Found 11 Results Sorted by Case Date
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Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son.  The child was born with a neural tube defect called spina bifida/myelomeningocele.

The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.

The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.

The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.

It was requested that the Board order one or more of the following penalties for the obstetrician: 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: Obstetrics


Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain


Diagnosis: Neurological Disease


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pregnant Patient With Abdominal Pain And Green Pelvic Discharge Diagnosed With Cervicitis And Urinary Tract Infection



On 3/24/2015, a 22-year-old female presented to an ED physician in the emergency department with complaints of abdominal pain.

The ED physician ordered the patient to undergo a urine pregnancy test and, based on the results, diagnosed her with pregnancy.

The ED physician ordered that the patient undergo a pelvic ultrasound, after performance of which the technician advised the ED physician the fetus estimated gestational age was thirty-five weeks and six days.  The ED physician performed a pelvic examination of the patient which revealed abnormal green discharge.

The ED physician ordered the patient undergo further urinalysis and based on the results, diagnosed her with cervicitis and urinary tract infection.

The ED  physician failed to consider possible premature rupture of membranes.  He also failed to consider possible premature labor.

The ED physician prescribed parenteral and oral antibiotics to the patient and discharged her home.

The patient’s medical condition required further emergent evaluation by an obstetrician.  The ED physician failed to arrange or failed to document arranging for transfer of the patient to an obstetrician for further evaluation.

On 3/25/2015, the ultrasound report was read by the radiologist whose impressions included: single live intrauterine pregnancy, a large disparity in estimated age based on measurements, and potential premature rupture of membranes.

Following an examination, the patient was emergently transferred to the labor and delivery department where the baby was delivered stillborn.

The Medical Board of Florida issued a letter of concern against the ED physician’s license.  The Medical Board of Florida ordered that the ED physician pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $4,445.91 and not to exceed $6,445.91.  The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in the area of high-risk emergency medicine, complete a medical records course, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Emergency Medicine, Obstetrics


Symptom: Abdominal Pain, Abnormal Vaginal Discharge


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Obstetrics – Non-Reactive Fetal Non-Stress Testing And Vaginal Infection Symptoms



On 8/2/2012, a patient presented to a health clinic for routine prenatal care at 41 weeks gestation and reported having yellow vaginal discharge.  The family practitioner performed a sterile speculum examination, which did not show evidence of rupture of membranes and a vaginal smear, which showed possible bacterial vaginosis (BV).  The family practitioner scheduled an induction for 8/6/2012.  Medication for BV was not prescribed for the patient and it was noted in the patient’s chart notes that the vaginal irritation did not bother her at that time.

On 8/3/2012, the patient returned to the clinic presenting with yellow and green water leakage.  The patient saw a different provider during this visit.  A sterile speculum examination and vaginal smear were performed.  Medication for the treatment of BV was prescribed to the patient, to be used for the following three nights prior to the patient’s scheduled induction.

On 8/4/2012, the patient returned to the clinic to discuss medical concerns with the family practitioner.  The patient requested an earlier than scheduled induction.  The family practitioner examined the patient and saw no evidence of rupture or indication for early induction.  Fetal Non-Stress Testing (NST) was performed and notes indicated “no [sic] entirely reactive strip but not really concerning.”  The family practitioner encouraged the patient to keep taking the prescribed medication for BV.  The patient was then sent home.

On 8/6/2012, the patient presented to the hospital for her scheduled induction.  Fetal heart tones were not detected and an emergent C-section was performed.  An autopsy report showed that the patient’s infant was stillborn with fulminant acute chorioamnionitis (inflammation of the fetal membranes due to a bacterial infection) and acute funisitis (inflammation of the connective tissue of the umbilical cord).  The infant had aspiration of meconium and inflamed amniotic fluid.

The family practitioner failed to timely and properly diagnose and respond to a non-reactive NST, he should have ensured that the patient had a reassuring fetal heart monitoring strip. The family practitioner failed to treat an intrauterine infection that contributed to the death of a fetus.

