By Kerry Klein, KVPR NPR Radio Central California
September 13, 2022
The California medical board accused Bakersfield obstetrician Dr. Arthur Park of gross negligence following several patient deaths. But he kept his medical license for more than 20 years. How did the medical and legal systems allow that to happen?
This story is part of the series Moms and Babies at Risk.
When Celeste Ortiz went into labor in September 2016, everything seemed to go smoothly. The 23-year-old checked into a Bakersfield hospital after her water broke, then delivered a healthy baby girl nine hours later.
It was only after delivery that the agony began.
“We heard Celeste scream from her room to the waiting room where we were,” said her mother, Angie Ortiz. “They said that her pulse was dropping, her heart rate was dropping, and they weren’t sure what was wrong.”
Shortly after delivering a healthy baby girl, 23-year-old Celeste Ortiz died of postpartum hemorrhage in September 2016, according to the Medical Board of California.
Celeste fell unconscious and the color drained from her face, according to medical board documents. She was rushed to the intensive care unit. After suffering two heart attacks, she was pronounced dead just seven hours after delivery. She never got to meet her daughter.
The coroner’s office and the Medical Board of California eventually pieced together what had happened: Celeste died of postpartum hemorrhage, according to an accusation filed by the medical board. The medical board alleged that her attending obstetrician, Dr. Arthur Park, was grossly negligent when he extracted her placenta, “despite the patient having a contracted cervix, without adequate pain control, and without ultrasound guidance,” the document reads. “The patient was screaming in pain and moving around in bed.”
That same document alleged Park failed to thoroughly examine her to determine whether her uterus had been lacerated, then failed to recognize that she was in shock. After investigating those allegations, the agency revoked his license, but stayed the revocation and placed him on probation for five years.
“He's still out there, walking free, living a great life, having a million dollar home…while we're out here trying to pick up the pieces,” Angie said.
KVPR attempted to talk with Dr. Park, reaching out to him by phone, email and certified letter, and although he submitted a statement by email he declined to be interviewed for this series.
Park, 63, graduated from a South Korean medical school in 1985, then was licensed in California in 1988. He saw patients at an OB-GYN clinic in Bakersfield alongside a few other doctors and, until 2021, delivered babies at hospitals across the city.
Throughout Park’s career in Bakersfield, at least five of his patients died, including two mothers and three babies, according to a KVPR review of medical board documents.
As a result, the medical board accused Park of negligence three times over the span of 20 years.
“The entire Dr. Park story is 25 years of harm,” said Consumer Watchdog patient advocate Michele Monserratt-Ramos. “It’s probably one of the most significant tragedies I’ve seen in over 15 years of monitoring the medical board.”
Park also reached financial settlements in at least three lawsuits filed against him for malpractice, personal injury or wrongful death, according to court documents and people involved in the lawsuits. A settlement is not necessarily an admission of guilt. In a fourth lawsuit, a legal document indicated Park reached a settlement with a patient but the filing did not disclose whether money changed hands.
Park is no longer practicing. He surrendered his license in December of last year. Still, Monserratt-Ramos and others can’t stop asking: How was he allowed to keep seeing patients for so long, and to stop only voluntarily?
“The system is incredibly flawed, incredibly flawed,” Monserratt-Ramos said.
Dr. Park faced many investigations, lawsuits
Review the paper trail on Park and trends emerge.
He allegedly induced labor without first confirming babies’ size or gestational age, according to the medical board and court documents. For some women, he allegedly broke their water manually, in his office, and as part of a malpractice suit filed in Kern County Superior Court in 2012, one of those patients testified before a judge that Park told her to lie to the hospital about how her water had broken. In Park’s subsequent deposition, he admitted he wasn’t sure if he had broken her water or not, but said he told the patient to tell the hospital he hadn’t done it intentionally.
He repeatedly failed to recognize emergency situations, according to medical board allegations and court documents.
