SARASOTA, Fla. — Paris Bean checked into Rosemary Birthing Home before the sun rose on the last Wednesday in January, excited to deliver her first child.

Two weeks past her original due date and plump from pregnancy, the 23-year-old lumbered into the freestanding birth center with her longtime partner, Jason Fisher.

The couple carried a load of clothes and blankets for the baby, a birthing kit for the midwife, several bags of ice and two homemade casseroles — enough for 25 people — to feed the entire birthing team that they expected to rally around them.

But just one person was there at the time, Bean and Fisher said.

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Newly licensed midwife Jordan Shockley welcomed the couple and ushered them into a private birthing room on the first floor of the converted, historic home.

It was just past 7 a.m.

Outside, the sun cast its first light on what would be their son’s birthday. A day that turned to horror after the baby went into cardiac arrest, respiratory failure and ultimately severe brain damage from which he may never fully recover, according to the midwife’s notes and records, an EMS report, and interviews with the family and a hospital official.

Brenden Charles Fisher is at Johns Hopkins All Children’s Hospital in St. Petersburg. He has a tube in his nose delivering a steady flow of oxygen. A tube in his leg administers fluids, nutrients and anti-seizure medication. Another tube in his throat provides tiny doses of breast milk in an attempt to wake up his digestive system.

He cannot swallow. His parents and nurses take turns suctioning saliva from his throat and mucous from his nose.

He doesn’t cry. His only sounds so far came from a bout of hiccups.

His long-term prognosis is unclear.

It is the latest incident at Rosemary Birthing Home, profiled last year as part of a nine-month investigation by GateHouse Media and the Herald-Tribune into the dangers of out-of-hospital births.

READ MORE: Failure to Deliver: How the rise of out-of-hospital births puts mothers and babies at risk, a special investigation by the Sarasota Herald-Tribune and GateHouse Media.

One of the area’s two birth centers, Rosemary has a troubled history that includes at least three deaths and a rash of hospital transfers. At least one of the deaths was due to a congenital heart defect and not preventable, according to the child’s mother.

The owner of Rosemary did not respond to an email seeking comment for this story.

When the investigation, called “Failure to Deliver,” was published in November, Bean said, she defended the birth center. Now, she said, it needs to be shut down.

“I have chills from all these moms that went through a similar situation,” she said. “This can’t happen to anyone ever again.”

‘So many things were done incorrectly’

Brenden Charles Fisher was a foot-first breech baby.

Most babies flip into a head-down position in the last weeks of pregnancy. But a small fraction do not flip and either their buttocks or feet point toward the birth canal instead. Most breech babies are delivered by cesarean section.

Shockley did not know the baby was breech when Bean checked into the birthing home that morning in active labor.

Nor did she know one hour later when she performed a vaginal exam and said she felt the baby’s head, Bean said.

She only discovered it when, after 2 p.m., she broke Bean’s water and felt a foot, according to Shockley’s notes, which Bean provided to the newspaper.

Shockley was reached by phone Thursday morning but said she was not able to immediately comment despite receiving Bean’s written consent to disclose client information. She said would call back but did not do so. She did not respond to two additional attempts to reach her.

The midwife’s own notes reflect she did not follow several state midwifery regulations prior to the baby’s traumatic delivery.

Florida regulations require midwives to perform an initial assessment at the onset of labor, including a vaginal examination to assess the baby’s presentation and position. Shockley’s notes show she did not do this. She said the exam was “declined.”

Florida regulations require midwives to refer their clients to a physician with hospital privileges if the baby has not flipped to the head down position after the 37th week of gestation. Shockley did not do this, according to her prenatal notes. There’s no mention of the baby’s position at the post-37-week appointments.

Florida regulations require midwives to refer their clients to a physician with hospital privileges if the baby’s gestational age is between 41 and 42 weeks. Shockley did not do this, according to her prenatal notes. She altered the due date instead, pushing it back by nine days less than a week before Bean was projected to give birth.

Florida regulations require midwives to consult with or transfer their clients to a physician with hospital privileges if the baby is breech during labor. Shockley did not do this, according to her labor notes. She attempted to deliver the baby herself at the birthing center.

“So many things were done incorrectly with this birth,” said Paris Bean’s mother, Nikki Bean.

‘I just can’t believe this all happened’

When Shockley felt the foot and told Bean the baby was breech, the laboring mother said she cried because she was scared. But Shockley reassured her that it wasn’t a problem, Bean recalled.

“She told me to push, and we could have the baby, and everything would be OK,” Bean said. “I just can’t believe this all happened. We were sold on this beautiful experience. I trusted her.”

