Case Title: Holmes v. Levine

Citation: 

Docket Number: 060682

State: virginia

Court: Virginia Supreme Court

Date: 2007-01-12T00:00:00Z

Document:
Present:  All the Justices 
 
PAUL HOLMES, ADMINISTRATOR OF THE 
ESTATE OF ELLA HOLMES 
 
v.  Record No. 060682  OPINION BY JUSTICE CYNTHIA D. KINSER 
 
 
 
 
 
 
 
 January 12, 2007 
JAY M. LEVINE, M.D., ET AL. 
 
 
FROM THE CIRCUIT COURT OF THE CITY OF RICHMOND 
Ernest P. Gates, Sr., Judge Designate 
 
 
In this wrongful-death action based on the alleged 
medical malpractice of a radiologist, the plaintiff asserts 
that the trial court erred by refusing to give the 
plaintiff’s requested jury instruction on the issue of 
proximate causation.  We agree and, for that reason, will 
reverse the trial court’s judgment in favor of the 
defendant-radiologist.  With regard to two other issues 
that may arise during a retrial, we conclude that the trial 
court did not err either in overruling the plaintiff’s 
objection that certain testimony of a treating physician 
did not satisfy the requirements of Code § 8.01-399(B) or 
in sustaining an objection to testimony elicited on cross-
examination of a medical expert witness concerning the 
cause of death listed in a death certificate. 
I. FACTS AND PROCEEDINGS 
 
Ella F. Holmes presented at a hospital emergency room 
on February 19, 2003, complaining of pain in her left flank 
 
2
and back.  Medical personnel performed a computed 
tomography (CT scan) of Holmes’ abdomen, which Dr. Jay M. 
Levine, a radiologist employed by Commonwealth Radiology, 
P.C., interpreted the same day.  Dr. Levine reported that 
the CT scan revealed Holmes’ bladder was distended, she was 
experiencing bilateral hydronephrosis and hydroureter, and 
she had a 1–2 mm calculus, or “stone,” near the point where 
her right ureter emptied into her bladder.  Dr. Levine did 
not make any differential diagnosis as to the cause of 
Holmes’ distended bladder or raise any suspicion of bladder 
cancer.  In March 2004, however, Holmes was diagnosed with 
metastatic transitional cell carcinoma of the bladder, from 
which she died in March 2005. 
 
In an amended motion for judgment filed against Dr. 
Levine and Commonwealth Radiology, P.C., Paul A. Holmes, 
the spouse of the decedent and administrator of her estate 
(the Administrator), alleged Dr. Levine deviated from the 
standard of care as a radiologist by failing to recognize 
the markers of transitional cell carcinoma in Holmes’ 
bladder, to recommend further studies, and to report an 
asymmetrical thickening of her bladder wall.  At the heart 
of the allegations was the contention that Dr. Levine 
breached his duty of care to Holmes by failing to interpret 
and report a gray-white area appearing on the February 2003 
 
3
CT scan as a focal thickening of her bladder wall 
consistent with a mass, thereby depriving Holmes’ other 
health care providers of vital information that would have 
enabled them to detect bladder cancer at an earlier stage 
and, in turn, to increase significantly her chance of 
survival. 
At trial, the Administrator presented expert testimony 
from several witnesses to support his allegations regarding 
Dr. Levine.  Dr. Lawrence M. Cohen, an expert in the field 
of radiology, testified that Dr. Levine, in interpreting 
the February 2003 CT scan, breached the standard of care by 
failing to recognize and report the thickening of Holmes’ 
bladder wall, by failing to include that information in his 
report, and by failing to make a diagnosis of possible 
transitional cell cancer of the bladder. 
Dr. David M. Pfeffer, an expert witness qualified in 
the field of urology, testified that a reasonably prudent 
urologist in 2003 who received a radiologist’s report 
identifying a focal thickening of a patient’s bladder wall 
suggestive of a tumor would have performed a biopsy.  But, 
according to Dr. Pfeffer, a reasonably prudent urologist in 
2003 would not, based on Dr. Levine’s report of the 
February 2003 CT scan, have performed a biopsy on Holmes’ 
bladder.  Dr. Pfeffer opined that if a biopsy had been 
 
