Evidence of delays in reviewing complaints against doctors is abundant in records of the Maryland Commission on Medical Discipline, including cases in which patients died or were severely injured.

In one instance, the commission failed to take action even when faced with a court request to do so. Only a second court request nine months later prompted commission action against an anesthesiologist accused of being dangerous and grossly incompetent due to brain damage.

The case involved Dr. Clarence Beverly and his treatment of Theodessa Tinkler, a 23-year-old sergeant in the Marine Corps.

According to court documents, Tinkler had a small cyst at the base of her spine, the result of an ingrown hair. In January 1983 she checked into Baltimore's Wyman Park Health Systems Inc. to have it removed surgically. Her heart arrested while she was on the operating table, and she later died of massive brain injuries.

Tinkler's family sued Beverly, contending in court papers that he improperly placed the anesthesia tube in their daughter's esophagus, pumping oxygen into her stomach instead of her lungs. During crucial moments when Beverly could have corrected the problem, the Tinklers contended, he was suffering from one of the occasional "blackouts" that had disabled him since he suffered a blow to the head in a fall eight years earlier. They also claimed Beverly was an alcoholic.

The Tinklers, who reached a $1 million settlement with Beverly's insurer, also took the unusual step of going to court to try to stop him from practicing medicine.

During a court hearing in August 1985, Baltimore Circuit Court Judge Joseph H.H. Kaplan was presented with a sworn depositon from a nurse present during the surgery. The nurse said that after Beverly placed the tube, she alerted him to odd "swishing sounds" in Tinkler's stomach, according to court documents. Beverly did not respond, she said in the deposition, and, despite repeated attempts, she was unable to get his attention until about five minutes had elapsed.

Attorneys for the Tinklers presented evidence that in 1980 Beverly had said in a sworn statement that he suffered blackouts every two to three weeks and that he had been advised by four doctors that he was no longer capable of practicing anesthesiology. Beverly's statements were made as part of a lawsuit he had filed in connection with the fall that injured him.

On Aug. 7, 1985, Kaplan took the unprecedented action of ordering an immediate halt to Beverly's practice in Maryland until his physical and mental competence could be examined by the Commission on Medical Discipline.

Nine months later, the commission had taken no formal action in the Beverly case.

Beverly, whose Maryland medical license was still intact, had begun practicing anesthesia in Barbados, commission records show. The Tinklers went back to court and obtained a second court order, later overturned, prohibiting Beverly from practicing anywhere, not just in Maryland.

On May 15, 1986, more than three years after Tinkler's death and nine months after Kaplan's first order, the commission issued an emergency suspension of Beverly's license, saying there was reason to believe his severe mental impairment posed a danger to the public. Based on the results of a neurological exam, the commission found that Beverly "has significant difficulty integrating visual patterns, even simple visual patterns such as facial patterns, into a cohesive whole."

Because of the commission's rules on confidentiality, it is not possible to determine when members first learned about Tinkler's death. Commission members declined to discuss their review of the case.

At the time of the suspension, the commission's executive secretary said the delay in resolving the Beverly case occurred because the commission met infrequently.

By then, Beverly was embroiled in another major malpractice lawsuit involving a Baltimore teacher who alleges that she suffered permanent brain damage after Beverly anesthetized her improperly during minor surgery. The case is scheduled for trial later this month.

"My problem was that I'd been away from anesthesia too long," Beverly said in a recent interview, when asked about these cases. He recently moved back to Maryland from Barbados but said that, at 64, he is ready to retire and will not seek commission reinstatement of his Maryland medical license.