The Commission stipulated that the family practitioner reimburse costs to the Commission, complete 5 hours of continuing education covering the subject of Fetal Non-Stress Testing, and write and submit a paper of at least 1000 words, with references, regarding Fetal Non-Stress Test interpretation.

State: Washington


Date: March 2016


Specialty: Obstetrics, Family Medicine


Symptom: Abnormal Vaginal Discharge


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Improper treatment


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Gynecology – Ultrasound Shows Fibroid In Patient With Vaginal Drainage and Abdominal Pain



In May 2012, a post-menopausal, nulligravida 60-year-old female with prior gastric bypass surgery and a family history of colon cancer presented to a gynecologist with intermittent left lower quadrant abdominal pain and a two-month history of vaginal drainage, sometimes with blood.  The gynecologist performed an in-office ultrasound, which showed a fibroid and a 1.1 cm endometrial stripe.  The medical records do not document a specific follow-up plan for this patient, but reference instruction that the patient should follow up with a neurosurgeon if her pain worsened.  It is not entirely clear as to why the gynecologist instructed the patient to follow up with her neurosurgeon if the pain were to worsen.

In November 2012, the patient returned with a chief complaint of over two months of continuous vaginal bleeding and constant left lower quadrant abdominal pain.  The gynecologist immediately performed a dilation and curettage, which showed endometrial cancer.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the gynecologist’s conduct to be below the minimum standard of competence given failure to arrange for an endometrial biopsy at the May 2012 visit.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: February 2016


Specialty: Gynecology


Symptom: Abnormal Vaginal Discharge, Bleeding, Abdominal Pain


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Diagnostic error, Failure to follow up


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Gynecology – Ultrasound Shows Fibroid In Patient With Vaginal Drainage And Abdominal Pain



In May 2012, a post-menopausal, nulligravida 60-year-old female with prior gastric bypass surgery and a family history of colon cancer presented to a gynecologist with intermittent left lower quadrant abdominal pain and a two month history of vaginal drainage, sometimes with blood.  The gynecologist performed an in-office ultrasound, which showed a fibroid and a 1.1 cm endometrial stripe.  The medical records do not document a specific follow up plan for this patient, but reference an instruction that the patient should follow up with a neurosurgeon if her pain worsened.  It remains unclear as to why the gynecologist instructed the patient to follow up with her neurosurgeon if the pain were to worsen.

In November 2012, the patient returned with a chief complaint of over two months of continuous vaginal bleeding and constant left lower quadrant abdominal pain.  The gynecologist immediately performed a dilation and curettage, which showed endometrial cancer.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the gynecologist’s conduct to be below the minimum standard of competence given failure to arrange for an endometrial biopsy at the May 2012 visit.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: February 2016


Specialty: Gynecology


Symptom: Abnormal Vaginal Discharge, Bleeding, Abdominal Pain


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 1


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



Washington – Gynecology – Morbidly Obese Patient With Extensive Abdominal Surgical History Undergoes Total Laparoscopic Hysterectomy With Resulting Complications



A 42-year-old morbidly obese female had a history of abdominal surgery that included a Cesarean section and tubal ligation in 2005, a laparoscopic cholecystectomy in December 2005, and a laparoscopic resection of endometriosis in November 2008.  Following the November 2008 procedure to remove endometriosis, the patient continued to experience pain, heavy bleeding with menses, and other symptoms.  The patient was informed of treatment options and chose to undergo total laparoscopic hysterectomy.

On 5/22/2012, a gynecologist began performing a laparoscopic total hysterectomy on the patient.  Before beginning the laparoscopic surgery, the gynecologist used a RUMI uterine manipulator to obtain better visualization and access during the laparoscopic procedure.  A uterine tip at the end of the RUMI device was advanced through the cervical canal, into the uterus, and secured into position with a balloon inflated with saline.  An attachment called a Koh cup was advanced along the RUMI device, into the vagina, and was seated at the opening of the cervix.

