SUMMARY OF ARIZONA MEDICAL BOARDS ACTION ON DR OGBONNAYA Preamble: Dr Ogbonnaya was arrested and initially charged with 15 sex

felonies on 9 women by the Mesa Police Department. Charges were subsequently re-packaged by the Maricopa County Attorney as 13 sex felonies. State of Arizona dropped one of the charges just before trial in January 2013! The verdict is in: Dr Ogbonnaya has been acquitted on ALL counts on 02/27/2013! This is a summary of the process by which the Arizona Medical Board revoked Dr Ogbonnayas medical license. The timeline of events is on the last page. The Boards Findings of Fact, Conclusions of Law and Order (Revocation Order) makes allegations of quality of care violations, allegations of sexual misconduct, and allegation of failure to do a psychosexual evaluation. ALL the alleged victims in the Medical Boards case were referred to them by the arresting police officer, Detective Laurie Kessler of Mesa Police Department OAH 129:7-11. Detective Kessler also worked with the Medical Board to build their case against Dr Ogbonnaya OAH 763:19-765:8. The Medical Boards investigative staff interviewed all but one of the women only telephonically. The Medical Board did not interview any of Dr Ogbonnayas staff OAH 142:15-143:18 or nonvictim witnesses as part of their investigation. They did not have the patients medical records OAH 453:25-454:20, transcripts, or DVDs of their police interviews OAH 132:7-13, and they did not follow-up on any collateral evidence NOT EVEN an office security video recording which showed the initial alleged victim, Patient AT, during the visit she claims she was abused by Dr Ogbonnaya. Dr Coffer, the Medical Boards consultant in the investigation, testified that she did not make any conclusions that any of the allegations against Dr Ogbonnayas conduct was true OAH 498:17-23. Ms Lisa Wynn, the Boards Executive Director testified that the Medical Board did not determine that the allegations were truthful prior to the Boards summary action meeting on June 30, 2010 when they suspended Dr Ogbonnayas license OAH 1065:19-1066:3 and at the time of the revocation hearing. The Medical Board acted solely on the potential of the allegations for harm to the public OAH 1066:4-9 The Executive Director also testified that absent the sexual allegations the Board would not have ordered the psychosexual evaluation OAH 1061:11-13 and that the Board would not have brought the alleged standard of care deviations for revocation hearings OAH 1060:17-25. Summary of Alleged Standard of Care Deviations: 1. Prescription Ibuprofen to Patient MAG: The Medical Board alleges that: On June 4, 2007, Patient MAG presented with severe symptoms of gastroesophageal reflux disease (GERD)... There is no indication that Respondent instructed Patient MAG to discontinue that medication in light of the GERD symptoms Medical Record shows that on June 4, 2007, MAG presented with acute lymphadenitis, not GERD. Ibuprofen 600mg PO tid #30 (a 10-day supply) was prescribed. Her only other Ibuprofen prescription for her entire tenure in the practice was another Ibuprofen 600mg PO tid #30 prescribed February 20, 2007. Dr Ogbonnaya was charged with a violation of quality of care standards in this instant because the Boards expert, Dr Coffer, opined that Ibuprofen 600mg PO tid #30 would last for 30-DAYS, instead of 10-days OAH 572:6-19. She assumed that MAG was still on her 24th day of the Ibuprofen prescription

when she presented with epigastric burning on June 28, 2007! Dr Coffer admitted her mistakes and testified that the Ibuprofen prescribed on June 4th 2007 lasted till June 14th 2007 OAH 575:16-20. Patient MAG remained Dr Ogbonnayas patient for 3 years afterwards and NEVER suffered any consequence from the said Ibuprofen prescription. The Boards Executive Director could not recall any other case in which the Board has revoked the license of a physician based on potential harm to one patient involving a standard dose of ibuprofen OAH 1045:6-10. 2. Dispensing/prescription of controlled substance to AT: The Board alleges that Dr Ogbonnaya interfered with Patient ATs on-going treatment for addiction by prescribing controlled substances, specifically Librium, Suboxone and xanax, to Patient AT without coordinating with the physicians treating her addiction. This charge was based on an opinion rendered by Dr Peairs, the Boards expert on Patient AT. Patient AT was a candidate in the Nursing Boards CANDO program. Dr Peairs testified she does not know anything about the CANDO program OAH 382:25-383:1;407:7. She did not know how CANDO participants and their prescribing physicians relate with the Nursing Board OAH 382:16-24, and she was not aware that CANDO is a monitoring and NOT a treatment program as she had suggested in her expert report OAH 383:2-12. After review of ATs controlled substance prescription database report, she withdrew her previous opinion: Q. Now does that address your concern that he [Dr Ogbonnaya] disbursed or prescribed controlled substances, Suboxone, Librium and Xanax, to a person actively undergoing treatment for chemical dependence? A. Yes. OAH 411:5-9 3. Increase in dose of narcotics for KH: The Board alleges that Dr Ogbonnaya deviated from the standard of care by increasing Patient KHs narcotics dose at her request, after having previously developed a treatment plan to wean Patient KH off narcotics and that Patient KH could have suffered harm due to the potential for narcotic and anxiolytic misuse and abuse. Dr Coffer did not consult any standard of care guideline in forming this expert opinion; not even the Arizona Medical Boards Guidelines for Opioid Addiction Treatment OAH 462:16-22. Section II of the Arizona Medical Boards Guidelines for Treatment of Chronic Pain states that, treatment planning should be tailored to both the individual and the presenting problem. At no place does the Guidelines indicate that it is a deviation from the standard of care to increase the dose of a patients narcotics after having previously developed a treatment plan to wean the patient off the medication. This is the summary of Dr Coffers testimony on this subject at the OAH: Q. Specifically, when patient KH came in, in January of 2010, she is reporting increasing pain because of aggravation of her back problem during the holidays. And Dr. Ogbonnaya examines her. And she asks for additional medicine. He prescribes the additional medicine. Under those circumstances, that wasn't below the standard of care, was it? A. No, ma'am. OAH 547:19-548:1 4. Inadequate Medical Records: The Board summarized the standards expected of a physicians medical record in Findings of Fact #66 of their Revocation Order. Dr Coffer served as the Boards expert on this matter. Her testimony at the OAH is summarized as follows: That all the medical records she reviewed met the standards outlined in the Findings of Fact #66 OAH 590:11-591:22. That her findings of some repetitions of physical findings and incompletely edited medication list is a known disadvantage of electronic medical records OAH 504:12-25, was not unique to Dr Ogbonnaya OAH 505:1-5, and she did not cite it as a deviation from standard of care OAH 504:12-23; 592:2-21.

