I-Team: Patient's Death Raises Questions About Doctor's Care, Medical Board Oversight

BOSTON (CBS) - A patient's death is raising serious questions about the care she received from her doctor, while critics say her story also highlights problems with the medical boards trusted to protect the public.

From the living room of her Seabrook, N.H. home, Elizabeth Marquis recalled the characteristics that defined her daughter, Kelly Deyo.

"She had a heart of gold. She wanted everyone happy. She wanted to be happy," Marquis said.

But Deyo also struggled with an addiction to heroin. To get clean, the mother of two kids moved away from family to receive treatment at a methadone clinic along the Maine coast.

Younger sister Shaylia Marquis remembers getting the agonizing phone call from her mother last April.

"She was just screaming and she said, 'Kelly's gone! Kelly's gone!' I couldn't believe it," Shaylia said.

Police found Deyo dead inside her apartment. The official cause of death was suicide. A medical examiner's report found morphine in her system, and a mix of other medications.

With a handwritten note, police had found Deyo surrounded by 19 empty pill bottles. Those pills had all been prescribed by the same Maine psychiatrist Deyo had just started seeing a month earlier.

The doctor is Reinaldo de los Heros, who runs his practice out of an office building north of Portland.

Pharmacy records Elizabeth shared with the I-Team show the psychiatrist immediately prescribed new medications when he first saw Deyo in March 2015. He also increased the dosage of other pills she had been taking, the records indicate.

"Why would you prescribe so much to someone who had a dependency?" Shaylia asked.

Troubling history of complaints, discipline

The I-Team reviewed a paper trail of troubling medical care connected to Dr. de los Heros.

In 1997, Massachusetts revoked his medical license after he was convicted of felony Medicaid fraud of $240,681.

Disciplinary documents also cited prescribing violations during that time period. According to the records, investigators said de los Heros left pre-signed, blank prescriptions at the front desk of his office for members of his staff to fill out when patients showed up for refills.

De los Heros was also clinically dependent on alcohol and abused other drugs, the documents say. The psychiatrist checked into a Virginia treatment facility and later received therapy and monitoring.

The criminal conviction caused de los Heros to also lose his licenses in New Hampshire and North Carolina.

But the psychiatrist resurfaced in Maine in 2006, receiving approval for a conditional license from the Board of Licensure in Medicine. The consent agreement required him to perform under the supervision of another doctor and submit random alcohol and drug tests.

Three year later, a patient complaint landed him on supervised probation. The Board ordered him to undergo a neuropsychiatric evaluation.

In an attempt to also regain a full, unrestricted Massachusetts license, de los Heros omitted some key details on his application about discipline in other states, an investigation by the Drug Enforcement Administration, and a malpractice insurance surcharge. The Board only reprimanded him.

By this time, de los Heros' disciplinary record caught the attention of the Center for Health Journalism.

"If Dr. Reinaldo de los Heros were a cat, he would have run out of lives," wrote reporter William Heisel. "But, thanks to accommodating medical boards up and down the East Coast, de los Heros has survived and thrived."

In 2012, another doctor filed a complaint about de los Heros' prescribing habits.

Tim Terranova, assistant executive director of the Maine Board of Licensure in Medicine, said there was an outside review by two psychiatrists.

"They agreed there was no evidence of gross deviation from standards of practice, but thought guidance would be beneficial," Terranova told the I-Team.

The letter advised de los Heros to limit the prescribing of multiple medications to patients.

"A failure to heed this guidance might lead to a disciplinary proceeding," the letter warned.

After mother's complaint, Board decides doctor's fate

Elizabeth Marquis could not believe it when she first heard of de los Heros' run-ins with various state medical boards.

"He's been behaving very unprofessionally for a very long time. How he's been getting away with it is beyond me," Elizabeth said. "Why does the board want a doctor that has to be babysat?"

Following her daughter's suicide, Elizabeth submitted a complaint to the Maine Board of Licensure in Medicine, asking how de los Heros was still allowed to practice.

The Board opened an investigation into the circumstances surrounding Deyo's death.

De los Heros was allowed to hire an expert witness, Harrison Pope, Jr. of Harvard Medical School, who wrote that the psychiatrist provided a "superior" level of patient monitoring and also diagnosed an appropriate amount of medications for the diagnosed disorders.

"I cannot find any instances in the record showing that Dr. de los Heros' conduct fell below the threshold," Pope wrote.

The Board disagreed. According to disciplinary documents, board members concluded de los Heros engaged in "unprofessional conduct."

They cited his failure to coordinate care with Deyo's other doctors and sloppy record keeping, making it difficult to determine what kind of treatment the patient had received.

But the Board could not conclusively say the psychiatrist over-prescribed to Deyo. The decision? Six months of supervised probation, a development that floored Deyo's mother.

"What will it take for that doctor to lose his license?" Elizabeth Marquis wondered.

Experts criticize Board's disciplinary decision

Dr. Michael Carome, an expert with Public Citizen's Health Research Group, was critical of the Board's disciplinary decision.

"In my view, a more serious action such as revocation or suspension would have been more appropriate," Carome told the I-Team. "To allow that physician to continue to practice puts patients in danger."

Carome follows the disciplinary actions of medical boards across the country. In the most recent rankings published by Public Citizen, Massachusetts was rated one of the worst states when it comes to imposing serious disciplinary actions against doctors.

Carome said there is a national trend of boards, often comprised of peers in the medical field, going easy on doctors who are the focus of complaints.

"State medical boards too often seem to be acting more in a way that protects physicians who are licensed in the states rather than protecting public health, which should be their primary focus," Carome said.

Terranova said each individual complaint is first assessed to see if it has enough merit to pursue as a disciplinary proceeding. If it meets that threshold, a physician's pattern of misconduct or previous complaints can be factored into a decision.

"There are doctors who receive one complaint and lose their license. Some doctors have multiple complaints and have never been disciplined," Terranova said.

Consumers can do their own homework about doctors, but it isn't an easy task, a topic extensively covered in a recent Consumer Reports article.

Dr. Tejal Gandhi, the president of the National Patient Safety Foundation, said transparency is improving in the medical field. However, it still varies a lot from state to state, making it difficult for consumers to track down a paper trail.

"It's very challenging and I think that's an area where we as a profession have not done as well as we need to," Gandhi said. "We've seen cases where doctors are disciplined in one state and they go to another state. We need to make sure that information flows to protect the safety of patients."

Doctor's response to accusations

De los Heros did not respond to the I-Team's initial requests for an interview about Deyo's death and his disciplinary history.

When the I-Team tried to ask questions outside of his practice, the doctor slammed and locked the door. He later emailed a statement, calling Deyo's death a "tragic loss," while expressing his condolences to her family.

"The Maine Board of Licensure in Medicine investigated the psychiatric treatment I provided this patient and determined I'm fit to continue to provide care to patients," de los Heros' statement said.

Later this fall, the Board will decide if the psychiatrist should remain on supervised probation.

Elizabeth Marquis is not giving up her fight. She is working with an attorney on filing a medical malpractice lawsuit.

"I don't want to see any other mother or family have to go through this," she said.

Ryan Kath can be reached at rkath@cbs.com. You can also follow him on Twitter or connect on Facebook.