Ex-UMC trauma surgeon faces overseas complaint

Evidence presented at a British coroner's inquest, which found in April that a tourist from Bristol, England was "unlawfully killed" as a result of a gallbladder operation at University Medical Center in Las Vegas, is at the heart of a complaint under review by the Nevada Board of Medical Examiners.

Filed in August by Britishers John and Nina Newsom, the 200-page complaint alleges that their longtime friend, 63-year-old Terence Brace, died in England in 2006 as a result of treatment he received from a UMC surgical team headed by Dr. James Tate.

"It is undeniably unusual to have a complaint filed from overseas," said Louis Ling, executive director of the medical board. "But it is something that bears looking at because the alleged treatment that took a man's life took place in Nevada. ... I don't know that this has ever happened before."

Tate, 64, the former head of trauma surgery at UMC, is a civil rights activist who is no stranger to the public spotlight.

Tate has accused politicians of keeping blacks off the medical board. In August, he told the Review-Journal that UMC is "going after" him because of his outspoken criticism of Dr. Dipak Desai, whose $1 million contract with the hospital was severed after his Las Vegas clinics were linked to a the hepatitis C outbreak in Southern Nevada.

Tate now is pursuing a federal lawsuit against UMC, saying it violated his constitutional rights and antitrust laws.

He wouldn't comment on the death of Brace and the medical board's investigation. But his attorney, Jacob Hafter, said in an e-mail to the Review- Journal that, "Dr. Tate has no knowledge or belief that his care was the causation of the patient's death."

"To date, we have cooperated to the fullest extent possible with the medical board to assist them in their investigation and hope that they reach an accurate conclusion to this matter," Hafter wrote.

Brace was transferred by air ambulance to the Bristol Royal Infirmary on Sept. 27, 2006, after nearly a month of treatment at UMC. He was a university art lecturer, died at the infirmary on Oct. 30, 2006, from multi-organ failure and sepsis, a severe condition in which the bloodstream is overwhelmed by bacteria.

The complaint contains a report from a physician that alleges Brace was "beyond salvage" by the time he was sent back to England.

Whether the medical board decides to go forward with a further investigation of Tate or determines there is not enough evidence to proceed could be decided this week during investigative committee hearings on Wednesday and Friday.

Though Ling said privacy statutes prevent him from discussing an ongoing case, Heather Higgins, the board investigator assigned to the case, e-mailed the Newsoms on Nov. 13 to say she expected the investigative committee to make a decision this month.

Three residents, physicians in training who were named as part of Tate's surgical team by the Newsoms, are named in the complaint filed by the British couple. But they are not referenced by Higgins in the e-mail, and Ling said he can't say whether they are part of the review.

Hafter said that although Tate was in charge, "he was part of a team. That's the way we do things in the United States."

To illustrate his point, Hafter said Tate questions whether nurses acted appropriately in the case.

UMC spokesman Rick Plummer said privacy regulations prevent hospital personnel from commenting on the case.

The Newsoms' complaint, as well as the "unlawfully killed" verdict handed down by Paul Forrest, coroner for the Avon district in England, relies heavily on an analysis written by Dr. Graeme J. Poston, a renowned surgeon hired by the Avon coroner's office to file an independent report.

Poston reviewed UMC and British medical records.

Poston said Tate was "unacceptably out of his depth in managing Mr. Brace" and should have not kept "digging" when he realized he didn't have the expertise to handle Brace's complicated case.

Under British law, a verdict of unlawful killing means a death was caused by another person. It can apply to cases of manslaughter, murder and causing death by dangerous driving. Inquests do not name any individual as responsible, but often lead to a police investigation, which may gather sufficient evidence to identify, charge and prosecute those believed culpable.

Because British authorities believe Brace's death was the result of his treatment in the United States, no police investigation was initiated.

The Review-Journal obtained a transcript of the April 22 inquest proceedings. In them, Forrest gave his explanation for handing down the "unlawful killing" finding in reference to Tate's surgical team:

"I am concerned whether, having discovered they were out of their depth and carrying on, they were more than grossly negligent in dealing with this case. Gross negligence can also be part of a criminal offense. In these circumstances I have to be sure, and satisfied that I'm sure, that what they, in fact, did went beyond just plain gross negligence. And, in fact, whether Mr. Brace was unlawfully killed. I have come to the conclusion that he was."

Ling said legal conclusions drawn by authorities in Great Britain have no bearing on work done by the medical board.

"It could be that the standard of care in England is identical to that in Nevada, but that doesn't necessarily have to be so," he said.

He said the investigative committee works under "the burden of proof of substantial evidence: Would a reasonable man looking at the facts lead him to believe something?"

Ling said it is possible that the investigative committee could look at the findings of British medical authorities and determine that a Nevada doctor "should do a peer review of the case and evaluate it from the standard of care of Nevada."

"We can't just go by expert opinion from a foreign doctor," he said.

According to John Newsom, Brace came to Las Vegas on vacation in August 2006, a month before he was scheduled for gallbladder removal surgery in England. Newsom said he learned from Teresa and David Hudd, a cousin vacationing with Brace, that his friend took a cab from the Plaza Hotel to UMC after complaining of a stomachache the night of Aug. 26, 2006.

UMC's Plummer said Brace came in through the emergency room and Tate was assigned the patient as part of his general surgery call.

