Opinion ID: 2537389
Heading Depth: 3
Heading Rank: 3

Heading: Merits of Defendants' motion

Text: 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.