Found 20 Results Sorted by Case Date
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Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000



On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding.  The patient was examined by a physician assistant supervised by an ED physician.

The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.

The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.

The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist.   The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.

The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.

The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.

The ED physician did not administer or order the administration of intravenous fluid and insulin.

On 8/26/2014, the patient expired due to diabetic ketoacidosis.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: permanent revocation or suspension of her 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: Emergency Medicine, Endocrinology, Physician Assistant


Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding


Diagnosis: Diabetes


Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Obstetrics – Postpartum Bleeding Following Early Labor In A Patient With A History Of Anemia



On 9/7/2012 at 8:00 p.m., a 27-year-old female presented to a medical center with a complaint of early labor.  The patient had a history of anemia.

At 8:50 p.m., a biophysical profile was ordered for the patient due to heart tracing concerns for the fetus.

By the time the patient arrived back from her biophysical profile, she was found to have made cervical changes from 1-½ cm to 4 cm, and she then very rapidly went from 4 cm to 9 cm.

At 11:15 p.m., the patient’s membranes were artificially ruptured and meconium stained fluid was obtained.  At this time, the cervix was now completely dilated.

At 11:55 p.m., an obstetrician applied a fetal scalp lead to better evaluate the monitor tracing.

At 12:15 a.m., the obstetrician then called in additional medical personnel and proceeded to apply a Kiwi vacuum extractor.

At 12:17 a.m., a second vacuum was applied and at 12:27 a.m. a third vacuum was applied.

At 12:27 a.m., the fetus was delivered with the baby weight 9 pounds and 8 ounces

The patient then experienced a severe postpartum hemorrhage, and the obstetrician inspected the cervix and found there to be no lacerations.  The obstetrician used appropriate medications to cause the uterus to clamp down.

At 12:45 a.m., the obstetrician repaired episiotomy and third-degree perineal laceration, and the uterus was still boggy in spite of the medications. The bleeding continued.

At 1:00 a.m., the uterus was described as firm, the bleeding had decreased and the patient was sleepy but responsive.

At 1:15 a.m., the patient had a steady trickle of lochia resulting in the obstetrician being called back into the room.

At 1:20 a.m., the obstetrician performed a repair of laceration.

At 1:25 a.m., the patient was administered a Foley catheter per the obstetrician’s instructions.

At 1:35 a.m., following repair of the laceration, the patient was bleeding dark blood vaginally.  Additionally, the patient was hypotensive and lethargic.

Sometime after 1:35 a.m. but before 2:10 a.m., the obstetrician left the hospital.

At 2:00 a.m., the patient continued to bleed vaginally, small to moderately.

At 2:10 a.m., the patient’s family called medical staff to the room due to the patient “acting funny” as the patient was lying on her stomach and moving her legs and moaning that she was hurting but would not say where.

At 2:10 a.m., the patient was noted to have bloody fluid in the Foley catheter.

The obstetrician was not present in the hospital at the time.  The obstetrician was informed of the patient’s behavior and the continuation of her steady trickle of blood.

At 2:25 a.m., a registered nurse stayed in the room with the patient as the patient became more combative and a large amount of blood poured from the patient’s vagina.

At 2:25 a.m., the obstetrician was called to return to the hospital.

At an unidentified time, the obstetrician was called again to ensure she was on her way back to the hospital.

At 2:55 a.m., the obstetrician arrived back in the hospital room with the patient.

At 3:14 a.m., the patient became unresponsive and a code blue was called.  The patient experienced cardiac arrest and cardiopulmonary resuscitation was started.

At 6:03 a.m., the patient was pronounced dead.

The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that she failed to determine the source of the bleeding for the patient who had been bleeding heavily after a vaginal delivery.  The obstetrician failed to transfer the patient to the operating room for evaluation. She also failed to remain at the physical location of the hospital to monitor the patient who had been bleeding continuously.

It was requested that the Medical Board of Florida order one or more of the following penalties for the obstetrician: permanent revocation or suspension of her 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: February 2017


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Gynecology – Complications After Hysterectomy For Patient With Simple Hyperplasia Without Atypia And A History Of Infraumbilical Midline Incision



A 46-year-old female presented to a gynecologist in July 2011 complaining of vaginal bleeding.  The patient had a history of ulcerative colitis and an infraumbilical midline incision. The patient next presented about one month later.  The laboratory results included small fibroids, a small polyp, and a small ovarian cyst. Based on these findings, the gynecologist recommended and performed an endometrial biopsy.  The result of the endometrial biopsy was simple hyperplasia without atypia. The gynecologist discussed the options for treatment with the patient and offered her medical treatment with repeat endometrial biopsy, dilation, and curettage with ablation, or hysterectomy.

