Doctor Garcia Choapoco testifies on monitoring failures during patient sedation

The Medical Board of California convened on May 14, 2025, to address critical issues surrounding patient safety and procedural oversight in a recent case involving Dr. Rowena Garcia Chiuapoco. The panel focused on inconsistencies in the monitoring of a patient’s oxygen saturation levels during a medical procedure, raising serious concerns about the responsibilities of both the physician and nursing staff.

During the meeting, Mr. Rosley, an expert witness, highlighted the troubling notion that a patient could experience dangerously low oxygen levels without proper documentation or timely intervention. He emphasized that it is "inconceivable" for such a situation to occur without corrective action being taken. This statement underscored the gravity of the case and the potential implications for patient safety protocols.

Dr. Chiuapoco, who was present to answer questions, did not provide an affirmative statement but was placed under oath to ensure the accuracy of her responses. Panel members, including Dr. Tsai and Dr. Heltzer, raised pointed questions regarding the monitoring equipment and the lack of alarms during the procedure. Dr. Chiuapoco explained that if the pulse oximeter was not functioning correctly, it could lead to gaps in vital sign readings. However, she acknowledged the expectation that nursing staff should alert her to any concerning changes in the patient's condition.

The discussion revealed a significant concern regarding the operational status of alarm systems in the medical facility. Dr. Heltzer questioned whether alarms were routinely disabled or set to a low volume, which could prevent timely alerts during critical situations. Dr. Chiuapoco stated that the responsibility for monitoring alarms lies with the nursing staff, indicating a potential breakdown in communication and oversight.

The meeting concluded without a definitive resolution, but the panel's inquiries highlighted the need for a thorough investigation into the practices at the endoscopy center. The implications of this case extend beyond individual accountability, raising broader questions about patient safety standards and the protocols that govern medical procedures in California. The Medical Board is expected to continue its review and may implement recommendations to enhance monitoring and communication practices in medical settings.