When a man died nine years ago at St. Anthony's Medical Center, a panel of doctors there said he had received substandard care from his psychiatrist, Dr. Surendra Chaganti.
While not blaming Chaganti for the man's death, the panel said Chaganti prescribed drugs that could have been harmful and failed to send the man to the emergency room after noting he had been given another patient's medicine.
The panel also criticized Chaganti's treatment of other patients, according to a complaint filed last month by a state board that regulates doctors. Those patients included a 9-year-old boy who spent 10 days at the hospital without being seen by Chaganti, and an elderly dementia patient who had been prescribed a drug that could be toxic for a man in his condition.
In 2002, the south St. Louis County hospital notified Chaganti that he could lose his hospital privileges.
Chaganti disputed that there was any legitimate basis for taking away his privileges.
His practice, Chaganti & Associates, in 2003 sued the chairman of the review panel and the president of the medical staff. Court records show those doctors and St. Anthony's later agreed to a settlement in which the hospital would accept Chaganti's resignation and not report it to a national databank set up to flag problem doctors.
"He would still look good on paper to everybody," U.S. District Judge Henry E. Autrey noted in a hearing in the case in 2004, according to a transcript. "... Everybody would be happy."
The agreement allowed Chaganti to keep practicing without putting a mark on his record. He kept treating hospital patients. He operated a group home. He helped coordinate clinical drug trials. St. Anthony's concerns could remain a secret.
This is a common issue across the country. Hospitals either aren't disciplining doctors who have had problems, or are finding ways to avoid federal reporting rules.
Last month, the Missouri Board of Registration for the Healing Arts, which licenses and monitors 22,000 doctors, filed a complaint against Chaganti, outlining St. Anthony's internal investigation and making it public.
The board also accused Chaganti — described as one of the area's busiest psychiatrists — of altering a patient's records, refusing to complete courses on treating delirium and failing to disclose his background to another hospital.
Chaganti did not return calls. In answer to the board's complaint, he denied all the charges. His lawyer and brother, Naren Chaganti, discounted the allegations and questioned why the charges were filed so long after the events.
"Something irregular is going on, and we may have to bring in some investigative agencies to find out what," he said.
The board said it acted on patient issues as quickly as it could. It pointed to a state law that makes private virtually all of its dealings with doctors. Neither the board nor the hospital would discuss the case.
Naren Chaganti chalked up the dispute to a disagreement among doctors that he said started when his brother criticized a decision by St. Anthony's chief executive. Then another physician, also the head of the internal review panel, began harassing his brother, he said.
In his lawsuit filed in 2003, Surendra Chaganti said he was singled out because of his heritage, and he derided the hospital's action as a "fake" review aimed to help other doctors "benefit from destroying their economic competitors."
That lawsuit was just one that Chaganti would file when questions were raised about his work. After a psychiatrist at St. Alexius Hospital complained to the healing arts board about Chaganti's patient care in 2003, Chaganti sued the psychiatrist. After CenterPointe Hospital in 2007 denied Chaganti's request for privileges, he filed suit against the hospital seeking an injunction. Naren Chaganti represented him in the lawsuits.
BOARD WANTS TO KNOW
Mistakes in hospitals are costly — in terms of cash and lives.
The Institute of Medicine estimates that 44,000 to 98,000 Americans die each year from medical mistakes in hospitals, and errors cost society nearly $40 billion annually.
It is often within hospitals that worries first arise about a physician's fitness to practice. When the standard of care is not met, or when bad practices are repeated, doctors and nurses notice.
Few are privy to what happens next. Internal hospital panels conduct proceedings known as peer reviews, which are confidential, and reviewers are supposed to be immune from lawsuits. The confidentiality and immunity are designed to encourage staff to candidly study what went wrong.
Nancy Foster, a vice president with the American Hospital Association, said hospitals worked hard to train doctors and study mistakes.
