The California Medical Board put a doctor with a flawed disciplinary history in charge of monitoring another troubled doctor who, while under supervision, allegedly mishandled an abortion leading to a patient's death.
On Tuesday, the board acknowledged it had made a mistake.
The regulators violated their own rules by naming Dr. Christopher Dotson Jr., a West Los Angeles-based obstetrician-gynecologist who had recently emerged from administrative probation, to supervise the probation of Andrew Rutland, an Orange County obstetrician. The rules require such overseers to have clean disciplinary records.
"This is a staff error that has been fixed," said Candis Cohen, the medical board spokeswoman.
Cohen said the board sent letters Friday removing Dotson as Rutland's monitor. Dotson could not be reached for comment.
Even before the death of the abortion patient last year, both doctors had had serious run-ins with regulators. In a high-profile case, Rutland surrendered his license in 2002 after the medical board accused him of mishandling the deliveries of two infants who died. He was allowed to return to practice under certain conditions, including that his work be monitored by another doctor.
Records show Dotson also had been accused of mishandling two cases in which patients died.
In 1998, the medical board accused Dotson of gross negligence in the care of a woman who bled to death after a cesarean delivery at Centinela Hospital Medical Center. The board said Dotson failed to take an adequate history and should have classified the woman as "high-risk" because of seven previous pregnancies. Dotson was placed on probation in California and, based on that, his license was suspended in New York.
In 2007, Dotson and a second physician, Josepha Seletz, of Eve Surgical Center, agreed to pay $1 million to settle a lawsuit over the death of a mother of two, according to documents filed in Los Angeles County Superior Court.
The family alleged that the woman, Oriane Shevin, was improperly given Mifepristone -- which is used for early pregnancy termination -- and did not receive proper follow-up care, the documents show. As a result, the family said in the court records, she acquired a fatal infection.
In 2007, Rutland argued that he had been rehabilitated and won the board's permission to practice again under probation. Despite Dotson's history, the medical board appointed him to oversee Rutland, at Rutland's request.
The board's violation of its own rules was first reported by William Heisel in his blog Antidote, carried on the Reporting on Health website, a project of the California Endowment.
While under Dotson's watch last July, the board alleges Rutland botched an abortion at a San Gabriel clinic that left 30-year-old Ying Chen dead. The medical board said Chen had a toxic reaction to a drug Rutland administered. It accused him of being ill-equipped to treat her reaction and of failing to call for emergency back-up in time.
The case is pending, and Rutland's attorney has said he is not at fault. Citing a "likelihood of injury to the public," an administrative law judge ordered Rutland last month to temporarily cease performing abortions, surgery and deliveries but stopped short of granting the board's request that his license be immediately suspended.
After the judge's decision, a frequent medical board critic who was observing the proceedings checked into Dotson's past and complained to the board.
"I was astonished that Dr. Dotson could be a Medical Board approved monitor, given his record of serious accusations . . . " Jeannette Dreisbach wrote in a Jan. 20 letter to the regulators.
Julianne D'Angelo Fellmeth, director of the Center for Public Interest Law in San Diego and a former legislative auditor of the medical board, was surprised as well.
"It's fairly astonishing that the medical board would approve of a physician as a practice monitor who has had similar disciplinary problems," she said.
Records show that Dotson wrote favorably on behalf of the accused physician, even after the abortion patient died.
In an Oct. 9 report to the state, for instance, Dotson wrote: "Dr. Rutland and I discussed at length the tragic death of a patient by the name of Ying Chen who after the injection of a local anesthetic preparatory for a pregnancy termination suffered an anaphylactic reaction. In spite of appropriate resuscitation efforts, she succumbed in the hospital.
"In my opinion, Dr. Rutland is taking his probation very seriously and doing everything he can to more than meet the requisite requirements."