Case Title: Atkinson v. Scheer

Citation: 

Docket Number: 972694

State: virginia

Court: Virginia Supreme Court

Date: 1998-11-06T00:00:00Z

Document:
Present:  All the Justices 
 
WALTER ATKINSON, ADMINISTRATOR OF THE 
 ESTATE OF RUBY E. ATKINSON, DECEASED 
 
 
            OPINION BY JUSTICE LEROY R. HASSELL, SR. 
v.  Record No. 972694 
November 6, 1998 
 
DANIEL W. SCHEER, D.O. 
 
FROM THE CIRCUIT COURT OF THE CITY OF RICHMOND 
James B. Wilkinson, Judge 
 
 
In this appeal of a judgment in a medical negligence 
action, we consider whether the defendant was entitled to 
present evidence that another doctor, who is not a party to 
this litigation, breached the standard of care owed to a 
patient. 
 
Walter Atkinson, administrator of the estate of Ruby E. 
Atkinson (Atkinson), filed a motion for judgment against 
Daniel W. Scheer, a doctor of osteopathic medicine.  The 
estate alleged that Dr. Scheer breached the standard of care 
owed to Atkinson and that her death was caused by Dr. Scheer's 
negligence.  Dr. Scheer filed a grounds of defense and denied 
any acts of negligence. 
 
During a jury trial, Dr. Scheer was permitted to ask the 
plaintiff's expert witness, over the plaintiff's objection, 
whether another physician who had also treated Atkinson had 
committed acts of negligence.  The trial court permitted Dr. 
Scheer to elicit such testimony, and at the conclusion of the 
trial, the jury returned a verdict in favor of Dr. Scheer.  
The plaintiff appeals. 
 
We will state the facts and all reasonable inferences 
therefrom in favor of Dr. Scheer, the recipient of a jury 
verdict confirmed by the trial court.  Atkinson began to 
experience symptoms of a heart attack around 5:00 p.m. on 
September 12, 1994.  She had pain and nausea, and she vomited.  
She arrived at Richmond Memorial Hospital's emergency room at 
6:50 p.m., and she complained of pain in her chest, neck, and 
left shoulder. 
 
An emergency room nurse placed Atkinson on oxygen, 
extracted a blood sample from her, and connected her to a 
continuous heart monitor.  The nurse gave Atkinson certain 
fluids intravenously and attached her to an 
electrocardiograph.  Dr. Scheer examined Atkinson around 7:15 
p.m., performed a physical evaluation, and ordered certain 
diagnostic tests. 
 
Dr. Scheer testified that even though he did not make a 
final diagnosis of Atkinson on September 12, he made a working 
diagnosis that "her etiology was probably cardiac in origin, 
probably cardiac ischemia."  Dr. Scheer stated that a working 
diagnosis is "the one most likely to be what was going on with 
the person."  Dr. Scheer described an ischemia as "a lack of 
oxygen going to the heart." 
 
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Subsequently, Dr. Scheer ordered that a patch of 
nitroglycerin paste be placed on Atkinson's chest to be 
absorbed through her skin into her body.  The nitroglycerin 
paste dilated her blood vessels, thereby reducing the strain 
on her heart which, in turn, decreased her heart's need for 
oxygen.  According to Dr. Scheer, after the nitroglycerin 
paste was administered, Atkinson's pain abated.  Atkinson's 
daughter, however, testified that her mother continued to 
experience pain. 
 
Dr. Scheer ordered a blood test to ascertain the presence 
of enzymes in Atkinson's body which would have been indicative 
of heart damage.  Dr. Scheer had not received the results of 
the blood test when his emergency room shift ended at 10:00 
p.m.   
 
Dr. Scheer also contacted Dr. Selwyn Goodwin by 
telephone.  Dr. Goodwin was a physician who was "on call" for 
Atkinson's regular treating physician.  Dr. Goodwin was aware 
of Atkinson's past history of pulmonary embolism, a condition 
which could also cause chest pain.  Dr. Goodwin suggested to 
Dr. Scheer that he order a ventilation protrusion scan which 
would detect the presence of this condition.  This scan is 
commonly referred to as a VQ scan.  The scan was performed, 
but the results were not available when Dr. Scheer's shift 
ended. 
 