"If you intervene early in a process to make sure those things don't ever get to that stage, you won't see many reports to the (databank), and that's exactly what we should be doing for our patients," she said.
A lawyer for the St. Anthony's doctors said in a federal court hearing in 2004 that it was best to keep the process out of the public domain.
"The peer review process is privileged, and the court's been nice enough to seal all these records to avoid public dissemination of the issues that gave rise to the things that started this whole process," said Winthrop Reed, of Lewis Rice Fingersh, according to a transcript.
When a peer review ends with a hospital's taking disciplinary action against a doctor, the information is supposed to be available to other hospitals.
Under a federal law, U.S. hospitals are mandated to report serious actions to the National Practitioner Data Bank, established by Congress in 1986 so doctors would not be able to hide malpractice, or actions by hospitals, licensing boards or professional societies. Although names in the databank are not open to everyone, they can be accessed by hospitals, and some medical practices and government agencies.
Hospitals must report anything more than a 30-day suspension — including cases in which a hospital accepts a doctor's resignation during or after an investigation, the databank rules say.
An analysis by the Post-Dispatch showed that from 2004 through 2008, Missouri's 140 hospitals reported 41 actions against 32 doctors — or a little more than eight a year. Other states report similar numbers.
Critics say hospitals are underreporting and that puts patients in harm's way. As long ago as 1996, a government agency concluded that the number of hospital reports was "unreasonably low." It has gotten even lower. In 2008, the number of reports was three-fourths of the 1996 total, according to the newspaper's analysis.
The consumer watchdog group Public Citizen reported that from 1990 to 2007, nearly half of hospitals had never made a databank report.
Missouri hospitals also are supposed to report disciplinary actions against physicians to the state healing arts board, which could take action against a doctor's license.
"If there is a true concern and we have an incompetent or impaired physician, yes, we'd like to know about that," said Tina Steinman, the board's executive director. But she said the board might never hear about some cases because hospitals might 'salvage" doctors through training or rehabilitation.
Steinman said she had no evidence that Missouri hospitals were underreporting discipline. The board declined to discuss Chaganti's case.
CLAIMS OF NEGLIGENCE
In its April complaint, the board accuses Chaganti of providing substandard care and of unethical or unprofessional conduct. The complaint discusses five patient cases.
The first was a patient who requested admission to St. Anthony's in July 2001. Other records identify him as Thomas Lawrence, 41, of Cape Girardeau, who had previous kidney damage. He was admitted to the hospital's Hyland Behavioral Health Center for detox.
Chaganti prescribed five psychiatric drugs, according to the complaint. The board said Chaganti gave Lawrence high doses of two drugs that are recommended only in small doses for kidney patients.
A high dosage of one drug caused him to become delirious, "which was not recognized and properly treated," the board said. Lawrence was then given a sixth drug, which worsened his delirium.
Medical records indicated that Lawrence was agitated, wandering around the ward and not following directions, said Medical Examiner Dr. Mary E. Case.
In court records, the Chagantis said other doctors had approved of Surendra Chaganti's treatment plan. But experts in drug reactions told the newspaper that the treatment plan was inappropriate and dangerous.
"From the perspective of prudence, of course this is ridiculous," said Jeffrey Lacasse, an assistant professor at Arizona State University whose research focus is psychiatric drugs.
"If you open up any psychopharmacology textbook, you would never find any evidence base for these kind of cocktails being thrown at people. ... If you give a patient five or six medications at once, you have no idea what is causing an adverse effect, and that's very dangerous."
After Lawrence was admitted to the hospital, there also was a drug mix-up. A report from the medical examiner said Lawrence got another patient's drugs by mistake.
The board complaint said Chaganti noted "incorrect" medication but did not have the patient evaluated in the emergency room. Lawrence died hours later.
Lawrence's wife sued the hospital for wrongful death; the case was settled confidentially out of court.
In court pleadings, the Chagantis insisted that the drug mix-up by a hospital staff member killed Lawrence.
