Case Title: Howerton v. Mary Immaculate Hospital

Citation: 

Docket Number: 011557

State: virginia

Court: Virginia Supreme Court

Date: 2002-06-07T00:00:00Z

Document:
Present:  Lacy, Hassell, Keenan, Koontz, Kinser, and Lemons, 
JJ., and Whiting, S.J. 
 
KACIE HOWERTON, AN INFANT, ET AL.        OPINION BY 
SENIOR JUSTICE HENRY H. WHITING 
v.  Record No. 011557 
June 7, 2002 
 
MARY IMMACULATE HOSPITAL, INC. 
 
FROM THE CIRCUIT COURT OF THE CITY OF NEWPORT NEWS 
H. Vincent Conway, Jr., Judge 
 
 
In this medical malpractice action, we review the trial 
court's ruling in striking the plaintiffs' evidence on the 
ground that it was insufficient as a matter of law to establish 
either that the defendant was negligent or that such alleged 
negligence was the proximate cause of the damages claimed.  
Because the trial court struck the plaintiffs' evidence, we 
state the evidence in the light most favorable to the 
plaintiffs.  E.g., Hadeed v. Medic-24, Ltd., 237 Va. 277, 281, 
377 S.E.2d 589, 590 (1989) (court struck evidence after jury 
failed to agree upon a verdict). 
 
On March 27, 1997, Lora Howerton, the only patient in the 
labor and delivery rooms of the Mary Immaculate Hospital, was 
awaiting the birth of her first child, later named Kacie 
Howerton.  A number of relatives were in the room with the 
expectant mother. 
 
That morning, at the direction of Dr. Kathy O'Connell, Mrs. 
Howerton's obstetrician/gynecologist, labor and delivery nurses 
employed by the hospital administered Pitocin, a drug designed 
to induce labor.  When Dr. O'Connell examined Mrs. Howerton at 
2:25 p.m., Dr. O'Connell thought that the frequency of her 
contractions and the dilation of her cervix indicated Mrs. 
Howerton was in the early stages of labor.  Dr. O'Connell 
directed that the Pitocin be continued and she did not expect 
the mother’s cervix to be sufficiently dilated for delivery of 
the baby for some time.  Although Dr. O'Connell left the 
hospital, she was available to be contacted through the hospital 
paging system. 
 
At 2:30 p.m. Mrs. Howerton was experiencing more intense 
contractions than she had that morning but the resulting pains 
were broad in nature, rather than in one particular spot, and 
the pains were not excruciating.  However, at 3:00 p.m., Mrs. 
Howerton testified that she experienced intense and different 
abdominal pains as if "someone had taken a knife and stuck it 
directly in me at that spot and twisted it."  Mrs. Howerton 
asked one of her relatives to get a nurse so that she could tell 
the nurse of the new and "totally different" pain. 
 
Whereupon, Howard Linwood Howerton, her husband, went to 
the nurses' station adjoining Mrs. Howerton's labor room and 
told the nurses that his wife was "in severe pain.  We need 
somebody to come in here now . . . she feels it's not normal."  
The response was: "It will be a few minutes.  We're in the 
middle of shift change."  Later, when Mrs. Howerton's mother 
 
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went to the nurses' station and stated that "My daughter needs 
you now . . . she’s having sharp pains," she received the same 
response.  Two of the nurses finally came to the room at 3:15 
p.m. after Mrs. Howerton's father, using strong language, 
demanded that they do so. 
 
The husband testified that when the nurses "came in the 
room and realized that something was going on . . . [one nurse] 
yelled, 'Stat.' "  "Stat" is a code word which signifies an 
emergency situation. 
 
There was a further delay in contacting the doctor because 
the one nurse suggested they not call the doctor "yet."  Some 
time later, at 3:23 p.m., another nurse, who disagreed with the 
first nurse, paged Dr. O'Connell on the doctor's cellular 
telephone using the "stat" designation of an emergency 
situation.  At that time, Dr. O'Connell was in her car some 
distance away from the hospital. 
 
When the doctor answered the emergency page at 3:25 p.m., 
she was advised that the undelivered baby's heart rate was in 
the "60s to 70s" (a normal heart rate being from 120 to 160) and 
that the mother was having some abdominal pain.  Dr. O'Connell 
learned that the infant's heart rate "had been down for a while, 
but [did not] recall exactly how many minutes at that point." 
 
