Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca8-05-01173/USCOURTS-ca8-05-01173-0/pdf.json

Parties Involved:
Robert E. Burdge
Appellee
Dennis F. Smith
Appellant
Marya Smith
Appellant
St. Louis University
Appellee
Tenet HealthSystem SL
Appellee
Tenet Healthcare Corporation
Appellee

Document Text:

1

The Honorable Donald J. Stohr, United States District Judge for the Eastern

District of Missouri.

United States Court of Appeals

FOR THE EIGHTH CIRCUIT

________________

No. 05-1173

________________

Dennis F. Smith; Marya Smith,

Appellants,

v.

Tenet Healthsystem SL, Inc.,

doing business as St. Louis

University Hospital; Tenet

Healthcare Corporation; St. Louis

University; Robert E. Burdge,

M.D.,

 Appellees.

*

*

*

*

*

*

*

*

*

*

*

*

*

Appeal from the United States

District Court, Eastern District of

Missouri.

________________

 Submitted: November 17, 2005 

 Filed: February 3, 2006

________________

Before MURPHY, BOWMAN and GRUENDER, Circuit Judges. 

________________

GRUENDER, Circuit Judge.

Dennis F. Smith (“Smith”) brought this two-count medical malpractice action

regarding the amputation of his right leg. The district court1

 granted partial summary

Appellate Case: 05-1173 Page: 1 Date Filed: 02/03/2006 Entry ID: 2005602
-2-

judgment and partial judgment as a matter of law in favor of the defendants on count

one. A jury returned a verdict in favor of the defendants on count two. The district

court then denied Smith’s motion for a new trial and taxed Smith for a portion of the

defendants’ costs. Smith raises eight issues on appeal. For the reasons discussed

below, we affirm the judgments and verdict but remand for a reduction of costs taxed

to Smith.

I. BACKGROUND

Smith, a 50-year-old former coal miner, has a 30-year history of medical

problems with his right knee. He has undergone more than a dozen surgeries on that

knee. In 1986, Dr. Robert Burdge replaced Smith’s right knee joint with a prosthesis.

Dr. Burdge warned Smith about the possibility of having his leg amputated if his knee

got worse and expressed concern about the effect of Smith’s heavy work as a coal

miner. In 1995, Smith received a total knee replacement by another physician and

began receiving Social Security disability benefits. When he received this prosthesis,

physicians informed him of substantial bone loss in his knee, precluding any future

knee replacements. In 2000, Dr. Burdge performed a bone graft procedure to stabilize

the total-knee prosthesis.

On January 5, 2001, Dr. Burdge performed a second bone graft procedure at

St. Louis University Hospital because Smith’s tibial plateau had collapsed. A few

days after the surgery, Smith began to develop severe, adverse symptoms around the

surgical site. On January 18, 2001, he went to a scheduled follow-up visit with Dr.

Burdge. Because of Smith’s symptoms, Dr. Burdge admitted Smith to St. Louis

University Hospital and prescribed an antibiotic treatment in case Smith had an

infection. Smith’s condition worsened and Dr. Burdge removed the bone grafts

because he suspected that Smith was experiencing a bone graft rejection. The

symptoms of infection are the same or similar to the symptoms of a bone graft

Appellate Case: 05-1173 Page: 2 Date Filed: 02/03/2006 Entry ID: 2005602
2

The district court granted summary judgment to a fourth defendant, Tenet

Healthcare Corporation, after determining that it was not an alter ego of Tenet

Healthsystem SL. Smith does not appeal this judgment.

3

In addition to these two counts, Smith’s wife, Marya Smith, brought two

derivative claims for loss of consortium. Being derivative, Mrs. Smith’s claims

follow the fate of her husband’s claims. Therefore, she cannot recover because we

conclude that Dennis Smith has no valid claim for his personal injuries. See

Richardson v. State Highway & Transp. Comm’n, 863 S.W.2d 876, 880 (Mo. banc

1993).

-3-

rejection. After numerous related hospital stays over the ensuing months and with all

other options seeming futile, Smith consented to have his right leg amputated above

the knee. That procedure was performed on September 20, 2001.

