Title: Powell v. Margileth

State: virginia

Issuer: Virginia Supreme Court

Document:

Present: Carrico, C.J., Compton, Lacy, Hassell, Keenan, Koontz, 
JJ., and Poff, Senior Justice 
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MARY ESTELLA POWELL, 
EXECUTRIX OF THE ESTATE OF 
WILLIAM G. POWELL, JR., DECEASED 
 
 
 
OPINION BY 
v.  Record No. 990319 
SENIOR JUSTICE RICHARD H. POFF 
 
 
 
January 14, 2000 
ANDREW MARGILETH, M.D. 
 
 
FROM THE CIRCUIT COURT OF THE CITY OF FREDERICKSBURG 
John W. Scott, Jr., Judge 
 
 
This litigation commenced in January 1994 when William G. 
Powell, Jr., (Powell) filed a motion for judgment against Dr. C. 
R. Massey, III, and Dr. Andrew Margileth alleging medical 
malpractice.  Following Powell's death in 1995, his widow, Mary 
Estella Powell, qualified as executrix of his estate, and the 
trial court converted the case into a wrongful death action. 
 
At the first trial of the case, the executrix non-suited 
Dr. Margileth, and the jury returned its verdict in favor of Dr. 
Massey.  In April 1996, the executrix filed a motion for 
judgment against Dr. Margileth alleging that his misdiagnosis 
and treatment of his patient caused Powell's death from cancer-
related pneumonia.  At the second trial conducted in June 1998, 
the trial court granted the defendant's motion to strike the 
plaintiff's evidence, and we awarded the plaintiff an appeal 
from the judgment entered on that ruling. 
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We will review the chronology of the facts in evidence 
related to questions presented by the plaintiff's assignment of 
error. 
 
On January 9, 1992, Dr. Massey, a specialist in 
otolaryngology, measured a node in Powell's neck as 4 cm x 3 cm 
and ordered a CT scan.  As interpreted by a radiologist, the 
scan conducted January 11, 1992 indicated that the size of the 
"left cervical mass . . . is due to an enlarged internal jugular 
node which most likely is an abscess . . . ." 
 
On January 14, 1992, Dr. Massey aspirated fluid from the  
enlarged node.  Although he discussed the CT scan with Powell 
and ordered cultures, he did not suggest a need for an 
examination to rule out cancer. 
 
Because Powell had told him that he had experienced some 
exposure to cats, Dr. Massey referred Powell on January 21, 1992 
to Dr. Margileth, an infectious disease specialist experienced 
in the diagnosis and treatment of cat scratch disease.  On 
January 27, 1992, Dr. Margileth performed tests for tuberculosis 
and cat scratch disease and measured the "swelling . . . in the 
left anterior superior neck" as 4.4 x 6 x 2.6 cm.  He advised 
his patient that he had cat scratch disease and prescribed 
antibiotics.  The results of the CT scan had been furnished to 
Dr. Margileth. 
 
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On February 18, 1992, Dr. Massey palpated a nodule in 
Powell's neck which measured 4 x 2.8 cm.  Dr. Massey performed 
another examination on April 7, 1992 in the course of which he 
suggested the possibility of cancer. 
 
In June 1992, Powell discovered a second lump in his neck 
and in July went for help to the Veterans Administration Medical 
Center Hospital.  A needle aspiration of the two lumps diagnosed 
cancer representing a progression from stage III in January 1992 
when the CT scan was conducted to stage IV in July 1992.  Powell 
underwent radiation therapy, surgery, and other treatment but 
died of cancer three years later at the age of 40. 
 
In the case of a wrongful death resulting from medical 
malpractice, the plaintiff must prove a breach of the standard 
of care and a proximate causal relationship between that breach 
and the injury alleged.  Griffett v. Ryan, 247 Va. 465, 470, 443 
S.E.2d 149, 151 (1994); 
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see also St. George v. Pariser, 253 Va. 
329, 484 S.E.2d 888 (1997); 
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Blondel v. Hays, 241 Va. 467, 403 
S.E.2d 340 (1991). 
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When ruling on a defendant's motion to strike the 
plaintiff's evidence, the trial court must draw all reasonable 
inferences the evidence may raise in favor of the plaintiff.  
Hadeed v. Medic–24 Ltd., 237 Va. 277, 285-86, 377 S.E.2d 589, 
593 (1989).  If it appears from the record that such inferences 
are reasonable, then the issues concerning standards of care and 
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proximate cause are questions of fact to be determined by a 
jury. 
 
