MICRA & Medical Errors: The Lightning That Keeps Striking By Eric Andrist “You know that saying, bad things don’t happen to good people? That’s a lie.”—Tori Amos I’ve been fascinated watching Leah Remini’s massacre of Scientology on TV. I couldn’t quite figure out why it was resonating so much with me, and then I got it. Scientology sort of works like a giant Borg-like brain where everyone must think the same way. (For you non-Trekkies, the Borg was a group of drone-like aliens whose minds were all linked together in a hive called “The Collective.”) When a Scientologist starts thinking for themselves instead of like the collective, the rest of the members have to “disconnect” from that person. Unlike the Amish who simply shun a person for life, Scientologists can get vindictive and do things to punish the disconnected. For most of my life, I was just an average Joe. I grew up the youngest of 4 with a mom who pretty much raised us alone. Two of my sisters were disabled: my eldest sister, Linda with epilepsy and the youngest of my sisters, Cali, born mentally retarded. Yes, I come from the generation that didn’t feel the need for politically correct terms like “mentally challenged,” she was always just mentally retarded. She actually didn’t let much of anything “challenge” her, so the term never seemed appropriate. My eldest sister died in a convalescent hospital after having a seizure and hitting her head when she fell; she was in a coma for about six months and then only lived for about a year after that. The convalescent hospital was abusive and stole most of her personal items including a television set. In 2001, just shortly after my mom had her 80th birthday (a workhorse who was still mowing her own lawn), she had a heart attack and I started to see my safe and comfortable world begin to crumble. She was living alone with Cali out in Rialto, a little town just west of San Bernardino, and I knew it really wasn’t safe for them to be there on their own. (It’s the town where Rodney King lived before he died.) So, my partner and I sold our little home in Burbank, sold my mom’s home, and bought a bigger house in the San Fernando Valley for us all to live in. Me with my sister Cali and my mother, Evelyn, shortly before her last mother’s day in 2003. I knew eventually that my mom wouldn’t be around anymore and I’d have to start caring for my sister full time. Fourteen months later, that came to be when my mom died from hospital acquired sepsis (a very harmful infection that quickly shuts down a person’s organs) after an elective surgery at Providence St. Joseph Medical Center in Burbank , just 1 month after actor John Ritter died there under suspicious circumstances. About 10 years later I would meet actress and patient safety advocate Alicia Cole who contracted flesh eating disease in that same hospital and nearly died. My mom and I were best friends, and I felt like my world had completely collapsed. But I knew I had to be strong for my sister’s sake, who I was now caring for full time. Ironically, Cali ended up being the strong one who often kept me going. Cali and Eric. Flash forward 9 years to 2012. One morning, Cali had a terrible stomach ache and I thought she had come down with the flu. By that evening she was much worse and I called an ambulance to take her to the emergency room. With not a lot of good hospitals to choose from in the Valley, we ended up back at the same hospital where our mother had died. Surely lightning couldn’t strike twice, right? Wrong. “GIVE MY DAUGHTER THE SHOT!” —Shirley MacLaine in “Terms of Endearment” Like a snowball rolling down an endless hill, horror after horror began to unfurl before me. It turns out my sister (at some point) had a strangulated bowel that burst and was seeping toxins into her abdomen (sepsis). The doctors and hospital never actually diagnosed this; we found out in a private autopsy after the fact. They “suspected” a bowel obstruction but didn’t appear to be all that concerned about it. They were more concerned with her irregular heartbeat, a condition she and I both have all the time, and getting her blood thinners low enough to go in for surgery. For 15 hours, my sister lay in her hospital bed writhing in pain and no one gave her any pain medication. While she didn’t really understand the theory of “God,” she laid there crying over and over, “Oh dear God, please help me...it hurts so bad.” Waiting, waiting and more waiting, with no pain medication. The pain medication had actually been prescribed just a few hours after we arrived, and even though I kept asking, kind of like Shirley MacLaine’s character in “Terms of Endearment,” the nurses just kept saying they’d get it. They eventually took her for a second and unnecessary CT scan, but shortly before she left, they gave her a radioactive beverage to drink (with no informed consent) and then finally some pain medication called Dilaudid, a drug 7 times stronger than Morphine, that knocked her