How could a surgeon mistake a liver for a spleen, kill a patient, and almost get away with it?
Dr. Thomas Shaknovsky was stripped of his medical license on September 24, 2024. Five weeks earlier, he effectively killed a patient by removing his liver instead of his spleen while operating room staff looked on, horrified. The hospital where he worked is "still investigating" the incident. How could such a thing happen?
Immediate danger demands immediate action
Why don't hospitals always operate based on an abundance of caution for the welfare of their patients? When Thomas Shaknovsky, DO (Doctor of Osteopathic Medicine), killed William Bryan by removing his liver instead of his spleen, it was the Florida Department of Health that investigated and the Surgeon General of Florida, Dr. Joseph Ladapo, who suspended his license, after determining that:
Dr. Shaknovsky's continued practice of osteopathic medicine constitutes an immediate, serious danger to the health, safety, or welfare of the citizens of the State of Florida.
The hospital, Ascension Sacred Heart Emerald Coast in Destin, Florida, is apparently “still investigating.”
So eager to operate
The incident occurred in August of this year, after the 70-year-old Bryan was admitted to Ascension hospital with pain in his left side. He had a series of imaging tests done which revealed a “suspected enlarged spleen” and blood in his peritoneum. Bryan wanted to return to his home state of Alabama for treatment but doctors in Ascension hospital persuaded him (over the course of three days of disagreement) to remain, claiming that he was too unstable to be transferred.
Surgery to remove his spleen was scheduled — it was to be a laparoscopic splenectomy. When the surgeon began the procedure, however, he decided to do open surgery instead due to the patient’s “distended colon and blood in the abdomen.” With Bryan’s abdomen open before him, Dr. Shaknovsky nonetheless removed not the spleen but the liver, directly causing the patient’s death.
Can organs migrate?
William Bryan’s widow is now suing the hospital. Statements by hospital staff taken in relation to the lawsuit revealed many troubling features. Perhaps most troubling is that this was not the first time that the doctor concerned had removed the wrong organ. On a previous occasion, around a year earlier, Dr. Shaknovsky had mistaken a pancreas for a kidney and removed pancreatic tissue instead of a growth on the adrenal gland. The patient did not die but he did suffer permanent harm.
Commenting on this earlier incident, the widow’s attorney, Joe Zarzaur, noted that:
The case settled pre-suit without the lawsuit being filed.
The hospital, apparently, concluded that the doctor was fit to continue to practice, even though Dr. Shaknovsky never admitted to his mistake and instead claimed that he was not at fault because the adrenal gland had “migrated” to a different part of the patient’s body.
'That's scary...' for the patient or the doctor?
A year later, staff working with Shaknovsky told Attorney Zarzaur that when they heard this particular surgeon was scheduled to perform the splenectomy, they “had concerns that he did not have the skill level to safely perform this procedure.” It was also three years since his previous spleen removal surgery.
They were also worried that the surgery was scheduled for so late in the day (four o’clock in the afternoon) when only a “skeletal crew” would be available. In fact, the doctor arrived only at five o’clock and the patient was wheeled into the OR at twenty-past-five.
Dr. Shaknovsky claimed both at the time and after the patient’s death that he had clamped the “splenic artery” and that the patient died when an aneurysm spontaneously ruptured.
Dr. Shaknovsky claimed that he fired the stapling device blindly in to the abdomen and removed an organ that he believed to be a spleen … Dr. Shaknovsky claims that due to his shock and the chaos of the situation, he was unable to properly identify the organ he removed and assumed it must be the spleen.
His account is contradicted by those of scrub technicians and OR nurses who all reported that the doctor did not use a clamp. Those who could see what was going on confirmed that the doctor was “operating blind” given the amount of blood — that he couldn’t see what he was cutting. Not one member of the OR staff claimed to have questioned the doctor’s actions at the time.
In fact, one staff member assisting in the operation said that the doctor had his finger on the artery he intended to cut after stapling and could feel it pulsing under his finger. The staff member added that Shaknovsky said, “That’s scary” — and then cut it.
Five days passed...
It turned out to be not the splenic artery but the inferior vena cava that he cut. The patient hemorrhaged and died, despite the best efforts of the entire OR staff, aside from the doctor who continued with the operation, removed the liver, and declared it to be the spleen.
Shaknovsky then told one of the staff members to label the organ “spleen” and send it to pathology. The staff member did as he was told.
That was on August 21st. Two days passed before the pathologist discussed the case with the surgeon and told him that he had removed the patient’s liver. Another three days passed before the medical examiner was informed. Media accounts and lawyers’ reports are absent of any suggestion that Ascension hospital took any steps against Dr. Shaknovsky either during this period or following it.
A row of red flags, ignored
If Ascension did in fact fail to take actiom, it would be quite in keeping with their previous record, given not only the botched operation a year earlier but also other incidents that came to light when Attorney Zarzaur interviewed medical staff. Apparently, there had been two other incidents in which serious damage was caused to patients and Dr. Shaknovsky underwent peer review as a result. The hospital authorities then concluded that the doctor had a “pattern of questionable decision-making; less so related to surgical technique and more related to post-operative management and complications…” and he continued to perform surgeries.
One scrub technician told Zarzaur that during a different operation, when Dr. Shaknovsky appeared to be cutting the wrong side of the body, she called him out but he claimed that the patient had “bilateral” issues. Since this was true, she backed down, assuming the doctor knew best — but it turned out that her instincts had been correct.
Another technician, when asked if she would speak up if she felt it was warranted, said she would, but,
I’m a Scrub Tech and the surgeon won’t listen to a Scrub Tech unfortunately.
Walton County Sheriff's Office is now “reviewing the facts involving the death of William Bryan to determine if anything criminal took place.”
Speak out at your peril
Why weren’t staff working at Ascension hospital more insistent about their misgivings? Why didn’t they take their evidence to outside authorities? The case of another doctor, at a different hospital, who did speak out is perhaps instructive.
Dr. Daniel West is a cardiologist with over thirty years of experience in his field. Around five years ago, he began to notice a colleague performing unnecessary surgeries based on misinterpreted test results “to make patients appear more sick than they were.” He alerted senior hospital officials, submitting a report that explained how the misinterpreted results led to patients being fitted with a special type of pacemaker that they didn’t need.
Shoran Reid Williams, Dr. West’s attorney, noted that her client’s assessment was correct:
Three of the doctors from the practice then went to all of those patient files to see if in their professional opinion they agreed that a device implant would have been warranted. It was discovered that it was not. There was a pattern that was discovered, that the doctor was altering those results in order to justify implanting these devices.
The response of the hospital authorities was to order Dr. West to destroy his report, claiming that it violated privacy laws. Two months later, they fired him. Dr. West is now suing.
When approached for comment, Trinity Health Muskegon officials told media:
While we are not able to comment on the specifics of active litigation, we will vigorously defend ourselves against any allegations which are inaccurate. We remain dedicated in our efforts to uphold high standards and integrity in all aspects of our healing ministry. We will continue to ensure that our actions are in the best interest of the patients and community we serve.
Commenting on the Shaknovsky case, John Kauchick RNBSN highlighted the “culture of fear” in the nation’s hospitals, with sometimes devastating results:
Nobody on the surgical team interceded? Even anesthesia would have peered over the drape and noticed as the surgeon was working on the wrong side. Plus, there were plenty of scans to refer to. Was an additional surgeon called in for the bleed-out? All said, it illustrates the culture of fear that the doctor went unquestioned during the procedure. [emphasis added]