The gynecologist then began the laparoscopic surgery.  She made an incision at the umbilicus, and after lifting the abdomen in attempt to separate any potential adhesions from the abdominal  wall, she placed a blunt tissue dissecting trocar using a laparoscope for visualization.  It immediately became apparent that the laparoscope was in the lumen of the small bowel.  The gynecologist and the assisting surgeon decided to convert the procedure to an open procedure, so that they could repair the perforation in the small bowel.  The gynecologist removed the RUMI device, but did not remove the Koh cup.  The assisting surgeon repaired the small bowel, and the gynecologist completed the hysterectomy.  Shortly following the gynecologist’s completion of the hysterectomy, the patient began experiencing declining oxygen saturation, requiring attention from multiple anesthesiologists.  After the procedure was completed, the patient was immediately taken for CT imaging, where it was determined that she did not have a pulmonary embolism.  The patient was subsequently taken to the Critical Care Unit by order of the anesthesiologist for treatment of her continued oxygen saturation issues, which resolved the following day without discovery of the etiology.  The Koh cup remained in the patient.

In the month following surgery, the patient experienced a foul smelling vaginal discharge, and abdominal pain that may have been associated with other medical issues.  On 6/25/2012, the patient’s regular gynecologist did a vaginal exam and discovered the unintentionally retained Koh cup.  The Koh cup was removed two days later, with the patient under general anesthesia.

In response to this event, the gynecologist now uses a RUMI device that does not separate from the vaginal cup.  The gynecologist also now requires that the Koh cup be accounted for by including it in the surgical checklist.

In addition to the retained foreign body issues, it is the Commission’s position that because of the patient’s history of abdominal surgery, with the attendant likelihood of abdominal adhesions, the gynecologist did not appropriately visualize the peritoneum for adhesions to the bowel before inserting the trocar and laparoscope.  The gynecologist should have either correctly performed the direct entry visualization technique that she used, or alternatively used an open laparoscopic approach (Hasson technique) to avoid the bowel injury that occurred.  Although bowel injury during the course of a total laparoscopic hysterectomy is a known complication, this injury might have been avoided in this case with the correct performance of an appropriate approach.

For this allegation and another, the Commission stipulated that the gynecologist reimburse costs to the Commission, develop a written protocol designed to prevent unintended retention of foreign body objects, write and submit a paper of at least 1000 words, with bibliography, in which she provides root cause analysis of the factors leading to the retained surgical sponge, write and submit a paper of at least 1000 words, with bibliography, containing a discussion regarding the need for visualization of the lining of the peritoneum and the correct performance of an appropriate laparoscopic approach for patients with a history of abdominal surgery, and present these two surgical cases to a peer group at a facility where she performs surgery.

State: Washington


Date: May 2015


Specialty: Gynecology


Symptom: Abnormal Vaginal Discharge, Abdominal Pain


Diagnosis: Post-operative/Operative Complication


Medical Error: Retained foreign body after surgery, Procedural error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



California – Obstetrics – History Of Coagulopathy And Long Distance Driving After Cesarean Section



On 4/18/2007, a 28-year-old married female presented to an obstetrician for her first prenatal visit.  She was Gravida 2, Para 0 (G2 P0); she had two pregnancies, but no live births. The patient’s last menstrual period was on 2/28/2007.  Her menses were irregular, and she had a history of infertility. The patient’s past medical history was subsequently noted as negative.  The obstetrician had previously treated the patient. The obstetrician had documented a diagnosis of polycystic ovary syndrome (PCOS) in the patient in 2000, presenting as androgen excess, hirsutism, anovulation, weight gain, and infertility.

The obstetrician treated the patient with metformin and recommended fertility treatment with Clomid when she was ready to conceive.  On 11/30/2006, the obstetrician referred the patient to a reproductive endocrinologist. Lab work on the patient dated 1/31/2007 reflected elevated testosterone and DHEAS, low progesterone, and the patient being heterozygous for the MTHFR mutation.  Anti-phospholipid antibody results were not obtained because the patient had no risk factors for thrombosis according to the obstetrician’s testification.