3
 
When Dr. Scheer left the emergency room at about 10:00 
p.m., Dr. Gayle Wampler-Adams, another emergency room 
physician, began treatment of Atkinson.  Dr. Wampler-Adams 
testified that it was her "recollection . . . that [Atkinson] 
had been cleared for discharge, that we were awaiting VQ scan 
results as a final diagnostic test." 
 
Dr. Wampler-Adams received the results of the VQ scan, 
which were negative.  Dr. Wampler-Adams spoke with Atkinson, 
performed a physical examination, and reviewed the EKG and 
laboratory results available to her.  Dr. Wampler-Adams noted 
in the emergency room record that her diagnosis of Atkinson's 
condition was "[a]typical chest pain, probable GE Reflux."  
Dr. Wampler-Adams also spoke by telephone with Dr. Goodwin.  
Dr. Wampler-Adams discharged Atkinson at 11:40 p.m. that 
night. 
 
Dr. Wampler-Adams testified, without contradiction, that 
she relied upon Dr. Scheer's "workup" of Atkinson when making 
the decision to discharge Atkinson.  Shortly after her 
discharge, Atkinson began to experience symptoms associated 
with a heart attack.  She began to vomit, and she complained 
of pain in her shoulder "down through her arm."  Her regular 
physician diagnosed her condition the next day as "a heart 
attack in progress," and she was admitted to Richmond Memorial 
 
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Hospital.  She died on October 4, 1994, as a result of her 
heart attack. 
 
Dr. Scheer did not present any expert witnesses at trial.  
His expert witnesses were disqualified from testifying in a 
pretrial order. 
 
Dr. David Munter, who qualified as an expert witness on 
behalf of the plaintiff on the subject of "emergency room care 
medicine," testified within a reasonable degree of medical 
certainty that Dr. Scheer breached the standard of care owed 
to Atkinson.  Specifically, Dr. Munter testified that Dr. 
Scheer had enough information to admit Atkinson as a patient 
to the hospital and that he breached the standard of care in 
failing to do so.  Dr. Munter also opined that Dr. Scheer 
should have been more aggressive in his treatment of Atkinson 
and that Atkinson would have "had a very high probability of 
surviving had she been admitted" to the hospital on the 
evening she was treated in the emergency room and that her 
"high likelihood of survivability was lost."  
 
During Dr. Scheer's cross-examination of Dr. Munter, the 
trial court permitted him to ask, over the plaintiff's 
objection, whether Dr. Wampler-Adams, who had settled the 
estate's claims against her, breached the standard of care 
owed to Atkinson.  Dr. Munter testified that Dr. Wampler-Adams 
had breached the standard of care by discharging Atkinson. 
 
5
 
Atkinson, relying upon Jenkins v. Payne, 251 Va. 122, 465 
S.E.2d 795 (1996), argues that the trial court erred by 
permitting Dr. Scheer to introduce evidence at trial that Dr. 
Wampler-Adams was negligent in her care and treatment of 
Atkinson.  Dr. Scheer responds that the trial court properly 
admitted this testimony in evidence because Dr. Wampler-Adams' 
conduct was negligent and such conduct was a superseding 
intervening cause of Atkinson's injury.  We disagree with Dr. 
Scheer. 
 
In Jenkins, we considered "whether the trial court erred 
in excluding from the jury's consideration (1) opinion 
evidence that another physician, who had settled the 
plaintiff's claim against him, was negligent in his treatment 
of the decedent, and (2) the defendants' argument that the 
settling physician was the sole proximate cause of the 
decedent's death."  Jenkins, 251 Va. at 124, 465 S.E.2d at 
796. 
 
