Title: First Commercial Trust Co. v. Rank

State: arkansas

Issuer: Arkansas Supreme Court

Document:

FIRST COMMERCIAL TRUST COMPANY, Substitute
Administrator of the Estate of Laura Allison
Fullbright, Deceased v. Joseph John RANK,
Mary Ellen Robbins, and Rheeta Stecker, M.D.

95-518                                             ___ S.W.2d ___

                    Supreme Court of Arkansas
               Opinion delivered February 12, 1996


1.   Evidence -- expert witness -- determination of qualifications.
     -- The determination of an expert witness's qualification is
     within the discretion of the trial judge; this discretion,
     however, is not absolute, and the appellate court will reverse
     if the trial court abuses its discretion.

2.   Evidence -- expert witness -- not critical whether medical
     expert is general practitioner or specialist. -- It is not
     critical whether a medical expert is a general practitioner or
     a specialist so long as he exhibits knowledge of the subject;
     where a duly licensed and practicing physician has gained
     knowledge of the standard of care applicable to a specialty in
     which he is not directly engaged but as to which he has an
     opinion based on education, experience, observation, or
     association with that specialty, his opinion is competent.

3.   Physicians & surgeons -- malpractice statute does not prohibit
     general practitioner from testifying as an expert. -- Where
     the particular issue relates to a question within the general
     practitioner's own area of expertise, he is not prohibited by
     the medical malpractice statute from testifying upon that
     question as an expert.

4.   Evidence -- expert witness -- emergency-medicine physician's
     opinion on standard of care for doctors in detecting and
     reporting child abuse was apposite -- variances in practices
     not pivotal factor in diagnosing child abuse. -- Where an
     emergency-medicine physician testified that the standard of
     care for doctors in detecting and reporting child abuse would
     be the same for emergency-room physicians and family
     practitioners and that no specialized technology available
     only to an emergency-room physician was necessary for these
     evaluations, and where the physician based his opinion on the
     pattern of visits made by the deceased child and her mother
     made to their family doctor's office in June and July 1992 and
     the medical records available, the supreme court saw no reason
     why the physician's opinion would not be apposite and was
     further persuaded that under the circumstances the variances
     in practices would not be a pivotal factor in diagnosing child
     abuse.

5.   Physicians & surgeons -- similar-locality rule -- medical
     expert not disqualified from testifying about child abuse. --
     The supreme court did not view Panama City, Florida, the
     medical expert's home town, as sufficiently dissimilar to Hot
     Springs, where the deceased child's family doctor practiced
     medicine, to disqualify the medical expert from testifying
     about child abuse; the similar-locality rule is not a strict-
     locality rule but incorporates the similar community into the
     picture;  the standard is not limited to that of a particular
     locality but is that of persons engaged in a similar practice
     in similar localities, giving consideration to geographical
     location, size, and character of the community; the similarity
     of communities should depend not on population or area in a
     medical-malpractice case, but rather upon their similarity
     from the standpoint of medical facilities, practices, and
     advantages.

6.   Evidence -- expert witness -- need not be one who has
     practiced in particular locality if appropriate foundation is
     established. -- An expert witness need not be one who has
     practiced in the particular locality or is intimately familiar
     with the practice in it in order to be qualified as an expert
     in a medical malpractice action if an appropriate foundation
     is established to demonstrate that the witness is familiar
     with the standard of practice in a similar locality, either by
     his testimony or by other evidence showing the similarity of
     localities; conclusory statements that the physician is so
     familiar are not enough, but the supreme court determined that
     that was not the situation in the present case.

7.   Evidence -- expert witness -- trial court abused its
     discretion in excluding medical-expert testimony. -- In light
     of the circumstances of the case, the supreme court concluded
     that the trial court abused its discretion in excluding the
     medical expert testimony of the emergency-medicine physician
     and reversed and remanded the matter for a new trial solely
     for the claim made under the Medical Malpractice Act.

8.   Physicians & surgeons -- medical malpractice -- medical injury
     defined -- statute encompasses cause of action for failure to
     diagnose child abuse under facts of case. -- "Medical injury"
     is defined under the Medical Malpractice Act at Ark. Code Ann.
      16-114-201(3) (1987) as "any adverse consequences arising
     out of or sustained in the course of the professional services
     being rendered by a medical care provider, whether resulting
     from negligence, error, or omission in the performance of such
     services; ... or from failure to diagnose, ... or otherwise
     arising out of or sustained in the course of such services";
     the supreme court concluded that this broad language
     encompasses a cause of action for failure to diagnose child
     abuse under the facts of the present case and held that the
     trial court appropriately refused to enter summary judgment in
     favor of appellee family doctor on this point.

9.   Negligence -- causation -- ordinarily a fact question for
     jury. -- Causation is ordinarily a fact question for the jury
     to decide.