In a memorandum opinion dated October 6, 1998 explaining 
its decision to grant the defendant's motion to strike the 
plaintiff's evidence, the trial court held that "there is no 
evidence or reasonable inference that would allow a jury of 
reasonable persons to conclude that the Defendant's breaches of 
the standards of care proximately caused the decedent's 
injuries; adversely altered the required method of treatment; or 
adversely affected his rate of survival." 
 
Dr. Francois E. Holder, one of the plaintiff's expert 
witnesses, testified that the defendant's misdiagnosis of cat 
scratch disease caused his patient delay in diagnosis and 
treatment of his cancer from January until July, and that if he 
had been "informed of the possibility of cancer in January, and 
options were offered in terms of biopsy for fine needle 
aspirations, Mr. Powell would have had a diagnosis of cancer 
probably the first week of February."  Asked whether the delay 
was "a direct and proximate cause of the failure of Dr. 
Margileth to comply with the required standard of care," Dr. 
Holder answered, "Yes, it was." 
 
Dr. M. Karim Ali, who had treated Powell at the VA 
Hospital, testified as an expert in the staging, treatment, and 
surgery of cancer.  Asked what would have been Powell's 
 
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"percentage chance of survival for 5 years" if he had "received 
him as a patient based on the January 11, 1992 CAT scan report," 
which identifies the cancer as stage III, Dr. Ali said that 
Powell would have had "[a]round 75 percent" chance of surviving 
5 years compared to the "15 to 20 percent" chance he had in July 
1992. 
 
Dr. Oscar Tercilla, a professor at Medical College of 
Virginia, was qualified as an expert in the staging and 
treatment of cancer, estimating prognosis at the cancer stage, 
and medical treatment caused by failure to make a timely 
diagnosis.  Dr. Tercilla testified as follows: 
If Mr. Powell had been treated in January as opposed to 
July it is my opinion that he had a higher likelihood of 
being controlled of this disease than he had when he 
presented at the VA in July.  Because of that, you would 
have avoided his recurrence which occurred in July of 1993 
with the tumor reappearing in his tonsil and subsequent 
treatment that came from that. 
 
 
Absent a recurrence, the witness agreed "[i]n all 
likelihood" that Dr. Margileth's patient "would still be alive."  
 
Dr. Barbara Kipreos, a pathologist at the VA center, was 
asked her opinion whether, "if Dr. Margileth would have 
requested a fine needle aspirate at the Mary Washington Hospital 
pathology laboratory" in January 1992, "Mr. Powell's cancer 
would have been diagnosed at that time."  In reply, the witness 
 
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said, "Yes, it is my opinion that it would have been diagnosed 
at that time."
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*
 
We disagree with the trial court's ruling that "there is no 
evidence or reasonable inference that would allow a jury of 
reasonable persons to conclude that the Defendant's breaches of 
the standards of care proximately caused the decedent's injuries 
. . . or adversely affected his rate of survival."  Qualified 
experts in the field testified otherwise. 
 
We hold, therefore, that the trial court erred in granting 
the defendant's motion to strike the plaintiff's evidence, and 
we will reverse the judgment entered below and remand the case 
for a new trial in accordance with this opinion. 
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Reversed and remanded. 
 
* The trial court found "no evidence before this court" that 
Powell would have consented to a fine needle aspiration if Dr. 
Margileth had recommended one during his examinations on January 
27 and January 30.  Irrespective of the issue whether such proof 
was required, we note that the record shows that Powell 
consented to such procedure on January 14 when his primary care 
physician, Dr. Massey, aspirated the large node in his neck. 
 
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