Found 39 Results Sorted by Case Date
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Indiana – Gynecology – Gynecologist Practices Psychiatric In-Home Counseling Outside Of His Capabilities



A gynecologist had been a patient’s provider since approximately 2006.  He was also the obstetrician for the prenatal care for the patient’s three children, delivery of two of the patient’s children, and postpartum depression following the birth of her third child.

The patient gave birth to her third child on 9/6/2013, and following the birth, the gynecologist treated her for postpartum depression.  The gynecologist had previously treated the patient for anxiety and depression for several years prior.

In late October 2013, out of concern for the patient’s mental and physical health resulting from her continued postpartum depression, the patient’s husband contacted the gynecologist to notify him of the patient’s concerning behavior in that she refused to get out of bed and was showing signs of increased depression.

During that same time, the patient’s husband sought medical advice and assistance from the gynecologist, which resulted in the gynecologist coming over to the patient’s house to assess the patient’s medical condition on at least two occasions.

Following these visits, the gynecologist recommended to the patient’s husband that he provide in-home counseling to the patient to treat her depression and anxiety.

From November 2013 through spring of 2014, the gynecologist visited the patient in her home and provided in-home counseling to the patient and frequently communicated with the patient via text message. The patient’s husband was present during several of the counseling sessions between the patient and the gynecologist.  The patient’s husband described the sessions with the gynecologist as typical counseling sessions based upon his attendance at previous counseling sessions with the patient and other providers.

The gynecologist failed to keep documentation regarding these sessions and did not bill the patient and the patient’s husband for these services.  Also the gynecologist was not qualified by training or experience to provide mental health counseling.

A typical OB/GYN practitioner, in handling patients suffering from postpartum depression, would question the patient in his office to determine whether mental health services were needed, and then refer the patient to a mental health provider, if necessary. They would only remain involved in the care of a patient’s postpartum depression by providing prescriptive support if the mental health provider he referred the patient to did not have prescriptive authority and medications were recommended by the mental health provider.

The gynecologist was not qualified by training or experience to provide mental health counseling.

In late 2013, the gynecologist referred the patient to a psychiatrist;  however, the gynecologist continued to provide in-home counseling sessions and medical care to the patient.

The patient received prescription medication from the psychiatrist after she was referred by the gynecologist to the psychiatrist.

The gynecologist and the patient discussed terminating the physician-patient relationship;  however, no letter was written formalizing the termination of the physician-patient relationship and the patient was not referred to another gynecologist by the gynecologist.

The gynecologist began a sexual relationship with the patient in early February 2014.

In November 2013, the gynecologist prescribed the patient Prestiz, a medication to treat depression.  The patient filled that medication from the gynecologist on 2/3/2014.

The gynecologist wrote the patient a prescription for birth control in November 2013.  The patient received monthly refills of that prescription, with the last refill dated on 2/14/2014.

On 12/30/2013, the gynecologist continued to provide medical care and treatment to the patient when he wrote a prescription for the patient for zolpidem (Ambien) 10 mg.  The gynecologist prescribed the patient refills of Ambien, one of which the patient filled on 3/26/2014.  On at least one occasion the gynecologist exchanged two of his tablets of Ambien 5 mg for one of the patient’s Ambien 10 mg tablets with her consent.

On 2/24/2014, the patient received a blood lab draw ordered by the psychiatrist.  The results of the blood draw indicated that the gynecologist was still the patient’s physician.

In May 2014, the gynecologist admitted to two physicians practicing at an OB/GYN clinic that he had an inappropriate and sexual relationship with the patient.

The patient also admitted that she had an affair with the gynecologist to her husband, her father, her sister, and several of her friends on approximately May 2014, after initially denying the affair.

In the spring of 2014, the patient recommended that her brother-in-law meet with the gynecologist to ask him questions regarding symptoms he was experiencing from a medication prescribed by another practitioner.

On 4/27/2014, the gynecologist prescribed Ambien to the brother-in-law during an in-home counseling session that took place in the brother-in law’s home.

