Title: Williams v. Le

State: virginia

Issuer: Virginia Supreme Court

Document:

Present:  All the Justices 
 
TAMEIKA WILLIAMS, ADMINISTRATOR 
AND PERSONAL REPRESENTATIVE OF 
THE ESTATE OF TAWANDA WILLIAMS, DECEASED 
 
v.  Record No. 071409 
OPINION BY JUSTICE DONALD W. LEMONS 
 
 
 
June 6, 2008 
CONG LE, M.D. 
 
FROM THE CIRCUIT COURT OF FAIRFAX COUNTY 
Jonathan C. Thacher, Judge 
 
 
In this appeal, we consider whether the trial court erred 
in instructing the jury on superseding intervening causation 
in a medical malpractice case. 
I. 
Facts and Proceedings Below 
 
On May 26, 2005, Tawanda Williams (“Williams”) saw Dr. 
Daniel G. Kaw ("Dr. Kaw"), a physician at the Fair Oaks Kaiser 
Permanente Center in Fairfax, for pain in her right calf and 
leg.  Dr. Kaw ordered a Doppler ultrasound to be performed on 
Williams' calf within the Kaiser system in mid-June.  Williams 
scheduled a follow-up appointment for "June 6 or PRN" ("as 
needed"). 
 
On June 1, 2005, Williams returned to the Fair Oaks 
Kaiser Permanente Center to see Dr. Paul McClain ("Dr. 
McClain"), her primary care physician.  Williams complained of 
ankle pain and discomfort in her calf.  Williams told Dr. 
McClain that she had "misstepped a few weeks earlier."  Dr. 
McClain thought Williams had a possible tear in the back of 
her calf muscle.  Dr. McClain ordered an ankle x-ray for June 
1, 2005, and rescheduled the Doppler ultrasound of her calf to 
be performed within 48 hours.  
 
Williams went to Tysons Corner Diagnostic Imaging for a 
Doppler ultrasound appointment on June 2, 2005.  Megan Murphy 
("Murphy"), a sonogram technician, performed the Doppler 
ultrasound on Williams.  Murphy called Dr. Cong Van Le ("Dr. 
Le"), a diagnostic radiologist who was working at Vienna 
Diagnostic Imaging,1 and sent him the image of Williams' right 
lower leg by electronic mail.  Murphy believed that the images 
showed that Williams had a deep vein thrombosis in her right 
lower leg.  Murphy told Dr. Le that she had informed Williams 
that there was a "positive finding," and that she should see 
her doctor as soon as possible. 
 
Upon reviewing the images of Williams' leg, Dr. Le 
diagnosed Williams with deep vein thrombosis in her right leg.2  
The presence of deep vein thrombosis put Williams at risk for 
pulmonary embolism, a life-threatening condition in which 
pieces of a deep vein clot break off and slip out of the 
vasculature of the legs and travel into the lungs. 
                     
1 Tysons Corner Diagnostic Imaging and Vienna Diagnostic 
Imaging are separate facilities that are part of the same 
corporation, Diagnostic Imaging Associates. 
2 Specifically, Dr. Le diagnosed Williams with two deep 
vein blood clots in the popliteal vein and the posterior 
tibial vein, and one blood clot in a superficial vein, the 
lesser saphenous vein. 
 
2
Dr. Le telephoned Dr. McClain's office to tell Dr. 
McClain the diagnosis of Williams' condition.  Dr. Le reached 
an automatic telephone system, followed the instructions, and 
then reached an operator.  He told the operator who he was, 
that he was a radiologist, and asked to speak to Dr. McClain.  
The operator told Dr. Le she would have to locate Dr. McClain, 
and then she put Dr. Le “on hold.”  Dr. Le was “on hold” long 
enough that he "lost [his] confidence to get in touch with 
[Dr. McClain] at that moment."  He stated that he was unable 
to leave a voicemail or talk to a human being.  Dr. Le 
testified that previously he had problems communicating with 
the doctors at Kaiser by telephone.  Dr. Le prepared a "wet 
read" (an emergency read) with his findings and drew a picture 
of Williams' lower extremity showing the location of the blood 
clots.  He placed the wet read in a "wet read box" to be sent 
immediately by facsimile to Dr. McClain. 
 
