As she watched a waiting room full of patients, mostly women, churn through the operating room at a Hialeah clinic, Fallon Freeman said she felt the urge to get up and leave what looked to her like an assembly line of cosmetic surgery.
But leaving would mean losing the $5,000 Freeman had already paid to remove excess fat from her back and stomach, and then have it grafted to her backside — a popular surgical procedure in South Florida known as a Brazilian butt lift.
"Everybody was rushed in and out," Freeman, 36, said this week. "It was like a chop shop. You go into a room, they push you out and another girl is rolled in."
Freeman said she was shocked by the inside of the operating room at Encore Plastic Surgery, which has changed its name twice since her operation in March 2016 and now goes by Jolie Plastic Surgery.
"There were bloodstained bandages under the operating table, and blood spattered on the walls," she said of the clinic, which has been linked to numerous patient injuries and deaths in the past. Prior state inspections of the clinic have turned up health and safety violations.
Freeman went through with the surgery, and would live to regret it. She got an MRSA infection, which is an antibiotic resistant bacteria, and was left with deep indentations in her stomach, knotted scars in her waist and an uneven bulge in her hips.
But Freeman said she feels lucky to be alive, especially after learning that the doctor who performed her surgery, James McAdoo, had performed the same procedure on a patient who later died in May 2016, a few months after Freeman's operation.
"I was just blown away," Freeman said. "That's when I started doing research and I later found out he wasn’t a [board certified] plastic surgeon."
This month, the Florida Department of Health filed a formal complaint against McAdoo, charging him with medical malpractice and failure to maintain medical records for a surgery that led to the death of Heather Meadows, a 29-year-old West Virginia woman.
McAdoo did not respond to requests for comment. Ryan Sanders, an attorney representing McAdoo in a medical malpractice lawsuit filed by a different patient, issued a written statement that McAdoo could not comment on the health department's complaint due to patient privacy.
“Dr. McAdoo disputes the allegations contained within the complaint," Sanders said, "and fully intends to contest these issues through the appropriate administrative process.”
According to the health department's complaint, McAdoo failed Meadows in a number of ways — by neglecting to examine her physically before the surgery, by rushing through certain steps of the surgical procedure and by not advising Meadows to wait a month to have the surgery.
The health department's complaint says Meadows was about two months postpartum when she had the surgery on May 11, 2016. "The standard of care requires a three-month postpartum minimum status for the patient," the complaint states.
Additionally, the complaint says McAdoo's anesthesia records indicate that Meadows was under general sedation for 105 minutes and that the surgical procedure took about 55 minutes — even though McAdoo had stated to the health department that the operation generally takes 90 minutes to two hours.
But the most telling detail in the health department's complaint is that McAdoo allegedly injected the fat he removed from Meadows' body into her "deep glutteal vein," said Dr. Pat Pazmiño, a board certified plastic surgeon and president of the Miami Society of Plastic Surgeons, who reviewed the document at the Herald's request.
Meadows died of fat clots in her lung and heart, which caused the organs to fail, according to the Miami-Dade medical examiner's autopsy report.
"That's the big reason," Pazmiño said, explaining that the clots traveled to the organs through the glutteal vein.
Pazmiño said the other allegations in the health department's complaint are relevant, and should raise red flags for patients who are seeking plastic surgery.
He advised patients to seek out surgeons certified by the American Board of Plastic Surgery, the only medical certification for plastic surgery recognized by the American Board of Medical Specialties. According to McAdoo's online physician profile with the health department, he is certified by the American Osteopathic Board of Surgery, a different organization.
Neglecting to perform a pre-operative physical examination and a medical history should also be cause for concern, Pazmiño said.
"If a patient sees a doctor not bothering to take a medical history, not spending time to get to know the patient’s medical condition, then that’s a warning sign," Pazmiño said, "and I think the patient has every right to ask, 'If the doctor doesn’t take the time to know me and get to know about me, then is he going to take the time to do the surgery as meticulously as it should be done?'"
Prior to the administrative complaint filed against him on May 10, McAdoo's profile maintained by the Florida Department of Health listed his license as clear and active, with no disciplinary history. But McAdoo and Encore have been sued numerous times by former patients in Miami-Dade civil court.
Meadows' mother, Tammy Meadows, filed a lawsuit against Encore Plastic Surgery in Miami-Dade civil court in November 2016. The case is open and scheduled for trial in August, and though the lawsuit names McAdoo as the doctor who performed her surgery, he is not a defendant in the case — though he may have settled with the family.
The attorney representing Tammy Meadows did not return calls seeking comment. But McAdoo is also a defendant in two open medical malpractice cases, also in Miami-Dade, including one in which Encore Plastic Surgery is a co-defendant.
Sanders, the attorney representing McAdoo in one of those cases, said in a written statement that McAdoo disputes the charges and provides "the highest level of care" to his patients.
"Dr. McAdoo is defending all of the lawsuits pending against him, all of which involve known complications, fully explained to Dr. McAdoo’s patients prior to surgery," he said. "Unfortunately, even with the utmost care, complications can occur in cosmetic surgery."
Though McAdoo has not received a judgment against him or settled the two cases, Pazmiño said patients have a right to know if their doctor — and the clinic where they intend to have surgery — is a defendant in numerous malpractice cases.
"As a patient, I would want to know that for sure," he said.
Freeman, the patient who learned of Meadows' death after her own surgery, said she found out about the incident when she returned to the Hialeah clinic to see McAdoo about three months after her procedure.
Freeman said she was unhappy with the surgery's results and wanted to ask for a revision.
"It was real lumpy," she said, "and my hips were uneven."
McAdoo was in, she said, but he refused to see her. Freeman, who lives in Central Florida, said she was forced to go into debt to have surgery to repair the work through a different doctor.
Freeman, a mother of five children who works as a medical assistant at a Florida hospital, said that prior to her surgery, she never thought of researching her doctor or Encore Plastic Surgery.
"I'm thinking it’s a legal business in Miami. The name is outside. They’re advertising," she said. "It felt just like going to the dentist. You don’t think when you do that, 'Let me Google and see if this dentist has a license'. You're not thinking, 'I have to research this doctor and make sure he is an actual doctor' before you go in there."