Title: Holley v. Pambianco

State: virginia

Issuer: Virginia Supreme Court

Document:

Present:  Hassell, C.J., Lacy, Keenan, Koontz, and Lemons, 
JJ., and Compton and Russell, S.JJ. 
 
DANNY R. HOLLEY 
             OPINION BY 
SENIOR JUSTICE CHARLES S. RUSSELL 
v.  Record No. 042275  
           June 9, 2005 
 
DANIEL J. PAMBIANCO, M.D., ET AL. 
 
FROM THE CIRCUIT COURT OF THE CITY OF CHARLOTTESVILLE 
Paul F. Sheridan, Judge Designate 
 
 
 
This appeal in a medical malpractice case concerns the 
admissibility of evidence tending to prove the inherent risks 
of the treatment that led to the plaintiff’s injury. 
Facts 
 
On November 28, 2000, Danny R. Holley was admitted to 
Martha Jefferson Hospital in Charlottesville as an outpatient 
to undergo a scheduled colonoscopy to be performed by Daniel 
J. Pambianco, M.D., a gastroenterologist.  During the 
colonoscopic examination, Dr. Pambianco discovered two sessile 
polyps in the colon, each about one centimeter in diameter.  
He removed both of them by a “hot biopsy forcep[s]” technique 
in which forceps, threaded through the colonoscope tube, carry 
an electric current to the site in order to cauterize the 
tissue.1 
                     
1 The record shows that a “colonoscopy” is a procedure 
whereby a “colonoscope,” a flexible device containing a light 
source, a series of lenses, and a facility to insert air to 
distend the colon and fluids to wash the lenses, is inserted 
into the colon to permit a thorough examination of its 
 
2
 
Holley was driven home by his wife after the procedure 
and went to bed.  That night he was unable to eat or drink and 
suffered abdominal distension and soreness.  The next day, he 
called Dr. Pambianco’s office, describing his symptoms.  A 
nurse told him that his symptoms were normal and that he 
should walk.  Later that day, the nurse called him and advised 
him to keep walking, to drink hot tea and to take a 
prescription that she would call in to his pharmacy.  His 
symptoms grew worse and on December 3, five days after the 
operation, he called Dr. Pambianco’s office again, describing 
his condition.  This time, Dr. Byrd S. Leavell, a colleague of 
Dr. Pambianco, returned his call and told him to report 
immediately to the emergency room at the hospital.  Upon 
examination, he was found to have a perforated colon leaking 
into the abdominal cavity, causing peritonitis.  He was given 
a colostomy and spent ten days in the hospital, seven of them 
in intensive care.  He was released with a colostomy bag 
attached to his side.  Several months later, he underwent a 
                                                                
interior walls.  The instrument also contains a channel 
through which surgical instruments may be introduced into the 
colon. “Polyps,” sometimes found attached to the interior 
colon walls, are abnormal growths protruding inward.  Because 
they may be or become cancerous, they are removed, if 
possible, during a colonoscopic procedure.  Such a removal is 
called a “polypectomy.”  Polyps may either be “pedunculated” 
(attached to the colon wall by a narrow stem and more easily 
removed) or “sessile” (having a broad base attached to the 
colon wall). 
 
3
third operation to close the colostomy and restore the 
continuity of the colon. 
Proceedings 
 
Holley brought this medical malpractice action against 
Dr. Pambianco and the medical group of which he was a member. 
The case was tried before a jury and resulted in a verdict for 
the defendants.  We awarded Holley an appeal limited to two 
issues:  (1) Whether the trial court erred by admitting 
evidence of the risks of perforation of the colon during a 
colonoscopy and polypectomy and permitting defense counsel to 
argue to the jury, in a case in which informed consent was not 
in issue, that such risks were normal, and (2) whether the 
trial court erred by refusing to instruct the jury that Dr. 
Pambianco’s failure to give the plaintiff discharge 
instructions constituted negligence per se. 
 
In pretrial proceedings, the parties agreed that no 
evidence or argument would be permitted with regard to a lack 
of informed consent and the court entered an order to that 
effect.  Holley filed a motion in limine, requesting the court 
to preclude the admission of any evidence concerning the known 
risks of colonoscopy and polypectomy, any discussion of such 
risks with him, and whether he had any awareness of the risks.  
Holley relied on our recent decision in Wright v. Kaye, 267 
Va. 510, 593 S.E.2d 307 (2004).  There, we held that where a 
 
4
lack of informed consent is not in issue in a medical 
malpractice case, evidence of information given to the patient 
concerning the risks of surgery is irrelevant to the sole 
issue in the case:  Whether the physician departed from the 
standard of care.  We observed that such evidence “could only 
serve to confuse the jury because the jury could conclude 
. . . that consent to the surgery was tantamount to consent to 
the injury. . . .” Id. at 528-29, 593 S.E.2d at 317. 
 
