Thousands of doctors across the U.S. are on medical probation for reasons including drug abuse, sexual misconduct, and making careless—sometimes deadly—mistakes. But they’re still out there practicing. And good luck figuring out who they are.
The state medical board’s report on Leonard Kurian, an obstetrician-gynecologist in Southern California, tells in stark clinical detail what it says happened to several patients in his care. And it’s not easy to read.
The report describes the time Kurian surgically removed the wrong ovary from a 37-year-old woman, a mistake the patient only learned about weeks later when, still in pain, she went for more tests. The good ovary was missing, and the cystic one was still inside her.
Kurian’s record gets worse from there. The report makes the case of how his errors of medical knowledge, judgment, protocol, and attentiveness contributed to the deaths of two patients. Both were young mothers who had recently given birth to healthy babies.
In its report, the Medical Board of California was quite specific as to what it says went wrong with the care Cynthia Mora received.
In the final weeks of her pregnancy, she went to the emergency room with excruciating pain in her side, and while there, her labor began. But that pain did not subside with the birth of her third child, a healthy daughter.
The medical board investigation found that Kurian missed signs of a ruptured appendix and for days stuck with an alternative diagnosis that didn’t match her symptoms. It said he also failed to run the right tests and “adequately evaluate [her] status” before discharging her.
Ismael Aguirre tells his story of his wife’s death to a Consumer Reports writer.
In the board findings, it said Kurian “later admitted that he never read the nurses’ notes documenting [her] three-day history of pain and change in vital signs” and that “doing so would not be part of his custom and practice.”
His unresponsiveness was also at issue. The report says that he “remained in his office during the day” and it took almost 10 hours and seven phone calls from nurses and worried family before Kurian went to see her after she was readmitted.
It was four days after giving birth, and she was suffering from high fever and debilitating pain. The report says she died two days later with complications that included infection, kidney failure, and cardiac arrest stemming from the ruptured appendix he failed to diagnose.
Kurian did not admit to all of the board’s allegations but chose not to fight any of them.
When asked why Kurian was allowed to continue practicing, Cassandra Hockenson, public affairs manager for the California medical board, declined to discuss the details of any particular case. More generally, the board considers probation “if we believe a physician can continue to practice with conditions and monitoring,” she says, adding, “It all boils down to the safety of the consumer.”
“Boards frequently don’t discipline physicians unless they are repeat offenses, says William Newkirk, a malpractice attorney in California who represents the family of Cynthia Mora, the patient of Kurian’s who died. Newkirk sees the imperfect system limited by the boards’ small staff and modest budgets. For a doctor to be sanctioned, Newkirk says, “the complaint has to be dramatic and the evidence strong.