"The admitting diagnosis was acute cholecystitis," or inflamed gallbladder, Tate wrote in a summary of the case that Hafter said has been filed with the medical board.

Hafter said Tate questions whether Brace should have gone on vacation when he was scheduled for surgery in a couple of weeks.

According to Tate, Brace insisted on having surgery at UMC.

"Initially, we discussed a medical approach to his (Brace's) ailments," Tate wrote in his case summary. "We advised him that he could use antibiotics to 'cool' his gallbladder down so that he would be stable enough to go back to Britain where he could continue his treatments from his existing physicians. The patient refused that course of treatment. The only alternative treatment plan involved surgery."

Poston, the author of eight books on surgery, said that based on UMC medical records it didn't take long for Tate to realize the operation was anything but straightforward.

At the inquest, Poston said records show that 50 percent of the gallbladder was buried within the liver, which was unusual and would make the surgery difficult.

It would mean, he said, that "the surgeon is going to have to operate on the liver, which most surgeons in this country would run a mile before operating on the liver."

Historically, he noted, liver surgery has been associated with massive blood loss because a quarter of a person's blood is in the liver at any given time.

"Right then, Dr. Tate should have backed off," Poston said in a telephone call to the Review-Journal. "He should have closed him up and said this is something for a specialist. Dr. Tate and his team clearly weren't specialists. He knew that. In the United States, there are centers of expertise in Los Angeles and Houston, Boston and New York and San Francisco and a few other places, but not in Las Vegas."

"In layman's terms, the operation was botched," Poston said at the inquest.

What made the procedure even more complicated, Poston noted under questioning by Forrest, is that "all the organs around the gallbladder were stuck to it; the duodenum, the colon, the stomach."

During the operation, Brace sustained injuries to both the portal vein, a major blood vessel supplying the liver, and the bile duct, a tubular structure draining bile from the liver and gallbladder to the intestine, Poston's report said.

Despite the fact that Tate changed the operation from one done through small incisions to one where the site of operation is fully opened, Poston said the team was still "lost."

"They remove the bile duct when they thought they were operating on the cystic duct," Poston said at the inquest.

Poston also said that Tate's team was "using instruments they shouldn't be using." He said they clamped the portal vein, "where they disrupted the blood supply to right liver and caused it to die."

In his summary of the operation that he sent to the medical board, Tate noted that he changed from a laparoscopic cholecystectomy to an open procedure because prolonged chronic inflammation of the gallbladder had made it impossible for the surgeon to see the traditional landmarks used in a laparoscopic operation.

"The only duct that we saw was the one that appeared to be the cystic duct going into the common duct," Tate wrote. "It turned out, later, upon further microscopic examination, that what we believed was the cystic duct was actually the common duct, itself."

Tate said the gallbladder fused with the ducts that became become part of the gallbladder.

"This is not a two-week phenomenon," he said. "Rather, based upon research and medical understandings, such a case occurs after 5 to 7 years of problems."

Tate went on to say that "during this surgery, inadvertently, the portal vein was injured. The injury was quickly identified and was repaired."

In his report to the medical board, Tate also said something happened during the treatment of Brace that "was very concerning to us."

He said the transhepatic catheter, a tube inserted into the bile duct to relieve an obstruction, "was somehow pulled out."

"The nurses claim they don't know how it happened, but the stent and the catheter were both removed," Tate wrote.

A stent is a tiny tube placed into an artery, blood vessel, or other duct to hold the structure open.

"As the patient was restrained and sedated, the only way such removal could have occurred is through a negligent or intentional removal by the nursing staff," Tate wrote.

Plummer said privacy regulations make it impossible for nurses who were at the procedures to discuss their work.

Tate did not say how long the stent and catheter stayed removed or what effect that would have had on Brace.

Poston said UMC did not provide him with the nursing records.

"Often they are the most detailed," he said.

The initial procedure and Tate's two follow-up procedures to try and correct problems only made things worse, Poston said.

"It is clear from the records that they were unsure what to do," he said. "When you don't know what you're doing in surgery, a cardinal rule is to stop digging."

Concerned about Brace's worsening condition, Newsom said that his friends, half sister and cousin had him flown back to England for treatment.

"By that time the die was cast," Poston told the Review-Journal. "There was really nothing they could do at the infirmary. It was a miracle they kept him alive as long as they did."

But Tate's report on Brace's progress at UMC was decidedly different.

"His condition gradually improved," Tate wrote. "He was discharged and cleared to go back to England by Medevac. Upon discharge, he was awake and alert, off the ventilator and doing quite well."

Newsom anxiously awaits action by the medical board. "I hope the truth comes out."

So does Hafter, who on behalf of Tate filed a federal lawsuit against UMC in September. The county hospital barred Tate in August from practicing as a trauma surgeon, saying he might pose an "unreasonable danger" to patients; but the lawsuit says that decision violated his constitutional rights and antitrust laws.

Tate, who has not been removed from UMC's general surgery schedule, allegedly was involved in an Aug. 5 physical confrontation with family members of a UMC patient.

"When the truth comes out about Dr. Tate, what people will realize is that this a fine surgeon who has saved many lives in his more than 20 years at UMC," Hafter said. "We need more physicians like him."

Contact reporter Paul Harasim at pharasim@reviewjournal.com or 702-387-2908.