Title: McMACKIN v. JOHNSON COUNTY HEALTHCARE CENTER

State: wyoming

Issuer: Wyoming Supreme Court

Document:

McMACKIN v. JOHNSON COUNTY HEALTHCARE CENTER2003 WY 9173 P.3d 1094Case Number: 01-214Decided: 08/01/2003
APRIL 
TERM, A.D. 2003

 

                                                                                                            

 

LESLIE 
McMACKIN, Personal Representative

of 
the Estate of  Harriette R. 
Brown,

 

Appellant(Plaintiff) 
,

 

v.

                                                                                                

JOHNSON 
COUNTY HEALTHCARE CENTER,

a 
Wyoming hospital district; MARK S.

SCHUELER, 
M.D.; LAWRENCE E. KIRVEN, M.D.

MEDICAL 
ASSOCIATES OF JOHNSON

COUNTY, 
P.C.; JENNIFER SATHER, R.N.; and

VICKI 
BLAKELY, L.P.N.,

 

Appellees(Defendants) 
.

 

The 
Honorable John C. Brackley, Judge

 

Representing 
Appellant:

Don 
W. Riske and James R. Salisbury of Riske & Arnold, P.C., Cheyenne, WY.  Argument by Mr. 
Riske.

 

Representing 
Appellees:

Michael 
K. Davis of Yonkee & Toner, Sheridan, WY for Johnson County Healthcare 
Center, Sather and Blakey;

George 
E. Powers, Jr. of Sundahl, Powers, Kapp & Martin, Cheyenne, WY for Dr. 
Schueler;

Jeffrey 
C. Brinkerhoff and Timothy M.Stubson of Brown, Drew & Massey, LLP, Casper, 
WY for Dr. Kirven and Medical Associates of Johnson 
County.

Argument 
by Messrs. Davis, Brinkerhoff, and Powers.

 

Before 
HILL, C.J., and GOLDEN, LEHMAN*, KITE, and VOIGT, JJ.

 

HILL, 
C.J., delivered the opinion of the Court; LEHMAN, J., filed a dissenting 
opinion.

 

*Chief 
Justice at time of oral argument.

 

 

            
HILL, Chief Justice.

 

[¶1]      Appellant, Leslie 
McMackin (McMackin), seeks review of the district court's order granting summary 
judgment to Appellees, Johnson County Healthcare Center (JCHC), Jennifer Sather, 
R.N. (Nurse Sather), Vicki Blakely, L.P.N. (Nurse Blakely), Mark S. Schueler, 
M.D. (Dr. Schueler), Lawrence E. Kirven, M.D. (Dr. Kirven), and Medical 
Associates of Johnson County, P.C. (MAJC).  
McMackin is the daughter of, and personal representative for the estate 
of, Harriette R. Brown (Brown), and she prosecuted these wrongful death and 
medical malpractice actions against the Appellees after her mother's death.  Brown died of a stroke, and it is 
McMackin's contention that the Appellees were negligent in their treatment of 
Brown.  The district court held that 
there was no genuine issue of material fact with respect to the "causation" 
prong of the elements necessary to constitute a medical malpractice claim and, 
on that basis, granted summary judgment for the Appellees.

 

[¶2]      We will reverse 
on the basis that McMackin's malpractice claims fall under the "loss of chance" 
doctrine and the facts alleged in her complaint and contained in her evidentiary 
submissions opposing the Appellees' summary judgment motions satisfy the 
causation element, at least for purposes of summary judgment, i.e., those 
facts structure a genuine issue of material fact.  The matter will be remanded to the 
district court for further proceedings consistent with this 
opinion.

 

ISSUES

[¶3]      McMackin 
articulates these issues:

 

I.  Whether 
the district court erred in granting the defendants' motions for summary 
judgment.

 

1A.  Whether 
appellees met the standards of establishing a prima facie case for summary 
judgment.

 

1B.  Whether 
the district court erred in ruling that appellees had established a prima facie 
case by demonstrating that appellant had failed to show that any treatment would 
have altered or made any difference in the outcome for Harriette 
Brown.

 

JCHC, 
Nurse Sather, and Nurse Blakely rephrase the issue to be:

 

Did 
the trial court err in granting the Appellees' motions for summary judgment when 
Appellant could not raise a genuine issue of material fact as to whether or not 
any medical intervention would more probably than not have prevented the death 
of her mother? 

 

Dr. 
Schueler states the issue on appeal as:

 

Whether 
the District Court properly granted summary judgment in a wrongful death case 
when the plaintiff failed to respond to the Defendants['] Motions for Summary 
Judgment with evidence which demonstrated that a genuine issue of material fact 
remained on the issue of causation.

 

Dr. 
Kirven and MAJC state the issues as:

 

A.  Whether 
summary judgment should be affirmed because Appellant failed to present 
admissible evidence that the failure to treat transient ischemic attacks caused 
the cerebral hemorrhage and death?

 

B.  Whether 
summary judgment for Appellee Kirven was appropriate on the additional grounds 
that Dr. Kirven's limited involvement caused no damages as admitted by 
Appellant's expert?

FACTS

 

[¶4]      In her amended 
complaint, McMackin averred that Brown was a resident at the Amie Holt Care 
Center in Buffalo from 1990 until her death on March 21, 1999.  The Amie Holt Care Center is a part of 
JCHC.  Nurse Sather and Nurse 
Blakely were employed at JCHC and provided care to Brown at various times 
pertinent to this matter.

 

[¶5]      In July of 1998, 
Brown began exhibiting symptoms of transient ischemic attacks (TIA's, also 
referred to as ministrokes), during which she would be confused and unable to 
verbalize.  These symptoms were 
noted many times on Brown's chart and they continued to occur at irregular 
intervals after July of 1998.  It is 
alleged that the Appellees took no action to refer Brown for a neurological 
workup, test her for causes of the TIA's, further diagnose, or prescribe 
meaningful treatment for her condition.

