Nevada couple files malpractice suit against Freeman, four doctors

Four Freeman Health doctors failed to correctly diagnose a Nevada woman's abdominal problems over the course of the past couple of years leaving her with continuing pain, medical costs and loss of income, according to a malpractice suit filed today in Jasper County Circuit Court.

The lawsuit, brought by Samantha and Jordan Leininger in addition to Freeman-Oak Hill Health System, lists T. Brad Coy, D .O,; Sarah Mingucci, D. O,; Brock Carney, M. D.; and Cory Emmert, D. O. as defendants.

From the petition:

In approximately the year 2012, Plaintiff Samantha Leininger underwent gastric band surgery. In 2017, she transferred her care to Robert Aragon, M.D. of KC Bariatric, who eventually removed the gastric band.

On June 23, 2020, Plaintiff underwent laparoscopic vertical sleeve gastrectomy with Dr. Aragon.

On January 26, 2023, Plaintiff underwent hiatal hernia repair surgery with Dr. Aragon, during which Dr. Aragon additionally converted her gastric sleeve to a gastric bypass.

On the evening of November 30, 2023, Plaintiff attended her daughter’s basketball game. While eating food from the concession stand, she suddenly developed severe abdominal pain and began sweating profusely. She went to the restroom, where she felt she either needed to have bowel movement or vomit. However, she was unable to do either.

Plaintiff left her daughter’s game and drove home, needing to stop her vehicle approximately three times on the way due to significant abdominal pain causing her to buckle over. When she arrived at her house, she took off her clothes and lay down on her bathroom floor. She was unable to get up off of the floor due to the severity of her pain.

Upon returning home from the basketball game, Plaintiff’s 12-year-old daughter found her mother lying on the bathroom floor in extreme pain. Plaintiff’s daughter called 911. She also called her father, Plaintiff Jordan Leininger, who was at work. Jordan left work immediately to meet Samantha.

Vernon County EMS transported Plaintiff from her house to Nevada Regional Medical Center (“NRMC”). They arrived at NRMC at approximately 7:18 PM. The emergency physician at NRMC noted Plaintiff’s medical history was significant for a gastric sleeve that had been revised. This physician examined Plaintiff’s abdomen and noted left lower quadrant tenderness and generalized tenderness to palpation, along with guarding and rebound tenderness; he then ordered a non-contrast CT scan of Plaintiff’s abdomen and pelvis.

Plaintiff’s CT scan was read by Jeremy Jagoda, M.D. In his report, signed at 9:23 PM, Dr. Jagoda noted Plaintiff’s previous Roux-en-Y gastric bypass and wrote that he observed no signs of bowel obstruction. However, he did note mesenteric edema in the central and upper quadrant mesentery with swirling of the vasculature, “suggesting midgut volvulus” (a condition where a portion of the intestine is twisted around itself, cutting off blood supply and causing a blockage).

The ED physician subsequently discussed the CT findings with Plaintiff, advising her that he believed she needed to see a surgeon. However, because no surgeon was available at NRMC, Plaintiff was set to be transferred to Freeman Hospital West (“Freeman”) in Joplin, MO.

Vernon County EMS arrived at NRMC at approximately 11:01 PM on November 30, 2023. Plaintiff’s EMS transfer paperwork indicated she was being transferred for a surgical consultation for a diagnosis of volvulus. Just prior to leaving NRMC, Plaintiff requested to use the restroom and did so independently. It was later noted that Plaintiff had experienced a large, foul-smelling, soft bowel movement during this trip to the restroom.

Plaintiff arrived at Freeman at approximately 12:26 AM on December 1, 2023. She was immediately seen by both an ED physician and a general/trauma surgeon, Defendant Sarah Mingucci, D.O. (hereinafter referred to as “Defendant Dr. Mingucci” or “Dr. Mingucci”). Plaintiff explained her history to Defendant Dr. Mingucci, who documented that Plaintiff had experienced acute cramping and abdominal pain for a period of a few hours. Plaintiff further reported that her pain had improved after the bowel movement she had experienced at NRMC. However, Plaintiff continued to complain of an ongoing sensation of bloating in her abdomen.