As Dr. O'Connell was driving rapidly toward the hospital, 
she called the labor room again at 3:30 p.m. and learned that 
 
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the baby's heart rate was "still low in the 60s to 70s."  At 
that time "we started talking about moving her back to the 
operating room for a C-section."  The doctor described a 
Caesarian section or C-section as "the most expeditious way to 
deliver a baby in an emergency situation."  Dr. O'Connell 
testified that if a reasonably prudent obstetrician/gynecologist 
is informed that "a patient was experiencing sudden pain that 
was out of the ordinary and there were some decelerations of the 
heart rate, one may start to think about a C-section." 
 
Dr. O'Connell was able to deliver Kacie Howerton by C-
section at 3:55 p.m., promptly after her arrival, because she 
had alerted the hospital to set up the C-section as she was 
driving toward the hospital.  After Kacie's delivery, it was 
discovered that the mother's uterus had ruptured in three places 
during labor resulting in extensive neurological damage to 
Kacie. 
 
Georgia Holder, a nurse with extensive experience in labor 
and delivery nursing, qualified as an expert witness on the 
standard of care required of labor and delivery nurses.  In 
Nurse Holder's opinion, this standard of care required one of 
the labor and delivery room nurses immediately to have gone to 
Mrs. Howerton when "notified of this worsening pain," evaluate 
her condition, and notify her physician. 
 
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Dr. Robert Juskevitch, an obstetrician/gynecologist, also 
testified as an expert witness.  Dr. Juskevitch stated that an 
expectant mother's complaints of pain of a different type and 
character and intensity than labor pains prior to delivery of 
the baby "could [indicate] a ruptured uterus, also could be a 
separation of placenta."  Hence, in the performance of the 
requisite standard of care, a reasonably prudent physician 
should immediately go to the mother's bedside and be prepared to 
perform any necessary C-section within 30 minutes of being 
informed of such complaints. 
 
Dr. Juskevitch also testified that Mrs. Howerton's 
complaints of a new and different deep, sharp, and knife-like 
pain indicated that there was "a rupture [or tearing of the 
uterus] that occurred at 3:00 [p.m.], and in general, things 
like this tend to be progressive."  "It might start out as a 
small tear and extend, become larger, over time."  Dr. 
Juskevitch opined that these knife-like instances of pain were 
associated with episodes of increased tearing. 
 
Dr. Juskevitch explained that these instances of tearing 
presented challenges to the unborn baby which began when the 
first tear occurred at 3:00 p.m., and were evident at 3:17 p.m. 
when "the nurses came into the room, realized that the baby's 
heart rate was erratic."  However, if these partial and 
progressive tears had not ruptured the blood vessels from which 
 
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the unborn baby received its necessary oxygen through the blood 
flowing through the mother's uterus to the placenta and from it 
to the baby, Dr. Juskevitch did not think that the baby would 
have suffered neurological damage provided it was delivered 
promptly after the tearing occurred. 
 
Dr. Juskevitch opined that if Dr O'Connell had been 
informed at 3:09 p.m., the baby should and would have been 
delivered by 3:39 p.m.  Because Dr. O'Connell was not advised by 
the nurses of the change in the mother's condition until 3:25 
p.m., the baby was not delivered until 3:55 p.m., thirty minutes 
after Dr. O'Connell responded to the delayed page. 
 
This delayed delivery was 46 minutes after the doctor 
should have been called at 3:09 p.m. and 16 minutes after the 
baby would have been delivered at 3:39 p.m., had the doctor been 
called at 3:09 p.m.1  According to Dr. Larry E. White, a child 
neurologist called as an expert witness by the plaintiff, if the 
                     
1 The time of 3:09 p.m. was used as a basis for Dr. 
Juskevitch's opinion because counsel for the defendant suggested 
to the court that Nurse Holder had testified this was the time 
when the nurses should have come in, evaluated the patent after 
her complaints of a worsening pain and immediately notified the 
doctor of this change in the nature of the pain.  Counsel was 
wrong about the time; Nurse Holder testified that the nurses 
should have come in when the relatives told them of the 
worsening pain and the husband's evidence was that he did so at 
3:00 p.m.  Had the correct earlier time been the basis for the 
opinion, the time period for a safe delivery would have 
increased. 
 
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baby had been delivered 15 minutes before 3:55 p.m., or by 3:40 
p.m., she would have sustained no neurological damage. 
 
Kacie, by her mother and next friend, and Kacie's parents 
joined in this action against Mary Immaculate Hospital to 
recover damages arising from Kacie's delayed delivery.  The 
plaintiffs have not appealed the trial court's limitation of 
their claims to the following: (1) Kacie, for her injuries and 
disabilities, (2) Kacie's parents, for their medical expenses, 
and (3) Kacie's mother, for her emotional distress.2
 
During the several-day jury trial, the court denied the 
defendant's motion to strike the plaintiffs' evidence made at 
the conclusion of the plaintiffs' evidence but took under 
advisement the same motion made at the conclusion of all the 
evidence.  When the jury was unable to agree upon a verdict 
following deliberation for a period of over two days, the court 
discharged the jury, declared a mistrial, and, after additional 
argument, finally struck the plaintiffs' evidence and entered 
summary judgment for the defendant.  The plaintiffs appeal. 
 
