By Harleen Dimopoulos (Sweetheart Harley)
The purpose of this paper is to examine the forensic psychology behind Christopher Duntsch, a doctor who went on a killing spree for three years giving him the notorious name, Dr. Death. This analysis will go into details of Duntsch’s life, what happened that spurred his killing spree, why it took so long to determine his killing patterns and was his sentencing the correct one. Should Duntsch have continued to operate on patients after he had a known drug addiction and forced leave from a medical institute?
Christopher Duntsch was a manipulative and malicious drug addict who wanted to earn a doctor’s salary at all costs, even when that meant putting patients’ lives in danger. He was operating on patients when he knew he shouldn’t, making conscious decisions to forge letters to work at hospitals to get money to fuel his lifestyle of partying and drugs, but also to feed his need for power by killing or maiming his patients.
Duntsch operated in the medical field for three years and left a trail of bodies behind him. From early on in his schooling and residency he was addicted to drugs and was operating on patients after partying all night with his assistant who he became romantically involved with. During his residency he was prohibited from doing operations without supervision and this forced him to have a two-year gap in his medical career, working in research instead of the medical field.
Duntsch worked for several hospitals that saw malpractice, including Baylor Scott & White Medical Center-Plano (Baylor Plano) that had him on staff for two years, including a suspension before bringing him back to work unsupervised during his procedure and surgeries. Baylor Plano never did a thorough check on his records or investigated his background before throwing him into surgeries. They let him have free range of his patients that gave him power and continued his cycle of malpractice, turning his patients into victims.
Most of the hospitals Duntsch worked for had concerns about his practices and let him go without ever filing a report to the National Practitioner Bank that would have opened an investigation into his background and the vast number of deaths in his patients in a small time. This would have taken away his medical license and prevented him from jumping from hospital to hospital and putting an end to his killing spree.
Duntsch lied his way from hospital to hospital with forged reports and patented a duo’s life’s work while purposely spelling their names wrong so he could take credit for it. He forged letters from his time in school to get jobs and hide the fact that he was not allowed to operate alone and never disclosed to any hospital that he was a drug addict and had criminal cases against him in other states.
Underneath his smooth exterior and master’s degree from University of Tennessee Health Center in Memphis Texas (UTHSC), Duntsch was a drug user during his residence that impacted his judgement throughout his time at UTHSC but followed him after into the medical field (Palmer, 2017, para. 2, 4). As per The aftermath of the Christopher Duntsch case (2019) he was not only using drugs but abusing them to the extent that he acknowledged it but he did not seek treatment and despite all the risks, he continued to operate on people (para. 42-43). “While at Plano, Duntsch reportedly used drugs the night before operating on patients. Several patients were severely injured during Duntsch’s surgeries, including Jerry Summers, who was paralyzed” (Anonymous, 2019, p. 2).
Kimberly Morgan, who was originally Duntsch’s assistant quickly became his girlfriend while he worked for St. Jude Children’s Hospital and reported that she had partied with him and watched him do LSD and cocaine right before he would go to work (Godman, 2016, para. 20-21). After Duntsch went to Baylor Plano, Morgan did not follow him, instead she filed a protection order against him before receiving an email from Duntsch stating he was one million dollars in debt (Goodman, 2016, para. 53-54). This email also contained Duntsch saying, “Anyone close to me thinks that I likely am something between god, einstein, and the antichrist. Because how can I do anything I want and cross every discipline boundary like its [sic] a playground and never ever lose” and "I am ready to leave the love and kindness and goodness and patience that I mix with everything else that I am and become a cold blooded killer" (Goodman, 2016, para. 54-55).
Duntsch worked at Baylor Plano, or Baylor Scott & White Medical Center-Plano, for two years and in that time, he had a body count stacking up including a woman Kellie Martin who died after surgery from loss of blood, Jerry Summers who could not move his arms or legs after a procedure by Duntsch, and Floella Brown who has a stroke after a vertebral artery was sliced during a procedure (Goodman, 2016, para. 11).
