HENRICO COUNTY, Va. — A former nurse is now serving three years in prison for injuring babies in the neonatal intensive care unit at Henrico Doctors' Hospital, but a special grand jury report raises serious concerns about the hospital's response — calling its actions indefensible, incomprehensible and reckless.
Erin Strotman was convicted in connection with broken bones found in NICU infants. The grand jury's findings, which CBS 6 has been investigating for a year and a half, reveal new details about what hospital leadership knew, when they knew it, and what they chose not to do.
When the Hackey family learned one of their twins had a broken leg while in the NICU at Henrico Doctors' Hospital in September 2023, Dominique Hackey texted his mother, who had worked as a NICU nurse.
"A nurse was standing over Noah swaddling him, looked back and said I noticed his left leg wasn't moving, it was kind of discolored," Hackey said.
His mother's reaction was immediate.
"She said, 'That is not right. I've worked in multiple NICUs and there has never ever been a fracture,'" Hackey said.
Hackey told CBS 6 in late 2024 that the hospital did not seem particularly concerned about the fracture. His mother contacted Child Protective Services.
"She said when she called CPS, they were like, 'Oh, you want to report the parents?' and my mom was like, 'No, I want to report the hospital,' and they couldn't believe what they were hearing at that time either," Hackey said.
According to the special grand jury report, CBS 6 was able to confirm for the first time that CPS screened out the grandmother's concern after calling Henrico Doctors' Hospital, speaking to one of the infant's physicians, and being told her concerns were unfounded.
By the day she called — Sept. 7, 2023 — the hospital was already aware of three other children with fractures dating back to early August. However, the hospital did not notify CPS about the four babies found with broken bones between Aug. 5 and Sept. 3, 2023, until Sept. 21 of that year.
Instead, the hospital consulted with a variety of radiologists, including Dr. Gerry Reece, who all expressed concerns about the fractures, which CBS 6 was the first to exclusively report in January of 2025.
Reece, an “experienced and well-regarded radiologist in the greater Richmond area,” told the Chief Medical Officer at HDH, Dr. Ajit Singh, on Sept. 11, 2023 that what he was observing in the images of the four babies with fractures "was inconsistent with normal handling and metabolic bone disease," according to the report. He said the injuries were concerning for "non-accidental, inflicted injury."
He even created a "windows of opportunity" document for HDH to explain when the fractures may have occurred.
After offering his opinion at the Sept. 11 meeting, “he was not consulted again."
The hospital even hired legal counsel to begin an internal investigation, and placed Strotman on administrative leave before CEO Ryan Jensen and VP of Quality Denise Weisberg called CPS to report the unexplainable fractures on Sept. 21.
The jurors stated this showed an attempt to obfuscate, and called the decision to defer notification reckless, saying it may have led to patient harm.
"How many more people need to tell you it's abuse or negligence before you do something? It doesn't make sense to me," Hackey said.
HCA told CBS 6 in a statement that it believes the suggestion that the hospital was late in reporting the 2023 events is "inaccurate." HCA said when the fractures were first found, the hospital did not have reason to suspect abuse, but once it suspected the injuries might have been caused by non-accidental trauma, it promptly reported the matter.
According to the jury report, leadership at Henrico Doctors' Hospital — including CEO Ryan Jensen — believed the injuries were the result of metabolic bone disease or spontaneous fractures, as opposed to abuse or negligence. They maintained that belief even after three more babies suffered broken bones in the NICU in late 2024, according to the report.
The jurors' report stated that theory was contrary to the state of medicine and the facts of the case, as well as videos of Strotman transferring body weight onto NICU infants. The report stated the reason for Jensen's position was to reduce the hospital's liability and allow the hospital to continue business as usual.
A footnote in the report does state the special grand jury was not unanimous in its belief that the hospital cares more about the brittle bone narrative than the care of its patients.
HCA told CBS 6 it does not accept the suggestion that the hospital placed self-interest above patient safety, and that characterization is wrong.
Because of the 2023 delay in reporting to CPS, the special grand jury stated the 2023 investigation by police and CPS was harmed and impeded, and investigators were not able to identify a suspect at that time.
The Commonwealth's Attorney and CPS did require the hospital to implement various safety measures, including video cameras in all NICU rooms. But by late 2024, more babies began suffering broken bones.
During the investigation of the 2024 fractures, investigators learned the hospital brought Strotman back to work in September 2024, then placed her on leave again once the first 2024 baby was found with fractures. According to the special grand jury, the hospital did not tell police that.
Henrico Commonwealth's Attorney Shannon Taylor addressed the hospital's handling of the situation after Strotman's sentencing hearing.
"Henrico Doctors' Hospital, the management of how they conducted the NICU back in 2023, was not good," Taylor said.
HCA stated its team consulted with the Commonwealth's Attorney's Office on Strotman's potential return in 2024 and that the office had "no concerns" as long as appropriate training and guardrails were in place. Taylor told CBS 6 that was not true, and that her office specifically said it could not take a position on their employees' status or their practices.
Jurors found the hospital had not been reviewing the recorded video footage and called the hospital's failure to monitor nursing care in the NICU after 2023 indefensible.
"It is shocking to me that the hospital didn't do more, that they let her come back, that they let this happen again. I don't know how this happens twice," Matthew Whitfield, whose baby was in the HDH NICU in late 2024, said.
CBS 6 still does not know why Strotman was brought back to work in 2024. The report states that because of the hospital's assertions of attorney-client privilege, the hospital will never be compelled to produce relevant material to the public — including the results of its 2023 internal investigation, what involvement Jensen had in the Strotman matter, whether he approved her return to work in 2024, or who did and why.