 

[¶6]      At some time 
prior to 9:00 p.m., on March 7, 1999, a JCHC employee discovered that Brown was 
having difficulty talking and was crying.  
This was reported to Nurse Sather, who examined Brown and noted in her 
chart that Brown's speech was slurred, that she was crying and suffering 
anxiety, had slight facial drooping on the left side, and her left eye was 
closed.  McMackin contends that 
there should have been an immediate medical response to her mother's condition, 
but there was not.  Nurse Sather 
examined Brown periodically between 11:00 p.m., on March 7, 1999, and 4:30 a.m. 
the following day, but took no action until 4:30 a.m., at which time she called 
Dr. Kirven who advised Nurse Sather to wait for Brown's treating physician, Dr. 
Schueler.  At 8:00 a.m. on March 8, 
1999, Nurse Blakely examined Brown and noted the symptoms which had persisted 
throughout the night.  Nurse Blakely 
called Dr. Schueler and noted on Brown's chart that the doctor would be there in 
about 30 minutes.  At about 9:00 
a.m. on March 8th, Dr. Schueler examined Brown and diagnosed a 
cerebrovascular accident (stroke) and arranged for her to be transferred to the 
hospital.  Brown did not recover 
from the stroke, and she died on March 21, 1999, as a consequence of 
it.

 

[¶7]      All Appellees 
filed motions for summary judgment.  
The record is voluminous; however, the basis for the grant of summary 
judgment is narrowly focused.  The 
district court's order granting the motions for summary judgment contains these 
conclusions:

 

1.  In a medical malpractice case, a 
plaintiff is required to prove through competent evidence that it is more likely 
than not that the defendant's negligence caused the plaintiff's injury.  Mize v. North Big Horn Hosp. 
Dist., 931 P.2d 229, 233 (Wyo. 1997).  
Summary judgment is appropriate if the plaintiff cannot establish 
causation.  
Id.

2.  The defendants have presented a prima 
facie case for Summary Judgment irrespective of the Affidavit of Richard L. 
Hughes, M.D., by demonstrating plaintiff's failure to show that any treatment 
would have altered the outcome for Harriette Brown.

3.  The Court also finds that the plaintiff 
has failed to present competent evidence that any treatment would more likely 
than not have prevented the hemorrhagic stroke or made a difference in Mrs. 
Brown's prognosis or outcome.

4.  The plaintiff has failed to present 
competent evidence that the alleged negligence of any of the defendants was a 
cause of the death of Harriette Brown.

5.  No genuine issue of material fact 
remains on the issue of causation, and all defendants are entitled to judgment 
as a matter of law.

 

We 
will utilize other facts in the context of our discussion of the 
issues.

 

STANDARD 
OF REVIEW

 

[¶8]      When we review a 
summary judgment, we have before us the same materials as did the district 
court, and we follow the same standards which applied to the proceedings 
below.  The propriety of granting a 
motion for summary judgment depends upon the correctness of the dual findings 
that there is no genuine issue as to any material fact and that the prevailing 
party is entitled to judgment as a matter of law.  Reed v. Miles Land and Livestock 
Company, 2001 WY 16, ¶9, 18 P.3d 1161, ¶9 (Wyo. 2001).  A genuine issue of material fact exists 
when a disputed fact, if proven, would have the effect of establishing or 
refuting an essential element of an asserted cause of action or defense.  We, of course, examine the record from a 
vantage point most favorable to that party who opposed the motion, affording to 
that party the benefit of all favorable inferences that fairly may be drawn from 
the record.  Central Wyoming 
Medical Laboratory, LLC v. Medical Testing Lab, Inc., 2002 WY 47, ¶15, 43 P.3d 121, ¶15 (Wyo. 2002); Scherer Construction, LLC v. Hedquist 
Construction, Inc., 2001 WY 23, ¶15, 18 P.3d 645, ¶15 (Wyo. 2001).  If the evidence leads to conflicting 
interpretations or if reasonable minds might differ, summary judgment is 
improper.  Wyoming Game and Fish 
Commission v. Mills Company, 701 P.2d 819, 821 (Wyo. 
1985).

 

[¶9]      That standard of 
review is refined somewhat when applied to a negligence action and, in 
particular, a malpractice case:

 

Summary 
judgment is not favored in a negligence action and is, therefore, subject to 
more exacting scrutiny.  Woodard 
v. Cook Ford Sales, Inc., 927 P.2d 1168, 1169 (Wyo.1996).  This is particularly true in malpractice 
suits.  DeHerrera v. Memorial 
Hospital of Carbon County, 590 P.2d 1342, 1345 (Wyo.1979) (quoting Holl 
v. Talcott, 191 So. 2d 40, 46 (Fla.1966)).  We have, however, affirmed summary 
judgment in negligence cases where the record failed to establish the existence 
of a genuine issue of material fact.  
See Krier v. Safeway Stores 46, Inc., 943 P.2d 405 (Wyo.1997) 
(failure to establish duty);  
Popejoy v. Steinle, 820 P.2d 545 (Wyo.1991) (failure of proof of 
underlying claim of a joint venture);  
MacKrell v. Bell H2S Safety, 795 P.2d 776 (Wyo.1990) (failure of 
proof of defendant's duty);  
DeWald v. State, 719 P.2d 643 (Wyo.1986) (cause element was pure 
speculation);  and Fiedler v. 
Steger, 713 P.2d 773 (Wyo.1986) (failure to establish cause in a medical 
malpractice action).

 

Garnett 
v. Coyle, 
2001 WY 94, ¶6, 33 P.3d 114, ¶6 (Wyo. 2001).