The gynecologist provided in-home counseling sessions to the patient’s brother-in-law on a second occasion.  During this session, the gynecologist told the brother-in-law that he was depressed and at times was suicidal and that the patient was the only person who could help him deal with his depression.

The gynecologist failed to maintain necessary patient records for the counseling sessions and the prescription that he provided to the patient’s brother-in-law.

The Board judged the gynecologist’s conduct to be below the minimum standard of competence given his failure to keep medical records and his ability to practice within his own specialty.

The Board ordered that the gynecologist’s license be suspended and ordered him to complete forty hours of continuing medical education divided into the following: eight hours on record keeping, eight hours on ethics, eight hours on confidentiality, eight hours on patient boundaries, and eight hours on controlled substance prescribing. Also, the gynecologist must have a course on psychiatric and psychological care. Finally, the Board ordered that the gynecologist pay a fine of $5,500.

State: Indiana


Date: October 2015


Specialty: Gynecology, Obstetrics, Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


Medical Error: Failure of communication with other providers, Ethics violation, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Physical Medicine and Rehabilitation – Anesthetic Needle Enters T3-T4 Intrathecal Space During Attempted Spinal Cord Stimulation Placement



A 47-year-old female had a 10-year history of severe cervical pain due to multiple cervical disc herniations with subsequent C4-C7 discectomy and fusion.  The patient had undergone a spinal cord stimulation trial in January 2012 with a resultant post-dural puncture headache. The patient’s pre-operative diagnosis included failed cervical surgery syndrome status post-C4 through C7 fusion, chronic pain syndrome, and complex regional pain syndrome.

On 4/6/2012, the patient underwent an implantation procedure with a physiatrist at the hospital with the assistance of an anesthesiologist.  The patient’s skin and subcutaneous tissue were anesthetized with 0.5% Marcaine with epinephrine. An incision was made with 15 blade and the use of electrocautery to stop the bleeding.  The physiatrist used a 3.5-inch spinal needle to anesthetize the deeper tissues down to the T3-T4 interspace with 0.5% Marcaine with epinephrine. They then identified the epidural space using loss of resistance.  The physiatrist then placed a spinal cord stimulator lead in the epidural space. The physiatrist advanced the lead to the cervical region when the anesthesiologist noticed the patient was no longer breathing simultaneously.

The physiatrist removed the stimulator lead.  After the wound was sterilely covered, the patient was turned supine for observation.  Her respiratory status improved over the next 5 minutes. The procedure was then aborted.  It was thought that the Marcaine injection resulted in a spinal block because the introduction of a spinal needle into the intrathecal space in the thoracic region posed the potential of causing spinal anesthesia high in the central nervous system, resulting in loss of respiratory function while the patient was fully awake.  Injury to the spinal cord by the needle tip and a post-dural puncture headache at this level were very likely.

The Medical Board of California judged that the physiatrist’s conduct departed from the standard of care because he entered into the intrathecal space with a spinal needle in the thoracic region and injecting Marcaine into that space because it placed her at a substantial risk of adverse consequences.

The Medical Board of California issued a public reprimand and ordered the physiatrist to complete a medical record keeping course and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.3

State: California


Date: October 2015


Specialty: Physical Medicine and Rehabilitation, Anesthesiology


Symptom: Back Pain, Pain


Diagnosis: Post-operative/Operative Complication, Neurological Disease, Spinal Injury Or Disorder


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Physical Medicine and Rehabilitation – Insufficient Preoperative Evaluation Leads To Longer Than Expected Implantation Procedure In Spine



A 51-year-old female had a longstanding history of upper extremity complex regional pain syndrome and chronic headaches.  The patient underwent a successful percutaneous spinal cord stimulator trial approximately 3 weeks prior to her schedule procedure with a physiatrist.  The patient was 5’1” tall and weighed approximately 175 lbs. With degenerative spine disease, the patient was likely to present a particular difficulty in accessing the epidural space.  The physiatrist, however, did not identify this preoperatively and obtain the appropriate consultation.