Veronica L. Payne filed a motion for judgment against 
Harold S. Jenkins, M.D., Jill W. York, R.N., P.N.P., Barry S. 
Rothman, M.D., and Doctors Rothman, Grapin, and McKnight, P.C.  
Payne alleged that these health care providers breached the 
applicable standards of care owed to her.  Payne died before 
trial, and her husband, Troy R. Payne, the personal 
representative of her estate, was substituted as plaintiff, 
 
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and the motion for judgment was amended to allege a cause of 
action for wrongful death. 
 
Veronica Payne had Paget's Disease, which is a cancer of 
the nipple and milk ducts.  While this cancer remains non-
invasive, it grows slowly and is highly curable.  There is 
about a 90% survival rate for patients with Paget's Disease 
who receive treatment before the cancer becomes invasive. 
 
Veronica Payne first sought treatment for her breast 
abnormalities when she was examined by York, a nurse 
practitioner working under the supervision of Dr. Jenkins.  
She was seen and treated twice by York, who referred her to a 
dermatologist.  Subsequently, Payne sought treatment from Dr. 
Rothman, a gynecologist, who prescribed oral antibiotics and a 
topical steroid to treat problems she was having with her 
breast.  Id. at 125-26, 465 S.E.2d at 797. 
 
Payne made several additional visits to both York and Dr. 
Rothman because she was concerned about sores on her breast 
which had not healed properly.  Subsequently, York examined 
Payne and discovered the presence of multiple masses in her 
breast, and Payne was referred to a surgical oncologist, who 
determined that she had aggressive cancer which had spread to 
her lymph nodes.  An expert witness testified at trial that 
Payne's death was the result of a misdiagnosed breast cancer 
and that she would have had a 10-year survival probability of 
 
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about 90% had her cancer been diagnosed when it was still non-
invasive. 
 
Before trial, the personal representative of Payne's 
estate settled his claim against Dr. Rothman and his 
professional corporation.  The plaintiff made a motion in 
limine requesting that the trial court exclude any opinion 
evidence that Dr. Rothman was negligent in his treatment of 
Veronica Payne.  The defendants objected, asserting that their 
defense would be based on a theory that Dr. Rothman's 
negligence was the sole proximate cause of Veronica Payne's 
death.  The trial court ultimately granted the motion, ruling 
that Dr. Rothman's conduct was "at the very best . . . 
concurrent negligence as opposed to [superseding negligence]."  
Id. at 124, 465 S.E.2d at 796. 
 
On appeal, the defendants in Jenkins argued that the 
trial court erred in refusing to permit them to present 
testimony that Dr. Rothman breached the standard of care owed 
to Payne because there was evidence that Dr. Rothman was the 
sole proximate cause of Veronica Payne's death.  Rejecting 
their contentions, we stated the following principles which 
are equally pertinent here. 
"Issues of negligence and proximate causation 
ordinarily are questions of fact for the jury's 
determination.  Brown v. Koulizakis, 229 Va. 524, 
531, 331 S.E.2d 440, 445 (1985).  A court decides 
these issues only when reasonable persons could not 
 
8
differ.  Hadeed v. Medic-24, Ltd., 237 Va. 277, 285, 
377 S.E.2d 589, 593 (1989). 
 
 
"'The proximate cause of an event is that act 
or omission which, in natural and continuing 
sequence, unbroken by an efficient intervening 
cause, produces the event, and without which that 
event would not have occurred.'  Beale v. Jones, 210 
Va. 519, 522, 171 S.E.2d 851, 853 (1970).  There may 
be more than one proximate cause of an event.  
Panousos v. Allen, 245 Va. 60, 65, 425 S.E.2d 496, 
499 (1993). 
 
