Case Title: Branch v. Cleveland Clinic Found.

Citation: 2012-Ohio-5345

Docket Number: 2011-1634

State: ohio

Court: Ohio Supreme Court

Date: 2012-11-21T00:00:00Z

Document:
[Until this opinion appears in the Ohio Official Reports advance sheets, it may be cited as 
Branch v. Cleveland Clinic Found., Slip Opinion No. 2012-Ohio-5345.] 
 
 
NOTICE 
This slip opinion is subject to formal revision before it is published in 
an advance sheet of the Ohio Official Reports.  Readers are requested 
to promptly notify the Reporter of Decisions, Supreme Court of Ohio, 
65 South Front Street, Columbus, Ohio 43215, of any typographical or 
other formal errors in the opinion, in order that corrections may be 
made before the opinion is published. 
 
SLIP OPINION NO. 2012-OHIO-5345 
BRANCH, APPELLEE, v. CLEVELAND CLINIC FOUNDATION, APPELLANT. 
[Until this opinion appears in the Ohio Official Reports advance sheets, 
 it may be cited as Branch v. Cleveland Clinic Found.,  
Slip Opinion No. 2012-Ohio-5345.] 
Medical-malpractice trial—Late production of demonstrative evidence—Adverse 
inference when evidence is not produced—Jury instruction regarding 
different methods of treatment. 
(No. 2011-1634—Submitted June 20, 2012—Decided November 21, 2012.) 
APPEAL from the Court of Appeals for Cuyahoga County,  
No. 95475, 2011-Ohio-3975. 
__________________ 
MCGEE BROWN, J. 
{¶ 1} This appeal involves three rulings in a medical-malpractice trial.  
Appellee, Margaret Branch, suffered a stroke during brain surgery performed at 
appellant, the Cleveland Clinic.  As a result, Branch sued the clinic, claiming that 
its surgeon had struck a ventricle, thus causing the stroke. 
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{¶ 2} Following a jury trial, verdict was entered for the clinic.  Branch 
appealed, and the Eighth District Court of Appeals found abuses of discretion in 
three rulings of the trial court.  Branch v. Cleveland Clinic Found., 8th Dist. No. 
95475, 2011-Ohio-3975, 2011 WL 3505286.  The court of appeals found that the 
trial court abused its discretion in (1) allowing the clinic to use demonstrative 
evidence recreating the surgery that was provided to counsel for Branch ten 
minutes before the expert using it testified, (2) ordering counsel for Branch not to 
argue an inference that because the best piece of evidence—a computerized image 
prepared prior to the surgery—was not saved, it must have been adverse to the 
clinic, and (3) instructing the jury that evidence of alternative medical approaches 
was not evidence of negligence, because no evidence of recognized alternate 
methods of treatment was even presented. 
{¶ 3} The clinic now asks us to determine that the Eighth District’s 
decision was, in each of these respects, “legally and factually flawed” and 
inconsistent with our precedent.  We agree.  Based on the record before us, the 
trial court did not abuse its discretion in any of the rulings at issue.  Therefore, we 
reverse the judgment of the Eighth District Court of Appeals and reinstate the jury 
verdict for the clinic. 
Background 
{¶ 4} Evidence at trial demonstrated that Branch is a highly 
accomplished attorney with a long history of advocating for injured plaintiffs.  
Prior to the surgery, Branch and her husband, Turner Branch, managed a law firm 
with approximately 30 staff members and 8 attorneys in Albuquerque, New 
Mexico. 
{¶ 5} Branch testified, however, that in 2003 she noticed symptoms of a 
neurological disorder known as cervical dystonia.  The condition irresistibly drew 
her head downwards and to the right, causing severe spasms and pain.  It led to 
serious struggles in Branch’s career, personal life, and mental health. 
January Term, 2012 
 
