AUSTIN (KXAN) — For Heather Kutyba, working with horses is all about being on a team.

“You both kind of have to work together to find good solutions to problems. If we listen to them, we can accomplish a whole lot,” the Cypress resident told us as she walked past several horses in the barn at her family’s property.

She said she has owned and ridden horses as long as she can remember, but memory of one particular horse, named Dazzle, brings tears to her eyes.

“She was incredibly kind. She was very trusting,” Kutyba said. “She was just different.”

When Dazzle seemed sore in one of her front legs, Kutyba said she took her to a specialist in order to be “proactive.”

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However, after treatment at a well-respected Texas animal hospital, Kutyba said Dazzle’s condition wasn’t improving. In fact, she said the horse showed soreness in her hind legs and developed trouble standing or walking.

“She would have walked through fire if I had asked her to, and she couldn’t move a few steps without agony,” she said.

Kutyba said she has always considered her horse’s veterinarians part of their “team,” but this time, she blamed the veterinarian who treated Dazzle for her condition.

She decided to file a complaint against the doctor with the Texas Board of Veterinary Medical Examiners, or TBVME.

“I felt like I had done my part. I had put the case in their hands,” she said.

The complaint process

TBVME regulates licensed veterinarians and equine dental providers. According to the mission statement on its website, the board’s first priority is to protect the public.

This duty includes investigating every complaint the agency receives about one of its licensees to determine if there was a violation of the Texas Veterinary Licensing Act or Rules of Professional Conduct.

Board meeting documents reveal some cases must undergo a medical review by a licensed vet on the board, while others are reviewed by agency staff. Ultimately, the case is presented to the full board for a vote on disciplinary action — which can range from an informal reprimand to a monetary fine, license suspension or even revocation.

Then, the licensee and the board must come to an agreement about the discipline in a signed Board Order. If they cannot come to an agreement, the board can file a case with the State Office of Administrative Hearings, and the case will go before a judge. If it finds no evidence to support a violation, the board will dismiss the complaint.

The Texas Veterinary Medical Association, which represents vets in the industry, told KXAN, a “thorough investigative process is critical, regardless of who files the complaint.” It noted that disgruntled employees, clients, and sometimes even competitors might file a complaint against veterinarian, so the board has to protect the public against the possibility of the complaint process being “abused.”

TBVME aims to resolve complaints against veterinarians and send the final action to the board for approval in an average of 180 days, according to the mission statement.

After filing her complaint in February 2016, Kutyba received a letter alerting her that her case was open and being processed. Over the next year, she received nearly a dozen more letters with the same message.

During that time, Kutyba said her family made the difficult decision to humanely euthanize Dazzle because of the filly’s condition.

By August 2017, more than 500 days had passed since she filed the complaint. She decided sue the veterinarian and the institution representing her in in civil court, seeking monetary damages. Around the same time, she began reaching out to her state representatives for help with her pending board investigation.

“I think at some point we have an obligation to each other,” she said. “If there is a problem — to say something. If somebody has done wrong… accountability is an important step. Otherwise, people just get hurt.”

Kutyba knew the TBVME was undergoing a legislative review during the time her complaint was pending.

The Texas Sunset Advisory Commission had found concerns about financial management, not enough oversight for controlled substance dispensing and a lack of necessary data to ensure a fair enforcement process by the agency. Plus, complainants and licensees both reported poor communication and difficulty getting basic updates about ongoing investigations.

In emails between Kutyba and agency representatives, she acknowledged the agency faced “restructuring,” but still hoped to get an update on her case.

By January 2018, more than 700 days after she filed her complaint, she decided to file a lawsuit against the TBVME.

“I felt that there were other people at risk because of their inaction,” Kutyba said.

One month later, court records show the TBVME denied all of Kutyba’s claims, demanding “proof.”

Concerns from the Capitol

The 2016-2017 Sunset report stated the agency was averaging 221 days to resolve its complaints during the previous fiscal year – and had resolved 566 complaints.

However, over the course of the Sunset review, TBVME provided five different numbers for this single data point, and Sunset staff “could not verify any of the reported numbers with a suitable degree of confidence.”  

Sunset staff noted data reliability proved to be a “pervasive” problem throughout the agency, since it provided them several different numbers for “basic enforcement data,” such as number of complaints resolved in a year and the number of disciplinary orders issued in a year. According to the report at the time, TBVME blamed these discrepancies on missing or wrong entries by staff in its database or “other clerical issues.”

By 2020, a limited scope review of the agency found the agency resolved most of the other issues it had identified, but was “still struggling” to manage agency data.  

First, Sunset staff acknowledged one of the vendors TBVME contracted to work on the database went out of business during the process, delaying the recommended IT upgrades. However, it also called out the agency for a lack of trend analysis and incomplete or inconsistent information on the agency’s website.