Shockley noted in her report that she had an “urgent discussion” with Bean about going to the hospital at that point, but that Bean refused. Both Bean and Fisher dispute that account. They said they never refused hospitalization and would have willingly gone then if their midwife advised them to do so.

Shockley then dialed an unidentified person for advice, the couple said. When she hung up, she called 911. Her notes from the labor report state that she “activated EMS, gave report of fetal breech presentation with needs for urgent support.”

An audio recording of the 911 call sounds anything but urgent.

“I have a mom in labor, everything’s fine, but her baby is breech,” Shockley told the dispatcher. “We broke her water and found a foot, so we kinda want 911 on ... she’ll have a baby by the time they get here, but just to have them here.”

Paramedics arrived three minutes later, according to the EMS report. Some gathered in the hallway, others in the birthing room, as Shockley instructed the mother to push, Bean and Fisher recalled.

“The main EMT said, ‘She shouldn’t push. We need to go right now,’” Fisher said. “But Jordan said, ‘No, just push.’ The arguing went on for it seems like forever.”

Neither the midwife’s labor notes nor the EMS record mentions an argument. The EMS record states simply: “Decision made to continue delivery at birthing center.”

But it appears paramedics broke their own protocol, established in 2015 in response to previous such incidents with out-of-hospital midwives.

“Licensed midwives attending childbirths at birthing centers or private residences are not healthcare professionals,” according to the Sarasota County EMS Handbook for Community Protocols. “Respond, assess, stabilize and transport the mother and/or newborn to an appropriate Resource Hospital. Staging at the birthing center and engaging in discussions with the midwife are not authorized.”

Sarasota Fire and EMS Chief Michael Regnier refused to answer questions directly related to that incident. He said each case is different.

The EMTs stayed at the birthing center for nearly 30 minutes, records show, while Shockley attempted to the deliver the baby herself.

According to her labor notes:

At 2:54 p.m., a foot emerged.

At 2:56 p.m., both feet and calves emerged.

At 2:59 p.m., Shockley claims she again advised her client of the need for urgent transport. Bean and Fisher strongly deny the midwife ever encouraged them to go to the hospital.

At 3 p.m., the buttocks emerged covered in meconium — the baby’s first stool.

At 3:02 p.m., the midsection emerged.

At 3:07 p.m., the arms emerged.

At 3:08 p.m., the head remained stuck and Shockley again claims she expressed an urgency to transport. Again, the couple denied this.

At 3:10 p.m., Bean is moved to the stretcher to begin transport to Sarasota Memorial Hospital.

‘There was a protocol, and I broke it’

Bean was on her back on the stretcher with a portion of her baby dangling from her vagina. Shockley got on the stretcher with her. Paramedics loaded them into the ambulance and left Rosemary at 3:13 p.m.

While en route to Sarasota Memorial Hospital, paramedics noticed the baby’s exposed umbilical cord stopped pulsing, the report states. This means it was no longer delivering blood and oxygen to the brain. They also discovered the mother’s placenta had detached.

They cut the cord and began chest compressions on the baby, with his head still lodged behind his mother’s pubic bone. Bean said she reached out and held her son’s hand.

The baby went into cardiac arrest at 3:18 p.m., according to the EMS report.

Back at the birth center, Fisher was standing in a daze on the street, he said. The ambulance had left him behind. He was covered in blood and meconium, unsure what to do. Eventually, someone took him to the hospital.

Mother and midwife arrived at Sarasota Memorial Hospital at 3:21 p.m., according to hospital spokeswoman Kim Savage, who had permission from the family to discuss their case with the media.

Shockley went into a waiting area while staff wheeled Bean into a room. After several attempts to have Bean push out the baby, the staff gave her a third-degree episiotomy — cutting her from the anus to the vagina — and pulled out her baby.

It was 3:29 p.m. Brenden was limp and unresponsive, Savage said in an email.

“He was in cardiac and respiratory failure at birth. His APGAR score at one minute after birth was zero,” Savage said in the email. “It increased to a 3 within five minutes and remained a 3 at 10 minutes.”

An APGAR score rates the baby’s condition at birth on a scale from 0-10, with 0 being lifeless and 10 being healthy. Midwives are required to submit that information to the state on their annual reports. Shockley noted in her labor report the baby’s 10-minute score was 4.

“His neurologic assessment was abnormal and consistent with severe hypoxic encephalopathy,” Savage added, referring to the brain damage that occurs when a person is deprived of oxygen.

