Found 51 Results Sorted by Case Date
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Florida – Anesthesiology – Wrong Site Procedure For A Transforaminal Epidural Steroid Injection



On 4/28/2015 an 80-year-old female, presented to an anesthesiologist for an initial consultation for possible epidural steroid injections.  On 4/28/2015, the patient had a history of left sided lower back pain and left lower extremity pain.

On 4/28/2015, the anesthesiologist scheduled the patient for a left transforaminal epidural steroid injection (TFESI) to be performed on 4/29/2015.

On 4/29/2015, the patient presented to the anesthesiologist at outpatient surgery and laser center for the planned left TFESI.  On 4/29/2015, the patient and anesthesiologist signed a consent form for a left TFESI.  After the patient was prepped for the procedure, the anesthesiologist performed a TFESI on the patient’s right side (the wrong site).  While the patient was still in the procedure room, the anesthesiologist was informed that he performed the TFESI on the incorrect side.  The anesthesiologist then performed a TFESI on the patient’s left side (the correct site).

The anesthesiologist’s procedure report on 4/29/2015 procedures did not accurately document the anesthesiologist’s performance of TFESI procedures on two different sides of the patient.

The Board ordered the anesthesiologist to pay a fine of $5,000 against his license.  Also, the Board ordered that the anesthesiologist pay reimbursement costs of $5,857.63.  The Board ordered that the anesthesiologist complete a medical records course.  The Board ordered that the anesthesiologist complete five hours of continuing medical education on “Risk Management.”  Also, the Board ordered the anesthesiologist to complete a one hour lecture on wrong site surgeries to medical staff at an approved site.

State: Florida


Date: December 2017


Specialty: Anesthesiology, Neurology


Symptom: Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Anesthesiology – Proceeding With A Colonoscopy With A Non-Functioning End Tidal CO2 Monitor



A 59-year-old female presented to an anesthesiologist during her colonoscopy.  The anesthesiologist conducted a pre-operative anesthesia assessment of the patient.  She was then transported to the procedure room where a certified registered nurse anesthetist (“CRNA”) was to provide total intravenous anesthesia to the patient.

The end-tidal CO2 monitor (“ETCO2 monitor”) located in the scheduled procedure room was non-functional on the day before the surgery and a functioning ETCO2 monitor had not been received on the day of the surgery.

The anesthesiologist instructed the CRNA to proceed with the anesthesia without the ETCO2 monitor.  The anesthesiologist did not delay the procedure or postpone it for another date to allow time to obtain a functioning ETCO2 monitor.  The anesthesiologist did not transfer the patient to another procedure room that had a functioning ETCO2 monitor.  The anesthesiologist did not implement additional precautionary measures by closely monitoring the patient with his presence since he elected to proceed without an ETCO2 monitor as recommended by the ASA (American Society of Anesthesiologists).  The anesthesiologist was not present in the procedure room during the procedure.

The CRNA experienced difficulties with the patient’s airway soon after the induction of anesthesia.  The oral airway was inserted to assist the patient’s breathing, and the amount of oxygen flow was increased to help with the falling oxygen saturation.  Despite the increase in the amount of oxygen flow, the CRNS reported transient desaturations and reported repositioning the pulse oximeter numerous times throughout the procedure.

The patient developed bradycardia, which culminated to intubation and cardiac arrest, and the anesthesiologist’s presence was requested in the procedure room.  The anesthesiologist started chest compressions and resuscitated the patient.

The Board judged the anesthesiologist’s conduct to be below the minimum standard of competence given that he should have delayed the procedure, or postponed it for another date to allow time to obtain a functioning ETCO2 monitor.  He should also have transferred the patient to another procedure room that had a functioning ETCO2 monitor and implemented additional precautionary measures by closely monitoring the patient with since he elected to proceed without an ETCO2 monitor.

The Board ordered that the anesthesiologist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $6,841.07 and not to exceed $8,841.07.  The Board also ordered that the anesthesiologist complete five hours of continuing medical education in general anesthesia and complete five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Anesthesiology – Multiple Procedural Errors While Performing Cervical Epidural Steroid Injections



On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.

An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis.  The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.

The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5.  The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.

The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.

The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.

The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6.  The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.

The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy.  He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI.  The anesthesiologist then injected the medication between C4 and C5 neural foramen.

The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5;  however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient.  He inappropriately elected to perform a CESI above C6-C7.  The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.

After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication.  The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.

The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.

After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: August 2017


Specialty: Anesthesiology


Symptom: Weakness/Fatigue, Numbness


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


Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Pain Management – Contrast And Steroid Injected Into The Intrathecal Space Instead Of The Epidural Space



Between February 2006 and September 2012, a patient presented to a pain specialist with complaints of chronic low back pain.