“Similar to the previous review, the agency still struggled to provide Sunset staff basic, verifiable, end-of-fiscal year enforcement data, such as the number of complaints resolved in a year, average number of days to resolve a complaint, the priority assigned to a complaint, sources of complaints, and number of backlogged cases. Not trusting their unreliable data, agency staff reported counting data points manually for verification, which is time consuming and risks additional human error. The lack of data significantly limits the agency’s ability to have a complete, accurate picture of its efforts and to make needed adjustments.”

Sunset Advisory Commission, 2020-2021 Staff Report with Final Results

The numbers

In spring 2022, months before the agency is set for another legislative review regarding these continued data problems, KXAN investigators discovered dozens of disciplinary records that still appeared to be missing from the agency’s licensee look-up website.

Around the same time, KXAN investigators asked the TBVME for the number of complaints the agency received since 2003. The board told KXAN it did not have logs of data prior to 2017. An attorney for the agency couldn’t provide aggregate numbers, but instead sent over several logs of complaint investigations.

Analyzing these records, KXAN counted more than 1,800 complaints have been lodged against Texas licensees over the last five years.

By cross-referencing these logs with disciplinary records that have been uploaded to the agency’s licensee look-up tool, we confirmed the board had not voted to revoke any licenses from veterinarians, but it had suspended around 40 licensees from practicing.

Board meeting minutes show the board has voted on over 200 other agreed orders, containing additional disciplinary action for licensees.

The complaint logs, which KXAN received in March 2022, also revealed more than 300 cases tied up in the agency’s legal department. By April 2022, at the board’s latest meeting, the agency’s attorney reported 428 cases in the legal department awaiting medical review, signatures for an Agreed Order or other next steps from staff or the board.

Board members discussed ways to assist agency staff with this “backlog.” Several staff members suggested board members could assist with more cases that staff are currently tasked with reviewing, since the agency was “short staffed” at the moment, but board President Dr. Jessica Quillivan worried that would create a greater backlog.

“All I hear from all our board members is, ‘We have too many cases, too many cases.’ Why are you wanting to add cases to board members?” she said.

“If we take these cases that won’t take as long, and it frees up the rest of the staff to continue doing their work,” board Secretary Dr. Sandra Criner responded.

Through the meeting, members also referred to the fact that the agency was currently hiring another attorney to help with these cases.

At the end of the meeting, one member, Victoria Whitehead, suggested the board meet more frequently to try and tackle more cases.

“We have a lot on our plate right now, in terms of agency operations,” she said. “I’d like to see us get to a point where we are a little more stable in terms of our numbers and in terms of our management.”

The board discussed how an upcoming move to a new state office building might make adding another meeting to the calendar difficult on staff, but ultimately decided to meet in June — before the next scheduled meeting in July.

At this meeting, board leadership declined to speak with KXAN in an on-camera interview regarding our questions about the data migration, amount of pending cases and other agency operations.

In an email, an agency spokesperson told us it had some “remaining” work on enforcement data to finish before the 2022 legislative review, but that would not impact the public’s ability to view Agreed Orders or disciplinary actions on its public look-up tool.

‘Just tears’

At that same board meeting, Heather Kutyba drove to Austin to speak to board members during public comment, since one of her lawsuits against the TBVME appeared on the agenda as an item for discussion. The board took all legal matters into Executive Session.

In 2018, the Board dismissed Kutyba’s complaint against the veterinarian who treated Dazzle, finding no violations of the Texas Veterinary Licensing Act or Rules of Professional Conduct. Her multiple legal pursuits have either been dismissed by the courts or put on hold.

However, in October 2021, she heard the same veterinarian had been charged with animal cruelty in a separate case.

“My first response was relief; the second was just tears,” Kutyba said, describing the moment she learned about the indictment.

According to a grand jury indictment filed in Brazos County, this doctor is accused of “torturing” a horse, named Allie, in 2019. State documents reveal the vet is accused of shocking Allie with a cattle prod for as long as thirty minutes, and an hour later, the horse died.

KXAN is not naming this doctor in this story in order to focus on greater accountability with the state licensing agency, but KXAN reached out to the attorney representing this veterinarian in the criminal case. He said his client is a “well-respected expert in equine veterinary medicine.” He noted she has been on staff at several nationally-respected institutions and has a “deep reverence for the lives of horses — and saving the lives of horses.”

In March 2021, TBVME filed a case with the State Office of Administrative Hearings, seeking revoke this veterinarian’s license, since the board and the vet failed to reach an Agreed Order. In its complaint, the board alleges “dishonest or illegal practices, and violation of Board Rules,” by this doctor.

“That could have been avoided. I don’t have any doubt about that,” Kutyba said. “If the board’s motto is to protect the public, then they need to get on to the business of protecting the public.”

Graphic Artist Rachel Gale, Director of Investigations & Innovation Josh Hinkle, Photojournalist Chris Nelson, Digital Special Projects Developer Robert Sims and Digital Director Kate Winkle contributed to this report.