What a Colorado Manslaughter Charge Reveals About a Broken Patient Safety System
Attorney Kay Van Wey
by Kay Van Wey, medical malpractice attorney.
Host of the AdvoKAYte: Holding Healthcare Accountable Podcast
Contact: kvw@vanweymetzler.com
I’ve spent my career investigating catastrophic medical errors and helping families pick up the pieces after a preventable medical mistake shatters their lives. Different families. Different doctors. Different hospitals. Different states. Different specialties.
Yet, the same system failures.
So, when I read about yet another patient dying during what should have been a routine procedure with alarms silenced, distractions normalized, and no one willing to speak up, I didn’t think, “How could this happen?”
I thought: “How many more times can this happen before anything changes?”
Because this is not new. It is not rare. And it is not about one bad doctor.
It is about a system that keeps failing patients in the exact same ways, repeatedly.
1. Anesthesia Can Be Boring. That’s the Job.
Anesthesia is like flying a commercial airplane: long stretches of routine punctuated by moments where everything depends on instant recognition and decisive action. When a patient’s oxygen drops or heart rhythm changes, there is no margin for inattention or delay.
In the hands of a competent, attentive anesthesiologist, anesthesia is remarkably safe. There are early warning signs of patient decompensation. Technology can detect dangerous trends in respiration, blood pressure and heart function. When the alarms sound (literally), and there is medication and equipment available to reverse the dangerous trends and treat the underlying issue. But, all of the technology in the world won’t save a patient trending towards trouble if the anesthesiologist has turned off the alarms and is not paying attention.
It is not a justification for distraction. Being annoyed by the sound of a machine sounding an alarm isn’t an excuse to turn it off. If an anesthesiologist reaches a point where they cannot tolerate the monotony and vigilance their job requires, they have an obligation to patients to leave the profession. That is non‑negotiable.
2 . In the event of a catastrophe, a physician goes home to his family. The pilot and crew go down with the plane.
Can you imagine an airplane suddenly losing altitude or an alarm signaling that an engine is going out and the pilot is unaware because he silenced the alarms and also didn’t notice because he was playing a game with the co-pilot on his phone? I cannot imagine this would ever happen.
For three reasons.
- There are stricter safety standards in the airline industry
- Unlike an inattentive or careless physician, a pilot goes down with the plane;
- The airline industry encourages an “if you see something, say something” culture, whereas the health care industry often encourages an “if you see something, keep your mouth shut.”
3. The Code of Silence, Again
In this case, evidence suggests people in the operating room knew a “music bingo” game was being played between the surgeon and the anesthesiologist during surgery.
If a flight attendant saw pilots playing a game mid‑flight, they would report it immediately. In healthcare, nurses and other staff often stay silent not because they do not care, but because they do not want to lose their jobs.
The system is built on a culture of silence: do not speak out, do not rock the boat. That has to change. Like the airline industry, healthcare workers must be encouraged and protected when they speak up about unsafe behavior, without fear of retaliation.
4. News Flash: Turning Off Alarms Is Not “Safe”
Anesthesia machines are equipped with audible alarms that can signal early respiratory compromise, blood pressure changes, heart issues and other critical problems the anesthesiologist is responsible for managing.
If the sound of life‑saving alarms bothers you as an anesthesiologist, here is the hard truth: find another job.
The surgery center should have had clear policies prohibiting the silencing of alarms. But in this case, who was going to discipline the anesthesiologist who was also the medical director? That role carries the responsibility to enforce safety standards and stop dangerous practices. When you put the fox in charge of the henhouse, patients pay the price.
5. Was This Reported to the National Practitioner Data Bank?
Under federal rules, resigning privileges while under investigation is supposed to be reported to the National Practitioner Data Bank (NPDB). This matters because it is one of the only tools we have to prevent dangerous doctors from quietly moving to another facility or another state and hiding what happened.
If this facility reported to the NPDB, good for them. If they did not, they are in large and troubling company. Roughly half of all hospitals and facilities in the United States have never reported a single doctor to the NPDB.
And if they did not report, will there be any consequences? My experience (and that of many patient safety advocates) is that facilities often face no real punishment for ignoring these reporting rules. We have been calling for reform for more than a decade. So far, the result: no meaningful change.
6. Self‑Reporting and Interstate Licensure
After this incident, this physician obtained a license in another state. Many state medical boards still rely heavily on physician self‑reporting instead of mandatory database checks.
It appears this physician did not “self‑report,” and the new state did not independently verify his history. If the facility failed to report to the NPDB, the doctor’s record might have looked clean. But if the state had at least run a mandatory check, he may never have been licensed there, and he should not have been.
Patients assume that when a doctor is licensed in their state, someone has looked under the hood. Too often, that is not true.
7. We Have Seen This Before: Dr. Death
It has been 13 years since Christopher Duntsch, known as “Dr. Death,” left a trail of harm and death across Texas. Since then, I and many others have pushed for system reforms to prevent more Dr. Deaths. Very little has changed, not because advocates lack passion or skill, but because there is no sustained political will to fix it.
One exception is Texas itself. After investigative reporting by Austin journalist Matt Grant at KXAN, Texas required its medical board to stop relying on physicians’ self‑reporting and to directly query the NPDB. The cost was modest and passed on to physicians. That reform only happened because the public learned what was happening and demanded action.
Public outrage moved the needle. Quiet concern did not.
8. Lack of transparency
The blunt truth is that we the patients can sometimes unwittingly be lambs led to slaughter. While much of healthcare is very safe and very necessary, the absolute gut-wrenching truth is that we patients are vulnerable. This poor gentleman had no idea he was going into a dangerous situation. There was no way he would have known or could have known. Yet, he is not alone. I am often haunted by my clients who did their due diligence thinking they were going into surgery with a brilliant young neurosurgeon with impeccable credentials. Yet, they had unwittingly put their lives in the hands of Dr. Death.
9. How Much More Are We Willing to Take?
This death was preventable. It followed a familiar pattern.
We do not let pilots self‑report crashes. We do not let airlines decide, in private, which disasters “really count.” Patients deserve the same level of protection.
Until medicine stops policing itself, and until reporting and oversight are mandatory, transparent, and enforced, these tragedies will continue.
The question is not whether more patients will be harmed. The question is: how many more, and when will the public decide it is enough?
Patients and families must demand better from hospitals, from medical boards, and from elected officials. Until there is public outrage loud enough that politicians cannot ignore it, the system will keep protecting itself instead of protecting patients.
10. This is a political problem.
Most politicians do not have patient safety on their political radar. We live in such divisive times. But, politicians need to realize that 100% of their constituents are patients and regardless of whether they are conservative or liberal, from a red or blue state, Republican or Democrat…no one. Repeat. NO ONE wants to put up with this level of lax oversight leading to preventable catastrophe. The health care system can so better. Some are trying. Some are doing their best, but many aren’t.
Let’s be honest. For the most part, we have a for-profit health care system. It is competitive. Private Equity is gobbling up hospitals and medical practices. The push with many is PROFIT. Profit is fine in America, but not on the backs of vulnerable patients.
In my experience, there are many in this industry who only react to one thing. Fear of financial loss. Meaning, an adverse jury verdict, a large and meaningful administrative penalty, or being stripped of government funding.
We have to demand more of our health care industry. The place to start if by demanding that those who can clean it up make it a priority to do so.