Opinion ID: 2429845
Heading Depth: 1
Heading Rank: 2

Heading: The Hospital's Liability

Text: The hospital argues that the plaintiff did not make a submissible case against it. It asserts, appropriately, that it does not practice medicine and that everything its employees did was consistent with the instructions of Dr. Sharma. It also asserts error in the verdict director and other trial error. We conclude that none of the errors claimed is established.
The defendant hospital argues that there is no evidence that it was negligent. The point can best be considered in the light of the plaintiff's verdict director against the hospital, which reads as follows: [9] Your verdict must be for Plaintiff and against defendant St. Luke's Hospital of Kansas City if you believe: First, plaintiff was the spouse of Gary L. Augustine, and Second, the employees of St. Luke's Hospital of Kansas City were acting within the scope and course of their employment by St. Luke's Hospital of Kansas City during Gary L. Augustine's admission and treatment at St. Luke's Hospital of Kansas City, and Third, defendant's employees failed to follow its critical values of blood policy and procedure, or failed to adequately monitor the lab reports of Gary L. Augustine's blood, or failed to timely order blood, or failed to see that blood was timely given. Fourth, defendant St. Luke's Hospital of Kansas City, in any one or more of the respects submitted in paragraph Second was thereby negligent, and Fifth, such negligence directly caused or directly contributed to cause the death of Gary L. Augustine. There is prejudicial error, of course, unless all four of the alternatives set forth in paragraph Third are supported by substantial evidence. We conclude that they are so supported. On Saturday morning, July 19, the hospital's employees became aware of the hematocrit reading of 16, which is well below the hospital's critical values. According to the plaintiff's experts, in the exercise of due care, a resident physician should have made arrangements to give blood sometime during the weekend, or, at the very least, to report the low reading to Dr. Sharma as the attending physician, in which case the hospital might be able to leave decisions to him. There is no evidence of any such report, and no indication that Sharma saw the patient on Saturday or Sunday. There was support then, for findings of failure to follow its critical values of blood policy and procedure and of failure to adequately monitor the lab reports. It is not necessary to point to any particular employee of the hospital as the person at fault, any more than it is necessary to decide which employee of a supermarket should have noticed a dangerous condition which is shown to have existed for a substantial time. [10] If a physician noticed the reading he or she should have taken action; if not, the hospital employees should have reported it to someone qualified to make decisions. The jury might also find a failure on the hospital's part to give prompt and proper attention to the Monday reading of 10. The record also supports a conclusion that the hospital failed to timely order blood. The record shows that resident physicians had the authority to order blood over the weekend and to cause it to be administered. If it were felt that blood should not have been administered without Dr. Sharma's approval, he could have been notified. Another possibility would be to order suitable blood to be available Monday morning, when Gary was next scheduled for dialysis. Blood is sometimes ordered so that it will be available if needed, even though it is not certain that it will be given. The jury might also believe that the hospital employees did not proceed so quickly as they should have after Dr. Sharma gave the blood order on July 21. The hospital employees knew how long the dialysis was expected to continue, and could have advised the blood bank that blood was needed in time to meet this schedule. They cannot excuse themselves by asserting that Dr. Sharma gave no STAT or ASAP order. They knew when the blood would be needed in order to carry out his orders. There is also evidence that the hospital failed to see that blood was promptly given. In addition to the delay over the weekend, the jury could also find the hospital at fault for the delay of more than two hours from the arrival of the blood to the beginning of the transfusion. Blood can be given much more efficiently during dialysis, yet the patient was returned to his room. The jury did not have to find that Dr. Sharma ordered the return. It might expect the hospital to explain why blood received at 3:15 was not administered until 5:30 P.M. The plaintiff's expert testimony indicated that every hour was important, especially after the hematocrit dropped to 10 Monday morning. The four particulars of negligence contained in the verdict director, then, are supported by the evidence. It follows that the plaintiff made a submissible case of negligence. To so hold does not make the hospital responsible for practicing medicine. Nor does it require the hospital residents or other employees to second guess the attending physician. The negligence asserted relates to the hospital's duty to provide care for the patient, and to carry out physicians' orders. We must remember that the patient is in the hospital constantly, while the attending physician sees him only briefly. Hospital employees, whether or not physicians, may be called upon to exercise judgment not inconsistent with the physician's orders, when the attending physician is not present or available. The jury could have found several instances in which prompt action by the hospital employees would have made the blood available sooner. The hospital also argues that the plaintiff has failed to establish causation. Its basic claim is that Gary died of a septicaemia, as shown by the autopsy finding of staphylococci in the blood, and that the low red cell content was not a contributing factor. [11] The plaintiff's experts concede the possibility of such an infection, but are positive in saying that the anemic condition, as evidenced by the constant decline in the hematocrit, contributed to the patient's death. The only way to raise the hematocrit quickly is to give blood. Time was of the essence. One witness said that the lack of red cells was a major cause of death. The test of causation is met. Jackson v. Ray Kruse Const. Co., 708 S.W.2d 664, 669 n. 6 (Mo. banc 1986). The issue is for the jury. We also reject the hospital's claim that the cross-examination rendered the expert testimony so uncertain that it could not support the essential findings. The cross-examination merely raised questions for the jury to evaluate, in the context of the entire record. Goslin v. Kurn, 351 Mo. 395, 173 S.W.2d 79, 87 (1943).