 

[¶10]   "The relative infrequency of 
decisions involving summary judgment in malpractice cases may exemplify the wide 
gulf between the ease of articulating the theory of summary judgment, and the 
difficulty of deciding particular cases."  
1 David W. Louisell and Harold Williams, Medical Malpractice, 
¶12.06 at 12-35 (2002):

 

            
Although the malpractice case appropriate for summary judgment on such 
issues as negligence or causation may be relatively rare, there are occasions 
where this device is an ideal remedy for the defense attorney for segregating a 
particular defense, e.g., that of the statute of limitations, from the case as a 
whole, and permitting its determination more or less in isolation, apart from 
the psychology of the trial itself.  
A motion for summary judgment appropriately timed, supported by carefully 
marshaled evidence, persuasively presented in a well documented fashion, can be 
a powerful weapon for defendant.

 

Id., 
at 12-35.

 

[¶11]   In order to defeat a motion for 
summary judgment in a medical malpractice action, the plaintiff must 
establish:  (1) the accepted 
standard of medical care or practice, (2) that the health care provider departed 
from that standard, (3) that the conduct was the legal cause of the injuries 
suffered, and, of course, (4) that the plaintiff was damaged by the 
conduct.  Oakden v. Roland, 
988 P.2d 1057, 1059 (Wyo. 1999); Sayer v. Williams, 962 P.2d 165, 167-68 
(Wyo. 1998); Fiedler v. Steger, 713 P.2d 773, 775 (Wyo. 1986).  In this case, it is not disputed that 
summary judgment was inappropriate vis- -vis the standard of care, the departure 
from that standard, or that McMackin suffered damage.  The focus of this appeal is solely on 
the issue of causation.

 

DISCUSSION

 

[¶12]   As noted in the fact section of 
this opinion, the primary contention made by McMackin is that the Appellees did 
not respond in a manner consistent with the applicable standard of care in 
treating the TIA's that Brown experienced, i.e., they did not refer her 
to a specialist (neurologist) for a work-up or otherwise attempt to employ 
available treatments.  Further, it 
is claimed that these omissions were the cause of Brown's "loss of a chance" to 
avoid the onset of the stroke.  
Secondarily, McMackin contends that once Brown presented with symptoms of 
a cerebral hemorrhage, Appellees failed to take any action to address that 
condition, and those omissions were the cause of Brown's "loss of a chance" to 
survive the stroke.  The following 
material helps to provide a superficial explanation of Brown's condition and 
provides background for our discussion:

 

[¶13]                                                   
     Ischemia

            
The greater number of strokes are ischemic in nature, (e.g., due to a 
lack of blood rather than hemorrhage).  
While very serious, ischemic strokes are not associated with the high 
mortality rates seen with hemorrhage.  
Perhaps as many as half of all ischemic strokes are preceded by one or 
more episodes known as "transient ischemic attacks" (TIA).  These consist of a typical stroke 
syndrome (sudden onset of localized brain dysfunction) [and] subside in minutes 
or hours.  While strokes occur 
without prior TIA's, and TIA's occur without strokes, there is a high 
correlation between the two, and TIA's are usually regarded as a stroke "early 
warning system."

 

            
The exact mechanisms of TIA's are not entirely understood.  There may be many mechanisms, but a 
microembolism is often implicated.  
In the past, these episodes have been thought due to vascular spasm, and 
they are sometimes referred to as "little strokes."  Most statistical studies have shown that 
about one-third of patients with TIA will have a permanent stroke, usually 
within a matter of months.  Because 
of this, these attacks are usually regarded as a grave warning.  Such patients often are given an intense 
medical investigation, to provide the most effective treatment available, hoping 
to prevent a subsequent stroke.  As 
with hemorrhage, little can be done once an ischemic stroke occurs.  The stroke results in the death of some 
brain tissue, which heals with a scar.  
The scar, of course, is not functional brain tissue, and while such 
patients usually survive the attack, a residual neurological deficit is the 
rule.  The recovery of function 
typical of strokes appears to result when uninvolved parts of the brain learn to 
perform the lost functions.

 

            
Ideally, then, treatment is most effective before the permanent stroke 
occurs.  Rational treatment can be 
based only on an accurate diagnosis  hence the intensive investigation of 
patients with TIA.  Consideration is 
usually given to:  (1) predisposing 
factors, (2) status of the blood vessels themselves, (3) factors that may 
precipitate ischemia, and (4) disorders that may masquerade as ischemic 
events.

 

5A 
Lawyers' Medical Cyclopedia of Personal Injuries and Allied Specialties, § 
34.27a(E) (Ischemia), at 265-66, Richard M. Patterson, Editor (4th 
ed. 1997).

 

[¶14]   Susan Cutchall, M.D., was retained 
by McMackin to be an expert witness.  
It was her opinion that the TIA's suffered by McMackin should have been 
aggressively treated, that lack of treatment was a direct cause of the 
debilitating stroke, and that it was possible that more aggressive action 
immediately following the discovery that Brown had suffered a stroke could have 
ameliorated Brown's condition.  
Another expert employed by McMackin agreed with Dr. Cutchall's 
assessment.  Dr. Cutchall 
specifically challenged the findings made by the Appellees' expert, Dr. Hughes, 
to the effect that Brown's condition could not have been diagnosed before her 
death, and that there was no treatment that could have prevented the hemorrhage 
or altered the outcome for Brown.