The patient requested a hysterectomy with removal of both ovaries for definitive treatment.  The gynecologist obtained consent for a robotic hysterectomy and discussed the risks of the procedure, which included the possibility of finding extensive adhesions that would require an open abdominal hysterectomy as opposed to the laparoscopic approach.

On 10/19/2011, the patient was taken to the operating room, where she underwent a diagnostic laparoscopy and a total abdominal hysterectomy and bilateral salpingo-oophorectomy.  The findings at the time of surgery included an enlarged uterus with several small fibroids, normal ovaries, and normal fallopian tubes. There were excessive thick adhesions from the small bowel and omentum to the anterior abdominal wall and the left pelvic sidewall.  There were also adhesions in the right upper quadrant from the omentum to the abdominal wall. The gynecologist used a closed technique to enter the abdominal cavity with a Veress needle. The gynecologist placed the patient in maximum Trendelenburg position and then made a small incision in the umbilicus and inserted the Veress needle.  After removing the Veress needle, the gynecologist placed a 5 mm trocar and was able to visualize the adhesions. She then placed a second 5 mm trocar under direct visualization in the area clear of adhesions and used monopolar scissors for approximately 5 minutes in the attempt to lyse the adhesions. The gynecologist noted that the adhesions were very thick and extensive and included the bowel. She did not feel as though it was safe to proceed with the robot.  The gynecologist removed the instruments and proceeded with an uneventful total abdominal hysterectomy and bilateral salpingo-oophorectomy through a Pfannenstiel incision.

The patient’s post-operative course was eventful.  On the first post-operative day, she was noted to have a pulse of 130 bpm.  She was in moderate pain despite IV pain medication. A CBC was drawn, which showed a normal WBC count of 3.5, but it showed 50% bands.  The bandemia was not noted in the post-operative note. On the second post-operative day, the gynecologist saw the patient again at 2 p.m. and noted that the patient remained on oxygen.  Her pulse also remained at 130. The gynecologist ordered an EKG and a chest x-ray, increased the pain medication, and advised the patient to ambulate. A CBC drawn that day was not mentioned in the post-operative note, but it showed a normal WBC count at 4.7 and again showed bandemia of 18%.  The gynecologist wrote a discharge order at 2:20 p.m. on that day without any parameters.

Tachycardia persisted, and the patient developed shortness of breath, pain with breathing, and an oxygen saturation level of 82% for which the nursing staff called the Rapid Response Team.  The patient was transferred to a critical care bed with the diagnosis of acute hypoxic respiratory failure and peritonitis, and the gynecologist on-call was notified. The gynecologist had signed out to the on-call gynecologist for the weekend.  During that weekend, the patient’s condition continued to worsen. A CT scan performed on the evening of 10/22/2011 showed multiple fluid and air collections in the abdomen, mesentery, and abdominal wall. Various medical specialists as well as the gynecologist on-call evaluated the patient throughout the weekend.  On the fifth post-operative day, a general surgeon was consulted, who immediately made the diagnosis of a bowel perforation and took the patient to the operating room for a bowel resection. The patient remained in the hospital and was discharged o 11/9/2011.

During the gynecologist’s care, treatment and management of the patient, the gynecologist obtained informed consent and, on multiple occasions, discussed the risks, benefits, and alternatives to the surgery and included the additional risks due to the patient’s earlier bowel surgery.  As part of the alternatives to surgery, the gynecologist offered the patient an endometrial ablation, which is contraindicated in the presence of endometrial hyperplasia, as this is considered a precancerous condition. During an interview with representatives of the Medical Board of California, the gynecologist explained that she would no longer operate on this patient, but would refer her to the new gynecologic oncologist at another hospital.

At the time of the interview, the gynecologist was aware that the patient’s condition was precancerous since she would now refer the patient to an oncologist.  Simple hyperplasia does not require referral to an oncologist, but, given that the pathology of simple hyperplasia is considered a precancerous condition, the offering of endometrial ablation as an alternative was not appropriate.

Bowel injury is a known complication during the performance of a hysterectomy, whether it is performed laparoscopically or as an open procedure.  The risk of bowel injury is increased in a patient who, like this patient, had undergone a previous abdominal or bowel surgery and in a patient with a vertical midline incision.