In 2002, Smith brought this two-count medical malpractice action based on

diversity jurisdiction against Dr. Burdge, Tenet Healthsystem SL, Inc., doing business

as St. Louis University Hospital (“Tenet”), and Dr. Burdge’s employer, St. Louis

University (“SLU”) (collectively, “the defendants”).2

 Smith alleged that the

defendants’ negligent treatment caused the amputation of his right leg. Count one

alleged that Tenet and SLU placed Smith in an “unclean hospital room” following his

January 5, 2001, procedure and failed to follow internal policies and federal

regulations regarding infection control (the “infection-control policies”). Count two

alleged that the defendants were liable for Dr. Burdge’s negligent failure to properly

diagnose, treat and monitor Smith’s knee.3

 The defendants denied all liability, denied

that Smith developed an infection in his right knee, and suggested that the cumulative

trauma from Smith’s history of knee problems was the sole cause of his amputation.

The district court granted summary judgment in favor of Tenet and SLU on the

portion of count one concerning the allegation of an unclean hospital room and

judgment as a matter of law in favor of Tenet and SLU on the remainder of count one.

Appellate Case: 05-1173 Page: 3 Date Filed: 02/03/2006 Entry ID: 2005602
-4-

A jury returned a verdict in favor of the defendants on count two, and the district

court denied Smith’s motion for a new trial and taxed Smith for a portion of the

defendants’ costs. Smith raises eight issues on appeal and renews his request for a

new trial. 

 

II. DISCUSSION

A. Voir Dire

Smith argues that the district court abused its discretion in disallowing certain

of his questions during voir dire because this limitation prevented an inquiry into

potential juror biases regarding tort reform, medical malpractice and plaintiffs with

preexisting medical conditions. Because Smith contemporaneously failed to object

to the way in which voir dire was conducted and did not request permission to

rephrase his questions, we review this issue for plain error to determine if the

limitation was so prejudicial as to cause a miscarriage of justice. Ratliff v. Schiber

Truck Co., Inc., 150 F.3d 949, 956 (8th Cir. 1998).

Given the questions asked of the potential jurors by the district court and

Smith’s attorney, we find no error. District courts have broad discretion to determine

the scope of voir dire. Id. at 956. Voir dire is proper provided that there is an

adequate inquiry to determine any juror bias or prejudice. See Nanninga v. Three

Rivers Elec. Coop., 236 F.3d 902, 906-07 (8th Cir. 2000). In this case, the district

court questioned the prospective jurors about experiences involving medical

malpractice. The court also gave each party twenty minutes to supplement the court’s

examination. See Fed. R. Civ. P. 47(a) (explaining that when the court examines

prospective jurors, “the court shall permit the parties or their attorneys to supplement

the examination by such further inquiry as it deems proper”) (emphasis added).

Appellate Case: 05-1173 Page: 4 Date Filed: 02/03/2006 Entry ID: 2005602
4

For example, Smith submitted the question: “Some people think that lawsuits

are frivolous–what are your thoughts?”

-5-

Prior to voir dire, the parties submitted proposed questions in writing. The

district court disallowed certain of Smith’s questions because they called for lengthy

responses from individual jurors.4

 However, during Smith’s supplementary

examination, Smith’s counsel was permitted to ask questions to individual potential

jurors. The district court even allowed potential jurors to respond to two questions

that Smith’s counsel asked about tort reform and medical malpractice despite the

district court’s instruction before voir dire that Smith’s counsel was not to ask those

questions. Voir dire provided an adequate inquiry to determine any juror bias or

prejudice.

B. Admission of Medical, Psychiatric and Social Security Records

The district court admitted into evidence some of Smith’s medical, psychiatric

and Social Security records over Smith’s objections that these records were irrelevant

and unduly prejudicial. Smith reiterates these arguments on appeal and argues that,

despite a request from Smith, the district court failed to weigh the probative value of

these records against their prejudicial effect. See Fed. R. Evid. 403. The Federal

Rules of Evidence govern the admissibility of evidence in a medical malpractice

action based upon diversity jurisdiction. See Sosna v. Binnington, 321 F.3d 742, 744-

45 (8th Cir. 2003). We review a district court’s rulings on the admissibility of

evidence for a clear and prejudicial abuse of discretion. Id. at 745.

We cannot say that the district court abused its discretion in determining that

these records were relevant. Evidence is relevant if it merely has “any tendency to

make the existence of any fact that is of consequence to the determination of the

action more probable or less probable than it would be without the evidence.” Fed.

