Opinion ID: 2537389
Heading Depth: 1
Heading Rank: 4

Heading: Defendants' Points on Cross-Appeal

Text: Defendants argue that the trial court erred in refusing to order that future damages be made in periodic payments pursuant to section 538.220. Sanders responds that section 538.220 is unconstitutional because it violates a number of Missouri's constitutional provisions: article I, section 22(a) (infringing upon the right of trial by jury); article II, section 1 (separation of powers); article I, section 26 (taking of private property without just compensation); and article III, section 40(28) (prohibition against special laws). As discussed in Part III.A, the legislature may define remedies for statutory causes of action. Section 538.220 does not violate the right to trial by jury, at the very least, in relation to periodic payments of damages for wrongful death claims. Nor does section 538.220 violate the principle of separation of powers. The statute is simply a limitation on a remedy. As reaffirmed above, the legislature may place limits on statutorily created remedies. [10] The other points Sanders raises the taking of private property for public use without just compensation (article I, section 26) and the prohibition against special laws (article III, section 40(28)) were not raised at the first opportunity and, thus, were waived. See Hollis v. Blevins, 926 S.W.2d 683, 684 (Mo. banc 1996). Unlike the trial by jury and separation of powers issues, these latter points were raised only after the civil trial had concluded.
The Court next determines whether the trial court abused its discretion in refusing to grant periodic payments of future damages. The provisions of section 538.220 give the circuit court, in the absence of a court-approved settlement between the parties, discretion in establishing the plan for future paymentswith two exceptions. Vincent by Vincent v. Johnson, 833 S.W.2d 859, 866 (Mo. banc 1992). First, all past damages must be paid in a lump sum at the time of judgment. Id. (citing section 538.220.1). Second, it is presumed that, absent the attorney's agreement, attorney's contingent fees will be paid at the time of judgment. Id. (citing section 538.220.4). The statute does not require any other amounts to be apportioned to future payments. Id. The jury's verdict designated $7.5 million in future non-economic damages and $1.7 million in past non-economic damages. The application of section 538.210.1 reduced the amount of recoverable non-economic damages to $632,603.82 per defendant, totaling $1,265,207.64. As the amount of non-economic damages recoverable after applying the caps is less than the total amount of past non-economic damages determined by the jury, it is within the discretion of the trial court to assign the entire $1,265,207.64 as past non-economic damages. Defendants' point is denied.
Defendants made a motion for directed verdict on the issue of vicarious liability at the close of Sanders's evidence. At the close of all evidence, Defendants made a motion for directed verdict on the issue of causation as well as vicarious liability. After trial, Defendants moved for judgment notwithstanding the verdict (JNOV) on the issue of causation. Sanders believes that a proper motion for directed verdict following plaintiff's evidence is required to preserve the availability of JNOVregardless of whether a motion for directed verdict is filed at the close of all evidence. Defendants claim that to preserve for JNOV, a motion for directed verdict need only be made at close of all evidence.
