Va Surgeon-dr. Jose Veizaga-mendez

[Berta]

from VA Watchdog today

"TRIBUNE EXCLUSIVE

Surgeon left trail of fatal errors

Doctor in Downstate death was barred in Massachusetts

By Deborah L. Shelton

Tribune staff reporter

A surgeon barred last year from practicing in Massachusetts after he was accused of providing "grossly substandard care," resulting in deaths and life-threatening complications, was operating on veterans at the Marion VA Medical Center as recently as last month.

Dr. Jose Veizaga-Mendez resigned from the Downstate hospital on Aug. 13, three days after one of his patients there bled to death after routine gallbladder surgery. Shortly after, inpatient surgeries were suspended at the hospital because a computer analysis had uncovered a spike in its number of post-surgical deaths.

On Tuesday, the wife of Robert Shank III, the man who died last month, filed an administrative claim against the U.S. Department of Veterans Affairs, the first step in a lawsuit.

"My husband did not get the care that he should have gotten," said Katrina Shank, who lives in Murray, Ky., about 50 miles southeast of Paducah. "We put our trust in the medical profession. Whether it be a VA or a private hospital, we put our trust and our lives in their hands. For somebody not to come out of a simple surgery, it's just not right."

The VA confirmed that Veizaga-Mendez was employed at Marion but said Wednesday it could not yet answer other questions about him, including whether he is part of an ongoing probe into deaths at the facility. Efforts to obtain comment from the doctor for this report were unsuccessful.

Four top officials, including the hospital director and chief of surgery, have been reassigned or placed on administrative leave as part of the shake-up at the medical center, which serves veterans from 52 counties in southern Illinois, southwestern Indiana and western Kentucky.

Veterans requiring inpatient surgeries are being referred to nearby VA hospitals and private hospitals during the investigation, expected to take at least several months.

In Massachusetts, the state regulatory board last year accused Veizaga-Mendez of failing to report malpractice cases in which he was a named defendant, and of providing woefully inferior care to seven patients. He agreed to surrender his Massachusetts medical license voluntarily in July 2006.

Yet the doctor continued to perform surgeries at the Marion VA, where he had been practicing since January of that year.

Veizaga-Mendez continues to hold a valid license to practice in the state of Illinois, though the state was alerted more than a year ago that he had surrendered his license in Massachusetts.

Veizaga-Mendez's license status in Massachusetts was reported to state medical boards in a national alert in July 2006 and is included in at least one national physician database used to check doctors' backgrounds. It also pops up among the top hits on a Google search of his name.

The VA said in a statement Wednesday that it completes a credentialing process of all physicians prior to granting clinical privileges, including verification with primary sources of information about physicians' education, training, license, certification and experience.

"All verifications are obtained and considered along with the results of queries to the National Practitioner Data Bank/Health Integrity and Protection Data Bank, as well as the Federation of State Medical Boards Disciplinary Alert Service prior to the granting of privileges," the statement said.

Veizaga-Mendez graduated from a medical school in Bolivia, according to the Massachusetts Board of Registration in Medicine.

A VA spokeswoman said she did not know if officials later found out Veizaga-Mendez's license had been surrendered in Massachusetts.

According to a spokeswoman for the Illinois Department of Financial and Professional Regulation, the agency launched an investigation within 30 days of the national alert. She said the agency's probe was not complete until April.

"It took this long to get all the information back," said spokeswoman Susan Hofer. "And we have to prioritize."

In June, officials scheduled a preliminary hearing to determine if Veizaga-Mendez's state license should be suspended or revoked on the basis of information obtained from Massachusetts.

Another hearing has been scheduled for mid-October. In the meantime, the doctor's state license remains valid.

Hofer said the agency typically is investigating more than 100 complaints against doctors at any given time. About 42,800 physicians and surgeons are licensed in Illinois.

A review of malpractice suits against Veizaga-Mendez and of cases investigated by Massachusetts authorities paints a disturbing picture of a surgeon who repeatedly made life-threatening errors but still was allowed to operate.

A May 2006 report by a peer reviewer spelled out in chilling detail surgical mistakes, errors in judgment, and delays in diagnosis and treatment.

Reviewing the case of a 58-year-old man who died after undergoing a procedure to treat gastroesophageal reflux disease, the report concluded "the standard of care was grossly unmet in this case."

It found that a surgical error committed by Veizaga-Mendez caused a stitch to dislodge and leak fluid from the man's esophagus, resulting in a massive blood infection and respiratory failure. The patient died six weeks later.

"This case is remarkable for multiple errors," the report said.

The family of that patient, Jeronimo Coronado, sued Veizaga-Mendez in a Massachusetts district court in 2003. A settlement was reached before the case went to trial.

"I have been doing this work for 26 years and he is among the very worst that I have ever run into," said Rhode Island malpractice attorney Bennett J. Bergman, who represented the family. "Sometimes doctors are careless and make errors, but in my opinion this went way beyond that. I felt the man was dangerous."

In a case not included in the state authorities' report, a jury awarded $652,000 to a Massachusetts man and his wife after Veizaga-Mendez placed two sutures from a hernia repair directly into his bladder. For almost four years, the man "suffered from blood in his urine, knee-buckling pain every time he moved his bowels or urinated, and couldn't work or have relations with his wife," said Byron Taylor, the Massachusetts attorney who represented him.

Other errors noted in the state report include misdiagnoses that led to the wrong surgical procedure being performed, prolonged delays in diagnosing post-surgical complications and the use of improper surgical methods.

Patients were described as requiring lengthy hospitalizations, unnecessary surgeries and prolonged pain. Some faced the possibility of future surgeries that should have been unnecessary.

In one case, Veizaga-Mendez had planned to treat and discharge a critically ill patient instead of performing surgery. After another physician intervened, Veizaga-Mendez operated, but his errors led to fever, blood infection, pneumonia and a heart attack, according to the investigator.

The report on the seven cases concluded: "I find that the most significant and repeating issue of the involved surgeon is a lack of judgment. ... Many of these complications could have been avoided by sound judgment and adherence to surgical fundamentals. ... This should be addressed to prevent injuries to future patients."

Air Force veteran Robert Shank, 50, was unaware of his surgeon's troubling past as he waited on the operating table at the VA in Marion last month. His mind, his wife said, was focused on hunting and fishing and spending time with his six children and four grandchildren.

"We told each other we loved each other. It was just like any day," a sobbing Katrina Shank recalled.

"It was supposed to be so simple."

She now wonders why Veizaga-Mendez was allowed to practice in Illinois given his past troubles.

"He's got to be stopped somehow," she said. "No other family should have to go through this."

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[carlie]

This is just heart breaking and pitiful. I feel that whether it's in the private sector or VA,

practicing medicine this way is unacceptable. Yes, mistakes are made but when it happens so often this doc needs to be stopped.

jmho,

carlie

[Pete53]

The VA owes the patients better protection from Doc's like this. They should know that if they have had practice problems that the VA is not a place for them to go. We deserve better.

[Tower_Rat]

Oh Great!!! Marion Il, is my primary care