Found 372 Results Sorted by Case Date
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California – Obstetrics – Vaginal Birth After Two Prior Children Delivered By Cesarean Section



At 8:15 a.m. on 10/3/1996, a 33-year-old female was 40 weeks pregnant, with two prior children delivered by Cesarean section, was admitted to a community hospital to have her baby delivered by an obstetrician.

Her cervix was dilated 3 cm, and her baby was at a high vertex station.  By 3:00 p.m., she had progressed to dilatation of 6-7 cm.  The obstetrician was paged and came to rupture her membranes.

Immediately after the rupture, the fetal heart monitor showed a fetal heart rate deceleration, which lasted about two minutes.  By 3:12 p.m., there were recurrent decelerations with each contraction.  The obstetrician left the hospital without evaluating the situation after he ruptured the membranes.

The obstetrician was informed by telephone of the decelerations at 3:45 p.m. and at 4:00 p.m.  He discussed performing a Cesarean section, an epidural anesthetic was ordered, and other preparations were made for surgery.  The obstetrician did not arrive at the hospital until 6:10 p.m., by which time the fetal heart rate decelerations were severe and deep.  He told the patient that he needed to perform the Cesarean section ASAP and obtained consent.

At 6:54 p.m., the obstetrician delivered the baby by Cesarean section, noting a complete rupture of the uterus during surgery.  Both the baby and placenta were found in the abdominal cavity.  The baby ultimately expired.

Given the above case and others, the obstetrician was placed on probation for 3 years with stipulations to complete the Physician Assessment and Clinical Education Program, complete 40 hours annually of continuing medical education while on probation, complete an ethics course, and undergo clinical monitoring.

State: California


Date: June 1999


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Failure to properly monitor patient, Underestimation of likelihood or severity, Improper treatment


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – General Surgeon – Lung Infiltrates On X-Ray Thought To Be From Radiation Done After Lumpectomy For Breast Carcinoma



A general surgeon provided medical care to a female patient from 1962 until her death in 1991.  The patient’s date of birth was 10/3/1922, and she was around 68-years-old at time of death.

In July of 1980, the general surgeon diagnosed right breast carcinoma and performed a lumpectomy followed by radiation therapy.

X-rays taken after radiation therapy revealed infiltrates in the lungs thought related to the radiation treatment.  Enlarging nodules in the right lung were also noted.

Board certified radiologists compared the x-rays made yearly between 1981 and 1991 and interpreted the x-rays as revealing gradually enlarging nodules of the right lung consistent with extremely slow growing metastases.

The general surgeon noted the findings and believed the patient to be clinically stable.  For this reason, he did not obtain pulmonary or oncology consultations to address the findings.

The Board ordered the general surgeon complete 20 hours of continuing medical education in the treatment of breast cancer.

State: Wisconsin


Date: October 1997


Specialty: General Surgery, Oncology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: Underestimation of likelihood or severity


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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