Medical board had many chances to stop ob-gyn with scary past

The Medical Board of California had been warned repeatedly about an obstetrician with a history of patient deaths and allegations of negligence, but, instead of taking action, the board appointed him to supervise a doctor who had been found negligent in the death of two children.

The Los Angeles Times reported last week that Jeannette Dreisbach, a frequent board critic, wrote the board on Jan. 20, saying that Dr. Christopher C. Dotson had a disciplinary history and should not be monitoring Dr. Andrew Rutland.

This, of course, casts a different light on the medical board's claim to Antidote last week that it had inadvertently overlooked Dotson's past and was unaware of Dotson's problems. It was only on Feb. 3 that board spokeswoman Candis Cohen said the board was removing Dotson as Rutland's practice monitor and reviewing all previous practice monitors to see if any others had disciplinary problems.

I asked Cohen about this seeming contradiction and was told that Dreisbach's letter was considered a complaint and therefore was a secret.

Except the letter already had been shared with the Times and with me. It was written to the medical board's president, Barbara Yaroslavsky, and to board member Dr. Jorge Carreon, an ob-gyn, and it makes a compelling argument against Dotson's appointment as a practice monitor. Dreisbach wrote:

One of Dr. Dotson's disciplines involved the death of a woman named Ramona Jackson. It defies any reasonable logic that Dr. Dotson, a former Probationer with a record of negligence and patient death, could be approved as a Monitor for Dr. Rutland.

Ramona Jackson had shown up at Centinela Hospital in Los Angeles in February 1992 in serious distress. Pregnant nearly to full term, Jackson had been bleeding from her uterus for at least 30 minutes before arriving at the ER. Dotson performed an emergency cesarean section and delivered a boy. Jackson continued to bleed from for the next two hours. The medical board, which referred to Jackson as R.J.I., wrote:

R.J.I. was returned to the operating room for a hysterectomy, but by then, her clotting factors were washed out and she began to bleed from all sites. Cardiac arrest ensued and the patient died at approximately 6:00 a.m.

Jackson's son would never be able to know his mother.

The board hammered Dotson for missing all the key warning signs about Jackson. The fact that she had been pregnant seven times alone put her at high risk for continued bleeding. Dotson should have had large amounts of blood on hand for a transfusion, the board said. Jackson's blood count called for at least four units of packed red blood cells. Dotson only ordered two units. He also failed to have the appropriate equipment on hand to continuously monitor Jackson's vital signs and note how much blood she was losing during the delivery. The board wrote:

[Dotson] should have stayed in the operating room with R.J.I. after the cesarean section, kept the abdomen open, and called for a hematologist. Instead, he closed the abdomen and sent the patient to the recovery room. The patient was not transfused soon enough and there was an inadequate attempt to stop the bleeding.

This wasn't the first time that Dreisbach had warned the medical board about Dotson. In 2005, after a 34-year-old attorney named Oriane Shevin died following an attempted abortion, she warned the board about Dotson, who helped run the clinic Shevin had visited.

The board's Consumer Services Analyst Michael Ginni wrote back on Sept. 8, 2005:

We have had an opportunity to review the issues raised in your complaint to assess whether a possible violation of the Medical Practice Act has occurred. When evaluating complaints which allege that the quality of care provided by a physician was inadequate, the Medical Board must be able to substantiate that the physician's care departed from the "standard of practice in medicine" in order to establish a violation of the Medical Practice Act. Based on information provided in your complaint, it does not appear that further investigation would likely result in action being taken against Dr. Dotson's license. However, you may have additional information which should be considered. If you have evidence that Dr. Dotson had any involvement in the care of the patient that may have been negligent, please provide this additional information in writing.

Remember, at the time of Shevin's death in June 2005, Dotson was just reaching the tail end of five years of probation. He had been disciplined by the board because of Jackson's death and another baby who was born stillborn because, as the board said, Dotson failed to notice that the baby's mother was suffering from a severe bowel obstruction. The medical board said Dotson had been negligent in both cases, that he had not performed adequate examinations and that he had not been prepared for complications.

The clinic where Shevin had received the ultimately fatal abortion pills, and where Dotson had been working as the registered agent, had a suspended business license. It had been suspended for nearly 10 years when Shevin died. Working without a business license was one of the charges the medical board later made against Rutland, but, in Dotson's case, it did not seem to matter.

Shevin's husband and children sued and won a $1 million settlement in 2007. Lawsuits have a way of producing evidence. But, still the board did nothing proactive to investigate Shevin's case further.

Instead, Dotson was given the power to protect a doctor just like him: Rutland.

Related posts:

Doctor appointed as medical board supervisor had been disciplined in New York, California

California governor and medical board should stand accused in patient's death

Doctors with addictions left hanging as diversion program dies