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A listener note, this story contains adult content and language in the spring and early summer of 2012, Dr. Christopher Denge didn't have privileges to work at any hospital.


Kimberly Morgan, who had been his medical assistant and his girlfriend, had left him some of the rumors among surgeons were that Kimberly had actually coached him through a few of his surgeries. Now she was gone. It wasn't a smooth breakup. He showed up at her house at two a.m. one night and started banging on her window. Since he wasn't able to operate anywhere, there wasn't a lot for his remaining staff to do. They played games, they read magazines, I stared at their phones.


They noticed changes in the boss.


He became depressed. He would come in and not say anything. He looked disheveled. He looked like he hadn't bathed. That's PJ Ellison, his office manager.


He might come in, not say anything and leave. And this would be weeks at a time.


His patients came in for checkups and he told them he'd be doing their operations any day now, telling them that as soon as we had privileges at a certain place that he wanted because they're up to date technology, then we would do surgery. Dench's ways were starting to bother her. I do not think it's ethical to keep stringing along patients that desperately need surgery without referring them on. I don't think it's right. I had also heard, Doctor, don't you tell a patient that he was going to open a multi-billion dollar clinic with the best and the greatest of neurosurgery.


And I'm listening to this. Thinking this is one big lie, this was right after his stint at Baylor Plano, every patient Donge had operated on since that December had had major complications, pain, paralysis, death. From there, he went on to Dallas Medical Center, where two of his three surgeries ended in disaster. After Florella Brown's surgery, BJ Ellison finally realized the same thing her friend Kimberly Morgan had Jerry Summers, Kelly Martin, Florella Brown, Mary Efford, these had not all been tragic flukes.


She quit. And before she left, Ellison called all the patients she could and all the hospitals. She knew where he was applying and told them, do not let him near you. Do not let him near any patient. And why did you do that? I didn't want him to have privileges anywhere, ever. What were you afraid of, someone dying or never walking again, being paralyzed?


And what went through your mind when you learned that he had kept operating even after he left asthmatic? Holy shit. That's what I thought. How are you people letting him operate? I'm sorry. That's vulgar, but that's what I thought. What in the heck is going on? Here's the thing about home security companies most trap you with high prices, tricky contracts and lousy customer support. So while there are a lot of options out there, there's only one no brainer simply safe.


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This is Episode four spinless. If Baylor Plano had fired Dungy outright at the first sign of trouble, this story could have ended right there. That would mean that after the operation on his friend Jerry Summers, there would have been no injury to Mary Efford or to Shirley Mark. Florella Brown and Kelly Martin would still be alive if they had fired him instead.


Dr. Denge operated 29 more times after Jerry Summers Baylor Plano allowed his abrupt departure to seem voluntary. He would go on to Dallas Medical Center and then on to still more hospitals. Why? Because when Baylor Plano let him resign, they failed to do two important things. The first thing that they didn't do was report him to the state medical board.


The number one role of any state medical board is to protect the public. No. One, that's that's their number one responsibility.


That's Dr. Henderson. Baylor could have told the board that they had conducted an investigation and found that one of their surgeons had severely mangled two operations in a row. The medical board is a panel of physicians appointed by the governor and anyone can report a doctor to them. The second thing they didn't do was that they did not report him to the National Practitioner Databank.


The databank is basically a way of keeping up with America's worst doctors. It was set up in the 1980s as a way to improve the quality of health care. The intention was to keep bad doctors from sneaking from hospital to hospital or state to state by keeping a national record of things that they'd done. You and I can't see this list. Other doctors can't see this list. One reason is that some reports are minor and depending on the context, don't necessarily mean a doctor's dangerous, but hospitals can see it.


And before they give privileges to a doctor, they must check to see if their new recruit is on it. A major report to the databank, like getting fired over mangled surgeries, can make it almost impossible to find a job. If Baylor had fired Dr Dungy outright, they would have been required by law to report him to the databank. Instead, they gave him a letter in April of 2012 that, while not exactly glowing, strongly implied that he had left on good terms.