On one or more occasions between February 2006 and September 2012, the pain specialist assessed the patient with, among other things, low back pain, lumbago, osteoarthritis, lumbar failed back surgery syndrome, lumbar radiculopathy, and lumbar muscle spasms.

On 9/28/2012, the patient presented to the pain specialist in order for him to perform a lumbar transforaminal epidural steroid injection with catheter and fluoroscopy.  Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord.

During the procedure, the pain specialist inserted the tip of the catheter through the patient’s epidural space and into the patient’s intrathecal space.  Intrathecal administration is a medical route of administration in which a drug or contrast agent is injected into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid.

During the procedure, the pain specialist injected contrast and injectate into the patient’s intrathecal space instead of the patient’s epidural space.

The pain specialist did not obtain an intra-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not obtain a post-injection lateral view epidurogram to confirm the location of the catheter tip and/or the dispersal pattern of the contrast and injectate.

The pain specialist did not recognize that he had performed an intrathecal injection instead of an epidural injection.

After the procedure, the patient complained of bilateral hip and leg pain, numbness, and paralysis.

The patient was transferred to a hospital where she was ultimately diagnosed with conus medullaris syndrome.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain specialist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: June 2017


Specialty: Pain Management, Anesthesiology


Symptom: Back Pain, Numbness, Extremity Pain, Pelvic/Groin Pain, Weakness/Fatigue


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


Medical Error: Wrong site procedure, Lack of proper documentation, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



California – Gastroenterology – Complication During Endoscopy With Colonoscopy For Nausea, Vomiting, And Epigastric Pain After Bone Marrow Transplant



On 11/17/2011, a 56-year-old female underwent a colonoscopy performed by a gastroenterologist.  The patient had undergone a bone marrow transplant for chronic lymphocytic leukemia.  After the procedure, the patient complained of nausea, vomiting, and epigastric pain.  An endoscopy was performed the prior day to rule out graft versus host disease or cytomegalovirus infection and the colonoscopy was a part of that procedure.

The gastroenterologist performed the coloscopy to the terminal ileum.  The patient was sedated with midazolam 8 mg IV, fentanyl 175 micrograms IV, and diphenhydramine 50 mg IV in divided doses as the patient exhibited any signs of discomfort.  Biopsies and cultures were obtained and submitted for evaluation.  Pathology results indicated apoptosis of the ileum and right colon, but negative findings for CMV.

During the course of the colonoscopic procedure, full sedation was not achieved.  The patient became drowsy, but she became fully awake during the procedure more than once, complained of pain, and asked that the procedure be stopped.  The gastroenterologist continued and completed the procedure despite the patient’s urgent requests.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California


Date: May 2017


Specialty: Gastroenterology, Anesthesiology, Hematology


Symptom: Abdominal Pain, Nausea Or Vomiting


Diagnosis: Post-operative/Operative Complication, Hematological Disease


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Anesthesiology – Anesthesia Procedural Errors During Elective Right Carotid Endarterectomy



On 5/6/2014, a patient was scheduled for an elective right carotid endarterectomy procedure with her vascular surgeon.  An anesthesiologist was assigned to the surgery and was proctored by another anesthesiologist throughout the procedure. The anesthesiologist wrote his pre-operative note at 11:10 a.m.  The note included the patient’s admitting vital signs and past history, which included a recent stroke and that she was a former smoker. His note listed her most recent labwork. The anesthesiologist did not include the patient’s pre-operative Doppler studies or her recent ECG.  The anesthesiologist noted that the patient had a prior Cesarean section, but listed her prior anesthetics as “none.” The anesthesiologist did not perform an exam of her heart or lungs, and he noted that he discussed a risk of nausea.

The anesthesiologist placed a right radial 22-gauge arterial line with local anesthetic prior to the patient being moved to the operating room.  He connected the patient to the proper monitoring machines. The anesthesiologist began anesthesia at 11:36 a.m. He provided 1 mg of midazolam, 5 mg of rocuronium, 40 mg of lidocaine, 40 mg of propofol, and incremental doses of 50 mcg x2 fentanyl.  He also administered sevoflurane and oxygen. The anesthesiologist then administered an additional dose of rocuronium and easily intubated the patient. The anesthesiologist began a phenylephrine infusion of 200 mcg/hr. At 11:45 a.m., the patient’s vital signs were recorded from the arterial line reading 130/55 and from the left cuff measuring 90/55 with pulse of 55.  During intubation, the patient’s blood pressure rose to 135/65 with a pulse of 60. The phenylephrine infusion was increased to 1000 mcg/hr and then decreased to 800 mcg/hr prior to the surgical incision at 12:17 p.m.