Dr. Pambianco responded by pointing out a difference 
between Wright and the present case.  In Wright, the patient's 
conduct after surgery was not in issue.  Here, the defense 
contends that Holley, having been informed of the risks of 
perforation of the colon, had a duty to mitigate his damages 
by making prompt report of his post-operative symptoms and 
that his four-day delay in doing so greatly exacerbated his 
injuries.  The defense informed the court that the evidence 
would support jury instructions on both mitigation of damages 
and contributory negligence.2 
 
The court took the question under advisement and 
ultimately ruled that the evidence would be admitted only for 
the limited purpose of the defendants’ contentions concerning 
                     
2 The defense ultimately decided not to ask for an 
instruction on contributory negligence.  The court did give 
the jury an instruction covering the plaintiff’s duty to 
"minimize" his damages. 
 
5
mitigation of damages and contributory negligence.  The court 
stated that jury instructions would ensure that the jury would 
not consider such evidence in connection with the plaintiff’s 
contention that the physician had departed from the standard 
of care.3 
 
At trial, Holley introduced an expert witness who 
testified that there are inherent risks in the use of a “hot 
biopsy forceps” technique in the removal of sessile polyps 
because the electric current sufficient to remove the polyp 
tissue may also be strong enough to burn a hole in the wall of 
the colon, particularly in areas where the colon wall is thin.  
It was his opinion that Dr. Pambianco had departed from the 
applicable standard of care by using that technique to remove 
polyps in the transverse colon, where the wall is typically 
thin, and that in the circumstances of this case, the standard 
would have required use of a “cold biopsy technique” instead, 
                     
3 The court gave the following instruction: 
 
 
"During this trial, evidence was introduced 
that Mr. Holley may have received information about 
the risks associated with his colonoscopy.  Whether 
or not Mr. Holley received such information is only 
relevant to the issue of whether Mr. Holley used 
ordinary care to mitigate his damages.  You may not 
consider that evidence on the issue of whether 
defendants breached the applicable standard of care.  
By consenting to the surgery, Mr. Holley did not 
consent to any adverse consequences, known or 
unknown."  
 
6
whereby the polyps would be removed surgically, in small 
pieces, without using an electric current. 
 
In cross-examination of the plaintiff’s expert witness, 
defense counsel elicited the statistical frequency of 
perforations of the colon wall during all colonoscopies and 
polypectomies.  The court overruled the plaintiff’s objection 
to this testimony.  The witness stated that perforations occur 
at the rate of 1 per 10,000 in colonoscopies and 13 per 10,000 
in polypectomies.  During the defendants’ case, defense 
counsel elicited similar testimony from Dr. Pambianco and each 
of the two expert witnesses called in his behalf, although all 
gave differing numbers.  Each of the three expert witnesses, 
however, in response to questioning by plaintiff’s counsel, 
testified that the statistics contained no breakdown between 
those cases involving perforations caused by negligence and 
those that did not. 
 
Over plaintiff’s objection, defense counsel, in his 
closing argument to the jury, referred to this testimony in 
the context of the standard of care:  “I’m arguing 
statistics. . . . [T]hat risk factor cannot be taken out of 
the procedure.  You can do everything exactly the way you’re 
supposed to do it, and you can be absolutely prudent, 
absolutely careful and we still have a situation like that 
that occurred with Mr. Holley.” 
 
7
Analysis 
 
That argument, and the statistical evidence on which it 
was based, had nothing to do with the issue of mitigation of 
damages.  Its admission was error for the reasons discussed in 
Wright. 
 
Further, the argument was based upon a premise 
unsupported by the evidence:  That perforations are just as 
likely to occur in the absence of negligence as in its 
presence.  The statistical evidence was so misleading that, 
for all the jury could determine, each of the perforations of 
the colon contained in the statistics may have been due to a 
physician’s negligence.  In that event, the jury could infer 
the direct opposite of defense counsel’s argument:  That 
perforations occur only where the physician is negligent.  See 
McCloud v. Commonwealth, 269 Va. 242, 259, 609 S.E.2d 16, 25 
(2005) (evidence of a raw number of events, without describing 
their circumstances, can be misleading or confusing to the 
jury); Sanitary Grocery Co. v. Steinbrecher, 183 Va. 495, 499-
500, 32 S.E.2d 685, 686-87 (1945) (evidence that 1,000 
customers per day visited grocery store without injury 
inadmissible as misleading and throwing no light upon the 
facts of the case before the jury).  We conclude that such raw 
statistical evidence is not probative of any issue in a 
medical malpractice case and should not be admitted. 
 