It said all investigations with respect to any areas of concern regarding Christopher Dench, M.D., have now been closed. As of this date, there have been no summary or administrative restrictions or suspension of Dr Dentists' medical staff membership or clinical privileges during the time he has practiced at Baylor Regional Medical Center at Plano. Dr. Henderson was shown that letter by the Dallas Medical Center administrator the day he was called in to take care of Mary Efford.


It was a short, brief, concise letter and that was pretty amazing because everybody in the rooms at this time was aware of the fact that he'd had two catastrophic surgeries, at least at that hospital.


Basically, Baylor got rid of him in a way that saved themselves a lot of red tape and legal fuss. Kick the can down the road, protect yourself first, protect the doctor second, and make it be somebody else's problem. It didn't make sense to me why Baylor would want to protect Dr. Denge, so I talked to Chavannes Way, a Dallas malpractice attorney who would end up representing more than a dozen of Dr. Dench's patients. She would join Dr. Henderson's effort to stop Christopher Dunn's.


Vanua explained that had Baylor fired and reported him, then they'd be the ones who could be saddled with a bunch of legal bills. Then, if Dr. Duncan was unable to get privileges at other hospitals, theoretically, Dr. Dodge could have sued Baylor and said, look, I could be making two million dollars a year here. And you've you made a wrong decision about me. You didn't have enough evidence on me. And you've ruined my career and you owe me two million dollars for the rest of my life.


Now, let's be clear, with his track record, it would be absurd for Dr. Dunnart to make a credible case that he was treated unfairly. But the fear of being sued and that culture of silence is real.


So real that a watchdog group called Public Citizen did a study a few years back to see how often hospitals do this.


They found that more than half the hospitals in the country had never reported a single doctor. Dallas Medical Center, where two of Dench's three cases ended tragically, didn't report him either.


So you might be wondering if his name ever made it to the databank, their reports aren't available to the public, but I was able to get my hands on Dr. Dench's from an outside source. Christopher Dunn was finally reported by Methodist Hospital in the Dallas suburb of McKinney. He never worked there, but he applied and based on what they learned happened at Baylor Methodist, McKinney rejected his application and did what Baylor should have done, report him to the databank.


But if you'll please leave your name, number and a detailed message, we'll get back to you as soon as we can. Thanks. Have a great day. Record your message. As you might imagine, I had a lot of questions for Baylor. I sent emails and left voicemail messages for months. Hi, Nikki.


Floraville, I just wanted to see if you had gotten my last email. I have some more questions. If you could give me a call back. Thank you.


But Dr. Henderson did talk to them.


I share this fact. Ravicher Henderson, I need to speak to your CEO or your administrator of the hospital, OK, to care for our president. Would that be the person you want? Gregarious. OK, fine, thank you.


This was on July 30th, 2012, just after Dr. Henderson had operated on Mary Efford at Dallas Medical Center. Jerry. Hey, Jerry. This Dr. Robert J. Henderson.


Jerry Garrison is the president of Baylor Plano. Hi, how are you? I'm good. I'm hoping you can help me with the problem. Um, are you familiar with a neurosurgeon by the name of Dr. Christopher Diaa? Yeah. Yeah. Oh, well, so am I. Unfortunately, I became aware of him on Friday.


Dr. Henderson tells Garrison about Florella Brown, the woman who never woke up after falling unconscious the morning after her surgery.


Then he tells Garrison about the patient he was brought in to operate on Mary EEF and put it bluntly, I'm concerned whether or not he's had any training whatsoever in spinal surgery. Anyone in that operating room could have done a better job. Henderson says he was trying to do a pliss itself by this one, and he starts listing off the damage. As near as I can tell, he may have destroyed four nerves on the left side. I destroyed them like transected.