 
"In order to relieve a defendant of liability 
for his negligent act, the negligence intervening 
between the defendant's negligent act and the injury 
must so entirely supersede the operation of the 
defendant's negligence that it alone, without any 
contributing negligence by the defendant in the 
slightest degree, causes the injury.  Id.; Coleman 
v. Blankenship Oil Corp., 221 Va. 124, 131, 267 
S.E.2d 143, 147 (1980); City of Richmond v. Gay, 103 
Va. 320, 324, 49 S.E. 482, 483 (1905).  Thus, a 
superseding cause of an injury 'constitutes a new 
effective cause and operates independently of any 
other act, making it and it only the proximate cause 
of injury.'  Maroulis v. Elliott, 207 Va. 503, 511, 
151 S.E.2d 339, 345 (1966)."  (Emphasis added).  
Jenkins, 251 Va. at 128-29, 465 S.E.2d at 799. 
 
We applied these principles in Jenkins, and we held that 
reasonable persons could not conclude from the evidence that 
Dr. Rothman's negligence alone, without any contributing 
negligence by the defendants in the slightest degree, caused 
Payne's death.   
 
We also note that we stated in Richmond v. Gay, 103 Va. 
320, 324, 49 S.E. 482, 483 (1905): 
"To be a superseding cause, whether intelligent or 
not, it must so entirely supersede the operation of 
the defendant's negligence, that it alone, without 
 
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the defendant's contributing negligence thereto in 
the slightest degree, produces the injury."  Accord 
Panousos v. Allen, 245 Va. 60, 64-65, 425 S.E.2d 
486, 499 (1993); Philip Morris, Inc. v. Emerson, 235 
Va. 380, 397, 368 S.E.2d 268, 277 (1988); Cox v. 
Mabe, 214 Va. 705, 708, 204 S.E.2d 253, 256 (1974); 
Savage Truck Line v. Traylor, 193 Va. 579, 585-86, 
69 S.E.2d 478, 482 (1952); Jefferson Hospital, Inc. 
v. Van Lear, 186 Va. 74, 81, 41 S.E.2d 441, 444 
(1947). 
 
 
Applying the principles that we enunciated in Jenkins and 
Gay, we hold, as a matter of law, that Dr. Wampler-Adams' 
conduct was not a superseding intervening cause of Atkinson's 
injury and, thus, the trial court erred by permitting Dr. 
Scheer to elicit testimony of Dr. Wampler-Adams' negligence.  
Dr. Scheer sought to relieve himself of liability for his 
purported negligent acts because of a claimed superseding 
intervening cause.  Therefore, he was required to prove that 
Dr. Wampler-Adams' failure to admit Atkinson to the hospital 
entirely superseded the operation of Dr. Scheer's own alleged 
negligence so that Dr. Wampler-Adams' negligence alone, 
without any contributing negligence, even in the slightest 
degree by Dr. Scheer, caused Atkinson's injuries.  Dr. Scheer 
failed to meet this burden. 
 
The uncontradicted evidence of record demonstrates that 
Dr. Scheer's alleged negligence contributed at least "in the 
slightest degree" to Atkinson's death because Dr. Wampler-
Adams testified without contradiction that she relied upon Dr. 
 
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Scheer's "workup" when she made the decision to discharge 
Atkinson.  Even though Dr. Wampler-Adams, just as Dr. Rothman 
in Jenkins, had the last opportunity to take acts which would 
have substantially increased the patient's probability of 
survival, Dr. Wampler-Adams' failure to act did not entirely 
sever the chain of proximate causation set in motion by Dr. 
Scheer's alleged negligence.   
 
Finding no merit in Dr. Scheer's remaining arguments, we 
will reverse the judgment of the trial court and remand this 
case for a new trial.  
Reversed and remanded. 
 
JUSTICE KOONTZ, with whom JUSTICE COMPTON and JUSTICE LACY 
join, dissenting. 
 
 
I respectfully dissent. 
 
The parties agree on appeal, as they did at trial, that 
the broad issue to be resolved is whether our decision in 
Payne v. Jenkins, 251 Va. 122, 465 S.E.2d 795 (1996), is 
controlling in the factual context of the present case.  The 
specific issue presented is whether it can be properly 
determined as a matter of law that the conduct of Dr. Wampler-
Adams was not a superseding intervening cause or the sole 
proximate cause of Ruby Atkinson’s death, or whether that 
conduct created an issue of fact with regard to causation to 
be determined by the jury.  I dissent because the majority 
 
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resolves that issue as a matter of law and, although 
inadvertently, effectively invades the province of the jury. 
 