out. She had at least a half a dozen contraindications for that drug, but the doctor hadn’t even bothered to do a physical of her in the 5 minutes he was in the room. “I don't trust doctors. It's not to say there ain't some good ones, but on a general level, no, I wouldn't trust 'em at all.” —Keith Richards We are pretty sure now that during the CT scan, Cali ended up aspirating the radioactive beverage into her lungs which caused pulmonary edema and sent her into cardiac arrest. In hindsight, I believe the nurse watching over her knew this, but said nothing. Her medical records mention that she’s “mentally retarded” no less than 24 times, as though that was the cause of all of her problems and it rendered her less of a person, thus, less deserving of care. In reality, it had nothing to do with why she was in the hospital and no bearing on her actual treatment. Because she was unconscious from the pain medication, I sat in her room while they took her for the CT scan, watching “I Love Lucy,” a show we both loved. It was only one of two times I was not by her side since we arrived, and it will always haunt me that I wasn’t with her when she needed me. A victim of Mt. Vesuvius. Cali looked very similar when coming back from her CT scan. When the nurses wheeled her back into her room, she looked like one of those screaming corpses frozen in time in the volcanic lava after Mount Vesuvius erupted; her mouth open in a silent scream, her skin pale and ashy. But the nurses didn’t seem particularly concerned; they just took their time moving her from the gurney back into her bed and rehooking up all her wires. Finally, nurse #1 walked in and gasped, “Oh my god, what happened?!” to nurse #2 who had gone with Cali to the radiology lab for the CT scan. Nurse #2 very flippantly replied, “Well, she’s a DNR.” (She was not a DNR, a “Do Not Resuscitate,” and I had told them that several times.) Nurse #1 turned to me and asked if that was true, and if I wanted them to revive her? I thought...wait a minute...revive her? What were they talking about? She looked terrible but she couldn’t be in need of any kind of reviving! I replied that of course I wanted them to revive her! They called a code blue and a swarm of doctors and nurses came flying into the room to work on her, while nurse #2 secretly slipped away, never to be seen again. There was never any explanation as to why the remote telemetry unit hadn’t already called a code blue by that point since they were supposed to be constantly monitoring her vitals. They revived her 17 minutes later, but it was too late, she was nearly brain dead by then. I currently have a nursing board complaint pending against these two nurses, and a videotaped deposition of nurse #1 testifying that she told nurse #2 that Cali was indeed a DNR. She also didn’t know if Cali had a color-coded wristband on signifying she was a DNR, and even if she did, she didn’t know what the color codes meant. They sent her to the ICU and for the next whole day doctors came in and out pretending like they were successfully healing her. At one point her eyes had rolled in different directions in their sockets. It was terrible, it looked like a scene out of a horror movie, and they eventually taped a washcloth over her eyes, I guess so that I couldn’t see them. When I asked about it, a nurse said, “Oh, we do that for all the patients so their eyes don’t dry out.” Uhhhh...right. In the ICU shortly before the machines were turned off. Doctor after doctor came in to give me reports on her progress, which I just wasn’t seeing. Finally, a very nice, older doctor came in, an infection specialist, and was the only one to be truly honest with me. He said that she was very, very ill and was not going to make it. He said she didn’t have anymore brain activity. I asked why then, they were keeping up this charade, and he just shrugged. I made the decision, as I had done with my mom 9 years earlier, just 5 beds down from where we stood at that very moment, to turn off the life- faking machinery. Later, I realized the doctors were keeping her alive just so they could keep billing for their services. Someone had caused her to be in this condition and the costs just kept tolling like the readout on an old-fashioned gas pump. Even though it was clear Cali was no longer there, I sang to her as her heart slowly came to stop and within about 20 minutes...she was gone. That night my cousin drove out to comfort me and we went to Barragan’s, my sister’s favorite Mexican restaurant in Burbank. While a part of me always likes to think that my mom and sister’s spirits watch over me, I don’t think I really believe it’s true. But that night, Barragan’s had a strolling mariachi group playing the typical Mexican ballads they usually play, all in Spanish. But when they got to our table, they played and sang “It’s a Small World,” in English . We had been going to that restaurant for over 20 years and had never seen a mariachi band