The Missouri Court of Appeals Western District (“Missouri Appellate Court”) held in its opinion filed on October 16, 2018 that the Missouri medical malpractice plaintiff was required to produce expert testimony to establish causation in a Missouri medical malpractice case, and therefore it was appropriate for the trial court to have granted the Missouri medical malpractice defendants summary judgment because the plaintiff failed to do so.
The plaintiff had received an excessive doise of morphine during her C-section delivery after which Narcan was administered to reverse the effects of the opioid overdose. The possible side effects from morphine include suppressed respiratory function, hallucinations or confusion, depression, drowsiness, lethargy, nausea, vomiting, and itching. These side effects can occur if the patient receives a normal dose of morphine or an overdose of morphine.
In addition to morphine, the Missouri medical malpractice plaintiff was given twelve other medications between approximately two hours before the delivery to fifteen minutes after the delivery. The other medications were ondansetron, nalbuphine, terbutaline, citric acid sodium citrate, bupivicaine, cefazolin, phenylephrine, norphine, oxytocin, fentanyl, midazolam, ketorolac, and ketamine. These medications all have possible side effects, including: (1) decreased respiratory rate (bupivacaine, fentanyl, and midazolam); (2) hallucinations and/or confusion (fentanyl and ketamine); (3) depression and/or anxiety (ondansetron, terbutaline, phenylephrine, fentanyl, and midazolam); (4) drowsiness, lethargy, and/or grogginess (ondansetron, nalbuphine, terbutaline, fentanyl, midazolam, and ketorolac); (5) nausea and/or vomiting (nalbuphine, terbutaline, citric acid sodium citrate, cefazolin, phenylephrine, oxytocin, fentanyl, midazolam, ketorolac, and ketamine); and (6) itching (ondansetron and fentanyl).
The plaintiff subsequently filed her Missouri medical malpractice case against the defendants, alleging that the defendants’ negligence caused her to suffer decreased respiratory rate, feelings of being overwhelmed, depression, dark thoughts, sleepiness, nausea, vomiting, and itching. She further alleged that she was unable to care for, nurture, and bond with her baby for days after the baby’s birth.
The plaintiff failed to designate an expert after which the defendants filed motions for summary judgment, asserting that the plaintiff bore the burden of establishing causation through expert testimony and that she had not put forth any expert testimony to support her claim that the alleged morphine overdose caused her injuries. The trial court granted summary judgment in favor of the defendants, and the plaintiff appealed.
Missouri Appellate Court Opinion
The Missouri Appellate Court stated that in order to make a claim for negligence, a plaintiff must establish: (1) that the defendant had a duty to protect the plaintiff from injury; (2) the defendant breached that duty; and (3) the defendant’s breach of duty caused the injury.
To establish causation, a plaintiff must show that the defendant’s conduct was both the cause in fact and the proximate or legal cause of her injuries. To demonstrate cause in fact, the plaintiff must show that, but for the defendant’s conduct, her injuries would not have occurred. To demonstrate proximate or legal cause, the plaintiff must show that her injuries were the natural and probable consequence of the defendant’s conduct.
The Missouri Appellate Court stated that in a medical malpractice case, where proof of causation requires a certain degree of expertise, the plaintiff must present expert testimony to establish causation. This is because in cases where there is a sophisticated injury, requiring surgical intervention or other highly scientific technique for diagnosis, proof of causation is not within a lay person’s understanding. Hence, expert medical testimony is necessary to prove a causal link between a health care provider’s negligence and the plaintiff’s injuries except where the want of skill or lack of care is so apparent as to require only common knowledge and experience to understand and judge it.
The Missouri Appellate Court further stated that when the plaintiff relies on expert testimony to provide evidence as to causation when there are two or more possible causes, that testimony must be given to a reasonable degree of medical certainty. If the plaintiff’s injuries may have resulted from either of two causes, one for which the defendant would be liable and the other for which the defendant would not be liable, the plaintiff must show with a reasonable degree of medical certainty that the cause for which the defendant would be liable produced the injury. Otherwise, any verdict would be based on speculation and surmise.
The plaintiff in this case argued that the fact that she received an incorrect dose of morphine, combined with the fact that she “immediately” began suffering “common symptoms of a morphine overdose” immediately afterwards, was sufficient circumstantial evidence to establish a causal link between the incorrect dose of morphine and her injuries.
The Missouri Appellate Court stated that the undisputed medical evidence in this case showed that the side effects of morphine, which include suppressed respiratory function, hallucinations or confusion, depression, drowsiness, lethargy, nausea, vomiting, and itching, can occur if a patient receives either a normal dose of morphine or an overdose of morphine. The undisputed medical evidence also showed that the plaintiff received twelve other medications at or around the same time that she received the alleged morphine overdose, and that those twelve other medications also cause the same side effects as morphine. Thus, the undisputed medical evidence indicated that the plaintiff’s injuries could have been caused by a morphine overdose, for which the defendants would be liable, or the plaintiff’s injuries could have been caused by a normal dose of morphine or some or all of the twelve other medications she received that day, for which the defendants would not be liable.
The Missouri Appellate Court held in the present case: “we cannot say that the logical conclusion from the evidence is that, if certain things (the administration of morphine to [the plaintiff]) were properly done, certain results ([the plaintiff’s] injuries) would not have occurred. [The plaintiff’s] injuries could have reasonably come from two or more possible causes, one or more of which was not the fault of Respondents; consequently, she was required to show with a reasonable degree of medical certainty that it was the alleged morphine overdose that caused those injuries … [b]ecause [the plaintiff’s] injuries could have been caused by a morphine overdose, a normal dose of morphine, or some or all of the twelve other medications she received that day, her injuries were sophisticated and required scientific technique for diagnosis … [t]herefore, [the plaintiff] was required to produce expert testimony that, with a reasonable degree of medical certainty, the alleged morphine overdose caused her injuries.”
Sudden Onset Doctrine
Pursuant to the sudden onset doctrine, causation may be established through the testimony of a lay witness where the obvious symptoms of the injury follow the trauma immediately, or with only short delay, and the injury is the type that is normally sustained in the kind of trauma involved.
The Missouri Appellate Court rejected the plaintiff’s argument that the sudden onset doctrine applied because the side effects of all of the medications that the plaintiff received are not readily separable based on common knowledge from her alleged injuries; hence, the sudden onset doctrine does not apply, as this is exactly the type of highly complex case where expert medical testimony is necessary to establish causation.
Source Love v. Waring, WD81495.
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