How a Liver Unit Failed

UCI continued to depend on Cao.

In November of that year, the hospital brought in two outside transplant surgeons to review the program and they identified a number of problems, including a high rate of organ refusals.

As a result, the transplant program changed the way it handled organ offers. Until then, the transplant coordinator on duty would receive the call, collect information about the organ and share it with the surgeon, who would decide whether to harvest it. Now, the calls would go directly to the surgeon.

The change excluded coordinators from the process, leaving them feeling jilted. It also meant that Cao could refuse organs without anyone inside the program immediately realizing it.

The refusals continued apace, even as the United Network for Organ Sharing, a national oversight group, conducted a routine audit in 2003.

Just eight transplants were performed that year, the same as in 2002.

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By early 2004, state health officials had seen enough to know that the program fell well below minimum standards for operating on patients on Medi-Cal, the state's health insurance program for the poor.

The hospital was not performing at least 18 liver transplants a year--the state requirement for maintaining proficiency, which is stricter than the federal standard.

In a Feb. 11, 2004, letter to the state Department of Health Services, Cygan wrote that the hospital was having trouble attracting liver transplant surgeons. One, from Philadelphia, had turned down a recent job offer.

Despite the doctor shortage -- and the fact that UCI was transplanting livers at less than one-third the rate of other hospitals in the region -- the medical center was still working to recruit patients for the waiting list.

The hospital planned to host dinners for physicians in the hope that they would refer more patients, Cygan wrote, and to put up a marquee commemorating upcoming National Organ Tissue and Donor Awareness Month.

Unmoved by UCI's response, the state pulled its certification for the program that May, meaning that it would no longer pay for Medi-Cal patients' surgeries.

By then, Cao was preparing to leave UCI. He instructed transplant coordinators to transfer patients to waiting lists at other hospitals, Gibson said.

"The sicker ones were the priority to move -- to get them listed at places where they had a better chance of getting a transplant," she said.