there before. Cali LOVED “It’s a Small World” at Disneyland...it was her very favorite ride and one of her favorite songs. I may not believe in ghosts, but I believe Cali was there that night to say goodbye. One of her favorite movies was “Mary Poppins,” and she loved the song “Feed the Birds,” ironically written by the same people that wrote “It’s a Small World.” In that song there is a lyric that has very special meaning now... “Though her words are simple and few, listen, listen, she’s calling to you.” Richard & Robert Sherman from the song “Feed the Birds” from “Mary Poppins.” Cali feeds the birds at the beach. I had expected to spend the rest of my life caring for Cali. I had given up my career in theatrical production and had become older and a little sedentary in the decade that had passed while caring for her, much too quickly. Okay, a lot sedentary. Now at age 50, I didn’t know what I was going to do next. When I applied for jobs they’d say, “You did what for the last nine years?” as though homecare giving wasn’t really a job. I did know, however, that what happened to my sister in that horrible hospital was wrong, and someone had some ‘splainin’ to do. While they scrambled over her during the code blue, I called the Burbank Police as I could sense things were going wrong fast and I wanted witnesses and an official record. They sent two officers who walked around briefly, looking like they didn’t know why they were there. Shortly before they left, one of the officers told my roommate that he didn’t believe the hospital could do anything wrong because he had his baby there and it was a great experience for him. So, they did nothing and left. I guess the Burbank police only “protect and serve” in certain places. The two Burbank Police officers who wouldn’t help because they couldn’t believe the hospital could ever harm anyone. The hospital pretended to be concerned about the death and offered their hollow apologies, not for anything they had done wrong of course, but for my “loss.” They told me they had begun an internal investigation into her death and would get to the bottom of it. Being that I was the only one that was with her the entire time (aside from not going with her for the CT scan, I left one other time to pee when a nurse told me I couldn’t use the bathroom in Cali’s room), they asked me if they could interview me about the experience but told me that they would not share any of the results with me. So why exactly would I participate in their investigation if it wasn’t going to help ME understand why she died? After that, things got a bit acrimonious between us and the hospital ended up siccing a hostile attorney on me who would write me snippy emails and evade my questions. I finally had to tell him to never contact me again. Their risk management person at one point told me that I should probably get a lawyer. So, I set out to do just that. “The only difference between doctors and lawyers is that lawyers merely rob you, whereas doctors rob you and kill you, too.” —Anton Chekhov Now, you know how people so easily say, “You better get a lawyer,” or “I’m going to get a lawyer and sue you?” Getting a lawyer is really not that easy, at least not when it comes to medical malpractice. While most probably think there are ambulance chaser-types scrambling to take your case, med-mal attorneys take very few cases because of the cost and risk of little to no payout. After contacting 4 or 5 different law offices, I learned that I was facing something called MICRA , a law in California that would severely limit the amount we could win in Cali’s case. MICRA was passed by Governor Jerry Brown in 1974 during a fake doctor insurance scare. Doctors threatened to leave the state if something wasn’t done to curb victims filing medical malpractice lawsuits. So, legislators created this law that put a $250,000 cap on pain and suffering damages (economic damages like medical bills and lost wages are not capped). The law was an instant failure, at least for victims as it made it so that lawyers couldn’t afford to take med-mal cases...the cost of getting a case to court was almost always higher than the $250,000 payout. MICRA particularly discriminates against the elderly, the disabled, children and people without a regular work income. It was also a failure in that doctor’s insurance costs did not go down, and in fact continued to rise. But it did cut down on the number of lawsuits against bad doctors, and the medical and insurance industry loved that. Governor Jerry Brown said in June of 1993 : “We have learned a lot about MICRA and the insurance industry in the seventeen years since MICRA was enacted. We have even witnessed yet another insurance crisis, and found that insurance company avarice, not utilization of the legal system by injured consumers, was responsible for excessive premiums. Saddest of all, MICRA has revealed itself to have an arbitrary and cruel effect upon the victims of malpractice. It