4
performed in 2003 on the thickened wall of Holmes’ bladder, 
that biopsy would have shown transitional cell carcinoma of 
the bladder.  He stated to a reasonable degree of medical 
probability that Holmes had bladder cancer in February 2003 
and that the delay in diagnosis until 2004 deprived her of 
a substantial possibility of survival. 
Dr. Samuel Denmeade, who testified on behalf of the 
Administrator as an expert in the field of oncology, 
corroborated much of Dr. Pfeffer’s testimony.  Dr. Denmeade 
agreed that Holmes had bladder cancer in February 2003 and 
further stated that, based on a biopsy performed in 2004, 
the type of cancer was “transitional cell cancer, which is 
a very specific cell type that’s really only found in the 
genito-urinary tract.”  He opined that Holmes’ cancer in 
2003 was at the Stage II level of progression but that, 
when it was finally diagnosed 13 months later, it had 
progressed to Stage IV.  According to Dr. Denmeade, 60 to 
70 percent of patients whose cancers are discovered at the 
Stage II level will live for five to ten years, whereas 
patients whose tumors remain undetected until they reach 
Stage IV, as occurred with Holmes, have only a 10 to 15 
percent survival rate over similar periods. 
In contrast, Dr. Levine claimed that the gray-white 
area on the February 2003 CT scan was merely normal anatomy 
 
5
for a woman who, like Holmes, had previously undergone a 
hysterectomy.  Specifically, he presented expert testimony 
that the alleged focal thickening of the bladder wall was 
actually Holmes’ vaginal cuff, which was a normal finding 
that did not need to be reported by Dr. Levine in his 
report of the February 2003 CT scan.  Moreover, Dr. Levine 
challenged the Administrator’s evidence that Holmes had 
cancer in her bladder in February 2003. 
In support of the latter position, Dr. Levine 
presented testimony from Dr. Baruch M. Grob, an expert in 
the field of urology and in the diagnosis and treatment of 
cancer involving the urinary tract.  Dr. Grob opined that, 
based on his review of Holmes’ medical records, her cancer 
began in her periurethral space and that in February 2003 
she did not have bladder cancer.  On cross-examination, the 
Administrator challenged Dr. Grob’s conclusion by asking 
about the cause of death listed on Holmes’ death 
certificate.1  The following exchange occurred: 
Q  Doctor, Mrs. Holmes died of bladder cancer, 
true? 
 
A  Not in my opinion, no. 
 
                     
1 Dr. Levine had objected to the death certificate’s 
introduction into evidence before trial on the basis that 
it lacked probative value, prejudiced his defense, and 
contained hearsay.  The record on appeal does not reflect 
the trial court’s ruling on this pre-trial objection. 
 
6
Q  You have looked at the medical records? 
 
A  Yes. 
 
Q  What is the cause of death on the death 
certificate signed by the physician? 
 
A  Well, death certificates can only use the 
information they have available. 
 
Q  What does it say, Doctor? 
 
Dr. Levine objected to the last question, arguing that it 
called for hearsay and that a death certificate is not a 
medical record.  The trial court overruled the objection.  
Dr. Grob then read the cause of death listed in Holmes’ 
death certificate:  “Bladder cancer, metastatic.” 
At the conclusion of his evidence, Dr. Levine renewed 
his objection to Dr. Grob’s testimony recounting the cause 
of death stated in the death certificate and moved the 
trial court to strike that testimony because it was 
hearsay.  The trial court granted the motion and instructed 
the jury not to consider that particular testimony. 
Dr. Levine also presented portions of a videotaped 
deposition of Dr. Nancy A. Huff, Holmes’ treating urologist 
from November 2002 through April 2003.  Holmes initially 
complained to Dr. Huff about unusual urinary frequency.  
Dr. Huff said she obtained a urinalysis, which did not 
 
7
reveal the presence of blood in Holmes’ urine.2  Dr. Huff 
testified that another urinalysis performed during Holmes’ 
emergency room visit in February 2003 showed “an occasional 
red blood cell per high-powered field.” 
Dr. Levine agreed to redact certain portions of Dr. 
Huff’s videotaped deposition.  As relevant to this appeal, 
Dr. Levine redacted a question asking Dr. Huff, during 
direct examination, whether she considered the red blood 
cells in Holmes’ urine to be hematuria, as well as Dr. 
Huff’s answer: “I did not consider this to be significant 
hematuria.  She only had an occasional red blood cell per 
high-powered field.”  However, Dr. Levine did not agree to 
redact the following exchange that occurred during the 
Administrator’s cross-examination of Dr. Huff: 
Q  The question that was originally asked of you 
was whether or not at the time you considered the 
presence of red blood cells in the urine to be 
hematuria.  Your answer was you did not believe it to 
be significant hematuria. 
 