The ED physician and Defendant Dr. Mingucci reviewed Plaintiff’s radiology report from NRMC, and both noted that it reflected a concern for volvulus. Defendant Dr. Mingucci personally reviewed the images from the NRMC CT scan and observed, in part, lymphadenopathy and edema of the mesentery. 

Dr. Mingucci documented that she believed the main superior mesenteric vessels appeared to be in normal position on transverse images and that they did not appear twisted. Dr. Mingucci further stated that her evaluation of the mesenteric vessels and mesentery was limited by the lack of contrast. Finally, Dr. Mingucc documented that, given Plaintiff’s history of gastric bypass, she recommended obtaining another CT with intravenous and oral contrast.

Plaintiff’s CT with contrast occurred at approximately 2:00 AM on December 1, 2023. The radiologist, Dmitry Bolkhovets, M.D., completed his read by 3:38 AM, when he called and spoke to Nichole Gadd, D.O., one of the ED physicians caring for Plaintiff, regarding “findings that may be critical to patient care.”

Dr. Gadd documented that she spoke with the virtual radiology radiologist (Dr. Bolkhovets), who stated that the stenosis/compression of the mesenteric artery and vein could be the result of a trans mesenteric hernia or adhesion; in addition, he observed dilation of the mesenteric vessels.

The findings Dr. Bolkhovets documented in his CT report mirrored the findings noted above; his “vasculature” findings reflected focal stenosis of the distal superior mesenteric artery, multiple expanded veins in the root of the mesentery, and focal stenosis of the superior mesenteric Martery and vein. His impression stated, “Evidence of stenosis of superior mesenteric artery and vein which may be due to adhesions or transmesenteric/other type of internal hernia.” This report was signed by Dr. Bolkhovets at 3:39 AM.

Dr. Gadd noted that she had discussed the above findings with Defendant Dr. Mingucci, who requested that Plaintiff be admitted to her service. At 5:11 AM, it was documented in Plaintiff’s chart that Defendant Dr. Mingucci had decided to admit Plaintiff to the hospital for observation.

At 5:18 AM, Dr. Bolkhovets addended his CT report, writing, “Findings discussed with Dr. Mingucci. No whirling of vessels is identified to indicate volvulus. No bowel wall thickening is identified. Mesenteric edema is present.”

At 5:21 AM, Defendant Dr. Mingucci addended her consult note. She noted that Plaintiff reported having experienced a second large and liquid bowel movement and was continuing to feel better. She summarized the written report from the radiologist and her own observations of the CT images. She also summarized her conversation with the radiologist and noted that she would discuss the findings with Plaintiff.

Between 6:00 AM and 6:08 AM, Plaintiff was discharged from the ED and transferred to a room. Her admitting diagnosis was “superior mesenteric artery stenosis.”

At 6:22 AM, Plaintiff Jordan Leininger received a text message asking how Samantha was doing. He replied, “Better but we are just now getting into room – the surgeon on call wanted to wait to consult with the bariatric surgeon this morning so just waiting. […] they redid the ct [sic] scan here and used contrast and it wasn’t showing the same twist as originally thought – the trauma surgeon spent a lot of time talking with the radiologist about what they were seeing on the scan – all I know is they talk like something has to be done just not sure how they want to approach it.

At 6:24 AM, Defendant Dr. Mingucci addended her consult note again, noting that she had discussed the radiology findings with Plaintiff and had “recommended diagnostic laparoscopy,” but Samantha declined to have the surgery because she was continuing to feel better and thought she could go home. Dr. Mingucci further documented that she had recommended admission with observation, and Samantha agreed to that.

Defendant Dr. Mingucci wrote that Plaintiff suggested the idea of seeing T. Brad Coy, D.O. (hereinafter referred to as “Defendant Dr. Coy” or “Dr. Coy”), a bariatric surgeon, “hoping he ma let her go home without surgery but stating she would ultimately have the operation if he wanted her to. I informed her that I believe he will recommend the same operation given the radiologist findings. […] I informed her that the radiologist is unsure what is causing the compression on the vessels in this area but that it could be scar tissue or a type of internal hernia that cannot be appreciated on CT scan […] I informed her of the risks of not receiving operation at this time, with potential for vascular compromise to her bowel, she voiced understanding.”

