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Prescription for Disaster: How loopholes in the system can let a bad doctor keep hurting people

What about the system that created and enabled Christopher Duntsch to move from hospital to hospital? That system left dozens of maimed and paralyzed patients in his wake. His attorneys argued the hospitals also have “blood on their hands.”

Don Martin smiles as he sorts through his VHS tapes.

It’s the story of his life with his wife and their two daughters.

His wife, Kellie, went in for what was supposed to be a minor back operation in 2012. It would turn out to be anything but.

She bled to death after her surgeon nicked an artery during the operation at Baylor Regional Medical Center at Plano. She was 54.

“I can’t get that image out of my mind that this could have been easily avoided,” said her husband, a retired Garland police officer. “I realize now that no surgery is minor.”

Last month her surgeon, Christopher Duntsch, was sentenced to life for the botched surgery of an elderly woman in a landmark case.

But what about the system that created and enabled Duntsch to move from hospital to hospital? That system left dozens of maimed and paralyzed patients in his wake. His attorneys argued the hospitals also have “blood on their hands.”

Duntsch is a case study of everything that can go wrong: How hospitals can pass along bad surgeons to the next unsuspecting hospital, how some hospitals ignore warning signs -- even after they’re warned -- how hospitals circumvent the National Practitioner Data Bank reporting process that’s supposed to help alert hospitals to bad doctors, and how the medical board sometimes fails to move quickly enough to avert a crisis.

It’s a prescription for disaster.

“We failed as a profession to acknowledge, recognize and try to stop somebody who was harming the public,” says Dr. Allan Shulkin, a former member of the Texas Medical Board.

The national data bank, created in 1986, was designed to protect patient safety and alert hospitals to a doctor’s disciplinary history.

It requires hospitals to report doctors whose privileges have been restricted or revoked for more than 30 days because of competency issues or professional misconduct. It requires them to report to the database if they accept surrender of clinical privileges while the doctor is under investigation for incompetence or professional misconduct. They also have to report if they drop the investigation in exchange for the doctor giving up his privileges.

But it only works if hospitals don’t circumvent the rules.

It’s instructive to take a look at what Baylor did after it hired Duntsch in 2011.

One surgery maimed Barry Morguloff in January 2012. A second surgery left his best friend, Jerry Summers, a quadriplegic, the next month. Kellie Martin died during a botched surgery in March 2012.

Baylor did not revoke or suspend Duntsch's surgical privileges. They instead allowed him to take two leaves of absence – one after the Summers surgery and one after the Martin surgery.

The hospital launched a peer review investigation after the Summers case.

But before that investigation was complete, they let him operate again. Hospital officials testified they did so because he had been cooperative and they did not want to interfere with his practice.

In the meantime, Duntsch had hired a lawyer to negotiate his exit from Baylor. Baylor finished both of their peer review investigations on April 18, 2012. The review concluded that he was the cause of Summers’ injuries and Martin’s death, and that he was below the standard of care.

Duntsch resigned two days after the review was completed.

The peer review committee recommended that it be reported to the medical board. The hospital doesn’t do it.

A medical board spokesman says the aw requires those results to be reported by either the committee or the hospital. There is also an obligation to report, if in the opinion or the committee, that the doctor poses “a continuing threat.”

Now, remember that the national data bank has a reporting requirement that a doctor has to be restricted or revoked for more than 30 days, or they have surrender clinical privileges during an investigation. Because of the way Baylor handled it, they did not have to report Duntsch to the data bank.

Shulkin says it happens all the time.

“That loophole is used too often to allow doctors to escape the consequence of peer review and to escape the consequences of poor performance,” says Shulkin, a lung specialist who served on the board for nine years.

He left the board in January.

“Having served as a chief of staff, I remember that we would offer somebody a deal: 'Leave and you don’t get reported,'” he says. “And that’s wrong.”

Shulkin says during his tenure on the board they frequently encountered situations where hospitals failed to report.

“We would ask ourselves why wasn’t this reported?” he said. “Why did it take such a catastrophe to lead to this person being reported to the medical board?”

Baylor even gave Duntsch a letter that helped him get his next job at Dallas Medical Center.

That letter, written by the hospital’s Director of Medical Services Patricia Sproles, says “all investigations with respect to any areas of concern” have been closed and that “there have been no summary or administrative restrictions or suspensions” of Duntsch’s clinical privileges.

“By letting him walk and writing a letter saying he resigned with full privileges, that was a bad deal,” Shulkin said. “Baylor’s not the only show in town. It could have happened at any other hospital in this community. 'Let him go. Let him walk. We don’t want to have to deal with a lawsuit.’”

Duntsch had impressed the CEO of Dallas Medical Center at a dinner meeting. He told her that he wanted work at a small hospital and have more one-on-one contact with his patients.

The hospital gave him temporary privileges in June 2012. It didn't wait for a copy of his credentialing file, which would have detailed the results of the peer review and the catastrophic results of the surgeries at Baylor.