Systolic blood pressure prior to incision was 180 and charted at 150/110 shortly thereafter.  Pulse rose from 58 bpm to 75 bpm. Heparin, 5000 units, was administered at 12:22 p.m. prior to surgical cross camp at 12:33 p.m.  During the cross-clamp period, anesthesia was maintained. The cross clamp was removed at 1:11 p.m. The phenylephrine infusion was continued until approximately 1:15 p.m.  Blood pressure during the cross-clamp period ranged between 145/70 and 170/60. At 1:15 p.m., the patient’s blood pressure was 200/60 with a pulse of 70 bpm. The anesthesiologist administered ondansetron at 1:15 p.m.  At 1:30 p.m., he administered 10 mg of hydralazine and 30 mg of esmolol. He provided another 40 mg dose of esmolol shortly thereafter. Surgery ended at 1:37 p.m. The anesthesiologist’s post-operative note, written the following morning, showed that the patient was essentially stable, and she was released home the following day.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he failed to mention the patient’s prior ECG or Doppler studies in his pre-operative note.  The anesthesiologist did not ask her about a prior history of chest pain or exercise intolerance during his pre-operative evaluation, did not list the type of prior anesthetic that she had received in her prior surgery in his pre-operative note, did not review the degree of patency or stenosis that the non-operative side would provide cerebral blood through the Circle of Willis, did not inform the patient that there would be a small, but not uncommon, risk of stroke, heart attack, or death, and did not examine or document a heart of lung exam of the patient during his pre-operative examination.  He also failed to anticipate the patient’s hemodynamic changes related to surgical incision and cross-clamping and unclamping during surgery. When the anesthesiologist did respond to hemodynamic changes, he provided inadequate responses and prolonged response times. The anesthesiologist failed to adequately reflect the wide variations in the monitored vital signs in his clinical chart and failed to terminate the phenylephrine infusion following removal of the cross-clamp despite the patient’s hypertension. The anesthesiologist failed to promptly adjust the mechanical ventilator after intubation and failed to proactively anticipate blood pressure increases and decreases in response to carotid de-clamping.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first year of probation, and a 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: May 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Delay in proper treatment, Improper medication management, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Anesthesiology – Improper Dosing Of Epinephrine And Atropine For Bradycardic Patient During Anesthesia For Colonoscopy



On 8/7/2015, a 51-year-old male presented to a surgical center for an outpatient esophagogastroduodenoscopy (EGD) and colonoscopy.

The patient had a history of bipolar disease, schizophrenia, obstructive sleep apnea on continuous positive airway pressure (CPAP), smoking, and morbid obesity.

The patient underwent EGD and colonoscopy via monitored anesthesia care with intravenous propofol.

During the patient’s colonoscopy, he became bradycardic, was mask ventilated, turned supine, and was given atropine, ephedrine, and epinephrine.

Specifically, the patient received two doses of 0.2 mg of epinephrine ten minutes apart.  These doses of epinephrine are not standard advanced cardiovascular life support (ACLS) resuscitation doses for a cardiac arrest.

The patient also received a 0.2 mg dose of atropine followed by a 0.4 mg dose.  The doses of atropine were inadequate for the patient’s size and considering that the patient was experiencing a bradycardic event.

The patient subsequently received cardiopulmonary resuscitation (CPR) and was transferred to a hospital for emergent care.  Shortly after arriving at the hospital, the patient passed away.

Prior to performing the procedures, the anesthesiologist failed to document a complete preoperative history and physical examination for the patient.

During the intraoperative course, the anesthesiologist failed to utilize and/or failed to document utilizing end-tidal CO2 (ETCO2) monitoring usage.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: May 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Cardiac Arrhythmia


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Gynecology – Pregnancy Test Performed Prior To Hysterectomy Turns Positive



On 12/27/2012, a patient with a history of uterine fibroids by ultrasound, two laparoscopies for adhesiolysis with bladder injury, presented to Gynecologic Oncologist A with complaints of a pelvic mass and endometriosis.  It was noted that there was an enlarged tender mass on exam consistent with endometriosis and fibroids and that the patient wanted definitive surgical intervention.

The patient was scheduled for an elective robotic hysterectomy with bilateral salpingo-oophorectomy on 1/17/2013.  The patient was planned for pre-operative lab testing, including a pregnancy test, within 72 hours of the scheduled surgery date.