has not lowered health care costs, only enriched insurers and placed negligent or incompetent physicians outside the reach of judicial accountability.” Governor Brown, however, has done nothing since he said this to get rid of this law even though he admitted MICRA didn’t work. To this day, MICRA is preventing victims from getting accountability for harm and death and has never been raised to match inflation. The $250,000 cap is in 1974-valued dollars, which should be well over a million dollars today. Also, a jury is never told about the MICRA law when they are considering a case. They often award multi-million-dollar verdicts to victims of medical errors, only to find out afterward that the judge will instantly cut it down to $250,000 due to MICRA. “I don’t like juries having the wool pulled over their eyes. I don’t think that’s what the Constitution is about.” —Nancy Grace After contacting a dozen or more law offices and having them all turn me down, I got very discouraged. Some of them didn’t even bother to call or answer my emails, which I found very unprofessional. They advertise that they want to take your case and help you, but when they learn there’s little to no money in it, they just ignore you. These were big-time L.A. law offices, bragging in videos about their huge medical malpractice wins. One of the biggest I turned to was Girardi-Keese, whose website says, “Where you turn when you’ve been hurt. The Los Angeles personal injury attorneys of Girardi-Keese have recovered more than $10 billion in verdicts and settlements.” One of their attorneys showed interest in my case for about a minute, but when the firm found out it was a straight MICRA case, they rejected it. Heaven forbid they put a dent in their $10 billion worth of verdicts in order to help someone. I would later go with another of their attorneys to speak to a legislator trying to get the cap raised during the Prop 46 campaign which I’ll talk more about later. I gave up my time to try and help lawyers be able to afford to take these cases, but 99% of the lawyers I sought help from, couldn’t be bothered with my case. She was appalled and saddened when she heard me tell my story. After the meeting I told her that her firm had rejected my case, and she seemed embarrassed. I was later invited to a big lawyer pat-on-the-back shindig in Sacramento where Thomas Girardi had put up the money to have singer Kenny Rogers perform, which couldn’t have been cheap. I’ll bet that concert cost more than my case would have. It’s clearly more important to him that rich attorneys are entertained than it is for victims of medical negligence to get justice. I started writing every agency I could trying to find help, including the Consumer Attorneys of California in Sacramento. A couple agencies replied that they could offer no help...most of the rest just didn’t reply. But, Eric Bailey and JG Preston, press reps for the Consumer Attorneys of California did, and they turned out to be great allies in this legal pit of hell I was living in. They were the ones who gave me the real story behind the MICRA law. Eventually I learned that CAOC was actually partially responsible for the MICRA law being passed in 1974, albeit not their intent, and were now working to get the law overturned. JG came down and interviewed me on video , and I was asked to be a part of the upcoming campaign to pass Prop 46, a bill that in part would raise the MICRA cap to match the 40 years of inflation that had passed. It was due to this association with CAOC that an attorney finally took my case. He, Chris Dolan, turned out to be a flashy, egotistical, big-shot San Francisco lawyer, the kind that always needs to be the center of attention, who was also a past President of the Consumer Attorneys of California. Even though we ended up not getting along and he let me down, I was truly grateful that he took my case. Now, I know I’ve heard people say this and I didn’t believe them, but I really didn’t care about the money that could be won from the lawsuit, I wanted to hear a jury say that the doctor was guilty, especially after the way the hospital treated me after my sister died. Dolan and his associate, Josh Watson, knew that and agreed to do all they could to get me to that end. But MICRA didn’t allow for that. My sister was disabled, unmarried, no children and incapable of earning a living, so she was the perfect victim that the MICRA law could successfully discriminate against. More than a year passed, but Prop 46 didn’t, due to the medical and insurance industry sinking tons of money into the campaign against it and lying big-time to voters. I was depressed over losing my sister, depressed over the drawn-out process of bringing the doctor and hospital to court, and after working extremely hard on the campaign, even more depressed when we lost. If it weren’t for the friendship of some of the victims and advocates I met along the way, I’m sure the depression would have