Texas board finds ER doctor failed to recognize newborn's vitamin K bleeding

State medical board disciplined the doctor but did not restrict her license

The Texas Medical Board disciplined ER doctor Nicole Malouf in October 2025 after finding that she failed to recognize Gwen Biesenbach’s life-threatening vitamin K-dependent bleeding disorder, failed to immediately transfer Gwen to a regional pediatric referral hospital better equipped to handle her condition, and failed to quantify the amount of blood the newborn had lost. The board also found that Lonestar 24HR ER did not have vitamin K shots on site. Its order required Malouf to complete 24 hours of continuing medical education and inform her employers of the discipline. It did not restrict her license, and she neither admitted nor denied the allegations but agreed to the final order. Gwen died shortly after 9 a.m., nearly 11 hours after her parents first brought her to the ER. The medical examiner listed vitamin K deficiency bleeding as her cause of death.

Stephanie and Eric Biesenbach’s account of their daughter begins at home. Stephanie gave birth to Gwen without complications in an inflatable tub in their living room. ProPublica described Gwen as “perfect,” with doelike eyes and a full head of brown hair that, when the light hit it, hinted at the red of her father’s beard. Her older brothers and sisters fussed over her like a birthday present, and her aunts from California and Louisiana came to meet her. When the house quieted, Gwen fell asleep to the rhythm of Stephanie’s chest rising and falling. Stephanie said Gwen seemed to study the faces of everyone who carried her. Even before she was two weeks old, the corners of Gwen’s mouth constantly turned up to form what her parents insisted were smiles, and she rarely cried when her siblings passed her around.

Stephanie and Eric met in 2010 while working at Chili’s. Both were Texas natives who had returned home after time in Florida, where Stephanie spent a semester interning at Walt Disney World Resort. “I was doing lawn care work and maintenance on restaurants,” Eric said before Stephanie interjected, “He moved there for a girl,” as the two laughed. He proposed to Stephanie on Christmas Eve, and they married at a vineyard on Halloween. The venue ended the night with fireworks. They later had a daughter and two sons and adopted the daughter of a relative who was too young to care for her. Just when they thought their family was complete, Stephanie became pregnant with Gwen. Overjoyed, they named her after Stephanie’s grandmother, Gwendolyn, who passed down a flowered baby blanket with “Gwen” embroidered in the corner.

There were no signs something might be wrong with Gwen until the day her parents took her to the ER. Stephanie texted her midwife first: “So sorry to bother you,” she wrote while explaining that Gwen’s belly button had been bleeding most of the day and would not stop. “How much blood is too much blood,” she asked. The midwife requested a photo, and Stephanie sent two: one showing dried blood on Gwen’s stomach and another showing bloodied tissues. The midwife instructed her to tape gauze over Gwen’s belly button. About 90 minutes later, just before bed, Stephanie sent another picture showing bright red blood soaking through the gauze and diaper and asked, “Are you sure this is fine?” The midwife told her to go to the emergency room.

The emergency room was a mile from the family’s Texas home, and Stephanie and Eric took comfort in that when Gwen would not stop bleeding from her belly button. At Lonestar 24HR ER, a freestanding department in New Braunfels next to a car wash, a McDonald’s and a deli, medical records from a warm August evening in 2023 described Gwen’s condition as a “generic problem” of a bleeding umbilical cord stump. Malouf, the emergency-room specialist on duty, had treated many bleeding stumps. She covered Gwen’s oozing belly button with special gauze, and when the flow appeared to stop, she sent Stephanie, Eric and Gwen home. They made it as far as the parking lot before Gwen bled through her footed pajamas. Eric lifted his 11-day-old daughter from the car seat, and the family walked back into the ER. Stephanie told Malouf that Gwen had been bleeding a bit after the scab that replaced her umbilical cord stump fell off. The amount of blood they saw that night worried Stephanie and Eric. She reported no fever, no vomiting and that Gwen was exclusively breastfed. Stephanie and Eric had declined a vitamin K shot when Gwen was born and instead had been giving her oral vitamin K drops, which they trusted would protect her.

Over nearly three hours, medical records show, Malouf used seven methods to stop the bleeding. She tried another type of pretreated gauze. When that did not work, she turned to silver nitrate, a chemical applied to the tip of a long matchlike stick that cauterizes blood vessels. Malouf rotated one stick after another inside Gwen’s belly button. At one point, Malouf applied enough pressure to a bandage that Gwen threw up, Stephanie said. ProPublica reported that the remedies treated the symptoms rather than the cause. Malouf said she called her husband, who is also a doctor, and a nurse at a local hospital to ask whether she was missing something. They were at a loss, and the nurse’s suggestions were remedies Malouf had already tried.