10.  Negligence -- causation -- fact issue existed on whether
     failure to diagnose and report child abuse was partial cause
     of child's death. -- While reporting child abuse would lead to
     an investigation that could result in some prophylactic action
     after the State entered the picture, the failure to report
     allows the matter to fester unabated; the supreme court
     concluded that a fact issue for the jury existed in the
     present case on whether the failure to diagnose and report was
     a partial cause of the child's death.

11.  Motions -- directed verdict -- whether family doctor had
     reasonable cause to suspect abuse was issue for resolution by
     jury. -- Regarding appellant Administrator's contention that
     the trial court erred in not directing a verdict in its favor
     on the count of the family doctor's failure to report
     reasonably suspected child abuse under Ark. Code Ann.  12-12-
     507 (Repl. 1995), the supreme court concluded that, while
     there was no doubt that the family doctor had suspicions about
     child abuse, the question was whether she had reasonable cause
     to suspect abuse; that was an issue for resolution by the
     jury, and the jury resolved the issue in favor of the family
     doctor.

12.  Motions -- directed verdict -- supreme court reluctant to
     affirm directed verdict on behalf of a plaintiff -- test not
     met. -- The supreme court is extremely reluctant to affirm a
     directed verdict on behalf of a plaintiff; no matter how
     strong the evidence of a party who has the burden of
     establishing negligence and proximate cause as facts may
     comparatively seem to be, he is not entitled to have those
     facts declared to have reality as a matter of law, unless
     there is utterly no rational basis in the situation,
     testimonially, circumstantially, or inferentially, for a jury
     to believe otherwise; the supreme court declared that the test
     was not met in this case and held that the trial court
     committed no error in denying appellee Administrator's motion
     for a directed verdict.

13.  Appeal & error -- prevailing party cannot appeal. -- The
     family doctor's cross-appeal on the "willful" component of the
     child-abuse-reporting statute was not entertained by the
     supreme court because she prevailed on that claim.


     Appeal from Garland Circuit Court; Walter G. Wright, Judge;
affirmed in part; reversed in part and remanded.
     Gary Eubanks & Associates, by: James Gerard Schulze and
William Gary Holt, for appellant/cross-appellee.
     D. Scott Hickam, for appellees/cross-appellants Joseph John
Rank and Mary Ellen Robbins.
     Friday, Eldredge & Clark, by: Tonia P. Jones, for
appellee/cross-appellant Rheeta Stecker.

     Robert L. Brown, Justice.Associate Justice Robert L. Brown
February 12, 1996 *ADVREP9*



FIRST COMMERCIAL TRUST COMPANY,
SUBSTITUTE ADMINISTRATOR OF THE
ESTATE OF LAURA ALLISON
FULLBRIGHT, DECEASED,
                    APPELLANT/
               CROSS-APPELLEE,

V.

JOSEPH JOHN RANK, MARY ELLEN
ROBBINS, AND RHEETA STECKER,
M.D.,
                    APPELLEES/
             CROSS-APPELLANTS,

95-518




APPEAL FROM THE GARLAND COUNTY
CIRCUIT COURT,
NO. CIV 93-523,
HON. WALTER G. WRIGHT, JUDGE,



AFFIRMED IN PART; REVERSED IN
PART AND REMANDED.