And my question is:  Was it hematuria? 
 
. . . 
 
A  I did not think that an occasional red blood 
cell would qualify for microscopic hematuria. 
 
                     
2 Evidence presented by both parties established that 
the presence of blood in a patient’s urine is correlative 
with the presence of bladder cancer in the patient. 
 
8
In a motion in limine, the Administrator argued this 
exchange was inadmissible because Dr. Huff’s testimony 
amounted to a medical diagnosis not documented in Holmes’ 
medical records and not stated to a reasonable degree of 
medical probability.  He also asserted that, since the 
question had been asked on cross-examination only as a 
follow-up to the earlier, redacted question by Dr. Levine, 
it likewise should have been redacted.  In opposing the 
motion, Dr. Levine argued that Dr. Huff was, for the most 
part, reading from her records concerning Holmes and was 
not rendering a medical diagnosis; rather, she was 
testifying to observations, signs, and symptoms documented 
in the record, as allowed under Code § 8.01-399(B).  The 
trial court denied the motion and admitted that portion of 
Dr. Huff’s testimony. 
After the close of all the evidence, the parties 
proffered jury instructions.  As pertinent to this appeal, 
they presented differing instructions on the issue of 
proximate cause.  The Administrator’s requested 
instruction, identified as Instruction No. 9, read, “A 
proximate cause of an injury or damage is a cause which in 
natural and continuous sequence produces the injury or 
damage.  It is a cause without which the injury would not 
have occurred.  There may be more than one proximate cause 
 
9
of an event.”  In nearly identical terms, save the last 
sentence, Dr. Levine proffered Instruction No. F, which 
stated, “A proximate cause of a death is a cause that in 
natural and continuous sequence produces the death.  It is 
a cause without which the death would not have occurred.”  
The trial court gave the jury Dr. Levine’s instruction and 
the administrator objected to the failure to give 
Instruction No. 9.3 
 
The issue of proximate cause was the subject of a 
question from the jury during the course of its 
deliberations.  Specifically, the written question read, “A 
jury member is deadlocked on Instruction B, Issue 2 that 
all other jury members are in agreement.  What is the 
course of action?”4  The trial court did not answer the 
question; rather, it summoned the jurors into the 
                     
3 During argument at trial concerning the difference 
between the two proffered proximate cause jury 
instructions, the Administrator did not object to the 
wording of Dr. Levine’s instruction but insisted that it 
should include the last sentence of his requested 
instruction: “There may be more than one proximate cause of 
an event.” 
4 Instruction B advised the jury that the issues in the 
case were: 
(1) Did Dr. Levine fail to use the degree of skill 
and diligence required of a reasonably prudent 
radiologist practicing in the Commonwealth of 
Virginia in his treatment of . . . Holmes? 
(2) If so, was that failure a proximate cause of 
. . . Holmes’ death? 
 
10
courtroom, asked them whether they could reach a verdict if 
they deliberated further, and instructed them to go back to 
the jury room and answer the court’s question. 
 
When the jury returned to the courtroom, however, it 
had reached a verdict in favor of Dr. Levine.  On the 
verdict form, there appeared a handwritten notation saying, 
“We find that Dr. Levine failed to use the degree of skill 
and diligence required of a reasonably prudent radiologist 
in the Commonwealth of Virginia in his treatment of . . . 
Holmes.  We did not find that this failure was a proximate 
cause of . . . Holmes [sic] death.” 
The Administrator moved the trial court to set aside 
the jury verdict, grant judgment in his favor on the issue 
of liability, and order a new trial on the issues of 
causation and damages.  The trial court denied the motion 
and entered judgment for Dr. Levine in accordance with the 
jury verdict.  The Administrator appeals from that 
judgment. 
II. ANALYSIS 
On appeal, the Administrator raises four assignments 
of error.  In the first assignment of error, the 
Administrator challenges the trial court’s evidentiary 
                                                             
(3) If the plaintiff is entitled to recover, what is 
the amount of his damages? 
 
