My Doctor Operated on the Wrong Vertebra and Tried to Conceal It

by

Comprehensive Overview of Surgical Encounter, Deviations, and Records Deletion

The Case of Michael Alan Stuart vs. Dr. Kesterson and the Center for Neurological Disorders.

Reference the JPS Surgery Records for August 3, 2021: These records were initially part of the hospital’s official documents but were subsequently removed by Dr. Kesterson and JPS Hospital.

Context of Reference:

  • Prior to their deletion, a copy of these records was obtained. Analysis of these documents reveals that initially, Dr. Kesterson and his team appeared to be operating in accordance with the planned procedure. However, it later became evident that they operated on the incorrect vertebrae. Instead of openly acknowledging this error, there was an alteration and removal of the medical records.
  • Following these actions, there was a noticeable withdrawal from providing post-surgical care, seemingly in an effort to evade responsibility for the mistake. This sequence of events raises serious concerns about professional conduct and adherence to medical ethics.
  • Dr. Kesterson and his partner, Dr. Cravens, also disbanded their practice, the Center for Neurological Disorders, shortly after this surgical error and subsequent cover-up.

Patient Information

  • Name: Michael Alan Stuart
  • MRN: 51590151
  • DOB: 1/13/1959
  • Sex: Male
  • Address: 1500 South Main St, Fort Worth, TX 76104
  • Admission: 8/3/2021
  • Discharge: 8/4/2021

Surgery Details (08/03/2021)

  • Time: 10:45 AM
  • Location: JPS Main OR, Room: Main OR 07
  • Service: Neurosurgery
  • Case: 431792
  • Planned Diagnosis: Lumbar Radiculopathy
  • Surgical Plan: Laminectomy, decompression of spinal cord/nerve, facetectomy, foraminotomy (left L2 and L3), TLIF L3-L4, pedicle screw fixation L2-L4

Performed Procedures

All procedures had an anesthesia type of General, on the lumbar spine region. For each procedure, the patient was positioned prone on a Table Spine ProAxis. The patient’s arms and l egs were flexed, and the head was aligned. Positioning was confirmed by Dr. Kesterson.

  1. Laminectomy and decompression (left L1 and L2 vertebrae)
  2. Additional laminectomy with facetectomy and foraminotomy (left L2 and L3 vertebrae)
  3. Spinal arthrodesis (posterior technique, L2-L4 pedicle screws)
  4. Posterior spinal instrumentation (3 to 6 vertebral segments)
  5. Bilateral somatosensory evoked potential monitoring
  • Case Completion:
    – Pre-op diagnosis: Lumbar radiculopathy [M54.16]
    – Post-op diagnosis: None

Surgical Team

  • Primary Surgeon: Dr. Oliver L Kesterson III, MD
  • Assisting: Dr. Harrison Scofield, MD (Resident)
  • Staff Involved:
    – Circulator: Bolo, Melody, RN
    – Scrub Person: Peters, Geri
    – Surgical Assistant: Whiddon, Taylor Leigh, PAC
    – Relief Circulator: Stuart, Debra, RN & Trull, Holly, RN
    – Radiology Technologist: Thompson, Joshua W, RT (ARRT)
    – Relief Scrub: Johnson, Mteesha
    – Anesthesiologist: Jones, Lauren H, MD & Bolar, Sudhir Narayana, MD
    – CRNA: Orellana, Alexander, APRN, CRNAVisitors :
    – Student Assisting: Abrahim Sharaf MS3
    – Neuro Monitoring Technician: Bianca Bojkovic
    – Vendor: Thomas Porter K2M

Post-Surgical Discrepancies

  • Actual Procedure: Fusion of L1-L3, not as per the original plan.
  • Post-op Diagnosis: Modified to Lumbar radiculopathy [54.16] L2-3 with lateral recess stenosis at L1-2, aligning with the conducted procedure.

Texas Medical Board Sanction

Allegations Regarding Record Deletion

  • These surgical records were deleted from the official record.
  • Possible Motives:
    • Concealing a mistake,
    • avoiding legal consequences,
    • protecting reputation,
    • reducing liability, or financial incentives.
  • Legal and Ethical Implications: This act raises significant legal and ethical concerns, including violation of healthcare regulations and undermining patient trust.

This summary encapsulates the key elements of the surgical encounter, subsequent discrepancies, and allegations, offering a comprehensive overview of the events and their implications.

Reference:

Altering Medical Records to Conceal Malpractice

In general, altering medical records to conceal malpractice can lead to:

  • Disciplinary Actions by the Texas Medical Board: This could include suspension or revocation of the physician’s medical license, fines, and mandatory corrective action.
  • Criminal Charges: Depending on the severity and nature of the falsification, criminal charges such as fraud or obstruction of justice could be applicable.
  • Civil Liability: The physician could face lawsuits for malpractice, fraud, or other causes of action, potentially leading to significant financial penalties and damages.
  • Reputational Damage: Professional reputation and credibility could be severely impacted, affecting career prospects and standing in the medical community.

It’s important to note that the specifics of any penalties would depend on the details of the case, including the nature and extent of the malpractice and the falsification of records.

Res Ipsa Loquitur

Under Texas state law, the doctrine of “res ipsa loquitur” can be applied in medical malpractice cases under certain circumstances. This doctrine is typically relevant in situations such as unintentional retention of medical equipment within a patient’s body post-surgery, or performing a surgical procedure on an incorrect body part while under the belief that it is the correct site as per the surgical plan.

Definition of Res Ipsa Loquitur:
Res ipsa loquitur is a legal doctrine used in personal injury law, which translates to “the thing speaks for itself.” In the context of medical malpractice, it refers to cases where the nature of the accident or injury is such that it implies negligence on the part of the defendant, without needing extensive proof. This doctrine is invoked when the injury would not typically occur without negligence and when other factors, such as the actions of the patient or a third party, can be ruled out. It shifts the burden of proof to the defendant, who must then demonstrate that there was no negligence.