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That has prompted Foster’s daughter to speak out about her mother’s death in order, she says, to help spur improvements in military medical care for others.

“The fact that she’s still practicing … I think that bothers me the most,” said Cynthia Hess, 26, of Jacksonville, Fla.

Foster, the wife of retired Chief Storekeeper William Foster, died March 1, 2002, about six weeks after a total hysterectomy that was supposed to be routine. The surgery was performed by Dr. Cynthia Wilkes, an obstetrician-gynecologist then at Jacksonville Naval Hospital.

Wilkes, a lieutenant commander, met with Foster on Dec. 10, 2001. Foster complained of “heavy menstrual periods and pain,” according to Wilkes’ taped and sworn deposition taken June 24, 2004. Wilkes said she discussed treatment options with her. However, Dr. Alexander Rosin, an independent physician who reviewed Foster’s medical records for the Jacksonville division of the U.S. District Court, found no evidence of such a discussion on the pre-printed consent form.

Wilkes also admitted in the deposition that she never reviewed Foster’s medical records. If she had, she would have found that Foster had undergone several previous abdominal surgeries, including one for a bowel obstruction, Rosin said. Such surgeries leave scar tissue that can complicate subsequent abdominal surgeries.

Wilkes said that had she known of the prior surgeries, she would not have performed surgery on the woman. Instead, she would have recommended that Foster get a second opinion from a surgeon experienced with more difficult surgeries.

The surgery took place Jan. 14, 2002. In one of her initial incisions, Wilkes sliced through a portion of Foster’s small intestine that was enmeshed in scar tissue from an earlier surgery and situated closer to the abdominal wall than normal. The bowel also hadn’t been properly “prepped,” or emptied, prior to surgery, so the contents spilled into the abdominal cavity, Rosin found.

Another surgeon attempted a repair, after which Wilkes proceeded with the hysterectomy. During the hysterectomy, Wilkes injured Foster’s bladder, which had to be repaired by yet another surgeon. The two-hour operation ended up lasting six hours.

“It was supposed to be so routine,” Hess said. So much so, she said, that her father remained on the job at Patuxent River Naval Air Station, Md., where he works as a contractor, while she waited outside the operating room in Florida.

Discharged on Jan. 19 — without antibiotics — Foster was readmitted the following day, complaining of nausea and vomiting. Wilkes kept the woman under observation for 10 days before ordering another surgery. A second surgeon attempting to repair the damaged bowel caused further damage, and another surgery by the same surgeon the following day was also unsuccessful.

Foster, transferred to a local civilian hospital, died a month later of sepsis, or a massive bacterial infection. She was buried in Jacksonville.

“It was hard to explain to my daughter,” Hess said. “And why her grandmother wasn’t coming back to see her.”

The government settled William Foster’s Federal Tort Claims Act lawsuit in November 2004 for $1 million. While the government cannot be sued for medical malpractice involving uniformed personnel, it can be sued for alleged medical malpractice involving family members.

Rosin, the physician who reviewed Foster’s medical records for the court, found that Wilkes committed 15 violations of the standards of care. According to Washington University Medical Center, the standard of care for a given procedure is, in legal terms, “what any reasonable physician would provide under similar circumstances.” It calls any treatment inferior to the standard treatment “unacceptable and unethical.”

Foster attorney Sean Cronin asked Wilkes during the deposition if she felt the failure to read Foster’s outpatient and prior surgical records was a violation of the standards of care. Wilkes, visibly shaken and her voice breaking slightly, replied, “That’s a hard one to answer, but yes.”

Wilkes, who had been transferred from Jacksonville to perform similar duties at the naval hospital in Naples, Italy, has subsequently been reassigned to Cherry Point Naval Hospital, N.C., Navy personnel officials confirmed.

Wilkes “respectfully declined” through a hospital spokeswoman to speak with Navy Times. She also asked the hospital not to provide any information about her present position at Cherry Point.

Wilkes, however, admitted her culpability in her sworn testimony. “I’m the one that’s responsible,” Wilkes said.

Of the 15 standards of care violations, Rosin wrote, the failure to review Foster’s medical records, obtain a complete and comprehensive history or properly evaluate her complaint of abnormal uterine bleeding were particularly critical.

“A physician has the sole responsibility to know the medical records of the patient upon whom she will perform an operation where the informed consent includes ‘possible death,’” Rosin wrote.

Wilkes’ explained her failure to review the record this way: “They didn’t give it to me … The Navy … the outpatient records department.” Such records, she explained, are automatically pulled when an appointment is made. No one from her office called to subsequently request it, she admitted. She also admitted not reviewing Foster’s surgical records, which include two Cesarean section births and two other surgeries, and not ordering any diagnostic tests to try and find the cause of the heavy periods.

For instance, Cronin pointed out during the deposition, a June 1996 note on Foster’s outpatient chart stated, “abdominal obstruction three years ago.” Wilkes agreed that this would have been important information but said that “I did not see it at the time.”

Rosin concluded that “a prudent physician would not have operated on Mrs. Foster.”

Cronin agreed. “If this woman had used common sense and reviewed the medical records, this wouldn’t have happened.”

Subsequent critical errors, Rosin said, included proceeding with the hysterectomy after the attempt to repair the bowel was complete. By opening the vagina without administration of an antibiotic before beginning the operation — Wilkes waited until after she’d begun, he found — “She unnecessarily and negligently introduced additional bacteria into the abdominal cavity.”

The final pathology report on Foster concluded, Rosin wrote, that Foster suffered from no more than common uterine fibroids, or growths, that could have been treated with drugs or handled with an outpatient procedure. The hysterectomy, therefore, was unnecessary.

Cronin said the primary problem appeared to be a deficiency in decision-making skills.

“She made the initial surgical error,” Cronin said. “She made a poor decision to continue with the operation after she was in over her head. And when Mrs. Foster was readmitted, she just compounded all of that by continuing to hold on to the patient and not getting help from others.”

The Navy Bureau of Medicine and Surgery monitors medical provider performance, as do individual medical centers. Doctors and nurses can be removed from patient care while a peer review panel hears a given case. The facility itself takes action against a negligent active-duty provider, subject to review by Navy Personnel Command.

Similarly, the cases of civilian doctors suspected of negligence can be examined by a hospital’s peer review committee, which can terminate medical staff privileges. Those decisions can be reviewed by a variety of organizations, including state licensure boards and independent peer review groups within the states. The credentialing of doctors is monitored by the National Practitioner Data Bank, established by federal law.

According to BuMed spokeswoman Christine Mahoney, a review of Wilkes’ role in Foster’s death was conducted. She declined to provide the outcome and said Dec. 22 that her organization’s lawyers wanted Navy Times to file a Freedom of Information Act request to obtain it. Such a request could not be filed and answered by the time this edition went to press.

Despite problems over the past four years that have produced at least 10 malpractice lawsuits involving the hospital, Mahoney noted that Jacksonville Naval Hospital earned “accreditation without recommendations for improvement” during a July 2005 no-notice review by the Joint Commission on Accreditation of Healthcare. The hospital also met all of the organization’s National Patient Safety Goals, she said.

For Hess, the revelations over malpractice at Jacksonville are all the more reason to speak out.