Trust me I'm a doctor: the case of the rogue spinal surgeon It didn't take long for Richard Kaul's spine surgery practice in the middle-class New Jersey suburb of Pompton Lakes to turn a profit. The Indian-born, British-raised doctor had been performing procedures in small surgeries for a number of years before he opened his own place in 2011. By 2012, he owned a $2m home in New Jersey, a Manhattan penthouse and an $8.3m brownstone on New York's Upper West Side, which boasted a soundproof media room, three terraces and nine fireplaces. Kaul's website attributed his success to his brilliance as a surgeon. He had, it said, "long been lauded as a pioneer in minimally invasive spine surgery" and had "performed the first outpatient spinal fusion in New Jersey." His medical training was "as extensive as it is impressive": he had graduated from the Royal Free Hospital School of Medicine in London in 1988 and trained in both the UK and US. It was armed with this information, and desperate for help, that James Jarrell first visited Kaul. He had experienced sporadic back pain for more than 20 years - half his working life had been spent in the drilling and blasting industry. For a year, he'd received cortisone shots, spinal manipulation and anaesthesia from a chiropractor, but eventually, on 5 September 2005, he was referred to Kaul. Kaul told him he would perform minimally invasive spinal surgery - he'd "make a cut down in the side and... put two very small holes where they can work through some tubes," Jarrell later recalled in court - and that he'd be back at work within two weeks. Kaul performed a discogram, injecting dye into the spinal discs to pinpoint the cause of the pain; a discectomy, removing disc material that was pressing on the nerves or spinal cord; a lumbar interbody fusion, in which two mesh cages were implanted between the spinal discs; and the insertion of pedicle screws - bone screws used to secure rods and plates to support the spine. When he awoke in the recovery room, Jarrell's right side felt better, but his left side was in agony: "I remember touching and complaining about my left leg which had never bothered me before." He had difficulty moving it, and walking on it hurt. When he got the x-rays back, Jarrell was told to return to the doctor immediately. They would not tell me what was wrong. I remember thinking, am I crippled? I was very upset. I was scared. Jarrell went back to see Kaul. "He just flipped the x-rays up to the light and said, "Oh, we can fix this: I just go up in there and scrape a little stuff out, and you'll be fine." And I said no, no, no. No, you're not touching me. A different doctor prescribed oxycodone and fentanyl patches for the pain. Jarrell was forced to wear a back and foot brace, but by March 2007 the pain was worsening and he developed depression. He sought treatment from a neurosurgeon who found that the implant material Kaul had installed was pinching a nerve; he also thought the screws had been misplaced. Jarrell underwent further surgery, after which he said he felt much better, but his ability to walk had been impaired. Jarrell sued Kaul and his practice for medical malpractice - his wife Sheila claimed she had lost her husband's "companionship, consortium and services," while Jarrell claimed he was left unable to walk properly or work because of the pain. The jury found that Kaul had deviated from the applicable standard of care and awarded Jarrell $500,000 for "pain, suffering, disability and the loss of the enjoyment of life" and $187,890 for medical expenses; Sheila got $250,000. But it transpired that Jarrell wasn't alone: he was one of 11 patients who claim to have been left injured after being operated on by Kaul. One, Patricia Maze, accused him of leaving her disabled after surgery on her lower back in 2008. Her attorney said Kaul attempted to perform a spinal fusion and that the result was permanent damage to her spine, which left her wheelchair-bound and in a "living hell." Kaul settled with Maze in March for a reported $450,000, just before her case went to trial. Kaul was found to have been grossly negligent and incompetent in those 11 cases; it also turned out that he wasn't a qualified spine surgeon at all - he was a doctor, yes, but an anaesthetist. Worse than that, he had a conviction for manslaughter in the UK. In 2001, a dental patient Kaul had anaesthetised died during routine treatment, and Kaul received a suspended prison sentence. He had neglected to tell the New Jersey medical board this - something he was required to do when he renewed his licence there, having been banned from practising medicine in Britain. I wanted to know what Kaul was doing now. Was he remorseful? Did he accept the court and medical board's findings - and would he talk to me? Born in Hyderabad in southern India, Richard Kaul moved to the UK when he was two and the family settled in Kent. He graduated from London's Royal Free hospital in 1988 and worked there and at the Lister hospital in Chelsea, before moving to the US in the 90s. After a handful of surgical internships in New York, Kaul began a three-year fellowship in anaesthesia in New Jersey, and was board certified by the American Medical Association in 1996. Visa restrictions meant he had to return to the UK for two years, where he undertook a one-year fellowship in pain management at the Bristol Royal Infirmary. He applied to the Royal College of Surgeons to get his American certification recognised in Britain, but it ruled that he would have to train for a further 18 months in a British hospital - a decision Kaul challenged but one that was upheld on appeal. Instead, with financial help from his brother, he purchased a dental clinic in Dalston, east London. Isatu Bangura died after a tooth extraction. Photograph: Rex In March 