Taylor previously said she would explore holding individuals accountable beyond Strotman if the evidence was there.
"They protected themselves and kept a lot of information that the grand jurors said ultimately we're not going to be able to do this prosecution because of the actions they definitely took back in September of 2023," Taylor said.
While the hospital has entered into financial settlement agreements with all the families, which precludes them from talking to CBS 6 about the findings in the report related to the hospital, Hackey previously had this to say about Henrico Doctors' Hospital.
"This is an institution that is supposed to protect the most innocent human beings, and they didn't. For the life of me I can't understand why," Hackey said.
The special grand jury also expressed concerns about why the hospital did not report Strotman to the Virginia Board of Nursing in 2023 or 2024. It also made several recommendations to the hospital and the General Assembly about actions they should take to protect vulnerable children in the future.
Among those recommendations to legislators:
- The General Assembly enact legislation that expands the power of VDH so that it can suspend the license of an individual unit inside of the hospital, not just the whole hospital.
- The Special Grand Jury also recommends that VDH and CPS be given the power to fine hospitals that are found to be out of compliance with safety plans implemented as the result of articulated concerns for abuse or neglect.
- The Special Grand Jury recommends that legislation be created that prohibits any health care entity from designating documents or investigation as protected by attorney-client privilege in a child abuse or neglect case.
Among those recommendations to HDH:
- The mandatory CPS reporting law of the Commonwealth be posted on HDH’s website, in every patient room, included in NICU onboarding materials, and reviewed with every individual working with NICU children at HDH.
- Contemporaneous video reviews should be conducted of patient care in the NICU on a quarterly basis to confirm patient safety.
- A mandatory annual in-service on HDH’s fragile bone protocol that includes the latest research should be conducted at HDH. HDH should retain a board-certified child abuse pediatrician on its staff and every CPS referral that is made should be reviewed by that physician.
- HDH should enhance its requirements for working in the NICU and establish minimum requirements of at least a Bachelor’s of Science in Nursing and five years of nursing experience.
- HDH should require mandatory prescription drug checks and random drug screens for employees assigned to the NICU.
CBS 6 asked HCA if it planned to implement any of the special grand jury's recommendations. HCA did not directly answer the question, but said it learned from the experience and has made meaningful changes to strengthen safety reporting and oversight in the NICU. Those actions include strengthening reporting protocols and mandatory training on identifying and reporting suspected abuse and neglect.
Here is HCA's full statement:
"We hope Ms. Strotman’s sentencing helps bring some measure of closure for the families impacted by her actions.
"The injuries suffered in the NICU are attributable to one thing and one thing only: the criminal conduct of Erin Strotman. What she did was incomprehensible. She was indicted and sentenced for her crimes because of the measures HDH took to monitor the NICU, the vigilance of our care teams, and the evidence our team helped provide to law enforcement and prosecutors.
"We are aware of the suggestion that Henrico Doctors’ Hospital was late in reporting the 2023 events. That suggestion is inaccurate. When the fractures were first found during routine care, the hospital did not have reason to suspect abuse. Still, the hospital undertook a thorough investigation to determine their cause. When the investigation was unable to identify an explanation and the hospital first suspected that the fractures might have been caused by non-accidental trauma, it promptly reported the matter to the proper authorities, as required by Virginia law.
"During our internal investigation of the injuries, our medical teams and hospital leadership evaluated all potential causes, consulted with independent outside medical experts, and asked difficult questions because a thorough patient-safety review requires that every possibility be considered. Furthermore, by installing video cameras, we were able to document Ms. Strotman’s behavior and establish once and for all the cause of these injuries.
"That truth does not lessen the heartbreak of what happened. Our hearts remain with the babies and families affected. What they experienced was devastating, and we continue to hold them at the center of our thoughts and actions.
"We do not accept the suggestion that HDH placed self-interest above patient safety. That characterization is wrong and does not reflect who we are or the actions we took to protect patients. Our teams escalated concerns, monitored the NICU, supported law enforcement with evidence, and worked with regulatory and oversight agencies throughout this process.
"The decision to allow Ms. Strotman to return to work was not made in isolation. Our team consulted with the Commonwealth’s Attorney’s Office on her potential return, and they had no concerns as long as appropriate training and guardrails were in place. Out of an abundance of caution, we also put other colleagues on administrative leave during the investigation who later returned to work.
"At the same time, we recognize the seriousness of what occurred and the responsibility we have to keep strengthening our systems. We have learned from this experience, and we have made meaningful changes.
"HDH has taken significant steps in partnership with regulatory and oversight agencies, law enforcement, and child protective services to strengthen safety, reporting, and oversight in our NICU. These actions include, but are not limited to, strengthening reporting protocols, mandatory training on identifying and reporting suspected abuse and neglect, increasing leadership rounding in the NICU, and 24/7 video recording in NICU rooms.
"Several of the special grand jury report’s recommendations, including fragile bone protocol training and video reviews of NICU patient care, were implemented in 2024 and 2025, along with additional enhancements to our processes and protocols.
"We are grateful for our care teams who continue to care for patients and families with compassion, professionalism and integrity."
CBS 6 is committed to sharing community voices on this important topic. Email your thoughts to the CBS 6 Newsroom.
📲: CONNECT WITH US
Blue Sky | Facebook | Instagram | X | Threads | TikTok | YouTube
This story was initially reported by a journalist and has been converted to this platform with the assistance of AI. Our editorial team verifies all reporting on all platforms for fairness and accuracy. To learn more about how we use AI in our newsroom, click here.