Appellate Case: 05-1173 Page: 5 Date Filed: 02/03/2006 Entry ID: 2005602
-6-

R. Evid. 401. “The trial judge has broad discretion in determining the relevance of

a given item of evidence.” United States v. Wilson, 787 F.2d 375, 389 (8th Cir.

1986). The defendants’ theory of the case was that Smith’s amputation was caused

by the cumulative trauma of his decades of knee problems. These records

substantiate Smith’s history of knee problems. The non-medical portions of the

records pertained to other issues at trial, such as the extent of Smith’s damages. 

 

We also cannot say that the district court abused its discretion in determining

that any prejudicial effect of these records did not substantially outweigh their

probative value. See Fed. R. Evid. 403; United States v. Derring, 592 F.2d 1003,

1007 (8th Cir. 1979) (“We do not reweigh the value of the material against its

potential for harm to the defendant, but determine only whether the district judge

abused his discretion in admitting it.”). Generally, the balance of Rule 403 weighing

should be struck in favor of admission. Block v. R.H. Macy & Co., Inc., 712 F.2d

1241, 1244 (8th Cir. 1983). We find nothing in the record to indicate that the district

court abused its discretion in following this general rule.

Smith argues that the district court abused its discretion because, despite

Smith’s motions and objections, the court did not actually weigh the evidence

pursuant to Rule 403. We presume that the district court weighed this evidence

pursuant to Rule 403 because the district court ruled on motions and objections in

which Smith specifically requested that the court weigh the probative value of the

records against their prejudicial effect. The district court’s mere failure to make a

record of its Rule 403 weighing is not reversible error. See United States v. Price,

617 F.2d 455, 460 (7th Cir. 1979) (holding that a trial judge’s failure to expressly

state reasons in the balancing of probative value and unfair prejudice, although

improper, did not warrant reversal, as the court of appeals would not presume wrong

reasons when correct ones were apparent). The fact that the probative value of these

records outweighs any prejudicial effect is apparent from the record.

Appellate Case: 05-1173 Page: 6 Date Filed: 02/03/2006 Entry ID: 2005602
-7-

C. Jury Instructions

Smith argues that the district court abused its discretion because it failed to

instruct the jury that the defendants would be liable if the jury found that the

defendants’ negligence was one of multiple causes of Smith’s amputation. In this

diversity case, Missouri law governs the substance of jury instructions while federal

law governs whether the district court abused its discretion in refusing or admitting

jury instructions. Crump v. Versa Prods., Inc., 400 F.3d 1104, 1107 (8th Cir. 2005).

District courts have “wide discretion” in drafting jury instructions. Omega

Healthcare Investors, Inc. v. Lantis Enters., Inc., 256 F.3d 774, 776 (8th Cir. 2001).

“Our review is limited to whether the instructions, viewed on the whole, fairly and

adequately represent the evidence and applicable law in light of the issues presented

to the jury . . . .” Id. (internal quotation omitted).

The district court did not abuse its wide discretion regarding jury instructions.

In jury instruction number eleven, the district court provided the following instruction

regarding the elements of a medical malpractice claim, including causation:

Your verdict must be for plaintiff Dennis Smith . . . if you believe:

First, Dr. Burdge failed to diagnose and treat an infection of Dennis

Smith’s right knee, and

Second, that Dr. Burdge was thereby negligent, and

Third, as a direct result of such negligence Dennis Smith sustained

damage. 

This instruction adequately represents the evidence and is an adequate summary of

Missouri law. See Tompkins v. Kusama, 822 S.W.2d 463, 464 (Mo. Ct. App. 1991)

(“Three elements must be established to make a prima facie case of medical

malpractice: (1) ‘proof that an act or omission of the defendant failed to meet the

Appellate Case: 05-1173 Page: 7 Date Filed: 02/03/2006 Entry ID: 2005602
-8-

requisite medical standard of care,’ (2) ‘proof that the act or omission was performed

negligently,’ and (3) ‘proof of a causal connection between the act or omission and

the injury sustained by the plaintiff.’”) (internal citation omitted).

