Margaret Lesch was gravely ill when she arrived at University of Maryland Hospital in September 1985. The 67-year-old South Carolina housewife had traveled from her home by ambulance plane to see one of the country's foremost experts in pancreatic surgery for treatment of a life-threatening abscess.

That physician, Dr. H. Harlan Stone, chief of surgery at the hospital, supervised Lesch's care and during the next six weeks brought her back to the brink of good health, according to a lawsuit filed against Stone. By Oct. 30, she had had three operations; just one more was required, an abdominal skin graft. Stone told the family it was a minor procedure, the lawsuit contends, but that he would take care to do it himself.

Lesch never woke up.

Lesch's family sued Stone in April 1986. That spring, so did the families of three other patients who died while in his care. What happened to Stone as a result illustrates the commission on medical discipline's reluctance to take emergency action to suspend a doctor's license before an investigation is completed. It also shows how the lack of prompt action can allow a doctor under scrutiny to leave Maryland and obtain a license elsewhere.

Five days after Lesch's surgery, she was pronounced brain dead and was disconnected from life support systems. Family members have said in the lawsuit that they were told her heart stopped inexplicably on the operating table.

An assistant state medical examiner, alerted by a suspicious funeral director, later announced that he investigated Lesch's death and found that her jugular vein had been punctured during the operation, causing massive blood loss and permanent brain injury. The lawsuit alleged that a resident under Stone's supervision punctured the vein.

The Lesch family and the family of another patient, Theodore Kozowyj, alleged that Stone and other doctors tried to cover up their surgical errors.

Kozowyj, an 87-year-old Ukrainian immigrant, died on Oct. 24, 1984, 10 days after Stone treated his blocked bowel by performing a colostomy. The Kozowyj family's suit against Stone alleges that he erroneously tied off the upper, functioning portion of the bowel. According to autopsy findings cited in the suit, Stone mistakenly diverted the lower portion of the bowel -- rendered nonfunctional by the surgery -- into the colostomy bag.

The suit alleges that after the operation, Stone and other members of the medical staff failed to recognize their error despite Kozowyj's absence of bowel function and increasingly distended abdomen. He suffered "excruciating" pain, according to the suit, and died of infection or septic shock caused by bacteria and deterioration of the bowel. The family alleges that doctors told them that Kozowyj was unable to withstand the surgery because of his age.

The lawsuits were widely publicized in 1986. Harlan Stone was forced to resign from the hospital after an evaluation of the surgery department by outside experts. Stone, now chief of surgery at Fairview General Hospital in Cleveland, tried unsuccessfully to sue the university and its hospital, charging violation of his employment contract and his right to due process.

Stone declined to comment on the malpractice cases. A spokesman for the hospital in Cleveland said officials were aware of his record in Maryland.

In September, a state health claims arbitration panel found Stone negligent in the Lesch case and awarded the family $500,000, but both sides have appealed. The Kozowyj lawsuit has not yet been heard. The two other lawsuits are pending.

In the meantime, Stone let his Maryland license lapse in September. It is unclear whether the commission on medical discipline, which to date has taken no action against Stone, still has the authority to cite him for violations and report him to other states.

Medical society officials estimate that 10 doctors in recent years have been able to avoid disciplinary action in Maryland by moving to another state before the commission charged them with a violation of the medical practices law.

They are pressing for legislation that would allow the commission to issue a disciplinary order against a doctor under investigation, even if his license has lapsed. That information would then be relayed to disciplinary boards in other states, enabling them to deny the doctor a license based on his Maryland history.