That the Board enjoins their reviewers to cite medical record deviations as aggravating factors, and not standard of care violations OAH 592:11-21. That the Board typically relies on her findings and recommendations as the primary document in reaching decisions regarding alleged standard of care deviations and aggravating factors OAH 509:1-5. That she did not recommend any disciplinary action against Dr Ogbonnaya to the Board or executive staff based on her standard of care review OAH 506:5-11. That she has not given any information about her quality of care review to any of the Board members OAH 453:4-7. That she would not have recommended suspension or revocation of Dr Ogbonnayas license based on her findings of alleged deviations in standard of care or aggravating factors OAH 505:6-506:4 That there has never been a case where a physicians license was suspended or revoked based on the standard of care deviations and aggravating factors she found in her review of this case OAH 506:23-507:1; 592:22-593:3

Date 06/09/2010 06/10/2010 06/15/2010

06/25/2010 06/30/2010

07/14/2010 08/03/2010 08/17/2010 10/28/2010 01/05/2011 03/04/2011 Aug. 2-5; Sep. 1-2, 2011 February 2012 Notes: 1.

TIMELINE OF MAJOR MEDICAL BOARD EVENTS Event 1st Arrest of Dr Ogbonnaya by Detective Kessler of Mesa Police Department Medical Board calls Dr Ogbonnayas cell phone demanding he surrenders his license and e-mails him a Consent Agreement to surrender his license by 10am 06/11/2010. 11:30am: Dr Ogbonnaya interviews with Medical Boards investigative staff 4pm: Emergency Board Meeting; They impose practice restrictions on Dr Ogbonnaya; Staff never gave Dr Ogbonnayas written response or investigational interview report to the Board! OAH 1066:11-1067:5 2nd Arrest of Dr Ogbonnaya by Detective Kessler Medical Board pushes a second Consent Agreement on Dr Ogbonnaya to surrender his license. He declines AMB summarily suspends his license, orders him to go out-of-state for psychosexual evaluation (PSE); Dr Ogbonnayas counsel notifies Board that Dr Ogbonnaya cannot go out-of-state because of his release conditions Arraignment Hearing: Court affirms existing release conditions so Dr Ogbonnaya still could not leave Arizona Board charges Dr Ogbonnaya with failure to do psychosexual evaluation Dr Ogbonnayas counsel advises Board that Dr Ogbonnaya still cannot leave AZ because of his release conditions SIRC Committee recommends that Dr Ogbonnayas failure to do PSE be referred to Office of Administrative Hearings (OAH) Medical Board pushes the 3rd Consent Agreement on Dr Ogbonnaya to surrender his license otherwise the Board will refer his case for revocation hearing in March 2012 Criminal Case remanded to Grand Jury; Medical Board backs off for a while Revocation Hearing at the OAH Administrative Law Judge upholds the Medical Boards complaints in its entirety including charges the Board withdrew or modified during the course of the OAH hearings! Medical Board adopts the ALJs Order as the Revocation Order with only slight modifications

2.

3.

PSE: psychosexual evaluation; OAH: Office of Administrative Hearings; ALJ: Administrative Law Judge The transcript of the Boards Executive Directors testimony at the OAH is a public document. You will be provided a copy if you need it. The rest of the referenced OAH transcripts are currently designated Non-Public. You will be provided copies of those for non-public viewing if necessary. Please follow us on Facebook: @Gabriel Ogbonnaya and Twitter: @OgbonnayaMD