Then he talks about a screw lost in Mary efforts body. He actually put the device in the left. So it's muscle trying to put a pedicle screw lateral to that in the left so it's muscle and lost it. And how Florella Brown had died. And the radiologist said it was a massive air embolism to the brain within Fastenal brain tissue. And then he gets to the reason for his call.


And then I heard he had problems at your hospital. Is that correct? No longer have to be very careful and correct. But Dr. Henderson knows that bad things happened at Baylor and he's wondering, well, what on earth is going on? I'll tell you, I'm really uncomfortable talking about this, but we have a very similar procedure and we tried our very best to actually take it from anywhere, anywhere else. I mean, this guy's a maniac and he's pathological.


Apparently, he he talked his way out of apparently these issues that your hospital declared he did not know. No. I mean, they are that I'm trying to stop this guy from being let operate anywhere, any time, any place conduct. OK, I appreciate it. Dr. Henderson never heard from Jerry Garrison again or anyone else from Baylor, Plano. I wanted to talk to Jerry Garrison myself, I wanted to ask why they'd handled Dr. Dunn just the way they did, but all I got back was this brief statement.


Our primary concern, as always, is with patients out of respect for the patients and families involved and the privileged nature of a number of details, we must continue to limit our comments. There is nothing more important to us than serving our community through high quality, trusted health care. I think the failure of Baylor in this case or other hospitals in subsequent cases is just beyond words.


Alan Shulgin was a doctor who sat on the Texas State Medical Board in 2012 after he got a call from a fellow surgeon about Dunwich shock and took the unusual step of reporting it to the board himself, the first formal notification they received.


But all this did was start a long, slow process. See reporting a doctor to the medical board launches an investigation which usually takes months. The speed at which they work gets a lot of criticism, but in most cases, that's not necessarily a bad thing.


This is, after all, an accusation that could destroy a doctor's reputation and livelihood. So the investigation needs to be done carefully. But again, if the reporting had come from Baylor and they'd shared their findings, then the board could have used the information the hospitals had already gathered and with an overwhelming reason for concern, they could act much, much faster.


How fast had Baylor alerted the board? Right away. I would anticipate the board would admit within days to have an immediate suspension. Wow, that can be done with or without notice if somebody's so bad, the board can say, stop now, then you can come back and tell us if we're wrong or you're right.


But stop now to protect the public. They they let him go around March or April of 20 of 2012. So you're telling me that if they had notified the board, he could have been stopped within days of that? They should have done that. They shouldn't have been afraid to do that. What's the worst that can happen? A lawsuit. Come on, money. These are people dying which stop it because you're afraid of a lawsuit. I know you can't speak for failure, but I'm sitting here wondering why would they protect him?


Like, what did they have in it? They were going to let him go. So why what would they have to gain by not reporting him? I have no idea. Maybe they don't want the hassle. I have no idea. And do you think this happens very often? Yes. Baylor's failure to report Dr. Denge to the Texas Medical Board would later trigger an investigation by state health authorities, Baylor Hospital did pay a price. Well, almost.


On December 10th, 2014, the state issued a notice of violation to Beyler and find them 100000 dollars.


There wasn't enough people died and continue to die. It's egregious beyond words, it's a moral human failure systems there to make to stop this kind of thing. The people who had chance to make the system happen ignored a year after Baylor was fined almost to the day the notice and fined or withdrawn. I failed to obtain the records of what happened in between, but was told by the state they were confidential. Changing up your hair color can change your whole day, week, month even.


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So if you'd like to hear it, listen, wherever you're listening right now. The hospitals weren't doing anything to stop Dr Dent, and without reporting him to the databank, there was no way for anyone to know how bad things really were.


And so Dr. Donge was not getting anything on his record. That's Dr. Randall Kirby, because Duncan wasn't getting reported. No one was connecting all the dots. But then Kirby had a chance meeting in the doctors lounge of another Dallas hospital in July of 2012.


He's a spine surgeon. I'm an access surgeon.


Dr. Robert Henderson, the doctor who had begun looking into his background and who happened to be working at the same hospital at the same time.