8
 
Because the case must be remanded, we will discuss other 
issues that may arise in any further proceedings in the trial 
court.  The trial court did not err in ruling that the defense 
had the right to attempt to prove that the plaintiff had 
failed to mitigate his damages.  See Sawyer v. Comerci, 264 
Va. 68, 76-77, 563 S.E.2d 748, 753 (2002).  In that 
connection, the defense had the right to adduce competent 
evidence that Holley had been warned of the danger of 
complications that might result from his surgery, of the 
symptoms that would signal such complications, and of the need 
to make prompt report of any such symptoms in order that 
appropriate and timely remedial steps could be taken.  The 
jury would be entitled to consider any failure or undue delay 
on his part in doing so, in the light of his condition at the 
time. 
 
The evidence offered at trial in support of that defense 
included a videotape shown to Holley in Dr. Pambianco’s office 
about six weeks before his colonoscopy. Prepared by the 
American Gastroenterological Association, the tape was less 
than 10 minutes in length and was designed to be shown to 
patients contemplating future colonoscopy.  Generally 
reassuring in tone, the tape contained only two caveats upon 
which the defense relied: 
 
9
Although colonoscopy is a safe procedure, complications 
can occur rarely. These include perforation; that is, 
puncture of the colon wall which could require surgical 
repair. 
 
. . . . 
 
Occasionally minor problems may persist, such as 
bloating, gas or mild cramping.  These should disappear 
in 24 hours or less.4 
 
 
The foregoing language contains no warning to the patient 
that a burden was being imposed upon him to take any post-
operative steps for his own protection.  Its reassuring tone 
was more conducive to the opposite conclusion:  That the 
procedure was "safe," that complications occur "rarely," that 
post-operative problems persist only "occasionally," and that 
if they do they "should disappear in 24 hours or less."  It 
had no tendency to prove that Holley had failed to mitigate 
his damages and its admission was error. 
 
In further support of their defense of failure to 
mitigate damages, the defendants relied on certain post-
operative instructions allegedly given by hospital personnel 
                     
4 By his motion in limine, Holley sought exclusion of the 
entire tape as unrelated to the issue of the standard of care.  
The defense asked for admission only of that portion of the 
tape containing the language quoted above, as relevant to the 
issue of mitigation of damages.  The trial court denied 
Holley's motion and ruled that the portion sought by the 
defense would be admitted, but advised counsel that the entire 
tape would be admitted, if Holley so desired, for the sake of 
completeness.  Ultimately, Holley chose that alternative and 
the entire tape was shown to the jury. 
 
10
to Holley’s wife5 and on the content of his two telephone 
conversations with Dr. Pambianco’s nurse on the day after his 
surgery.  These matters were probative as to the defense of 
mitigation of damages and the trial court did not err in 
admitting them.  Their weight and sufficiency, of course, were 
issues for the jury, which was entitled to consider their 
content, their timing, and the patient’s ability to comprehend 
them.  See Lawrence v. Wirth, 226 Va. 408, 412-13, 309 S.E.2d 
315, 317 (1983). 
                     
5 There was a conflict in the evidence whether Holley 
received post-operative instructions.  He and his wife 
testified that they did not recall receiving them.  The 
defendants relied on the standard discharge instructions 
traditionally given at the hospital after colonoscopy 
procedures.  The plaintiff argued that no reference was made 
to such instructions in his hospital chart and that therefore 
the court should hold that none were given and that this 
failure on Dr. Pambianco’s part constituted negligence per se. 
The defense failed to produce any discharge instructions in 
response to discovery, having received none in response to a 
subpoena of the hospital’s records.  On the evening before 
trial, Dr. Pambianco visited the hospital and found a form, 
signed by Holley, acknowledging receipt of discharge 
instructions.  The court refused to admit the form into 
evidence at trial because of the lateness of its production, 
but Holley’s counsel stated that Holley agreed that the 
signature on it was his.  The court instructed the jury:  “A 
physician who has performed surgery has a duty to have his 
patient receive post[-]operative instructions.”  The court 
refused plaintiff’s proposed instruction stating that the 
physician’s failure to give discharge instructions would 
constitute negligence per se. The court correctly ruled that 
the question whether discharge instructions were actually 
given was an issue of fact for the jury.  Because the peculiar 
factual circumstances of the trial, especially the timing of 
the production of the hospital form, are unlikely to reoccur 
 
11
Conclusion 
 
For the reasons stated above, we will reverse the 
judgment of the trial court and remand the case for further 
proceedings consistent with this opinion. 
Reversed and remanded. 
                                                                
in any future proceedings, we do not reach the assignment of 
error relating to these instructions.