 

[¶15]   McMackin contends that the district 
court shifted the usual summary judgment burden to her  to come forward with 
expert testimony to establish causation  rather than placing it on Appellees to 
come forward with evidence establishing the lack of causation.  See Metzger v. Kalke, 709 P.2d 414, 420-23 (Wyo. 1985).  We agree 
with McMackin that there are genuine issues of material fact and that Appellees 
were not entitled to judgment as a matter of law.  Our reasoning, however, is founded in a 
doctrine known as "loss of chance."  
"Loss of chance" cases typically turn on causation:

 

Generally, 
to prevail on a claim that the physician's failure to evaluate and treat a 
patient caused the patient to lose the chance for survival, the plaintiff must 
show the following:

(1)  The 
patient has in fact been deprived of the chance for successful treatment; 
and

(2)  The 
decreased chance for successful treatment more likely than not resulted from the 
physician's negligence.

Under 
this analysis, the causal connection between the defendant's omission and the 
decedent's stroke can be established if the defendant's omissions increased the 
risk of the harm suffered by the plaintiff.

 

1 
Louisell & Williams, Medical Malpractice, supra, ¶8.07[2] at 8-94; 
¶9.04[4] at 9-22 -27; Clementi v. Procacci, 762 A.2d 1086, 1091-92 
(Pa.Super. 2000); 1 Barry R. Furrow, Thomas L. Greaney, Sandra H. Johnson, 
Timothy Stoltzfus Jost, Robert L. Schwartz, Health Law § 6-7b. at 308-12 
(2nd ed. 2000).

 

[¶16]   In such cases, the "causation" 
element does not require that it be shown that the patient was certain to have 
recovered or improved with sound medical care, and it has often been said that 
the plaintiff may sustain the burden of establishing proximate causation with 
evidence that the patient could have been helped by proper treatment. John D. 
Hodson, Annotation, Medical Malpractice: "Loss of Chance" Causality, 54 
A.L.R. 4th 10 at 18 (1987 and Supp. 2002); Boryla v. Pash, 960 P.2d 123 (Colo. 1998).  J. Stephen 
Phillips, The "Lost Chance" Theory of Recovery, The Colorado Lawyer, Vol. 
27, No. 11, at 85 (November 1998); Kevin Joseph Willging, Case Note, "Falcon 
v. Memorial Hospital:  A 
Rational Approach to Loss-of-Chance Tort Actions," 9 Journal of Contemporary 
Health Law and Policy 545 (1993); Alberts v. Schultz, 1999-NMSC-15, 
¶¶10-33, 975 P.2d 1279, ¶¶10-33 (N.M. 1999).

 

Where 
a physician is negligent in diagnosing a disease, and the resulting delay 
reduces the plaintiff's chances of survival (even though the chance of survival 
was below fifty percent before the missed diagnosis), a strong argument can be 
made that the physician should be responsible for the value of the chance that 
the plaintiff lost, so long as the initial act of the physician was itself 
negligent.  First, the loss of an 
improved chance of survival or improvement in condition, even if the original 
odds were less than fifty percent, is an opportunity lost due to 
negligence.  Much treatment of 
diseases is aimed at extending life for brief periods and improving its quality 
rather than curing the underlying disease.  
Much of the American health care dollar is spent on such treatments, 
aimed at improving the odds.  In the 
words of the Delaware Supreme Court, "[i]t is unjust not to remedy such a 
loss."  Second, immunizing whole 
areas of medical practice from liability by requiring proof by more than fifty 
percent that the negligence caused the injury fails to deter negligence 
conduct.  As Judge Posner wrote in 
DePass v. U.S., "A tortfeasor should not get off scot free because instead of 
killing his victim outright he inflicts an injury that is likely though not 
certain to shorten the victim's life."

 

Courts 
have wrestled with the concept of loss of a chance or increased risk over the 
past twenty years, adopting one of several approaches to the problem.  First, the traditionalists have refused 
to budge in considering loss chances below fifty percent.  A minority of jurisdictions either 
expressly reject the loss of chance theory or have simply continued to adhere to 
the traditional strict causation standard.  
Their justifications include a fear that the jury is forced to speculate 
as to the causes of plaintiff's ultimate injury, with only disputed expert 
probabilities to guide them; that the jury will be misled and impressed by the 
probabilistic evidence; and that in many cases statistical evidence will be 
either unavailable or based on inadequate evidence.

 

A 
second approach is the "pure" lost chance approach, also called the "increased 
risk" or "relaxed causation" approach by some courts.  If a plaintiff can prove that the 
defendant's negligence decreased the plaintiff's chance, no matter how slight, 
he can recover full damages from the trier of fact.  Some courts have recognized the theory 
by classifying the destruction or reduction of a chance for recovery as an 
independent, compensable harm.  
These courts concentrate on the causal relationship between the negligent 
conduct and the statistical loss or reduction in the patient's chances for 
recovery.  They apply the 
traditional evidentiary standard to this new kind of compensable interest.  Most courts have relaxed one of the two 
traditional legal standards for a prima facie case of causation.  Some have employed a standard which 
allows a plaintiff to meet his burden by proving that the defendant's negligence 
eliminated a substantial possibility of recovery or survival.  Other courts have held that a plaintiff 
has met his burden by showing that the defendant's negligence increased the risk 
of harm or injury.  Courts in these 
jurisdictions require that the jury find that the conduct was a "substantial 
factor" in causing the injury.  
Another judicial approach to these calculations is to treat the loss of a 
chance as a wrong separate from wrongful death, and allow the jury to set a 
dollar amount based on all the evidence, without mechanically applying a 
percentage to a total damage award.  

 

The 
third approach is that of proportional "loss of chance," adopted by many courts 
that have considered the issue.  The 
leading case is Herskovits v. Group Health Cooperative [664 P.2d 474 
(Wash. 1983)], where the court considered the consequences of a physician's 
missed diagnosis of lung cancer on the plaintiff's future.  The court found that the plaintiff's 
chances of survival dropped from 39 percent to 25 percent, and that such a loss 
of a chance to survive was the proximate cause of his death.  In the court's words, " * * * [t]o 
decide otherwise would be a blanket release from liability for doctors and 
hospitals any time there was less than a 50 percent chance of survival, 
regardless of how flagrant the negligence."