Plaintiffs have a different recollection of the discussion that Defendant Dr. Mingucci documented at 6:24 AM. They recall a general discussion about potential surgery during this conversation with Dr. Mingucci, but they recall that Dr. Mingucci wanted to wait to obtain Dr. Coy’s opinion about what to do, given her uncertainty about what the CT findings indicated.

Notwithstanding the differences noted above, it is undisputed that Plaintiff agreed to remain in the hospital to see Defendant Dr. Coy and that Plaintiff agreed to have surgery if Dr. Coy recommended it.

Defendant Dr. Mingucci further wrote in her 6:24 AM addendum that she had informed Plaintiff she would be signing her care over to Defendant Brock Carney, M.D. (hereinafter referred to as “Defendant Dr. Carney” or “Dr. Carney”), another general surgeon, at 7:00 AM. She noted that she would ask Dr. Coy if he had time to see Plaintiff, but Dr. Carney would ultimately be making recommendations on Plaintiff’s care.

At 6:33 AM, Defendant Dr. Mingucci entered an order with instructions to the nursing staff, stating, “Please call Dr. Carney if patient develops nausea or increasing abdominal pain. Thank you.”

At 6:59 AM, Defendant Dr. Mingucci addended her consult note for a final time, stating in relevant part, “I updated Dr. Carney with patient’s case. I called Dr. Coy and reviewed the case with him, he is happy to take a look, much appreciated.”

The evidence thus far indicates that Defendant Dr. Carney never came to assess Plaintiff, nor did he generate any documentation in her medical chart.

Plaintiffs recall seeing Defendant Dr. Coy sometime during the morning hours of December 1 (although Dr. Coy did not generate an encounter note until later that afternoon). Plaintiffs recall Dr. Coy commenting that he had seen Samantha’s CT scans and that Samantha still had blood flow to her intestines. Plaintiffs also recall that Dr. Coy advised them he believed Samantha had likely had gastroenteritis, and if she could tolerate a liquid diet, she could go home.

Prior to the subject events, Plaintiffs had established plans to travel to Mexico for a vacation from December 7 to December 14, 2023. During their discussion with Defendant Dr. Coy, Plaintiffs specifically inquired about whether it would be safe for Plaintiff to travel to Mexico in light of the events that had brought her to the hospital. Plaintiffs recall Dr. Coy assuring them that he was not concerned.

At 12:06 PM, Defendant Dr. Coy’s nurse practitioner entered an order for a bariatric full liquid diet.
At 2:45 PM, Plaintiff’s nurse documented that she had notified Defendant Dr. Coy of Plaintiff having tolerated a diet of soup, cream of wheat and Jell-O. Dr. Coy gave discharge orders during this conversation.

At 2:59 PM, Defendant Dr. Coy completed a brief provider note for Plaintiff which stated that he had seen and examined Samantha and had reviewed her CT scans. He noted that she felt better with no abdominal pain, and her CTs had not revealed any significant pathology. He wrote that he did not believe she had superior mesenteric artery narrowing, and he did not see a small bowel obstruction. He wrote, “I think this was gastroenteritis from her eating yesterday or poss[ibly] dumping syndrome. If she tolerates diet she could go home.”

Around the same time as Defendant Dr. Coy’s note, Plaintiff’s discharge summary was completed. The discharge summary reflected final diagnoses of abdominal pain and nausea, stating that Plaintiff should remain on a full liquid diet for 1-2 days and then advance her diet as tolerated. Plaintiff was advised to call Dr. Coy for follow up “if needed.”

At 3:35 PM on December 1, 2023, Plaintiff was discharged home.

Between her discharge from Freeman on December 1 and December 21, 2023, Plaintiff experienced normal bowel function and no abdominal pain.

Plaintiffs went on their previously planned trip to Mexico from December 7 to December 14, 2023 without incident.

At approximately 5:30 PM on December 21, 2023, while at a Christmas party for her job, Plaintiff suddenly began sweating profusely and developed a recurrence of the severe abdominal pain she had experienced on November 30, 2023.