11
ruling admitting Dr. Huff’s testimony about hematuria.  The 
trial court’s evidentiary ruling striking Dr. Grob’s 
testimony about the cause of death listed in the death 
certificate is the subject of the second assignment of 
error.  The third assignment of error contests the trial 
court’s refusal to give the Administrator’s jury 
instruction on the issue of proximate causation, and the 
fourth assignment of error attacks the sufficiency of the 
evidence.  With regard to the third assignment of error, we 
conclude the trial court committed reversible error and 
that we must therefore remand this case for a new trial.  
We will also address the first and second assignments of 
error since they present issues that may arise again upon 
retrial.  See Lopez v. Dobson, 240 Va. 421, 424, 397 S.E.2d 
863, 865 (1990) (addressing issue that may arise again upon 
retrial). 
A. Proximate-Cause Jury Instruction 
 
The Administrator argues the trial court improperly 
refused to grant a jury instruction that would have enabled 
him to argue to the jury that it did not need to find Dr. 
Levine’s alleged negligence was the only proximate cause of 
Holmes’ death.  For his part, Dr. Levine contends the 
instructions granted by the trial court, taken together, 
sufficiently advised jurors that the Administrator had to 
 
12
prove only that Dr. Levine’s breach of the standard of care 
was “a” proximate cause of Holmes’ death.5 
 
As we have made clear in the past, “[a] litigant is 
entitled to jury instructions supporting his or her theory 
of the case if sufficient evidence is introduced to support 
that theory and if the instructions correctly state the 
law.”  Schlimmer v. Poverty Hunt Club, 268 Va. 74, 78, 597 
S.E.2d 43, 45 (2004); accord Honsinger v. Egan, 266 Va. 
269, 274, 585 S.E.2d 597, 600 (2003).  The evidence 
introduced in support of a requested instruction “must 
amount to more than a scintilla.”  Schlimmer, 268 Va. at 
78, 597 S.E.2d at 45 (citing Justus v. Commonwealth, 222 
Va. 667, 678, 283 S.E.2d 905, 911 (1981)).  “If a proffered 
instruction finds any support in credible evidence, its 
refusal is reversible error.”  McClung v. Commonwealth, 215 
Va. 654, 657, 212 S.E.2d 290, 293 (1975). 
The Administrator’s position at trial was that there 
were two proximate causes of Holmes’ death: the cancer 
itself and, separately, the delay in diagnosis occasioned 
by Dr. Levine’s alleged breach of the standard of care, 
which deprived Holmes of a significantly better chance of 
survival.  Both factors find support in the evidence 
                     
5 We observe that Dr. Levine did not argue this point 
at trial.  To the contrary, he asserted that “there can be 
 
13
admitted at trial, which we review in the light most 
favorable to the refused instruction’s proponent.  
Honsinger, 266 Va. at 274, 585 S.E.2d at 600.  The 
testimony of Drs. Pfeffer and Denmeade clearly provided 
“more than a scintilla” of evidence to support the 
Administrator’s theory of his case.  Both opined that the 
delay in diagnosing Holmes’ cancer caused by Dr. Levine’s 
failure to report the focal thickening in Holmes’ bladder 
significantly reduced her chance of survival.  Further, the 
Administrator’s requested instruction was an accurate 
statement of settled law in Virginia holding, “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). 
 
Dr. Levine, however, argues that the additional 
sentence in the Administrator’s version of the proximate-
cause instruction would have been duplicative of other 
instructions given by the trial court.  He contends the use 
of the indefinite article “a” to modify the element of 
proximate cause in other jury instructions fully covered 
the principle of law and adequately apprised the jury that 
it could find Dr. Levine liable notwithstanding the 
possibility of other proximate causes of Holmes’ death.  A 
                                                             
only one proximate cause of [Holmes’] death.” 
 
