Anniversary: "I knew I screwed up."

On December 8, 1994, 23-year-old Magdalena Rodriguez went to Suresh Gandotra's clinic, El Norte Clinica Medica, for what she thought was a second-trimester abortion. Gandotra later said, "I knew I screwed up," when he pulled out bowel instead of fetal parts.

Gandotra called a hospital and asked for directions to send Magdalena there by car. The staff at the hospital insisted that Magdalena should be transported by ambulance. They began to assemble an expert team for the expected catastrophic injuries.

In the mean time, Gandotra left Magdalena unattended while he did abortions on other patients. After a half-hour delay, he finally called an ambulance, but did not inform them about the hospital that was awaiting her arrival with a team ready to treat her.

When the ambulance crew arrived, they found Magdalena in ventricular fibrillation, with no pulse, bleeding, and on the floor. Since they'd not been told there was a hospital awaiting her with a team of surgeons ready, they took Magdalena to another hospital, one that was not prepared to treat a patient with her specific injuries.

Gandotra sent Magdalena to the hospital without a medical history or any information about her condition or what he'd done to her. The staff were totally unprepared for what they found when they examined her. Magdalena had no vitals on arrival at hospital. She was unresponsive with fixed, dilated pupils.

When the surgeon at the hospital opened Magdalena's peritoneum, it was so distended that the operating room was spattered with the escaping blood. Magdalena's uterus was ruptured, with a fetal limb protruding into her abdomen. Her cervix, uterus, bladder, and colon were lacerated. The mangled and partially dismembered fetus was of approximately 30 weeks gestation. As the autopsy describes it, "the body of the baby was not complete when autopsied. Both arms had been cut off; the heart, lungs, liver, and other organs had been cut out, the front of the chest and abdomen were missing, the right femur was fractured, the head was intact except for an area on the scalp which had been taken off from the back of the head."

Magdalena bled to death during surgery. Her death was attributed to "complications of the acute pelvic injuries which consisted of lacerations of the lower uterus, vagina, bladder and colon."

Gandotra told the medical board that he had delayed calling an ambulance because he had no admitting privileges and that Magdalena had asked to be released so she could walk home. In a seriously injured patient, this is a sign of hemorrhagic shock, which a physician should have recognized.

Gandotra's attorney said, "We don't believe this was blow the standard of care nor do we believe it was malpractice." A nurse at the hospital that tried to save Magdalena's life said, "I've never seen anything like this before and I don't want to again."

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