gotten the best of me. The organizations that we were helping with the campaign (CAOC and Consumer Watchdog) basically dropped us when they no longer needed us on the campaign anymore. That didn’t feel good either. From the Prop 46 campaign. As we neared our court date, the court mandated that we go into mediation with the other side. So, we met in a private mediator’s office and spent all day playing the ridiculous game of bartering settlement amounts over the death of my sister. It was insulting and sickening. The first thing Dolan said to me that day, even though he knew my goal was to hear that jury shout “Guilty!” was to tell me that if the other side came anywhere close to the settlement amount he was seeking, he “wasn’t going to sink another dime into the case” (lawyers take these types of cases on a contingency basis, fronting all the costs for the case). My heart sank into my stomach. Here I was facing yet another loss, even if we won the settlement, and he was going back on his word to see my case to a jury. He told me that if I insisted on moving ahead with a trial, he was going to invoke a clause in our contract that would require me to put up a $10,000 retainer, an amount he knew I couldn’t afford, and an amount that Josh Watson had told me before I signed my contract, they’d never charge me. How much more was I expected to endure? “It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience.” —Julius Caesar I had no choice but to accept the settlement. Even though I was furious over my own lawyer strong-arming me into it, I cried with relief that it was finally over. But was it over? Of course not. Now I needed to file a case with the Medical Board of California so that I could finally see the doctor get some discipline. The lawsuit was only a slap on the wrist and his insurance company paid the settlement, but he wasn’t really punished for causing Cali’s death. During this time, I stayed in touch with a core group of victims and advocates and we all tried to stay busy working on patient safety issues. I took great interest in news articles about bad doctors and how they were harming so many people and started noticing just how many doctors were being charged with sexual misconduct. I started a blog called “ The Bad Doctor Database ,” chronicling news stories of bad doctors across the country. I contacted a fellow advocate from San Diego, Marian Hollingsworth, and found she had also noticed the trend. We started researching and were contacted, out of the blue, by an anonymous source who sent us over 4,000 disciplinary documents and news articles about sex-offending doctors from around the country. We pulled out all of the cases of doctors who practiced in California and found we had over 400 right here in our own state. We created an online spreadsheet and started researching each of the California cases and found some pretty horrific stuff. We even found that there were at least three doctors in the Los Angeles area who were currently practicing medicine, who were listed on the Sex Offender Registry, two involving cases of sexual molestation of young girls. We started wondering at that point if our state medical board was truly doing its job, so we began looking deeper into the board. What we found was disheartening and maddening. “Our society must make it right and possible for old people not to fear the young or be deserted by them, for the test of a civilization is the way that it cares for its helpless members.” —Pearl S. Buck Marian Hollingsworth had lost her father , a well known dentist in the San Diego area, to medical errors. Her father ended up in a convalescent hospital to recuperate and was given the antipsychotic drugs Haldol and Risperdal to keep him drugged and and in a diaper so they could spend less time caring for him. Informed consent documents were falsified and the nursing home never discussed drugging him with Marian. In less than three weeks, he suffered severe dehydration, heart and kidney problems, 7 falls in 12 days, contracted a MRSA infection, developed a bedsore, and suddenly became diabetic. He ended up in a different hospital after the 7th fall, where they were told his heart and kidneys were failing. They were also told that his mental decline was not due to any drugs or hospital delirium, but rather to “sudden onset Alzheimer’s.” His condition continued to deteriorate, and he was dead within a month. He had none of these problems before his hospital stays. After her father’s death, she obtained the nursing home and hospital records and realized what they had done to him, and how many doctors had deliberately lied to her. She also discovered the falsified consent forms, including a “do not resuscitate” order. She filed a lawsuit against the nursing home, but lost in forced arbitration. She also filed a complaint with the Medical Board (which took 3 years and 2 months to complete), but all they were able to come up with was a letter of reprimand for