The Bad: The Dallas VA and UT Southwestern
In March 2021, the Dallas VA, through its community care program, hired both Dr. Kesterson and UT Southwestern (UTSW) to perform and oversee spinal surgery for Michael Stuart.
- VA Community care agreements require detailed medical records and outcomes for all medical procedures provided.
- Dr. Kesterson and UTSW failed to deliver medical records or outcomes, highlighting broader systemic problems within the VA community care program.
Michael Stuart underwent spinal surgery performed by Dr. Kesterson on August 3, 2021, which quickly failed. Subsequently, the VA contracted UTSW for intervention, who did not succeed until their contract ended in March 2023. Eventually, Baylor Scott & White executed the corrective surgery on January 4, 2024.
This sequence included the following events:
- Pr-surgery image reports showed lumbar spine problems but normal lordosis.
- Medical records document a plan for the fusion of the L2-L4 vertebrae and a TLIF at L3-L4.
- However, the surgical records showed an unexpected change: a fusion from L1-L3.
- Post-operation, Dr. Kesterson modified records to indicate an original plan of L1-L3 fusion.
- Post-surgery, Mr. Stuart suffered abnormal pain, and Dr. Kesterson ended his care abruptly, failing to submit necessary medical records to the Dallas VA.
- Dr. Kesterson’s medical practice abruptly closed sometime before January 1, 2022.
- The VA engaged UTSW to examine the issue of the loose screws they failed to diagnose through March 2023.
- Baylor Scott & White was hired by Mr. Stuart in November 2023. They diagnosed the unsuccessful surgery and performed corrective surgery in January 2024
Due to Dr. Kesterson’s unauthorized change in the surgical plan, the Texas Medical Board took corrective action against Dr. Kesterson on August 19, 2022.
Concerning the Dallas VA and UTSW:
- Seeking relief from post-surgery pain, Mr. Stuart approached Dallas VA. An October 30, 2021, CT scan revealed loose screws and failed surgery, which Dallas VA failed to diagnose or treat for over two years.
- The VA engaged community care provider UT Southwestern (UTSW) to examine the issue of the loose screws under a one-year contract, yet UTSW failed to fulfill their responsibilities. UTSW was also enlisted to assist Kesterson during the pre-surgical diagnosis phase. Their questionable actions may be clear in hindsight, but initially, it caused confusion and delays.
- Mr. Stuart’s condition worsened to the point of needing a wheelchair. He then acquired private insurance through the Affordable Care Act and consulted Dr. Rizkalla and Dr. Avramis, orthopedic surgeons at Baylor Scott & White. They performed corrective surgery on January 4, 2024.
UTSW: Throughout their contract with the VA, from January 2021 to March 2023, UTSW did not identify or address the issues of the failed surgery, including the loose screws and non-union fusion. Baylor Scott & White accomplished in just a few weeks what UTSW was initially contracted to do
Baylor Scott & White: Brought on board in November 2023, quickly diagnosed the unsuccessful surgery and flat back syndrome within two weeks and conducted the corrective operation in January 2024. Their surgical report revealed that the damage from the initial surgery was more severe than anticipated, with the loose screws causing harm to the vertebrae and breaching the spinal canal.
Allegations of Negligence:
- Mr. Stuart is leveling accusations of medical malpractice against Dr. Kesterson and UTSW, seeking redress in the civil courts of Fort Worth and Dallas.
- Additionally, he has submitted a disability claim under 38 USC 1151 to the VA, citing their mishandling of his spinal condition.
Violations of Medical Standards:
Dr. Kesterson:
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- Expected Standard: Adhering to the surgical plan, effective post-surgery care, and clear communication about changes.
- Violation: Unexplained deviation from the surgery plan and abrupt stop in post-surgery care, with poor record-keeping.
- Resulting Harm: Complications and chronic pain, leading to additional surgery.
Dr Patel, UT Southwestern (UTSW):
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- Expected Standard: Correct interpretation of tests, spotting surgical complications, and timely treatment referrals.
- Violation: Missed diagnosis, including ignoring the loss of lordosis, leading to untreated surgical failure.
- Resulting Harm: Worsening of Mr. Stuart’s condition, leading to severe mobility issues and flat back syndrome.
- Dr Patel UTSW Negligence Claim
Expert Analysis:
- Dr. Rizkalla and Dr. Avramis, orthopedic surgery experts, stress the importance of accurate, timely post-surgery diagnosis and treatment. They point out the standard of care failures by Dr. Kesterson and Dallas VA primary care, contributing to Mr. Stuart’s declining health.
- Dr. Kesterson, UTSW, and the Dallas VA’s care were subpar, significantly worsening Mr. Stuart’s health.
VA Negligence: Failure to Address Known Surgical Complication
VA 38 USC 1151: The inability of Dallas VA primary care to diagnose and manage complications from Mr. Stuart’s spinal surgery is directly relevant to his 38 USC 1151 claim.
The medical record reveals a multi-layered failure of oversight and care that extends well beyond individual error. While the initial surgical missteps occurred under Dr. Kesterson at UT Southwestern, the VA’s subsequent actions – or more precisely, inactions – represent the more severe breach of medical responsibility. As the primary healthcare institution charged with your care, the VA had both the evidence and the obligation to address the documented surgical complications.
- The timeline is particularly damning: VA imaging from October 2021 clearly showed loose hardware and canal breach, yet for over two years, they merely documented the deterioration without taking corrective action. This pattern of passive observation continued until Baylor Scott & White’s surgical team, led by Dr. Avramis and later Dr. Chavarria, finally exposed the full extent of the damage. Their operative findings, as detailed in the January 2024 surgical notes, meticulously document how the untreated condition had progressed to require extensive reconstruction from T4 to the pelvis, complicated by infection and severe structural damage.
- The stark contrast between the VA’s lengthy period of inaction and Baylor’s immediate recognition and intervention underscores a troubling pattern of institutional negligence. The forthcoming federal court proceedings will likely scrutinize this documented trail of oversight failures, particularly focusing on how a major healthcare system could allow such clearly evidenced complications to go unaddressed for so long.
The medical record provides a clear timeline of opportunities for intervention that were repeatedly missed or ignored, creating a compelling narrative of institutional accountability that will now be examined within the federal judicial system.
Organizations complicit with efforts to “deny and defend” Dr. Kesterson’s surgical falure include:
- UT Southwestern Dallas (UTSW)
- Center for Neurological disorder (CND)
- John Peter Smith Hospital Fort Worth (JPS)
While the VA wasn’t complicit with “deny and defend” efforts by the private care providers, the VA’s negligence manifested through two years of inaction. Despite their October 2021 CT scan clearly showing loose hardware, the VA failed to address these known complications, allowing the loose screws to destroy the L1 and L3 vertebrae while untreated L3-L4 instability progressed to flatback syndrome and complete mobility loss.
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