On 10/26/2011, the patient underwent an implantation procedure with the physiatrist at the hospital with the assistance of an anesthesiologist.  After being placed in position, the patient was scrubbed with Betadine and draped steriles. The physiatrist then used fluoroscopy to identify the T4-T5 interspace.  The physiatrist entered the epidural space, but had difficulty advancing the lead past the C7-T1 level. The physiatrist withdrew the needle and made a second attempt at the T3-T4 interspace.  He eventually placed the leads at the C2-C4 level. The physiatrist was then able to place the generator. The total duration for this procedure was 6 hours and 12 minutes, an excessively prolonged time.

The Medical Board of California judged that the physiatrist’s conduct departed from the standard of care because he failed to anticipate the complexity of the procedure in this patient, and the resulting prolonged time it took him to complete the procedure.

The Medical Board of California issued a public reprimand and ordered the physiatrist to complete a medical record keeping course and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: October 2015


Specialty: Physical Medicine and Rehabilitation, Anesthesiology


Symptom: Headache, Back Pain


Diagnosis: Spinal Injury Or Disorder, Neurological Disease


Medical Error: Procedural error, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Plastic Surgery – Breast Reduction Surgery To Lose Weight



On 1/28/2010, a female patient visited a plastic surgeon’s practice to inquire about the lap band procedure in order to reduce her weight.  The patient was encouraged to have breast reduction surgery instead of bariatric surgery. On 4/22/2010, the patient underwent a reduction mammaplasty and suction-assisted lipectomy of her breasts bilaterally, which was performed by the plastic surgeon.  She had a large volume of material removed and suffered a right nipple-areolar loss with loss of sensation and asymmetry requiring re-operation.

The patient remained a patient of the plastic surgeon’s practice and participated in preparations to undergo bariatric surgery.  As part of these preparations, she was instructed to undergo a sleep apnea study, endoscopy, and ultrasound. In February 2011, she was told by the plastic surgeon’s staff that she “qualified for a C-PAP (continuous positive airway pressure machine).”  The C-PAP machine was designed to help patients with documented obstructive sleep apnea to increase inflow of air while they sleep. It was designed specifically for patients with a documented diagnosis of obstructive sleep apnea. The patient never had any complaints or diagnoses of obstructive sleep apnea.

The standard of care is to do all those medical actions that are medically necessary to ensure the successful and safe outcome of the procedure in a human and ethical manner.  Accordingly, any pre-operative testing that may contribute to improved patient safety during the operative procedure is certainly within the standard of care. However, offering the patient inaccurate or misleading information about their health status is not within the standard of care.  The patient’s medical chart was devoid of the sleep apnea test results for which the plastic surgeon referred her.

The Medical Board of California issued a public reprimand and ordered the plastic surgeon to complete an ethics course and a medical record-keeping course.

State: California


Date: October 2015


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Unnecessary or excessive treatment or surgery, Ethics violation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Neurosurgery – Installation Of Live Bacteria Cultures Of Enterobacter Aerogenes Into Brain Tumor Bed As “Innovative Therapy”



From October 2010 through March 2011, a neurosurgeon was involved in the treatment of three patients with gliobastoma brain tumors.  He administered live bacterial cultures of Enterobacter aerogenes into the tumor operative bed of the patients.  The procedure was done under the theory that the live bacteria would induce the immune system to attack the tumor and prolong survival.

The neurosurgeon believed the placement of live bacteria in the patient’s brain constituted “innovative therapy” as opposed to “research.”  He did not include in the informed consent form that this approach had never been tried in humans.

On 10/17/2010, Patient A underwent surgery followed by installation of gelform soaked into Enterobacter aerogenes cultures.  Patient A later became septic.  Over time, MRI revealed an abscess in the brain stem, and the patient passed away.

On 11/19/2010, Patient B underwent surgery that included “installation of probiotic therapy consisting of Enterobacter into the tumor bed and in the bone flap.”  On 10/6/2011, the neurosurgeon noted in the record that there was tumor regression.  Patient B eventually required a bone flap removal for what was deemed a chronic infection of the wound and died one month after the declared tumor regression.

