Source: http://www.danaise.com/hh-v-shinseki-11-1612/
Timestamp: 2019-04-25 16:07:06+00:00

Document:
THE BOARD FAILED TO OBTAIN THE ENTIRE MEDICAL RECORD, FAILED TO ORDER A MEDICAL EXPERT EVALUATION OF THE ISSUES PRESENTED AT THE 9/30/2004 EVENT, AND FAILED TO DELIBERATE AND RENDER A DECISION REGARDING WHETHER THE ALLEGED NEGLIGENCE BY THE VA MET 38 USC §1151.
THE BOARD INAPPROPRIATELY LIMITED ITS INQUIRY TO THE CARE VETERAN RECEIVED PRIOR TO HIS DEMISE IN APRIL 2005 RATHER THAN TO 9/30/2004 WHEN THE ALLEGED NEGLIGENCE OCCURRED.
THE BOARD MINIMIZED THE TOXIC EFFECTS OF DILANTIN.
THE VA STAFF’S DECISION TO ADMINISTER DILANTIN RATHER THAN OTHER ANTISEIZURE MEDICATION WAS NEGLIGENT.
THE DECISION TO DISCHARGE THE VETERAN WITHIN A FEW HOURS FROM HIS ADMISSION ON SEPTEMBER 30, 2004, WAS NEGLIGENT.
THE ADMINISTRATION OF DILANTIN BY THE APPELLANT WITH NO INSTRUCTION OR SUPERVISION BY MEDICAL STAFF WAS NEGLIGENT UNDER THE CIRCUMSTANCES.
AS A RESULT OF ERRORS BY THE EMPLOYEES OF THE VA ON SEPTEMBER 30, 2004, THE VETERAN SUFFERED IRREVERSIBLE DAMAGE TO HIS HEALTH THAT LED TO HIS DEMISE.
THE BOARD FAILED TO ASSIST APPELLANT (VETERAN’S WIDOW).
THE BOARD ERRED IN NOT APPLYING THE BENEFIT-OF-THE-DOUBT DOCTRINE.
Mattson in New England Journal of Medicine 1985, 31.3, 145 and Smith D.B., Results of nationwide Veteran Administration Cooperative Study, comparing the efficacy and toxicity of carbamazepine, phenobarbital, Dilantin published in Epilepsia in 1987, 28 supplement 3, page 550.
West’s Encyclopedia of American Law, Edition 2, Copyright 2008 The Gale Group, Inc.
Potentially Inappropriate Antiepileptic Drugs for Elderly Patients with Epilepsy. Mary Joe Pugh, PhD, et al; JAGS Volume 52:417-422, 2004.
Seizure Disorders in the Elderly. Lourdes Velez, M.D., and Linda M. Selva, M.D. Am Fam Physician 2003; 67:325-32. Copyright © 2003 American Academy of Family Physicians.
Toxic Neuropathies Associated with Pharmaceutic and Industrial Agents. Neurologic Clinics – Volume 25, Issue 1 (Feb.2007) Copyright © 2007 W. B. Saunders Co.
Whether the Board’s decision to deny Appellant (Veteran’s widow) DIB pursuant to 38 USC §1151 is clearly erroneous and therefore must be reversed?
Whether the Board’s finding that no nexus is found between Veteran’s injury by the VA on 9/30/2004 and his ultimate demise in 4/2005 is clearly erroneous and therefore must be reversed?
In the alternative whether the Board failed to assist Appellant (Veteran’s widow) in adequately investigating Appellant’s complaint?
In the alternative whether the Board erred in not applying the benefit-of-the-doubt doctrine?