The defendant hospital has two additional criticisms of the verdict director against it as quoted above. The conjunction, and is omitted between paragraph Third and paragraph Fourth, with a period rather than a comma at the end of paragraph Third. Then paragraph Fourth refers to negligence in the respects submitted in paragraph Second, whereas the particulars of negligence are submitted in paragraph Third. Only the first of these complaints is challenged in the motion for new trial, Item 20 of which reads as follows: The court erred in submitting plaintiff's verdict directing Instruction No. 8 against St. Luke's Hospital since the verdict director erroneously eliminated the conjunctive and at the end of the third proposition of Instruction No. 8 and before the fourth proposition of Instruction No. 8, in direct violation of M.A.I. 20.20. Rule 70.03 of our rules reads as follows: Counsel need not object to any instructions to be given at the request of any other party or by the court on its own motion or to the refusal of any instructions requested by such party. Specific objections to instructions shall be required in motions for new trial unless made at trial. The making of objections during trial shall not preclude making additional objections to the same or other instructions in the motion for new trial. No general objection to instructions is required. The hospital has preserved only the failure to insert the conjunction, and. The complaint about the mix-up in paragraphs was not mentioned in the new trial motion. By Rule 70.02(c) the deviation from MAI is error, but we are required to determine whether the omission of and was prejudicial. The governing rule is Rule 84.13(b) reading as follows: Materiality of Error. No appellate court shall reverse any judgment unless it finds that error was committed by the trial court against the appellant materially affecting the merits of the action. We conclude that the omission of and was not prejudicial. Paragraph Third contains four hypotheses in the disjunctive, separated by or. It is difficult to see how any literate juror could conclude that the jury did not have to find the facts submitted in paragraph Fourth, in addition to one of the alternate submissions of paragraph Third. There is no ground for confusion. Cf., Lee v. Mirbaha, 722 S.W.2d 80, 84 (Mo. banc 1986) (finding no prejudicial error in the use of these in converse instructions, when the appropriate and responsive word would have been this.) In Kirkendall v. Townsend, 559 S.W.2d 561 (Mo.App.1977), the court was confronted with an instruction in which the and had been omitted between all paragraphs of a verdict directing instruction. The trial court had granted a new trial on this basis, and the court of appeals affirmed. The holding is appropriate because the judgment of the trial court on matters of prejudicial error is entitled to great weight. Here the trial court overruled the motion for new trial, and so our holding is entirely consistent with Kirkendall . Even so, the Kirkendall opinion expresses dissatisfaction with a situation in which the least typographical error would mandate a new trial. The defendants cite Brown v. St. Louis Public Service Company, 421 S.W.2d 255 (Mo. banc 1967), for the proposition that any deviation from the MAI patterns requires reversal unless it is made perfectly clear by the proponent of the instruction that no prejudice could have resulted from such deviation. The case is distinguishable for several reasons. In the first place, it was directed toward attempts at deliberate deviation from, or attempted improvement of, MAI Instructions, in order to make it clear to the bar that counsel should not substitute variations of their own for the MAI text. The opinion expressly disclaims any intention of holding that all typos or inadvertent variances require reversal. Secondly, the trial court in that case granted a new trial because of the deviation from the patterns, and so the proponent of the instruction had the burden of demonstrating error on appeal. Third, we sense no purpose in that opinion of departing from the long-established proposition of Rule 84.13(b), quoted above. [12] Brown does not require reversal in this case. The defendant hospital, in its argument to the jury, clearly stated that the plaintiff had to establish each of the five propositions set forth in the verdict director. The plaintiff squarely took on each of the alternatives of paragraph Third, and argued that the record demonstrated negligence in each