On 3/3/2011, Patient C, a 61-year-old woman with newly diagnosed glioblastoma in the brain, underwent surgery that included “installation of probiotic therapy consisting of Enterobacter into the tumor bed and in the bone flap.”  The patient developed sepsis, lapsed into a coma, developed a purulent ventriculitis, and died within two weeks of therapy, rather than surviving the average fifteen months.

The Board issued a public reprimand with the stipulation to complete a professionalism program.

State: California


Date: October 2015


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Cancer


Medical Error: Ethics violation, Improper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Plastic Surgery – New Breast Implantations For Recurrent Capsular Contracture



A female patient was attracted to a plastic surgeon’s practice as a result of paid advertising.  She met with the plastic surgeon on 2/20/2007. He diagnosed her with capsular contracture of both breasts.  They decided to proceed with surgery consisting of removal of the ruptured silicone gel implants that the patient had from prior surgery, and the capsule around the old breast implants that was responsible for the patient’s discomfort would be removed.  New breast implants would also be placed.

The surgery was performed on 2/28/2009.  To the patient’s distress, she suffered a recurrence of capsular contracture shortly after her operation.  Following her surgery, she was seen for a follow-up visit the next day, 2/29/2008, and approximately two weeks later on 3/4/2008, when she had the surgical drains removed.  However, her medical chart contained no reference to any additional follow-up visits for two years until 3/10/2010. There was also no record of the plastic surgeon’s office attempting to contact the patient for follow-up or missed follow-up appointments.  On 4/3/2010, the plastic surgeon diagnosed the patient with a recurrence of capsular contracture for which revision surgery was proposed.

It is the standard of care to be available to meet and re-examine the post-operative patient as frequently as needed or to provide alternative medical coverage.  The care of the patient with capsular contracture continues beyond the operative room, and especially from one who has had a recurrence. The plastic surgeon was unavailable for the post-operative care of the patient from a week after the 2/28/2008 surgery until March 2010, two years later.  The plastic surgeon’s failure to properly follow up with the patient, or to make arrangements for another physician to do so, was a departure from the standard of care.

The Medical Board of California judged that the plastic surgeon’s conduct departed from the standard of care because he was unavailable to the patient for post-operative care, failed to maintain complete medical records, and did not show that the patient gave informed consent about the high probability of a post-operative recurrence of capsular contracture.

The Medical Board of California issued a public reprimand and ordered the plastic surgeon to complete an ethics course and a  medical record-keeping course.

State: California


Date: October 2015


Specialty: Plastic Surgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Failure to follow up, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Failure To Timely Attend To A Patient In Labor And Order Intrapartum Chemoprophylaxis



A patient was a 35-year-old G5P4 who was admitted per an obstetrician’s telephone orders at 5:00 a.m. on 7/4/2011.

At 6:30 a.m., the obstetrician was contacted by telephone and advised that she come in and attend the labor of a patient with a prior Cesarean section.  The obstetrician again was contacted at 7:33 a.m.  The nursing supervisor and the OB/GYN Department Cahir were also contacted.

It was noted that the OB/GYN department-wide rate of nurse deliveries was two percent.  The obstetrician’s rate of nurse deliveries was ten percent and remained greater than eight percent going into 2013.

When later questioned by hospital officials why she took so long to attend the delivery, the obstetrician stated that depending on traffic it could take up to 40 minutes to drive from her home to the hospital.  Various internet sources placed the trip at a maximum duration of 31 minutes and a minimum of 23 minutes.

The obstetrician was advised, during the second contact, that the patient’s Group B Strep (GBS) status was unknown.  Notwithstanding this notice, the obstetrician declined to order antibiotics.

By 10:14 a.m., the patient’s cervix was completely dilated.  At 10:40 a.m., the obstetrician delivered the baby vaginally.

The obstetrician prepared a delivery note on 7/4/2011 and a progress note incorrectly indicating postpartum day 3 on 7/6/2011.  The obstetrician failed to prepare a progress note for postpartum day 1, which was on 7/5/2011.

The Board judged the obstetrician’s conduct to have fallen below the standard of care given failure to attend the patient’s labor in a timely manner, the obstetrician’s initial refusal to attend to the patient’s labor, her refusal to order intrapartum chemoprophylaxis, and failure to write a daily progress note.