But an autopsy found that the mix-up was not a factor. Case said Lawrence's death was from heart disease and high blood pressure.
She said his psychiatric disorder — and agitation — contributed to his death.
She did not look at what had caused the agitation.
In a second case, the board said Chaganti saw a man in April 2001 for mental illness and substance abuse. The patient was violent and was taken to a hospital in handcuffs after assaulting a police officer.
The board said Chaganti treated him with seven drugs, which may have contributed to further agitation. Providing such medication to a patient known to abuse drugs, without documenting the rationale, was below the standard of care, the board alleged.
"The science in combining even two drugs is limited, and there are no studies that I have ever seen that involve combining three or more psychiatric drugs," said David Antonuccio, professor of psychiatry at University of Nevada, Reno.
"There is plenty of science to suggest that when medications are combined the risks certainly increase. ... From my perspective there's not a scientific basis to support combining psychiatric drugs."
In a third case, in January 2002, the board said Chaganti saw a 9-year-old boy who was "acting out." According to the board, the treatment plan was to adjust the boy's medicines.
During 10 days at St. Anthony's, Chaganti never saw the boy or documented an adjustment to his medication, according to the complaint.
Naren Chaganti said the hospital never told Surendra Chaganti that the boy had been admitted. The hospital declined to comment.
In a fourth case, Chaganti saw an elderly man in February 2002 for senile dementia. The man was agitated, confused and not eating properly. Chaganti started him on Marinol — the so-called medical marijuana — to help stimulate his appetite.
The board said Marinol can be toxic for elderly dementia patients.
In a court filing, Chaganti argued that the patient did well on the drug and that when the hospital questioned him about it, he presented a peer-reviewed article supporting his choice.
In a fifth case, Chaganti is accused of "documentation discrepancies." The board said it appeared medical records were altered. For example, it said Chaganti listed a discharge date as May 2003, when the patient had been discharged nine months earlier.
'STILL LOOK GOOD'
The board complaint says that during its investigation of Chaganti, St. Anthony's tried to review files from 50 of his patients but learned he was involved in treating only 4 percent of patients assigned to him.
Naren Chaganti said his brother had delegated care of those patients to others in his practice.
In March 2002, St. Anthony's told Chaganti his privileges would be revoked if he failed to take courses and a test for prescribing medicines. Chaganti sued in February 2003 as the one-year deadline neared. In June 2003, he received a letter revoking his privileges, court records show.
According to court records, in talks about resolving the lawsuit, the hospital again indicated it would let him take courses to regain privileges. Lawyer Naren Chaganti broached the idea of a resignation.
At the court hearing in 2004, transcripts show, Reed, the hospital's lawyer, said the Chagantis had insisted a condition of any settlement be that Surendra Chaganti not be reported to the databank.
Reed said the hospital concluded that a databank report could be avoided.
The judge asked, "So .. .the parties had agreed that if Chaganti resigned, certain things would occur or not occur, and with reference to his future, he would still look good?"
Said Reed, "Absolutely."
However, Surendra Chaganti refused to sign the agreement, and the dispute dragged on three more years while Chaganti appealed the judge's order enforcing the deal. A U.S. appeals court affirmed the order in 2007.
Hospitals are required to report a physician's surrender or restriction of privileges, including times when a doctor withdraws his application in return for the hospital's dropping an investigation, the rules say.
"The purpose of these requirements is to ensure that hospitals will not resort to 'plea bargains' in which a physician agrees to a surrender of clinical privileges in return for the hospital's promise not to report the physician to the NPDB," said Martin Kramer, director of communications for the Health Resources and Services Administration, which oversees the databank.
"While such agreements may serve the immediate self-interests of the two parties in volved, they may jeopardize the health and safety of future patients."
St. Anthony's declined to answer questions from a reporter. It issued a statement: "St. Anthony's is aware of the reporting requirements and complies with them. St. Anthony's is unable to provide any further comments."