Richard H (“Veteran”) served on active duty from July 1946 to January 1948 and passed away in April 2005. Appellant is Veteran’s surviving spouse (“Appellant”). The case was before the Board of Veterans’ Appeals. After a July 2005 rating decision which had denied benefits, Appellant sought an appeal (R. 2487). A hearing before a BVA board member was held in August 2006 (R. 2491). The widow testified at a hearing (R. 2491) that prior to Veteran’s hospitalization on September 30, 2004, Veteran had been functional at home and had never been admitted to a nursing home or any extended care facility for any extended period of time. Appellant testified that on September 30, 2004, she called 911, because Veteran was diabetic, and she suspected diabetic problems. At the hospital, physicians told Appellant that they suspected that Veteran had had a seizure. Veteran was promptly discharged and taken home that night. The hospital personnel gave Veteran two pills of Dilantin and told Appellant to give him two pills every day and three pills every night. (R. 2491). She was instructed to make an appointment in two weeks.
On October 14, 2004, Appellant called for an ambulance to bring Veteran back to the hospital. Dilantin toxicity was diagnosed. Dilantin level was twice the upper limit of the therapeutic level. (R. 2498). Due to Veteran’s marked medical deterioration as a result of the Dilantin toxicity, Veteran was admitted first to the hospital and then to a nursing facility. He never returned home. Veteran was admitted to the hospital in April 2005 in a severely debilitative state and succumbed shortly to sepsis.
Mr. Knox, who was Veteran’s representative, stated (R. 2505) that prior to Veteran’s exposure to Dilantin, Veteran was fully functional at home, had not been in any medical facilities, and had not been under any hospital care. He was actually helping to take care of his wife. Veteran actually was well enough to be sent home after only a brief stay at the ER on September 30, 2004. After the Dilantin episode, Veteran remained under hospital and nursing care until his demise. Mr. Knox argued, with no objection from the hearing judge, that Dilantin toxicity was an aggravated cause of injury, which led directly to Veteran’s death with no intervening causes.
Pursuant to 38 CFR 3.358, the representative argued that the Board must compare the physical condition of Veteran immediately prior to the disease or injury to the physical condition of Veteran after the disease or injury. Veteran was admitted on October 14, 2004, because of Dilantin toxicity, and Veteran never returned home to his full strength or intellectual capacity after that episode.
The BVA judge remanded the case to the RO. Specifically this judge did not limit the inquiry to April 2005. Rather, the Judge held that the file would be forwarded for review to a qualified physician who had not previously treated or evaluated Veteran, and the expert would answer the question whether Veteran’s death was caused or in any way contributed to by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the relevant treatment, including views on Dilantin, or due to an event not reasonably foreseen. The opinion would address the principal of “it is as likely as not to at least a 50-50 degree of probability.” The case would then be reviewed and a supplemental statement of the case would be issued and then returned to the Board.
The BVA heard Veteran’s case on February 28, 2011, on appeal from the Department of Veterans’ Affairs, Regional Office in Houston, Texas. Appellant requested Entitlement to Dependency and Indemnity Compensation (Ole) benefits under 38 USC §1151.
The BVA noted that Veteran died on April 10, 2005. The immediate cause of death was reported as gram negative sepsis due to or as a likely consequence of pneumonia, due to or as a likely consequence of acute myocardial infarction. No other significant condition contributing to death was reported on the death certificate.
In an October 2004 VA hospital entry, it was noted that Veteran had been admitted and was treated for Dilantin toxicity. In a statement from Veteran’s attending physician dated prior to his death in April 2005, it was noted that his primary diagnoses were severe dementia; a moderate seizure disorder; and diabetes. In a July 2005 VA medical opinion, the clinician noted that he was asked to determine if Veteran’s death was the result of an overmedication with Dilantin. He noted that the record revealed Veteran died from gram negative sepsis, pneumonia, and acute myocardial infarction.
