The Bad: 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.
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.
- Seeking relief from post-surgery pain, Mr. Stuart approached VA. An October 30, 2021, CT scan revealed loose screws from the failed surgery.
- The VA engaged UTSW to examine the issue of the loose screws, but they failed to diagnose through March 2023. Mr. Stuart’s condition worsened to the point of needing a wheelchair.
- Dr. Rizkalla and Dr. Avramis, orthopedic surgeons at Baylor Scott & White, performed corrective surgery on January 4, 2024.
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.
Violations of Medical Standards
- 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.
VA Community care agreements require detailed medical records and outcomes for all medical procedures provided. UTSW failed to deliver medical records or outcomes, highlighting broader systemic problems within the VA community care program.
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.
Organizations complicit with these efforts include:
- UT Southwestern Dallas (UTSW)
- Center for Neurological disorder (CND)
- John Peter Smith Hospital Fort Worth (JPS)
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