Malouf initially planned to transfer Gwen to a small local hospital with pediatric specialists and a neonatal intensive care unit. While she waited for confirmation that the hospital would accept Gwen, Stephanie reported that Gwen had bled through the latest dressing. Records showed that Gwen’s blood vessels also took longer to refill than when she had arrived. Gwen grew increasingly pale, and her heart raced at 177 beats per minute. Gwen’s condition was growing more dire, and Malouf had reached the limits of what she could do; ProPublica reported that what followed also would not be enough. In many states, all emergency rooms are in hospitals, where patients can be transferred to other units for more care. In Texas, more than 200 ERs are freestanding facilities separate from hospitals. Around 1:40 a.m., Stephanie and Eric received their first piece of good news: Malouf was transferring Gwen. She had scrapped her plan to send Gwen to the local hospital and would instead transfer her to North Central Baptist, a larger hospital in nearby San Antonio with more specialists. North Central was about half an hour away and was sending a NICU transport team.

Eric watched a large clock as 10 minutes passed, then 20, then 30 and finally an hour. He asked whether he could drive Gwen to the hospital himself. Eric said Malouf told him that would be too dangerous. Malouf said she told him he would have to sign paperwork acknowledging that he was leaving against medical advice, that the transport team would carry blood and IVs and that Gwen was stable. Malouf said she called to check on the ambulance’s status and was told the crew was on their way. Stephanie and Eric said that was the last time they spoke with Malouf that night.

By the time the ambulance arrived, nearly two hours had passed since Malouf requested it. One of the crew’s first questions was whether Gwen had received a vitamin K shot. The ER nurse told the transport team that the facility did not have the shot on hand. It was the first time since entering the ER, Stephanie said, that anyone had suggested vitamin K might be both the cause of the bleeding and its treatment. At 3:45 a.m., within minutes of the team’s arrival, the crew gave Gwen a vitamin K shot in her left thigh. Over the next two hours, they placed an IV, drew blood for laboratory tests and gave her antibiotics. Records showed that those steps had not been taken during Gwen’s hours at the ER, and Malouf did not answer questions about why they had not been done earlier.

Stephanie and Eric observed the ambulance team as it worked, bantering and discussing another call that had come in. Just as the team was about to leave, it waited for one member to go to the bathroom. Stephanie and Eric said the team’s laidback pace, together with Malouf’s reassurances that Gwen was stable, encouraged them enough to split up. Eric went home to the children, who had been with his mother all night, to get them ready for their first day of school. “Grab me a change of clothes and coffee,” Stephanie called to him as he left. Stephanie remained with Gwen and planned to ride in the ambulance. The team transferred Gwen to a temperature-controlled enclosed incubator. As they prepared to leave, Gwen began to whimper with each breath. Stephanie said the sound was weak, high-pitched and unnatural. She reached through the incubator’s opening and ran her hands back and forth across her daughter’s chest.

The ambulance headed down Interstate 35 with its sirens and lights on at 5:55 a.m., seven hours after Gwen was first admitted to the ER. Her blood pressure dropped during the trip. “Infant looks much more lethargic,” the team wrote in its notes. The crew placed a mask on Gwen to increase her oxygen and gave her an infusion of saline in hopes of improving her blood volume.

Almost immediately after the ambulance reached North Central Baptist, Gwen’s heart stopped. Doctors inserted a breathing tube, pressed down on her chest with two fingers to pump blood through her body and pushed epinephrine into her IV to stimulate her heart. That appeared to work. Stephanie said she could not comprehend what was happening. All night, she said, no one had acted as though Gwen’s life was in danger. Suddenly, her daughter was covered in tubes and doctors were performing CPR. Stephanie said she heard someone yelling into a phone, “Where is the blood?” She texted her family, “I need you to pray for Gwen like her life depends on it,” and called Eric: “You need to get here now.” Eric pressed the accelerator of Stephanie’s Honda and sped to the hospital. He pushed through a group of doctors to find Stephanie crying in the corner of the room. For the first time, he worried he might lose his daughter. They prayed together, and a chaplain stopped by the room to check on them. He noted in the records that they were anxious but hopeful.

Less than two hours after Gwen was admitted, she crashed again. The medical team called a code blue and performed CPR for 34 minutes, giving her four more doses of epinephrine. She had lost so much blood that her heart was barely pumping. Doctors told Stephanie and Eric that they could continue resuscitation or have Gwen removed from the machines so they could hold her. Stephanie sobbed, and Eric collapsed at her knees. She told him she could not make the decision. Eric said they wanted to spend Gwen’s final moments with her. The doctors unhooked Gwen from the machines and handed her to him. Stephanie and Eric told Gwen how much they loved her and how much they would miss her.