In a May 2010 VA medical opinion, it was opined that the death of Veteran was less likely as not caused by, contributed to, or as the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the relevant treatment including use of Dilantin and/or due to an event not reasonably foreseeable. The rationale given was that the 2004 Annual Report of the American Association of Poison Control Center’s Toxic Exposure Surveillance System reviewed 4,059 toxic Dilantin exposures in 2003 that resulted in only seven deaths, six of which included combined exposures to Dilantin and other drugs. Although rarely used today for cardiac arrhythmias, the FDA only noted 10 deaths from cardiac events between 1997 and 2002 due to the infusion of fosDilantin. It was noted that adverse cardiac events from Dilantin toxicity are [relatively very] rare compared to the frequency of toxic and/or therapeutic exposure to this drug. Adverse cardiac events were frequently associated with additional predisposing factors beyond just Dilantin.
The clinician further noted that the date of death was April 10, 2005, and that the hospital discharge summary noting the resolved Dilantin toxicity was dated November 2, 2004 (date of admission October 14, 2004).
Mr. Knox, who was Veteran’s representative, argued that pursuant to 38 CFR 3.358, the Board must compare the physical condition of Veteran immediately prior to the disease or injury to the physical condition of Veteran after the disease or injury. Veteran was admitted on October 14, 2004, because of Dilantin toxicity, and Veteran never returned home to his full strength or intellectual capacity after that episode.
The BVA judge remanded the case to the RO. Specifically this judge did not limit the inquiry to April 2005. Rather, the Judge held that the file would be forwarded for review to a qualified physician who had not previously treated or evaluated Veteran, and the expert would answer the question whether Veteran’s death was caused or in any way contributed to by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the relevant treatment.
The BVA heard Veteran’s case on February 28, 2011. The BVA limited its review to Veteran’s admission to the hospital on April 10, 2005. They noted that the immediate cause of death was reported as gram negative sepsis due to or as a likely consequence of pneumonia, due to or as a likely consequence of acute myocardial infarction. No other significant condition contributing to death was reported on the death certificate. With that fact alone, the BVA concluded that the Veteran was not eligible for disability based on 38 USC §1151.
The decision to discharge Veteran within a few hours from his admission on September 30, 2004, was negligent.
As a result of errors by the employees of the VA on September 30, 2004, the Veteran suffered irreversible damage to his health that led directly to his final demise on April 10, 2005, with no further intervening cause.
The BVA erred by limiting the inquiry to the events of April 2005.
No error in care was shown during that hospitalization.
The death certificate did not indicate that the cause of death was Dilantin toxicity.
Direct death from cardiac toxicity caused by Dilantin is rare.
The Board ignored Appellant’s direct request during the 2006 hearing to have the Board investigate the events that led to Veteran’s death in April 2005 which emanated from proven Dilantin toxicity in October 2004. At the BVA hearing in 2006, Veteran’s Representative argued, with no objection from the hearing judge, that Dilantin toxicity was an aggravated cause of injury, which led directly to Veteran’s death with no intervening causes. Pursuant to 38 CFR 3.358, the Representative argued that the Board must compare the physical condition of Veteran immediately prior to the disease or injury, to the physical condition of Veteran after the disease or injury. Veteran was admitted by VA records because of Dilantin toxicity, and Veteran never returned home to his full strength or intellect after that episode.
The interpretation of the statute asserted by the VA appears at 38 CFR §3.358 (1992). The regulation provides that a veteran must prove he suffered a disability, disease, or injury, or aggravation thereof, as the result of a specified VA service, and not merely coincidental with it. 38 CFR §3.358(c)(1). Compensation is payable in the event of the occurrence of an “accident” (an unforeseen, untoward event), causing additional disability or death proximately resulting from Department of Veterans’ Affairs hospitalization or medical or surgical care. 38 CFR §3.358(c)(3).