 

1 
Furrow, Greaney, Johnson, Jost & Schwartz, Health Law, supra, 
at 309-11; also see John H. Derrick, Annotation, Medical 
Malpractice:  Liability for Failure 
of Physician to Inform Patient of Alternative Modes of Diagnosis or 
Treatment, 38 A.L.R.4th 900 (1985 and Supp. 2001); Jack W. Shaw 
Jr., Annotation, Malpractice:  
Failure of Physician to Notify Patient of Unfavorable Diagnosis or 
Test, 49 A.L.R.3d 501 (1973 and Supp. 2002); Jerald J. Director, Annotation, 
Malpractice:  Physician's Failure 
to Advise Patient to Consult Specialist or One Qualified in a Method of 
Treatment Which Physician is Not Qualified to Give, 35 A.L.R.3d 349 (1971 
and Supp. 2002); C. T. Drechsler, Annotation, Liability of Physician for Lack 
of Diligence in Attending Patient, 57 A.L.R.2d 379 (1958 and Later Case 
Service 1994, Supp. 2002).

 

[¶17]   We hold that the doctrine of "loss 
of chance" is cognizable in Wyoming and that there is a genuine issue of 
material fact with respect to causation in this case.  McMackin's contention is that the 
Appellees' conduct was the legal cause of Brown's loss of a chance for survival 
or for a better outcome.  The 
allegations in her complaint, as well as the expert testimony she offered in 
resistance to the motion for summary judgment, preclude summary judgment in 
favor of Appellees on the issue of causation.

 

[¶18]   We would be remiss if we did not at 
least provide some minimal guidance with respect to the measure of damages in 
such a case.  There is an abundance 
of pertinent authority, but no clear-cut rule that can govern in all such 
cases.  Instructions to the jury 
with respect to damages must be tailored to each case based on its peculiar 
facts.  See 2 David W. 
Louisell and Harold Williams, Medical Malpractice ¶18.07 at 18-80  18-86 
(2002); 1 Furrow, Greaney, Johnson, Jost & Schwartz, Health Law, 
supra, at 309-11; Martin J. McMahon, Annotation, Medical 
Malpractice:  Measure and Elements 
of Damages in Actions Based on Loss of Chance, 81 A.L.R.4th 485 
(1990 and Supp. 2002); Martin J. McMahon, Annotation, Damages for Loss of 
Chance of Cure, 12 Am. Jur. POF3d 621 (1991 and Supp. 2001); and Todd S. 
Aagaard, Case Note, Identifying and Valuing the Injury in Lost Chance 
Cases, 96 Mich. L. R. 1335 (1998).  
This case presents one of the simplest and most straightforward set of 
circumstances, i.e., the calamity suffered is death, and the full 
measure of damages would be those ordinarily allowed in a wrongful death action, 
reduced by the statistical or percentage loss of chance for survival.  See McKellips v. Saint Francis 
Hospital, Inc., 741 P.2d 467, 475-77 (Okl. 1987).  Of course, the final determination of an 
appropriate measure for damages must be based on the evidence presented at 
trial.

 

CONCLUSION

 

[¶19]   The summary judgment order is 
reversed and this matter is remanded to the district court for further 
proceedings consistent with this opinion.

  

LEHMAN, 
Justice, dissenting.

 

[¶20]   In 
reaching its decision, the district court found appellees had presented a prima 
facie case for summary judgment irrespective of the affidavit of appellees' 
medical expert, Dr. Richard Hughes, by demonstrating McMackin's failure to show 
that any treatment would have altered the death of Ms. Brown.  The district court also ruled that 
McMackin had failed to present competent evidence that any treatment more likely 
than not would have prevented the massive hemorrhage in Ms. Brown's brain, which 
resulted in her death.  Therefore, 
the district court determined that no genuine issue of material fact remained on 
the issue of causation and appellees were entitled to summary judgment. 

 

[¶21]   In a medical malpractice action the 
plaintiff is required to prove that failure to perform a required duty 
proximately caused the damages alleged by the plaintiff.  Fiedler v. Steger, 713 P.2d 773, 
775 (Wyo. 1986) (citing Vassos v. Roussalis, 625 P.2d 768, 772 (Wyo. 
1981)).  Proximate cause means that 
the accident or injury must be the natural and probable consequence of the act 
of negligence.  Fiedler v. 
Steger, at 775 (citing McClellan v. Tottenhoff, 666 P.2d 408, 414 
(Wyo. 1983) and Harris v. Grizzle, 625 P.2d 747, 753 (Wyo. 1981)).  The establishment of the element of 
proximate cause is normally a question of fact for the jury unless the evidence 
is such that reasonable minds could not disagree wherein such issue becomes a 
matter of law.  Stephenson v. 
Pacific Power & Light Co., 779 P.2d 1169, 1178 (Wyo. 1989); Kopriva 
v. Union Pacific Railroad Co., 592 P.2d 711, 713 (Wyo. 1979).  

 

[¶22]   Wyoming Rules of Civil Procedure 
56(e) further requires that both supporting and opposing affidavits with respect 
to motions for summary judgment be made on personal knowledge, set forth such 
facts as would be admissible in evidence, and show affirmatively that the 
affiant is competent to testify to the matters stated therein.  Moreover, after the movant makes a prima 
facie showing that there are no issues of material fact involved and that an 
inquiry into the facts is unnecessary to clarify the applicable law, the burden 
of proof shifts to the opposing party who must show a genuine issue of material 
fact or come forward with competent evidence of specific facts countering 
the facts presented by the movant.  
The burden is on the nonmoving party to show specific facts as opposed to 
general allegations.  The material 
presented must be admissible at trial.  
Conclusory statements are inadmissible.  Mercado v. Trujillo, 980 P.2d 824, 825-26 (Wyo. 1999) (citing Nowotny v. L & B Contract Industries, 
933 P.2d 452, 455 (Wyo. 1997) and Thomas by Thomas v. South Cheyenne Water 
and Sewer Dist., 702 P.2d 1303, 1304 (Wyo. 1985)).

