A doctor wrongly removed a healthy kidney from a woman during an operation to fix her lower back pain after mistaking the organ for a cancerous tumor.
Maureen Pacheco, now 53, had suffered lower back pain for years after a car accident.
Eventually, in April 2016, she went to discuss the option of surgery at Wellington Regional Medical Center in Wellington, Florida, with Dr Ramon Vazquez, a highly qualified surgeon with decades of experience.
Dr Vazquez recommended having bones in the affected area fused together: he would open her up, and an orthopedic surgeon would do the fusing.
However, at the crucial moment when Dr Vazquez was meant to step aside, he spotted a mass in her pelvis, declared an emergency, and decided to remove Pacheco's kidney before allowing his colleagues to proceed, according to the Palm Beach Post.
It transpired that Dr Vazquez had not seen two MRI scans taken before the operation showing Pacheco had a pelvic kidney, the result of a harmless, but unusual, birth defect.
When Pacheco woke up from anesthesia, she was informed that they had mistakenly removed a kidney.
The scandal provoked a two-year legal battle, which was settled in September for more than $500,000 - but Pacheco now faces a life with just one kidney, at risk of chronic kidney disease and renal failure.
Pacheco's primary surgeons who were supposed to fuse the bones in her lower back, Dr John Britt and Dr Jeffrey Kugler, settled for $250,000 each, according to records from the state's Office of Insurance Regulation.
Dr Vazquez's attorney, Mark Mittlemark, wrote in an email to the Palm Beach Post that the doctor settled for a 'nominal amount'.
The Health Department says that Dr Vazquez did not have malpractice insurance unlike the other two surgeons.
According to 2018 Florida Statutes, the maximum amount of he would be required to pay is $250,000.
Meanwhile, as a claim to rescind his medical license continues, Dr Vazquez is still practicing, having been appointed chairman of surgery at Palm Beach Gardens Medical Center in January this year.
He currently maintains staff privileges at Palm Beach Gardens Medical Center, St Mary's Medical Center, Good Samaritan Hospital and Bethesda Memorial Hospital.
'As you can imagine, when someone goes in for a back surgery, she would never expect to wake up and be told when she's just waking up from anesthesia, that one of her kidneys has been unnecessarily removed,' said Pacheco's attorney, Donald J. Ward.
Prior to the suit, Dr Vazquez didn't have any complaints against him, and his lawyers claim it was the responsibility of other members of the medical team to inform Dr Vazquez that his patient's kidney was in her pelvis.
The Health Department, however, questions how swiftly he made a 'presumptive' diagnosis with dramatic consequences.
Dr Vazquez, a general and vascular surgeon, had been brought in for the first step because, due to Pacheco's injuries, the operation was being performed through the front of her body.
In those cases, it is common for a general or vascular surgeon to perform the first step, which can be risky due to all the vital organs in the way, before handing over to an orthopedic surgeon to finish the job.
It was from this vantage point that he saw the offending kidney.
Legal papers indicate that despite him viewing the mass as 'malignant', he did not order a biopsy before he removed the organ.
Mittlemark said the blame falls on Wellington Regional for failing to inform Dr Vazquez that Pacheco had a pelvic kidney.