Smith argues that because the defendants offered evidence at trial that Smith’s

preexisting condition was the sole cause of the amputation, the district court was

required to give an instruction that the defendants would be liable even if their

negligence was but one of multiple causes of Smith’s amputation. See Tillman v.

Elrod, 897 S.W.2d 116, 118 (Mo. Ct. App. 1995) (“Where concurrent or successive

negligence combined together results in injury, the injured party may recover

damages of either or both, and neither can use the defense that the prior occurrence

or negligence of the other contributed to the injury.”). Smith tendered a non-Missouri

Approved Instruction (“MAI”) on multiple causation which provided that the

defendants had the burden of proving that Smith’s preexisting knee problems were

the sole cause of the amputation. The district court did not abuse its discretion in

refusing to give that instruction because it misstates Missouri law, under which

defendants do not bear the burden of disproving the elements of a negligence claim.

Birmingham v. Smith, 420 S.W.2d 514, 517 (Mo. 1967).

Although an explicit instruction on multiple causation might have been

permissible, Smith did not request the applicable instruction, MAI 19.01. See

Missouri Supreme Court Rule 70.02(b) (“Whenever Missouri Approved Instructions

contains an instruction applicable in a particular case . . . such instruction shall be

given to the exclusion of any other instructions on the same subject.”). Because

Smith did not request MAI 19.01 and because the instructions, as given, fairly and

adequately represent the evidence and applicable law in light of the issues presented

to the jury, we see no abuse of discretion. 

Appellate Case: 05-1173 Page: 8 Date Filed: 02/03/2006 Entry ID: 2005602
-9-

D. Third Amended Complaint

Smith argues that the district court abused its discretion in denying his motion

for leave to file a third amended complaint. See Hannah v. City of Overland, Mo.,

795 F.2d 1385, 1392 (8th Cir. 1986) (reviewing for abuse of discretion a ruling on a

motion for leave to amend a complaint). We disagree.

Smith filed his original complaint on April 9, 2002, and his first amended

complaint on May 10, 2002. The district court’s Case Management Order, issued

October 25, 2002, indicated that all motions to amend pleadings and to join parties

were required to be filed by December 30, 2002. Nevertheless, the court permitted

Smith to file a second amended complaint on January 16, 2003. Nine months later

and six weeks after the amended deadline to complete discovery, on November 13,

2003, Smith filed a motion for leave to file a third amended complaint. That motion

sought to add new claims and to join additional parties regarding an alleged failure

to prescribe physical therapy to Smith after the amputation. The district court denied

this motion, explaining that it was untimely because Smith knew about this physical

therapy issue as early as May 2003 but did not file a motion to amend until almost six

months later.

The district court did not abuse its discretion in denying Smith leave to file a

third amended complaint. Amendments should be freely granted when justice so

requires, see Fed. R. Civ. P. 15(a), and the district court demonstrated its compliance

with this rule when it permitted Smith to file his second amended complaint after the

deadline for amendments. However, it was not an abuse of discretion to deny Smith’s

motion to file a third amended complaint eleven months after the district court’s

amendment deadline because, for example, the parties would have needed additional

time for discovery regarding the physical therapy issue. See Popp Telecom v. Am.

Appellate Case: 05-1173 Page: 9 Date Filed: 02/03/2006 Entry ID: 2005602
-10-

Sharecom, Inc., 210 F.3d 928, 943 (8th Cir. 2000) (finding no abuse of discretion in

district court’s denial of a pleading amendment that would have resulted in additional

discovery and delayed the proceedings).

Smith also argues that the district court should have allowed this amendment

because, after denying the motion, the district court granted a four-month continuance

due to Dr. Burdge’s ailing health. However, the district court’s subsequent grant of

a continuance for a reason wholly unrelated to the substance of the case has no

bearing on whether the district court abused its discretion in its earlier decision to

deny Smith’s untimely request to amend his complaint. 