     The appellant, First Commercial Trust Company, Administrator
of the Estate of Laura Fullbright, appeals from a judgment in favor
of appellee Dr. Rheeta Stecker, who was the family doctor for Laura
Fullbright and her mother, Mary Ellen Robbins.  The Administrator
asserts that the trial court abused its discretion in refusing to
allow a medical expert, Dr. Frederick Epstein, to testify with
respect to the standard of medical care regarding child abuse in
Hot Springs.  We agree that this was error, and we reverse the
judgment in favor of Dr. Stecker and remand the matter for a new
trial on the medical negligence count.  We affirm the judgment in
favor of Dr. Stecker on the count relating to failure to report
under the child abuse reporting statute, and we hold that the
refusal of the trial court to direct a verdict on this count in
favor of the Administrator was not error.
     On June 12, 1992, Mary Ellen Robbins took her 12 1/2-month-old
baby, Laura Fullbright, to Dr. Rheeta Stecker for a "well-baby
checkup."  Robbins was a pharmacist and had been a patient herself
of Dr. Stecker's for approximately five years.  Dr. Stecker
referred to her as a "colleague."  During that checkup, Dr. Stecker
noticed that Laura's forearm was angulated and swollen, but upon
checking, she determined that it was not tender and there was no
bruising.  An X-ray showed that there was a fracture to both of the
bones of the lower left arm.  Robbins and her boyfriend, Joe Rank,
stated that they did not know what had caused the fractures.  Dr.
Stecker then referred Robbins to Dr. Robert Olive, an orthopedic
surgeon, to assure that the bone would heal properly.  At that
time, Dr. Stecker believed that there was a possibility the child
had been neglected, and that belief was communicated to Dr. Olive. 
After treating Laura, Dr. Olive stated in a letter to Dr. Stecker
that the bones would heal nicely and that there did not appear to
be any evidence of neglect.
     On July 9, 1992, Robbins visited Dr. Stecker's office again. 
During that visit, Robbins complained that Laura was "wobbly" and
unbalanced.  Dr. Stecker did not find any signs of head trauma. 
Dr. Stecker decided that Robbins had given Laura too much juice. 
Because Laura had been on multiple antibiotics frequently for a
chronic ear infection, Dr. Stecker opined that there might be an
overabundance of yeast in her stomach, causing her to become
intoxicated.
     On July 21, 1992, Robbins returned with Laura again.  Dr.
Stecker was not there, but her husband, Dr. Elton Stecker, was
present and treated Laura.  Dr. Elton Stecker's records state that
Laura had been nauseated the previous day and had vomited that
morning.  When the child awoke, there was swelling on the right
side of the head in the temple area and over the right eye. 
Robbins told Dr. Elton Stecker that the bruise above the right ear
was caused by a fall the week before.
     The next morning, on July 22, 1992, Robbins made two phone
calls to the Stecker clinic.  In the first of those calls, she
stated that she believed Laura was having an allergic reaction and
that the swelling over the right eye had gone down but that the
other eye had become swollen.  Later on that morning, Robbins
called and stated that both eyes seemed to be swollen and that
Laura was running a temperature of approximately 99.5 degrees.  She
was told by the nurse to bring Laura in.
     When Laura was brought into the clinic, Dr. Rheeta Stecker
examined her.  Prior to this examination, she referred to the notes
taken by her husband the previous day.  Both of Laura's eyes now
appeared to be swollen, and there was some purplish discoloration. 
Robbins informed Dr. Stecker that the child had fallen down several
stairs the week before and that several of the bruises were related
to that fall.  Robbins asked if the swelling of the upper lids
could be related to allergies or to spider bites.  Robbins told her
that Laura had had a watery nasal discharge for the last few days
which she thought was due to an allergy.  At that point, Dr.
Stecker discussed the possibility of abuse with Robbins.  Robbins
informed her that it was highly unlikely, but that her son,
Matthew, might have dropped Laura.  She further stated that her
boyfriend, Joe Rank, was not the type to have a bad temper.  Dr.
Stecker did not report her suspicions to the Arkansas Department of
Human Services.
     On September 12, 1992, Robbins was working and left Laura with
Joe Rank.  When she returned Rank informed her that Laura was
taking a nap and that she had fallen down in the driveway.  When
Robbins went to wake Laura from her nap, she found Laura lying in
bed and moving her head from side to side.  When she took a closer
look, she saw what appeared to be either juice or blood draining
from the corner of her mouth.  When she picked Laura up, the child
was limp.  She immediately took Laura to St. Joseph's Regional
Health Center in Hot Springs.  At St. Joseph's, Laura was not
breathing and did not have a pulse.  She was transported to
Arkansas Children's Hospital in Little Rock where she was later
pronounced dead. 
     The medical examiner, Dr. William Sturner, determined that the
cause of death was homicide.  He found four bruises on the child's
scalp and bruises on her left hand and arm.  He also found abraded
contusions on the mid-chest of the body and on the face, forehead,
the right eyebrow, and the right cheek.  The most significant
injury, he concluded, was a fracture to the child's skull, with
corresponding brain damage.  Dr. Sturner opined that those injuries
would have had to have been caused by a marked or severe force.
     Suit was commenced on behalf of Laura's estate.  The suit
alleged that Joe Rank intentionally assaulted Laura Fullbright and
that her mother, Mary Ellen Robbins, negligently placed Laura in
the care of Rank with the knowledge of his past abusive behavior. 
Medical negligence was alleged against Dr. Rheeta Stecker in
addition to her failure to report her suspicions of child abuse
under the child abuse reporting statute.  Prior to trial, Dr.
Stecker moved twice for summary judgment on the basis that the
alleged actions on her part were not violative of the child abuse
reporting statute.  The second motion included a prayer for summary
judgment on the medical malpractice claim against her.  The trial
court denied the motions.
     The case went to trial, and the trial court, at the conclusion
of the plaintiff's case, granted a partial directed verdict in
favor of Rheeta Stecker on the issue of medical malpractice after
refusing to allow the plaintiff's expert, Dr. Frederick Epstein, to
testify as to the standard of medical care concerning child abuse
in Hot Springs.  The case proceeded on the remaining issues, and
the jury returned a verdict against Joe Rank in favor of Matthew
Robbins, Laura's half-brother, in the amount of $1,000,000.  The
jury found in favor of Mary Ellen Robbins and Dr. Rheeta Stecker on
the remaining failure to report count.  Judgment was entered
accordingly.