Rule 72.01 governs motions for directed verdict and for judgment notwithstanding the verdict: (a) Motion for Directed Verdict: When Made: Effect. A party may move for a directed verdict at the close of the evidence offered by an opponent. The filing of such motion does not constitute a waiver of movant's right to offer evidence to the same extent as if the motion had not been made. A motion which is not granted is not a waiver of trial by jury even though all parties to the action have moved for directed verdicts. A motion for a directed verdict shall state the specific grounds therefor. . . . (b) Motion for Judgment Notwithstanding the Verdict. A party may move for a directed verdict at the close of all the evidence. . . . Not later than thirty days after entry of judgment, a party who has moved for a directed verdict may move to have the verdict and any judgment entered thereon set aside and to have judgment entered in accordance with the motion for a directed verdict. . . . A motion for a new trial may be joined with this motion, or a new trial may be prayed for in the alternative. . . . Conflict exists as to whether a party must move for directed verdict both at the close of the opposing party's evidence and again at close of all evidence, or whether a sole motion at close of all evidence suffices to preserve the issue. The court of appeals has stated that [t]o preserve the question of submissibility for appellate review in a jury-tried case, a motion for directed verdict must be filed at the close of the plaintiff's case and again at the close of all evidence. Goede v. Aerojet Gen. Corp., 143 S.W.3d 14, 18 (Mo.App.2004) (citations omitted). This conflicts with an earlier statement by that court: If [a] moving party presented no evidence, then the required motion is made at the close of plaintiff's evidence. If, however, the moving party presents evidence, the moving party waives any trial court error in denying the motion filed at the close of plaintiff's case. If the moving party, as here, presented evidence, the required motion for a directed verdict must be made at the close of all the evidence. Failure to file such a motion waives a contention that plaintiff failed to make a submissible case. Schnatzmeyer v. Nat'l Life Ins. Co., 791 S.W.2d 815, 819 (Mo.App.1990). Rule 72.01 provides the procedure for challenging the submissibility of plaintiff's case. It does not, however, state what is required to preserve that issue for appeal. Generally, the requirement that an issue be preserved is based on ideas of efficiency and fair play. A party should make any objection to the trial process at the earliest opportunity to allow the other party to correct the problem without undue expense or prejudice. Having been informed of the objection, the opposing party can choose to eliminate the complaint or may stand his or her ground and risk reversal on appeal. Likewise, if a party fails to make an objection when the concern can be corrected at the earliest and easiest opportunity, he or she will not be heard to complain later when the cost of correction may be far more onerous. When applying this rationale to motions for directed verdict, consideration must be given to the decisions made at different stages during the trial: at the close of plaintiff's evidence and at the close of all evidence. At the close of plaintiff's evidence, Rule 72.01(a) provides defendant with the opportunity to challenge whether plaintiff has made a submissible case. If no further evidence is introduced, the caseboth at trial and on appealis determined by the evidence on the record at that point. Should the trial court overrule the motion, defendant then has the choice of putting on evidence of his or her own. If defendant introduces evidence, the state of the record at the close of plaintiff's case is waived and the caseboth at trial and on appealis determined in accordance with all evidence admitted: plaintiff's and defendant's. Rule 72.01(b) allows defendant the opportunity to move for a directed verdict at the close of all evidence. In terms of preservation, a motion for directed verdict at the close of plaintiff's case is necessary only if defendant seeks to have the case determined at that point without introduction of additional evidence. Alternatively, if defendant chooses to put on evidence, the state of the record changes. The case then is decided on all of the evidence. A motion for directed verdict at the close of all evidence becomes the meaningful motion to preserve the issue as it presented itself to the trial court at that time, prior to submission to the jury. After verdict, of course, a motion for JNOV also is required to preserve the issues raised for appeal. See Rule 72.
Sanders next claims that Defendants failed to make their motion for directed verdict with requisite specificity. Defendants' oral motion stated, We think plaintiff failed to make a submissible case on issues of negligent causation. . . . Rule 72.01 requires that a motion for directed verdict state the specific grounds therefore. Defendants stated the grounds for their motion, i.e., the failure to show causation. The motion might have been more specific but was sufficient to preserve the issue.
