My little brother Jose was always at the center of my life — despite and because of his serious developmental disability.
In winter 2021, we had just bought him a home where my father planned to live and care for him but had not yet moved him in. He was temporarily living at a long-term care facility the night he was admitted to the emergency room because he was having trouble breathing.
With his disability, Jose required constant monitoring. Yet, shortly after he was admitted, Jose was left alone in a room. By the time the nurses returned he had wandered off. Jose was found on the bathroom floor, unconscious, not breathing and with no pulse. He was later pronounced dead.
How did the situation take such a rapid turn that I lost my dear brother in a day? I wanted answers and accountability.
Soon after reviewing his medical records, I filed a complaint with the Medical Board of California, the state agency charged with doctor oversight. Records indicated that the hospital knew Jose had sepsis when he arrived but did not begin treatment for it. Had the doctor started treatment immediately, it could have begun to stabilize him. He also would have been monitored and not allowed to leave his room and collapse unattended.
I was shocked when I got a form letter saying the board had dismissed my complaint, stating it was “unable to meet the burden of proof required to pursue action against the doctor.” No one at the board ever interviewed me.
If they had, I would have given them a copy of the toxicology report I had requested shortly after filing my complaint. It showed another error that stole any chance Jose had to live: One of Jose’s medications should not have been taken with a drug the emergency room doctor gave Jose while attempting to resuscitate him. That fatal drug interaction meant Jose never stood a chance.
When the board gets a complaint, medical professionals are asked for their side of the story, but the victims have no such opportunity. That means the board is not gathering all the information necessary to make a fully informed decision. This one-sided inquiry mostly provides results in favor of medical professionals. Last year, 83% of complaints were closed at this stage, when a patient interview is not mandatory.
A bill currently facing its final votes in the state Legislature, SB 815 by Sen. Richard Roth, D-Riverside, is the start to reforming how the medical board handles investigations. It would require the board to interview complainants before their cases are closed. It would also create a public liaison unit to guide complainants through the investigation process.
The bill would give families and patients the opportunity to make a victim impact statement before discipline is issued, so the board understands the human impact of medical negligence. And it would reduce the standard of proof the board uses in most cases, bringing California in line with the standard currently enforced in 41 other states.
With an interview and a lower burden of proof, there might have been accountability for the doctor whose negligence cost Jose his life. That, in turn, might prevent the same thing from happening to your family.
Lobbyists for the doctors want to weaken the bill. I ask members of the Assembly to stand strong and pass SB 815 intact to restore patients’ voices at the medical board and improve oversight of doctors.
Maria Ibarra Navarrette is a San Jose resident and volunteer patient advocate with Consumer Watchdog.
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