After the Doppler ultrasound was performed, Williams 
telephoned Dr. McClain on June 2.  She left a message for Dr. 
McClain advising him that she had been told by Murphy to call 
him.  Dr. McClain did not personally receive Williams' 
message. 
 
At 10:43 p.m. on June 2, 2005, Dr. McClain sent the 
following electronic mail message regarding Williams to his 
clinical assistant, Lynne Stidman ("Stidman"): "Lynne - Would 
 
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you get the results of the Doppler study of the leg from Tyson 
Corner Diagnostic Imaging Center. . . .  Please place the 
result in a Pace note and message me.  Thanks.  Dr. McClain."  
"PACE" is Kaiser's electronic system for patient medical 
records and internal non-urgent messages.  On the morning of 
June 3, 2005, Stidman called the imaging center and had the 
results of the Doppler study sent to her by facsimile.  
Stidman received the report and entered it into the PACE 
system.  At 10:24 a.m. on June 3, 2005, Stidman sent the 
following message to Dr. McClain: "Patient's Doppler results 
are in the computer."  Dr. McClain did not read Stidman's 
message until June 15, 2005, after Williams died. 
 
Dr. McClain had an appointment scheduled with Williams on 
June 6, which Williams did not attend.  Williams died on June 
8, 2005, from a pulmonary embolism.  Dr. McClain did not look 
at the results of the Doppler ultrasound of Williams' leg 
until February of 2006.  Dr. McClain testified that normally, 
if there was a positive finding from a Doppler ultrasound, he 
would be notified by the radiologist with “direct contact,” 
which was “[g]enerally voice-to-voice contact.”  Dr. McClain 
testified that had he received direct contact, he would have 
immediately started Williams on anticoagulant therapy.  The 
plaintiff's expert testified that “anticoagulation would have 
prevented [Williams] from developing a pulmonary embolism,” 
 
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and that if the anticoagulant therapy had been started anytime 
before the morning of June 7, 2005, the treatment would likely 
have prevented Williams' death. 
 
Tameika Williams ("Tameika"), as administrator and 
personal representative of the estate of Williams, filed a 
complaint against Kaiser Foundation Health Plan of the Mid-
Atlantic States, Inc., Mid-Atlantic Permanente Medical Group, 
P.C., Tyson's Corner Diagnostic Imaging, Inc., Vienna 
Diagnostic Imaging, Inc., and Dr. Le, alleging negligence in a 
wrongful death action.  Tameika nonsuited her claims against 
Tysons Corner Diagnostic Imaging, Inc. and Vienna Diagnostic 
Imaging, Inc.  Tameika settled her claims against Kaiser 
Foundation Health Plan of the Mid-Atlantic States, Inc. and 
Mid-Atlantic Permanente Medical Group, P.C.  The case 
proceeded to trial solely against Dr. Le. 
 
At trial, Tameika presented expert testimony that the 
standard of care requires that a radiologist who diagnoses a 
patient with deep vein thrombosis make “direct communication 
with the physician who ordered the study or with one of their 
physicians who was covering or a nurse or the patient 
directly,” so that the treating physician can “institute 
prompt treatment.”  At the conclusion of the evidence, over 
Tameika’s objection, the trial judge gave the following 
instruction on superseding intervening causation: 
 
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A superseding cause is an independent event, not 
reasonably foreseeable, that completely breaks 
the connection between the Defendant's negligent 
act and the alleged injury or death.  A 
superseding cause breaks the chain of events so 
that the Defendant's original negligent act is 
not a proximate cause of the Plaintiff's injury 
in the slightest degree. 
 
 
On March 21, 2007, the jury returned a verdict for Dr. 
Le.  The trial court entered a final order confirming the 
jury's verdict in favor of Dr. Le.  Tameika appeals from the 
final order on one assignment of error: "In this medical 
malpractice case the trial court erred in instructing the jury 
on superseding intervening cause (Instruction N)." 
II.  Analysis 
“When asked to review jury instructions given by a trial 
court, ‘our responsibility is to see that the law has been 
clearly stated and that the instructions cover all issues which 
the evidence fairly raises.’ ”  Monahan v. Obici Med. Mgmt. 
Servs., 271 Va. 621, 636, 628 S.E.2d 330, 339 (2006) (quoting 
Lombard v. Rohrbaugh, 262 Va. 484, 498, 551 S.E.2d 349, 356 
(2001)).  “[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.  The evidence introduced in support of 
a requested instruction must amount to more than a scintilla.”  
 
