Center for Neurological Disorders, Dr. Kesterson

The Ugly: Dr. Kesterson

Dr. Kesterson operated on the wrong vertebrae and engaged in subsequent unethical actions, such as attempting to hide the mistake, failing to disclose it, deleting medical records, and denying the error. 

Several potential areas of negligence and breaches of standard care can be identified:

  • Wrong-Site Surgery: Operating on the wrong body part is a clear violation of surgical standards and protocols. It reflects a failure in pre-operative planning and verification processes, which are crucial for patient safety.
  • Lack of Informed Consent: Patients have the right to be informed about their medical care. Operating on an incorrect site without patient consent breaches this fundamental ethical and legal requirement.
  • Failure to Disclose Medical Errors: Ethical and professional standards require doctors to inform patients about all aspects of their medical care, including any errors or complications that occur during treatment.
  • Tampering with Medical Records: Altering or deleting medical records to conceal a mistake is not only unethical but also often illegal. Medical records are legal documents, and their integrity is paramount.
  • Denial of Error: Refusing to acknowledge a mistake, especially when there is clear evidence, is a breach of professional responsibility. It undermines the trust in the patient-doctor relationship and can hinder subsequent care.
  • Post-Operative Care and Follow-Up: Failing to provide adequate post-operative care and follow-up, particularly after a serious error, compromises patient safety and recovery.
  • Standard Operating Procedures: Established protocols and checks (like the surgical “time-out” procedure) are in place to prevent wrong-site surgery. Failure to adhere to these protocols is a severe lapse in the standard of care.

These issues reflect a combination of medical negligence and ethical violations. Dr. Kesterson deviated from the accepted standard of care, and this deviation directly caused harm to the patient.

Altered Medical Records

Concerns have arisen from an analysis of the medical records provided by Dr. Kesterson, his previous assertion that all records are held at JPS, and the records downloaded from JPS prior to Dr. Kesterson being notified of potential civil litigation. The comparison involves:

  • Medical Records initially downloaded from JPS.
  • Medical Records downloaded post-notification of intent to sue.
  • Medical Records removed by Dr. Kesterson from JPS and not disclosed in civil litigation.

Most troubling is:

  1. The removal and failure to disclose records detailing the surgical procedure, specifically those identifying personnel in the operating room and the hospital’s timeout procedures designed to prevent wrong-site surgical errors.
  2. The creation of a record, timestamped minutes after the surgery, which retroactively alters the pre-op diagnosis. This record is misleadingly labeled as if it were created before the surgery.
  3. The content of Dr. Kesterson’s operating report, where he neglects to explain the deviation from the agreed-upon surgical plan and fails to acknowledge the change in the surgical procedure.

It appears that Dr. Kesterson attempted to conceal his surgical mistake and the identities of witnesses by omitting and deleting records that depict the surgery team operating under the belief that they were following the correct plan from 3pm to 7pm. The realization of their error seems to have led to an abrupt cessation of record-keeping.

Subsequently, Dr. Kesterson entered an anomalous record titled as a ‘brief op note’ at 3:08pm but timestamped at 7:04pm. In this note, he retroactively modifies the pre-op diagnosis to align with the surgical error, in what seems to be an attempt to cover up his mistake. This fabricated diagnosis is then echoed in his operative report. However, the Texas Medical Board has taken remedial action against Dr. Kesterson for his failure to document the reasons behind altering the surgical procedure.

This sequence of events – the alteration of records and the lack of proper documentation in the operative report – raises serious concerns about the integrity of the medical process and Dr. Kesterson’s professional conduct. His actions appear to prioritize obfuscation over the consideration of the patient’s welfare and the necessity of addressing the surgical error appropriately.

Dr. Kesterson’s Conduct

Numerous unresolved issues compound the concerns regarding Dr. Kesterson’s conduct. To this date, Dr. Kesterson has not provided explanations for a series of critical actions:

  1. Reason for Changing the Surgical Procedure: He has not clarified why the surgical procedure was altered from the initially agreed-upon plan.
  2. Non-Disclosure of the Error: There has been no disclosure or acknowledgment of the surgical error from his side.
  3. Alteration and Deletion of Medical Records: The reasons behind altering and deleting pertinent medical records remain unexplained.
  4. Abrupt Termination of Post-Surgical Care: He abruptly ceased providing post-operative care, leaving the patient without necessary medical support.
  5. Lack of Communication: Despite repeated attempts, Dr. Kesterson did not respond to the patient’s phone calls seeking assistance post-surgery.
  6. Closure of Practice: Shortly after the surgery, he closed his medical practice, which raises further questions about the timing and reasoning behind this decision.
  7. Post-Error Malpractice Insurance: Notably, Dr. Kesterson obtained malpractice insurance two weeks after the surgical error, a decision that is questionable in its timing and intent.
  8. Failure to Deliver Records to the VA: He did not provide the required medical records and outcome data to the VA, as mandated by the contract under which he performed the surgery and was to provide post-care. This breach of contract is yet another concern.

Dr. Kesterson’s conduct and his avoidance of key questions raise serious concerns about his professional ethics and disregard for patient welfare. His post-surgery actions, which are documented in medical records and have prompted a response from the Texas Medical Board, highlight significant ethical breaches and underscore the gravity of the situation.

A background check on Dr. Kesterson has revealed a past with concerning patterns.

Organizations complicit with Dr. Kesterson’s efforts to “deny and defend” include:

Research references

  • NIH Non-Disclosure of Medical Errors an Egregious Violation of Ethical Principles
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709172/
    BEdwin A. Non-disclosure of medical errors an egregious violation of ethical principles. Ghana Med J. 2009 Mar;43(1):34-9. PMID: 19652753; PMCID: PMC2709172.

Although most doctors believe that errors should be disclosed to patients when they occur, in reality, most doctors and institutions do not disclose such mishaps to patients and their families. Rather, they engage in extensive cover ups under the guise of protecting the doctor-patient relationship and not causing harm to patients. Non-disclosure of medical errors to patients and/or their families is a violation of ethical principles and cannot ever be justified. By not disclosing a medical error, the doctor conspicuously places his own interests above that of the patient to the detriment of the patient, thereby violating a patient-centered ethic.