the nursing home doctor, a discipline that is reserved for cases where the patient suffered no harm. “I am, as I’ve said, merely competent. But in an age of incompetence, that makes me extraordinary.” —Billy Joel Six months passed without my hearing anything from the Medical Board on my own complaint. In the interim, I started really researching the board and asking a lot of questions, which clearly was not sitting well with them. On the very day that I was having an email battle with their staff attorney, Kerrie Webb, I also sent an email inquiring into the status of my complaint, since I had literally heard nothing from them. No investigators called me to get my account of the events, no documents were ever requested. Within hours of my email, I received an email back from them saying that they were closing my complaint due to a lack of evidence proving the doctor acted below the standard of care. What??? How could they not prove he acted below the standard of care? My sister was dead and the negligence couldn’t have been any clearer. I stewed for a couple of days and tried to figure out what could have possibly gone wrong. How could they look at the hospital records and not see that his actions, or inactions, led to my sister’s death? Did they even look at the medical records? Why hadn’t anyone called to interview me? I emailed the hospital to see what records they sent them...maybe they hadn’t sent them the complete file. To my astonishment, the Medical Board hadn’t contacted the hospital to request the records, even though I signed a consent form for them to do so. So, what in the world did they use to determine that the complaint deserved to be closed? Email from the hospital verifying that they never received a request for Cali’s records. I inquired with Christine Delp, the head of enforcement at the Medical Board, an employee who had transferred to the Medical Board from the Contractor’s State License Board; because the expertise for both boards are identical, right? She told me that they had gotten the records from the accused doctor himself. I need to backtrack slightly here. When I saw so many things going wrong at the hospital, I fired the doctor and instructed the hospital to not allow him any access to my sister or her files any longer. So how could they have gotten the medical records from the doctor himself if he had no access to them? According to Delp, the doctor (or his lawyers) had to turn the records over to the Board as one of the requirements of his malpractice settlement with me. But still, why would the Medical Board trust medical records from the accused doctor himself, when they could have easily been tampered with? That’s kind of like OJ Simpson hiring his own team to perform his blood tests, and then turning those tests over to investigators to use in the case against him! Who would trust them? Not only did they not get a certified copy of the medical records from the hospital, they also didn’t have a copy of the private autopsy I had done, which is the only document that lists Cali’s true cause of death. Remember, no one at the hospital ever diagnosed her condition with any certainty, and they most certainly didn’t know how she died, so the medical records weren’t going to reflect that. The hospital couldn’t even get her cause of death right for the death certificate. The County of Los Angeles rejected the first death certificate the hospital sent. I only found this out because the mortuary that was holding her body for cremation called me and said they couldn’t cremate her without the death certificate and the hospital was holding up that process. Cali had to stay in their morgue for 11 days before being cremated due to the hospital’s inability to list the correct cause of death. Even though the second death certificate was accepted, it still lists the wrong cause of death, because they didn’t know what it was. From Cali’s private autopsy report. The hospital never knew exactly why she died, but the Medical Board relied only on hospital records to make a decision on their complaint. Cali needed emergency surgery the moment we got to the hospital, but she never got it. I complained to the Medical Board and they ended up re-opening the complaint. Two months later, they just closed it down again. They clearly had no intention of truly investigating my complaint, especially with me asking so many questions about their motives and procedures. Consumers also have no option to appeal any decision of the Medical Board, even though Doctors can appeal decisions against them. A consumer has no right to know who the “experts” were that looked at their case or see any of the information used in the so-called investigation; there is literally no public oversight and the medical board could be screwing it all up, and no one would ever know it. When I filed a California Public Records Act request to get my sister’s file, their attorney illegally denied it by not following all the