The standard of care dictates that when the patient is at high risk for bowel injury, the surgeon must take all available precautions in order to avoid this complication and have a high index of suspicion of bowel injury if the patient’s post-operative course is complicated.  The gynecologist was well aware of the patient’s higher risk for pelvic adhesions. The patient had a vertical midline incision from a previous colectomy, and on multiple occasions, the gynecologist discussed the high likelihood of adhesions with the patient.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she did not use a safer technique when inserting the Veress needle, offered her the alternative of endometrial ablation, and failed to recognize in a timely manner that the patient had sustained a bowel injury.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record-keeping course and education course for at least 40 hours for every year of probation.

State: California


Date: November 2016


Specialty: Gynecology


Symptom: Abnormal Vaginal Bleeding, Pelvic/Groin Pain, Shortness of Breath


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


Medical Error: Procedural error, Diagnostic error, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Emergency Medicine – Syncope And A History Of Menorrhagia



On 6/6/2012, a 47-year-old female was transported to the emergency department by EMT’s for a brief syncopal episode.  The patient had been sitting in a chair and had lost consciousness, falling to the floor, but she recovered consciousness right away.  The patient had a medical history of menorrhagia and current bleeding (10-15 pads per day in the nurse’s notes). EMT’s noted tachycardia.  An ED physician’s history of the patient only noted prodromal lightheadedness, 2-3 seconds loss of consciousness, and the fall. He did not mention the current bleeding, and although he indicated a head injury in the record, nothing was mentioned concerning examination, diagnosis or treatment.  The ED physician did note that the patient’s gynecologist had recommended a hysterectomy. The ED physician’s review of systems was checked normal, which was inaccurate because menstrual history was included, and the patient was presently experiencing a very heavy menstrual period, consistent with past episodes of menorrhagia.  Vital signs were low blood pressure at 120/49 mmHg and elevated heart rate at 94 bpm, rising from 96 to 106 from supine to standing on orthostatic measurement. No positives were noted on physical examination except for “pale conjunctiva” and “pale palms.” No pelvic or rectal examination was documented. The ED physician ordered normal saline IV at 150 mL per hour.  Laboratory studies were returned with hemoglobin and hematocrit of 6.4 g/dL (extremely low) and 18.9% (very low).

The ED physician called the on-call family practitioner at 5:18 p.m., and the consultant was at bedside at 6:10 p.m.  The patient was admitted with improved vital signs. The consultant immediately ordered the transfusion of 3 units of blood.  The patient’s hemorrhaging continued after admission, so the following day, she underwent the previously recommended hysterectomy.

The Medical Board of California judged that the ED physician’s conduct departed from the standard of care because his medical examination was inappropriately limited.  The ED physician failed to perform an appropriate history and physical examination and appropriate medical tests as needed to evaluate for potentially life-threatening illness.  The ED physician’s notations appeared to indicate he may have been unaware of the current menstrual bleeding in the patient that was documented in the nurse’s notes, and he did not do a pelvic examination.  Although the ED physician noted a head injury, there was no indication that it was examined or treated. Neither the head injury nor the ongoing bleeding was addressed. The ED physician’s final diagnosis was syncope and anemia with no specific cause.  He failed to adequately examine and document findings pertinent to the patient’s presentation.

The ED physician’s final diagnosis was syncope and anemia, but syncope was a symptom of ongoing hemorrhage, not a diagnosis, and the ED physician did not document the apparent cause for the anemia.  The patient had hemorrhaged to the point where she fainted from hypotension. The ED physician consulted the on-call family practitioner when the appropriate consult would have been a gynecologist. The ED physician did not appreciate that syncope was a symptom of menorrhagia/hemorrhage, not a diagnosis.

For this case and others, the Medical Board of California placed the ED physician on probation for 5 years and ordered the ED physician to complete a medical record keeping course, an education course (at least 40 hours per 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.  The ED physician was assigned a practice monitor and prohibited from supervising physician assistants.

State: California


Date: September 2016


Specialty: Emergency Medicine


Symptom: Syncope, Abnormal Vaginal Bleeding


Diagnosis: Hemorrhage


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, 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 – Gynecology – Fever After Dilation And Curettage For Evaluation Of An Enlarged Uterus



A female presented to a gynecologist on 5/10/2012 reporting a 4-week-long history of abnormal uterine bleeding.  The patient’s past medical history included chronic lung disease, morbid obesity, insulin-dependent diabetes, hypothyroidism, hypercholesterolemia, and hypertension.  She was 22 years post-menopausal and had previously been pregnant 5 times, one ending in a Cesarean delivery.

The gynecologist performed a pelvic exam and Pap cytologic smear at his office.  The gynecologist noted that the uterus was palpably enlarged. The patient had a CT scan of the abdomen and pelvis performed at a hospital on 5/8/2012.  That imaging study described an enlarged uterus, though the dimensions were not specified. A blood count demonstrated a mild anemia, a normal white count, and normal platelet count.