“There was a dissection of one patient's esophagus, and screws that an indictment labeled "far too long" that caused significant blood loss in another patient. One surgeon described these as "never events." They shouldn't ever happen in someone's entire career. And yet they occurred in Duntsch's operating rooms over a period of just two years” (Goodman. 2016, para. 11).
Duntsch was on a leave of absence during his time of Baylor Plano due to the incidents that occurred, but they never filed a report to the National Practitioner Data Bank, or NPDB, which would have ended his career in the medical field and instead brought him back to work after a period of time with no additional training or supervision (Anonymous, 2019, p. 2).
After earning his medical degree at UTHSC, Duntsch went to the Semmes Murphy Neurological and Spine Clinic, which is part of UTHSC, for his fellowship before running test labs in which he raised millions of grants (Palmer, 2017, para. 2).
“Never was it disclosed that Duntsch had issues with drugs during his training; this fact did not come out until his father testified in court for a different criminal case in another state that his son had drug issues. Rumors circulated of Duntsch's heavy partying before rounds, as well as his drug and alcohol abuse” (Palmer, 2017, para. 5).
Duntsch went to work at Baylor Plano, where patients were either severely injured or died under the care of him, and Baylor Plano never reported their forced temporary leave of absence of Duntsch to the NPDB before reinstating him (Anonymous, 2019, p. 2).
Duntsch resigned from Baylor Plano and went to work at Dallas Medical Center (DMC) without the hospital going through a credential process which led to more deaths and a patient, Mary Efurd, having spinal fusion hardware placed in her back (Anonymous, 2019, p. 2). After Dr, Robert Henderson investigated the pain Efurd was having after her surgery, he saw on a cat scan (CT) the hardware sitting in the soft tissue of her back, a nerve root had altogether been amputated, and a screw had been drilled into the base of her spine, where it was not supposed to be, which led to Duntsch being removed from the facility (Goodman, 2016, para. 56).
Henderson started to reach out to other sources that Duntsch had worked for and called Baylor Plano with the information he had on Duntsch’s trail of blood, but Baylor Plano kept him on staff off reports from his residency that he used to get hired (Goodman, 2016, para. 58). Duntsch continued to work not only at Baylor Plano, but with several other physicians and it was not until 2013 that the Texas Medical Board suspended his license (Anonymous, 2019, p. 3).
Liar and Thief
Duntsch started working with a pair of scientists, Valery Kikekov and Tatyana Ignatova, who had spent their life’s work researching brain tumors and stem cell research which was being presented as a new development in cancer drugs (Goodman, 2016, para. 16). Duntsch was focused on money instead of the inventions, but he filed each discovery as a patient with all three names on them with Kikekov and Ignatova’s names being misspelled, and Duntsch took the credit for all new discoveries (Goodman, 2016, para. 17-18). “"It wasn't his invention," Kukekov says. "It was the invention of me and my wife, because we made all primary experiments. We discovered it"” (Goodman, 2016, para. 18).
“He always had a plan, always had a pitch, always had a way to fix you. His fellow neurosurgeons found him to be fast-talking and cocksure, a bit of a loner. And yet nearly all who met him said they liked him immediately” (Goodman, 2016, para. 5).
At one point Baylor Plano contacted the University of Tennessee about Duntsch’s recommendation, and everything that was written about him in that letter turned out to be forged and false, and Duntsch has his rights taken away to perform any surgery alone in training. Due to Baylor Plano not thoroughly looking into Duntsch’s background such as addressing the long gap he had in clinical activity and their lack of supervision, it was the perfect slaughtering ground for Duntsch to go around unobserved at his free will to do whatever he wanted (Anonymous, 2019, p. 3).