1999, Isatu Bangura, 56, came in for a routine tooth extraction and two fillings, but the mother of six was anxious and asked for a general anaesthetic. Kaul gave her the sedative midazolam and the analgesic fentanyl. When the dentist began, Kaul later recalled, it became evident Bangura could still feel pain, so he gave her a dose of the barbiturate methohexital. What happened next formed the basis of a court case at the Old Bailey in which Kaul answered a charge of manslaughter: Bangura's heart stopped during the dental procedure and she died six days later. The court heard that a receptionist had acted as an unqualified dental nurse; she testified that Kaul had asked her to switch off an alarm monitoring Bangura's blood pressure and oxygen level because the noise annoyed him. She also said he was looking out of the window and talking on his phone when she noticed Bangura wasn't breathing - claims Kaul denied. William Boyce, prosecuting, said Kaul used "back door" methods not approved by the General Dental Council; that he administered anaesthetic too quickly or in too great a quantity. Kaul failed to call an ambulance for 30 minutes after Bangura stopped breathing, Boyce said, and refused to accompany her to hospital. In an 11-1 majority verdict, Kaul was found guilty and given a six-month suspended prison sentence. But Kaul still had his US anaesthesia accreditation and had no intention of quitting. He sent off an application form to renew his medical licence, on which he was asked if he'd ever been charged with a crime, or if his licence had ever been suspended. Kaul ticked no to both - a move he would later say he made because he believed it referred to crimes in the US, not the UK. It would be another year before the General Medical Council struck Kaul off its register, so for the time being he was still licensed to practise in the UK. He embarked on a business venture with his brother, Peter, taking telephone consultations from patients experiencing impotence issues and dispensing Viagra - then a new "wonder drug." When Kaul moved back to the US in September 2001, Peter, who was not a doctor, continued to operate the business. Shortly after, officers from the Medicines and Healthcare Products Regulatory Agency - the body responsible for ensuring the safety of medicines in the UK - raided the company's offices and seized their computers. In New York, Kaul was visited by agents from the US Drug Enforcement Administration and later received a summons to appear at court in London; but he told his brother that unless they extradited him, he was not returning. Peter was fined £200,000. Kaul claims he paid most of that sum himself - but that when the final court date arrived, the judge sent his brother to prison for a year - the amount hadn't been paid in full. Richard Kaul leaving the General Medical Council in London in January 2002 after being struck off its register. News of Kaul's conviction for manslaughter and of the GMC hearing finally crossed the pond, and in 2002 he was told the New Jersey medical board intended to revoke his licence. It took a year for his licence hearing to come to court. Kaul argued that if Bangura's death had happened in the US, it would have resulted in a malpractice suit, not a charge of manslaughter. But the board fined him $10,000 and suspended his licence for six months. Kaul later wrote that he wanted to use this time to acquire skills in minimally invasive spine surgery which he could see was a developing field. He travelled to South Korea to attend a two-week spine surgery course. When he returned to New York, with his medical licence reinstated, he worked in pain management treatment centres and began performing spinal surgery on patients. Maze and Jarrell were among 11 whose testimony was taken into consideration by the New Jersey state attorney general after a complaint was filed with the board of medical examiners. Their findings were damning. Kaul had performed spine surgeries for which he was not qualified, the report said: "There was nothing in his education or training that provided him with the experience necessary to perform spinal surgeries. In fact, the first time he ever inserted a pedicle screw on a live patient was at a surgery centre when he was on his own. There was no one to monitor the surgery or assess his skill level. For claiming he was a minimally invasive spine specialist, and telling patients he had the skills to perform those surgeries, the report said he "engaged in dishonesty, fraud, deception [and] misrepresentation." He also failed to maintain medical malpractice insurance. In March this year, the board revoked Kaul's licence and fined him $300,000, ordering him to pay the state's expenses of $174,000. But Kaul refused to accept this. He launched an audacious PR campaign, including a billboard in Times Square and a YouTube channel - the first video, entitled Exposing Lies, dealt with what he said was the inaccuracy of press coverage he had received. He set up a Facebook page, on which he posted videos of patients claiming he'd been unfairly treated, and issued press releases on behalf of the Society for Advanced Spine Intervention, an organisation he had started. So who exactly is Richard Kaul? One clue is his ghostwritten autobiography, self-published earlier this year, called Arjun Rising. The book begins with a potted history of India's struggle for independence, into which Kaul weaves his family history. He says he feels "spiritually connected" to an Indian prince called Arjuna, who features in some ancient Sanskrit texts and from whom Kaul gets his middle name. It's a curious mix of self-aggrandisement and bizarre confessions: "Every year, up until 18, I ranked number one academically and I constantly won the award for best sportsman of the year"; "Once [as a toddler] when