14
closer look at the record reveals, however, the trial court 
also used the definite article “the” when instructing the 
jury that “[t]he burden is upon the plaintiff to prove by a 
preponderance of the evidence that Dr. Levine was negligent 
and that any such negligence was the proximate cause of the 
death of . . . Holmes.”  Thus, we cannot say that the 
granted instructions fully and fairly covered the principle 
of proximate causation as it pertained to the evidence in 
the record.  See Poliquin v. Daniels, 254 Va. 51, 59, 486 
S.E.2d 530, 535 (1997) (a trial court does not abuse its 
discretion by refusing to give a jury instruction related 
to the same legal principle that is fully and fairly 
covered by other instructions). 
In light of the Administrator’s theory of the case and 
the evidence in support of that theory, we conclude that 
the trial court erred by refusing to include in the 
instruction on proximate cause the additional sentence 
requested by the Administrator.  For that reason, we must 
remand this case for a new trial. 
B. Dr. Huff 
The Administrator argues that Dr. Huff’s testimony 
stating she “did not think that an occasional red blood 
cell would qualify for microscopic hematuria” was 
inadmissible under Code § 8.01-399(B).  Consequently, he 
 
15
contends the trial court committed reversible error when it 
admitted the testimony into evidence, and again when it 
failed to correct the problem by setting aside the verdict 
and ordering a new trial.  In relevant part, Code § 8.01-
399(B) states: 
If the physical or mental condition of the 
patient is at issue in a civil action, the 
diagnoses, signs and symptoms, observations, 
evaluations, histories, or treatment plan of the 
practitioner, obtained or formulated as 
contemporaneously documented during the course of 
the practitioner’s treatment, together with the 
facts communicated to, or otherwise learned by, 
such practitioner in connection with such 
attendance, examination or treatment shall be 
disclosed but only in discovery pursuant to the 
Rules of Court or through testimony at the trial 
of the action. . . . Only diagnosis offered to a 
reasonable degree of medical probability shall be 
admissible at trial. 
 
At issue in this appeal are the portions of this 
subsection referring to “diagnoses, signs and symptoms, 
observations, evaluations, histories, or treatment plan” 
that are “contemporaneously documented during the course of 
the practitioner’s treatment” and the requirement that a 
diagnosis must be “offered to a reasonable degree of 
medical probability” in order for it to be admissible at 
trial.  Code § 8.01-399(B) (emphasis added).  The 
Administrator contends that the portion of Dr. Huff’s 
testimony at issue was not contemporaneously documented in 
Holmes’ medical records and constituted a diagnosis not 
 
16
offered to a reasonable degree of medical probability.  For 
both reasons, the Administrator argues the testimony was 
inadmissible.  Dr. Levine contends the challenged testimony 
was not a medical diagnosis but, instead, merely reflected 
Dr. Huff’s impressions and conclusions reached during her 
treatment of Holmes.  Dr. Levine also argues that the 
absence of a notation in the medical records about 
hematuria did not render Dr. Huff’s testimony inadmissible. 
In Pettus v. Gottfried, 269 Va. 69, 606 S.E.2d 819 
(2005), we addressed both of these statutory provisions.6  
In that wrongful-death case, the plaintiff alleged that the 
defendant-doctor misdiagnosed the decedent’s chest pain and 
negligently discharged the decedent from a hospital 
emergency room.  Id. at 73, 606 S.E.2d at 822.  A few days 
later, a cardiologist admitted the decedent to the hospital 
although the decedent was free of chest pain at that time.  
Id. at 72, 606 S.E.2d at 822.  The next morning, the 
decedent’s mental status became a matter of concern, and 
after the cardiologist ordered a neurology consultation, 
                     
6 Since our decision in Pettus, the General Assembly 
amended Code § 8.01-399(B).  2005 Acts chs. 649, 692.  As 
pertinent to the case before us, the first sentence in the 
prior version of Code § 8.01-399(B) referred only to 
documentation of a practitioner’s “diagnosis or treatment 
plan.”  The General Assembly did not make any changes in 
the language that “[o]nly diagnosis offered to a reasonable 
 