The gynecologist admitted the patient to a medical center on the evening of 5/10/2012 and performed a comprehensive pre-operative medical evaluation.  He further obtained a pre-operative cardiology consultation by a cardiologist. An echocardiogram on 5/19/2011 had shown a normal 82% cardiac ejection fraction.  The consent form for a dilation and curettage (D&C) was signed and witnessed at 7:00 p.m. on 5/10/2012. Pre-operative pelvic CT scan with contrast was ordered on 5/10/2012 at 6:00 p.m.  It was not done preoperatively, but instead was accomplished on the morning of the first post-operative day.

The medical records showed that the gynecologist did not perform a pelvic examination under anesthesia.  A pelvic examination under anesthesia would allow the gynecologist to better appreciate the actual degree of uterine enlargement prior to instrumenting the uterus.  The gynecologist dictated an operative report at 5:54 p.m. The operative report did not specifically mention the use of a sharp metal curette nor did that operative report indicate any suspicion of uterine perforation.

According to the subsequently dictated History and Physical at another medical center on 5/12/2012, the gynecologist indicated that he realized the possibility of a uterine perforation caused by the No. 6 suction cannula at the time of the D&C.  In that dictation, he stated that he realized the perforation, intraoperatively, upon placing the unknown device into the uterus. He continued “minimal amount of D&C was done.” However, his operative report, dictated immediately postoperatively, included no mention of any suspicion for uterine perforation.

The gynecologist obtained approximately 50 mL of clot and enough tissue to make a conclusive histopathologic diagnosis.  The histopathologic report from the D&C procedure gave no indication of any extra uterine tissue suctioned into the specimen.  If the gynecologist suspected uterine perforation intraoperatively, he should have left the offending instrument in place and should have immediately discontinued the procedure.

The gynecologist did not immediately begin prophylactic antibiotics.  Ceftriaxone was initiated only after the patient had spiked a temperature, postoperatively, in the ICU.  After determining there was excessive uterine bleeding, an immediate laparoscopic or open abdominal pelvic assessment was necessary.  The medical records described a large amount of blood with an estimated blood loss of 400 mL. Postoperatively, the patient was admitted to the ICU for closer observation in light of the excessive blood loss.  The handwritten operative note indicated that no complications were suspected or realized. However, the gynecologist’s post-operative report, dictated the following day, clearly suggested that he was aware of the perforation at the time of surgery.

At the gynecologist’s Subject Interview, he indicated that he was aware, or at minimum suspected, perforation of the uterus.  He also indicated that he did not give prophylactic antibiotics upon suspecting uterine perforation at the time of the D&C. The gynecologist suspected a uterine perforation had occurred but still curetted the uterine cavity.

Postoperatively, the patient continued to have ongoing vaginal bleeding, requiring that pads be changed every several hours.  A post-operative blood count showed an elevated white count and a significant and progressive anemia. These values represented marked changes when compared to the corresponding pre-operative values.

On the patient’s first post-operative day in the ICU, she experienced a generally declining trend in blood pressure, and no clear trend in pulse rate.  The gynecologist was called approximately 12 hours postoperatively because the patient was crying in pain. However, the records reflected that 2 hours later, she was sleeping soundly.  No indication of why this occurred was included in her chart. The morning of the first post-operative day, a CT of the pelvis demonstrated a 15 x 10 mesenteric abscess with free air in the abdominal cavity.  The gynecologist sought to consult with other general surgeons at the hospital, but they deferred his request.

Approximately 24 hours postoperatively, the patient’s temperature rose to 101.3 F, and blood cultures were drawn.  Ceftriaxone was begun in the evening of 5/12/2012. Also, that evening blood products were typed and crossed in preparation for a potential transfusion.  The gynecologist spend several hours trying to arrange transfer of the patient to the ICU, but they were at capacity. The gynecologist then contacted a medical center, where he had admitting privileges, to arrange for a transfer to their ICU.  Medical records were faxed to the medical center at 7:00 p.m. At 8:00 p.m., the patient was transferred to the medical center via ambulance.

The D&C Surgical Pathology Report demonstrated a malignant mixed Mullerian tumor.  Incidentally, that report gave no indication of extra uterine tissue having been suctioned into the specimen.

Upon arrival at the medical center, the patient was in septic shock and unresponsive.  The gynecologist contacted a gynecological oncologist and a general surgeon. The patient underwent an immediate hernia repair, hysterectomy, and omentectomy.  A critical care general surgeon served as the primary surgeon for this exploratory laparotomy procedure. At his Subject Interview, the gynecologist stated that he felt that it was unwise to take the patient to the OR so quickly at such time that she was suffering from severe diabetic ketoacidosis.

