The Investigative Prosecutor Raúl Garzón brought to trial the case for the serial murders committed in the most relevant public maternity hospital in the province of Córdoba: the nurse Brenda Agüero is accused of five deaths and the attempted eight. That step was expected, but the surprise lay in the other move that the prosecutor made: he aggravated the accusation to aggravated concealment of six former officials of the Ministry of Health, including himself. Diego Cardozothe strong man of Córdoba politics who managed the public life of Córdoba residents during the 2020 and 2021 pandemic.

For this, a testimony from just a few weeks ago was decisive, which confirmed what other middle managers of Neonatal itself had already anticipated: when they removed Brenda Agüero on June 6, they already knew that she was the author. But to «dissimulate», they excused 22 other Neonatal employees, alleging an internal investigation by the Ministry of Health headed by Marcela Yanover, director of Maternity and Childhood, and Genoveva Ávila, director of Nursing at the Ministry of Health. Alejandro Escudero Salama, deputy administrative director of the hospital, begins a series of interviews in alphabetical order. They did not advance beyond the “C”: they already had Agüero.

However, they did not go to court. The most they had done was to report the death of Angeline Rojas and Melody Molina for doubtful death in the judicial unit that is one block from the Neonatal. That step was taken by two doctors and is what enabled the autopsy to be carried out, but nothing more than that. Garzón understands that between March 18 and July 4, the date on which an individual makes a complaint that falls to his prosecutor’s office and he orders the raid on the Neonatal, they had plenty of elements to report to Justice the obvious anomalies that they happened there. At least three of the five deaths could have been prevented.

But no: the accused officials decided to close the internal investigation and, following the advice of deputy prosecutor José Gómez Demmel, present the “closed case” to the attorney general. They say that they were going to do it on Tuesday, August 16, after the holiday of the 15th. They wanted it not to be known, they did not even plan to give an explanation to those mothers who left empty-handed. But it hit the media the previous Thursday and the plan was thwarted.

What they didn’t do

Former Minister Cardozo is accused of the crime of “concealment doubly qualified by the preceding fact and by his capacity as a public official; the former Secretary of Health, Pablo Carvajal and the former legal secretary of the Ministry Alejandro Gauto. On the Neonatal side, with the same criminal charge, the former director Liliana Asís (detained), the former deputy medical director, Claudia Ringelgheim and the former administrative deputy director Alejando Escudero Salama are charged. Until now, Gauto was not accused of anything and everyone (except Asís) had omitted the duties of a public official. This figure provides for a fine as a sanction, aggravated concealment reaches six years in prison.

To arrive at this accusation, the investigation considered that there was a whole chain of responsibilities that pertain to those charges and that they decidedly had the will to hide.

They knew almost from the beginning. The first death attributed to Brenda Agüero is that of Francisco Cáceres, on March 23: he weighed 3,260 kilos and was in excellent health. The baby decompensated, had two cardiac arrests and died. That case was rare, inexplicable, but an undetected congenital pathology is always a possibility.

The second unexplained death occurred exactly one month later: Benjamín Bustamante, on Saturday, April 23. On Sunday the 24th there were two decompensated babies (Bustamante and Hermosilla) within a few hours of life, with bradycardia and hyperkalemia, with bruising in the area where the vitamin K is placed, the left thigh, in front. On Monday Asís goes in person to the Ministry, meets with Carvajal and asks him to change the brand of vitamin. Carvajal traces in other maternity hospitals if something similar happened with the Biol vitamin that was used, but everything was normal. Likewise, he allows the hospital to buy a different brand, something strange because purchases are centralized. Baby Francisco, from March, was not linked to vitamin K, but Benjamin was, plus the adverse reactions in two more babies. Meanwhile, samples are sent to be analyzed by Ceprocor and four reports of adverse events are submitted to the National Administration of Medicines, Food and Medical Technology (Anmat) questioning vitamin K. These reports are not frequent and are endorsed by the company itself. Ministry of Health. This was key for the prosecutor, because both Cardozo and Carvajal in their defense claim that they only found out about everything on June 7, after that fateful guard in which four babies were attacked, two of whom died.

It wasn’t the vitamin. On Tuesday, April 26, the baby Barrionuevo decompensated: she had purple lips and tachycardia. They detected a bleeding puncture behind her leg, when the vitamin K had been placed in front. They thought of scorpions, glass or forgotten needles. They check everything, they inspect the sharps discarders, they check the medication vials and they check the baby’s clothes. They don’t find anything. On Thursday, April 28, the “root cause analysis” of the Bustamante baby, who died on the 23rd, is carried out. The ACR is a kind of “storm” of ideas in which everyone throws out possible hypotheses to explain what happened. 14 professionals participated without reaching an eloquent conclusion. It is impossible to imagine that the highest Health authorities did not know that an ACR had been performed in the most relevant maternity hospital in the Province without finding a cause. In that hospital, an average of 12 babies die per month: none full-term, healthy, weighing more than three kilos.