The standard for reviewing a denied motion for JNOV is essentially the same as for reviewing the denial of a motion for directed verdict. Dhyne v. State Farm Fire & Cas. Co., 188 S.W.3d 454, 456 (Mo. banc 2006). A case may not be submitted unless legal and substantial evidence supports each fact essential to liability. Id. at 456-57. The court views the evidence in the light most favorable to the jury's verdict, giving the plaintiff the benefit of all reasonable inferences and disregarding evidence and inferences that conflict with that verdict. Giddens v. Kansas City S. Ry. Co., 29 S.W.3d 813, 818 (Mo. banc 2000). A court may reverse the jury's verdict for insufficient evidence only when there is a complete absence of probative fact to support the jury's conclusion. Investors Title Co., Inc. v. Hammonds, 217 S.W.3d 288, 296 (Mo. banc 2007). To make a submissible case in a wrongful death suit, a plaintiff must show that the negligence of the defendant directly caused or directly contributed to cause the patient's death. [11] Kivland v. Columbia Orthopaedic Group, LLP, 331 S.W.3d 299, 306 (Mo. banc 2011). Missouri requires a showing of two types of causation: but-for causation and proximate causation. Callahan, 863 S.W.2d at 863, 865. In a medical malpractice case, where proof of causation requires a certain degree of expertise, the plaintiff must present expert testimony to establish causation. Sundermeyer, 271 S.W.3d at 554. Sanders relied on his expert, Dr. Richard Bonfiglio, to establish causation. Dr. Bonfiglio testified that, although there were other contributing factors, including seizures and the temporary loss of oxygen to Ms. Sanders's brain, [i]t's quite clear from the record that [Ms. Sanders's] brain injury was caused by the elevated ammonia level. Defendants cite to those contributing factors, as well as facts that Ms. Sanders was in a coma and that she did not die until two years later, for the proposition that Dr. Bonfiglio's expert opinion was speculative and not supported by the evidence in the record. Defendants' argument fails, because it confuses the admissibility of Dr. Bonfiglio's opinion testimony with the issue of submissibility of a plaintiff's case. In Washington v. Barnes Hospital, this Court discussed the distinction between admissibility of expert opinion testimony and the submissibility of a plaintiff's case in reliance thereon. 897 S.W.2d 611, 616 (Mo. banc 1995). If a question exists as to whether the proffered opinion testimony of an expert is supported by a sufficient factual or scientific foundation, the question is one of admissibility. It must be raised by a timely objection or motion to strike. Id. Once opinion testimony has been admitted, as other evidence, it may be relied upon for purposes of determining the submissibility of the case. Id. (citing Goodman v. Allen Cab Co., 360 Mo. 1094, 232 S.W.2d 535, 539 (1950)). The jury then considers the natural probative effect of the opinion testimony. Id. (citing De Moulin v. Roetheli, 354 Mo. 425, 189 S.W.2d 562, 565 (1945)). Defendants in this case did not challenge the scientific or factual foundation of Dr. Bonfiglio's opinion or otherwise object during Dr. Bonfiglio's testimony. [A]n objection or motion to strike is untimely if it comes `too late to give opposing counsel an opportunity to correct any deficiencies in the questions or lay an appropriate foundation for the witness's opinion.' Id. (quoting Seabaugh v. Milde Farms, Inc., 816 S.W.2d 202, 209 (Mo. banc 1991)). By failing to both timely object and move to strike, Defendants waived any issue regarding the admissibility of Dr. Bonfiglio's opinion testimony. In wrongful death actions, a plaintiff must establish that but for the defendant's actions or inactions, the patient would not have died. Sundermeyer, 271 S.W.3d at 554. But-for causation is also known as causation in fact. Washington, 897 S.W.2d at 617 n. 2. This Court has explained: The general rule is that if a defendant is negligent and his [or her] negligence combines with that of another, or with any other independent, intervening cause, he [or she] is liable, although his [or her] negligence was not the sole negligence or the sole proximate cause, and although his [or her] negligence, without such other independent intervening cause, would not have produced the injury. Id. at 554-55 (alterations in original) (quoting Harvey v. Washington, 95 S.W.3d 93, 96 (Mo. banc 2003). Two causes that combine can constitute `but for' causation. Harvey, 95 S.W.3d 93, 96 (citation omitted)). Dr. Bonfiglio testified that Ms. Sanders experienced seizures while in a coma on May 27; Ms. Sanders also aspirated vomit into her lungs, which caused oxygen deprivation to her brain. Dr. Bonfiglio testified that Dr. Ahmed prescribed Depakote, which increases the amount of ammonia present in the body. Dr. Bonfiglio opined that Dr. Ahmed was negligent in not ordering a test to determine the amount of ammonia present in Ms. Sanders's body, in continuing to prescribe Depakote, and in failing to prescribe Lactulose (an ammonia-flushing laxative). Dr. Bonfiglio testified about the effects of Depakote and its byproduct ammonia on Ms. Sanders: [A]dding more Depakote to somebody who already is having seizures, is in a coma already, has an elevated ammonia level, it's like trying to put out a fire with gasoline. It's just the worst possible thing you can do is to give more Depakote, further raising the ammonia level and prolonging how long the brain is going to be exposed to ammonia. [Ammonia] causes the brain to swell. It interferes with brain function. If the brain is exposed to ammonia long enough, it actually causes the brain cells to die and it can cause a severe brain injury as it did in this case. Dr. Bonfiglio concluded: It's quite clear from the record that her brain injury was caused by the elevated ammonia level. It stayed elevated for days. There were other contributing factors. . . . [These] increased the risk of insult to her brain. . . . Bottom line, its most serious effect on her was the elevated ammonia level from Depakote that caused her very profound brain injury. . . . . . . . . . [U]nfortunately, she had a number of medical complications that are known in individuals that suffer brain injury. She had . . . aspiration pneumonia. There was also an infected hip . . . [which], when you have a brain injury like this, [is] one of the things that can happen. . . . She also had blood clots that developed, including a clot that went to her lung. The medical term for that is pulmonary embolism. She has had quite a number of complications of this severe brain injury and . . . she ended up dying as a consequence of her brain injury. . . . My opinion is that the . . . substandard care provided by Dr. Ahmed did directly contribute to the patient subsequently developing complications that led to her death. It took some time, but it was a direct consequence of the care he provided. Dr. Bonfiglio testified that Dr. Ahmed should have stopped prescribing Depakote and should have prescribed Lactulose to bring down Ms. Sanders's ammonia level. Dr. Bonfiglio stated unequivocally that, in his expert opinion, Dr. Ahmed's substandard care directly contributed to Ms. Sanders's death. Reviewing this evidence in the light most favorable to the jury's verdict, there was legal and substantial evidence of but for causation. Proximate causation requires something in addition to a `but for' causation test because the `but for' causation test serves only to exclude items that are not causal in fact. Callahan, 863 S.W.2d at 865. Missouri courts have generally said that the injury must be a reasonable and probable consequence of the act or omission of the defendant. Id. This is generally a `look back' test but, to the extent it requires that the injury be `natural and probable,' it probably includes a sprinkling of foreseeability. Id. To the extent the damages are surprising, unexpected, or freakish, they may not be the natural and probable consequences of a defendant's actions. State ex rel. Missouri Highway & Transp. Comm'n v. Dierker, 961 S.W.2d 58, 61 (Mo. banc 1998) (citation omitted). When a physician or nurse acts negligently in the treatment of a patient, later harm arising from that injury is naturally foreseeable. Callahan, 863 S.W.2d at 865-66. Defendants argue that there is an absence of probative fact from which a jury could find for Sanders. Defendants believe they have found persuasive precedent in Delisi v. St. Luke's Episcopal-Presbyterian Hosp., Inc., 701 S.W.2d 170 (Mo.App. 1985). In Delisi, the defendant doctor's treatment of the plaintiff's hand wound did not include prophylactic antibiotics; the wound later became infected. Id. at 172. The plaintiff adduced no expert testimony that antibiotics would have prevented the ensuing infection. Id. Instead, the plaintiff relied on the circumstantial evidence that 1) he had not received antibiotics initially and 2) antibiotics later cured the infection. Id. at 176. The court held that, because the therapeutic properties of antibiotics are beyond the realm of knowledge for an average juror, submitting to the jury on circumstantial evidence alone would inevitably lead the jurors into the forbidden realm of conjecture and surmise. Id. This case is distinguishable from Delisi in that Sanders did present direct evidence of causation by evincing testimony from Dr. Bonfiglio. Dr. Bonfiglio testified that the normal range for an ammonia level is 0 to 37, and on May 27, Ms. Sanders registered an ammonia level at 181, a very dangerous level. He stated that had the ammonia level been reduced by administering Lactulose and by ceasing Depakote, Ms. Sanders would have had a much better outcome. He opined that it was the elevated ammonia level from Depakote that caused her very profound brain injury. . . . Dr. Bonfiglio affirmed, My opinion is that the . . . substandard care provided by Dr. Ahmed did directly contribute to the patient subsequently developing complications that led to her death. It cannot be said that there is a complete absence of probative fact regarding the element of causation. See Edgerton v. Morrison, 280 S.W.3d 62, 69-70 (Mo. banc 2009). Sanders made a submissible case for the jury.
Defendants' next assignment of error concerns the trial court's refusal to grant a mistrial upon allegedly improper comments made by Sanders's counsel during closing argument. Specifically, Defendants argue that counsel's statements were designed to ask the jury to send a message to Dr. Ahmed and to deter other doctors from like conduct by arguing for punitive damages. At the beginning of his closing, Sanders's counsel stated, without drawing objection: I told you this case could have significance beyond this courtroom, actually beyond this city. It could affect this whole region. It could affect this whole country. Twenty-two pages later in the transcript, counsel said, As I said, I think the range is anywhere from $5 to $26 million is fair in this case. I think that's what you've got to do, because a doctor like this isn't going to get the word. He isn't going to understand. Defendants' counsel objected, citing improper argument, and the court sustained the objection. Defendants' counsel made no further request for relief. It has repeatedly been held that when the trial court sustains an objection to improper argument, and no further remedial action is requested, no error is preserved for appellate review. Olsten v. Susman, 391 S.W.2d 328, 330 (Mo.1965). Defendants' point is denied.
Defendants finally allege the trial court erred in denying Defendants' motion for reduction. Section 537.060 permits a defendant's liability to be reduced by the amounts of settlements with joint tortfeasors. Teeter v. Mo. Highway & Transp. Comm'n, 891 S.W.2d 817, 820 (Mo. banc 1995). Section 537.060 provides in part: When an agreement by release, covenant not to sue or not to enforce a judgment is given in good faith to one of two or more persons liable in tort for the same injury or wrongful death, such agreement shall not discharge any of the other tort-feasors for the damage unless the terms of the agreement so provide; however, such agreement shall reduce the claim by the stipulated amount of the agreement, or in the amount of consideration paid, whichever is greater. A reduction under section 537.060 is a satisfaction of an amount owed. . . and must be pleaded and proved as an affirmative defense. Norman v. Wright, 100 S.W.3d 783, 785 (Mo. banc 2003). The defendant bears the burden of pleading and proving the elements of the defense. It is uncontested that reduction requires a defendant to plead and prove 1) the existence of a settlement and 2) the stipulated amount of the agreement or the amount in fact paid. The parties disagree as to who bears the burden of proving that a settling party was jointly liable for the same injury or wrongful death. Joint and several liability occurs where the concurrent or successive negligent acts or omissions of two or more persons, although acting independently of each other, are, in combination, the direct and proximate cause of a single injury to a third person, and it is impossible to determine in what proportion each contributed to the injury. Glick, 396 S.W.2d at 613 (Mo.1965), overruled on other grounds by Bennett, 896 S.W.2d 464. This situation can be distinguished from one in which an injury occurs and the negligence of a third party aggravates the initial injury. In such a situation, the third party would be liable only for the damage attributable to the aggravation and not for the initial injury. See State ex rel. Baldwin v. Gaertner, 613 S.W.2d 638, 640 (Mo. banc 1981). Sanders argues that for Defendants to receive reduction, they must plead and prove a medical malpractice action against each settling defendant for whose payment they claim a reduction. The cases Sanders cites for this proposition do not support his reading of the statute. In Stevenson v. Aquila Foreign Qualifications Corp., 326 S.W.3d 920, 928 (Mo. App.2010), the court stated that a non-settling tortfeasor who claims a settlement affords a right to reduction under section 537.060 bears the burden of proving it had joint liability with the settling tortfeasor, a burden which is not met by the fact that a plaintiff has merely claimed joint liability. (emphasis omitted). In Stevenson, the plaintiff was injured in an automobile collision by one set of defendants who later settled. Id. at 923. Three years later, the plaintiff's injuries were aggravated in a second automobile collision with the trial defendants. Id. Under the facts as pleaded, a jury could not find both sets of defendants jointly liable, as the injuries for which the trial defendants were sued were divisible from those governed by the settlement. Id. at 928. Because the plaintiff's pleadings could not establish joint liability, the burden of proving that element remained on the non-settling defendant. Id. In Walihan v. St. Louis-Clayton Orthopedic Group, Inc., 849 S.W.2d 177, 180 (Mo.App.1993), the court held that the defendants had failed to plead facts sufficient for summary judgment on section 537.060 reduction. In that case, the decedent was injured working for his Illinois employer and later received negligent medical treatment by a Missouri doctor and hospital, resulting in death. Id. at 179. The executrix sued the Illinois defendants in Illinois and sued the Missouri defendants in Missouri. Id. The Illinois defendants settled two causes of actionone for the underlying workplace injury and one for the ensuing death. [12] Id. at 180-81. The Missouri suit included only damages related to wrongful death. Id. at 181. The Missouri defendants sought reduction and provided evidence of the total amount of the Illinois settlement. Id. at 181. The settlement applied to multiple claims, of which the Missouri defendants were only liable for damages related to wrongful death. Id. Thus, a court could not determine without further inquiry the consideration paid to settle the wrongful death claim. Id. The court of appeals, therefore, overturned the trial court's application of reduction by the entirety of the settlement and remanded for a determination of the settlement amount attributable to wrongful death. Id. The burden of proof is on the party seeking reduction. For the purposes of statutory reduction, a rebuttable presumption of joint liability for the same injury or wrongful death can arise from the plaintiff's pleadings and ensuing settlement. Once that presumption arises, it falls to the plaintiff to show that the injuries are divisible. This interpretation fits with the purpose of section 537.060 to implement the common law rule that a plaintiff is entitled to only one satisfaction for the same wrong. See State ex rel. Normandy Orthopedics, Inc., v. Crandall, 581 S.W.2d 829, 832 n. 1 (Mo. banc 1979). Here, Sanders sued settling defendants Kansas City University of Medicine and Biosciences, Carol E. Kirila and Midwest Division M.C.I., LLC. Sanders also sued non-settling defendants Dr. Ahmed and Dr. Iftekhar Ahmed P.A., among others. In his third amended pleading, Sanders alleged: As a direct and proximate consequence of the acts, omissions and conduct of the defendants set out herein, Paulette Sanders developed an elevation in her serum ammonia level, . . . which in turn caused her to become bedridden, physically disabled and mentally incapacitated, the complications of which ultimately directly caused or directly contributed to cause her death on August 24, 2005. In this pleading, Sanders alleges joint and several liability. When combined with the later settlement between some of these defendants and Sanders, such a pleading suffices to raise a rebuttable presumption that the settlement and suit pertained to the same injury or wrongful death for the purposes of section 537.060. Given the existence of that presumption, the burden still falls to Defendants to plead and prove the existence and applicability of the settlement and the amount paid thereunder. The trial court held Defendants' motion for discovery of the settlement terms in abeyance until the close of the trial. Although Defendants pleaded that Sanders had settled, the trial court's denial of discovery frustrated their ability to do anything further. Trial courts have broad discretion in administering rules of discovery, which this Court will not disturb absent an abuse of discretion. State ex rel. Delmar Gardens N. Operating, LLC v. Gaertner, 239 S.W.3d 608, 610 (Mo.2007) (citing State ex rel. Plank v. Koehr, 831 S.W.2d 926, 927 (Mo. banc 1992)). However, a trial court has no discretion to deny discovery of matters that are relevant to a lawsuit and are reasonably calculated to lead to the discovery of admissible evidence when the matters are neither work product nor privileged. State ex rel. BNSF Ry. Co. v. Neill, 356 S.W.3d 169, 172 (Mo. banc 2011) (internal quotation marks and punctuation omitted). Here, the discovery of the settlement terms was crucial to Defendants' affirmative defense of reduction, and the discovery denial prejudiced their ability to plead and prove that defense. Within this context, it would be an injustice to hold that Defendants are precluded from a reduction because of their failure to plead and prove what the trial court withheld from them. [13] Sanders's pleading of joint and several liability along with the existence of a settlement with named defendants raises the presumption that the settlement was for the same injury as recovered under the jury's verdict. The statutory cap reduced the recoverable non-economic damages from $9.2 million to $1,265,207.64. The total settlement compensation is less than the difference between the verdict and the cap. However, Sanders's pleadings sought both non-economic and economic damages. Insofar as the settlements included economic damages, the cap will not obviate statutory reduction. Accordingly, a question also exists as to whether Sanders receives a double recovery of economic damages.