During the laparotomy, the uterine perforation was discovered.  The peritoneum contained 1500 mL of blood and clots. The blood in the peritoneal cavity was foul-smelling, suggesting infection from the perforated uterus.  The retroperitoneal space also contained a hematoma, and the surgical pathology report indicated an acutely-inflamed hernia sac. The uterine specimen, from the supracervical hysterectomy done by the gynecologist, featured acute and chronic endometritis, perforation, and a malignant mixed Mullerian tumor.  Abscess formation involved the adjacent ovary.

Postoperatively, the patient was noted to be severely acidemic.  Additionally, the patient’s troponin was elevated. The patient required intubation.  She went into diffuse intravascular coagulation and had multiple cardiac arrests. She was pronounced dead on 5/13/2012 at 11:15 p.m.  The preliminary cause of death was cardiac arrest secondary to severe sepsis.

The gynecologist’s medical records were often illegible and conflicting.  He dictated his pre-operative history and physical on 7/18/2012 for an admission on 5/10/2012, 2-months after the event.  His handwritten operative note of 5/11/2012 written at 6:00 p.m. was cursory and did not meet the basic requirements of a post-operative note.  The gynecologist’s dictated post-operative note reflected no suspicion or recognition of a uterine perforation. He dictated his Discharge Summary at a medical center reflecting an uncomplicated D&C and a normal brief post-operative course.  This representation was not consistent with the patient’s actual excessive bleeding at surgery and her complicated post-operative course in the ICU.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because he curetted the uterine cavity when he suspected a uterine perforation, failed to pursue an aggressive evaluation, either laparoscopy or laparotomy, when he suspected a uterine perforation, did not perform a pelvic examination under anesthesia before or during the procedure, did not immediately initiate prophylactic antibiotics when he suspected a uterine perforation, had a 2-month gap in time between his dictated pre-operative history and physical for an admission, and failed to maintain adequate medical records.

The Medical Board of California placed the gynecologist on probation for 3 years and ordered the gynecologist to complete a medical record keeping course 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.  The gynecologist was assigned a practice monitor and was prohibited from supervising physician assistants. His license was later revoked.

State: California


Date: November 2015


Specialty: Gynecology


Symptom: Abnormal Vaginal Bleeding


Diagnosis: Post-operative/Operative Complication, Sepsis


Medical Error: Procedural error, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


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



California – Gynecology – Inadequate Incision Size And Inadvertent Clamping During Abdominal Hysterectomy For Uterine Fibroids



A 34-year-old female with severe mental retardation accompanied by her mother presented to a gynecologist during February 2012 with complaints of abdominal pain, dysmenorrhea, and heavy, long menstrual periods.  Imaging confirmed the presence of a large 30 cm by 8 cm by 22 cm uterus with masses consistent with uterine fibroids. The patient’s uterus was firm and filled her pelvis, extending above the umbilicus. Based on the gynecologist’s examination of, and tests performed on, the patient, the gynecologist decided, with the consent of the patient’s mother, to proceed with a total abdominal hysterectomy on 3/21/2012.

On 3/31/2012, the gynecologist began surgery at 2:08 p.m. with the assistance of another gynecologist.  The gynecologist performed a 12 cm low transverse (Pfannenstiel) incision. This incision was not adequate to perform the surgery, and the gynecologist converted the incision to a T-shape by creating a vertical midline incision.

During the course of the surgery and dissection, before a gynecologic oncologist arrived to assist, a clamp was inadvertently placed on the patient’s right ureter.  When it was recognized, the clamp was quickly removed.

The gynecologist called for a gynecologic oncologist to assist with the surgery.  The gynecologic oncologist noted inadequate surgical exposure for the size of the fibroid uterus and extended the vertical midline incision cephalad.  The physicians proceeded with, and completed, the patient’s hysterectomy. At the conclusion of the hysterectomy, the gynecologic oncologist noted that the patient’s right ureter appeared denuded over the course of a 2 cm segment.  The obstetrician then divulged that a clamp had been inadvertently placed across the ureter prior to the gynecologic oncologist’s arrival, more than 1 hour previously. The gynecologic oncologist consulted with a urologist, and a ureteral stent was placed.  The remainder of the operation proceeded uneventfully.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she failed to make an adequate incision at the start of surgery and/or making a 12 cm low transverse incision for the removal of a large, firm, fibroid-filled uterus, which limited mobility and visualization and also extended above the patient’s umbilicus.  The gynecologist also failed to communicate the occurrence of the patient’s ureteral crush injury to the gynecologic oncologist in a prompt and/or timely manner.