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{¶ 6} As the condition took its toll, Branch learned that the clinic offered 
a new procedure for dystonia, known as deep-brain stimulation (“DBS”).  In 
DBS, surgeons implant electrodes within the brain to defeat destructive brain 
impulses such as those causing dystonia.  After consulting with clinic physicians, 
Branch elected to undergo the surgery. 
{¶ 7} During surgery, Branch suffered a stroke that caused significant 
damage to her physical and cognitive abilities.  Branch then sued the clinic, 
contending that the clinic committed medical negligence that caused permanent 
brain damage, partial paralysis, impaired vision and speech, lost ability to pursue 
her chosen occupation, and severe pain and suffering. 
{¶ 8} At one time, the complaint also included counts of lack of 
informed consent and negligent credentialing, as well as a loss-of-consortium 
claim for Branch’s husband, Turner.  Before trial, however, Branch dropped all 
these claims except for a portion of the lack of informed-consent claim relating to 
the experience, knowledge, and identity of the doctors performing Branch’s 
surgery. 
{¶ 9} After a two-week trial, a unanimous jury found for the clinic.  
Branch appealed, and the Eighth District identified three abuses of discretion that 
warranted reversal and a new trial.  Branch, 2011-Ohio-3975. 
{¶ 10} The first error related to the clinic’s use of demonstrative evidence.  
Branch argued at trial that the clinic improperly failed to retain a three-
dimensional mapping of her brain that was created before the surgery to assist the 
surgeon in directing the probe that would be inserted into her brain.  The clinic 
admitted that the surgeon had not saved the electronic image, but countered that it 
had kept all the surgeon’s notes detailing the surgical procedure. 
{¶ 11} To illustrate the point, the clinic produced a three-dimensional 
computer simulation of the brain mapping, using data it had retained from the 
surgeon’s notes regarding Branch’s procedure.  Branch objected, claiming that the 
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simulation was prejudicial and that the clinic had not provided adequate notice of 
its intent to offer the exhibit.  After discussion with counsel, the trial court 
permitted the clinic to use the exhibit.  The Eighth District, however, concluded 
that the late admission of the evidence prejudiced Branch because she had no 
opportunity to prepare effective cross-examination.  Branch, 2011-Ohio-3975, at 
¶ 18, 27. 
{¶ 12} The second error identified by the Eighth District also involved the 
surgery plan.  At trial, the clinic explained that its computer systems automatically 
deleted surgery plans unless clinic employees affirmatively saved them, which 
they typically did for clinical studies only.  Branch, however, suggested that the 
clinic’s failure to save the plan after a significant complication was suspicious. 
{¶ 13} The trial court allowed Branch to refer to this failure repeatedly.  
But when Branch’s counsel began to argue in closing that the failure to maintain 
the plan was suspicious, and compared the clinic’s action to BP’s destruction of 
safety plans after the disastrous 2010 oil spill in the Gulf of Mexico, the trial court 
ordered Branch to “avoid that topic” because “there’s no suggestion that there’s 
anything willful about the destruction of any documents.”  Branch claims that this 
directive effectively prevented her from seeking an adverse inference that the plan 
would have been unfavorable to the clinic, because the clinic had failed to save it.  
The Eighth District agreed and found that the trial court abused its discretion in 
the ruling.  Branch, 2011-Ohio-3975, at ¶ 63-64. 
{¶ 14} The third and final error identified by the Eighth District related to 
a instruction given by the trial court at the clinic’s request that informed the jury 
that alternative methods could be used and that the use of one medical approach 
rather than another did not necessarily constitute negligence.  The Eighth District 
determined that this instruction was not appropriate because the dispute turned on 
whether a clinic surgeon had violated a standard of care and thus had caused the 
bleed by improperly striking Branch’s ventricle, a vascular structure in the brain.  
January Term, 2012 
 
