Unconscionable: Veterans Administration Hospital Botches 92 of 116 Prostate Cancer Treatments

Not only did the hospital botch the procedures, but regulators not only overlooked the errors, but made attempts to allow the doctor to revise his treatment plan for some of those patients to make the errors "go away".

Most of the seeds, 40 in all, landed in the patient’s healthy bladder, not the prostate.

It was a serious mistake, and under federal rules, regulators investigated. But Dr. Kao, with their consent, made his mistake all but disappear.

He simply rewrote his surgical plan to match the number of seeds in the prostate, investigators said.

The revision may have made Dr. Kao look better, but it did nothing for the patient, who had to undergo a second implant. It failed, too, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.

Two years later, in 2005, Dr. Kao rewrote another surgical plan after putting half the seeds in the wrong organ. Once again, regulators did not object.

Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years — and then kept quiet about it, according to interviews with investigators, government officials and public records.

This is medical malpractice coupled with government failures. Not only did the doctors work for the Veterans Administration, but the VA failed to provide proper oversight or notice anything wrong with the treatment being offered in the cancer unit.

How many men suffered needless complications from this one doctor's malpractice?

One of the men didn't realize it was medical malpractice until he went to another hospital outside the VA to treat his condition and they informed him of the errors made by the prior doctors at the VA.

The problem at the Philadelphia hospital isn't alone. Several other cancer units at VA hospitals in Jackson, Miss., and Cincinnati, Ohio, were also closed, although the problems weren't nearly as widespread as the Philadelphia case.

In fact, none of the errors at this hospital might have been uncovered but for a clerical error where seeds of lower dosage were reported. That resulted in closer scrutiny by the NRC, which governs radiation usage, and the discovery of dozens of cases of improper placement of the seeds used in brachytherapy.

So, while the doctors in this program were contractors operating at the behest of the hospital, the doctrine of respondeat superior is going to hold the hospital liable because of the failure to oversee the program.