On 6/22/2010, Gastroenterologist A provided a consultation for a patient after an abdominal ultrasound showed that the patient had cholelithiasis and choledocholithiasis.  The patient’s elevated liver enzymes and dilated bile duct indicated a moderate to high probability of the possibility of stones and warranted a preoperative ERCP and sphincterotomy.  The purpose of the consultation was to remove a suspected common bile duct stone prior to a cholecystectomy.

On 6/28/2010, Gastroenterologist A performed an ERCP with sphincterotomy and balloon sweeping of the common bile duct.  He was unable to determine if he had successfully removed the suspected common bile duct stone from the patient’s dilated bile duct and placed an 8.5-French 5 cm stent into the common bile duct.

In the patient’s chart, Gastroenterologist A noted: “will pull the stent out in 2 months.”

On 11/24/2010, Gastroenterologist A next saw the patient in his office.  A second ERCP was scheduled for 2/10/2011 to remove the stent.  The patient’s medical chart contains no record of instructions given to the patient or his family members regarding the removal of the stent.  The patient’s medical chart contains no explanation for the passage of time between the placement of the stent on 6/28/2010 and the removal of the stent on 2/10/2011.  The Board noted that stents can be expected to occlude after six months and form a nidus for the formation of other stones, mud, and debris.

At 8:30 a.m. on 2/10/2011, Gastroenterologist A performed a second ERCP on the patient and removed the stent.  During the second ERCP, Gastroenterologist A performed a balloon sweep.  The patient’s medical chart contains no clear documentation that all ducts were swept.  No antibiotics were prescribed or administered to the patient immediately before, during, or after the second ERCP.  After the second ERCP, the patient was discharged from the endoscopy facility.  Several hours later, the patient’s wife called Gastroenterologist A’s office to report that the patient was experiencing chills and pain in his back and stomach.  Gastroenterologist A and/or his staff advised that the patient should be brought to Gastroenterologist A’s office right away.

At 6:00 p.m., after efforts to convince the patient’s wife to bring the patient to his office had been unsuccessful, Gastroenterologist A noted in the patient’s chart that he advised the patient’s wife to bring the patient to the office the following morning if the pain were to continue.

Thereafter, Gastroenterologist A prescribed amoxicillin 500 mg to be taken three times a day for the patient.

The following morning, the patient’s condition had not improved.  Further conversations took place between Gastroenterologist A and/or his office staff and the patient’s wife.

At noon on 2/11/2011, the patient arrived at the hospital.

On 10/7/2014, Gastroenterologist A testified that there had been several telephone calls between his office and the patient’s wife on 2/10/2011 and 2/11/2011.  Further, he stated that he and/or his staff had impressed upon the patient’s wife the severity of the patient’s condition and that it was matter of life and death that the patient receive urgent medical attention, but that patient’s wife apparently failed to understand and/or take Gastroenterologist A’s comments seriously.

However, Gastroenterologist A did not document in the cart for the patient.  He did not document the frequency of the conversations, the information given to the patient’s wife, or his wife’s failure or refusal to understand the information.

At 1:30 p.m. on 2/11/2011, the patient was admitted to a hospital and was found to be critically ill with severe sepsis.

Gastroenterologist A consulted Gastroenterologist B, who performed an ERCP on the patient on 2/12/2011.  Gastroenterologist B found “clear evidence of a biliary obstruction as evidenced by darkly pigmented bile and extensive amounts of bloody liquid and sand-like material concerning for hemobilia.”  Gastroenterologist B diagnosed “biliary obstruction resulting in ascending cholangitis and sepsis” and placed a stent in the common bile duct.

On 2/12/2011, the patient passed away.

On 2/16/2011, Gastroenterologist A completed a two-page note in the patient’s medical chart entitled “Death Summary” and marked “Final Report, ” in which he made the following comments.

“Endoscopic retrograde cholangiopancreatography was performed 2 or 3 months ago … for common bile stone retrieval with stenting of the common bile duct … His condition continued to deteriorate.  During the night, his oxygen saturation began to deteriorate, suggesting acute respiratory distress syndrome.  He was intubated and put on the machine.  The blood pressure was kept on Dopamine and Neo-Synephrine.  But, in spite of this, on 2/12/2011 after all the resources have [sic] been pulled out, I have a hunch that he would not make it because of multiorgan [sic] failure.  Therefore, I called the family and explained the grave situation as best that I could.  The patient finally expired on 2/12/2011.”

Gastroenterologist A listed the final diagnosis as “septic shock, death.”

Gastroenterologist’s “Death Summary” for the patient contained no mention of the third ERCP, performed on 2/12/2011, or Gastroenterologist’s B diagnosis of biliary obstruction.

After a hearing, the State Medical Board concluded that Gastroenterologist A committed repeated negligent acts given failure to ensure timely removal of the temporary stent, failure to ensure that the patient had a clear understanding of the importance of timely removal of the temporary stent, failure to ensure that the patient had an understanding of the risks associated with performing the second ERCP and the possible warning signs to monitor after the procedure, and failure to maintain appropriate documentation of his care and treatment of the patient.

The State Medical Board placed Gastroenterologist A on probation with stipulations to complete a professionalism program, complete a medical record keeping course, complete 40 hours annually of continuing medical education for each year of probation, and undergo clinical practice monitoring with an emphasis on medical record keeping.  During probation, Gastroenterologist A was prohibited from performing ERCP procedures.

State: California

Date: May 2017

Specialty: Gastroenterology, Internal Medicine

Symptom: Fever

Diagnosis: Sepsis

Medical Error: Physician concern overridden, Delay in proper treatment, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF