Opinion ID: 39534
Heading Depth: 2
Heading Rank: 2

Heading: Liability of Dr. Cruz

Text: It has long been the law in Texas that a plaintiff in a medical negligence case must “prove by a preponderance of the evidence that the allegedly negligent act or omission was a proximate cause of the harm alleged.” See, e.g., Archer v. Warren, 118 S.W.3d 779, 782 (Tex. App.–Amarillo 2003); Park Place Hosp. v. Estate of Milo, 909 S.W.2d 508, 511 (Tex. 1995); Kramer v. Lewisville Mem’l Hosp., 858 S.W.2d 397, 399–400 (Tex. 1993); Bowles v. Bourdon, 219 S.W.2d 779, 782 (Tex. 1949). For the alleged negligence to be a proximate cause of the harm, the harm must have been a foreseeable result of the negligence, and the negligence must have been “a substantial factor in bringing about the harm, and without which the harm would not have occurred.”3 Archer, 118 3 The inquiry is sometimes described as a “reasonable medical probability” that the alleged negligence proximately caused the harm, but the ultimate standard is the same. See Park Place, 909 S.W.2d at 511; Kramer, 858 S.W.2d at 6 S.W.3d at 782; Park Place, 909 S.W.2d at 511; Kramer, 858 S.W.2d at 400. Because medical treatment is beyond the reach of a layperson’s knowledge and experience, expert evidence is required to show both a breach of a standard of care and that the breach was a proximate cause of the harm suffered. See Chambers v. Conaway, 883 S.W.2d 156, 158 (Tex. 1993); Bowles, 219 S.W.2d at 782–83. In granting Dr. Cruz’s motion, the district court concluded that Guile’s expert had not established that any negligence on the part of Dr. Cruz was a proximate cause of Emiko Guile’s suicide.
Guile argues that the testimony of his expert, Dr. George Meyer, did establish breaches of the relevant standard of care. The breaches that Guile contends were established are: improper drug dosing, lack of necessary suicide precautions, improper handling of test results, failure to re-evaluate the treatment plan, failure to transfer Mrs. Guile to another hospital, improper discussion of discharge with Mrs. Guile, improper sending of Mrs. Guile out on a pass, and failure to have the armoires removed from Mrs. Guile’s room.4 In the case of some of these alleged breaches, there is no evidence that Dr. Cruz committed the alleged act or omission, 400. 4 There were a few other breaches alleged at trial, but those listed here are the ones Guile briefs on appeal. The district court correctly concluded that there was insufficient evidence to find that Dr. Cruz committed any other breaches that were a proximate cause of Mrs. Guile’s death. 7 whether or not such act or omission would constitute a breach of the standard of care. For example, the expert’s reference to discussion of discharge with Mrs. Guile involved acts of Dr. DeVargas, not Dr. Cruz. All evidence showed that Dr. Cruz continually re-evaluated and adjusted the treatment plan, including seeking of second opinions. Dr. Cruz did read the results of the testing she ordered, and discussed the results with the testing psychologist. There was no evidence that Dr. Cruz had anything to do with any subsequent unavailability of the test results. Mrs. Guile’s charts showed that Dr. Cruz did increase the dosages of medication over time, as Dr. Meyer testified was necessary to meet the standard of care. Furthermore, there was no evidence that Dr. Cruz knew about the armoires in Mrs. Guile’s room. Dr. Cruz testified that she had not been in Mrs. Guile’s room and did not know about the furniture, and there was no evidence that she had been in the room. Guile argues that there was sufficient circumstantial evidence for the jury to infer that Dr. Cruz had seen the armoires or should have seen them.5 Inferences drawn from circumstantial evidence must be reasonable inferences, however. Seven-Up Co. v. Coca-Cola Co., 86 F.3d 1379, 1387 (5th Cir. 1996); Brock v. Merrell Dow Pharm., Inc., 874 F.2d 307, 308 (5th Cir. 1989). An inference that Dr. Cruz 5 A nurse testified that it was “no big deal” for a doctor to go into a patient’s room, but did not specifically recall having seen Dr. Cruz do so. There was also testimony that the nurse’s station was close enough to Mrs. Guile’s room that the furniture could be seen from there. 8 should have noticed the furniture in Mrs. Guile’s room because it may have been possible to see the furniture from the nurse’s station is not a reasonable inference in view of evidence that (1) her practice was to see patients in her office, and (2) the arrangement of patient rooms was not her responsibility (so that there would be no reason for her to be looking at the patient rooms while at the nurse’s station). Such an inference would be “mere speculation and conjecture,” which is not sufficient to support a jury verdict. Anthony v. Chevron USA, Inc., 284 F.3d 578, 583–84 (5th Cir. 2002)(concluding that testimony showing ways in which it was possible that an oil drilling operation contaminated an aquifer was not sufficient to allow an inference that the operation actually did so). Dr. Cruz can of course not be held liable for these acts or omissions that she was not shown to have committed. For most of the remaining alleged breaches, there was not substantial evidence that these were actually breaches of the relevant standard of care, where the standard of care is that of a psychiatrist exercising ordinary care. Although Dr. Meyer testified that he would have used higher dosages on Mrs. Guile’s medications, he agreed that Dr. Cruz’s adjustment of the medications met the standard of care. With regard to transferring Mrs. Guile to another hospital, Dr. Meyer at one point said that transfer to a facility having electroconvulsive therapy (ECT) capability would be appropriate, but he later conceded that ECT was 9 not required to meet the standard of care and might