“I've only seen in my career probably three doctors that I would characterize as being dangerous and scary, and Dr. Park would be one of them,” said Linda Fermoyle Rice, a Los Angeles-based lawyer who brought two cases against him. “It's based on my own experience with his practice. It's based on feedback I've had from other lawyers who have handled cases against him. It's based on the medical board accusations that have been filed against him over the years. There are just some people who should not be practicing medicine.”
Rice’s two cases involved large babies. The exact circumstances differed, but legal filings alleged that during delivery, both got stuck in their mothers’ birth canals and Park had to forcibly pull them out. Both survived, but were permanently disabled with a condition known as shoulder dystocia, the filings allege. One also suffered developmental and motor delays and “probably perinatal asphyxia,” according to medical records submitted to Kern County Superior Court. In a deposition in that case, a medical expert referred to Park’s care as “grossly substandard” and testified that the baby was so large, Park should never have attempted a vaginal delivery.
Rice confirmed that she negotiated financial settlements for both clients but could not disclose the dollar amounts due to a confidentiality clause. “All I can really say is that the cases were resolved to Plaintiffs’ satisfaction,” she wrote in an email.
One might wonder if all these cases were just bad luck. After all, some doctors simply take on higher-risk patients, and not all injuries and deaths can be prevented. Rice, however, says the distinction doesn’t matter, because medical experts in so many of these cases found that Park had failed to follow the standard protocols for these situations.
“Anything that deviates from the standard of care is negligence,” she said.
The medical board recognized this. As documented in two disciplinary decisions posted to Park’s public profile, the agency first accused Park of negligence in 1999, following the deaths of two babies he had just delivered, and again in 2019, following Celeste Ortiz’s death. In the earlier decision, Park admitted to repeated acts of negligence. Both times, the agency revoked his license, then stayed the revocation and placed him on probation for a number of years.
A third accusation, which launched an investigation into his practice in 2021, alleged again that he had been grossly negligent and had inadequately maintained records, but he surrendered his license before that investigation could be concluded.
Representatives of the medical board have not given a clear answer as to why the agency repeatedly stopped short of revoking his license. Instead, they have defended why probation was sufficient.
“The terms and conditions of this probation are designed to protect the public, and to also address Dr. Park’s deficiencies to improve his practice through the additional education courses required and rigorous evaluation and monitoring,” read a 2020 letter penned by the board in response to an inquiry about Park by State Sen. Melissa Hurtado.
The medical board provided an additional explanation in its 2000 disciplinary decision.
It claimed that “removing Dr. Park from the pool of physicians providing obstetrical and gynecological services to Medi-Cal beneficiaries in the Bakersfield area would adversely impact the availability of such services to Medi-Cal patients.”
In an email statement, Park didn’t respond to specific questions about Ortiz or any other patients. However, he alleged that Adventist Health Bakersfield, formerly known as San Joaquin Community Hospital, had falsified medical records from the late 1990s that were then used to substantiate the medical board’s first accusation of negligence against him. He also claimed that those documents were part of a decades-long attempt at retaliation for the fact that he was a witness in a workers’ compensation lawsuit against the hospital in the 1990s.
An Adventist representative responded to say it supports the medical board’s work and that Park would have had an opportunity to represent his interests during the agency’s investigations. She also said that his statements “have no basis in fact.”
The Medical Board of California is “completely impotent,” according to a board member
Last fall, a Los Angeles Times investigation found that the medical board regularly shies away from disciplining negligent doctors, which the outlet partly blamed onlobbying from the powerful doctor-led California Medical Association.
Experts who spoke with KVPR agreed.
“California has not one of the best but one of the worst records in the country of failing to discipline doctors even after there's clear, unequivocal evidence they have done something,” said Dr. Sidney Wolfe, a physician and co-founder of the non-profit watchdog group Public Citizen. “And the discipline too often is a slap in the wrist, probation, that lets them practice as they have been before.”