Given the concerns brought up by this instance in addition to others, the Board issued a public reprimand with stipulations to complete a course in medical record keeping and a course in obstetrics with duration of at least 16 hours.

State: California


Date: October 2015


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Delay in proper treatment, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Obstetrics – Failure To Attend Delivery In A Timely Manner And Failure To Write A Daily Progress Note



At noon on 7/3/2012, a 38-year-old G1P0 at term was admitted with ruptured membranes by Obstetrician A.

Obstetrician A ordered Pitocin to be administered if the patient did not commence spontaneous labor.  Obstetrician A examined her around 1:00 p.m. and found her cervix to be 1 cm dilated, 50% effaced, at -2 station.  Pitocin was started at around 4:00 p.m.

On 7/4/2012, the patient’s cervix had attained complete dilation by 2:38 p.m.  At that point in time, the fetal station was -1.  By 4:10 p.m., there had been 1 cm descent down to 0 station.

At 2:00 p.m. on 7/4/2012 and again at 2:14 p.m., messages were left for Obstetrician B on her home and cell phones.  The labor and delivery nurse spoke with obstetrician B by telephone at 2:20 p.m.

At 4:10 p.m., less than 2 hours later, the obstetrician B again was telephoned.  When she did not answer, messages again were left.  Obstetrician B was paged at 4:26 p.m.

Obstetrician B eventually arrived at the medical center.  At 6:20 p.m., she examined the patient and determined that the fetal station was +1.  At the same time, Obstetrician B reviewed the external fetal monitoring strip.  At 6:30 p.m., she was pushing with the patient.

Obstetrician B offered the patient the option of a Cesarean section.  The patient agreed.  The surgery was performed by Obstetrician B.  She was assisted by Obstetrician C.  The baby was delivered at 7:34 p.m. on 7/4/2012.

On 7/5/2012, the patient was seen by Obstetrician B, postoperatively.  On 7/7/2012, Obstetrician B was notified that the patient had been seen only once postoperatively.  There are no records showing that Obstetrician B saw the patient on 7/7/2012 or at any other time postoperatively other than on 7/5/2012.

On 7/8/2012, the patient was discharged.  Obstetrician B dictated the discharge summary.

The Board judged the Obstetrician B’s conduct to have fallen below the standard of care given failure to attend the patient’s labor in a timely manner and failure to write a daily progress note.

Given the concerns brought up by this instance in addition to others, the Board issued a public reprimand with stipulations to complete a course in medical record keeping and a course in obstetrics with duration of at least 16 hours.

State: California


Date: October 2015


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Delay in proper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Obstetrics – Twin Gestation With Premature Spontaneous Rupture Of Membranes Complicated By Infection And Numerous Drug Allergies



On 6/23/2013, a 30-year-old G2P1 with twin gestation, due date 9/3/2013, and allergies to antibiotics, experienced preterm premature spontaneous rupture of membranes during her 29th-30th week of pregnancy.  She was admitted by Obstetrician A, who was covering for Obstetrician B.

At 8:59 p.m. on 6/24/2013, Obstetrician B dictated the patient’s admission history and physical.  The patient was given tocolytics (nifedipine) to inhibit uterine contractions.  Clindamycin was also given (presumably for group B streptococcus chemoprophylaxis) along with azithromycin.  Vaginal cultures for group B streptococcus, mycoplasma, and ureaplasma were ordered.  On 6/25/2013, the cultures came back positive for group B streptococcus and yeast.

The patient was allergic to penicillin, sulfa, aspirin, and trimethoprim.  Magnesium sulfate was given presumably for neuroprotection and tocolysis; betamethasone was given for fetal maturation.

Bu 9:20 p.m. on 6/24/2013, Obstetrician B appeared to be the responsible obstetrician.  On that day, the patient’s uterus continued to contract despite the combination of tocolytics and an increasing magnesium sulfate infusion rate.  The labor and delivery nurse was able to contact Obstetrician B during this patient’s preterm labor.