Mistakes are made every day, no one person is perfect and all it takes is the wrong day and the wrong people to be plastered across every news outlet there is. This is what happened to Dr. Christopher Duntsch. After working his way up through a medical degree, he made a few mistakes which happens to everyone, including doctors, and because of this he was sent to life in prison.
Duntsch knew surgery and operation protocol, and had every patient fill out consent forms along with explaining in detail what the procedure would entail, including the risks. The patients he operated on knew here may be adverse outcomes, as there is with any surgery, and they trusted Duntsch as a doctor to perform their surgeries.
While Duntsch was sent out on a leave from Baylor Plano he was never assisted in anyway if the hospital thought he needed mental help, and he was brought back to work soon after. There are numerous doctors who worked with him and they all testified he was perfectly fine during surgeries, focused, and doing his job.
Duntsch showed compassion for patients that were in pain by trying to help them. In the case of Efurd, she said she was in pain after a procedure, so Duntsch went out of his way to personally schedule another appointment and surgery for her to find out what was causing her pain. Over the years he had the same patients come back to him regardless of what hospital he worked at because they trusted him from prior surgeries, he had done on them.
Duntsch found himself in the wrong place, on the wrong day, and facing an unfair and unjust trial. The state presented images of surgeries, playing at the jury’s emotions instead of giving the facts. Duntsch had doctors, assistants, and other people who worked with him all testify that he operated to the best of his ability with no malicious intent and the state used this case as a door to start questioning every mistake any doctor has ever made.
Before any surgery takes place, the individual must sign a consent form that includes there may be adverse outcomes, and prior to Duntsch performing surgery on Efrud, she signed the consent form that agreed to insert a form of hardware as well as fuse two of her vertebrae to relieve her backpain (Duntsch v. State, 2018, p. 199-201).
“Raji Kumar testified she was the CEO of DMC at the time of Efurd's second surgery by appellant described above. Kumar stated she received appellant's name "through somebody in town" and contacted him because "[w]e were looking for spine surgeons." She met with appellant and "was so happy to see that a surgeon was so put together and cared so much about his patients" (Duntsch v. State, 2018, p. 202).
Duntsch was targeted during his trial and the state failed to provide any evidence of his mental state within the time that he was operating in a single surgery (Duntsch v. State, 2018, p. 221). As per Impaired Healthcare Workers Threaten Safety, But Also Need Support (2021), it is a necessity that a hospital organization have guidelines for impaired individuals working in their facilities, and a ser of guides even if the hospital thinks someone is an impaired worker, whether that be mental or physical, and they are to provide help for them through rehabilitation programs, physician health program, or wellness committee to help them before returning to work (para. 1-8). When Duntsch was placed on a leave from Baylor Plano, he did not receive any kind of help if they thought he was a risk, ad they also did not report it to the National Practitioner Data Bank to put it on the record that he was a harm (Anonymous, 2019, p. 2).
Concern for Patient
During the court testimony, there was a weight on the fact that Duntsch cared about his patients because after the surgery with Efrud, he performed another surgery to try and correct any mishaps the first time and find what the cause of her pain was, showing that he has concern for the pain she was in (Duntsch v. State, 2018, p. 218). Dr. Carlos Bagley testified that adverse outcomes have happened to other surgeons before, and well it is rare, it does happen and an inexperience surgeon in a chaotic operating room may impact the outcome of a surgery (Duntsch v. State, 2018, p. 218).
Duntsch was given an unfair trial since there is no significant evidence that his intention was to harm Efurd in anyway and Henderson testified that Duntsch did not know it would or could cause bodily harm (Duntsch v. State, 2018, p. 217).
“The effect was that the prosecutor stressed evidence that was irrelevant and inadmissible pursuant to Rule 404(b) in order to scare and browbeat the jury into finding a culpable mental state for the charged offense where no evidence of one existed, or for the extraneous offenses, for that matter” (Duntsch v. State, 2018, p. 221).
