Death case raises troubling questions about AZ dental board's discipline, response

The Arizona dental board refused to forward information about a controversial death to law enforcement and is accused of purposely going easy on the dentist found at fault in the case.

The ABC15 Investigators also discovered the chief investigative reviewer assigned to the death resigned in protest because of how the case was handled, citing the dental board’s “desire for tolerance and non-intervention,’ records show.

It’s a case and level of discipline that also troubled attorneys, state auditors and patients. A top law enforcement official says the case also exposes a concerning void in state law.

THE DEATH AND DR. DOYON

On July 21, 2010, a man died after sitting in the chair of Dr. Glen Doyon.

During a three-hour procedure, Dr. Doyon over-sedated his patient and failed to properly monitor his condition, records show.

The patient would die later that night.

READ THE DENTAL BOARD’S DISCIPLINARY ACTION AND ORDER

Dr. Doyon did not return multiple requests for comment. A message left with a secretary in his office also wasn’t returned.

Dr. Doyon’s actions “contributed to the patient’s death,” records show. He also had “four deviations from the standard of care, such as inadequately performing the physical examination, the lack of proper monitoring skills, and using an inappropriate conscious sedation technique.”

But as punishment, the dental board ordered just 16 hours of continuing education and his sedation permit was suspended for six months.

In 2014, state auditors highlighted the case as its first example to question the board’s level of discipline.

“The Board may not have imposed disciplinary action that was consistent with the nature and severity of the…substantiated violations,” auditors wrote.     

ABC15 also spoke with another patient who was treated by Dr. Doyon after the death. Victoria Kobrick said she was shocked to learn what happened.

“I was literally blown away,” she said. “I wouldn’t have ended up in his chair had I known that.”

Kobrick filed her own complaint against Dr. Doyon. She addressed the board last year, saying she had permanent damage from a procedure, received unnecessary treatment and chemicals were used in her mouth without her consent.

Her complaint was dismissed. She said she’s contacting lawmakers about her experience.

“I thought it was such a joke,” Kobrick said. “This is the Arizona State Dental Board. This is an entity that should be there to protect the public, and they are not taking it seriously.”                    

NEW INFORMATION, NEW QUESTIONS

The ABC15 spent months working to get more information about the death case. Expect for final orders and decisions, dental board records and investigations are largely confidential.

An autopsy was never conducted on the body, records show.

ABC15 also learned that the patient’s family in the death case also settled before filing a lawsuit, meaning important details and evidence will never be public.

However, ABC15 obtained an email written to state lawmakers about the case written by the dental board’s chief investigator on the death, Dr. Donald Hoaglin. 

READ THE CHIEF INVESTIGATIVE REVIEWER’S EMAIL

It contains troubling information.

“When I asked why NO professional punitive or license restriction was applied to the dentist,” Hoaglin writes, “the response was, ‘because he’s a good Christian and he does things for the board.”

It goes deeper than just the level of discipline.

The email raises concerns about a loophole that appears to give the dental board complete discretion about whether a case needs to be forwarded to law enforcement.

“In this state, when a negligent homicide occurs by the actions of a dentist (improper use of general anesthetic drugs by improperly trained dentist), the dental statutes do NOT make it mandatory for the dental board to report this type of case to the legal authorities for review,” according to the email.

Dr. Hoaglin also wrote, “The response I received about why this case did not go for legal review was, ‘We do not have to according to the state statutes.”

Dr. Hoaglin, who resigned from serving the state board after the case, declined to be interviewed about his letter, saying it speaks for itself.

A top attorney said his concerns are legitimate and accurate.

ABC15 pulled state statutes and dental board rules and brought them to former U.S. Attorney for Arizona Paul Charlton.

“There’s a void in the law,” Charlton said. “There would have to be some other law to be put into place if the board would be required to move this on to law enforcement for further review.”

Regarding the investigative reviewer’s concerns, Dental Board Executive Director Elaine Hugunin sent ABC15 an emailed response.

“Based on your inquiry, the Board is concerned that you may have received information regarding a Board investigation that is confidential,” Hugunin wrote.   

She added, “the Board did not refer (the case) to a law enforcement agency because the complaint contained allegations of unprofessional conduct under the Dental Practice Act and did not allege violations of the state or federal criminal code.”                                                                                  

It’s a response that doesn’t sit well with Charlton.

“I think it would safe to say as a matter of public policy, when there’s a death, when there’s the ultimate taking from a family, yes it seems reasonable that someone outside the dental board should make sure this matter has been reviewed; and that if a crime has occurred, it is given proper attention,” Charlton said.

When asked why Charlton believes that’s reasonable, the former federal prosecutor replied, “They aren’t qualified to determine when and if a crime has occurred. When something as rare as a death occurs, it ought to be given to someone who has the expertise, someone with a degree of fluency with the law.”

**This story is part of an ongoing investigation into Arizona’s dental dangers. Find the full series here.

Contact ABC15 Investigator Dave Biscobing at dbiscobing@abc15.com.

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