In Roberson v. Shinseki, 607 F.3d 809, a leading case for the evaluation of 38 USC §1151, (a case that has ended in the United States Supreme Court), Appellant Catherine Roberson appealed the decision of the Court of Appeals for Veterans’ Claims (Veterans’ Court) affirming the Board of Veterans’ Appeals (Board) decision denying Mrs. Roberson’s claim for death and indemnity compensation (DIC) pursuant to former 38 USC §1151 for her husband’s death from non-service-connected cancer. It was determined that onset of the cancer occurred four to six months before the August 1995 diagnosis. Mrs. Roberson appealed the Board’s decision to the Veterans’ Court asserting that VA treatment, that is, the failure to diagnose her husband’s cancer, had the effect of hastening his death. Thus the Board correctly evaluated the events that led to the veteran’s death 6 months earlier and not simply the final days of his death from cancer.
The BVA failed to assist appellant.
In the present case, after reviewing the entire medical record composed of more than 2600 pages certified by the board as evidence, we are still puzzled as to exactly what happened on September 30, 2004. Attached are additional records from the VA hospital regarding the 9/30/2004 admission to the ER. These documents were forwarded to the VA attorney and the central staff prior to the conference but were clearly not reviewed by the Board. The few pages of medical records from 9/30/2004 do not shed sufficient light as to exactly what was found, what instructions were given, and exactly what the personnel did regarding Veteran’s care. It is obvious from Appellant’s testimony and from the medical records of the visit on October 14, 2004, that the September admission resulted in the dramatic deterioration in Veteran’s health and led to his ultimate demise.
Following the conference, it appears to us that the VA attorney does not contest that the inquiry should be limited to 4/2005, but rather he wishes to defend the decisions made by the VA based in part on the records we have obtained that were not made part of the record before you until now. We argue that the sole remedy for the failure of the BVA to review Veteran’s claim fully is a remand. The Board failed to obtain the entire medical record, failed to order a medical expert evaluation of the issues presented on 9/30/2004, and failed to deliberate and render a decision regarding whether the alleged negligence by the VA met 38 USC §1151.
Affairs (VA), and includes the Board of Veterans’ Appeals (BVA). The law specifies the VA’s duty to assist the appellant in obtaining evidence necessary to substantiate a claim and includes an enhanced duty to notify the appellant as to the information and evidence necessary to substantiate a claim for VA benefits. The VA must make reasonable efforts to obtain relevant evidence, such as private medical records, employment records, or records from state or local government agencies.
It is clear from the record that Appellant, through her representative, specifically asked the BVA judge at the 2006 hearing to investigate the events beginning in 9/30/2004, and not only the 4/2005 admission.
“In the Statement of the Case the question the doctor was asked was, was the veteran’s cause of death the result of overmedication with Dilantin. We feel like this question is not actually the appropriate question to be asked in this situation. The CFR 38 3.358 states that all we have to show is that it was an aggravated cause of the veteran’s death, did it cause disability, meaning did it deprive the veteran of physical and, which is basically the definition of disability, physical, mental or intellectual strength. I think by the story we heard definitely denied the veteran of his physical and his mental strength. The veteran was hospitalized up until that point and never returned home after that until his demise.” (R. 2505).
The BVA judge remanded the case to the RO. (R. 2491). Specifically, this judge did not limit the inquiry to April 2005. Rather, the Judge held that the file would be forwarded for review to a qualified physician who had not previously treated or evaluated Veteran, and the expert would answer the question whether Veteran’s death was caused or in any way contributed to by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the relevant treatment, including views on Dilantin, or due to an event not reasonably foreseen. The opinion would address the principal of “it is as likely as not to at least a 50-50 degree of probability.” The case would then be reviewed and a supplemental statement of the case would be issued and then returned to the Board. Regrettably the original judge did not participate in the 2011 proceedings, and it is obvious that his intent for a full review was not carried out. This is a legal error, and the only remedy is a remand.
Once the claimant has met his burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded under §5107(a), the burden then shifts to the Secretary to “assist such a claimant in developing the facts pertinent to the claim.” 38 USC §5107(a).