                    I. Medical Expert Witness
     The Administrator's first argument is the trial court erred in
excluding the testimony of Dr. Frederick Epstein on the standard of
care for diagnosing child abuse in Hot Springs, as required by the
Medical Malpractice Act and specifically by Ark. Code Ann.  16-
114-206(a)(1) (1987).  Dr. Epstein testified that he was an
emergency medicine physician from Panama City, Florida.  His
curriculum vitae confirmed that he was a highly qualified
physician.
     Dr. Epstein testified that Panama City had a population of
approximately 80,000 people.  He further testified that in terms of
the medical facilities available, Panama City was "very similar" to
Hot Springs and that he was unaware of any facilities needed to
detect possible child abuse that would have been available in
Panama City but not available in Hot Springs.  He added that he was
familiar with the type of practice in which Dr. Stecker was
involved and had formulated an opinion about the standard of care. 
At that point, the Administrator requested Dr. Epstein's opinion on
whether or not Dr. Stecker breached the standard of care.
     Prior to the opinion being rendered, Dr. Stecker's attorney
asked to voir dire the witness on his qualifications.  Dr. Epstein
admitted that he was an emergency room specialist rather than a
family practitioner and that he did not practice family medicine. 
He added that the difference in the two specialties was that family
practitioners have an on-going doctor/patient relationship and that
that was usually not present in emergency room practice.  He
testified, nevertheless, that the standard of care for doctors in
detecting and reporting child abuse would be the same for both
emergency room physicians and family practitioners.  Counsel for
Dr. Stecker then objected to the admission of Dr. Epstein's opinion
on the standard of care relating to diagnosis of child abuse on
grounds of dissimilar practice and locality.  The trial court
conditionally granted Dr. Stecker's motion to exclude the expert
testimony but allowed the Administrator to make a proffer of proof.
     The Administrator first proffered the testimony of Dr. Stecker
concerning the medical community in Hot Springs.  Dr. Stecker,
under questioning by the Administrator's counsel, testified that
Hot Springs, a community with a population of approximately 35,000,
had two acute and two subacute hospitals.  One of the acute
hospitals usually had an occupancy of about 120 beds, although it
had a capacity of around 270.  The other acute care hospital had a
capacity of closer to 70 beds, although it had an average occupancy
of about 60 patients.  Dr. Stecker testified that although the
hospitals were located in Hot Springs, both of the hospitals drew
patients from throughout Garland County.  She also testified that
there were approximately 150 physicians in Hot Springs, eight or
nine of whom were pediatricians.  She added that the only equipment
needed in the evaluation of Laura Fullbright was X-ray equipment
and possibly a CT scanner, both of which were available to her. 
She further testified that the injuries that she encountered in her
examination of Laura Fullbright were injuries that might be treated
by an emergency room physician.
     After Dr. Stecker's testimony, the Administrator recalled Dr.
Epstein as part of his proffer.  Dr. Epstein opined that based on
the testimony of Dr. Stecker it was his opinion that Panama City
was a comparable locality to Hot Springs.  Dr. Epstein was then
handed a Hot Springs telephone book and was asked if he could draw
any conclusions about the makeup of the medical community based on
the yellow pages.  From that, he testified that the range of
specialties and subspecialties available in Hot Springs was
comparable to the range of specialties available in Panama City. 
He stated that the majority of patients that he encountered in the
emergency room were not suffering from life-threatening injuries
and that, although it was not intended for that purpose, the
emergency room is used by some as a clinic.  Therefore, in reality,
he was able to know some of the patient's families and history as
well as Dr. Stecker might in her family practice.  He added that
sometimes he saw patients as many as three times a month.  He
concluded by stating that his opinion on this case turned more on
the history of the case and the physical examinations than on any
technology that was or was not available to Dr. Stecker.  A Hot
Springs physician, he maintained, would apply the same standards in
taking the history of the case and performing the physical
examination that a Panama City physician would.
     After the Administrator's proffer of Dr. Epstein's
qualifications, the trial court made the following ruling on the
admissibility of Dr. Epstein's opinion testimony:
     The one burdensome thing that concerns the Court is that
     you have a highly skilled expert, emergency room
     practice, has written numerous times, has a curriculum
     that's several pages.  And here is a family practitioner. 
     And I just hesitate to find that that highly skilled
     doctor would know what the standard is here in Hot
     Springs, Arkansas, or this locale.  For that reason, I
     would exclude it.
Dr. Epstein then proffered his opinion that after reviewing the
documentation, he believed Dr. Stecker failed to meet the standard
of care by not reporting the suspected child abuse to investigating
agencies on July 22, 1992.
     The determination of an expert witness's qualification is
within the discretion of the trial judge.  Goodwin v. Harrison, 300
Ark. 474,