of these respects. It is proper to consider counsels' arguments in determining prejudicial error. Welch v. Hyatt, 578 S.W.2d 905, 914 (Mo. banc 1979). We are not persuaded that we should reverse the trial court for the reason assigned. Nor do we find plain error in the confusion between paragraph Second and paragraph Third. We may raise an eyebrow at the lack of careful proofreading in a case of this importance, but we cannot say that the jury was misled as to the issues it was required to decide. Because of the failure of preservation we do not have the benefit of the trial judge's views, and we decline to reverse him. Failure of the defendant hospital to object before the instructions were given to the jury plays no part in our decision. We have reviewed the error preserved and find it not to be prejudicial. This is in line with other recent cases, in which the appellate courts give great deference to the conclusion of the trial judge as to the prejudicial effect of errors in instruction, [13] and are reluctant to reverse for error which does not give indication of prejudice. [14] It is nevertheless appropriate to observe that a lawyer who finds something in his opponent's instruction which may adversely affect presentation to the jury may speak up at the time, in an effort to obtain the best legal submission for his client. The lawyer who does not do so is not doing his best to win the case before the jury, but rather is thinking of appeal before the verdict is in. The lawyer who remains silent is entitled to review under Rule 70.03, but is not entitled to reversal unless prejudice is established. This is the teaching of our recent cases. [15] The plaintiff was allowed to read in evidence portions of the deposition of Donna Cling, a nurse employed by St. Luke's as supervisor of incenter dialysis. St. Luke's objected on the ground that the plaintiff had not shown that she was unavailable as required by Rule 57.07(a)(3). The plaintiff countered with the argument that Cling's statements could be received as admissions of St. Luke's because of her supervisory position. The trial court overruled the objection. The court of appeals found error sufficient to require reversal. We agree that there was error but do not discern prejudice. Even though the witness had an important supervisory position she was not a managerial person whose statements constitute admissions by her employer, [16] nor was she acting within the scope of her employment when she made the statement. [17] She testified on deposition at the instance of the plaintiff and not as an officer of the hospital. [18] She is not shown to have participated in Gary's care. Testimony in open court remains the rule and deposition testimony the exception, requiring a showing of unavailability. But error does not necessarily require reversal. Prejudice must appear. Rule 84.13(b). The deposition testimony was given under oath, with all parties having the right to full examination. The witness said, essentially, that she would report a hematocrit reading which was below 20 to the responsible physicians, and that with a reading of 18 or 16 blood would probably be given. This is consistent with St. Luke's procedural manual received in evidence. St. Luke's did not express disagreement and did not call any witness to challenge the testimony. There is no reason to assume that Cling's testimony in open court would have differed from the deposition testimony. Under these circumstances, prejudice to St. Luke's is not apparent. St. Luke's argues that the trial judge compounded the error when he would not allow it to read other portions of Cling's deposition during its case. The trial court's ruling is consistent with his major premise that the plaintiff could read portions of the depositions as admissions. If this were correct, the defendant had no right to read additional portions as substantive evidence. As we have held, however, the trial judge's assumption was not correct, and St. Luke's had as much right to read from the deposition as the plaintiff did. St. Luke's is not entitled to reversal, however, because it made no offer of proof as to the additional portions of the deposition which it wanted to read. [19] The offer, pointing up the contention of prejudice, is an essential condition of relief at the appellate level. St. Luke's could also have made an effort to bring the witness in and, if she were unavailable, could then read from the deposition. But it made no attempt to follow this course of action, possibly