On 4/26/2007, the patient presented to the emergency department complaining of pelvic pain.  The emergency department records documented that the patient’s medications included 40 mg SQ Lovenox, baby ASA, folic acid, and progesterone.  An intrauterine pregnancy showing 2 gestational sacs with fetal poles was identified. A past history of coagulopathy resulting in a “hypercoagulable” state was listed.  The physical exam was negative. An ultrasound confirmed a twin gestation at 7 weeks 4 days with fluid in the gestational sacs. The final diagnosis was threatened abortion with a ruptured ovarian cyst.

On 4/30/2007, the patient was referred to a perinatologist (a maternal and fetal medicine specialist).  On 5/22/2007, the patient received an ultrasound with the perinatologist. It revealed “no obvious problems in either fetus.”  The plan was to await biochemistry results. He documented that it was an in vitro fertilization pregnancy. The patient had no history of pregnancy losses or DVT.  However, the perinatologist noted there was a family history of coagulopathies. The perinatologist recommended continuing aspirin alone without metformin or Lovenox but noted that complete blood work was not available for review.  He noted that the patient was at increased risk for gestational diabetes, given her history of PCOS, twins, and maternal obesity. On 5/22/2007, the patient also received genetic counseling, where risk factors were reviewed. The patient reported that her sister had lupus, anti-phospholipid syndrome, positive anti-cardiolipins, a history of fetal demise, MTHFR mutation, and a child with autism.  On that basis, the perinatologist recommended that the patient undergo further testing. The risks of progesterone, Lovenox, and ASA administration during pregnancy were reviewed.

The patient was allergic to sulfa.  The patient’s family history was noted as positive for breast cancer and heart disease.  The obstetrician made no reference in the ACOG records, or any medical records, of the patient’s family history of coagulopathy.  Genetic screening was checked off as all negative, including no blood disorders, no recurrent pregnancy loss, no current medications, and no over-the-counter drugs or supplements.  The obstetrician made no reference in the ACOG records, or any other medical records, of the patient’s current medications, progesterone, ASA or Lovenox, and he did not evaluate their use.  The obstetrician made no reference to the patient’s fertility problems, or that she had achieved the current pregnancy through in vitro fertilization, in the ACOG records, or any other medical records, of the patient, to any consultation with the reproductive endocrinologist seen by the patient.  The circumstances of the IVF were not considered.

On 5/31/2007, the patient’s physical examination was remarkable for a 14 to 16-week size uterus and “narrow pelvis.”  Two cold sores were noted. The patient was given an expected date of delivery of 12/5/2007. In June 2007, at 16-week gestation, as indicated by the obstetrician’s medical records, the patient called the obstetrician’s office and was anxious in light of her sister’s history of incompetent cervix resulting in a miscarriage at 25 weeks.  On 8/2/2007, a follow-up ultrasound was performed for the perinatologist. It revealed a normal twin pregnancy at 22 weeks. The patient’s cervical length was normal. The patient was advised to reduce activity by 50%.

On 8/13/2007, the patient was admitted to the hospital in premature labor.  Her cervical length was shortened with funneling. The patient was treated with magnesium sulfate and bed rest. Labor was successfully stopped.  The patient remained in the hospital on bedrest. The obstetrician treated the patient during her hospital stay. On 8/21/2007, sequential suppression boots (thromboguards) were ordered for the patient.

On 9/25/2007, the patient was discharged from the hospital to home care.  Upon discharge, an ultrasound identified a 23-week twin gestation with no fluid around twin A.  The patient was documented as having reported leakage over the past few days. After having been discharged, the patient was readmitted to the hospital with preterm premature rupture of membrane and treated with “rescue” steroids, IV antibiotics, and “not aggressive” tocolysis.  The patient complained of sharp pain in her left groin area unrelated to uterine contractions. The obstetrician’s partner was notified. The patient’s pain resolved in a few hours. The patient was observed on bedrest for the remainder of her pregnancy under the obstetrician’s care.  During her hospital stay, the patient was noted to have edema, and the patient complained of left inguinal pain.