In light of the breakthrough labor and preterm twins, the plan was to perform a Cesarean section.  However, while the spinal anesthetic was being administered, the first twin delivered spontaneously in the vertex presentation at 8:13 p.m.  The patient then underwent a primary Cesarean section for twin B, who was in the breech presentation.

At 8:59 p.m. on 6/24/2013, Obstetrician B completed a handwritten operative note.  The placental pathology confirmed chorioamnionitis (an infection around the fetuses).

On 6/28/2013, the patient was discharged home.

On 7/3/2013, the patient presented at the emergency department with a fever of 102 degrees.  She had bleeding from her incision, which appeared indurated and erythematous with a mucoid-serous discharge.  It was tender to palpation.  The admission white blood cell count was elevated at 14,200.  Her urinalysis was contaminated.

At 4:41 a.m., the patient was admitted from the emergency department by Obstetrician A.  At 4:00 p.m., later in the day, Obstetrician B wrote orders.

The wound culture grew out E. coli, group B streptococcus, and diphtheroids.  The urine culture also grew out group B streptococcus.  The patient’s blood cultures were all negative.  Due to her allergies, the patient was administered vancomycin, gentamycin, aztreonam, and clindamycin.  A pelvic ultrasound demonstrated a small uterine hematoma.

On 7/5/2013, the patient was discharged by Obstetrician B.

Given this instance and several others, the Board outlined the applicable standards of care relevant to Obstetrician B.  The Board noted a physician responsible for a patient on labor and delivery must remain reasonably available to respond.  The physician must come in for emergency or urgent situations that require evaluation or management decisions that are beyond the scope of the labor and delivery nurse.

The Board also noted that when a vaginal delivery is anticipated for a woman in active labor with unknown group B streptococcus status, intrapartum chemoprophylaxis must be provided.  Penicillin is recommended, but if the patient is allergic to penicillin, alternative agents include cefazolin or vancomycin.

The Board issued a public reprimand with stipulations for Obstetrician B to complete a medical record keeping course and an obstetrics course.

State: California


Date: October 2015


Specialty: Obstetrics


Symptom: Bleeding, Fever, Wound Drainage


Diagnosis: Post-operative/Operative Complication


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – High-Risk Pregnancy Complicated By Diabetes, Previous Cesarean Sections, Obesity, High Blood Pressure, Proteinuria, Abdominal Pain, And Abnormal Discharge



On 5/12/2011, a patient presented to an obstetrician for prenatal care as a new obstetric patient.  The patient’s last menstrual period was on 3/17/2011, and her expected delivery date was confirmed by ultrasound to be 12/22/2011.  Although this was a new pregnancy, the patient had been known to the obstetrician since the age of 15 because the obstetrician had treated the patient for at least two other prior pregnancies, and the obstetrician had known about the patient’s medical history and prior Cesarean sections.

Since the patient’s first delivery, the patient has had two additional Cesarean sections as well as an early miscarriage.  Despite knowing the patient’s medical history, the obstetrician reported no significant past medical history, but elevated blood pressures were documented outside of pregnancy, and the obstetrician documented that the patient was obese.  The history of a prior classical Cesarean delivery was not recorded on the ACOG flow sheets in this pregnancy or in the 2010 pregnancy for which the obstetrician also provide care.  The diagnosis of insulin-requiring gestational diabetes and preeclampsia in the patient’s 2010 pregnancy was also not documented.

On 5/12/2011, the patient’s first prenatal care, 2+ proteinuria was documented.  Although the patient’s protein levels fluctuated and rose throughout her pregnancy, records show that the obstetrician merely instructed the patient to drink more water, but did not show that the obstetrician referred the patient to a specialist to treat the proteinuria.  The patient failed her one-hour glucose tolerance test, which was elevated at 213.  There was no record that a diagnostic three-hour test was performed.  On 9/15/2011 (25 weeks) and 9/26/2011 (27 weeks), the patient complained of pressure and spotting.  Progress notes did not document a speculum exam, digital cervical exam, or ultrasound.  No record was found of any ultrasound besides the ultrasound performed on the initial visit.