 

            
When the party moving for summary judgment has established a prima facie 
case, the burden of production shifts to the opposing party who then is obliged 
to marshal admissible evidence, as opposed to general or conclusory 
allegations, establishing continuing viability of an issue of material 
fact.  Such evidence must be 
competent and admissible, lest the rule permitting summary judgments be entirely 
eviscerated by plaintiffs proceeding to trial on the basis of mere conjecture or 
wishful speculation. 

 

Campbell 
ex. rel Campbell v. Studer, Inc., 
970 P.2d 389, 392 (Wyo. 1998) (emphasis added) (quoting Estate of Coleman v. 
Casper Concrete Co., 939 P.2d 233, 236 (Wyo. 1997)).  See also Mize v. North Big 
Horn Hosp. Dist., 931 P.2d 229, 233 (Wyo. 1997); Harris v. Grizzle, 
625 P.2d  at 751 and 753.

 

[¶23]   In 
support of their motions for summary judgment, appellees tendered the pleadings 
of record; the deposition transcripts of Dr. Kirven, Dr. Schueler, Jennifer 
Sather, R.N., Dr. Cutchall, and Diana Ward-Collins, R.N.; the initial report 
issued by Dr. Cutchall; and the affidavit of Dr. Hughes.  Review of Dr. Kirven's deposition 
transcript evidences that he did not believe any treatment could have been given 
to Ms. Brown that would have been of assistance to her when he was contacted on 
March 8, 1999, at approximately 4:30 a.m.  
Dr. Kirven also indicated that, given Ms. Brown's medical history, 
administering treatment to her prior to that time on March 7 or 8, 1999, would 
have proven unsuccessful.  
Similarly, Dr. Schueler testified in his deposition that, given Ms. 
Brown's medical history and the fact that she had either experienced a stroke or 
a 
hemorrhage in her brain 
as of the morning of March 8, 1999, no treatment given to her earlier on March 7 
or 8, 1999, would have mitigated her injury.  These doctors also generally testified 
that the medical treatment they each rendered to Ms. Brown from July of 1998 
until March 7, 1999, was appropriate given the specific situation and 
circumstances experienced by Ms. Brown.1

 

[¶24]   Dr. Cutchall, a family 
practitioner, through McMackin's supplemental designation of expert witnesses 
and her own deposition, stated that Ms. Brown died from complications of a 
hemorrhagic stroke preceded by untreated TIAs and attributed the death of Ms. 
Brown to the negligence of each of the appellees.  Dr. Cutchall, in her deposition, 
however, goes on to merely theorize that an ischemic/embolic/thrombotic 
stroke2 may precede and be the cause of a 
hemorrhage and that she suspected that this was what occurred with Ms. 
Brown.  In fact, she admitted that 
in the vast majority of cases, hemorrhagic strokes,3 like those suffered by Ms. Brown, 
are unrelated to embolic strokes, and no medical literature exists that 
establishes a connection between the two.  

 

[¶25]   Specifically, Dr. Cutchall stated 
her theory was that Ms. Brown had recurring TIAs that were not treated, 
resulting in an embolic stroke which may have caused the hemorrhagic 
stroke.  However, she stated that 
one cannot distinguish between an embolic stroke and a hemorrhagic stroke with a 
clinical examination and the only way to distinguish between the two is with a 
CT scan.  Dr. Cutchall further 
admitted that the CT scan performed upon Ms. Brown did not reveal an embolic 
stroke that she testified may have occurred but revealed only a hemorrhagic 
stroke caused by a massive hemorrhage.  
Finally, Dr. Cutchall admitted that absolutely no evidence existed 
in this case that would establish that Ms. Brown had previously suffered from an 
embolic stroke, a crucial part of her theorized expert opinion.  

 

[¶26]   Dr. Cutchall also confirmed that 
Ms. Brown could have simply had a spontaneous bleed.  She further advised that she could 
not testify to a reasonable degree of medical probability that the massive 
hemorrhage had not been present since the onset of Ms. Brown's TIA 
symptoms.  Dr. Cutchall also 
admitted that, while TIAs may be a predictor of an embolic stroke, TIAs are not 
a predictor of a hemorrhagic stroke, the condition that caused Ms. Brown's 
death.  In addition, Dr. Cutchall 
affirmed that it is often common, even after a full neurological workup is 
performed on a patient experiencing TIAs, for the specific etiology of the TIAs 
to remain undetermined.  

 

[¶27]   Based upon her assumption that Ms. 
Brown may have had an embolic stroke preceding the hemorrhagic stroke, Dr. 
Cutchall proffered various treatments that could have been ordered for Ms. Brown 
before the massive hemorrhage.  
However, Dr. Cutchall and the other medical experts stated that no known 
treatment would have prevented the cerebral hemorrhage which took Ms. Brown's 
life.  Further, there is primarily 
no treatment for a cerebral hemorrhage after it occurs other than comfort and 
care.  Critically, Dr. Cutchall also 
stated that she did not personally review the CT scan taken of Ms. Brown but 
only reviewed the CT scan reports as a basis for her opinion.  She further stated that she did not hold 
herself out as a neurologist and that a neurologist would have a much better 
opinion of the cause and possible treatment of Ms. Brown's massive cerebral 
hemorrhage due to a neurologist's more specific expertise in the area.  