On 11/9/2007, at 36-weeks gestation, the obstetrician performed an elective Cesarean section on the patient without complications.  The patient gave birth to a healthy baby girl and a healthy baby boy. The twin babies did well. On 11/12/2007, the patient was discharged from the hospital.  The patient’s hemoglobin was 8.6, which was out of range. The patient was taking Repliva, an iron supplement, and hydrocodone, a narcotic pain-reliever. On 11/20/2007, the patient had a regular follow-up appointment with the obstetrician to review any complaints she had and to check her incision, consistent with his custom and practice.  The obstetrician documented no complaints and noted the incision was healing well. Aside from referencing the incision, no physical exam or discussion with the obstetrician was described. Family members of the patient reported that, at the time, the patient had a slight fever, an irritating cough, was complaining of painful swelling in her legs and ankles, and she urinated frequently, 2-3 times per day.  Lactation was difficult, as she produced little milk. She stated she felt cold all of the time. The patient was concerned she was having post-partum depression.

On 12/4/2007, the patient had her final appointment with the obstetrician.  The obstetrician documented that she complained of depression, weakness, and a cough.  The obstetrician documented that the patient’s lungs were clear to auscultation and documented prescribing the patient a cough suppressant and an antidepressant, and ordered lab work.  The obstetrician ordered a CBC and thyroid studies. The obstetrician knew that the patient’s family planned to move to Idaho and would be driving there soon. The obstetrician gave the patient no directives and made no recommendations to the patient about the driving trip to move to Idaho or any subsequent treatment.  The obstetrician had no concerns about her driving aside from the usual situation when people are driving any distance when they are pregnant or in the post-partum period, notwithstanding the risks for the patient developing thrombosis.

On 12/6/2007, the patient and her family began their drive to Idaho.  On 12/7/2007 at 4:30 p.m., the patient and her family arrived at the home of relatives in Idaho.  The patient visited with immediate and extended family. Less than 2 hours later, the patient lifted a bag, climbed the stairs of her family’s home, collapsed, and lost consciousness.  Relatives called 911 and summoned an ambulance. An ambulance arrived, but emergency medical personnel were unable to revive the patient. They drove her to a hospital where she was officially pronounced dead.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he initiated obstetric care of the patient without first obtaining a complete history of her then current pregnancy, list of her then current medications, and family history, failed to recognize the patient’s risk of thrombosis, and failed to anticoagulate the patient in the weeks following her Cesarean section.

For this case and others, the Medical Board of California placed the obstetrician on probation for 7 years and ordered the obstetrician to complete a medical record-keeping course, an education course (at least 40 hours for each year of probation), a professionalism program (ethics 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.

State: California


Date: April 2015


Specialty: Obstetrics


Symptom: Pelvic/Groin Pain, Cough, Fever, Abnormal Vaginal Discharge, Psychiatric Symptoms, Swelling, Urinary Problems, Weakness/Fatigue


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus


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


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Family Medicine – Diagnosis Of PID Without Justification And Other Errors



On 1/9/2004, a 29-year-old female patient presented to a family practitioner for an initial history and examination.  The patient’s physical exam was documented mostly via checkmarks on a template form. The patient was noted to have her last pap smear 6 months prior to the visit, which was reported by the patient as normal.  The patient’s vital signs were listed with normal results. Breast and pelvic exams were not documented. The records did not contain a “plan” section, although a copy of a prescription for condoms, OrthoNovum 7-7-7, and doxycycline were found in the record.  No indication for doxycycline was found in the record.