In Patton, the CAVC held that during personal hearings conducted by VA adjudicators, pursuant to 38 CFR §3.103(c), the VA has the responsibility to “suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant’s position.” Accordingly, if the claimant or the records in the claims file put the VA on notice of the existence of evidence that may help substantiate the claim, the VA is required to obtain the evidence itself or advise the claimant to submit the evidence.
It is indisputable that Veteran suffered from Dilantin toxicity. The Dilantin level measured at his admission to the hospital was twice the therapeutic dose (R. 2498). The Board recognized in its decision that Veteran arrived at the hospital a few days before his death in April 2005 in an extreme state of malnutrition and debility. The physician who reviewed the case for the Board stated that Veteran was admitted to the hospital with cachexia and numerous chronic health problems. The only question is whether there is a nexus between the Dilantin toxicity (October 2004) and Veteran’s ultimate demise (April 2005). The Board cited a report by the American Association of Poison Control noting that only 10 cardiac deaths were caused by Dilantin.
cerebral cortex over long periods of time, as well as causing atrophy of the cerebellum when administered at chronically high levels. At therapeutic doses, Dilantin produces horizontal gaze nystagmus. At toxic doses, patients experience sedation, cerebellar ataxia, and ophthalmoparesis, as well as seizures. Idiosyncratic side-effects of Dilantin, as with other anticonvulsants, include rash and severe allergic reactions. Dilantin causes a reduction in folic acid levels, predisposing patients to megaloblastic anemia. Folic acid is presented in foods as polyglutamate, which is then converted into monoglutamates by intestinal conjugase. Dilantin acts by inhibiting this enzyme, thereby causing folate deficiency. Other side effects may include: agranulocytosis, aplastic anemia, leukopenia [thrombocytopenia]. The FDA has also warned of an increased suicide risk for any patients treated with certain anti-seizure drugs. The study of 44,000 patients found that patients whose epilepsy is treated with drugs face about twice the risk of suicidal thoughts compared to placebo-takers. The VA’s own study concluded that Dilantin is highly toxic and should not be prescribed to the elderly. (See infra).
As a result of errors by the employees of the VA on September 30, 2004, the Veteran suffered irreversible damage to his health that led directly with no further intervening cause to his final demise on April 10, 2005.
The record of September 30, 2004, does not adequately describe a seizure event. The record of 9/30/2004 obtained by us and provided to the VA counsel shows that the EEG performed on 9/30/2004 did not find seizure activity. Clearly the VA staff failed to investigate the cause of the Veteran’s seizure and discharged the Veteran immediately.
The Appellant testified that on September 30, 2004, she called 911, because the Veteran was diabetic, and she suspected diabetic problems. At the hospital, Appellant was told that they suspected a seizure, and they gave Veteran Dilantin. Thus, the first time that Veteran was ever given Dilantin was in that hospitalization of September 30, 2004. The Veteran was promptly discharged and was taken home that night. The hospital personnel gave Veteran two pills of Dilantin and told Appellant to give him two more pills every day and three more pills every night. She was instructed to make an appointment in two weeks. At some later point, the Appellant called for an ambulance to bring Veteran back to the hospital.
cerebral cortex over long periods of time, as well as causing atrophy of the cerebellumwhen administered at chronically high levels. Appellant was never advised about Dilantin toxicity. No blood levels were ordered, and the delicate titration of the drug was left in the hands of a disabled lay person.
To prove her case under 38 US 1151, Appellant only needed to prove that the Dilantin toxicity was as likely as not a major contributory cause to Veteran’s demise, not necessarily the only cause. In Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990), the Court held that, in order to deny benefits, the negative evidence cannot be phrased as “not as likely,” but rather the preponderance of the evidence must be against the claim, i.e., that there is no reasonable possibility that Veteran is correct.
