Patient advocates press Medical Board to publish reports, fix complaint form and increase discipline

Public commenters at the Medical Board of California’s Aug. 19, 2025, meeting pressed the board for clearer enforcement outcomes, faster investigations and correction of the board’s public-complaint processes. Advocates described repeated failures to produce promised reports, concerns that relevant documents and data are being withheld, and a perception that the board protects licensees more than patients.

Several speakers asked the board to release a maternal mortality/maternal health report the board committed to at its August 2023 meeting. “At the August 2023 meeting, this board agreed to provide the public with the maternal mortality, maternal health report,” said Michelle Montserrat Ramos of Consumer Watchdog. “Two years later, board staff still has not provided this report to the public. Please provide the report at the next board meeting.”

Why it matters: Complainants said delays and a difficult online complaint form make it harder for families to get their concerns investigated. Multiple speakers tied slow investigation timelines to harm: they argued the public depends on the board to identify and discipline unsafe practitioners. The board’s enforcement staff and investigators acknowledged process improvements are underway, including a new complainant-liaison unit, but advocates said more transparency and better outreach are needed.

Key public comments and board response - Rob Gordon, a public commenter, announced an advocacy effort to abolish the Medical Board, calling the board structurally unfixable. He urged people not to use a specific web form on the board site, saying in his view the form “is a trap.” (public comment) - Marian Hollingsworth, a patient-safety advocate, said she has read thousands of cases and asked the board for an agenda item describing how new board members are selected and when they complete training. She recounted local cases she said favored doctors over patients and asked for stakeholder meetings and better public convenience for hearings. (public comment) - Paloma Serna, mother of Alyssa Serna, urged disciplinary action against a named physician she said contributed to her daughter’s death; board staff clarified the presently discussed matters were closed cases. (public comment) - Multiple speakers — including Eric Andrews and other advocates — said California disciplines too few physicians, cited a low discipline rate and requested the board pursue more robust enforcement. (public comment)

Board staff said enforcement metrics are improving and outlined reforms: the Health Quality Investigation Unit (HQIU) reported shrinking vacancy rates in some regions and a new complainant-liaison unit has extended hundreds of interview offers to complainants; enforcement leaders said they are prioritizing aging cases and expect to implement a collaborative model between HQIU and the Office of the Attorney General to reduce returns for supplemental investigations.

Discussion vs. formal action This agenda item was public comment and discussion; no board policy was adopted during this portion of the meeting. Board staff provided program updates and said they will continue to report on improvements and the complainant-liaison unit’s work.

Ending note Advocates said the board should publish the maternal mortality report and revise the complaint form to make it less likely complainants inadvertently waive rights; board staff accepted the request for continued engagement and said they are implementing the complainant-liaison interviews and other process changes in response to prior recommendations.