Duntsch’s trial could open the door for lawyers and prosecutors to start looking into every doctor or surgeons who have done their job and at times lost a life while performing surgeries or procedures to save lives (Duntsch v. State, 2018, p. 221).
Prior to researching Dr. Christopher Duntsch, I had mental expectations on both sides of the argument; he’s a psychopathic doctor who set out to kill or he is a man doing his job that made one too many mistakes. What I found was much deeper with endless turns that could justify that he is a murderous psychopath or that he was a doctor just trying to do his best. I found the arguments that ended up convicting him as a felon overwhelming due to the massive amounts of evidence against him.
He is a multilayered individual with psychopathic tendencies and manipulative to the point that he knew he was operating on patients while on drugs and none of the other surgeons in the room ever testified that he wasn’t doing everything he could to help the patients, so yes, I do think he was on drugs while operating on patients. The question of should he have ever been allowed to operate, no, I can confidently say he should not have been allowed to operate on any patient due to the proof of emails he sent his ex-girlfriend saying he was going to be a killer and accompanied by reports of him not being allowed to operate on his own.
Reading through the court reports and appeals I second guessed it, maybe they got it wrong, but no, they did not. The proof presented in court and his long record of malpractice that hospitals either terminated him for or swept under the rug, I can say yes, he knew exactly what he was doing and how he was manipulating the system. Can a hospital be responsible for a crime? Yes, the hospitals are also at fault in this case for never reporting him to have his license taken away, it could have happened as early as his time in residency, and it was continuously bypassed, and because of the ignorance that every hospital Duntsch worked at, many lives were lost.
Dr Christopher Duntsch worked his way up through medical school for years and completed his PhD to be able to work researcher before going on to work in the field as a doctor, but behind his friendly and caring façade there was a malicious and manipulative psychopath using anyone, and anything to get what he wanted. Duntsch manipulated everyone he ever met, with a caring and convincing smile only to use them as bait to patent researchers’ life work and claim it as his own, falsify documents for jobs, plead not guilty in front of a jury knowing what he had done, and left a trail of maimed and dead patients behind as he flew under the radar, never being reported for his malpractice. Duntsch used his nine lives and flew too close to the sun by operating on patients that became victims while he was on drugs, and within three years of him getting his medical license it was taken away. Duntsch should have neve been operating on patients, and because hospital after hospital let him, too many patients ended up buried.
Anonymous, (2019). Reflecting on the Christopher Duntsch case, three years later. Medical Staff Briefing, 29(3), 1-5. http://library.esc.edu/login?url=https://www.proquest.com/trade- journals/reflecting-on-christopher-duntsch-case-three/docview/2196477354/se-2?accountid=8067
Duntsch v. State, 568 SW 3d 193 https://scholar.google.com/198–241 (Tex: Court of Appeals, 5th Dist. December 10, 2018). Retrieved from https://scholar.google.com/scholar_case?case=83231292193292867&hl=en&as_sdt=6,33.
Goodman, M. (2016). THE CHARMING DR. DUNTSCH. D - Dallas/Fort Worth, 43, 69- 73,142,144. http://library.esc.edu/login?url=https://www.proquest.com/magazines/charming-dr- duntsch/docview/1836566560/se-2?accountid=8067
Impaired healthcare workers threaten safety, but also need support. (2021). Healthcare Risk Management, 43(9) http://library.esc.edu/login?url=https://www.proquest.com/trade- journals/impaired-healthcare-workers-threaten-safety-also/docview/2564808924/se- 2?accountid=8067
Palmer, M., (2017). Christopher Duntsch: Profile of a 21st century Swango. In Credentialing Resource Center Journal (Vol. 26, Issue 11, pp. 14–17). HCPro, Inc.
The aftermath of the Christopher Duntsch case. (2019, April). Medical Staff Briefing, 29(4). https://link.gale.com/apps/doc/A583176982/AONE?u=esc&sid=bookmark-AONE&xid=2db13f7b