SAN DIEGO (KGTV) — A California state senator says that there's reason for concern after watching ABC 10News' Team 10 investigation into why a local plastic surgeon and his nurse, who are charged with involuntary manslaughter, can keep practicing medicine without notifying patients.
Team 10 interviewed the lawmaker and patient-safety advocates, who are calling for more transparency within the Medical Board of California.
"I think that there's a big problem and a big concern here," said Central Valley State Senator Melissa Hurtado. She spoke to Team 10 after watching the February investigation into Dr. Carlos Chacon and nurse Heather Lang of Bonita's Divino Plastic Surgery Center.
They were criminally charged in December with involuntary manslaughter for their alleged role in 36-year-old San Diego mother Megan Espinoza's 2018 botched surgery and death.
Even though the patient died more than three years ago, nothing about it was available for the public to view on the Medical Board of California's website until the criminal charges were filed three months ago.
"The system that the Medical Board has in place is not adequate and it shouldn't take three years because three years is really a matter of life or death for not just one but for many patients," said Senator Hurtado.
Carmen Balber is the Executive Director of Consumer Watchdog, a patient safety advocacy nonprofit group. She stated, "There's an urgent need for the Medical Board of California to speed up the pace of their investigations and to prioritize investigations that involve serious negligence that caused long lasting harm, and as happened in this case, death."
A formal accusation by the Medical Board of California was made public in December, three years after the death.
According to the report, Dr. Chacon later admitted that prior to surgery, "…there was no discussion with [the patient] regarding the absence of an anesthesiologist."
The report alleges that the nurse sedated Espinoza, even though she reportedly didn't have adequate training to do so. About two hours into the procedure, Espinoza went into "cardiac arrest.”
The report reads that an AED, CPR, and various medications were used.
Instead of calling 911, the report states that the doctor "called two anesthesiologists he worked with for advice,” but he allegedly "concealed" from them how life-threatening her situation was.
One anesthesiologist reportedly offered to come in and help, but Dr. Chacon declined.
The other anesthesiologist spoke to him twice and said to "immediately call 911, and that she needed to be intubated by paramedics,” but according to the report, Dr. Chacon didn't call 911, "…even as [she] started to make gurgling noises and exhibit seizure-like activity."
Medics were finally called "more than three hours after CPR" and later indicated they were in "disbelief" that it took that long to make the call.
She was found to be brain-dead at the hospital, where she died five weeks later.
Dr. Chacon and his nurse have pleaded not guilty. The patient's family has filed a lawsuit.
Dr. Chacon's attorney previously wrote to Team 10 that he is aggressively defending himself in this case. Lang's attorney explained that they can't comment because of the ongoing litigation.
The DA's Office and the Medical Board of California have not commented on why it took three years to file charges and publish an accusation, citing that this is a pending case.
In December, the Medical Board of California requested a court order for Dr. Chacon to cease practice pending the outcome of the criminal charges. The hearing was scheduled for late March, but was pushed back to July. Until then, he and the nurse can practice with some limitations, like only performing surgeries with a licensed anesthesiologist or a certified registered nurse anesthetist present.
According to the Board, "To create a requirement for a physician charged with a crime to notify their patients would require the legislature to pass, and the governor to sign, a new law."
"Currently, you have a surgeon and a nurse who've been criminally charged with involuntary manslaughter, yet they are not required to notify their patients that they have been criminally charged. That's California law. Does that need to change?" Team 10 asked Sen. Hurtado. She replied, "Absolutely. It's about patient protection."
Consumer Watchdog is pushing for legislative reforms to increase transparency and accountability.
"It's time finally for the State of California to prioritize protecting patients over protecting the livelihood of doctors," said Balber.
Consumer Watchdog is pushing for expanding disclosure on the Medical Board of California's website to include pending investigations if the doctor's conduct resulted in serious harm or death. Or, if the doctor is a repeat offender.
"I think that...things need to change, drastically," added Sen. Hurtado.
A Medical Board of California spokesperson wrote to Team 10 in part, "..the Board has not discussed these proposals and as such, has no information to share at this time."
The Medical Board of California has requested a number of other reforms from lawmakers, increasing funding, lowering its required burden of proof against doctors to speed up investigations, and putting a deadline on when doctors must be interviewed if they're being investigated.