The plaintiffs contend that their evidence was sufficient 
to raise two factual issues: (1) whether the nurses were 
negligent in their delayed response and notification of Dr. 
O'Connell; and (2) whether that negligence was a proximate cause 
 
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of Kacie's neurological disabilities and the other damages 
claimed.  During oral argument on appeal, the defendant 
conceded, and we agree, that the evidence was sufficient to 
create a jury issue regarding the alleged negligence of the 
nurses.  Defendant argues, however, that the plaintiffs' 
evidence was insufficient as a matter of law to establish that 
such negligence was a proximate cause of the damages sustained.  
 
To support that claim, the defendant argues that, even if 
the nurses were negligent between "3:00 and 3:11,"3 there was no 
evidence that, had the necessary information been communicated 
to a reasonably prudent obstetrician/gynecologist during that 
period, anything he or she would or should have done "would have 
changed the result to Kacie."  We do not agree with the 
defendant. 
 
The defendant fails to state the evidence and all 
reasonable inferences deducible therefrom in the light most 
favorable to the plaintiffs whose evidence was struck, as 
required by well-settled appellate principles exemplified in 
Hadeed.  Instead, the defendant seeks to confine the crucial 
period of its negligence to an 11-minute period, overlooking 
evidence in the record from which a jury could have found that 
                                                                  
2 We refused the defendant's appeal of the court's 
recognition of the mother's right to assert a claim for 
emotional distress. 
3 The defendant does not cite a source for its 3:11 p.m.  
 
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its negligence extended over the 25-minute period before the 
nurses informed Dr. O'Connell of the mother's change of 
condition.  The jury could have found that this 25-minute 
period, when combined with the 30-minute period it took Dr. 
O'Connell to deliver Kacie after the 25-minute delayed 
notification, effectively destroyed Kacie's chances of being 
delivered without neurological damage. 
 
This was because Dr. White opined that the neurological 
damage to Kacie occurred 15 minutes before her birth at 3:55 
p.m. and that no such damage would have occurred if Kacie had 
been delivered 16 minutes earlier, or by 3:39 p.m.  Thus, the 
jury could have found that had Dr. O'Connell been notified by 
3:09 p.m., she would have delivered Kacie without neurological 
damage by 3:39 p.m.4
 
Indeed, the jury could have found proximate causation even 
under the theory of the defendant's expert witness, Dr. Jay Paul 
Goldsmith.  He opined that the uterine rupture was complete and 
the blood flow to the fetus had entirely ceased between 3:23 
p.m. and 3:25 p.m. and that "you had 10 to 20 minutes after that 
when the injury occurred."  Reviewing this evidence in the light 
                                                                  
hypothesized time and we were unable find one. 
4 The defendant advisedly does not claim that Dr. O'Connell 
negligently delayed Kacie's delivery.  Three doctors, two of 
whom were defendant's experts, testified that a 30-minute 
reaction time after the doctor’s notification was within the 
standard of care. 
 
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most favorable to the plaintiffs, the jury could have concluded 
that if Dr. O'Connell had been called promptly at 3:00 p.m., the 
baby could have been delivered without extensive neurological 
damage at any time up to 3:45 p.m., "20 minutes after" the blood 
flow entirely ceased. 
 
In explaining why it sustained the defendant's motion to 
strike the evidence, the trial court discussed and rejected 
parts of Dr. Juskevitch's opinion which conflicted with the 
opinions of the defendant's experts.  In doing so, the trial 
court violated the principle we articulated in a similar 
situation in Austin v. Shoney's, Inc., 254 Va. 134, 138, 486 
S.E.2d 285, 287 (1997), by assessing the weight and credibility 
of the evidence and rejecting inferences favorable to the 
plaintiffs which did not defy logic and common sense. 
 
Reviewing the evidence in accordance with the principles 
set forth above, we conclude that the evidence was sufficient to 
raise a jury issue regarding the nurses' negligence and whether 
such negligence proximately caused Kacie's injuries and the 
other injuries and losses claimed.  Hence, we hold that the 
trial court erred in striking the plaintiffs' evidence and in 
entering summary judgment for the defendant. 
 
Accordingly, we will reverse the judgment in favor of the 
defendant and remand the case for a new trial. 
                                                                  
 
 
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Reversed and remanded. 
 
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