St. Anthony's did make a databank report in 2006 after permanently suspending the privileges of another doctor, Robert C. Egan, according to documents filed with the Missouri Administrative Hearing Commission. Missouri hospitals made just eight reports to the databank that year, the newspaper found.
While the St. Anthony's lawsuit continued, Chaganti applied in January 2006 to renew his privileges at SSM DePaul Health Center. Chaganti did not list all of his past hospital affiliations on his application, the healing arts board said in its complaint.
DePaul learned that he had practiced at St. Anthony's, according to the board.
But when DePaul asked, St. Anthony's would not confirm Chaganti was on staff or discuss his status, the healing arts board complaint says.
DePaul and another SSM hospital, St. Mary's Health Center, then revoked his privileges.
Chaganti applied for privileges at CenterPointe Hospital in 2005. When he was denied in 2007, he went to court to get an injunction but lost the case.
When Chaganti applied to the healing arts board to renew his license in November 2007, he reported the DePaul revocation. That led to the disclosure about the St. Anthony's case.
Chaganti now practices out of offices in St. Louis, Crystal City and south St. Louis County. He retains privileges at St. Alexius Hospital in south St. Louis, which mainly treats people who lack private insurance.
Last year, his practice received about $400,000 in Medicaid payments through the state of Missouri.
Chaganti has run into disputes at St. Alexius, too. The healing arts board has received at least three complaints about his treatment of patients there, according to court records. The board cleared him in at least two cases; the disposition of the third was not included in court files.
One was an anonymous complaint in 2003 complaining that patients were being "badly neglected" by Chaganti. It included a list of 43 patients assigned to Chaganti in a single day.
In 2005, the board notified Chaganti that no action would follow.
The board also got a 2003 letter from Dr. Jitendra Patel alleging unethical conduct by Chaganti. In 2004, the board notified Chaganti that no action would be taken.
Surendra Chaganti then sued Patel in state court for defamation. He lost the case.
Chaganti has been involved with clinical drug trials and group homes. State and federal authorities have cited problems with some of those as well.
Chaganti received a warning letter in 2007 from the U.S. Food and Drug Administration accusing him of medical and ethical violations related to his participation in clinical drug trials for patients with mental illness.
The FDA found that Chaganti failed to promptly report 'serious adverse events" that occurred to trial subjects, such as when one was diagnosed with breast cancer and another was hospitalized for an infected lymph gland. It documented dosing errors and said Chaganti had used a study coordinator who was not qualified to perform drug trials.
Both Chagantis own group homes. In January, authorities shut down Whispering Oaks, a residential care facility Naren Chaganti owns in Wildwood, after health officials discovered it had no running water. They moved 12 of its 30 residents to Loving Care Home in St. Louis, owned by Surendra Chaganti.
In April 2009, according to Department of Health and Senior Services inspection report, state investigators found that Surendra Chaganti had prescribed an anti-psychotic drug for an intoxicated Whispering Oaks resident, a violation of state policy.
Also that month, the state said a Loving Care resident was not given prescribed medications for high blood pressure and asthma, and patients weren't given required health assessments.
In response, Loving Care administrators told regulators that they make every effort to keep residents safe and healthy.
Naren Chaganti said the Post-Dispatch was to blame for the new scrutiny of his family because reporters started asking about his brother's record after the Whispering Oaks closure earlier this year.
He said he would defend his brother aggressively in the healing arts board case. He showed a reporter a copy of an e-mail from board lawyer Glenn Bradford saying the board was concerned about Chaganti's problems at St. Anthony's and other hospitals but didn't necessarily want to discipline him, just make sure he was "good to continue."
If Chaganti agreed to an assessment, the e-mail said, "then we could back burner the case until we see how that shakes out and perhaps save everybody a lot of time, money and distress."
No way, said Naren Chaganti.
"Why would anybody do that?" he asked. "They don't have a case."