The neonatal intensive care team resuscitated the baby and restored his heartbeat, but he was unable to breathe on his own and needed to be intubated, Savage said in the email. The team also began immediate cooling treatment, lowering his body temperature in an attempt to reduce brain damage. He was transferred three hours later to Johns Hopkins All Children’s Hospital in St. Petersburg.

“They told me before they took him,” Fisher said, ”‘If he makes it through the night, he will never wake up again. He’s totally brain dead.’”

While sitting in the hospital waiting room with Shockley, Fisher said he asked her what happened.

“She told me, ‘There was a protocol, and I broke it,’” he said.

Bean’s sister, Sadiee Bean, said she asked the midwife the same question later that night.

“She was telling me a bit of what happened and said, ‘I’ve seen so many beautiful breech birth videos on Instagram, and I just thought this was going to be one of those,’” said Sadiee Bean. “She was very emotional. She kept saying, ‘This is the worst night of my life.’”

‘I’m very frustrated with Rosemary’

Shockley had been Sadiee Bean’s midwife, too, delivering the woman’s son in October as an assistant to licensed midwife Harmony Miller, who owns Rosemary Birthing Home. It was an uncomplicated delivery, and the baby was born healthy and pink.

At the time, Shockley was a still a student midwife.

State regulations require student midwives be under the direct supervision of a preceptor during their clinical training, including when they conduct prenatal visits and deliver babies. Both Sadiee and Paris Bean said Shockley did all their prenatal appointments alone.

Shockley received her midwifery license from the state on Nov. 5, less than three months before attempting to deliver Paris Bean’s breech baby without another licensed midwife present.

The Bean sisters knew Shockley was a student but assumed everything had been done by the books.

Bean chose to deliver her baby at Rosemary on the recommendation of friends and family, including her sister, who chose an out-of-hospital birth after a bad experience at Sarasota Memorial Hospital two years ago this month.

The hospital staff were bossy and rude, refused to let her change positions, and caused her to break her tailbone during delivery, the family said.

“While I’m very frustrated with Rosemary, I do want to express that the hospital’s rigid rules and cold practices and standards are why so many mothers are seeking birthing home births,” said their mother, Nikki Bean. “These birthing homes wouldn’t be in business if hospitals were doing a better job of meeting these mothers’ needs.”

‘I just knew something wasn’t right’

This is not the first time midwives with Rosemary Birthing Home failed to adequately determine a baby’s position, according to state records that show at least one other instance since 2016 when an “unplanned breech” delivery occurred. Birth center owner and licensed midwife Harmony Miller oversaw that delivery, records show.

Miller also oversaw the attempted delivery of another unplanned breech baby in January 2014, said Jennifer Smith, who accompanied her pregnant daughter to the birthing home where she labored for hours without progress.

“I just knew something wasn’t right,” Smith said.

Smith said she eventually encouraged her daughter to go to the hospital over the objections of Miller, whom she said had assured them everything was fine.

When they arrived at Sarasota Memorial Hospital, staff confirmed the baby was in the breech position and needed to be delivered by C-section, Smith said. Baby Cooper was born on New Year’s Day, pink and healthy.

Annual reports submitted to the state by Rosemary Birthing Home show a patient transferred to the hospital during labor for failure to progress the same day.

Smith said she reported the incident to the Florida Department of Health, which regulates licensed midwives under its Council for Licensed Midwifery. But she said she never heard back.

“How did she not know this baby was breech?” Smith said. “My concern is that she doesn’t pay attention to her patients.”

Rosemary Birthing Home opened in 2003 and changed ownership in 2007. Its midwives offer prenatal care, labor and delivery, postnatal care and family education. Deliveries occur both inside the birth center and at the clients’ homes.

It is one of two freestanding birth centers in Sarasota. Birthways Family Birth Center is the other. Together, they called 911 for more emergency transfers than almost anywhere else in Florida. During the past three years, one-third of local home and birth center deliveries ended at the hospital.

The emergencies prompted paramedics to change how they respond to calls from birth centers, while distraught staff at Sarasota Memorial Hospital began tracking the transfers themselves.

“Many of these women have been in labor for three or four days,” John Abu, a physician who heads Sarasota Memorial’s emergency obstetrics, told the newspaper last year. “They’re exhausted. They’re terrified. They have a fever and higher rate of infection.”

‘They essentially told me he would be a vegetable’

Nikki Bean raced from Parrish to Sarasota Memorial after getting a text from Fisher that something had gone wrong during her daughter’s delivery.