We had to sit in the same doctor's lounge while waiting for the rooms to turn over. And it's a small doctor's lounge at Pine Creek Medical Center. And since I knew that Dr. Henderson had done the recovery surgery on this effort, I went and talked to Dr. Henderson when I saw about what happened up there. Bad news travels fast in Dallas.


He had come in contact with other patients that had been injured by Dr. Duncan, and he was more intimately aware of what had happened the previous hospital. Also, he heard about my situation with Mrs. Effort.


He's an extremely conservative, mature surgeon.


He's not as outspoken as I am. And for him to get up this upset about something was very, very unusual.


The to make something of an odd pair. Kirby speaks in passionate flourishes. Henderson is understated and deliberate. They both decided to call the Texas Medical Board.


And I said, listen, we've had egregious results of Baylor, Plano. He was not reported the day bank. We've had egregious results in Dallas Medical Center. And I said he's got to be stopped. I told him that not only should he not be in an operating room, he should not be evaluating her interfacing with patients, period, until he was fully evaluated from both a mental and capability standpoint. And what did they say? They said they would get back to me.


And thank you very much for reporting the issue. And then the conversation was terminated. They didn't want to hear it. And so they didn't feel that they had enough to act on do.


They had two dead patients?


They had a quadriplegic and paraplegic. And that wasn't enough. That wasn't enough for them that. As it turned out, they weren't the only ones calling the board, there were a number of practitioners here in Dallas who were calling down to the Texas Medical Board saying we have got a real problem with this neurosurgeon. And before this, how many surgeons or how many doctors have you reported to the medical board before? I've never reported on Texas Medical Board. And you've been practicing for how many years?




I mean, if I were you, I'd do everything I could to just to just say, no, I can't recommend him at this time.


A few weeks later, Henderson got a call from Dentures, old fellowship supervisor at the University of Tennessee Medical School, Dr. Kevin Foley. Remember, Foley is the one Henderson talked to right after Mary Efford surgery when he thought that had to be an impostor. Foley was also an investor in the company that helped found Genex. Christopher Dant was applying to work at a new hospital. The hospital needed Foley once again to vouch for his credentials.


You know, I kind of chuckled and I said, well, at least you know what to do with that. But then Dr. Foley says he can't mention what he's heard in Dallas. He says, well, not really that simple. They're asking me how he performed during his time under my tutelage. He's under my tutelage for a year. He did about six months of surgery and then he did about six months in research because he has a PhD, too.


And he said he was fine. You know, I'd say he was average. Was he superlative now? Was he was he terrible? No, he was average. And that that's all they're asking for.


How'd he do while he was under my tutelage? And I said, yeah, but don't they say, would you recommend him to be on your hospital staff or don't they know there's no questions like that? And he said, I mean, there's none none of those.


Thali tells him that there's a box for comments. And Foley says when he got the same form from Dallas Medical Center, he'd written in that box about two problematic cases at his prior hospital that should be looked into and said, there you go. Just tell them what you know says, well, all that's hearsay. I didn't see it. I said, we'll use my name then because you heard it from me. And I personally saw the damage that he created, says, well, I really can't do that.


Foley goes on to tell Henderson about the case of a doctor in Tennessee who tried to stop another doctor he thought was dangerous. The second doctor, the one being accused, sued the first and won. And it says in from my standpoint, I don't know of a physician that will write a negative reference letter about another physician in Tennessee. And of course, I was flabbergasted about this. And I just said, you're in a very unique position where you get notified every time this guy wants privileges someplace.


And now you're even more in a position that you you've been notified that he had two catastrophic events at Baylor and that I've had two catastrophic events, you know, within six or eight weeks later at another hospital. And if that doesn't raise any red flags for you or anyone else in your position, that has some control over this, Dr. Foley says there are limits to what he can do because he didn't personally observe gross incompetence.


But hospitals, he says, well, they're the ones who have the responsibility to check him out.