For this case and others, the Medical Board of California placed the gynecologist on probation for 7 years and ordered the gynecologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each 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.  The gynecologist was also ordered to have a psychiatric evaluation and receive psychotherapy. The gynecologist was required to have a practice monitor.

State: California


Date: September 2015


Specialty: Gynecology


Symptom: Abdominal Pain, Gynecological Symptoms, Abnormal Vaginal Bleeding


Diagnosis: Gynecological Disease


Medical Error: Procedural error, Failure of communication with other providers, Delay in proper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Cesarean Section Complicated By Large Fibroid And Post-Operative Hypotension



A 36-year-old female, who had one prior delivery by Cesarean section, presented to the hospital on 7/22/2010 at 36 weeks 3 days gestation complaining of painful regular uterine contractions.  The patient had been receiving prenatal care with her regular physician and was known to have a 10 cm fibroid in her lower uterine segment.

On 7/22/2010, an obstetrician was the physician on call and covering for the patient’s regular physician that day.  The patient arrived at the labor and delivery ward and was admitted to triage at 9:07 a.m. on 7/22/2012. She was examined by a nurse at 9:31 a.m. and found to be in active labor.  The patient reported that the fetus had been in the breech position earlier during the pregnancy, but the fetal presentation could not be determined by the nurse. Nursing notes documented that the obstetrician was at the patient’s bedside, discussing Cesarean section, planned incision, and her known uterine fibroids at 10:15 a.m.  At that time, the patient was prepared for surgery. Spinal anesthetic was complete at 10:20 a.m. The obstetrician entered a history and physical for the patient and signed this note at 10:26 a.m. The surgery started at 10:34 a.m.

The history and physical note completed by the obstetrician on 7/22/2010 at 10:26 a.m. made no mention of any vaginal or complete pelvic exam, an ultrasound being done after admission to check for fetal position, any detailed information about the patient’s fibroids, such as size, number, and/or location, documentation of informed consent for the surgery, any critical assessment of surgical risks in light of the patient’s large fibroid, any reference to the obstetrician having reviewed the patient’s prenatal chart of previous ultrasound imaging, and critical analysis for her surgical plan.  The obstetrician also did not consult with the patient’s regular physician before proceeding with surgery.

When dealing with an enlarged fibroid uterus, particularly in pregnancy, having adequate surgical exposure is critical to optimize care and minimize maternal and fetal risks.  A vertical skin incision would be the appropriate choice in these circumstances.

At 10:34 a.m., the obstetrician made a low transverse Pfannenstiel skin incision with another physician as her assistant.  She then noted that the baby was not breech, but vertex with the head somewhat entrapped behind the large uterine fibroid in the lower uterus.  The obstetrician encountered difficulty delivering the baby due to the lack of exposure and space and made a vertical midline incision on the patient’s skin down through the fascia allowing greater exposure of the uterus.  Delivery time was 10:50 a.m.

After the delivery, the obstetrician noted extensive bleeding from the classical uterine incision site.  A perinatologist was called in to assist. The obstetrician and assisting physicians decided that, in order to be able to close the uterine incision, removal of the 10 cm lower uterine fibroid was the best decision.  The obstetrician performed removal of the fibroid, followed by closing the uterine incision in layers. When hemostasis was assured, an intraperitoneal drain was placed in the left lower quadrant, and all fascial and subcutaneous layers were closed.  The obstetrician closed the low transverse and vertical midline (inverted T incision) with staples and applied a pressure dressing.

The Cesarean section was completed at 1:02 p.m.  The patient’s pre-operative hemoglobin was 13.5, and postoperatively, it was 7.5, indicating that the patient had lost approximately half of her blood volume with surgery.  The obstetrician recorded an estimated blood loss of 1500 ml during the patient’s surgery. The patient was transferred to the recovery room, where she was monitored. The nurse noted oozing from the incision area that gradually increased over the course of observation.

At 1:30 p.m., the patient’s blood pressure was 91/52 and her pulse was 122.  The obstetrician was paged by the nurse at 1:49 p.m. At 2:00 p.m., the patient’s blood pressure was 77/46 and pulse 112.  A CBC was returned at 2:15 p.m. with hemoglobin 7.5, hematocrit 21, and platelets 124. Coagulation studies were consistent with DIC.  From approximately 2:15 p.m. to 2:32 p.m., the patient continued to have hypotension, with a blood pressure ranging from 76-89/44-51 and a pulse range of 106 to 122.  At 2:32 p.m., transfusion of 2 units of packed red blood cells was started, as ordered by the anesthesiologist for the patient’s Cesarean section.