Serum results for 1/9/2004 for cholesterol and random glucose were elevated.  The abnormal results appeared to have been left unaddressed, and the patient did not appear to be treated for such abnormalities.  The urine dipstick result performed by the family practitioner’s office on 1/9/2004 differed from the lab urinalysis result of the same date.  Specifically, the pH by the family practitioner’s office was reported to be 6.0, the character noted as cloudy, the white blood cell count was 3+, and the red blood cell count was noted as 1+.  The lab urinalysis results indicated that the pH was 8.0, the character was clear, and the white blood cell count and the red blood cell count were both none.

On 2/6/2004, the patient presented to the family practitioner with complaints of urinary frequency and burning urine.  She was noted to have suprapubic tenderness, diagnosed with recurrent urinary tract infections, and given a prescription of Cipro.  The patient was also given refills of condoms and OrthoNovum 7-7-7. The patient again presented to the family practitioner on 4/2/2004 with complaints of a vaginal discharge and milky mucous with a strong odor.  The length of the symptoms was not recorded.

On examination, the patient was noted to be slightly distressed and with normal neck, chest, breast, lungs, heart, abdominal, rectal, extremity findings as indicated by circles on “WNL” by each category.  The pelvic exam section only documented a vaginal discharge, but did not describe the discharge. KOH or wet mount were not performed or documented. Vaginitis was diagnosed and treated with Cleocin. A prescription for contraceptives was refilled.

Under “Impressions,” a statement, “r/o PID” was noted on 1/9/2004 and 2/6/2004.  This diagnosis was made without supporting history or exam findings. The diagnosis of PID was left by the family practitioner without work-up or treatment.  The family practitioner did not conduct or perform a breast or pelvic examination during the course of treating the patient.

On 7/15/2005, the family practitioner met with a Medical Board investigator.  The family practitioner gave statements and failed to recognize basic medical facts that indicated a lack of knowledge.  They include: (1) failure to acknowledge that cancers of the uterus or breast are contraindications for the use of oral contraceptives; (2) failure to consider the that the presence of vaginal bleeding does not rule out pregnancy; (3) stated that doxycycline was active for Trichomonas, Chlamydia, and Gonorrhea; and (4) failure to recognize that strong or foul smelling discharge is usually caused by bacterial vaginosis.

The family practitioner committed negligence in his care and treatment of the patient in the following: made the assessment of r/o PID without supporting history, exam findings, or objective studies.  The family practitioner’s assessment was inconsistent with the patient’s presentation; prescribed oral contraceptive medications without conducting a pap smear or pelvic examination; prescribed doxycycline without a documented medical indication; failed to adequately evaluate and treat for potential diabetes in the setting of an abnormal glucose result; failed to adequately treat hypercholesterolemia; failed to determine the type of vaginitis suffered by the patient and did not offer treatment; and failed to settle the discrepancies between the patient’s dipstick and that of the laboratory’s results on the urinalysis.

For this allegation and others, the Medical Board of California issued the family practitioner to be placed on probation for two years, attend a professionalism program, a physician enhancement program, and be prohibited from supervising physician assistants.

State: California


Date: June 2014


Specialty: Family Medicine, Internal Medicine


Symptom: Urinary Problems, Abnormal Vaginal Discharge


Diagnosis: Gynecological Disease


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to follow up, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Family Medicine – Failure To Treat And Determine Type Of Vulvovaginitis And Recognize An Increased Risk Of Gallbladder Carcinoma



On 2/26/2002, a 31-year-old female presented to a family practitioner for multiple complaints.  The family practitioner treated this patient from this date through 6/9/2004. The patient was seen by the family practitioner 22 times from 2/26/2002 to 6/9/2004.

Consistently, the subjective portion of the progress notes in the medical records of the patient were merely comprised of listed complaints and lacked pertinent positives/negatives, descriptions of patient complaints, or history of such complaints.   Consistently, the physical examination findings contained in the progress notes were merely comprised of circles over pre-written words. There was no description provided as to the location of the findings, their severity or quality, or any other essential information that would aid in making a diagnosis of the patient’s condition, or would alert another physician who reviews the records to the condition of the patient.