 E. Exclusion of Evidence Regarding Smith’s Lower Back Problems

Smith argues that the district court abused its discretion in granting the

defendants’ motions to exclude any reference to or evidence of the lower back

problems Smith suffered after his amputation. In his second amended complaint,

Smith pled as part of his damages that his amputation has required him to place

greater stress on his lower back with the likelihood of sustaining additional disability

to his lower back. We do not need to decide whether the exclusion of evidence

regarding his lower back was an abuse of discretion because any error would be

harmless. Smith has the burden of proving that the inclusion of this evidence would

have produced a different verdict. Mems v. City of St. Paul, 327 F.3d 771, 779 (8th

Cir. 2003). He cannot meet this burden because evidence of his lower back problems

pertains only to the extent of his damages and the jury ruled against him on the issue

of liability. See Kontz v. K-Mart Corp., 712 F.2d 1302, 1304 n.2 (8th Cir. 1983) (per

curiam) (finding that the exclusion of evidence relevant to punitive damages was

harmless where a jury found for the defendant on the question of liability).

Appellate Case: 05-1173 Page: 10 Date Filed: 02/03/2006 Entry ID: 2005602
-11-

F. Judgment as a Matter of Law

Smith argues that the district court erred in granting judgment as a matter of

law in favor of Tenet and SLU on the portion of count one that alleged that Tenet and

SLU caused Smith’s amputation by failing to comply with infection-control policies.

“We review the grant or denial of judgment as a matter of law de novo.” First Union

Nat’l Bank v. Benham, 423 F.3d 855, 863 (8th Cir. 2005).

We hold that the district court properly granted judgment as a matter of law

because Smith failed to offer expert medical testimony from which a reasonable juror

could conclude that Tenet’s and SLU’s alleged failure to comply with infectioncontrol policies caused Smith’s amputation. One of the elements of a medical

malpractice claim is causation. Tompkins v. Kasama, 822 S.W.2d 463, 464 (Mo. Ct.

App. 1991). “When a party suffers a sophisticated injury, which requires surgical

intervention or other highly scientific technique for diagnosis, proof of causation is

not within a lay person’s understanding and expert testimony is required.” Echard

v. Barnes-Jewish Hosp., 98 S.W.3d 558, 566 (Mo. Ct. App. 2002). Therefore, to

prevail on count one, Smith needed to present expert medical testimony to establish

that the failure to comply with infection-control policies caused Smith’s alleged

infection and that Smith’s alleged infection caused Smith’s amputation. His failure

to present such testimony entitled Tenet and SLU to judgment as a matter of law.

Smith argues that causation on count one can be proven without expert

testimony because hospitals, unlike physicians, are held to only an ordinary care

standard. See, e.g., Stacy v. Truman Med. Ctr., 836 S.W.2d 911, 922 (Mo. banc 1992)

(holding a hospital to an ordinary care standard when a patient died in a fire started

by another patient who was smoking a cigarette and using a flammable cup as an ash

tray); Poluski v. Richardson Transp., 877 S.W.2d 709, 713 (Mo. Ct. App. 1994)

Appellate Case: 05-1173 Page: 11 Date Filed: 02/03/2006 Entry ID: 2005602
-12-

(holding a hospital to an ordinary care standard when a patient was injured while

being transported to another healthcare facility). However, the cases on which Smith

relies are distinguishable from this case because they involve liability for injuries that

are not related to the provision of medical care, see, e.g., M.W. v. Jewish Hosp. Ass’n

of St. Louis, 637 S.W.2d 74, 76 (Mo. Ct. App. 1982) (“Those cases where conduct

involves nonmedical, administrative, ministerial or routine care require only a finding

that the hospital breached the obligation of ordinary care.”), or they involve the

doctrine of res ipsa loquitur, see, e.g., Zumwalt v. Koreckij, 24 S.W.3d 166, 168 (Mo.

Ct. App. 2000). Smith’s allegations that Tenet and SLU failed to abide by infectioncontrol policies are directly related to the quality of Smith’s medical care, and this

case is not a candidate for res ipsa loquitur because amputations regularly occur

without someone’s negligence. See, e.g., State ex rel. GS Techs. Operating Co., Inc.

v. Pub. Serv. Comm’n of Mo., 116 S.W.3d 680, 694 n.9 (Mo. Ct. App. 2003) (holding

that, to apply the doctrine of res ipsa loquitur, the plaintiff must prove that “the

incident resulting in injury is of the kind which ordinarily does not occur without

someone’s negligence”). Consequently, causation cannot be presumed and Smith was

required to provide expert medical testimony sufficient to establish that Tenet and

SLU caused Smith’s amputation.