Gwen died shortly after 9 a.m. The team took the family to a private room where they could mourn, and the family spent hours there. They gave Gwen a bath and allowed family members to visit. Stephanie’s sister picked up the couple’s children from school so they could say goodbye to their baby sister. Two nurses made molds of Gwen’s hands and feet. When Eric and Stephanie finally left the hospital, Gwen’s car seat was empty. Their two youngest children slept in their bed that night. Stephanie later jolted awake and turned to Eric. The look in his eyes told her that Gwen’s death had not been a dream. Without making a sound that could wake their children, they cried themselves back to sleep.

Eric’s grief soon turned to anger. His brother-in-law drove him to the Lonestar ER to retrieve Gwen’s medical records because Eric did not trust himself to go inside. The file contained 15 pages of payment and registration forms but no clinical material the parents could use. They searched for a clue that could explain what happened to their daughter. “I was constantly assured that it wasn’t that bad,” Eric said. “I can’t tell you how many times they said, ‘Don’t worry, babies are very resilient.’” The family planned Gwen’s funeral. When they could not find a coffin small enough for Gwen’s 8-pound body, Eric’s brother, who makes custom cabinets, built one. They wrapped her for the viewing in the flowered blanket Stephanie’s grandmother had embroidered with her name.

The family attended a grief camp run by a local hospice group, painted a garden pole with items that reminded them of Gwen and went to Stephanie’s sister’s house in Colorado around Thanksgiving to avoid questions about how they were coping. Eric later had Gwen’s handprints tattooed on his chest, the last place he felt them before she died. Stephanie chose Gwen’s footprints, but the tattoo artist had to reduce their size to fit. “She had such big feet,” Eric said. “She was gonna be a tall girl.” Stephanie answered, “Or clown,” half laughing and half crying. “One of the two.”

The family consulted medical-malpractice attorney Byron Miller, who sought records from Malouf, the ER, the ambulance company and the hospital. Miller investigated whether negligence in Gwen’s care had resulted in her death. The medical expert hired to review the case focused instead on Stephanie and Eric’s decision to give Gwen drops rather than the shot. Without an expert’s supporting opinion, which Miller said was a state requirement, his office could not continue the case. Miller recommended that the family contact the Texas Medical Board.

That next December, Stephanie sat down at the kitchen table, pulled out her laptop and said someone had to hold Malouf accountable. She found the Texas Medical Board’s website and followed the instructions to file a complaint. “When Dr Malouf decided to provide medical care to our daughter, despite her lack of training in neonatal emergency care, and lack of appropriate monitoring equipment,” Stephanie wrote to the board, “Gwen was deprived of any potential life saving intervention.” She wrote that the seven hours they had spent in the ER could have been used to save Gwen’s life and stressed that the ER nurse had said the facility did not carry the vitamin K injection. “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.” Stephanie also described the pain of driving past a Lonestar billboard bearing Malouf’s photograph every day. She wrote that Malouf failed to recognize that Gwen’s life was in danger: “I just don’t understand how it can go from a calm relaxed environment to all of a sudden your child is dead.” Stephanie recounted feeling intimidated when Eric asked whether they could leave as Gwen’s color began to change and Malouf advised against it. She added: “To this date, Dr Nicole Malouf does not even know that my daughter died under her care.”

The Texas Medical Board launched an investigation, subpoenaed records and reviewed the medical documents. In September 2025, it held a virtual hearing closed to the public. Stephanie and Eric appeared, as did Malouf and her attorney. A board staff attorney charged that Malouf had not met the standard of care, had failed to halt or limit Gwen’s bleeding and that her lack of timely care ultimately resulted in Gwen’s death. Citing confidentiality, the board did not release a recording or transcript. The next month, the board issued its decision and imposed the education and employer-notification requirements. Malouf said she completed courses on pediatric advanced life support, communicating with patients and vitamin K deficiency bleeding. A board spokesperson would not answer specific questions about Gwen’s case but said the board expects all licensees “to provide appropriate treatment and, if the necessary supplies are not available, to make arrangements for transport to a higher level of care.”

The ER, the ambulance company and the hospital did not respond to multiple requests for comment. The nurse on duty at Lonestar that night also did not respond to requests for comment. After Gwen died, Malouf said, a doctor from the hospital called her, and the news of Gwen’s death came as a surprise. Malouf said the doctor told her the hospital would conduct its own review and had already identified some issues, including questions about the transport team.