At approximately 5:57 PM on December 21, 2023, Plaintiff returned to the emergency department at Nevada Regional Medical Center (“NRMC”). Plaintiff underwent another CT scan of her abdomen/pelvis. Dr. Jagoda, the same radiologist who had read Plaintiff’s first CT on November 30, reviewed the CT. Dr. Jagoda again noted findings consistent with midgut volvulus, writing, “swirling pattern in the left paracentral midgut mesentery surrounding vasculature is consistent with midgut volvulus, with progression of edema and fluid throughout this region with reactive lymph nodes since the prior [scan].”

The ED physician again contacted Freeman about transferring Plaintiff for a surgical consult. During a phone call that occurred at approximately 8:20 PM, Defendant Dr. Cory Emmert (hereinafter referred to as “Defendant Dr. Emmert” or “Dr. Emmert”), a general surgeon at Freeman, accepted Plaintiff as a patient but advised the ED physician that Samantha needed to wait for a bed to become available before she could be transferred. At 10:15 PM, it was noted that Plaintiff had a bed assignment at Freeman. At 10:51 PM, EMS arrived at NRMC to transport Plaintiff back to Freeman. Plaintiff arrived at Freeman shortly after midnight on December 22.

Between Plaintiff’s arrival at NRMC at 5:57 PM and her arrival at Freeman shortly after midnight, she received a variety of medications including fentanyl for pain control (nearly 300 mcg total), Zofran for nausea/vomiting, and hydromorphone for pain control.

At 12:19 AM on December 22, it was noted that Defendant Dr. Emmert had been notified of Plaintiff’s arrival at Freeman.

No physician came to see Plaintiff between her arrival at Freeman and approximately 8:00 AM. During this eight-hour time period, Plaintiff consistently received medications for pain and nausea from the nurse.

On December 22, 2023, at approximately 8:00 AM, Defendant Dr. Emmert came to see Plaintiff. Dr. Emmert documented in part, “Etiology of pain is unclear at this time. Internal hernia is a possibility given considerable weight loss and [history] of Roux-en-Y. Will plan to perform diagnostic laparoscopy. If mesenteric defect is identified then we will plan to suture this.”

Plaintiff’s surgery with Defendant Dr. Emmert began more than eight hours later at 4:38 PM.

Defendant Dr. Emmert began Plaintiff’s surgery laparoscopically. Upon entering the abdomen, Dr. Emmert encountered a significant amount of milky white fluid (chylous ascites, a lymphatic fluid containing a high concentration of triglycerides, associated with internal hernias in patients with a history of Roux-en-Y gastric bypass). Dr. Emmert suctioned some of the fluid and sent it for microbiological analysis to confirm the presence of triglycerides.

Dr. Emmert found Plaintiff’s anatomy to be significantly contorted, including a “very large” loop of colon, along with the appendix (typically located in the right lower quadrant of the abdomen), in the left upper quadrant of the abdomen. Plaintiff’s small bowel was also cyanotic (blue in color due to lack of oxygen).

Dr. Emmert became concerned about a possible cecal volvulus (a twisting at the cecum, where the small bowel meets the large intestine). He noted that he anticipated he might need to perform a right hemicolectomy (removal of the right colon), and he converted to an open procedure, making specific note of the fact that Plaintiff’s cecum was “quite distended.”

Upon converting to an open procedure, Defendant Dr. Emmert discovered a twist at the root of Plaintiff’s mesentery (the fold of tissue that holds the intestines in place and transports blood/nutrients to and from the intestines). 

When this twist was detorsed, the cyanosis in Plaintiff’s small intestine appeared to improve, but Dr. Emmert further noted that Plaintiff had developed “several areas of [clotted] mesenteric veins.” He evaluated the blood flow of the small bowel and mesenteric venous structures and described the flow into the venous system as “sluggish.” Dr. Emmert’s operative report does not contain a description of the blood flow to/from the colon.

Defendant Dr. Emmert confirmed the presence of an internal hernia, noting that “all of [Plaintiff’s] small bowel and right colon” had passed through a hole, or defect, in the mesentery.

After reducing (pulling the small intestine and right colon back out of the hole/defect) the hernia, Dr. Emmert surgically closed the defect in the mesentery.

After the surgical procedure on December 22, Defendant Dr. Emmert spoke to Plaintiff Jordan Leininger and advised him that “pretty much the entirety” of Samantha’s remaining small bowel and colon had passed through the defect and had become twisted, causing her colon to become obstructed and her mesentery to become clotted. He noted that Samantha would not have survived if she had gone much longer without intervention. He confirmed that her intestines had shown signs of ischemia, and he described her colon as “really big.”