 

[¶28]   In his affidavit submitted by 
appellees in support of their motions for summary judgment, Dr. Hughes, a 
neurologist, opined based upon a reasonable degree of medical probability 
that Ms. Brown's history was consistent with a condition known as amyloid 
angiopathy, which is a well documented condition related to aging that causes a 
crystal-like substance to form in the arteries of the brain.4  This condition is often preceded by 
multiple episodes clinically indistinguishable from TIAs.  The artery eventually breaks in the 
periphery, causing a hemorrhage.  
Dr. Hughes also stated that Ms. Brown's medical history evidenced that 
she had previously suffered from white matter disease, which was consistent with 
a hemorrhage secondary to amyloid angiopathy.  Moreover, amyloid angiopathy is normally 
diagnosed only after there has been a hemorrhage, and there is no treatment 
other than blood pressure monitoring, which was performed in this case.  

 

[¶29]   Alternatively, Dr. Hughes suggested 
that an artery in Ms. Brown's brain may have became blocked or occluded, and the 
resulting pressure caused it to rupture and hemorrhage.  However, Dr. Hughes stated that this 
scenario was unlikely since Ms. Brown experienced a large cerebral bleed as 
demonstrated by the CT scan, hemorrhages caused by a prior embolism normally do 
not result in as much bleeding, and only 1 out of 200 hemorrhages is the result 
of a prior embolism.  Therefore, Dr. 
Hughes concluded that the cerebral hemorrhage suffered by Ms. Brown was not 
preceded by or caused by an embolic stroke.  Dr. Hughes also attested that a 
hemorrhage can result from hypertension; but this was unlikely in Ms. Brown's 
case since bleeding caused by hypertension is usually deep within the brain, and 
Ms. Brown's bleeding occurred on the periphery as shown by the CT scan.  Therefore, Dr. Hughes concluded that the 
probable cause of the cerebral hemorrhage incurred by Ms. Brown was amyloid 
angiopathy.  He also stated that 
there was no treatment that would have prevented or altered the cerebral 
hemorrhage suffered by Ms. Brown regardless of which of the three events he 
referred to had caused that hemorrhage.  

 

[¶30]   Further, Dr. Hughes stated that if 
medications were given to Ms. Brown to prevent stroke, it would have likely 
precipitated a bleed and Ms. Brown would have died even earlier.  Finally, Dr. Hughes opined that, even if 
Ms. Brown had been treated by a neurologist who was aware of an impending 
stroke, the outcome would have been no different.  (Id.)

 

[¶31]   Accordingly, given my independent 
review of the record, I agree with the  
district court's determination that appellees presented adequate 
evidence, even outside consideration of the substantial affidavit submitted by 
Dr. Hughes, to make a prima facie showing that no genuine issue of material fact 
existed as to the issue of causation.  
Upon consideration of the affidavit of Dr. Hughes, the district court's 
conclusion is certainly even more supported.  Therefore, I would hold that the 
district court did not err in its determination that appellees had presented 
adequate evidence to make a prima facie showing for the granting of summary 
judgment.

 

[¶32]   As indicated above, after the 
movant makes a prima facie showing that there are no issues of material fact 
involved and that an inquiry into the facts is unnecessary to clarify the 
applicable law, the burden of proof shifts to the opposing party who must show a 
genuine issue of material fact or come forward with competent evidence of 
specific facts countering the facts presented by the movant.  However, 
review 
of the testimony of Dr. Cutchall noted in detail above evidences her opinion 
concerning causation is conjectural at best, and a more thorough review of her 
total testimony evidences that her opinion as to causation is merely 
speculative.  Indeed, when asked the 
specific basis for her opinion concerning causation, Dr. Cutchall admitted that 
the foundation leading her to this conclusion was simply her own personal 
patient history.  Dr. Cutchall could 
not give any scientifically based detailed analysis.  

 

[¶33]   Dr. Mitchell Felder's affidavit was 
also proffered in opposition to the summary judgment motions.  Dr. Felder, a neurologist, stated 
through an opinion letter attached to his affidavit, that the cause of Ms. 
Brown's death was a massive hemorrhage which was preceded by untreated 
TIAs.  He offered several possible 
alternatives as to the cause of the fatal hemorrhage but did not conclude which 
of them was its probable cause.  He 
also, like Dr. Cutchall, describes theoretical treatments that could have been 
given to Ms. Brown concerning the TIAs she was experiencing.  However, Dr. Felder did not state that 
these treatments would have in any way prevented the massive hemorrhage that Ms. 
Brown experienced.  Again, the 
statements of Dr. Felder are solely conclusory and, as such, fall short of 
establishing a material question of fact with respect to causation. 

 

[¶34]   The principles adopted by this 
court in Weber v. McCoy, 950 P.2d 548 (Wyo. 1997) and Vassos v. 
Roussalis, 658 P.2d 1284 (Wyo. 1983) make it clear that medical experts need 
not assert their opinions through utilization of specific terms to be 
valid.  However, the expert 
opinion rendered must be based in fact and on an adequate foundation.  Expert opinion cannot be based on mere 
inferences, conclusions, and assertions, as such opinion is not sufficient to 
defeat summary judgment.  
Garnett v. Coyle, 2001 WY 94, ¶¶3-6, 33 P.3d 114, ¶¶3-6 (citing 
McClellan v. Britain, 826 P.2d 245, 247 (Wyo. 1992); Mayflower 
Restaurant Co. v. Griego, 741 P.2d 1106, 1113 (Wyo. 1987); Stundon v. 
Sterling, 736 P.2d 317, 318 (Wyo. 1987)); Blackmore v. Davis Oil Co., 
671 P.2d 334, 336-37 (Wyo. 1983) (quoting Gennings v. First Nat'l Bank at 
Thermopolis, 654 P.2d 154, 155 (Wyo. 1982)).