At 2:50 p.m., “state OB Team Bravo” code was called when the patient’s blood pressure was 64/29 and pulse 104.  Moderate oozing and bleeding was noted from her surgical incision, blood filled the surgical drain, the patient was having vaginal bleeding, and her abdomen was becoming distended.  CBC returned at 3:13 p.m. with hemoglobin 8.1 and platelets 109. Transfusion of the second unit of blood was complete by 3:21 p.m. The perinatologist performed a bedside ultrasound at 3:25 p.m., which confirmed large hemoperitoneum.  The decision was made to return to the operating room for exploratory laparotomy with likely hysterectomy. The gynecologic oncologist was called to assist.

The obstetrician arrived back at the patient’s bedside and/or again became directly involved in her care at 3:25 p.m.  After her arrival, the obstetrician took the patient for surgery with the gynecologic oncologist. At 4:24 p.m., CBC returned with hemoglobin 6.7 and platelets 84.  Surgery on the patient began at 4:30 p.m. Upon entry into the abdomen, the gynecologic oncologist noted 3-4 L of blood with continuous oozing from various surfaces of the uterine incision.  The gynecologic oncologist performed a hysterectomy with the obstetrician assisting. The gynecologic oncologist recorded an estimated intraoperative blood loss at approximately 1 L. During the surgery, the patient received a total of 8 units of packed red blood cells, 8 units of fresh frozen plasma, 1 unit of cryoprecipitate, and 1 platelet pack.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she failed to recognize massive blood loss and the emergent need for transfusion and management during the patient’s Cesarean section and/or during her immediate post-operative period as well as failed to respond in a timely manner when she was paged at or around 1:49 p.m. in connection with a critical post-operative patient.  The obstetrician also failed to evaluate and examine the patient completely and/or adequately prior to starting her Cesarean section on 7/22/2010, and incorrectly made a low transverse incision.

For this case and others, the Medical Board of California placed the obstetrician on probation for 7 years and ordered the gynecologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each 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.  The obstetrician was also ordered to have a psychiatric evaluation and receive psychotherapy. The obstetrician was required to have a practice monitor.

State: California


Date: September 2015


Specialty: Obstetrics


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abnormal Vaginal Bleeding, Wound Drainage


Diagnosis: Obstetrical Hemorrhage, Gynecological Disease


Medical Error: Delay in diagnosis, Failure to examine or evaluate patient properly, Failure of communication with other providers, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Obstetrics – Vaginal Bleeding During Third Trimester Due To Placenta Previa And Breech Position



On 8/19/2011, a 25-year-old female saw an obstetrician for a pregnancy that was approximately 17 to 18-weeks gestational age.  The patient’s last menstrual period was on 4/17/2011, which gave her a calculated due date of 1/25/2012. On 5/20/2011, she had been seen for vaginal bleeding in early pregnancy.  The patient had also received prenatal care since 6/9/2011. The obstetrician’s medical records of the patient generally suggested that the patient had an essentially uncomplicated pregnancy, and there was no documentation of any third-trimester bleeding episodes.

The hospital patient records for the patient showed that she was admitted there on 11/29/2011, presenting with vaginal bleeding at 32-weeks gestation.  The hospital records also contained copies of the patient’s records from the previous prenatal clinic, but none from the obstetrician’s office. The hospital admission history and physicals stated that the patient had six in-office ultrasounds, which was consistent with the obstetrician’s statement that he performed ultrasounds at every patient visit.  An ultrasound performed at the hospital upon admissions showed a complete placenta previa and a breech-presenting fetus. The fetal heart rate was borderline bradycardic. Steroids and magnesium sulfate tocolytics were administered, and the patient had a recurrent hemorrhagic event. On 11/30/2011, a Cesarean section was performed.

The obstetrician had assumed prenatal care of the patient at 17 to 18 weeks.  Placenta previa is often present in mid-pregnancy, but in the vast majority of cases, resolves by 28 to 30-weeks gestation.  The obstetrician, who saw the patient four times, stated in his Board interview that he performed ultrasounds at every visit.  The patient’s history at the hospital also suggested that the patient underwent multiple ultrasounds. However, the obstetrician’s patient records contained no documentation that ultrasounds were ordered or performed, or that any findings were noted.  Had ultrasounds been properly performed and the findings documented, the patient would have known of her placenta previa when she experienced vaginal bleeding in the third trimester. She would likely have been placed on modified rest and pelvic rest, mitigating the likelihood of such a bleeding episode.  In his Board interview, the obstetrician stated that he does “limited,” “informal,” and “casual” in-office ultrasounds on a routine basis, but such ultrasounds are not the standard of practice for every prenatal visit. If the obstetrician did only limited ultrasounds on the patient, a formal, more complete ultrasound should have been ordered or performed as well.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to identify the patient’s placenta previa and breech presentation or failed to order or perform a more complete ultrasound, failed to document his in-office ultrasound studies, and routinely performed “limited,” “informal,” and “casual” in-office ultrasounds on the patient for every visit.

