Opinion ID: 509579
Heading Depth: 4
Heading Rank: 1

Heading: Duty of Referral

Text: 103 The district court concluded that Dr. Channing was not negligent in failing to refer Karen Keir to an ophthalmologist, and concluded that the SOP did not create an actionable duty because under New Jersey law tort obligations cannot be created by private action. 7 To support this conclusion, the district court placed heavy reliance on Coyle v. Englander's, 199 N.J.Super. 212, 488 A.2d 1083 (1985). In our view, the district court's reliance on Coyle is misplaced. 104 In Coyle, the issue presented for disposition by the court was whether a disappointed promisee may recover traditional tort damages for his personal injuries caused by a breaching promisor's failure to perform a contractual term. Id. at 214, 488 A.2d at 1083. The facts indicated that plaintiff sustained injuries when moving band equipment onto a truck after defendants breached their contractual obligation to provide assistance in this endeavor. The court construed plaintiff's claim solely as a claim that breach of a contractual term caused personal injuries to him. Id. at 217, 488 A.2d at 1085. The court concluded that the failure to perform a contractual duty could not serve as the basis for imposition of damages for personal injury where no breach of any common-law duty is implicated in the slightest.... Id. at 276, 488 A.2d at 1090. Accordingly, recovery was denied. 105 In our view, Coyle does not control disposition of the present case. The duty to refer in the present case need not have been created by the SOP. Rather, the duty of due care existed by virtue of the health care provider/patient relationship. The critical question that must be answered upon a review of the record focuses on the nature of that duty. Thus, the mere fact that the SOP did not create a duty of referral does not mean that the SOP becomes irrelevant. Instead, the SOP is useful in determining the scope of the duty owed by Dr. Channing to Karen Keir. 106 This court has recognized that consideration of a standard operating procedure is appropriate in considering the scope of duty flowing from the defendant to a plaintiff in a negligence action. In Downs, 522 F.2d at 990, two hostages were killed during the course of the FBI's attempt to stop a hijacking at a Florida airport. Their survivors brought an action against the United States, alleging that the FBI agent was negligent in handling the situation. We concluded that, although the FBI internal hostage guidelines did not in themselves create a duty to the hostages or their survivors, the guidelines were relevant to determination of the scope of the duty. Moreover, the agent's failure to comply with those guidelines was relevant on the issue of whether he had acted as a reasonably prudent FBI agent under the circumstances. 107 Similarly, many other courts have held that hospital internal regulations are relevant in considering the scope of the duty of care owed by the hospital to the patient. See, e.g., Marks v. Mandel, 477 So.2d 1036 (Fla.Dist.Ct.App.1985) (per curiam) (hospital emergency room manual relevant on issue of whether the hospital violated the applicable standard of care); Darling v. Charleston Community Memorial Hosp., 33 Ill.2d 326, 211 N.E.2d 253 (1965) (state hospital regulations, standards for accreditation, and by-laws of hospital did not conclusively determine standard of care but were relevant to this determination), cert. denied, 383 U.S. 946, 86 S.Ct. 1204, 16 L.Ed.2d 209 (1966); Taylor v. City of Beardstown, 142 Ill.App.3d 584, 96 Ill.Dec. 524, 491 N.E.2d 803 (1986) (hospital regulations, standards, and by-laws admissible to determine appropriate standard of care). 108 In a recent decision, a New Jersey appellate court has indicated that regulatory guidelines may be relevant in determining the appropriate standard of care. In Sanna v. Nat'l Sponge Co., 209 N.J.Super. 60, 506 A.2d 1258 (1986), plaintiff alleged that he was injured as a result of the use of improperly constructed scaffolding. The court noted that OSHA regulations contain precise guidelines for the construction of scaffolding, and such regulations could be established as objective safety standards generally prevailing in the community if expert testimony indicated that they were accepted in such. Id. at 69, 506 A.2d at 1263. Thus, Sanna supports the conclusion that the standard operating procedure is relevant in determining whether or not Dr. Channing was negligent, but that it does not necessarily create or define the precise scope of the duty running from Dr. Channing to Karen Keir. 8 109 Our review of the record compels the conclusion that the district court was clearly erroneous in determining that Dr. Channing was not negligent in failing to refer Karen Keir. As an initial matter, it appears that Dr. Channing's failure to comply with the SOP occurred because he disagreed with Dr. Mignone about its usefulness. Dr. Channing and Dr. Mignone had argued about the viability of the SOP after Dr. Mignone became Chief of Ophthalmology at Walston Army Hospital, and Dr. Mignone insisted that the SOP would remain in place. Nevertheless, Dr. Channing believed that the SOP was not livable, and thus he and the other optometrists utilized their own discretion in determining whether to refer patients to ophthalmology. J.A. 178-79, 185. 110 The overwhelming evidence presented in the record indicates that Dr. Channing should have referred Karen Keir to ophthalmology upon her first visit. Dr. Mignone stated that, aside from the SOP, the standard of care at Fort Dix required an optometrist to refer a child like Karen to ophthalmology. J.A. at 269. Dr. Ralph Wesley, who had served considerable time in the Army as an ophthalmologist, stated that in his experience cases such as Karen's were routinely referred to ophthalmology. J.A. at 315. 111 Dr. Estes agreed that the standard operating procedure represented reasonable standards of health care practice for treating patients like Karen Keir. J.A. at 352. In his letter to Dr. Channing, Dr. Tirrill stated that Karen should be seen by an ophthalmologist. At trial, Dr. Tirrill testified that he made this recommendation because of Karen's long history of ocular difficulties. Even Dr. Hiatt, one of the government's witnesses, criticized Dr. Channing's failure to refer, stating that he is not a substitute for an ophthalmologist. Joint Appendix at 627. 112 There is some indication that even if Karen had not been referred initially, she should have been referred on February 12, 1980. Dr. Mignone testified that, assuming Karen's vision had not improved after the initial course of patching, referral should have been made at that time. J.A. 281-82. The assumption upon which the response was based is not entirely accurate, as there was some improvement in Karen's far visual acuity. J.A. 211, 256. Dr. Wesley testified that, given Karen's difficulty in adapting to the patching therapy, referral should have been made on February 12, 1980. J.A. 327. Dr. Feman indicated that, because the course of treatment utilized by Dr. Channing did not result in significant improvement, further evaluation should have been made through a repeated dilated examination or referral to another physician. J.A. 434. 113 On this state of the record, we are left with a definite and firm conviction that the district court's finding regarding the absence of negligence in the failure to refer is erroneous. Anderson, 470 U.S. at 573-74, 105 S.Ct. at 1511, Downs, 522 F.2d at 990. Accordingly, the district court's finding cannot be upheld. 114