 

[¶35]   Certainly, while both experts 
proffered by McMackin testified that Ms. Brown died of a cerebral hemorrhage in 
her brain that was preceded by untreated TIAs, neither could sufficiently draw 
any further specific conclusion regarding the cause of her death and that 
appellees' actions contributed to her death.  Simply put, in this case an essential 
element, the causal connection between the alleged breach of a duty owed and the 
injury sustained, is missing.  

 

[¶36]   Furthermore, when reviewing expert 
testimony, a trial court is required to act as a "gatekeeper" to determine the 
reliability of the proffered expert testimony by applying the flexible criteria 
set forth in our opinion in Bunting v. Jamieson, 984 P.2d 467, 471-73 
(Wyo. 1999) (formally adopting in Wyoming the four non-exclusive tests to the 
facts at hand enunciated in Daubert v. Merrell Dow Pharmaceuticals, Inc., 
509 U.S. 579, 592-94, 113 S. Ct. 2786, 2796-97, 125 L. Ed. 2d 469 (1993)).  A trial court must be given broad 
latitude in determining whether expert testimony is based upon reliable 
scientific methodology so as to make the conclusions offered by an expert 
admissible.  Thus, our scope in 
reviewing such issues is very narrowreversing the trial court's decision only 
if we conclude that 
it abused its discretion in excluding expert testimony.  Hollander 
v. Sandoz Pharmaceuticals Corp., 
289 F.3d 1193, 1206-07 (10th Cir. 2002).

 

[¶37]   As indicated above, the 
district court was presented with voluminous materials to assist it in its 
ruling on the motions for summary judgment and ultimately applied the Daubert 
principles before rendering its decision.  Upon review of the district court's 
analysis, I cannot conclude that the district court clearly abused its 
discretion in rendering its decision.  
To the contrary, the district court, based on the specific materials 
provided to it, reasonably determined that the evidence presented was 
insufficient to scientifically establish that a cause-effect connection existed 
in this case.  Therefore, I concur 
with the conclusion reached by the district court that McMackin failed to 
present 
competent and admissible evidence that any treatment more likely than not would 
have prevented the massive hemorrhage in Ms. Brown's brain, which resulted in 
her death.

 

[¶38]   The majority bases its reasoning on 
the "loss of chance" doctrine.  
Nevertheless, the application of that doctrine does not obviate the 
mandate that a plaintiff must show by competent and admissible evidence the 
causal connection between the defendant's omission and the damage allegedly 
suffered.  I agree that expert 
testimony must be based on reliable methodology, but need not be so persuasive 
as to meet the proponent's ultimate burden of proof, and that if the 
admissibility bar is raised too high, the court usurps the jury's duty to 
evaluate the expert's credibility and weigh the evidence.  See Bunting, 984 P.2d  at 
473 and Heller v. Shaw Industries, 
Inc., 167 F.3d 146, 156 (3rd Cir. 1999).  However, this did not occur in this 
instance because McMackin failed to present any expert opinion based on reliable 
scientific foundation.    

 

[¶39]   I would, therefore, affirm the 
ruling of the district court granting summary judgment in favor of 
appellees.

 

FOOTNOTES

 

1Ms. Sather's deposition transcript simply evidences her recollection of 
what had occurred during the evening of March 7, 1999, and the morning of March 
8, 1999, concerning the nursing care Ms. Brown received.  Specific issues concerning causation 
were not addressed through this deposition.

 

In similar fashion, the deposition transcript of Ms. Ward-Collins, the 
nursing expert designated by McMackin, deals almost exclusively with the subject 
of standard of care as it relates to nursing, and no issues regarding causation 
were addressed through this deposition.  
However, it is interesting to note that Ms. Ward-Collins testified that 
Vicki Blakely, L.P.N. met the standard of care for nurses regarding the nursing 
care she rendered to Ms. Brown on the morning of March 8, 1999.  

 

2"Embolic" is defined as "[r]elating to an embolus or to an embolism." 
"Embolism" is defined as an "[o]bstruction or occlusion of a vessel by an 
embolus."  "Embolus" is defined as 
"[a] plug, composed of a detached thrombus or vegetation, mass of bacteria or 
other foreign body, occluding a vessel." "Thrombotic" is defined as "[r]elating 
to, caused by, or characterized by thrombosis," while "thrombosus" is defined as 
"[f]ormation or presence of a thrombus; clotting within a blood vessel which may 
cause infarction of tissues supplied by the vessel."  "Thrombus" is defined as "[a] clot in 
the cardiovascular systems formed during life from constituents of blood; it may 
be occlusive or attached to the vessel or heart wall without obstructing the 
lumen."  See Steadman's 
Medical Dictionary, 25th Edition Illustrated (1990). 

 

For ease of reference an ischemic/embolic/thrombotic stroke will be 
simply referred to as an embolic stroke.

 

3"Hemorrhagic" is defined as "[r]elating to or marked by hemorrhage."  "Hemorrhage" is defined as "[h]emorrhea; 
bleeding; an escape of blood through the ruptured or unruptured vessel walls" 
or  "[t]o bleed." See 
Steadman's Medical Dictionary, 25th Edition Illustrated 
(1990).

4It is recognized that the district court expressly did not rely upon the 
affidavit of Dr. Hughes in making its determination that appellees had 
established a prima facie case for the granting of summary judgment.  However, it is well established that 
this court may affirm a district court's grant of summary judgment under any 
proper legal theory on the record presented.  Vernon T. Delgado Family Ltd. 
Partnership v. Shaw, 9 P.3d 982, 983 (Wyo. 2000) (quoting Hulse v. First 
Interstate Bank of Commerce-Gillette, 994 P.2d 957, 958-59 (Wyo. 
2000)).