I was trying to make a statement, I took my nappy off and released my entire bowel in the middle of the living room floor." Then there are lengthy sections that deal, in graphic detail, with Kaul's sexual exploits. There's the tally he kept at medical school "to see how many nurses we could have sex with over the years" and the time he "met this stunning girl from Athens and had great raw sex with her." He also writes of his mother's death from lung and skin cancer at the age of 43, how this affected him, and how he became addicted to recreational and prescription drugs, and spent periods in rehab. One line stayed with me: "The internal makeup of doctors is generally described as egocentric... [there's] a cliff of expectations, ambitions and goals that they're invincible and they will save the world." Although he responds to my email fairly quickly, Kaul says he's going to be out of the country, and we don't meet until two months later. His office is on the ground floor of a nondescript building in a New Jersey suburb. He greets me at the door, smiling, wearing a black V-neck sweater and glasses. The office space he rents is empty save for some cardboard boxes and piles of paperwork: Kaul says that because he can no longer practise medicine, he's not renewing the lease. We sit in an empty boardroom at a large wooden table. Kaul is disarmingly polite as he leads me through what he sees as the saga of his life. His girlfriend sits with us throughout. It all began, he says, with the death of Isatu Bangura. He insists his former receptionist was lying about him being on his mobile phone while Bangura stopped breathing in the dentist's chair. Having experienced the loss of my mother, I understood very well what her family were going through and at the end of the trial. I wanted to apologise to them. But they weren't ready to accept the apology. Has he apologised to them since? No, I haven't. And that's something that has always stuck with me. When they first started this nonsense, if I had packed my bags and run away, that would have communicated to people that I was trying to hide something. Photograph: 2014 Amy Newman/northjersey.com Kaul insists he was trained sufficiently to carry out the spinal procedures, and that they formed part of his anaesthesia training. "I have done thousands of cases," he says, "and the evolution from interventional pain management into minimally invasive spine surgery is a very logical, natural one." He says there is no recognised fellowship in minimally invasive spine surgery. So when a doctor wants to get training, he goes and undertakes the same types of courses I had undertaken since 2002. There were no standards; there wasn't one specific qualification or programme, and there still isn't. He says he performed "800 of these minimally invasive spinal procedures" and that out of those, only 11 people complained. (Later on, I speak to Dr Russell Nelson, founder and medical director of the Nelson Spine Institute in California and a spine surgeon for 30 years. Nelson tells me that someone trained in anaesthesia is not trained in spinal anatomy. There are two ways to become a spine surgeon in the US: you either train in orthopaedics or neurosurgery - both of which would usually be followed by a year-long spine fellowship taught by expert physicians. Doctors would then have to keep up with the latest developments via courses throughout their careers.) But Kaul believes New Jersey governor Chris Christie was given money by a small group of surgeons in return for asking the state's medical board to take action against him, because he was operating on their turf. He insists he's the victim of a "corrupt system" - that powerful interests came after him because "I was building a successful practice and moving medicine forward in a way that entrenched interests didn't want." Kaul tells me that patients found out about him on the internet because of the press the Bangura case received, and brought it up during their consultations with him. It got to the point, he says, that he couldn't ignore it, so he came up with the idea for the autobiography to "set the record straight. I still feel I did nothing wrong. You know, when they first started this nonsense, if I had packed my bags and run away, I think that would have communicated to people that I was trying to hide something; that I was guilty of something. But that's not the case. While he is candid and friendly during our meeting, Kaul's answers seem self-serving, unremorseful, or both. I wonder if his unwillingness to admit he was wrong and his subsequent PR campaign and book are the hallmarks of a narcissist."Yeah, there will be people who'll say that," he says. But I don't think so. I did a lot of charity work here and treated a lot of patients who had no medical insurance, and I did that for free. I took my own money and used that to set up the Spine Africa Project, to do something positive where people had no healthcare. Kaul set up his charity in 2008 to offer treatment to people across the continent suffering from degenerative spine injuries and deformities. Now that he's closing his private practice in New Jersey, he says, he'll channel all his efforts into that. On the Spine Africa website, the charity promises to train local doctors, improve facilities and raise awareness; it will also be treating people afflicted with spinal conditions. There's a video documentary, too, that shows Kaul visiting the Panzi hospital in the Democratic Republic of the Congo in 2011. He meets the hospital's director and various patients. At the end, accompanied by uplifting music, Kaul operates on a boy with a spinal condition. "We're all very excited for him," he says as he removes the dressing covering the boy's back. He seems to be making progress in the right direction here.