aspects of the public records law. I’ve since brought this to the attention of the entire staff and board, including Judge Katherine Feinstein, who is a medical board member, and they just ignore me. Note: Judge Katherine Feinstein said some not-so-favorable things about the Medical Board during her short tenure, and then all of a sudden she was gone...off the Board with no announcement, no explanation. With a public record request I was able to get a copy of her resignation letter that stated that “due to reasons both personal and professional, I can no longer continue to fulfill the important duties of a Board member in a manner that meets the standards I set for myself.” So, did that mean her standards wanted to protect citizens more than the Board would allow? Borg disconnect. At that point, I dove in head first into a full blown investigation of the medical board or at least as much as a citizen could do on their own. I started collecting information and watching their every move. In San Diego, Marian had been collecting information as well and had stumbled onto an interesting set of facts about board member, Dr. Dev GnanaDev. “Nobody asked what my rapist was wearing.”—Unknown Dr. Hari Reddy , a doctor in the high desert area of the Inland Empire, was arrested in 1999 on criminal charges of sexual assault. It was determined that he was responsible for sexual misconduct with 4 female patients, including a 16-year-old girl. He was convicted of misdemeanor battery for one of the patients and sentenced to 3 years of supervised criminal probation and other penalties. His medical license was revoked in 2003. Dr. Hari Reddy, arrested for sexual assault in 2000. In 2007 Hari Reddy applied to get his license back, but his request was denied. In May of 2010, he filed a second petition to have his license reinstated. In August of 2011, his case was submitted to Panel B of the Medical Board (one of two board subsets that decides the outcomes of disciplinary cases). It was scheduled for a hearing on February 2, 2012. During this time, Dr. Hari Reddy’s brother-in-law, Prime Healthcare’s Dr. Prem Reddy (and here’s where the names start making it confusing; the two Reddy’s are related by marriage), started making large donations to Governor Jerry Browns political campaign and pet causes. We were able to find at least $237,000 in donations from Republican Prem Reddy to Democratic Governor, Jerry Brown. Prem Reddy and his Prime Healthcare were charged with allegations that 14 of their hospitals in California knowingly submitted false claims to Medicare by admitting patients who required less costly, outpatient care and by billing for more expensive patient diagnoses, a practice known as up-coding. Reddy and Prime agreed to pay $65 million to resolve the allegations. The San Bernardino Sun, 8/03/2018, pictured are Prem Reddy and Dr. Dev GnanaDev. In December of 2011, Governor Brown appointed Dr. Dev GnanaDev to the Medical Board, despite a sensational scandal occurring at Arrowhead Regional Medical Center where GnanaDev was serving as Medical Director. According to the Medical Board’s website, GnanaDev, Hari Reddy and Prem Reddy all went to the same medical school in India with Prem and GnanaDev graduating the same year. The Fair Political Practices Commission (FPPC) found that GnanaDev had missed his filing deadline for his Form 700, Statement of Economic Interest. Apparently GnanaDev had a history of filing inaccurate or incomplete conflict of interest forms. GnanaDev was then assigned to Panel B, the very panel that would be deciding whether to reinstate the license of his former classmate and colleague, the convicted Dr. Hari Reddy. On GnanaDev’s very first panel while serving on the Medical Board, he was a part of reinstating Dr. Hari Reddy’s medical license. We tried to get information from the board as to whether GnanaDev reported any conflicts of interest in this matter, but they wouldn’t say. Hari Reddy’s license became effective again in March of 2013. Just a year later, his brother-in-law, Prem Reddy, donated at least $40 million to Dr. Dev GnanaDev’s new medical school project in the Inland Empire, and now serves as its Chairman of the Board. Governor Brown went on to reappoint GnanaDev to the Medical Board for a second term in 2015 just after Prem Reddy donated $100,000 to Brown’s pet project, The Oakland Military Institute. In July of 2016, GnanaDev became the president of the medical board. “Confidence...thrives on honesty, on honor, on the sacredness of obligations, on faithful protection and on unselfish performance. Without them it cannot live.” —Franklin D. Roosevelt It’s hard now to have any confidence in the Medical Board of California. By law, their primary duty is to protect consumers...not bad doctors, and most certainly not themselves. We’ve studied thousands of disciplinary cases and have found far too many where the board protected the doctor over any kind of protection for consumers. Recently I found a case of a doctor Ryszard Chetkowski of Berkeley who runs a fertility clinic. He was accused of sexually assaulting six of his female patients, but the Medical Board decided that was only worth a Public Reprimand. That took place in 1997; Public Reprimands only are available for public online view for 10 years so now when you look at his profile on the Medical Board’s website, it’s completely clear. We have multiple cases of sexual misconduct and patient harm where the doctor was simply put on probation and told to take some classes. But far more egregious, we’re finding that a huge majority of complaints are simply being closed without any type of a real investigation...just like mine. Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity. —Martin Luther King, Jr. • Annette Ramirez went in for a hysterectomy in 2012. During her surgery, the surgeon unknowingly sliced her bowel. Diligent post-operative care would have revealed the problem, but for more than 36 hours, the nurses failed to report her abnormal vital signs, which were classic symptoms of a leaky bowel. Her doctors failed to adequately follow up to check her condition after surgery. Because of their negligence, an infection spread through her system, and gangrene spread to all of her arms and legs. When she finally went home to her husband and children, she did so with all of her arms and legs amputated. Annette filed a complaint with the Medical Board, but they closed it without any discipline for the doctors. • Mario Guzman was a triathlete. One day on a jog, he twisted his ankle and a couple of days later it became swollen and red, and hurt so much that he could not put weight on it. He also had a fever of 100 °. He made a visit to a hurried doctor who did a bare-bones examination, who diagnosed him with the flu and a sprained ankle. In the following days his condition worsened and he ended up in the emergency room. By then, though, he was already in septic and toxic shock caused by a Streptococcus Pyogenes infection, something that would have been easily treated with penicillin if they had caught it in time. He spent over 4 months hospitalized and lost portions of all his limbs. He is now paralyzed with severe nerve damage caused by sepsis because a doctor didn’t run a few inexpensive tests that would have revealed the problem. Mario filed a Medical Board complaint, but they closed it with no disciplinary action for the doctor. • Morgan Westhoff and her identical twin sister were born with one of the more common congenital heart defects. They both went in for procedures to correct the defect when the girls were 18 months old. Her sister’s procedure was successful, but Morgan’s was not. The doctor performed the procedure on Morgan even though she had an abnormally high blood pressure reading. The instructions for the device they were going to use during the procedure clearly stated that it should not be used in patients with high blood pressure readings. Even though another procedure could have been performed that didn’t utilize that device, the doctor proceeded anyway, and Morgan died. The Westhoff’s filed a Medical Board complaint, but it was closed with no disciplinary action for the doctor. “We live in a stage of politics, where legislators seem to regard the passage of laws as much more important than the results of their enforcement.” —William Howard Taft (1916) We knew something had to be done about this. The Medical Board wasn’t doing its job and doctors were literally and figuratively getting away with murder. In a very short time we uncovered over 100 news articles detailing over four decades of Medical Board of California incompetence, and even older articles showing that it’s been problematic from the start...over 100 years. One article from 1993 told of how medical board workers blew the whistle on their superiors when they found their bosses were throwing hundreds of legitimate citizen complaints against bad doctors in the trash. One investigator recalled, “You would see a stack of files two feet high on a supervisor’s desk one day and by the next hardly any would be left.” Was this happening again? The board’s own documents show that while they take in nearly 10,000 consumer complaints in a year, the number of disciplines for doctors almost never goes above 400....that’s just 4% of the complaints leading to disciplinary action. What is happening to all of the other complaints? The board loves to brag about it’s website and encourage consumers to look up their doctors, but they aren’t very quick to tell you how poorly it actually works. The board allows doctors to use aliases so Dr. Michael Feiz , whose real name is Farzin Michael Feizbakhsh , is nearly impossible to find because he doesn’t advertise or use his full name in real life. Doctors who settle medical malpractice lawsuits are required to have amassed 3-4 malpractice settlements within a 5-year period before they’ll ever show up on the