Medical Errors: Learning What Questions to Ask
-- in Order to Ask Why.
by Kay Van Wey, medical malpractice attorney.
Host of the AdvoKAYte: Holding Healthcare Accountable Podcast
Contact: kvw@vanweymetzler.com
Another patient died under the incompetent hands of a doctor who should not have been a surgeon, this time in Florida.
In August 2024, a 70-year-old man from Alabama died on an operating table in Miramar Beach, a popular resort town on Florida’s panhandle. A grand jury indicted Dr. Thomas Shaknovsky on a second-degree murder charge earlier this week. According to Florida prosecutors, Shaknovsky first convinced the patient he needed surgery to repair his spleen. During the surgery, Shaknovsky proceeded to remove the patient’s liver, which caused the patient’s death from catastrophic blood loss.
We don’t know much more about this case at this time. It’s possible there is a case of systemic malpractice that goes beyond the manslaughter charge Shaknovsky was indicted under. I suspect when the evidence all comes out, it will reveal that there were signs and signals that should have been heeded somewhere or sometime in Shaknovsky’s career. I suspect he should have been acted upon before it came to this.
Something went wrong, causing catastrophic results. I’ve spent a career trying to understand the hows and whys of these kinds of incidents. There are a number of questions to answer to get some sense of clarity.
It’s awful to examine a tragedy from all angles. These are real people’s lives that ended in avoidable deaths. The hardest part, for me, is how many deaths or injuries could have been prevented if someone else, somewhere along the line, had simply done their job.
As an attorney, here’s how I go about assessing the facts of a case. Since we know we don’t have all the facts, we need to ask a series of questions to try to figure them out.
How to ask why in cases of medical malpractice.
In a medical malpractice case, a doctor’s negligence or a doctor’s conduct is adjudicated by a certain standard; what would a reasonable or prudent physician do or fail to do under the same or similar circumstances. In this case, there is an entirely different standard, a criminal manslaughter standard. By the Florida statute he was charged under, the definition would be that the State must show “... a reckless disregard for human life or an equivalent of reckless conduct higher than simple civil negligence.”
We don’t have all the facts, but I think that any lawyer or reasonable person could conclude that failing to recognize the basic anatomy of the patient is an automatic disqualifier for a surgeon. Any reasonable and prudent physician should and would recognize the difference between a liver and a spleen. Not recognizing that difference is not only negligence, but it also shows a reckless disregard for human life or reckless conduct.
The next question is, why did these medical errors happen?
At this point, “why” is too wide a question. We can’t safely speculate as to why at this point because we simply don’t have enough information. That said, this is where I’d look for enough information to know what the right questions to ask are.
- What 44-year old surgeon would not know the difference between a spleen and a liver? We certainly know that any doctor graduating from a basic medical program would be expected to know basic anatomy. Knowing basic anatomy is non-negotiable.
- #2, 44 years old is awfully young in a surgeon’s career. We’re not looking at somebody who has dementia or something like that. It raises concerns there is something going on in terms of a mental disability, a substance or alcohol abuse addiction, or some other cognitive or mental impairment.
It reminds me of the Dr. Death case because in some of those cases, he was noted by other surgeons to not be able to even recognize the basic anatomy. Duntsch thought he was in the spinal column, but he was actually operating outside, in the musculature. We now know the reason Christopher Duntsch couldn’t discern basic anatomy. We don’t know why Shaknovsky couldn’t.
In the case of Dr. Raynoldo Ortiz here in Dallas, we know that he did some despicable things because of some kind of personality disorder. I don’t know if anyone ever knew if he was a sociopath or a psychopath or whatever. Was it intentional or was it because the surgeon was somehow impaired? There are always more questions than answers in mental health or competency cases.
Perhaps the most important questions of all are:
Had Shaknovsky been at other hospitals or other facilities prior to being given credentials at this facility?
- Has he practiced in other states?
- Was he run off from other institutions?
- Had he been disciplined by other medical boards?
It would be odd to me that someone would be this criminally responsible or this grossly negligent and not have had prior problems in their career. The first season of my podcast, AdvoKAYte, talks at length about how poorly national and state-level reporting and accountability systems are used in the actual business of modern medicine.
To fill in the blanks about Shaknovsky, there are three basic areas of inquiry I’d want to look into.
- Concerns of potential impairment, whether it be mental or addiction-based.
- Questions about a course of prior conduct. Whether he had a history of unexplained horrific circumstances or patient outcomes at prior hospitals in prior states, I’d be very surprised if this were just a one-off, “out of the blue” incident.
Were there signs or signals that should have been noticed and dealt with? If there was, why weren’t they?
When a patient dies because someone made a mistake, a lot of questions need to be asked. This is especially true because there are supposed to be systems in place to ensure patient safety. Something, or a set of things, failed. You need to ask a lot of questions to get to the truth of most matters, and there are answers for every set of questions. In cases like this, you need to get a lot of answers to learn which questions to ask before you can even begin to ask the most important question of all,
”Why did this happen?”
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For more details about this case.