The “Assessment” section of the medical records of the patient which was labeled as “Impression(s),” consistently listed diagnoses, or often was comprised of a list of complaints.  Pertinent descriptions of the diagnoses were absent and suspected causes were not described. The “Plan” section of the progress notes usually and consistently listed medications exclusively.  There was no documentation or referrals to specialists or requested follow up visits. Additionally, there was no documentation of general counseling or specific counseling regarding any of the listed diagnoses being provided to the patient.

On 2/26/2002, the patient complained to the family practitioner of having a milky, cheese-like vaginal discharge.  A diagnosis of vulvovaginitis was made. No wet mount, KOH test, or culture was performed to confirm or determine the type of diagnosis.  An undescribed vaginal discharge was the only finding listed, and there was no indication that a pelvic examination was performed. No medications were prescribed.  On 7/29/2002, 9/10/2002, 4/15/2003, 11/18/2003, and 12/29/2003, the patient presented to the family practitioner with complaints similar to those described. On each occasion, there was no assessment as to the type of vulvovaginitis listed.  On each occasion, no wet mount, KOH test, or culture was performed to confirm or determine the type of diagnosis. On each visit, the patient was either treated with Monistat or left untreated altogether. Throughout the medical records, a palpable gallbladder was documented. This finding typically would increase concern for gallbladder carcinoma.  An abdominal ultrasound was ordered on 2/26/2002. The only ultrasound found in the patient’s medical record was dated 4/15/2003 and reported “slightly calcified thickening of gallbladder walls as well as ‘sludge visualized.’” There was no evidence of further workup for the calcified gallbladder wall.

On 2/26/2002, 10/9/2002, and 11/18/2003, a urinary tract infection was diagnosed.  There was no urine dipstick analysis, urinalysis, or urine culture performed. On 4/15/2003 and 9/22/2003, urinary tract infection was diagnosed, and a urinalysis appeared to have been performed.  Nonetheless, on none of these occasions were antibiotics prescribed or a referral made to a urologist for this patient’s recurrent cystitis/urinary tract infections. On 9/10/2002, the patient presented to the family practitioner complaining of neck pain, following serious acute head trauma.  No x-rays were ordered, and no physical therapy or orthopedic consultations were recommended. On 9/10/2002, the patient presented with complaints of chest pain. The family practitioner diagnosed her with chest pains and exertional angina. Despite the diagnosis, no EKG, stress testing or referral to an emergency room or cardiologist was made to rule out acute myocardial infarction or ischemic heart disease.

On 7/20/2005 and 8/17/2005, the family practitioner participated in interviews with the Medical Board of California regarding her care of the patient.  During this interview, the family practitioner demonstrated a lack of knowledge by making the following statements: (1) Ultram was not an addictive medication; and (2) a patient with a hysterectomy is in menopause due to the lack of menstruations.

The family practitioner was grossly negligent in the overall care and treatment of the patient in the following: failure to perform and document pertinent histories on nearly all patient visits; failure to perform and document adequate assessment and physical examination on nearly all patient visits; made assessments of medical conditions without supporting history, exam findings, or objective studies; failure to develop and document reasonable plans for evaluating and treating the patient’s presenting complaints/diagnosis; failure to evaluate and treat the patient’s vulvovaginitis and urinary tract infections on several occasions; failure to recognize the signs of gallbladder carcinoma; and failure to adequately evaluate the patient’s acute neck pain in the setting of severe head trauma.

For this allegation and others, the Medical Board of California issued the family practitioner to be placed on probation for two years, attend a professionalism program, a physician enhancement program, and be prohibited from supervising physician assistants.

State: California


Date: June 2014


Specialty: Family Medicine, Internal Medicine


Symptom: Head/Neck Pain, Abnormal Vaginal Discharge, Chest Pain


Diagnosis: Cancer


Medical Error: Improper treatment, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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