Sitting in her home office, with her framed degrees hanging on the wall behind her, Malouf spoke to ProPublica for nearly three hours about what happened. She and her husband have three daughters, for whom she serves as team mom for cheerleading and president of the Fine Arts Boosters. Racks of uniforms filled her home’s entryway in preparation for an upcoming sale. Malouf said she repeatedly relived the details of that night with her therapist. The first few sessions, she said, were just the two of them crying. They discussed what was in her control and what was not. “Every life is precious,” Malouf said, “but it’s one thing to lose a 95-year-old grandmother with a long list of medical problems. It’s another to lose a baby.” “I still have my three daughters,” Malouf said, pushing back her long, dark hair, “and now she has lost hers.”

Malouf said she had done everything she could with the resources available and maintained that she recognized Gwen’s vitamin K deficiency bleeding that night. She said she did not immediately administer the shot because she believed it would no longer work in time. “It’s really not even going to take effect at that stage,” she said. “As soon as you give vitamin K, the earliest it’s even going to start working is 10 to 12 hours.” Malouf said the board did not believe she recognized the condition because she had not acted “in a panicked manner.” She said she asked the nurse for the shot and remained unsure whether the ER carried it that night or whether it was somewhere the nurse could not find it. She believed that giving it to Gwen at that point would have been to make her chart look good.

Several doctors told ProPublica that vitamin K should be given immediately whenever there is even suspicion of vitamin K deficiency bleeding. They said doctors should not wait for confirmation and that there is no downside to administering it. They said it may need to be followed with blood or blood products, such as fresh frozen plasma, which is rich in proteins that help blood clot. Vitamin K can quickly help stop the bleeding, but it cannot reverse bleeding that has already occurred. It also has to be given in time, and some babies need more than one dose to recover. One doctor who reviewed Gwen’s records said she needed vitamin K, blood and blood products much sooner than she received them.

Malouf said she learned about vitamin K deficiency bleeding in medical school and during her residency but could not recall seeing it in practice. Nearly every medical student learns about the coagulation cascade, but not all doctors know or remember how to diagnose and treat an infant who arrives at an ER bleeding, often in the brain and invisible to the eye. Some physicians completed their training when vitamin K deficiency bleeding was still considered a historic condition, much like measles. Malouf said the Lonestar staff had since been trained on the importance of vitamin K, that the ER now keeps it in stock and that every ER should carry it. “I still gravely regret that the outcome was still the same,” she said, “even after again assuming that, ‘Hey, I’m putting this baby in y’all’s hands. You guys are the experts. Fix her.’”

Malouf said she did not understand how the board found that her care fell short and said she did not intentionally harm her patient. “I can state my whole case and literally one of the board members goes, ‘Well, I just don’t believe you,’” Malouf recalled. “I said, ‘Well, then I don’t know what more to tell you.’” In addition to working at the ER, Malouf had a part-time telehealth job. She said the telehealth company fired her after she disclosed the board’s action. As of August, she was still working some shifts at Lonestar, and the board’s decision did not affect her ability to practice. Following the interview, she declined further comment. “I feel like the only way to change the outcome is to go back to the beginning, that fork in the road,” she said. “And go, ‘OK, well let’s give vitamin K after birth.’”

Since the 1960s, the vast majority of newborns in the United States have received the vitamin K shot, and the injection virtually eliminated vitamin K deficiency bleeding, a rare condition that can cause catastrophic bleeding and death. ProPublica described families that had begun to shun the shot as “mistrustful of medical interventions, misled by social media and devoted to a birth experience they deem natural.” Two studies published the previous week, each involving millions of births, found that babies who did not receive the shot had an increased risk of bleeding. One study found that the rate of vitamin K deficiency bleeding increased 347% between 2017 and 2025. ProPublica also reported that babies were dying after the shot was skipped, that autopsies showed their systems shutting down without warning and that parents who declined the shot were left mourning the loss of their children.

A single vitamin K shot acts quickly, after which the liver stores the remaining vitamin and slowly releases it into the baby’s system over months. For decades, the recommendation from doctors, hospitals and medical organizations generally has been the shot. The Centers for Disease Control and Prevention, the American Academy of Pediatrics and the World Health Organization call for giving the shot to all newborns. It is not a vaccine and is a single, inexpensive injection. “While some countries outside of the U.S. sometimes administer vitamin K orally, it has not been approved by the Food and Drug Administration,” the American Academy of Pediatrics wrote in May, reiterating its longstanding position, “and it is less effective than an intramuscular injection.” Many medical experts consider the drops inferior for several reasons, including that some babies cannot absorb them or may spit them up. There are also concerns about harried parents of a newborn forgetting a dose and cases of vitamin K deficiency bleeding being reported even when drops are used. Limited data exists about the drops, much of it from Europe, where the drops are more common. In the U.S., the Food and Drug Administration does not provide oversight of the drops, which parents can add to their Amazon carts without verification of what they contain or whether they are safe and effective.