The Medical Board of California placed the obstetrician on probation for 3 years and ordered the obstetrician to complete a medical record keeping course and education course.  The obstetrician was also prohibited from supervising physician assistants.

State: California


Date: July 2015


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding


Diagnosis: Obstetrical Complication, Obstetrical Hemorrhage


Medical Error: Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Pregnancy With Placenta Previa 4 Weeks After Normal Vaginal Delivery



On January 2009, a patient saw an obstetrician while she was in the late part of her first pregnancy.  On 1/19/2009, the patient had a normal spontaneous vaginal delivery by a different obstetrician without complication.  The obstetrician saw the patient for two post-partum visits (2/26/2009 and 3/4/2009). The obstetrician’s charting of the patient’s visits were scant, and he failed to chart a plan for the patient’s contraception to her medical record notes for her visits on 2/26/2009 and 3/4/2009.

Approximately 4 weeks after the delivery of her first baby, the patient conceived again.  She tested positive in a pregnancy test at the clinic on 7/10/2009. Her first prenatal visit occurred on 8/13/2009.  The obstetrician saw the patient next on 8/19/2009, and at that time, he ordered an ultrasound. The patient complained of intermittent vaginal spotting and was told by the obstetrician that it was normal.  The obstetrician informed the patient that she might have a condition called partial placenta previa, but that usually resolved later on in the pregnancy. If not, she might need a Cesarean section. No other explanation was given to the patient, and he charted no notes of the patient’s complaints of vaginal bleeding in her medical record.

On 9/24/2009, the patient’s next visit, the obstetrician charted positive fetal movement and fetal size consistent with the dates of conception.  On 10/2/2009, the previously ordered ultrasound was performed. The obstetrician’s next undated chart note described the result of the ultrasound test, and he signed, but did not date, the formal ultrasound report, which showed the placenta to be posterior with total previa noted on the first and second page of the report.  The obstetrician transcribed the data from the report to the patient’s antenatal pregnancy flow sheet, but he failed to include the critical finding of placenta previa, and there was no formal problem list on the flow sheet that would alert a health provider who looked at her chart that the patient had a potentially serious problem with her pregnancy.  The patient called the obstetrician’s office to learn of the results of the ultrasound test and was told that she would have been notified if there was a problem.

The patient did not keep her next appointments with the obstetrician, which were scheduled for 10/21/2009 and 10/29/2009.  After the patient missed her appointments, the obstetrician did not contact her to inform her about her ultrasound test results or to reschedule the missed appointments.  The patient was not informed about her ultrasound test results or the potential ramifications of placenta previa.

On 11/6/2009, the patient was seen at a hospital complaining of a gush of fluid and bleeding.  An ultrasound was taken, which showed complete placenta previa with minimal bleeding. The patient was transferred to another hospital, and, in her history and physical, she stated that she had had intercourse within 24 hours of admission and the previous week.  The patient began to bleed profusely and was taken to the operating room where she had a Cesarean section delivery of a 635 g female baby from the breech position with Apgar scores of 4 and 7.

The obstetrician saw the patient for 2 postpartum visits on 11/18/2009 and 12/15/2009.  The patient’s baby remained in NICU until 3/31/2010, where she was treated for prematurity syndrome and developed retinopathy and COPD associated with premature birth.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to adequately inform the patient about the diagnosis of placenta previa by providing her with precautions, including but not limited to precautions about bleeding, intercourse, or contractions that could lead to hemorrhage and early delivery.  The obstetrician also failed to keep complete, adequate or accurate records for the patient because he failed to include the critical finding of placenta previa on her antenatal flow sheet, accurately document the patient’s medical records regarding discussions about contraception in order to plan the timing of future pregnancies,  accurately document the patient’s medical records regarding discussions of vaginal bleeding, and have office procedures in place to reschedule missed appointments.

The Medical Board of California issued a public reprimand and ordered the obstetrician 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: June 2015


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding


Diagnosis: Obstetrical Complication, Obstetrical Hemorrhage


Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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