Alternatively, the Ortiz court noted the benefit-of-the-doubt rule may be viewed as shifting the “risk of non-persuasion” onto the VA to prove that the veteran is not entitled to benefits, citing the Supreme Court decision in Dep’t of Labor v. Greenwich Collieries, 512 U.S. 267, 281, 129 L. Ed. 2d 221, 114 S. Ct. 2251. According to the Ortiz ruling, to deny benefits, the preponderance of the evidence must be against granting benefits in the veteran’s claim. It is only when the evidence is clearly negative that the VA has overcome its risk of non-persuasion.
The benefit-of-the-doubt doctrine imposes an additional duty on the court. When 38 USCA §4004(d)(1) has been complied with, and when this Court is reviewing Board decisions which do not apply the “benefit-of-the-doubt” standard, then the Court is engaged in two separate analyses. Pursuant to 38 USC §4061(a)(4), the Court must first determine if the Board’s findings of material fact made in reaching its decision were clearly erroneous. Second, after making these determinations, this Court must use them and apply 38 USC §4061(a)(1), (3) to decide whether the Board’s decision not to apply the “benefit of the doubt” standard was in accordance with 38 USC §3007(b). Though these two analyses are interrelated, they are still made independently of one another and under different scopes of review.
We argue that as a result of errors by the employees of the VA on September 30, 2004, Veteran suffered irreversible damage to his health that led directly with no further intervening cause to his final demise on April 10, 2005 The Board failed to obtain the entire medical record, failed order a medical expert evaluation of the issues presented on 9/30/2004, and failed to deliberate and render a decision regarding whether the alleged negligence by the VA met 38 USC §1151. The Board inappropriately limited its inquiry to the care Veteran received prior to his demise in April 2005, rather than to 9/30/2004, when the alleged negligence occurred. Remand is necessary, therefore, to allow adequate review of the medical records and expert testimony regarding the events of 9/30/2004.
 38 CFR 3.358 – Compensation for disability or death from hospitalization, medical or surgical treatment, examinations or vocational rehabilitation training (§ 3.800). (a) General. This section applies to claims received by VA before October 1, 1997. If it is determined that there is additional disability resulting from a disease or injury or aggravation of an existing disease or injury suffered as a result of hospitalization, medical or surgical treatment, examination, or vocational rehabilitation training, compensation will be payable for such additional disability. For (b) Additional disability. In determining that additional disability exists, the following considerations will govern: (1) The veteran’s physical condition immediately prior to the disease or injury on which the claim for compensation is based will be compared with the subsequent physical condition resulting from the disease or injury, each body part involved being considered separately.
MR. KNOX. What I wanted to point to, Judge, was that we’re referencing 3.358 in CFR, whereas the, and according to subparagraph one, the veteran’s physical condition immediately (inaudible) to the disease or injury will be compared with the physical condition resulting from the disease or injury or body part involved. Prior to admittance to this situation – to the Dilantin episode – the veteran was fully engaged with wife, had not been in any facilities, had not been under any hospital care. He was actually helping to take care of his wife; … and the vet actually was well enough for the VA to send home. After the Dilantin episode, the veteran remained under hospital care and under hospital and medical care until his demise. We are claiming that the Dilantin was an aggravated cause of the injury, of the final injury of death. In the Statement of the Case the question the doctor was asked was, was the veteran’s cause of death the result of overmedication with Dilantin. We feel like this question is not actually the appropriate question to be asked in this situation. The CFR 38 3.358 states that all we have to show is that it was an aggravated cause of the veteran’s death, did it cause disability, meaning did it deprive the veteran of physical and, which is basically the definition of disability, physical, mental or intellectual strength. I think by the story we heard definitely denied the veteran of his physical and his mental strength. The veteran was hospitalized up until that point and never returned home after that until his demise.
 Nystagmus: A rapid, involuntary, oscillatory motion of the eyeball.
Mattson in New England Journal of Medicine 1985, :31.3, :145 and Smith D.B., results of nationwide Veteran Administration Cooperative Study, comparing the efficacy and toxicity of carbamazepine, phenobarbital, Dilantin published in Epilepsia in 1987, 28 supplement 3, page 550.

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