The Death of Baby Cairo: A Case Study in Implicit Bias


Cornell Gunter’s Twitter feed read, “My son is gone. @Orlando Health killed my son.”


I stared at the tweet in disbelief. Orlando Health? The one in my community? The one where retired Residency Director, Dr. Steve Carlan managed most of my high-risk pregnant patients with compassion, laser-beam focus and clinical excellence? THAT Orlando Health?


On April 21, 2021, 4-day old Cornell Gunter left this earth, although he should have remained. The chronology of events that his father, Gunter, documented are chilling:


04/17/2021 Gunter’s fiancé arrives at Orlando Health triage at 11:55 p.m. with complaints of decreased fetal movement x 10 hours at 40 weeks.

  • The American College of Obstetrician and Gynecologists recommend induction of labor at 39 weeks to reduce adverse outcomes.

Per Gunter’s note, the front desk clerk comments that “she’s been getting a lot of folks with complaints of babies not moving” and instructs Baby Cairo’s parents to have a seat where they wait for approximately 25 minutes

  • Ten hours of decreased fetal movement is a red flag of potential problems. The standard of care is an immediate evaluation to document fetal well being with an ultrasound

At 12:30 a.m., a nurse arrives and asks, “What’s wrong?” Baby Cairo’s parents explain that Nicole is leaking meconium-stained fluid and is well-versed in its adverse effects, especially if Baby Cairo swallows it.


Per Gunter’s note, the nurse challenged Nicole’s answer and asked, “How do you know it’s meconium?”

  • The nurse’s challenge is the first example of implicit bias as well as a nurse disbelieving a patient

2:00 a.m. A pelvic exam by the nurse proves that Nicole was correct. Nicole now requires a COVID test and then the nurse recommends monitoring Baby Cairo. The nurse performs a brief ultrasound and documents that Baby Cairo’s head is down

  • It does not appear that fetal monitoring was done to document a normal heart rate.
  • Two student nurses attempt to start an IV and fail, although Nicole explicitly provided written objection to be part of nursing student training.
  • The use of student nurses is not appropriate in an emergency setting, especially when the patient documented her decision.

Anesthesia arrives to place an epidural, and Baby Cairo’s parents now wait to see if it is working.  Minutes later, the sound of an alarm causes six nurses to enter the room and begin fetal resuscitation, although per Gunter, no one gives them an explanation. Nicole must flip from one side to another because Baby Cairo’s heart rate dropped. This maneuver is called fetal resuscitation.  It is 5:00 a.m. and approximately five hours after Baby Ciaro’s parents arrive in OB Triage.


An ob-gyn physician enters the room. She is of the same ethnicity as Baby Cairo’s parents. She examines Nicole, but she is unable to determine if the cervix has dilated. She requests another fetal monitor but the student nurse fumbles In her attempt to connect the cables.


Despite an emergency C. Section, but Baby Cairo did not breathe, although he had a heartbeat. The pediatricians instruct his parents to take pictures with their phones. He did not receive oxygen for eight minutes, and the prognosis was not good.


Baby Cairo’s dad hit social media with a vengeance, and rightfully so because his son fought valiantly for his life but lost.


Baby Cairo’s parents aren’t the only ones who placed Orlando Health in an unwelcoming spotlight. On September 19, 2016, Baby Reggie Jacques took his last breath at Orlando Health after 95 days of struggling to live. He, too, was born with brain damage after not receiving enough oxygen. His grieving mother, Ruth, handed out flyers in front of the hospital advising prospective patients to stay away from the physician who had performed her delivery. Her lawyer made her stop for reasons articulated in the Miami Herald article.


Facts checked: The U.S. has 4.5 million Black college graduates, 16.6 million Black college students, 8 percent Black millionaires, and 1.2 percent billionaires, two which come from humble beginnings (Oprah Winfrey and Sean Carter (aka Jay-Z). Kanya West is also a black billionaire, but his late mom held a PhD. In psychology).

Do not assume that all black people are stupid because we are not. We shouldn’t have to walk around with our credentials or bank accounts tattooed on our foreheads before we garner respect. Implicit bias is real, dangerous, and needs to stop.


Baby Cairo should be sleeping in his comfortable crib rather than in a grave.


Orlando Health, please fix this.


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