The Shadow Practice, Part 10: Coroner rules mistakes that killed patient a "therapeutic misadventure"
When Dr. Harrell Robinson walked into the surgical suite to start a liposuction procedure on Maria Garcia he was already in a world of trouble.
Robinson was being investigated by the U.S. Drug Enforcement Agency for his role in a clinic in a low-income neighborhood that had been selling huge quantities of painkillers dating back to 2006. He was selling so many painkillers out of the Madre Maria Ines Teresa Health Center in 2007 that one of his wholesalers threatened to cut him off. His solved that problem by having the shipments go instead to his office at – where else? – 145 S. Chaparral Court in Anaheim, California.
At the same time, the Medical Board of California had been documenting a series of patient complaints about botched plastic surgeries going back to 2004, including one where a woman's breast implants poked through an open hole in her skin.
All of these allegations and documented accounts of patient abuse remained a secret when Garcia, 39, agreed to go under Robinson's knife in March 2008 at Anaheim Hills Surgery Center. It would be another year before the DEA took away his ability to sell drugs or the Medical Board took away his license.
For Garcia, this was her first time undergoing plastic surgery of any sort, and it would be the last thing she ever did.
When Robinson walked into that surgical suite, Garcia was bleeding internally from a puncture wound left during a vaginal rejuvenation surgery performed by his colleague, Dr. Lawrence Hansen. Robinson proceeded to cut Garcia 16 times in her abdomen, buttocks and knees to remove fat through liposuction.
As Antidote explained last week, Hansen and Robinson were performing these procedures in an unlicensed clinic and, by giving Garcia heavy doses of anesthesia in this setting, were flouting state laws on anesthesia use.
This might help explain what happened next.
When Robinson was finished, Garcia was face down with liposuction incisions all over her thighs and buttocks. Garcia's oxygen and carbon dioxide levels had plummeted, putting her in serious danger, according to the Medical Board of California. She was turned over onto her back and the staff at Anaheim Hills Surgery Center attempted cardiopulmonary resuscitation at 1:39 p.m., according to the autopsy notes. Then they called paramedics. Garcia was taken to Kaiser Hospital-Anaheim where she was found to be in full cardiac arrest. She was pronounced dead one hour later. The staff there called the Orange County Sheriff Coroner Division at 5:06 p.m.
The coroner then stumbled upon a few curious facts. The first curious fact was that Anaheim Hills Surgery Center had not released Garcia's medical records to Kaiser.The coroner's office did not make much of this. They simply waited until the center got around to providing the records.
Garcia's brother presented the second curious fact, telling the coroner's office that his sister had been taking medications for migraine headaches. Any number of these medications, including propranolol and Demerol, could interact badly with anesthesia and cause a patient to go into cardiac arrest. The coroner appears to have ignored this fact, too.
The third curious fact was found on Garcia's body: a "puncture wound in the posterior cul-de-sac" of her vagina. This, too, did not lead anywhere. A review of the autopsy and case notes shows no mention of Hansen, even though he was the one who performed the surgery on Garcia's vagina.
For an investigation of the death of a healthy 39-year-old woman who had undergone two invasive procedures in an unlicensed surgery center, the coroner's office thought it sufficient to talk with Garcia's brother and her estranged husband. According to the autopsy case notes, they did not interview Robinson or anyone on the medical staff.
The curious facts added up to nothing in the coroner's investigation. Instead, the coroner's office called the case an accident and a "therapeutic misadventure."
Garcia's death was well on its way to becoming nothing more than a few extra pieces of paperwork in somebody's drawer.
Next: How the state and the Joint Commission allowed Garcia's death to disappear
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