I just have to throw that ball back into the Dallas court, Folly says. As the car goes on, you can hear Dr. Henderson's frustration grow as he tries to get Foley to write something on the form that will stop Dutch.


I just said, do what you got to do. But I know what I would do. And I would I would tell the truth and I would do everything I can to make sure this individual is enabled to not only diagnose patients, but surgically treat patients in the foreseeable future.


Finally, Henderson lets Dr. Foley know he's got to go. Well, I've actually got that. I've got the patient I'm dealing with here in the office right now. They brought her in on a stretcher from the rehab center. So the patient who's just arrived for a follow up visit is Mary Efford. So that. Dr. Foley wouldn't talk to me, and neither would anyone else from the University of Tennessee, I got a long letter about their unhappiness with previous news coverage about Dr.


Foley's connection to Christopher Dunwich. And then it said Dr. Foley does not intend to give an interview in connection with this matter.


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In our latest series, we unbox the shipping wars as upstart FedEx takes on the behemoth UPS. Listen to FedEx versus UPS on business wars, on Apple podcast Spotify or the Wonder App. Dr. Henderson and Dr. Kirby didn't hear anything about Christopher Dunned for a few months, they figured he was finally done, that his medical mistakes had caught up with him and he wasn't operating anymore.


Dr. Henderson, we always wonder where he went, but we didn't hear any rumors in the grapevine from anywhere about him.


But then in December of 2012, Dr. Kirby got a call.


I had the most stad coming at me because I have privileges everywhere he operated. And so I worked at the same doctors and nurses that he was interacting with.


The call was for Dr. Kirby to come help with a woman who had suffered severe complications from a cervical spine surgery. Her name was Jacqueline Troy. Her operation was at a place called the Legacy Surgery Center in one of the northern suburbs. But she had been transported by ambulance to a large hospital in Dallas. Her incision was severely infected, her vocal cords cut and her windpipe had a hole in it. Dr. Kirby had a hunch about who'd performed the surgery, says a guy named Christopher Dutch.


It was I knew, the urologist that ran Legacy Surgery Center Fresco, and I called him and I said, you guys better get him off staff as fast as you possibly can, which they didn't.


Jacqueline Troy survived.


But today, her voice is nothing more than a raspy whisper because her vocal cords never recovered. Kirby and Henderson kept hammering the medical board, but they felt they were getting nowhere. Then six months later, I got an invitation to go to a nice restaurant here in Dallas or Warsaw to meet with Dr. Dutch and be introduced to him as their new spine surgeons University General Hospital.


The hospital's called university general, but it's not affiliated with any university. It was once named Southhampton Community Hospital, but was purchased by new owners in 2012. At the time, the move was welcome. The hospital, which had already been through two bankruptcies, is in southern Dallas, a lower income part of town that's lacking in good hospitals.


When Kirby got the invitation and I called down there and raised holy hell, but Dr. Shehadeh said that's the owner of university general, there was nothing he could do because he hadn't done anything really egregious down there. University General Hospital, which was a lie because he was having terrible results down there. But at least the owner or the owner of the hospital felt that if he cut Dr. Douglas off the medical staff, the Dr. Donge would sue him.


So I'm guessing you didn't go to the dinner? I didn't get dinner with Dr. Chehade. I told you there was nothing in the data bank. Yeah, it sure did, because I checked. That was not true. I have the data bank report that they got and it was clearly on there. Well, he won't talk.


He hasn't returned my phone calls in two years because that because he he said, Randy, Randy, Randy, we can't do anything about him. He's got a clean record, even though he's had these complications and he's going to sue the hospital if we release him.


Less than two weeks later, on June 13th, 2013, Dr. Kirby's fears were realised. The hospital's owner called him. He goes, Randy, right. We've got a real problem down there in your loan to fix it. Jeff Gladwell had broken his back during a motorcycle accident more than a decade ago, and since then he's been living on disability. In 2012, he developed a pinched nerve in his neck.


When you get a death that's pinching nerves, it's it just feels just like getting electrocuted.


