PHOENIX, Ariz- Peter Normann was board certified in Internal Medicine yet performing plastic surgery inside his clinic in Anthem.
In a seven-month time between 2006 and 2007, three of his patients died.
The Daisy Mountain Fire Department responded to all of them.
Paramedic Jeff Hinrichs went out on the second call.
"After the second time and then we heard they'd gone back a third, kind of makes you scratch your head and go what's going on?" he said.
According to Maricopa County Superior Court records, after the third patient died, the paramedics filed a complaint to the Arizona Medical Board.
Other board certified plastic surgeons, like Dr John Corey, believe all doctors should be required to notify the board after a patient death.
"Physicians can retreat to their offices, do procedures and have bad outcomes and then not have to report that to anyone," he said. "You'd like to think the board would investigate any type of death in an office setting.”
The Executive Director for the Arizona Medical Board, Lisa Wynn, said the Normann case is so rare, there is no need to consider changing any policy.
“The challenge is any time a case comes up, you know when you start to build legislation for one specific instance, it may or may not ever come up again," she said. "We like to support legislation that's more broad that's going to effectively protect the public in a number of scenarios not just one isolated type of example."
But Corey believes tougher rules need to be imposed arguing some doctors will take advantage of the current system.
"I think the game has changed, so I think it's time for everyone to change," Corey said. "Lawmakers and the Board of Medicine, I think what they've done and what they continue to do is great but I think the game has changed and the players have changed."
The paramedics who witnessed the problems inside Normann’s clinic share a similar viewpoint.
"Hopefully the entire Valley can learn from this experience and take some preventative measures in the future to avoid this ever happening again," Hinrichs said.
Normann is schedule to be sentenced this Friday, August 19.