When she arrived, her daughter was in surgery having her episiotomy laceration repaired and her grandson was in the newborn intensive care unit.

Frantic for an update, she texted the midwife.

“I’m here with the baby,” Shockley replied.

“Is the prognosis still the same?” Nikki Bean texted.

“Yes,” Shockley said.

“No brain activity. Is that what they’re saying,” Nikki Bean asked.

“Yes,” Shockley replied, before informing her that the baby has “always had a heart rate.”

The text did not disclose that the baby had gone into cardiac arrest and the hospital performed chest compressions to restore his heartbeat after he was delivered.

Three hours after his emergency delivery, the baby was transferred to All Children’s Hospital by helicopter. Fisher was given the option to accompany his son or stay with his wife, who needed to recover from her surgery overnight at Sarasota Memorial.

“I stayed with Paris,” he said, “since they essentially told me he would be a vegetable.”

Shockley visited her client the next morning in Bean’s hospital room. She brought flowers, snacks, kombucha, coconut water and amethyst. Nikki Bean and Fisher had to leave the room. They said they couldn’t stand to look at her.

“When she came up to talk to us, I feel like she was looking for somebody to comfort her, to make her feel better about the decisions that she had made,” Nikki Bean said. “My jaw just dropped. I felt like I was talking to a high school student, not a medical professional or someone who was capable in her skills.”

Shockley has continued to reach out to Paris Bean in the weeks since the incident, but Bean said she has stopped responding. She no longer wants to communicate with the midwife. She said she is angry, upset, betrayed.

“The whole thing is just so sad and ridiculous,” Bean said. “Even all the doctors here say it’s 100 percent because of how the birthing went.”

‘This whole thing was avoidable’

Bean and Fisher have spent every day since then by their son’s side at All Children’s Hospital, where he remains connected to machines to keep him sustained.

Baby Bean, as his parents affectionately call him, has made steady improvements since Feb. 7, when doctors recommended they consider removing life support because he had no brain activity.

That was on a Thursday.

The couple took the weekend to think it over and wait for the results of the next MRI. The results came back that Monday: There was brain activity.

In another sign of good news, Brenden started to breathe some on his own. So the care team gradually reduced the ventilator until they were able to shut it off entirely. The oxygen he receives now keeps his lungs expanded but does not breathe for him.

“Until he started making improvements, I was feeling so guilty and so awful about myself,” Fisher said. “Now we’re just focused on him getting better. We’re taking it day by day.”

Best-case scenario, doctors told them, is that Brenden goes home in another six weeks. What that looks like when they get there, no one can say. But nobody mentions the worst-case scenario anymore.

Brenden was 9.9 pounds and 22 inches at birth. With deep blue eyes and a shock of red hair, he resembles a photo of his infant father taken 37 years ago.

“We’re Irish,” Fisher said with a grin.

Fisher was sitting in the dimmed room near his son’s crib Tuesday morning. Every few minutes, he rose to check the baby, who lay silently on a blanket next to a crocheted octopus gifted by a hospital volunteer.

Bean sat nearby, looking tired but determined. The couple hasn’t been home in three weeks. They spend all day at the hospital and sleep at the Ronald McDonald House down the street.

“We are well taken care of here,” Bean said about All Children’s Hospital. “We feel very blessed. They all love Brenden. They hold his hand and they come in and sing to him and play guitars. They all check up on us and make sure we’re OK. It’s nice to be surrounded by such kind people.”

A nurse entered the room and smiled. She approached the crib and swaddled Brenden in a blanket, then handed him to his mother. Bean cradled the baby as the nurse attached the tube in his mouth to a little machine that drips breast milk into his stomach. Bean has been pumping her milk for Brenden, hoping one day to feed him herself.

She looked down at her son and smiled.

“Once we get home there will be an emotional release,” she said, “but I have had to hold my emotions in for him and focus on him and his growth.”

They closed their business and sole source of income, The Green Bean Coffee House on Bradenton Road in Sarasota, because neither one wants to leave their baby’s side. They don’t know how they’ll manage financially, especially once the medical bills roll in.

They started a GoFundMe page to help cover Brenden’s medical care and physical therapy, as well as to help them reopen the coffee shop when they return. The goal is $100,000. They had raised $1,226 as of Thursday.

Bean and Fisher try to remain positive. They want to believe their son will keep beating the odds and live a full life. But the whole family has a long road ahead, one fraught with uncertainty, unanswered questions and a lot of emotions to process.

“Every time I look at my grandson I well up with so much anger,” Nikki Bean said, “because this whole thing was avoidable had Jordan followed the rules.”