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Id. at ¶ 49, 51, 54.  Therefore, according to the Eighth District, the issue before 
the jury was not whether the clinic had employed the best of several appropriate 
medical methods, but rather, whether the method chosen was properly performed.  
Id. at ¶ 51-52. 
{¶ 15} The clinic appealed, and this court accepted review. 131 Ohio 
St.3d 1410, 2012-Ohio-136, 959 N.E.2d 1055. 
Admission of Demonstrative Evidence 
{¶ 16} The clinic’s first proposition of law alleges that the Eighth 
District’s decision disallowing the use of demonstrative evidence at the trial was 
both legally and factually flawed. 
{¶ 17} In considering this proposition, we are mindful that a trial court is 
in the best position to make evidentiary rulings and that an appellate court should 
not substitute its judgment for that of the trial judge absent an abuse of discretion.  
Vogel v. Wells, 57 Ohio St.3d 91, 95, 566 N.E.2d 154 (1991) (a trial court did not 
abuse its discretion when it allowed a videotaped reconstruction of an accident to 
be admitted into evidence); State v. Cowans, 87 Ohio St.3d 68, 73, 717 N.E.2d 
298 (1999) (a trial court did not abuse its discretion when it allowed a video 
recreation of a bloodhound’s path in tracking a suspect to be admitted into 
evidence).  We do not, however, defer to trial court rulings that are unreasonable, 
arbitrary, or unconscionable.  Blakemore v. Blakemore, 5 Ohio St.3d 217, 450 
N.E.2d 1140 (1983). 
{¶ 18} In this case, the trial judge carefully reviewed both parties’ 
arguments and was well aware of the issue’s importance.  Indeed, before 
exercising his discretion to allow the demonstration, the judge explained that it 
was a “tough” decision.  The result was not an abuse of discretion.  Branch was 
permitted to use an exhibit that the trial court deemed to be comparable to the 
clinic’s exhibit.  Branch’s counsel had access to the same notes that the clinic 
used in preparing its demonstrative aid, and we defer to the trial court’s judgment 
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that counsel for Branch had adequate opportunity to cross-examine clinic doctors 
with respect to the exhibit despite the minimal notice. 
{¶ 19} We conclude that the trial court reasonably exercised its discretion 
in allowing the clinic’s demonstration.  That court’s decision was far from 
unreasonable, arbitrary, or unconscionable.  The Eighth District’s ruling to the 
contrary was in error. 
Adverse Inference 
{¶ 20} The clinic next argues that the Eighth District erred in finding that 
Branch was unable to argue an adverse inference of negligence after the trial court 
refused to allow her to refer to the BP oil disaster during closing arguments. 
{¶ 21} In other words, the clinic challenges the Eighth District’s 
determination that Branch was entitled to argue an adverse inference arising from 
the clinic’s failure to retain the plan developed for surgery.  The Eighth District 
stated that an adverse inference that the missing evidence would be unfavorable to 
the party who failed to produce it arises “ ‘ “where there is relevant evidence 
under the control of a party who fails to produce it without satisfactory 
explanation.” ’ ”  Branch, 2011-Ohio-3975, at ¶ 62, quoting Signs v. Ohio Dept. 
of Rehab. & Corr., 10th Dist. No. 94AP105-628, 1994 WL 663454, *2 (Nov. 22, 
1994).  The issue here, however, was not that the clinic failed to produce evidence 
in its control, but that Branch disagreed with the clinic’s standard practice of 
deleting surgical plans.  The clinic produced the written records from the surgery 
that detailed the path the surgeon had used in inserting the probe into the brain. 
{¶ 22} More importantly, the trial court did not prevent Branch from 
actually arguing for the adverse inference.  The order to avoid references to the 
topic occurred just moments before the end of Branch’s closing argument.  Up 
until that point, Branch referred to the missing records repeatedly.  The trial court 
did not forbid the jury from considering Branch’s argument in this respect. 
January Term, 2012 
 