On 7/15/2011, an elevated blood pressure was first detected at 17+ weeks of gestation.   Blood pressure was again increased on 10/26/2011 at 142/82 (at 31 5/7 weeks of gestation).  No note was made of this in the visit summary, and the patient was scheduled to return in two weeks.

On 11/10/2011 (34 weeks pregnant), the patient complained of pain/cramping, and the patient’s proteinuria was 4+. The abdominal exam was listed as “normal.”  No fetal heart rate was documented.  The patient was given a prescription for a narcotic pain reliever and terbutaline.  The obstetrician continued to follow the expected delivery date, which was scheduled for 12/15/2011.

On 11/17/2011, the patient presented to the hospital complaining of abdominal pain, vaginal bleeding, and having passed a large blood clot.  The patient was noted to be contracting irregularly.  Her blood pressure was elevated and proteinuria was again present.  After nursing staff communicated these findings to the obstetrician, he treated the patient by phone and ordered one liter IV hydration, a one-time dose of methyldopa (Aldomet), and IV butorphanol (Stadol).  A verbal order was also given to discharge the patient if the pain resolved.  The obstetrician did not examine the patient in person.

The obstetrician did not see the patient again until 11/29/2011, 19 days after her prior office visit.  The patient’s blood pressure was 152/85 and 4+ proteinuria was noted. The patient’s weight also increased 8 pounds in two weeks to 210 pounds.  No fetal heart rate was documented.  The patient complained of increased swelling, off and on headaches, and a pink vaginal discharge.  The patient was given a prescription for Aldomet and instructed to rest.  The visit summary documented a plan for a follow-up appointment in one week.

At 3:50 p.m. on 11/29/2011, the patient presented to the labor and delivery department of the hospital complaining of severe abdominal pain and no fetal activity for one-hour.  The nurses placed the patient in her bed but could not document a fetal heart rate.  The obstetrician was called at 3:56 p.m. and arrived at 4:02 p.m.  The obstetrician documented a very slow fetal heart rate by ultrasound.  An emergency Cesarean section was performed.  A uterine rupture and complete abruption of the placenta occurred, and the fetus was not alive when evacuated from the uterus.

Proteinuria on a subsequent formal UA was 2+.  The obstetrician did not mention a diagnosis of preeclampsia in his notes, nor did he order magnesium sulfate for seizure prophylaxis.  The blood pressure was noted to be 147/85 on post-operative day one.  The patient was discharged on post-operative day two.  The patient was seen for a post-operative visit for staple removal on 12/5/2011.  The patient had lost 25 pounds in five days, and her blood pressure was 169/94 at that time.  This was not mentioned in the visit summary.  There was no documentation that the patient was questioned about symptoms of preeclampsia or that any additional evaluation was ordered.  The patient was scheduled to return in five weeks.

The Medical Board of California judged that the obstetrician committed gross negligence in his care and treatment of the patient given that he failed to properly manage a high-risk pregnancy with a prior classical Cesarean section, diagnose and manage a pregnant woman with chronic hypertension, chronic proteinuria, and suspected preeclampsia and gestational diabetes, maintain and/or document the patient’s medical/surgical history as well as the care and procedures provided during patient visits, and deliver the baby earlier despite signs of fetal distress, which were evident before 11/29/2011 and the previously scheduled expected delivery date of 12/15/2011. The obstetrician also allowed a 19-day interval between the last two patient visits in a high-risk patient as well as failed to follow up on an elevated one-hour glucose, document any laboratory evaluation of proteinuria, document any sonograms, non-stress test, or biophysical profiles, and evaluate vaginal bleeding notes at 25 and 27 weeks gestation.

The Medical Board of California ordered that the obstetrician complete an education course, medical record keeping course, and clinical training program equivalent to the courses offered at the University of California San Diego School of Medicine (Program).

State: California


Date: October 2015


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding, Abnormal Vaginal Discharge, Headache, Abdominal Pain


Diagnosis: Preeclampsia, Diabetes


Medical Error: Failure to examine or evaluate patient properly, Underestimation of likelihood or severity, Failure to follow up, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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