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OHSU initially linked wrong oral surgeon to patient's death. He blew the whistle and was placed on leave.

CONTRIBUTED PHOTO - David Lambert has since moved to North Carolina after the experience that could have ended his career at OHSU.When it came, the information that changed David Lambert's life was delivered in an almost casual tone.

A patient at Lambert's workplace, Oregon Health & Science University's oral surgery clinic, was near death. Standing in the clinic two days after the surgery, Lambert's boss, Pamela Hughes, told the assistant professor of oral surgery that he'd be listed as the attending physician — responsible, in other words.

A patient's death is always disturbing, but in this case Lambert was particularly troubled. That's because Lambert had not performed, supervised or played any other role in the surgery on 52-year-old Larry Dean Black, who died on Oct 22, 2015 after being sent home from surgery at OHSU.

"I never saw him. I never evaluated him," says Lambert. "I had absolutely nothing to do with this guy's treatment."

The Oregon Board of Dentistry eventually agreed with Lambert and instead took enforcement action against his boss, Hughes.

Lambert says his refusal to take the fall for his department chair is why he is no longer at OHSU.

"They were trying to hang this on me," Lambert says. "They tried everything they could."

Lambert said he's come forward because the public and Black's family "deserved to know the truth," including that Black didn't need to die.

Hughes, who declined to be interviewed, still remains at OHSU, overseeing students as chair of the oral surgery department, even as she decides whether to fight the dental board's findings.

After mostly declining to comment for a Portland Tribune story published last week, OHSU released a fuller statement:

"While federal patient privacy laws prevent us from discussing protected health information, we are fully confident that the appropriate actions were taken in this case. Any allegation that OHSU concealed or misrepresented information is completely unfounded."

Black's case is relevant now because, alerted by Lambert, lawyers for the dead man's sister are suing OHSU as well as Hughes and Philipp Kupfer, the surgeon-in-training who was on duty that day.

Click here to read the federal lawsuit against OHSU.

Black's death also raises larger questions about how OHSU supervises trainees, tracks internal records and handles a vulnerable group of patients — those with failing livers.

Black was one of them. His liver had problems producing the clotting agents the body relies on to cause scabs and stop bleeding. Removal of his infected teeth was a necessary precondition to getting a much-needed liver transplant.

However, OHSU chose to pull 12 teeth at once, watched him for just an hour, and then allowed Black's brother-in-law to take him on the three-and-a-half hour car trip home to Bend.

Bleeing risk

That series of decisions may have led to Black's death, judging by interviews with several doctors experienced with liver patients and oral surgery, including two who published peer-reviewed research on the subject.

They previously told the Portland Tribune that in such a case, they would have hospitalized the patient overnight or removed only a couple of teeth at first to see if his blood clotted normally.

The pre-surgery test results indicated red flags that were "clear," said Skagit Valley Hospital hematologist Bruce Mathey.

In January 2017, after investigating the matter, the Oregon Board of Dentistry issued a proposed consent decree against Hughes saying her treatment plan of Black constituted unacceptable patient care. It said Hughes' plan did not address liver disease complications such as "life threatening bleeding," and did not include "hospitalization or close follow-up" after surgery.

Here is the dental board's proposed consent decree regarding Hughes.

OHSU told the Tribune that Hughes, Kupfer and Phil Marucha, dentistry dean, had no comment.

Long career

Lambert was a pharmacist before enrolling in dental school and later becoming an oral surgeon, teaching at a dental school in Chapel Hill, North Carolina. He joined OHSU in 2014.

"He's just a brilliant surgeon," said Shannon Schulte, a former oral surgery assistant at OHSU who worked frequently with Lambert. "He's wonderful to work with."

But a tense working relationship developed between Lambert and Hughes, Schulte said.

"You could just tell when she didn't like somebody,' she said. "I think it's because he had certain standards and questioned things."