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{¶ 23} The trial court was well within its discretion to determine the 
boundaries of closing argument absent an abuse of discretion.  Pang v. Minch, 53 
Ohio St.3d 186, 559 N.E.2d 1313 (1990).  The Eighth District’s ruling to the 
contrary was in error. 
Jury Instruction Regarding Different Methods 
{¶ 24} Finally, the clinic argues that the Eighth District erred in 
“disallowing the different methods jury instruction.”  We agree. 
{¶ 25} We have previously reviewed the role of the “different methods” 
jury instruction in medical-malpractice cases.  Pesek v. Univ. Neurologists Assoc., 
Inc., 87 Ohio St.3d 495, 498, 721 N.E.2d 1011 (2000).  In Pesek, we explained 
that the instruction is “grounded ‘on the principle that juries, with their limited 
medical knowledge, should not be forced to decide which of two acceptable 
treatments should have been performed by a defendant physician.’ ”  Id., quoting 
Dailey, The Two Schools of Thought and Informed Consent Doctrines in 
Pennsylvania: A Model for Integration, 98 Dickinson L.Rev. 713, 713 (1994). 
{¶ 26} We held in Pesek that the different-methods charge is appropriate 
only if “there is evidence that more than one method of diagnosis or treatment is 
acceptable for a particular medical condition.”  Id. at syllabus.  Regardless, we 
found that the trial court erred in giving the instruction in that case because no 
acceptable alternative methods of treatment were presented; instead, Pesek turned 
on a classic misdiagnosis.  Id. at 499. 
{¶ 27} The Eighth District found that it was error to give the different-
methods instruction in this case because Branch claimed that the clinic’s surgeon 
was negligent in striking the ventricle wall.  Id. at ¶ 51.  The surgeon denied, 
however, that he had struck the ventricle wall.  In other words, the dispute turned 
on facts, not legal theories.  However, this analysis oversimplifies what transpired 
at trial.  In fact, the parties’ experts raised a number of questions regarding how 
different planning and procedures could have prevented the stroke, all of which 
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required the jury to determine whether another medical approach would have 
been preferable. 
{¶ 28} For example, the parties disputed whether the clinic’s planned 
trajectory into Branch’s brain was dangerously close to vascular structures in the 
middle of her brain; Branch’s experts proposed an alternative trajectory that they 
claim would have been safer.  Similarly, Branch’s experts challenged the clinic’s 
approach in creating the map of Branch’s brain for surgery and testified to an 
alternative mapping strategy that the clinic could have employed.  Likewise, 
Branch’s experts questioned whether the clinic’s surgeon conducted too many 
“tracks” into Branch’s brain while searching for the best site for electrode 
placement.  With respect to each of these issues, medical professionals in the case 
disagreed about the best method of performing the surgery. 
{¶ 29} In short, Branch raised a number of questions about whether the 
clinic adopted the correct medical approach in her surgery despite the existence of 
alternative methods.  These questions fall outside the limited medical knowledge 
that we expect of juries.  Therefore, the trial court did not err in allowing the 
different-methods instruction. 
Conclusion 
{¶ 30} Based on the foregoing, we conclude that the trial court did not 
abuse its discretion in any of the three rulings at issue.  Accordingly, we reverse 
the decision of the Eighth District Court of Appeals, and we reinstate the jury 
verdict for the clinic. 
Judgment reversed. 
O’CONNOR, C.J., and LUNDBERG STRATTON, O’DONNELL, LANZINGER, 
and CUPP, JJ., concur. 
PFEIFER, J., dissents. 
__________________ 
 
 
January Term, 2012 
 
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PFEIFER, J., dissenting. 
{¶ 31} In this case, we review a court of appeals’ review of a trial court’s 
evidentiary and jury-instruction decisions.  Our holding is that “the trial court did 
not abuse its discretion in any of the three rulings at issue.”  Undoubtedly, this 
case is a matter of great personal interest for the Branches and a matter of great 
corporate interest for the Cleveland Clinic Foundation, but it does not meet this 
court’s jurisdictional requirement of a case “of public or great general interest.” 
Ohio Constitution, Article IV, Section 2(B)(2)(e).  I would hold that jurisdiction 
was improvidently allowed in this case. 
__________________ 
Paul W. Flowers Co., L.P.A., and Paul Flowers; and Becker Law Firm and 
Michael Becker, for appellee. 
Roetzel & Andress, L.P.A., Douglas G. Leak, Anna Moore Carulas, and 
Ingrid Kinkopf-Zajac, for appellant. 
______________________