17
the decedent had a seizure and died.  Id. at 72−73, 606 
S.E.2d at 822.  The defendant introduced the cardiologist’s 
deposition testimony, which stated that, during the course 
of treating the decedent, the cardiologist formed an 
opinion that the cause of the abrupt change in the 
decedent’s mental status could have been “a central nervous 
system event.”  Id. at 73, 77, 606 S.E.2d at 822, 824. 
The plaintiff argued that the cardiologist’s testimony 
that the decedent’s mental disorientation “could have been” 
a central nervous system event was inadmissible because it 
was a diagnosis not offered to a reasonable degree of 
medical probability.  The plaintiff also asserted that the 
testimony was inadmissible because it deviated from the 
cardiologist’s entries in the decedent’s medical records.  
We rejected both arguments. 
First, we concluded that the testimony, which was 
given in response to the defendant’s question about whether 
the cardiologist had formed an opinion about the cause of 
the decedent’s change in mental status, “was factual in 
nature because it served to explain the impressions and 
conclusions [the cardiologist] reached while treating [the 
decedent].”  Id. at 77-78, 606 S.E.2d at 824-25.  We 
                                                             
degree of medical probability shall be admissible at 
trial.”  Code § 8.01-399(B). 
 
18
further stated that the testimony was neither an expert 
medical opinion offered at trial nor a diagnosis.  Id. at 
78, 606 S.E.2d at 825.  Thus, we concluded the challenged 
testimony “was not subject to the general rule that a 
medical expert opinion must be rendered to a reasonable 
degree of medical probability.”  Id. 
We reach the same conclusion with regard to the 
challenged portion of Dr. Huff’s testimony.  Her testimony, 
like that of the cardiologist in Pettus, must be read in 
context.  Dr. Huff testified that the February 20, 2003 
urinalysis showed “an occasional red blood cell per high-
powered field.”  Her subsequent testimony, stated in the 
past tense and in response to the Administrator’s question 
whether the level of red blood cells present in Holmes’ 
urine specimen was hematuria, reflected Dr. Huff’s 
impression reached at the time she was treating Holmes.  
Like the cardiologist in Pettus, she was not offering a 
diagnosis or her present medical expert opinion about the 
clinical significance of the results of Holmes’ urinalysis.  
Instead, she was merely stating that, at the time she 
received the urinalysis results, she did not think the 
presence of a few red blood cells in Holmes’ urine was 
clinically significant or tantamount to microscopic 
hematuria. 
 
19
In Pettus, we further disagreed with the plaintiff’s 
argument that the cardiologist’s testimony deviated from 
the entries in the relevant medical records.  Id. at 78, 
606 S.E.2d at 825.  As we explained, the decedent’s medical 
records prepared by the cardiologist referred “to the 
possibility of a central nervous system embolic event.”  
Id.  We concluded that any difference between the “written 
entry and [the cardiologist’s] testimony did not affect the 
admissibility of the testimony.”7  Id.  While the plaintiff 
argued that Code § 8.01-399(B) limited the scope of 
admissible trial testimony by a treating physician, it was 
not necessary to decide that issue because, as already 
noted, the documentation in the decedent’s medical records 
mentioned a central nervous system event. 
Similarly, in the case before us, it is not necessary 
to determine whether the provisions of Code § 8.01-399(B) 
merely specify the nature of confidential physician-patient 
information that must be disclosed in discovery or through 
trial testimony when a patient’s physical or mental 
condition is at issue in a civil action or whether the 
statute states an outside limit on the scope of trial 
                     
7 With regard to an objection in Pettus that another 
treating physician’s testimony was not admissible under 
Code § 8.01-399(B), there was an inadequate record on 
 
20
testimony by a treating physician.  This is so because the 
results of the February 20, 2003 urinalysis were in Holmes’ 
medical records and showed only a “trace” of blood in her 
urine.8  As in Pettus, any distinction between the 
documentation in Holmes’ medical records and Dr. Huff’s 
testimony that the presence of a few red blood cells did 
not qualify as microscopic hematuria “did not affect the 
admissibility of the testimony but was a proper subject for 
cross-examination of the witness.”  269 Va. at 78, 696 
S.E.2d at 825.  Thus, we conclude that the trial court did 
not abuse its discretion in admitting the challenged 
portion of Dr. Huff’s deposition testimony.9  See Gray v. 
Rhoads, 268 Va. 81, 86, 597 S.E.2d 93, 96 (2004) (“A trial 
court’s exercise of discretion to admit or exclude evidence 
will not be overturned on appeal unless the court abused 
its discretion.”) 
C. Cause of Death 
 