Stephanie appreciated the importance of vitamin K, and all of her other children had received the shot shortly after birth. But she and Eric had grown wary of medical intervention. When their youngest son was nearly 2, Stephanie and Eric said, they fell behind on his vaccines. After receiving several vaccines at one appointment, he developed a high fever and stopped talking for about a year. He was later diagnosed with autism. “I think that they just gave him too much at once,” Eric said. Research from numerous sources has found that multiple vaccines given at once do not overwhelm or weaken a child’s immune system or increase the risk of serious or long-term adverse effects. Stephanie and Eric nevertheless said they became convinced their son’s symptoms were connected to the vaccines and stopped vaccinating their children.

Before Gwen’s birth, Stephanie’s midwife gave her a five-page handout about newborn vitamin K. It explained that babies need vitamin K to help their blood clot and cautioned that those without enough can begin bleeding without warning. The handout compared the shot with oral drops, noting that some babies may not absorb the drops or may spit them up and that the drops do not eliminate the risk of bleeding. Stephanie initially signed a document agreeing to the shot. As her due date neared, she and Eric changed their minds, reasoning that if both options worked, they would spare their baby the needle. “We did our own research,” Stephanie said. “I don’t remember feeling like there were red flags. I felt like the information we had was sufficient.” She did not recall exactly which sources she consulted, but she read articles online and spoke with people who worked in medicine. No one warned her against the drops, she said. She did not ask her mother, Lauren Hoel, a longtime family nurse practitioner, about the drops. Stephanie knew exactly what her mother would say.

ProPublica reported that vaccine skepticism grew after the COVID-19 pandemic and wrote that, under the direction of Health and Human Services Secretary Robert F. Kennedy Jr., “the federal government has fed those doubts.” The source reported that Stephanie and Eric voted for President Donald Trump, supported Kennedy and the Make America Healthy Again movement and welcomed the changes. In December, the CDC stopped recommending that all newborns receive the hepatitis B vaccine. In January, the agency revised its childhood vaccination schedule, reducing the number of routinely recommended shots by six. A federal judge temporarily blocked that move in March, but ProPublica said the CDC’s decisions appeared to have caused a ripple effect beyond vaccines.

After the January change to the vaccine schedule, an analysis of more than a million newborns found that the rate of babies not receiving the vitamin K shot rose from 5.2% to 8.1% between January and June of this year. Despite being asked multiple times at a congressional hearing to assure parents that the vitamin K shot is safe, Kennedy responded that he had not said anything publicly about it. An HHS spokesperson did not answer ProPublica’s questions but said the CDC recommends that parents give newborns the shot within six hours of birth to prevent vitamin K deficiency bleeding.

Stephanie and Eric also asked themselves what they should have done differently. They wished they had left the ER and driven Gwen to a hospital. “We were just trusting that the person who went to school their whole life for this would know more than us,” Eric said. In their view, the vitamin K decision had overshadowed the medical mistakes they believed were most responsible for Gwen’s death. By the time Gwen arrived at the hospital, her organs were already starting to shut down. The autopsy found tiny spots of bleeding in her kidneys and small intestine and a scrape on her chest where doctors had pushed during CPR. The medical examiner noted Gwen’s precipitous decline and listed her cause of death as vitamin K deficiency bleeding. If they could go back, both said they would have gotten the vitamin K shot for Gwen. “I don’t trust a lot of things,” Stephanie said, “but get peace of mind and get the vitamin K shot.”

Stephanie and her mother had several conversations about vitamin K. Hoel remembered learning in the 1980s, while in nursing school, that all babies need a vitamin K shot at birth. Hoel did not know that Stephanie and Eric had declined it for Gwen. “It never occurred to me that people would refuse the vitamin K shot,” she said. Hoel said Malouf’s failure to send Gwen to a neonatal intensive care unit was the graver error. “She should have said, ‘That’s a newborn. Take it to a NICU,’” Hoel said. “And by not doing that, the fate was sealed.”

A few months after Gwen’s death, Stephanie learned she was pregnant again. She gave birth to a girl in 2024, and the family welcomed another daughter in summer 2026. Both received vitamin K shots.