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 MidAtlantic 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 

7
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
9

“[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.