Opinion ID: 1300934
Heading Depth: 2
Heading Rank: 1

Heading: directed verdict regarding conflicting discharge instructions

Text: Appellant argues the trial court erred in granting a directed verdict on the issue of whether Hospital and its agent, King, were negligent in providing conflicting discharge instructions to Decedent. I agree. It is undisputed Decedent was given conflicting discharge instructions by King and Hospital's staff. King testified he verbally told Decedent to follow up with his cardiologist, Reeves, the next morning and he documented this instruction in emergency room records which were not provided to Decedent the night of his visit. In contrast, the written discharge instructions Decedent received from Hospital's staff, titled Aftercare Instructions, stated: THESE ARE YOUR FOLLOW-UP INSTRUCTIONS! Call Dr. Hiott [Decedent's family doctor] in 2 days if not much better. Call sooner if worsening. On cross-examination, Appellant denied knowing Decedent was told at the time of his discharge from the emergency room to contact his cardiologist in the morning. At the close of Appellant's case, Hospital moved for a directed verdict on the allegation Hospital was negligent in giving conflicting discharge instructions. The trial judge granted the motion, ruling Appellant had not presented expert testimony the conflicting instructions were the proximate cause of Decedent's death. This ruling constitutes reversible error. Appellant produced no explicit expert testimony Decedent's death was proximately caused by the failure to see his cardiologist the next morning. See e.g. Bramlette v. Charter-Medical-Columbia, 302 S.C. 68, 72, 393 S.E.2d 914, 916 (1990) (expert testimony is required to establish proximate cause in a medical malpractice case if outside the common knowledge or experience of laypersons); Gooding v. St. Francis Xavier Hosp., 326 S.C. 248, 254, 487 S.E.2d 596, 599 (1997) (unless the subject is a matter of common knowledge, the plaintiff must use expert testimony to establish both the standard of care and the defendant's failure to conform to that standard). I disagree with the majority's conclusion the record contains no expert testimony Decedent's death was proximately caused by the failure to see his cardiologist the next morning. I also disagree with the majority's conclusion the record contains no evidence Decedent relied on the conflicting aftercare instructions. A plaintiff may present both expert testimony and circumstantial evidence of a physician's culpability, and the inquiry need only be whether there is sufficient competent evidence from which the jury may infer a causal connection between the physician's conduct and the injury. Green v. Lilliewood, 272 S.C. 186, 189-93, 249 S.E.2d 910, 912-13 (1978) (reversing grant of directed verdict for defendant physician where plaintiff relied on both expert testimony and circumstantial evidence which showed plaintiff's medical problems began soon after insertion of intrauterine device); Shelnitz v. Greenberg, 200 Conn. 58, 509 A.2d 1023, 1027 (1986) (causation in medical malpractice case may be proven both by expert testimony, which usually is necessary to establish the standard of care, and circumstantial evidence); 1 Dan B. Dobbs, The Law of Torts § 173 (2001) (courts recognize juries must be permitted to make causal judgments from ordinary experience without demanding an impossible degree of proof and [e]ven scientific or medical causation might be proven by circumstantial evidence leading to an inference of causation); Prosser & Keeton on the Law of Torts § 41 (5th ed. 1984) (Circumstantial evidence, expert testimony, or common knowledge may provide a basis from which the causal sequence may be inferred.). Appellant's expert, Wood, testified that had Decedent been admitted to the hospital rather than discharged, he more than likely would have survived. Wood testified people have heart attacks and get hospitalized for it all the time, and, you know, these are general statistics, but probably ninety percent of people that get hospitalized with heart attacks live. A reasonable inference which may be drawn from this testimony is if Decedent had seen his cardiologist the next morning as directed by King, he could have been admitted to the hospital where he most likely would have survived his heart attack. The expert's testimony that the proximate cause of Decedent's death was the lack of hospitalization at the time of his cardiac arrest was sufficient to submit to the jury the issue of Hospital's negligence, regardless of whether the lack of hospitalization occurred on the night of his visit to the emergency room or the morning after. Therefore, liberally construing the evidence Decedent did not return to his cardiologist the next morning as directed by King, Hospital gave Decedent discharge instructions stating he should wait two days to see his family doctor, and expert testimony he most likely would have survived had he been hospitalized at the time of his heart attack, it is reasonably probable a verdict would have been rendered in Appellant's favor had the jury been allowed to consider negligence allegations relating to the conflicting discharge instructions. In addition, the record contains circumstantial evidence Decedent relied on Hospital's written discharge instruction (call family doctor in 2 days if not much better. Call sooner if worsening.) instead of King's verbal instruction (see cardiologist the next morning). Appellant testified Decedent stated on September 3 he did not need to return to the hospital because, although King had told Decedent he would have a terrible headache from the nitroglycerin, he expected to be better in a day or two. Thus Decedent told his wife he needed to give his condition a couple of days to improve  just like Hospital told him to do in its written discharge instructions. See e.g. Mahaffey v. Ahl, 264 S.C. 241, 247, 214 S.E.2d 119, 122 (1975) (it is axiomatic in this State that issues of negligence and proximate cause may be resolved by direct or circumstantial evidence). In pointing to circumstantial evidence surrounding Decedent's actions, I do not suggest expert testimony is not usually required to prove medical malpractice. I do conclude that expert testimony identifying the lack of hospitalization as a proximate cause of Decedent's death, combined with circumstantial evidence Decedent may have relied on discharge instructions in which he was not told to follow up promptly with a cardiologist who may have admitted him to the hospital before he suffered a fatal heart attack, are sufficient to create a jury question on whether Hospital and its admitted agent were negligent. See Green, 272 S.C. at 189-93, 249 S.E.2d at 912-13; Shelnitz, 509 A.2d at 1027.