Shulkin says the decision not to wait for the file was “crazy” and “insane.”

“Why did he leave the other hospital?” he says. “Who is this guy?”

Duntsch would end up having surgical privileges there for barely a week. He performed three surgeries. The first surgery seemingly went fine. It was later revealed to have been botched, too.

The second surgery on Floella Brown ended with horrific results. Duntsch injured the vertebral artery. She had a stroke and died.

As Brown lay dying, Duntsch operated on Mary Efurd. Duntsch put metal spinal fusion hardware in the muscles rather than on her spine. The surgery crippled her.

Another hospital neurosurgeon, who tried to repair Duntsch’s mistakes on Efurd, thought Duntsch might be an imposter. To make sure, he faxed a picture to the head of the residency program at the University of Tennessee Health Science Center.

After the Brown and Efurd surgeries, the hospital withdrew Duntsch’s temporary privileges. It didn't conduct a peer review investigation.

"We did not want to take a chance of harming any patients and wanted to just make sure that this patient was safe,” CEO Raji Kumar testified. “And that we felt that there were too many red flags.”

The hospital did not report that they revoked his surgical privileges over the botched surgeries to the data bank as required.

Kumar indicated to prosecutors that the hospital did not report him because their lawyers told them that the data bank makes a distinction between temporary and permanent privileges. Their attorneys were worried that they would get sued for reporting him to the data bank.

In fact, according to the data bank’s website, the data bank does not generally draw a distinction between temporary or permanent privileges. So the hospital should have reported him when they yanked his temporary privileges.

After leaving Dallas Medical Center, Duntsch moved on to the now-closed University General Hospital in Oak Cliff and to a surgery center in Frisco.

Testimony showed that both were warned by others about Duntsch’s troubled history. They let him operate anyway. Patients continued to be maimed along the way.

All the while, the medical board received complaint after complaint about Duntsch.

Between August 2012 and February 2013, the board received at least a half dozen complaints about horrifically botched surgeries.

Shulkin believes he was the first to complain.

He contacted the executive director of the board after another doctor called him telling him that people were being hurt. The doctor had supplied Shulkin with the names of patients and where the surgeries had occurred.

One surgeon even called the chairman of the medical board at his private office to tell him about Duntsch.

It’s not until June 2013 that the board finally acted to suspend Duntsch’s license.

By then, Duntsch had nearly decapitated Jeff Glidewell at University General. Duntsch cut a hole in his esophagus, cut his left vertebral artery, and severed his left vocal cord.

“Then he stuck a sponge in my esophagus and sewed me up and managed to slip another sponge into the count so that no one would miss it,” Glidewell said on the day Duntsch was convicted. “Then he tells my family that he found a tumor… and left me lying there for three days in ICU to die. He tried to kill me.”

Dr. Randy Kirby, a vascular surgeon, was called in to operate on Glidewell. He was already familiar with the what had happened in some of the other cases.

Kirby was so horrified that he packaged up the records of Glidewell, Martin, Summers, and others and sent them to the medical board, along with a five-page letter outlining Duntsch’s trail of botched surgeries.

The board finally acted days later.

“The Texas Medical Board is not set up to stop someone like Christopher Duntsch,” Kirby said. “They were forced to do something then.”

So why did it take so long for the board to act?

“Why it took so long I can’t answer that, but I’m unhappy with that,” he said. “There were too many opportunities to stop it.”

Shulkin had recused himself after reporting Duntsch, but he says it does take time for the board to gather records and options from experts in the same specialty. He believes that laws needs to be changed to allow the board to move more quickly.

The Frisco surgery center suspended Duntsch's privileges the day after the board acted. They never reported to the board or to the data bank. University General suspended his privileges after Glidewell and another botched case. They reported it to the data bank within a month.

What is clear is that time was not on the side of the Duntsch patients.

“I’m towards the end you know,” says Philip Mayfield, a Princeton resident. “There was a pattern of performance that fell so far below any acceptable standard that it should have been stopped. There were too many opportunities to stop it.”

Duntsch cut Mayfield's spinal cord at the Frisco surgery center. He is now in constant pain that he describes as feeling like he’s on fire.

His wife, Angela, quit her job to take care of him.

“The system failed us,” his wife says. “The state board... it failed us.”

So are their other Duntsches out there?

“I hope not,” Shulkin says.

Are there lesser Duntsches?

“Probably,” he says.

Don Martin has gone through counseling to come to terms with his wife's death. They met in college freshman English decades ago.

“She really was my best friend. We were just attached at the hip,” he says. “We were meant to be.”

His voice cracked as he talked of those final moments of saying goodbye to his wife. That is when his nightmare began.

Martin wonders how many people have to be buried before the state changes a broken system.

“The hospitals should have told everybody in the community to beware of this guy,” he said. “If you are a medical practitioner or a hospital, you have a responsibility. You take an oath. Why not report him anyway?”

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