As we initially noted in Jenkins, ordinarily issues of 
negligence and proximate causation are questions of fact for 
the jury’s determination and only become questions of law when 
reasonable persons could not differ.  “In order to relieve a 
defendant of liability for his negligent act, the negligence 
intervening between the defendant’s negligent act and the 
injury must so entirely supersede the operation of the 
defendant’s negligence that it alone, without any contributing 
negligence by the defendant in the slightest degree, causes 
the injury.”  Jenkins, 251 Va. at 129, 465 S.E.2d at 799. 
 
Guided by these well established principles, we held in 
Jenkins that two medical practitioners were not entitled to 
present opinion evidence that the negligence of a third 
defendant, against whom claims had been nonsuited following 
settlement of the claims against him, was the sole proximate 
cause of the patient’s death.  In that case, the evidence 
showed that all of the defendants concurrently treated the 
patient and   were subject to the same standard of care of the 
patient.  Therefore, the evidence would not support a finding 
that only the nonsuited defendant’s negligence contributed to 
the patient’s death.  Id.  Accordingly, we agreed with the 
trial court that while evidence establishing the facts 
 
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surrounding the treatment of the patient by the nonsuited 
defendant was admissible, id. at 124 n.1, 465 S.E.2d 796 n.1, 
expert opinion as to whether he had breached the standard of 
care in his treatment of the patient was irrelevant to the 
issue of whether the defendants also were negligent in their 
treatment of the patient. 
 
I begin my analysis by noting the obvious distinction 
between the factual context in which the causation issue 
arises in the present case and that existing in Jenkins.  
Unlike Jenkins, the present case does not involve concurrent 
medical treatment of a mutual patient.  Here, Dr. Scheer and 
Dr. Wampler-Adams, while subject to the same standard of care 
in their treatment of Atkinson, did not concurrently treat 
her.  Rather, Dr. Munter’s testimony established that, 
consistent with the standard of care for patients in the 
emergency room, Scheer’s treatment of Atkinson terminated at 
the end of Scheer’s shift in the emergency room, and Atkinson 
thereafter became solely the patient of Wampler-Adams. 
 
This factual distinction is significant.  This is 
particularly so in light of plaintiff’s theory of liability 
and additional undisputed facts in this case.  The thrust of 
plaintiff’s theory of liability is that Dr. Scheer was 
negligent in failing to diagnose Atkinson’s cardiac condition 
and, moreover, in failing to promptly admit her to the 
 
13
hospital for appropriate intensive cardiac care treatment.  
Indeed, plaintiff called Dr. Munter, as an expert witness, in 
support of that theory of liability.  Dr. Munter, as noted by 
the majority, opined that Dr. Scheer was negligent in not 
admitting Atkinson to the hospital and that her very high 
probability of survivability was lost because she was not 
admitted to the hospital on the evening she was treated in the 
emergency room. 
 
However, Dr. Munter did not testify that this probability 
of survivability was lost solely as a result of Dr. Scheer’s 
failure to admit Atkinson to the hospital.  At that point in 
the succession of events to which Dr. Munter’s testimony 
related, it is undisputed that when Dr. Scheer terminated his 
treatment of her, Atkinson remained in the emergency room.  In 
addition, it is undisputed that Atkinson’s condition was then 
stable.  Plaintiff’s other expert witness, Dr. Archer 
Baskerville, a board certified cardiologist, testified that 
Atkinson had suffered an “incomplete heart attack” before 
arriving at the emergency room and that the application of 
nitroglycerin stopped the heart attack for the period during 
which it was applied.  Finally, it is also undisputed that Dr. 
Wampler-Adams did not admit Atkinson to the hospital, but, 
rather, after reviewing Dr. Scheer’s notes on Atkinson’s chart 
and the results of prior tests, conducting a physical 
 
14
examination, and receiving the negative results from the VQ 
scan, she discharged Atkinson with what proved to be an 
erroneous diagnosis of “[a]typical chest pain, probable GE 
Reflux.” 
 