G. Expert Witness Testimony Based on Previously Undisclosed

Information

Smith argues that the district court abused its discretion in allowing two of the

defendants’ experts, Dr. Donald Brancato and Dr. Charles Mannis, to base their

testimony on information they did not disclose in their pretrial reports. See Fed. R.

Civ. P. 26(a)(2)(B), (e). We review the district court’s rulings regarding expert

witnesses’ duty to disclose facts on which they base their testimony for an abuse of

discretion. Phil Crowley Steel Corp. v. Macomber, Inc., 601 F.2d 342, 344 (8th Cir.

1979).

Appellate Case: 05-1173 Page: 12 Date Filed: 02/03/2006 Entry ID: 2005602
-13-

Smith complains that Dr. Brancato relied on x-rays that he did not disclose in

his pretrial report to support his conclusion at trial that Smith should have had his leg

amputated many years prior to the surgical complications in 2001. We do not need

to decide whether the district court abused its discretion in allowing this testimony

because any error would be harmless. Rule 26(a)(2) “imposes an additional duty to

disclose information regarding expert testimony sufficiently in advance of trial that

opposing parties have a reasonable opportunity to prepare for effective cross

examination and perhaps arrange for expert testimony from other witnesses.” Fed.

R. Civ. P. 26, advisory committee notes (1993 Amendments). While Dr. Brancato did

not include his reliance on x-rays in his pretrial disclosure, he did discuss these x-rays

during his deposition. Therefore, Smith was on notice that Dr. Brancato might rely

on these x-rays during his trial testimony. A harmless violation of Rule 26 does not

mandate exclusion of the evidence. See Fed. R. Civ. P. 37(c)(1).

Smith also complains that Dr. Mannis reviewed additional information after he

submitted his pretrial report and gave his deposition. However, Smith does not allege

that Dr. Mannis based his trial testimony on this new information. Accordingly, any

error would be harmless and does not mandate exclusion of the evidence. See Fed.

R. Civ. P. 37(c)(1).

H. Costs

District courts may award costs to a prevailing party. Fed. R. Civ. P. 54(d).

However, such costs must be set out in 28 U.S.C. § 1920 or some other statutory

authorization. Crawford Fitting Co. v. J.T. Gibbons, Inc., 482 U.S. 437, 438 (1987).

The district court ordered $27,515.25 taxed against Smith for the defendants’ costs.

Smith argues that the district court abused its discretion because taxing such an

allegedly exorbitant amount will deter poor individuals from seeking redress. District

courts have substantial discretion in awarding costs under Rule 54(d). Zotos v.

Appellate Case: 05-1173 Page: 13 Date Filed: 02/03/2006 Entry ID: 2005602
-14-

Lindbergh Sch. Dist., 121 F.3d 356, 363 (8th Cir. 1997). We find no basis for

reversing the district court’s decision to impose costs in favor of the defendants.

Smith also argues that the district court abused its discretion by taxing him for

depositions that the defendants did not use at trial and for the delivery costs of

deposition transcripts. The district court did not abuse its discretion in awarding

costs for depositions. “[E]ven if a deposition is not introduced at trial, a district court

has discretion to award costs if the deposition was ‘necessarily obtained for use in [a]

case’ and was not ‘purely investigative.’” Id. (citation omitted). However, Smith

should not have been taxed the delivery costs for these depositions. See Cleveland

v. North Am. Van Lines, Inc., 154 F.R.D. 37, 38 (N.D.N.Y. 1994) (finding deposition

costs recoverable but associated delivery costs not recoverable). Section 1920 does

not authorize taxing Smith for the defendants’ postage and delivery expenses. See

Duckworth v. Whisenant, 97 F.3d 1393, 1399 (11th Cir. 1996) (holding that postage

expenses are “clearly nonrecoverable”); Hollenbeck v. Falstaff Brewing Corp., 605

F. Supp. 421, 439 (E.D. Mo. 1985) (same).

We are unable to ascertain from the record the amount of delivery costs taxed

to Smith. Therefore, we remand this case for the limited purpose of reducing the

costs taxed to Smith by the amount of postage and delivery fees for depositions.

III. CONCLUSION

For the reasons set forth above, we affirm the verdict but remand for a

recalculation of the costs taxed to Smith.

______________________________

Appellate Case: 05-1173 Page: 14 Date Filed: 02/03/2006 Entry ID: 2005602