Dr. Emmert further advised Jordan that Samantha was not out of the woods and might require anticoagulation due to the clotting in her mesenteric veins, which could be life-threatening.

During the same conversation with Defendant Dr. Emmert, Plaintiff Jordan Leininger mentioned that Defendant Dr. Coy had previously told Plaintiffs that he thought everything was fine. Dr. Emmert replied that he had spoken to Dr. Coy about Samantha multiple times that day because he knew Dr. Coy had seen her previously. Dr. Emmert further advised Jordan that he had spoken to Dr. Coy again about his findings in surgery.

Plaintiff remained NPO (nothing by mouth) on December 23, 2023. Plaintiff was started on a clear liquid diet around 8:21 AM on December 24, 2023.

Plaintiff was discharged from Freeman around 1:48 PM on December 24, 2023. She had not had a bowel movement prior to discharge. She was instructed to remain on a full liquid diet until she experienced a bowel movement and then to advance her diet as tolerated thereafter.

In the days following her discharge, Plaintiff began experiencing frequent episodes of liquid diarrhea, in some cases as many as 15-20 episodes per day. Plaintiff called Defendant Dr. Emmert’s office on the following dates regarding her frequent episodes of diarrhea: December 26, 2023; December 29, 2023; and January 2, 2024. She reported that by January 2, she had lost eight (8) pounds since her December 22 surgery. 

In addition, Plaintiff called Defendant Dr. Coy’s office on December 31, 2023, regarding her frequent episodes of diarrhea. In response to these phone calls, Plaintiff was advised to increase her fiber intake, drink a lot of water, try various prescriptions and come to the lab to provide a stool sample for testing.

On January 8, 2024, Plaintiff presented to Defendant Dr. Emmert’s office for her regular postoperative follow-up appointment. She reported 10-15 liquid bowel movements per day, despite taking all the recommended medications and increasing her fiber. The note from this visit reflected in part, “[Patient] tearful due to stress.” Plaintiff was advised to increase the medications she was taking for diarrhea. It was also noted, “If diarrhea does not subside after these [medication] changes, we may consider adding [antibiotics] for possible bacterial overgrowth. If no improvement with [antibiotics] she will need to be referred to gastroenterology.” The note described Plaintiff as “stable post op.”

Plaintiff briefly experienced mild improvement with her diarrhea symptoms after the January 8, 2024 appointment. On January 23, 2024, she called Defendant Dr. Emmert’s office to report that although she had experienced some improvement, she was still experiencing approximately twelve (12) loose stools per day. She was described as tearful, and she asked what else she could do.

On January 24, 2024, Plaintiff called Defendant Dr. Emmert’s office again and asked what else she could do in light of her continued frequent diarrhea.

On January 25, 2024, Defendant Dr. Emmert’s nurse called Plaintiff back to advise that Dr. Emmert had ordered another prescription for Plaintiff to try.

On January 26, 2024, Plaintiff followed up with Dr. Aragon, the bariatric surgeon in Kansas City who had performed her Roux-en-Y the year prior. Dr. Aragon ordered bloodwork and antibiotics to treat suspected small intestine bacterial overgrowth. Plaintiff’s health insurance would not cover the antibiotics that Dr. Aragon ordered, and the antibiotics would have cost Plaintiff roughly $2,400 out of pocket, so she was unable to obtain them.

On January 30, 2024, Plaintiff called Defendant Dr. Emmert’s office again. The phone note reciting this call states in part, “Patient called and is still having loose stools every day, all day long. Beginning to feel very stressed due to chronic diarrhea. [Patient] is tearful each time she calls. Has tried everything to control the diarrhea.” The nurse advised Plaintiff that Dr. Emmert had called in a new prescription for Bactrim, another antibiotic.

On February 5, 2024, Plaintiff called Defendant Dr. Emmert’s office again to report that she had experienced no improvement and was still experiencing 15 episodes of diarrhea per day. She reported experiencing depression because of the ongoing situation. She was again described as tearful. The nurse spoke with Dr. Emmert and was advised to send an urgent referral to the University of Kansas Health System (“KU”) Gastroenterology.