On cross-examination, Dr. Munter conceded that it was not 
a breach of the standard of care for Dr. Scheer to turn the 
treatment of Atkinson over to Dr. Wampler-Adams at the end of 
his shift, but “it should never have reached that point.”  As 
Dr. Scheer’s counsel proceeded to question Dr. Munter about 
Dr.  Wampler-Adams’ treatment of Atkinson, plaintiff objected, 
asserting that “[t]he case is not about Dr. Adams.”  Dr. 
Scheer contended that he was attempting to show a superseding 
cause arising from the negligence of Dr. Wampler-Adams.  
Plaintiff renewed the motion in limine and the trial court 
replied, “I think that’s relevant,” and noted plaintiff’s 
objection.  Dr. Munter then testified that Dr. Wampler-Adams 
had a duty to conduct her own examination and evaluation of 
the patient and that, based on the information available, Dr. 
Wampler-Adams or “anybody associated with this case in the 
emergency department should have admitted” Atkinson. 
 
It is then in this factual context, in contrast to that 
in Jenkins, that the majority holds, as a matter of law, that 
Dr. Wampler-Adams’ conduct was not a superseding intervening 
cause of Atkinson’s death and, thus, that the trial court 
 
15
erred by permitting Dr. Scheer to elicit testimony of Dr. 
Wampler-Adams’ negligence.  The majority correctly notes that 
Dr. Scheer had the burden to prove that Dr. Wampler-Adams’ 
failure to admit Atkinson to the hospital entirely superseded 
the operation of Dr. Scheer’s own alleged negligence so that 
Dr. Wampler-Adams’ negligence alone, without any contributing 
negligence, even in the slightest degree, by Dr. Scheer, 
caused Atkinson’s death.  However, the majority then finds, as 
a matter of law, that Dr. Scheer failed to meet this burden 
because Dr. Wampler-Adams testified without contradiction that 
she relied upon Dr. Scheer’s “workup” when she made the 
decision to discharge Atkinson.  In addition, the majority 
reasons that even though Dr. Wampler-Adams had the last 
opportunity to take acts which would have substantially 
increased Atkinson’s probability of survival, Dr. Wampler-
Adams’ failure to act did not entirely sever the chain of 
proximate causation set in motion by Dr. Scheer’s alleged 
negligence. 
 
The majority fails to consider the effect of the 
testimony of Dr. Baskerville that the application of 
nitroglycerin stopped Atkinson’s heart attack for the period 
during which it was applied.  This evidence establishes that, 
at the time Scheer terminated his treatment of Atkinson, she 
was in a stable condition and had not been discharged from the 
 
16
emergency room and was available to be admitted to the cardiac 
unit of the hospital at that time by Dr. Wampler-Adams.  These 
facts distinguish this case from Jenkins.  Moreover, they 
create a jury issue on causation. 
 
Dr. Wampler-Adams’ reliance upon Dr. Scheer’s “workup” 
may well explain in part her decision to discharge Atkinson.  
However, that reliance at best creates a factual issue whether 
Dr. Wampler-Adams’ conduct was a superseding intervening cause 
or the sole proximate cause of Atkinson’s death.  This is so 
simply because, on the evidence presented, reasonable persons 
could have differed as to whether Dr. Wampler-Adams’ conduct 
so entirely superseded the operation of Dr. Scheer’s failure 
to admit Atkinson to the hospital, that it alone, without Dr. 
Scheer’s alleged negligence contributing thereto in the 
slightest degree, caused Atkinson’s subsequent death.  
Accordingly, since a factual issue was presented in the 
context of this causation issue, Scheer was entitled to 
present expert opinion in support of his theory of non-
liability. 
 
For these reasons, I would affirm the judgment of the 
trial court. 
 
 
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