be inappropriate in some cases. Dr. Meyer’s statement that Mrs. Guile should have been transferred to a safer facility was a reference to the lassitude of Rojas and Padilla, which was not foreseeable to Dr. Cruz. In the case of suicide precautions, Dr. Meyer at one point asserts that Dr. Cruz did not properly maintain suicide precautions, and at another point allows that the ongoing suicide assessments of Mrs. Guile met the standard of care. Guile argues that the district court was incorrect in concluding that Dr. Meyer had retracted his statements asserting that Dr. Cruz breached the standard of care. He argues that Dr. Meyer instead created “contradictions” the resolution of which is the province of the jury. We must remember, however, that evidence sufficient to support a jury verdict must be substantial evidence. Anthony, 284 F.3d at 583. An expert’s opinion must be supported to provide substantial evidence; “we look to the basis of the expert’s opinion, and not the bare opinion alone.” Archer, 118 S.W.3d at 782. “A claim cannot stand or fall on the mere ipse dixit of a credentialed witness.” Id. (footnote omitted). Many of the alleged breaches described above come from statements of Dr. Meyer that are unsupported by any data (such as studies evaluating treatment techniques), in addition to being later contradicted by him, or to be nothing but his incorrect factual assumptions based on examination of incomplete records. The contradictions coupled 10 with the lack of support for the statements take them out of the realm of substantive evidence. In the context of admissibility of expert testimony, this court has noted that “[i]f an opinion is fundamentally unsupported, then it offers no expert assistance to the jury.” Viterbo v. Dow Chem. Co., 826 F.2d 420, 422 (5th Cir. 1987).
Even to the extent Guile could establish any breaches of the standard of care, there can be no liability unless such breaches are shown to be a proximate cause of Mrs. Guile’s death. For example, Dr. Meyer did testify to a belief that Dr. Cruz breached the standard of care when she allowed Mrs. Guile to go on a pass with her family on May 28. This was arguably contradicted by his later testimony acknowledging that Mrs. Guile’s passes appeared to make her feel better, but even if we assume that the pass was a breach of the standard of care, there can be no liability from this breach because Dr. Meyer testified that the pass was not a cause of Mrs. Guile’s death. Similarly, there is no expert evidence establishing that any of the alleged breaches by Dr. Cruz were a proximate cause of Mrs. Guile’s suicide. Evidence of proximate cause must show that in the absence of the alleged breach the harm would not have occurred, and must state, describe or explain the connection between the breach and the harm in sufficient detail to support the expert’s assertion 11 of proximate cause. See, e.g., Bottoms v. Smith, 923 S.W.2d 247, 251–52 (Tex. App.–Houston 1996) (holding that fact issue existed as to proximate cause when expert opined that polyp would more likely than not have been diagnosed if omitted test had been done, that polyp diagnosed at that time would more likely than not have been at cancer stage having an 88% or better survival rate, and that delay in diagnosis resulted in a cancer stage having a 0% survival rate). Dr. Meyer’s statements regarding the causes of Emiko Guile’s suicide do not provide a sufficient connection between any alleged breaches of Dr. Cruz and Mrs. Guile’s death. There was no expert testimony that any one or more alleged breaches of care by Dr. Cruz caused Emiko Guile’s death. As noted in Guile’s brief, Dr. Meyer stated generally that “in totality” all breaches by all the multiple actors involved combined to cause Mrs. Guile’s suicide. 6 These unexplained, conclusory statements do not establish proximate cause for any particular breach or combination of particular breaches by Dr. Cruz, because they do not describe or state how any particular asserted breach or breaches by Dr. Cruz related to the 6 Acts and omissions by other actors that were brought up during the trial as potential causes include: Rojas’s sleeping during her shift; Padilla’s failure to check on Mrs. Guile; an unidentified nurse or technician’s failure to confiscate Mrs. Guile’s bathrobe belt; a June 9 meeting regarding discharge planning that upset Mrs. Guile and her husband; Guile’s failure to take Mrs. Guile out on her usual Saturday pass June 13 or to acknowledge their June 12 wedding anniversary; Guile’s June 13 argument with Mrs. Guile in which he reiterated that he would not let her come home until she was well; Dr. Anderson’s June 13 assignment to Mrs. Guile to prepare a time line of events in her life; and placement by unidentified personnel of the armoires in Mrs. Guile’s room. 12 suicide and do not state that without Dr. Cruz’s alleged breach or breaches the suicide would not have occurred. This is especially so in that several asserted deficiencies which Dr. Meyer assumed were attributable to Dr. Cruz were shown by uncontradicted evidence either not to have occurred at all or not to have been attributable to Dr. Cruz (and the others were essentially withdrawn by Dr. Meyer).7 The same is true for Dr. Meyer’s generalized statements that Mrs. Guile’s illness was treatable or that her suicide was preventable. Dr. Meyer further testified that he could not guarantee within a reasonable degree of medical probability that Mrs. Guile would not have committed suicide on June 14, 1998 even if she had received the care that he testified was appropriate. Because Guile did not establish by expert testimony any negligence on the part of Dr. Cruz that was a proximate cause of Emiko Guile’s suicide, the district court was correct in granting Dr. Cruz’s motion for judgment as a matter of law.