through fear of condoning the error previously asserted. A party confronted with an erroneous ruling may be expected to take reasonable steps to blunt the effect. St. Luke's also objects to the trial court's refusal to allow it to present Dr. Thomas Wiegmann as an additional expert witness. The initial order of denial was entered when the trial was scheduled to go forward on October 28, 1985, and the proposed witness had not been listed until October 21. Then there was a postponement until January 21, 1986. St. Luke's argues that there was a sufficient change of circumstances so that it should not be denied the additional expert witness testimony it desired. Although the trial court has great discretion in maintaining the integrity of discovery in prior pretrial proceedings, it should hesitate to deny a party the right to important testimony. St. Luke's, however, has failed to point out on the record of the trial court, and to us, the testimony it expected from Dr. Wiegmann. Its supplemental answers to interrogatories, filed October 21, 1985, indicate only the areas to be covered and do not indicate disagreements with the plaintiff's experts. No further offer was made at trial. We are unable to determine how it was harmed by the denial. This relieves us of determining whether the trial court abused its discretion. The judgment against St. Luke's Hospital is affirmed. The judgment against Dr. Crouch is reversed and the case is remanded for such further proceedings as may be indicated. BILLINGS, C.J. and HIGGINS, J., concur. ROBERTSON, J., concurs in result. DONNELLY, J., dissents in separate opinion filed. WELLIVER and RENDLEN, JJ., dissent and concur in separate dissenting opinion of DONNELLY, J. DONNELLY, Judge, dissenting. In Brown v. St. Louis Public Service Company, 421 S.W.2d 255, 259 (1967), this Court held that where there is deviation from an applicable MAI instruction which does not need modification under the facts in the particular case, prejudicial error will be presumed unless it is made perfectly clear by the proponent of the instruction that no prejudice could have resulted from such deviation. The rationale for the Brown holding was articulated by Judge Ben W. Swofford in McGowan v. Hoffman, 609 S.W.2d 160, 163 (Mo.App.1980): The Supreme Court of this state with laudable intent and worthy and efficient aspiration adopted MAI and ruled so as to enforce upon the bench and bar a very strict code of restriction by and compliance with its mandatory use, all of which has effected a vast savings in judicial time and taxpayers' money. But the gate of restriction and compliance must in the interest of fundamental justice be left somewhat ajar. Thus, from the consistent and binding decisional law, since the adoption of MAI and Rule 70.02, the principle has evolved that courts faced with violations or impermissible modifications of MAI must gauge the prejudicial effect thereof. Such defect in submission of a case must be shown to be non-prejudicial before it can be given. It appears to this Court that it must be shown, and the judicial mind and conscience satisfied by means of some positive force of fact or logic, that no prejudicial effect has resulted from the erroneous instruction. The burden to make this showing rests upon the party offering the instruction. In Hudson v. Carr, 668 S.W.2d 68 (Mo. banc 1984), an instruction on damages, taken from MAI without change, was given in behalf of plaintiff. Defendant asserted on appeal that under the evidence the MAI instruction should have been modified. The Court held, in such circumstance, that when the instruction is only abstractly erroneous there is a need for balancing and balancing in this instance indicates that a new trial is not necessary. Hudson v. Carr, 668 S.W.2d at 72. In Fowler v. Park Corp., 673 S.W.2d 749, 756 (Mo. banc 1984), the wrong MAI instruction on standard of care was given in behalf of plaintiff and the Court, without mentioning Brown, placed the burden of demonstrating prejudice on the party opposing the instruction and held that we should reverse only for defects of substance with substantial potential for prejudicial effect. It must be said that Fowler was an unwarranted and unwise extension of Hudson. See Points v. Dzur, 713 S.W.2d 634 (Mo.App.1986); Abshire v. Nordson Corp., 688 S.W.2d 1, 2 (Mo.App.1985) (Stewart, J., dissenting); McCarter and Behr, MAI Error After Fowler v. Park Corp.: Prejudicial or Not?, 41 J. of Mo. Bar 308 (July-August 1985). But Fowler remains intact. I dissent.