Dr Patel, UT Southwestern failure to diagnose and treat spine issues after radilogy found loose pedicle screws
The UTSW consultation highlights a series of systemic failures in the care of a patient with a history of lumbar surgeries. There were communication breakdowns between the VA and outside providers, a conflict of interest in referring the patient back to the original surgical team, and missed opportunities for intervention due to delayed access to critical imaging and inadequate follow-up on known hardware complications. These failures, starting with the initial surgery and continuing through the UTSW visit, directly led to the patient’s deteriorating condition, culminating in emergency surgery and permanent disability. The analysis concludes that negligent oversight by the VA compounded errors made at every stage of care.
Dr Patel, UT Southwestern (UTSW)
UT Southwestern’s failure to diagnose and treat Dr. Kesterson’s failed surgery and this marks the next chapter in my quest against healthcare in-justice and the “Deny and Defend tactics” some of them take when they make a mistake.
- The journey began with post-surgery complications from Dr. Kesterson, leading to the VA’s discovery of the surgery’s failure due to loose screws, posing significant risks. The VA enlisted UTSW for further investigation and intervention. However, UTSW’s response, marred by delays and a defensive posture, was both unexpected and disheartening.
- A turning point came with Baylor’s involvement in November 2023, whose swift and decisive action led to the surgical intervention that corrected the failed surgery and its severe effects on my spine. The Baylor operative report emerged as a potent piece of evidence, highlighting the initial surgery’s failure and the damage I suffered as a result.
This document clearly illustrates UTSW’s failure in promptly diagnosing and managing the condition, presenting a clear-cut case of negligence.
UTSW Negligence
- Failed to properly investigate despite:
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- Known hardware issues from CT
- Direct patient reports of feeling loose screws
- Documented complaints of unusual pain
- Development of visible deformity
- Documentation of Active Avoidance:
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- Ignored patient messages about hardware issues
- Failed to order necessary imaging
- Didn’t provide required documentation to VA
- Possible pattern of discrimination against veterans
- Concealment of Error:
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- Associated with original wrong-level surgery
- Had incentive to minimize complications
- Failed to investigate obvious symptoms
- May have actively avoided discovering surgical error
Causation Chain:
- Wrong-level surgery by Dr. Kesterson
- Dr Patel’s VA contract for pre-surgery and post-surgery support
- Patient abandonment by Kesterson and Patel after the surgical mistake
- Dr Patel’s failure to properly evaluate complications found post-surgery
- Progression to visible deformity
- Dr. Eversull’s immediate recognition of issues
- Emergency surgery required at Baylor
- Permanent ankylosis result
Legal Considerations:
- Evidence of coordinated failure in care
- Clear documentation of negligence
- Significant permanent harm resulted
What standards of care did Dr Patel Violate?
- ignored obvious surgical error
- Dismissed reports of unusual pain
- Failed to properly investigate hardware issues
The VA’s Obligations
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 and June 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.
Baylor Medical Center Saves the Day
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.