He needed to find a neurosurgeon who would take his insurance after consulting Google. He happened upon the website of Christopher Dent, his website.


He was a Ph.D. and a neurosurgeon, M.D. and there was not one flaw on his website, nothing but good reports and a list of accolades that were two pages long. There was a YouTube video.


That was sponsored by the Best Arts Network, and it looked like he won an award or was being interviewed or being found to show how good a doctor he was.


It's a miracle, is all I've got to say about it. Dr. Dachas, one great man.


I wasn't aware that they were a paid advertiser paid to to take care of this website.


Dr. Tunt hadn't won an award. The video was an infomercial, slickly camouflaged to look like an honor.


He is the best doctor I think that anybody could ever go to. And if you're having the problems that I had, you know, gave him a call because he'll fix.


And another thing, there's something off about Dr. Dench's delivery.


It just isn't as polished as the production around him, and that's due to a degenerative arthritic type disease in the bony elements and the joints.


And this the tissues of the spine that does that infomercial helped convince Gladwell that he'd found the right guy, even more so after he met Dr. Dunta in person.


I was actually so happy with the way it went that I called my wife and my mother and said, I think I found somebody on my insurance that's going to fix my neck. When the university general owner called in, Dr. Kirby, he told him the patient had, quote, a retained foreign body in his neck.


But it was a lot worse than that. Dr. Dontcha supposed to take a disease discount in the cervical spine. Dr. Dutch made an incision in the neck in the wrong place, totally disoriented, and then he went through the left lobe. But Mr. Sidewalls, thyroid gland destroyed.


And then Dr. Donge proceeded to cut through the side of Mr. Glide Well's esophagus, which is the food pipe that goes from the mouth to the stomach, and then he proceeded to drill a hole in the neck lateral to where it should have been. He drilled a two ping pong ball sized hole in the musculoskeletal pillar of Mr. Sidewalls, left neck and in the process injured the left four people artery, which is a very big artery that bleeds profusely. And to stop the bleeding, Dr.


Dunwich took a sponge and shoved it in the hole. And then Dr. Denge had sewn Jeff Gladwell up sponge and all the retained foreign body that was the sponge left inside his neck when Dr. Kirby came in, he had Gladwell transferred to another hospital.


I'm not ready for this room and I'm white smoke. In a way, it's going to be, like, bad. Well, the problem is we've already started here.


He is enduring a nurse, changing the vacuum tube, going into his throat with oh oh oh.


Gladwell did finally have the next surgery he needed in December of 2015.


On Friday the 13th, he figured he didn't have any more bad luck, left it.


Nothing like this has ever happened in the United States of America. It may happen somewhere else, but there's never been any sequence of events that comes close to this. Even if he was impaired, intoxicated, performed this horrible operation, he would you would think he'd want to get the patient to someone. They can take care of the problem. And he did. And he just disappeared. And that moment, Dr. Kirby decided this went beyond medical boards and hospital administrators.


This was not an operation that was performed. This was attempted murder.


This is a criminal act. This is something that's intentionally hurting people. He got in touch with Dr. Henderson. It was time to notify the Dallas district attorney. That's next time on Dr. Death. Well, don't take medication in slam from one tree.


This is part four of six of Dr. Death, an investigative miniseries about the system that failed to protect 33 patients in Dallas. If you'd like to help us spread the word, please give us a five star review and tell your friends to subscribe. Were available on Apple podcast, Spotify, NPR, one and every major listing app, as well as Wonder Dotcom if you're listening on a smartphone tap or swipe over the cover art of this podcast, you'll find episode notes, including some details you may have missed.


You'll also find offers from some of our sponsors. Please support our show by supporting them. And thank you. Dr. Death was written, reported and hosted by me. Laura Beil, Sound Design by Jeff Schmidt. Story consultant is Jonathan Hirsch, associate producer is Pallavi.


Could the massive executive produced by George Lavender, Marshall Louis and Hernan Lopez for one brief.