Safety

Life in prison for surgeon dubbed 'Dr. Death'

Hospital Safety Insider, February 23, 2017

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A former surgeon was sentenced in Texas this week to life in prison for harming patients in a spree of medical errors described by doctors and lawyers as among the most egregious in memory.

Christopher Duntsch, MD, PhD, had his medical license suspended after being accused of killing two patients and severely injuring others in various Dallas-area operating rooms in 2012 and 2013, but some contend that even more should have been done to halt the dangerous physician more quickly.

“My whole summation of all this is [that] this is a complete and utter failure of the entire system of checks and balances and for the safety of patients from start to finish,” Carlos Bagley, MD, director of the University of Texas Southwestern Medical Center neurological surgery spine program, testified during Duntsch’s trial, as local TV station WFAA reported.

Bagley, who was the only expert witness to testify for the defense team, said Duntsch should have been reported to the national practitioner database and the Texas Medical Board sooner. The defense sought to argue that Duntsch was poorly trained and inexperienced, but prosecutors painted the surgeon as well aware of his actions.

"He chose not to get help," prosecutor Michelle Shughart said, as The Dallas Morning News reported. "He chose to continue maiming and killing patients."

The trial focused on one first-degree felony charge that Duntsch had injured an elderly person “intentionally, knowingly, recklessly, or with criminal negligence.” The victim, who was 74 years old at the time of her 2012 surgery, suffered severe blood loss and can no longer use her legs.

Other botched surgeries left two women dead and others with serious injuries, as D Magazine reported in depth last fall, dubbing Duntsch “Dr. Death.”

“But the real tragedy of the Christopher Duntsch story is how preventable it was,” wrote Saul Elbein for the Texas Observer in 2013. Despite his blatant and well-documented mistakes, Duntsch continued practicing medicine for more than a year before the Texas Medical Board stopped him.

“In Duntsch’s case, we see the weakness of Texas’ unregulated system of health care, a system built to protect doctors and hospitals. And a system in which there’s no way to know for sure if your doctor is dangerous,” Elbein wrote for the progressive newsmagazine.

Erica Mobley, director of communications and development for Washington-based nonprofit The Leapfrog Group, says the case is perhaps the most appalling story of its kind that she’s heard. While the jury ultimately determined that the surgeon committed egregious criminal acts on his own, she says, the case also carries a solemn reminder for hospital safety professionals to ensure that every staffer feels empowered to call out troubling physician behavior.

“It is a good lesson for hospitals to learn about the importance of implementing that safety culture, where anyone feels that they can speak up if they sense that something is going wrong, and that they will not be reprimanded for doing so,” Mobley says, acknowledging that physicians who observed Duntsch’s troubling behavior did report him.

Although this case seems to be an outlier in terms of how irresponsible one doctor was, hospitals should respond to it by renewing their commitments to systems that can keep individual bad actors from carrying on unchecked, Mobley says.

“When a hospital has that culture in place to prevent those systems from breaking down, it can be really, really powerful in preventing errors from harming patients,” Mobley says, “and catching them before they got to a point where they’re affecting a patient.”



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