory medical care.
The agreement includes significant medical staff training improvements and upgrades, including:
“Within six (6) months of the Effective Date of this Agreement, Cedars-Sinai shall require that all Department Workforce Members complete training on Cedars-Sinai’s Obstetric Hemorrhage Management policy. Cedars-Sinai shall incorporate such training into its standard onboarding process for Department Workforce Members in patient care settings. Cedars-Sinai shall additionally make such training available to all Medical Staff Members with Privileges, and shall recommend to the Executive Committee that such training be mandatorily incorporated into the standard re-credentialing process for Medical Staff Members treating patients in the Department.
In addition, Cedars-Sinai shall provide Department Workforce Members refresher training on the above referenced obligations within one (1) year of the initial training required pursuant to this Agreement, or shall incorporate such training into its annual training program, and retain attendance logs for all attendees for the duration of this Agreement. The attendance logs shall be forwarded to OCR upon request…
Cedars-Sinai shall implement an online reporting tool, or shall review with OCR existing reporting tools, to document incidents of bias or suspected bias experienced by Department patients and the public during interactions with Workforce Members and Medical Staff Members with Privileges…
Cedars-Sinai is encouraged to participate in and/or provide additional training to its Physicians, Physician Assistants, Nurse Practitioners, and other appropriate direct service Workforce Members and Medical Staff Members with Privileges through the following HHS programs, which will support its compliance efforts under Title VI and Section 1557. Cedars-Sinai agrees to share any information with OCR regarding its participation and/or supplemental training obtained from the below HHS agencies within one (1) month of implementation.”
HHS initiated this case with a compliance review of Cedars-Sinai in response to public reports indicating that racial bias in healthcare decision making and treatment contributed to the death of Kira Johnson, who died approximately 10 hours after delivering her son at Cedars-Sinai Medical Center. HHS further investigated general allegations that despite medical staff bias and racial discrimination training, Black patients and other patients of color receiving pregnancy and maternity care at Cedars-Sinai regularly experience discrimination and are at greater risk for adverse maternal health outcomes due to patterns of racial bias and discrimination at the medical center.
According to Parents.com:
“When Charles Johnson IV accompanied his wife, Kira, to Cedars-Sinai Medical Center in Los Angeles on April 12, 2016, for the birth of their second child, he never expected to leave there without her. The couple had one son already, Charles V, and Kira’s second pregnancy had been textbook normal. The 39-year-old was in perfect health.
Kira’s scheduled cesarean section should’ve been a routine surgical birth for a healthy, uncomplicated pregnancy. But shortly after their son, Langston, was born healthy, it became apparent to Johnson that his wife’s recovery was anything but normal.”
After giving birth to a boy by Cesarean Section, Kira Johnson began experiencing significant medical complications. Her blood work was abnormal, she was sensitive to the touch, and had started to lose color. These and other indicators suggested that Ms. Johnson was bleeding internally. At approximately 4 pm, la CT Scan was called for, no scan was performed, according to Parents.com.
By 9 p.m., Mr. Johnson asked a nurse’s aside why no scan had been taken of his wife. “The woman looked me right in the eyes and said, ‘Sir, your wife just isn’t a priority right now.'”
Parents.com reported:
“After midnight, [many hours after giving birth,] Cedars-Sinai staff members transported Kira Johnson to an operating room. As they walked down the hall, Johnson recalls Kira turning to him and saying, “Baby, I’m scared.” They continued down the hall until they reached double doors to the OR and Johnson was told he could not go any further. “‘One of the doctors said ‘It’s not a big deal, sometimes these things happen … She’ll be back in 15 minutes.'”
Mr. Johnson never saw his wife alive again.
“Kira Johnson was left for more than ten hours with a hemorrhage bleeding into her abdomen. When the surgical team reopened Kira’s incision, they found 3.5 liters of blood in her abdomen—normal adult blood volume is around five liters. Kira lost about 70% of her circulating blood volume while waiting for doctors to address her and her husband’s concerns. She coded on the operating table and they were unable to revive her.
The thing that we are clear about is that there was a failure for the staff and the team at Cedars to see my wife the same way that they would view their daughter, their sister, or their wife,” says Johnson. “Kira deserved so much better.”
Johnson says that as a result of his wife’s death, he has recurring nightmares. “I sit up at night and I struggle. What should I have done differently? Should I have yelled, should I have grabbed a doctor by the collar? But that is the reality of our lived experience,” he says.
Among the agreement’s changes to Cedars-Sinai procedures are the following new rules for medical staff oversight.
“Medical Staff Oversight and Communication
- Within twelve (12) months of the effective date of this Agreement, Cedars-Sinai leadership shall meet with the Executive Committee to review current oversight, supervision, and peer review practices and make recommendations related to the following:
- Internal monitoring and auditing;
- Implementation of compliance and practice standards through the development of written standards and procedures;
- Additional training and education on practice standards and procedures;
- Mechanisms to respond promptly and appropriately to violations through the investigation of allegations and the disclosure of incidents to appropriate Cedars-Sinai officials and/or government entities;
- Development of open lines of communication between Patients, Medical Staff Members, and Workforce Members;
- Enforcement of disciplinary standards.”
This tragic case reveals the critical importance of effective staff training about federal requirements under the Civil Rights Act of 1964 and Affordable Care Act. Training for training’s sake to mark a check on a compliance list is not enough. Providing medical staff education that will prompt necessary introspective changes and raise awareness of federal non-discrimination obligations is especially salient when providing non-discriminatory medical care instead of care that treats patients’ differently because of their race, color, or national origin and ends in a tragedy that was avoidable.
© Bruce L. Adelson 2025 All Rights Reserved The material herein is educational and informational only. No legal advice is intended or conveyed.
Bruce L. Adelson, Esq., is nationally recognized for his compliance expertise. Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney. Mr. Adelson is a faculty member at the Georgetown University School of Medicine and University of Pittsburgh School of Law where he teaches organizational culture, implicit bias, cultural and civil rights awareness.
Mr. Adelson’s blogs are a Bromberg exclusive.