It took a jury just four hours to convict Christopher Duntsch of a first degree felony for harming an elderly woman in his operating room. He stared forward, seemingly in a daze, after the verdict was read, just as he had for the two weeks of testimony. Duntsch’s case is perhaps unique to the justice system—it’s incredibly rare for a surgeon to be indicted, much less convicted, for the care he or she provided. But Duntsch was uniquely egregious.

He was indicted on five counts of aggravated assault with a deadly weapon and a single count of harming an elderly person. The prosecution chose to try the latter charge and built a macabre road map of patients that ended with the elderly victim, Mary Efurd, on the surgical table at Dallas Medical Center in 2012. She was 74 at the time of her surgery, what should’ve been a simple fusion of two vertebrae. Yet she woke up with severe pain from the fusion hardware being misplaced in her soft muscle. She had severed nerve roots and misplaced screw holes on the opposite side of her spine.

Seated in a wheelchair in a turquoise jumpsuit, she spoke to reporters with tears in her eyes moments after the verdict.

“I think it’s going to be like a floodgate that’s going to really open, crying. I’ll do some crying. And I’ll reflect back on how difficult those first months were afterwards. I had so much anger, because my life changed so much. I was very independent and I had to become dependent on others for transportation, for my meals, for a lot of things,” she said. “I think all of us will be thinking about things like this, and hopefully there will be some tighter controls, more accountability in a lot of areas so something like this won’t happen again. It shouldn’t happen again.”

Throughout the testimony, prosecutors narrated what Assistant District Attorney Stephanie Martin called the “path of pain” that led Duntsch to Efurd. That narrative was likely key to achieving the guilty verdict—the prosecution needed to prove that Duntsch’s care was beyond the generally accepted standard as judged by an ordinary person. They had to prove that he knew what he was doing, or that he was aware that he was likely to cause harm and proceeded anyway. Hours of testimony amounted to spinal anatomy, explaining how these procedures—such as the fusion of two vertebrae and the removal and replacement of degenerative discs—should’ve looked.

The state argued that Duntsch, who earned an MD and a PhD at the University of Tennessee Health Science Center in Memphis, knew that his outcomes were so poor that Efurd was likely to wind up injured under his knife. To illustrate, they explored the cases of Jerry Summers (left a quadriplegic), Floella Brown (suffered a massive stroke after significant blood loss), Kellie Martin (bled to death after having her vertebral artery sliced), Barry Morguloff (bone fragments lodged in his spinal canal caused massive pain and the inability for him to raise his foot), and Lee Passmore (nerve damage and a misplaced spinal cage). Our November cover story also explored these cases.

In all, prosecutors identified more than 30 patients who suffered harm at the hands of Duntsch. Many of them will testify during the sentencing phase, which begins on Wednesday. Duntsch faces life in prison. Philip Mayfield sat outside the courtroom after the verdict, clutching a cane. He says he can’t feel the right side of his body, that Duntsch cut through a critical spinal nerve while trying to treat a herniated disc.

“There was no mercy that he showed, no compassion that he showed towards any of the patients,” Mayfield said. “Physically, I’m nowhere near what I intended on being. I’m a lot worse. It was supposed to be a minor procedure to relieve some pain in my arms … and he ended up cutting into my spinal cord.”

Jennifer Rich sat across from him, sitting next to Jimmy Simmons, who helps take care of her as well as Rich’s 6- and 8-year-old children. She, too, clutched a cane and fought back tears as she discussed hearing that he was guilty. In her minimally invasive fusion, she’d lost half her blood volume. Duntsch reportedly told her family the surgery went fine, just as he did with Efurd.

“He cut through my artery and I lost a lot of my blood and I didn’t find out about it until three months later,” she said. “Physically, I can’t do the things with my children that I want to. …it’s hard when someone tells you that you can’t pick up your two-and-a-half year old. They had to learn to crawl in my lap.”

The defense called just one expert witness. On Monday, Dr. Carlos Bagley, the director of the Neurological Surgery Spine program at UT Southwestern, took the stand and joined the choir of surgeons who have called Duntsch’s surgical techniques poor and the outcomes “sub-optimal.” But he argued that the blame extended beyond Duntsch. It was the failure of the system as a whole—Baylor Regional Medical Center at Plano did not refer Duntsch to the National Practitioners Databank after Kellie Martin bled to death and he gave up his privileges. The renowned Memphis neurosurgeon Dr. Kevin Foley allowed him to leave a yearlong minimally invasive spine fellowship and did not mention hearing of adverse outcomes when hospitals in Dallas contacted him for a reference. The University of Tennessee Health Science Center allowed him to practice after residency and medical school, despite his skills being questionable. The Texas Medical Board allowed him to keep his license for more than a year after first being notified. Dallas Medical Center CEO Raji Kumar did not inform the hospital’s chief medical officer that Duntsch had self-reported a bad outcome and resigned from Baylor Plano. (Dallas Medical Center is where Efurd and Brown were operated on.)

“For the number of catastrophic injuries that occurred over a short period of time, it would be hard-pressed for those deficiencies to not show during training,” Bagley said. “This was a complete and utter failure of the entire system of checks and balances for patient safety.”

The defense, usually through attorney Robbie McClung, objected each time prosecutors discussed a case that wasn’t Efurd’s. They maintained what happened to the other patients weren’t pertinent, that the state should stick to discussing the charge they’re trying. The judge always overruled; as prosecutors argued, the jury would need to interpret the repetition of the outcomes to determine intent. That the system failed did not free Duntsch from culpability, argued lead prosecutor Michelle Shughart: “He’s the one who put those knives in those patients’ backs,” she said. “He was slivering between those hospitals with the help of a lawyer.” She summoned excerpts from an email Duntsch sent to his surgical assistant girlfriend, in which he called himself a “motherfucker stone cold killer” as evidence that he was cognizant of the impact of his behavior. Martin locked eyes with Duntsch during her time in front of the jury, saying, “Hey man, you made your best friend a quadriplegic. Do you really need that in writing?”

The courtroom was standing room only for the closing arguments on Tuesday, even attracting new District Attorney Faith Johnson. After the verdict, Johnson strolled out of the back of the courtroom into the hall smiling broadly. To begin the defense’s closing argument, McClung forcefully stood up and marched behind the lawyers’ bench toward the jury, gesturing to the packed room. Inside included victims and family members, including Don Martin, the husband of Kellie Martin; Mayfield; Efurd; Kenneth Fennell (Duntsch’s first victim) and his wife Glenda. McClung told the jury they don’t owe anyone in the room a thing; not closure, not a reaction to public opinion, not a verdict to please the cameras. She urged them to focus on Efurd’s case and argued that Duntsch was just a bad surgeon. She called up testimony from corrective surgeon Dr. Robert Henderson, who was so aghast at Efurd’s outcome that he contacted the medical school to see if he was an imposter.

She maintained that Duntsch in Efurd’s operating room was distracted, just like the many drivers who checked their phones as they drove in to work in the rain this morning. Did that rise to criminality? Did that indicate that Duntsch knowingly caused harm in Efurd? She said it didn’t. But Shughart got the final word, reminding the jury that Brown lay dying while Duntsch performed the elective procedure that harmed Efurd. Brown had lost an inordinate amount of blood during surgery and later had a stroke; it took seven hours for her to be transferred to UT Southwestern, where she died.

“He is the only one who had all of the information,” she said. “He chose to hide it, he chose not to get help and continued maiming and killing patients.”