It is understandable that no one, on that date, had crossed the hypothesis of an intentional attack, but on the day of the ACR there was one death, three decompensations and a strange puncture. But neither Director Asís nor Vice President Ringelgheim as authorities gave sufficient importance to the inexplicable puncture.

Rumors. By the end of April, beginning of May, a rumor was already circulating that someone was attacking the babies. Brenda Agüero herself confessed it during a night shift: she approached a nurse (SM, according to the witness) and said to her in the living room, where there were other colleagues: “Did you see girls that all my colleagues say I am?” «I’m the one who kills babies?» The nurse replied that they didn’t know anything, that it left them cold. Another colleague, LN, said that she told him something similar: “Did you see that the people from the

«Accuses me that I am the one responsible for the deaths of the babies?» Those present responded that they had never heard that and they were all struck by the comment, which came out of nowhere.

Internal warnings. On May 1, 90 minutes after being born, baby Bustamante was detected with two bleeding punctures in his right leg, one in the back and the other in the front. He decompensates, goes to therapy. Vitamin K had been placed in the left. They tear up the crib mattresses to see if there were bugs or missing needles, but they don’t find anything.

On May 6, the head of Neonatology Martha Gómez Flores and the Patient Safety representative sent a written letter to Asís and the administrative vice director, Alejandro Escudero, requesting an urgent meeting to analyze the “serious” events that were happening at the Center. Obstetric, which included the death of a healthy baby. The meeting takes place on the same day: the four conclude that there were no causes that explain the physiopathogenesis of the injuries. Escudero asks for a report with the story of the professionals who intervened in the cases. Gómez Flores will send both directors that story, in writing, on May 10. There they describe four cases in chronological order: that of Martínez on March 18, that of Francisco, who died on March 18; Benjamín, died in April and the babies González, on April 24 and Barrionuevo, on May 1. Neither of those two letters nor the meeting was mentioned by Escudero in his written statement before the prosecutor.

With all these elements, none of them indicates an internal investigation, a summary, nothing. Unforgivable for old connoisseurs of the pulse of public management. “It’s the first thing to do, the ABC,” they say. That momentous step was not taken by Asís or Escudero: they were convinced that they could handle the situation.

During those days, Gómez Flores entered an office and confided to a person (very aware of what was happening, although this newspaper will reserve his identity) that they suspected a nurse. “But how are we going to point it out without evidence? The union kills us,” she says he told her. She did not perform Nursing or Midwifery. Some point out that at that time they could have decided to rotate personnel or look for a way to move Agüero from his duties. We must not ignore the weight of the Public Employees Union, with high ascendancy in nursing, where it often has “co-management.” The decision was not to make waves.

What came next

If until then something had to be done and was not done, on May 16 there will be no doubt that everything that was done afterwards was wrong. That day, at the request of deputy prosecutor José Gómez Demmel, Escudero meets with the head of Forensic Medicine, David Dib and prosecutor Guillermo González. Dib and González say that there was no talk of deaths, strange because Escudero already had that story of May 10 in his possession. González says that he recommended that he report, Escudero says that it was not like that. But Escudero is a lawyer and with all the facts that he had in his possession, he decided to do nothing at that moment. But the worst is missing.

Another death. A week after that meeting, on May 23, Ibrahim died. He was sleeping in his crib and when his mother returns from bathing she finds him not breathing. It was exasperating. The mother says that she asked for an autopsy and that a woman with short hair (she later recognized Asís) told her that “it was not necessary, that the death of her son was natural.” It was already the third unexplained death. The mother stuck with that advice that she regrets to this day.

Don’t let it be talked about. Different testimonies indicate that Assisi decided that nothing would come to light. He challenged the nurses who took photos of the broken mattresses, he told the residents “you better not talk because otherwise you already know what is happening to you.” Asís applied a top-down leadership, where everything had to go through his control and the supreme desire not to sully “his” hospital and its management, of course, prevailed.

Between May 23 and June 6, no measures were taken inside the hospital. Until on Monday the 6th what happened happened: four decompensated babies in the same guard, two died. In the last one they realized that someone had purposely injected him with potassium.

On Tuesday the 7th, Asís appeared before Carvajal in his office with Escudero. He cried. “The hospital got out of hand,” they say he told her. There was some deployment: Yanover and Ávila disembarked at the maternity hospital, took testimonies, excused 23. They decided to move forward with the internal investigation but without notifying Justice, despite the fact that there were five deaths and one suspicious. Escudero was named as “intervenor” of that process: strange, because he also had to be investigated.

None demanded the intervention of Justice. They believed that it was good for the Ministry of Health to take action on the matter and they surely imagined that they were going to do it well. They did not preserve vital tests, they did not complete medical histories that are a shame for their imprecision and laxity. Gómez Demmel, according to some people involved, recommended that they take everything resolved to the Attorney General. No deadlines were imposed and even the initial impetus liquefied with the days. In short, the events had already ceased. They did not even start an internal procedure with Agüero. They believed that they could control everything. It never occurred to the authorities that the facts were going to come to light. Until it happened.