On Oct. 20, 2015, Hughes was set to be the attending physician while a beginning surgeon, or resident, performed the surgery on Black. Hughes had met with Black months before the surgery and later helped prepare the treatment plan.

But new lab tests to check on Black's blood took longer than expected. Hughes had her resident call Lambert, who was due at the clinic at 1 p.m., to ask if Kupfer, the afternoon resident, could take on the surgery. Hughes then texted Lambert to confirm it.

After the test results came back at 11:47 a.m., Hughes and Kupfer decided to proceed with surgery.

This is why, two days afterward, Lambert was shocked when Hughes told him he was being listed as the attending physician.

He had been scheduled to be "the attending" physician starting at 1 p.m. But that didn't mean responsibility for Black transferred to him.COURTESY OF LENORA HOUSER - Larry Dean Black was 52 when he reported to OHSU to get teeth extracted. He was sent home to Bend where he bled to death, leading to two lawsuits and a dental board finding that a high-ranking OHSU oral surgeon violated standards by failing to plan for bleeding.

In fact, Lambert's first and only encounter with Black was walking into the clinic when the surgery was almost done.

Lambert says by telling him he'd be listed as responsible for the surgery, Hughes was putting him in line for any dental board discipline. It was, he says, like saying, "Just a heads-up that I'm throwing you under the bus."

On Nov. 6, 2015, Lambert received word from the Oregon Board of Dentistry confirming his worst fears.

"Dear Dr. Lambert," the letter began. "We understand that you were supervising ... during the treatment of Larry Dean Black."

If Lambert could not clear his name, the investigation threatened to push him from his chosen calling.

"I knew that the outcome of this was going to be bad," he said. "I was 58. This could be a career ending thing for me."

As he researched the case, he was surprised to find that the anesthesia record initially said the surgery began at 12:45 p.m., supporting his story — only to have that time scribbled out and replaced with 1:45 p.m., after his shift started.

Still, he says, the university didn't back him up, and the dean, Marucha, rejected Lambert's pleas to intervene. Kupfer, the resident who performed the surgery, characterized Lambert as his attending physician on the case to the board.

Lambert notes that he and Kupfer initially shared the same lawyer, paid by OHSU. He feels that the university's legal office had decided to defend Hughes, but considered him expendable.

Hughes, in her initial Oct. 30, 2015 statement to the board, did not acknowledge her presence in the clinic while the surgery took place. "I was not scheduled to be in the clinic that afternoon," she wrote.

On Nov. 11 she sent "clarification" that she was "peripherally present" but not in the operating room supervising.

On Dec. 17, asked for further clarification, she claimed Lambert was Kupfer's supervisor for Black's surgery.

"She lied," Lambert says. "It was her word against my word, and she was definitely going to win."

Five weeks later, that changed.

On Jan. 24, 2016, Lambert's claim that he wasn't present for the surgery was verified by an unexpected source.

Searching on the internet, Lambert learned that the GPS function of his Android phone tracks his whereabouts.

It showed he did not arrive at OHSU's clinic building until 1:12 p.m. on the day of Black's surgery, supporting his claim that he didn't walk into the clinic until about 1:20 p.m.

Echoing the scribbled-out notation on the anesthesia record, the GPS data backed up his account that it was Hughes, not he, who was responsible for Black's surgery.

He shared the evidence with the dental board investigator, whose focus turned to Hughes.

Still, Lambert's defiant emails to Marucha, the dental school dean, and continuing tension with Hughes led to Lambert being placed on leave. He gave 90-days' notice. The university responded that he didn't need to wait.

For Lambert, now back in North Carolina, the story is a cautionary tale about the hazards of office politics in medical school.

But his main concerns are OHSU's failure to treat Black with adequate precautions, and what he views as the university's efforts to avoid accountability while protecting higher-ups.

"At the end of the day, this guy did not have to die."

Read part one of Lambert's fight by clicking here

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