6
Holmes v. Levine, 273 Va. 150, 159, 639 S.E.2d 235, 239 (2007) 
(citations omitted). 
Dr. Le argued two separate theories at trial to avoid 
liability.  First, he argued that he was not liable because the 
standard of care did not require him to make direct contact 
with Dr. McClain, a member of Dr. McClain’s team, or the 
patient herself.  In furtherance of this theory, Dr. Le’s 
expert testified that communication directly with a physician 
when reporting non-routine ultrasound results was not required, 
and that sending test results by facsimile was within the 
standard of care.  Second, Dr. Le argued that even if he was 
negligent for not making direct contact with Dr. McClain, a 
member of Dr. McClain’s team, or Williams, his negligence was 
not a proximate cause of Williams’ death because Dr. McClain’s 
subsequent negligence in failing to check the diagnostic report 
completely broke the chain of events between Dr. Le’s 
negligence and Williams’ death. 
“The proximate cause of an event is that act or omission 
which, in natural and continuous sequence, unbroken by an 
efficient intervening cause, produces the event, and without 
which that event would not have occurred."  Beverly 
Enterprises-Virginia v. Nichols, 247 Va. 264, 269, 441 S.E.2d 
1, 4 (quoting Coleman v. Blankenship Oil Corp., 221 Va. 124, 
131, 267 S.E.2d 143, 147 (1980)).  There may be more than one 
 
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proximate cause of an event.  Panousos v. Allen, 245 Va. 60, 
65, 425 S.E.2d 496, 499 (1993).  A subsequent proximate cause 
may or may not relieve a defendant of liability for his 
negligence.  “In order to relieve a defendant of liability for 
his negligent act, the negligence intervening between the 
defendant’s negligent act and the injury must so entirely 
supersede the operation of the defendant’s negligence that it 
alone, without any contributing negligence by the defendant in 
the slightest degree, causes the injury.”  Atkinson v. Scheer, 
256 Va. 448, 454, 508 S.E.2d 68, 71 (1998) (quoting Jenkins v. 
Payne, 251 Va. 122, 128-29, 465 S.E.2d 795, 799 (1996)). 
An instruction may be given if the evidence is sufficient 
to support the theory of the instruction.  Accordingly, in this 
case, such an instruction would be properly given only if 
reasonable persons could conclude from the evidence and 
reasonable inferences therefrom that Dr. McClain’s later 
negligence alone, “without any contributing negligence by [Dr. 
Le] in the slightest degree, caused [Williams’] death.”  
Atkinson, 256 Va. at 454, 508 S.E.2d at 72; Panousos, 245 Va. 
at 65-66, 425 S.E.2d at 499. 
On the question of causation, the evidence proved without 
contradiction that the communication problems in this case were 
begun and put in motion by Dr. Le’s failure to make direct 
contact with Dr. McClain, a member of his team, or Williams.  
 
8
 
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“[A]n intervening cause does not operate to exempt a defendant 
from liability if that cause is put into operation by the 
defendant’s wrongful act or omission.”  Jefferson Hosp., Inc. 
v. Van Lear, 186 Va. 74, 81, 41 S.E.2d 441, 444 (1947).  On 
this record, it cannot be said that Dr. Le’s alleged negligence 
was not contributing “in the slightest degree” to the death of 
Williams.  The trial court therefore erred in granting the 
superseding intervening causation instruction.  “[W]here . . . 
an instruction [has] been erroneously submitted to the jury and 
the record does not reflect whether such . . . instruction 
formed the basis of the jury’s verdict, we must presume that 
the jury relied on such . . . instruction in making its 
decision.”  Monahan, 271 Va. at 635, 628 S.E.2d at 338 (quoting 
Johnson v. Raviotta, 264 Va. 27, 39, 563 S.E.2d 727, 735 
(2002)).  
III. Conclusion 
For the reasons stated, the judgment of the trial court 
will be reversed and the case remanded for a new trial. 
Reversed and remanded.