The earliest appointment offered to Plaintiff by KU Gastroenterology was September 25, 2024.

During February and March of 2024, Plaintiff continued to suffer frequent liquid bowel movements, often more than fifteen (15) times each day. Plaintiff continued to take the various recommended medications to try and relieve her symptoms. She was able to eat; however, she would very quickly experience a bowel movement afterward, excreting the same food she had just consumed. Additionally, Plaintiff dealt with constant and severe stomach bloating.

On March 7, 2024, Plaintiff saw Joseph Dodd, M.D., a general surgeon at Nevada Regional Medical Center (“NRMC”). Dr. Dodd noted in part that Plaintiff had been experiencing fatigue and had unintentionally lost twenty (20) pounds since her surgery with Defendant Dr. Emmert in December 2023. He decided to conduct upper and lower scopes to evaluate Plaintiff’s gastrointestinal system.

On March 20, 2024, Plaintiff underwent an EGD and colonoscopy with Dr. Dodd. The scopes did not reveal a cause for her symptoms.

On March 21, 2024, Plaintiff passed out on the toilet while having a bowel movement. Plaintiffs decided Samantha could not wait until the September 25, 2024 appointment with KU Gastroenterology and drove from Nevada, Missouri to the emergency department at KU. They arrived in the ED at 1:12 AM.

Plaintiff was admitted to KU from March 22 through March 29, 2024. Gastroenterology and bariatric surgery were consulted. Plaintiff was found to be malnourished, with severe muscle wasting and fat loss on exam. It was ultimately determined that her inability to absorb nutrition was likely explained by injury to her bowel due to her prolonged internal hernia, resulting in poor function of the bowel. She was placed on total parental nutrition (TPN) through a PICC line.

Although Plaintiff’s nutritional status improved as a result of the TPN, she continued to experience significant diarrhea on a daily basis.

On April 29, 2024, Plaintiff followed up with Dr. Dodd at NRMC. Dr. Dodd explained that she might be a candidate for Gattex (teduglutide), a prescription medication intended to aid in absorption of liquids and nutrients through the intestines. Gattex is typically prescribed for patients with short bowel syndrome. Dr. Dodd initiated the application process for the drug.

Plaintiff began taking Gattex in June 2024 after being approved for the drug.

On September 3, 2024, Plaintiff established care with the Intestinal Rehabilitation Program at Nebraska Medical Center. There, she was ultimately diagnosed with intestinal failure/functional short bowel syndrome – that is, although none of Plaintiff’s intestines had been physically removed, her bowel functioned similarly to that of someone with short bowel syndrome.

Plaintiff has developed an inability to adequately regulate her blood sugar and experiences frequent, severe episodes of hypoglycemia. Plaintiff wears a glucose monitoring device and frequently supplements her blood sugar with a Glucagon pen, glucose tabs and Kool-Aid.

Following the subject surgery on December 21, 2023, Plaintiff developed a ventral hernia which measured approximately 12 cm by 5 cm. This hernia was ultimately repaired by David Mercer, M.D. at Nebraska Medical Center on March 27, 2025. Plaintiff continues with a significant scar on her mid-abdomen and remains at high risk of ventral hernia recurrence.

Plaintiff ultimately weaned off TPN but continues to take Gattex injections weekly. Plaintiff also continues to rely on roughly 12-14 daily medications to manage her chronic diarrhea.

Plaintiff’s life is substantially disrupted on a daily basis due to fatigue, frequent episodes of diarrhea and chronically feeling ill.

Plaintiff’s sleep, and that of her husband Jordan, is substantially disrupted nightly due to episodes of diarrhea and/or low blood sugar.

Plaintiff attempted to continue working at her full-time job following the subject events,

and her employer graciously made many concessions for her. Unfortunately, Plaintiff ultimately had no choice but to transition to long-term disability.

The six-count lawsuit includes one count of liability against Freeman, one count of medical negligence against each of the four doctors and one count on behalf of Jordan Leininger for loss of consortium against all defendants.,

The Leiningers, who are represented by Robert D. Kingsland of Dempsey, Kingsland & Osteen PC of Kansas City, are demanding a jury trial.