“We are completely impotent in actually executing our authority,” agreed Eserick “TJ” Watkins, a non-physician member of the medical board.
The fitness trainer and life coach was appointed to the board by the Senate Rules Committee in 2019. In the last year, Watkins emerged as an outspoken critic of the agency. He said that Park’s light disciplinary history was not unusual.
“How we deal with Dr. Park…multiple probation periods, throw the book at him, but never take his license, that is typical,” he said.
Kristina Lawson, president of the medical board, defended the agency’s process of investigating and disciplining doctors. A lawyer appointed to the board in 2015 by then-Gov. Jerry Brown, Lawson argued that the agency’s board and staff members take their mission of protecting patients seriously.
“Our process is very complex and it really is difficult for consumers or observers to understand, frankly. It was difficult for me to get up to speed on and understand exactly how the process works,” she said.
Lawson agreed, however, that the agency has been chronically underfunded, and acknowledged that stopping Park’s discipline at probation may not have ultimately protected other patients.
“No one should ever be harmed or die or have circumstances like have occurred with Dr. Park’s case,” she said. “I wish we could have done more.”
Medical Board of California president Kristina Lawson spoke in April in support of Assembly Bill 2060, which would have established a public member majority on the board. The bill, introduced by Democratic Assemblymember Dr. Bill Quirk, eventually died in the state Assembly.
The legal system has also likely stymied efforts to correct patient harm: For decades, a state law put a cap on the amount of money that patients or their families could receive from malpractice settlements. The state law, known as the Medical Injury Compensation Reform Act (MICRA), limited non-economic damages due to pain and suffering to $250,000—an amount so low, few lawyers would take those cases on for fear that they wouldn’t recoup even their legal fees. As a result, only the most egregious cases would receive any daylight.
That’s not to say, however, that lawsuits, even successful ones, always serve patients or the public.
For instance, any settlement under $30,000 that a doctor pays doesn’t have to be reported to the medical board. A physician must accumulate enough settlements of $30,000 or higher—three or four settlements over a 5-year period, depending on the circumstances—in order for them to be posted to the doctor’s public profile on the medical board website.
After Celeste Ortiz’s death, her family sued both Park and the hospital where she died. The hospital was not required to pay a financial settlement, according to Angie, and Park agreed to a settlement of $29,999, just below the reportable threshold. In a legal filing, Park’s legal team advocated for that amount because she had been in and out of jail during her pregnancy and did not have custody of her two older children at the time of her death.
“Her life was only worth $29,000? That’s all her life was worth?” asked Angie Ortiz. “Regardless of what she had done in her life or what trouble she's got into, that doesn't justify what he did to her.”
Change, however, appears to be coming.
For the first time in more than 40 years, MICRA was updated this year, when Gov. Gavin Newsom signed a law that raised the cap on non-economic damages awarded in malpractice or wrongful death lawsuits and allows it to continue rising every year for the next decade.
Also earlier this year, the medical board itself lobbied the legislature for reforms to step up its investigations of doctors, including by raising physicians’ licensing fees and lowering the burden of proof required to determine a doctor’s behavior had been problematic.
Medical board member Watkins, however, remains skeptical that the legislature will approve any significant reforms. He also argued that a shift needs to happen within the agency first, for instance by replacing the executive director and other management.
“The board needs to be rehabilitated from the point of view of the culture,” he said.
Kerry Klein is an award-winning reporter whose coverage of public health, air pollution, drinking water access and wildfires in the San Joaquin Valley has been featured on NPR, KQED, Science Friday and Kaiser Health News. Her work has earned numerous regional Edward R. Murrow and Golden Mike Awards and has been recognized by the Association of Health Care Journalists and Society of Environmental Journalists. Her podcast Escape From Mammoth Pool was named a podcast “listeners couldn’t get enough of in 2021” by the radio aggregator NPR One.