By Tom Kisken, VENTURA COUNTY STAR
Judy Gorcey wants change.
Her 36-year-old daughter, Megan Espinoza, died after her heart stopped during breast implant surgery four years ago. Prosecutors charged San Diego-area plastic surgeon Dr. Carlos Chacon with second-degree murder earlier this month in addition to charges including involuntary manslaughter filed in December 2021. They said the doctor waited about three hours after starting CPR to call 911, ordered other employees not to make the call and instead tried to resuscitate her without the help of paramedics.
Heather Lang Vass, a nurse who administered anesthesia, is charged with involuntary manslaughter. She and Chacon have pleaded not guilty. The doctor, released on $500,000 bail, awaits a June preliminary hearing.
Gorcey, 73, of Oxnard, wants her daughter back more than anything. Because that can’t happen, she’s fighting for reform that would compel doctors to inform patients of criminal accusations they face.
The retired elementary school teacher also wants more transparency and quicker investigations from the Medical Board of California, the state agency that regulates doctors. The board turned over its investigation of Chacon to criminal prosecutors close to three years after Espinoza died.
Gorcey, her husband, David Gorcey, and their son-in-law, Moises Espinoza, also of Oxnard, contend the changes could help keep others from what they have lived through for more than four years.
“It’s the worst pain anyone could know,” Gorcey said. “How could she go in for a common simple procedure and never come out?”
‘I never got that call’
Espinoza grew up in Oxnard in a house now filled with her photos. She met Moises Espinoza when they were both students at Oxnard High School on a blind prom date set up by a friend. They married after she graduated from CSU San Marcos and raised their two boys, now ages 6 and 10, in Chula Vista.
She was a kindergarten teacher and a born organizer who put together reunion getaways for her and college friends. Her mother said she was kind, loving and “feisty” at times.
“She was a great daughter,” Gorcey said.
Espinoza wanted breast augmentation surgery. She told her mother she researched available doctors, selecting Chacon who operated Divino Plastic Surgery in Bonita. The center’s website calls the doctor one of the industry’s best-trained cosmetic surgeons, citing his time as chief resident in a plastic surgery program at UC San Francisco and also his completion of an advanced fellowship training program at USC.
The website also notes Chacon was a plastic surgeon for the ABC series, “Extreme Makeover: Weight Loss Edition.”
The doctor and his attorneys did not return messages.
Megan Espinoza went in for surgery on Dec. 19, 2018. Chacon opted not to use an anesthesiologist. Instead, his nurse, Vass, administered a cocktail of drugs, including fentanyl, intended to keep the patient sedated but still able to respond. San Diego County prosecutors also charged the nurse with a felony because she was not certified for anesthesiology.
Espinoza’s heart stopped about two hours into the operation, the Medical Board investigation said. Chacon performed chest compressions and the heart resumed, but Espinoza was unconscious and not breathing on her own, investigators said.
Prosecutors alleged three hours passed before 911 was called, as Chacon and his staff tried to resuscitate the patient. He ordered nine doses of Narcan, a drug typically employed to revive people who have overdosed on opioids, according to Medical Board records.
Chacon called two anesthesiologists for consultations but is accused of not telling them Espinoza’s true condition, court records indicate. Members of his staff wanted to call 911 but were afraid to defy the doctor’s orders, an arrest warrant declaration alleged. The statement from the San Diego County District Attorney’s Office also alleged the doctor continued to see other patients while his staff cared for Espinoza.
Moises Espinoza said he called the doctor’s office twice and was told his wife was still in surgery and that he would be called when it was time to pick her up.
“I never got that call,” he said. Instead, the office called to tell him his wife had been taken by ambulance to Scripps Mercy Hospital. There, she was placed on a ventilator, prosecutors said. She never gained consciousness.
In a story in the Times of San Diego, one of Chacon’s attorneys, David Rosenberg, said the doctor did not immediately call 911 because Espinoza’s oxygen levels and pulse were within normal limits.
“To say that he ignored this patient and had no concern for her defies the medical records,” he said.
Judy and David Gorcey learned of their daughter’s condition in a phone call from their son-in-law. They left their home at 3 a.m. and drove to Chula Vista where Espinoza lay in a hospital bed, her head covered in bandages, tubes connected to her everywhere. She had low levels of oxygen in her blood and excess fluid in her lungs, according to Medical Board documents.
She was transferred again to UC San Diego Medical Center, where she spent more than a month.