The patient presented on 1/15/2013 to have pre-operative labs drawn.  The lab results were logged into the patient’s chart the next day.  These lab results included a positive pregnancy test.  Registered Nurse A was responsible for collecting lab findings prior to the operation on a form.  On that form, the “pregnant” and “lactating” questions were answered with a “no.”

On the day of surgery, Registered Nurse B was responsible for reviewing physician orders and labs.  Registered Nurse C did not confirm the results of the patient’s pre-op pregnancy test.  Anesthesiologist A signed an anesthesia pre-op order form which called for a pregnancy test on all patients similar to the patient, unless specifically waived.  Anesthesiologist A did not obtain a waiver and did not confirm the results of the patient’s pre-op pregnancy test.

Gynecologic Oncologist A performed surgery on patient A, during which it was found that the patient was pregnant.

Anesthesiologist A and Gynecologic Oncologist A were deemed to have engaged in unprofessional conduct by engaging in conduct which increases the risk of danger to the health, welfare, or safety of a patient.

State: Wisconsin


Date: May 2017


Specialty: Gynecology, Anesthesiology


Symptom: Mass (Breast Mass, Lump, etc.), Gynecological Symptoms


Diagnosis: Gynecological Disease


Medical Error: Failure to follow up, Failure of communication with other providers, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pain Management – Wrong Concentration Of Hydromorphone Programmed Into Intrathecal Pain Pump



In December 2007, a 55-year-old male had an intrathecal pain pump inserted for pain control at the recommendation of his pain management specialist.  He had been prescribing the patient hydromorphone with a concentration of 10 mg/ml.

From 1/31/2012 to 2/15/2012, upon referral by his physician, the patient presented to a new pain management specialist for pain management.

At the initial visit, on 1/31/2012, the pain management specialist ordered a prescription of hydromorphone injectable solution with a concentration of 30 mg/ml to refill the patient’s intrathecal pain pump.

On 2/15/2012, the patient presented to a pain management center to have his intrathecal pain pump refilled with the hydromorphone prescription and reprogrammed.

A physician assistant refilled the patient’s intrathecal pain pump with hydromorphone with a concentration of 30 mg/ml; however, the concentration of the hydromorphone that was programmed into the intrathecal pain pump remained at 10 mg/ml.

The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he failed to verify that the correct concentration of hydromorphone was administered into the intrathecal pain pump after it was refilled on 2/15/2012 and he failed to verify the correct concentration of the hydromorphone was programmed into the intrathecal pain pump.

The patient expired at his home on 2/15/2012.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Pain Management, Anesthesiology


Symptom: Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error, Improper supervision


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Pain Management – Infection Of Left Prosthetic Knee Following Injections Of Zeel And Traumeel With Bupivacaine



On 9/15/2011, a 57-year-old male presented to a pain management specialist with complaints of knee pain in his prosthetic knees.

On 10/13/2011, the pain management specialist established a treatment plan to obtain x-rays of the patient’s knees and refer him to an orthopedic surgeon for evaluation of his prosthetic knees.

The pain management specialist failed to review, or document reviewing, x-rays of the patient’s prosthetic knees.  He also failed to refer the patient to an orthopedic surgeon for evaluation of his knee pain, per his treatment plan.

On 2/2/2012, the pain management specialist injected Zeel and Traumeel (both homeopathic products) with bupivacaine into the patient’s prosthetic left knee.

The pain management specialist did not create or maintain records documenting an examination of the patient’s left knee for the 2/2/2012 appointment.

On 2/8/2012, the pain management specialist performed a second injection of Zeel and Traumeel with bupivacaine into the patient’s prosthetic left knee.  He did not create or maintain records documenting an examination of the patient’s left knee for the 2/8/2012 appointment.

Shortly after the second injection, the patient’s left knee began to swell, and on 2/21/2012, he presented to an orthopedic institute with complaints of pain, swelling, and redness.

An orthopedic surgeon admitted the patient to a hospital for further evaluation.  At the hospital, the patient was diagnosed with acutely infected left total knee arthroplasty and, on 2/25/2012, underwent surgery to remove part of the left knee prosthesis, insert an antibiotic disc and PICC line, and begin IV antibiotics.

The Medical Board of Florida judged the pain management specialists conduct to be below the minimal standard of competence given that he should not have injected homeopathic substances into the patient’s prosthetic left knee and he did not refer the patient to an orthopedic surgeon for evaluation of his left knee pain.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pain management specialist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Pain Management, Anesthesiology, Orthopedic Surgery


Symptom: Joint Pain, Swelling


Diagnosis: Procedural Site Infection


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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