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Prisoner’s Healthy Kidney Erroneously Removed; Surgeon Receives Probation

The California Medical Board placed a doctor on three years’ probation for removing the wrong kidney during surgery on a federal prisoner.

The unidentified 59-year-old prisoner, held at FCI Terminal Island, was diagnosed with a cancerous left kidney following a September 18, 2011 CAT scan. He was referred to Dr. Charles C. Streit at St. Jude’s Medical Center. Streit, who had been a physician and surgeon since 1973, specialized in urology. He examined the prisoner and scheduled surgery for February 7, 2012.

The standard of medical practice for the attending physician is to “preoperatively, positively identify, validate, and confirm the location and side of the patient’s disease process upon which the surgery is to be performed,” according to an accusation filed by the Medical Board. “Dr. Streit proceeded with surgery despite not having access to the patient’s medical records on the date of surgery. Lacking the chart, he had to rely solely on his personal recollection as to the location of the tumor.” The doctor also failed to “perform a preoperative renal ultrasound to confirm the location of the tumor.”

“It was our failure to follow our protocol regarding displaying the patient’s diagnostic images that ultimately resulted in this error,” said DruAnn Copping, a spokeswoman for St. Jude’s, which was fined $100,000 for the surgical mistake.

Dr. Streit admitted to the facts in the accusation. As a result, the Medical Board entered an order on November 26, 2014 that placed him on three years’ probation and suspended his medical license. He also was required to complete a Wrong-Site Surgery Course and prohibited from supervising physician assistants.

The removal of the prisoner’s healthy kidney resulted in a second surgery to remove the diseased one, “putting the patient’s future renal function in jeopardy.” According to a 2006 study published in the Journal of the American Medical Association, wrong-site surgeries are exceedingly rare, occurring only once every five to ten years at large hospitals. What is perhaps most ironic, given the typically poor quality of correctional medical care, is that the removal of the prisoner’s wrong kidney was not performed by a prison physician.

The Medical Board’s license suspension was effective June 25, 2015 and will remain in place until November 2017, though Dr. Streit stated “he does not intend to seek re-licensure or reinstatement as a physician and surgeon.” See: In the Matter of the Accusation Against: Charles C. Streit, M.D., Medical Board of California, Case No. 11-2012-224390. 

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Related legal case

In the Matter of the Accusation Against: Charles C. Streit, M.D.