“They told us she probably would never wake up,” Judy Gorcey said. The chances of regaining consciousness were placed at less than 1%. The family chose to have her removed from the ventilator and placed in palliative care.
She died in the hospital on Jan. 28, 2019.
“That started our life sentence of difficulty and pain,” Gorcey said.
Board accuses Chacon of violations
Chacon’s care was reported to the Medical Board on Dec. 28, 2018, by the paramedics who took her from the surgery center to the hospital, according to an arrest warrant declaration from the district attorney’s Office. Close to three years later, the board accused Chacon of violations, including gross negligence and incompetence. Investigators alleged he aided in the unlicensed practice of medicine by allowing Vass to select drugs for sedation and using medical assistants to administer other intravenous medications.
A hearing is set for August. Discipline could include the revocation or suspension of Chacon’s license.
The disciplinary process takes far too long, said Carmen Balber, executive director of Consumer Watchdog, an advocacy group working with the Gorcey family.
“The medical board needs to investigate and charge doctors more quickly in order to protect patients,” she said.
Carlos Villatoro, spokesman for the medical board, said he can’t comment on the case because it’s still active. He also declined comment on proposed reform but noted the medical board submitted a report to the state Legislature on its performance and needs.
Prosecutors filed manslaughter charges in December 2021. They accused the doctor of murder earlier this month, alleging in an arrest warrant declaration he acted with “conscious disregard for human life.”
Marc Carlos, an attorney for Chacon, did not respond to repeated requests for comments but in earlier stories said nothing in the case had changed and asserted the murder charge is not justified.
“I’ve never seen anything like this, and I really think that doctors out there should be concerned because if something bad happens, this is what’s happening to them next,” Carlos told the Times of San Diego.”
Following the manslaughter charge, a San Diego County Superior Court judge said Chacon can not perform surgery unless he uses a physician licensed as an anesthesiologist or a certified registered nurse anesthetist permitted to work without supervision. After the murder charge, a judge ordered Chacon to tell surgical patients about the charges he faces.
At the preliminary hearing, a ruling could also come on a motion to suspend Chacon’s license.
Gorcey said the restrictions don’t go far enough. She wants regulations that automatically prohibit doctors from practice when they face criminal charges but conceded such a law is unlikely. More importantly, she said, accused doctors should have to notify all patients of any charges.
Balber said more transparency would help consumers protect themselves when making medical choices.
“So many people were harmed by this doctor when they didn’t need to be,” Balber said.
Two patients filed malpractice lawsuits against Chacon in 2022 in San Diego County Superior Court. Balber, who said other patients have contacted her group with complaints against Chacon, said the alleged harm could possibly have been stopped if people knew Espinoza’s story.
“Patients need greater information about their doctors histories,” she said.
‘It wasn’t just her life’
Judy Gorcey has told her daughter’s story at a Medical Board meeting. So has her son, David Gorcey Jr., and her son-in-law, Moises Espinoza. Gorcey has also testified before the state Senate Business, Professions and Economic Development Committee that is part of a required sunset review process needed to keep the regulatory agency operating.
On Monday, the committee approved a bill that would continue the board’s operations to 2028 and increase a financially strapped budget, theoretically expanding the board’s ability to investigate alleged violations. The board would also be expanded so a majority of its members would not be doctors. The standard of proof required to discipline doctors in some cases would be reduced.
The proposal would not compel physicians to notify patients of criminal accusations. It now advances to the Senate Appropriations Committee.
Gorcey wants more information provided to families and other patients. She wants more restrictions on accused doctors. Mostly, she wants to be convinced the regulatory system is dedicated wholly to protect patients.
“I’m not 100% sure that’s the case,” she said.
Moises Espinoza moved back to Oxnard after his wife died. He said the boys needed to be closer to their grandparents.
Sitting in his in-laws’ living room, his sons playing upstairs, his eyes teared when he tried to explain what the death meant to his family.
“It wasn’t just her life; it was my life,” he said. “A big part of my life was taken away.”
He’s not alone. High school senior photographs of Megan Espinoza and her brother, David, hang on a wall in their parents’ bedroom. At the night, shafts of moonlight illuminate Megan’s image. It’s the last thing her father, David Gorcey, sees before he falls asleep.
He talks to her too on the daily walks he likes to take alone. Sometimes, the picture and the conversations, bring back happy memories. Often they make him think of what happened.
“I think of the loss,” he said.