Stephanie and Eric Biesenbach lived just a mile from the Texas emergency room where they sought help for their newborn daughter, Gwen. The 11 day old baby had been bleeding from her belly button, and her parents could not make it stop.

Medical records from the August 2023 visit described the issue as a “generic problem” involving a bleeding umbilical cord stump. Emergency room doctor Nicole Malouf applied special gauze, and when the bleeding appeared to stop, she discharged the family.

They reached the parking lot before discovering that blood had soaked through Gwen’s footed pajamas. The family returned to Lonestar 24HR ER, a freestanding emergency department in New Braunfels, where Malouf continued trying to control the bleeding.

Stephanie explained that Gwen had no fever or vomiting and was exclusively breastfed. She also disclosed that the family had declined the vitamin K shot at birth and had instead been giving Gwen oral vitamin K drops.

Malouf tried another type of treated gauze, followed by silver nitrate applied with matchlike sticks to cauterize blood vessels. Over nearly three hours, records show, she used seven methods, but the measures treated the visible bleeding without resolving its cause.

Malouf said she called her husband, who is also a doctor, and a nurse at a local hospital for advice. She eventually decided Gwen needed transfer to a hospital with pediatric specialists and a neonatal intensive care unit.

As the wait continued, Gwen bled through another dressing. Her blood vessels were refilling more slowly, her skin was becoming pale, and her heart rate reached 177 beats a minute.

Around 1:40 a.m., Malouf arranged transfer to North Central Baptist, a larger hospital in San Antonio. A neonatal intensive care transport team was supposed to collect Gwen, but nearly two hours passed before the ambulance arrived.

One of the team’s first questions was whether Gwen had received vitamin K. The emergency room nurse said the facility did not have the shot, marking the first time that night, Stephanie said, anyone suggested vitamin K as both the possible culprit and treatment.

At 3:45 a.m., within minutes of arriving, the transport team injected vitamin K into Gwen’s left thigh. Team members also started an IV, drew blood for laboratory testing and administered antibiotics, steps that records indicate had not previously been taken.

Gwen was placed inside a temperature controlled incubator. At 5:55 a.m., seven hours after she was first admitted to the emergency room, the ambulance left for San Antonio with its lights and sirens activated.

During the trip, Gwen’s blood pressure fell and she became increasingly lethargic. The team provided additional oxygen and infused saline in an attempt to improve her blood volume.

Almost immediately after Gwen reached the hospital, her heart stopped. Doctors inserted a breathing tube, performed CPR and administered epinephrine, which appeared to restart her heart.

Less than two hours after admission, Gwen crashed again. Doctors performed CPR for 34 minutes and gave her epinephrine four more times, but she had lost so much blood that her heart was barely pumping.

Stephanie and Eric chose to hold Gwen during her final moments after doctors explained they could continue resuscitation or disconnect the machines. Shortly after 9 a.m., nearly 11 hours after her parents first brought her to the emergency room, Gwen died.

Vitamin K helps blood clot, and newborn injections have been widely used in the United States since the 1960s. The shot virtually eliminated vitamin K deficiency bleeding, a rare condition that can cause catastrophic blood loss and death.

Two studies involving millions of births found that babies who did not receive the injection faced increased bleeding risks. One reported that the rate of vitamin K deficiency bleeding rose 347% between 2017 and 2025.

Medical experts consider oral drops inferior because babies may not absorb them or may spit them up, and bleeding has occurred even when drops were used. The Food and Drug Administration does not oversee the drops sold in the United States.

A single injection acts quickly, while the liver stores vitamin K and gradually releases it over several months. The Centers for Disease Control and Prevention, American Academy of Pediatrics and World Health Organization recommend the shot for all newborns.

Stephanie later filed a complaint with the Texas Medical Board, arguing that the seven hours at Lonestar could have been used to save Gwen. “If Vitamin K was a vital part of the evening,” she wrote, “then we should have been pointed to another location that was fully equipped sooner.”