Former PCH anesthesiologist found guilty of professional misconduct in 2020 patient death

Dr. Sheshagiri Bengeri arrives for his hearing at P.E.I. College of Physicians and Surgeons on Jan. 30, 2024. (Laura Meader/CBC - image credit)
Dr. Sheshagiri Bengeri arrives for his hearing at P.E.I. College of Physicians and Surgeons on Jan. 30, 2024. (Laura Meader/CBC - image credit)

A Prince Edward Island watchdog agency has found an anesthesiologist who was working temporarily at Prince County Hospital in Summerside guilty of misconduct with regard to a patient who died three years ago.

Dr. Sheshagiri Bengeri had just started working as a locum at PCH in September 2020 when a man he was treating died after an operation.

After 62-year-old Richard Kelly's death, his family lodged a complaint against Bengeri with P.E.I.'s College of Physicians and Surgeons.

The complaint included three allegations: two involving professional misconduct, and one saying he demonstrated a lack of knowledge, skill or judgment.

Five days of hearing were held in late January and early February to look into the allegations.

The recently released decision says Bengeri failed to maintain accepted standards during a procedure. The three-person hearing panel found him guilty on one of the allegations of professional misconduct, and not guilty in connection with the two other allegations.

Kelly was a patient at Prince County Hospital in 2020, undergoing several procedures related to a hernia. After the last one on Sept. 30, he died.

Richard Kelly was 62 when he died in 2020.
Richard Kelly was 62 when he died in 2020.

Richard Kelly was 62 when he died after surgery at Prince County Hospital in 2020. (Submitted by Norma Costain)

Norma Costain, Kelly's common-law partner of 12 years and a former paramedic, lodged the complaint after reading hospital reports on what had happened.

Bengeri was the anesthesiologist during an operation conducted to repair a leak in Kelly's small bowel.

Costain said Kelly was nauseous when she visited with him before the surgery, and witnesses including doctors and nurses involved in the operation testified there was evidence of bile in Kelly's mouth and fluid build-up in his lungs.

Condition deteriorated after surgery

The surgeon, Dr. Lygia Perron, told the panel Kelly aspirated a significant amount of bile in the operating room, meaning it went into his lungs. The surgeon didn't know about the issue until Kelly's condition started declining after the procedure.

Perron said if the anesthesiologist had a suspicion of aspiration, they would typically communicate that issue to the surgeon.

The panel heard that Perron contacted Costain at 3:14 p.m. to inform her that Kelly's surgery had been a success and that she could expect to see him in the intensive-care unit within the hour.

By the time Costain arrived at the hospital, a "considerable number" of medical staff had surrounded Kelly's bedside. A doctor later told Costain that Kelly's condition was deteriorating, with progressive organ failure due to the aspiration.

Kelly died at around 9 p.m. that night.

Patient had 'plethora' of risk factors

Bengeri completed his anesthesiologist training in 1993. He began the locum position at PCH on Sept. 28, 2020, just a few days before Kelly's operation.

When the panel questioned him earlier this year, Bengeri said he had difficulty recalling most of the events of that day, describing it as "extremely challenging, leading to feelings of guilt, anxiety, depression and suicidal thoughts."

He acknowledged he did not tell the surgical team about the presence of bile in Kelly's mouth before he administered the anesthesia.

The panel pointed out that Kelly had a "plethora" of risk factors going into the operation, and said Bengeri should have been aware of the high risk of aspiration.

'Ongoing deviation from the standard of care'

It noted that Bengeri's failure to suction Kelly's airway following the operation "indicated, on the balance of probabilities, a repeated and ongoing deviation from the standard of care during anesthesia administration, constituting marked and repeated instances of neglect."

However, the panel said it was unable to find evidence of wilful negligence or blatant disregard for Kelly's welfare.

There hasn't been a decision about restrictions against Bengeri yet. That's expected in about a month.

CBC News reached out to Bengeri's legal team for comment, but hasn't received a response yet. Health P.E.I. told CBC News Bengeri has not worked in P.E.I. since 2020.