The Administrator claims the trial court properly 
applied Code § 8.01-401.1 when it initially allowed Dr. 
                                                             
appeal to address the merits of the argument.  269 Va. at 
81, 606 S.E.2d at 827. 
8 We note that one of Dr. Levine’s expert witnesses 
testified that blood in the urine is synonymous with the 
term “hematuria.” 
9 We find no merit in the Administrator’s argument that 
the challenged portion of Dr. Huff’s testimony should not 
 
21
Grob to testify about the cause of death set forth in 
Holmes’ death certificate, but that it erred when it later 
reversed its decision and directed the jury to disregard 
that testimony.  He argues that, since Dr. Grob testified 
he had reviewed Holmes’ medical records in the course of 
arriving at his conclusions that she did not have bladder 
cancer in February 2003 and that the cancer originated in 
her periurethral space, the provisions of Code § 8.01-401.1 
permit an inquiry on cross-examination into “the . . . 
facts or data” underlying Dr. Grob’s opinions, especially 
those that did not support his conclusions.10  Further, the 
Administrator contends that Dr. Levine’s objection, 
predicated on our holding in McMunn v. Tatum, 237 Va. 558, 
379 S.E.2d 908 (1989), was misplaced because, according to 
the Administrator, that decision restricted an expert 
witness from testifying only during direct examination as 
to hearsay matters of opinion upon which the expert relied 
in reaching his own opinion. 
                                                             
have been admitted simply because Dr. Levine agreed to 
redact other portions of her testimony on the same subject. 
10 This Court has held that a death certificate is not 
“competent to show the cause of [a] decedent’s death” 
because, when offered for that purpose, it merely 
represents “the expression of an opinion by the physician 
signing the certificate.”  Edwards v. Jackson, 210 Va. 450, 
453, 171 S.E.2d 854, 856 (1970). 
 
22
 
To resolve the issue about Dr. Grob’s testimony, we 
need not determine the extent of the holding in McMunn 
because the contents of the death certificate were not 
facts or data upon which Dr. Grob relied in forming his 
opinions.  The relevant statute states, in pertinent part: 
In any civil action any expert witness may 
give testimony and render an opinion or draw 
inferences from facts, circumstances or data made 
known to or perceived by such witness at or 
before the hearing or trial during which he is 
called upon to testify.  The facts, circumstances 
or data relied upon by such witness in forming an 
opinion or drawing inferences, if of a type 
normally relied upon by others in the particular 
field of expertise in forming opinions and 
drawing inferences, need not be admissible in 
evidence. 
 
The expert may testify in terms of opinion 
or inference and give his reasons therefor 
without prior disclosure of the underlying facts 
or data, unless the court requires otherwise.  
The expert may in any event be required to 
disclose the underlying facts or data on cross-
examination. 
 
Code § 8.01-401.1 (emphasis added).  The record is devoid 
of any evidence that Dr. Grob relied on the death 
certificate and its statement as to the cause of Holmes’ 
death in forming his opinions about which he testified.  
The only foundation laid by the Administrator for 
introducing the cause of death stated in the death 
certificate was that Dr. Grob had “looked at the medical 
records.”  From his comment that “death certificates can 
 
23
only use the information they have available,” it is clear 
that Dr. Grob discounted the document’s persuasiveness and 
did not rely upon it in forming his opinions.  Thus, we 
conclude the trial court did not abuse its discretion in 
striking Dr. Grob’s hearsay testimony.11  Our conclusion, 
however, does not mean that the Administrator was precluded 
from cross-examining Dr. Grob about whether he relied on 
the death certificate in formulating his opinions and, if 
not, why he discounted the information contained in the 
death certificate. 
CONCLUSION 
 
For the reasons stated, we will reverse in part, and 
affirm in part, the circuit court’s judgment and remand the 
case for a new trial on all issues consistent with the 
principles expressed in this opinion.12 
Reversed in part, 
affirmed in part, 
 
 
 
 
 
   and remanded. 
                     
11 We reject the Administrator’s argument that the 
trial court’s striking that portion of Dr. Grob’s testimony 
deprived him of the opportunity to test Dr. Grob’s 
credibility and to cross-examine him for bias. 
12 In light of our decision, we do not address the 
Administrator’s fourth assignment of error.