Opinion ID: 1276333
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Heading Rank: 1

Heading: Instruction 14BSpecific Negligence.

Text: Trial court's instruction 14 explained the res ipsa loquitur doctrine and provided its elements. The general duty of care of a specialist was explained in instruction 14B, which was identical with uniform instruction 13.3. In instruction 14B, however, the court submitted the following: You are instructed that a doctor cannot be found negligent merely because he makes a mistake in the treatment of a patient. Any error in treatment, if you find any, does not in and of itself constitute negligence. For a doctor to be found negligent, it must be shown by a preponderance of the evidence that the doctor, in treating the patient, failed to follow the customary practice and procedures of doctors under similar circumstances and in similar localities. This is the standard by which the doctors are to be judged. Plaintiff objected there were no facts in the record to support instruction 14B, it was inapplicable in a res ipsa case where there were no allegations of specific negligence against the physicians involved, and this was not a case involving diagnosis. The above instruction apparently derived from Sinkey v. Surgical Associates, 186 N.W.2d 658 (Iowa 1971), which case in turn spawned Iowa uniform instruction 13.9. Sinkey was a case of misdiagnosis. The defendant doctor's evidence disclosed plaintiff's symptoms and x-ray findings were consistent with both tonsillitis and appendicitis. In absence of any contrary expert testimony for plaintiff, we held the defendant doctor was not negligent in mistakenly diagnosing plaintiff's illness as tonsillitis, and affirmed a judgment entered on a directed verdict for defendants. Trial court obviously patterned instruction 14B after uniform instruction 13.9, except the clause diagnosis and treatment was narrowed to the word treatment. Plaintiff asserts this mutation of the Sinkey rule produced a potentially misleading instruction, there was insufficient evidence of specific acts of negligent treatment to justify submitting it, and it was at war with the res ipsa loquitur instruction. Defendants argue the instruction was a proper statement of law, it was a permissible effort to explain the doctors' duty of care and what would constitute a variance from that duty, and this instruction was compatible with the res ipsa loquitur instruction because it informed the jury that if any mistake in treatment occurred, it must be a negligent mistake. Alternatively, defendants contend submission of instruction 14B was harmless error because plaintiff's claim should have been dismissed as a matter of law. We discuss this issue in division III. Uniform instruction 13.9 has never been scrutinized by this court, nor are we required now to determine whether the modified version utilized in this case would be applicable in other circumstances. It was reversible error to submit instruction 14B in this case because it effectively denied plaintiff the benefit of the res ipsa inference of negligence by requiring her to establish a specific error in treatment that did not conform to the customary practice and procedures of doctors under similar circumstances and in similar localities. Res ipsa loquitur is a rule of evidence which, when applied, permits but does not compel an inference that defendant was negligent. Under the doctrine the happening of an injury permits an inference of negligence where plaintiff produces substantial evidence that (1) the injury is caused by an agency or instrumentality under the exclusive control and management of defendant and (2) the occurrence is such as in the ordinary course of things would not happen if reasonable care had been used. Fosselman v. Waterloo Community School District, 229 N.W.2d 280, 283 (Iowa 1975) (citation omitted). See also Dorcas v. Aikman, 259 Iowa 63, 70, 143 N.W.2d 396, 401 (1966) (Under the res ipsa doctrine ... the happening of the injury permits but does not compel an inference that defendant was negligent.). The submission of res ipsa is a matter for the court, Highland Golf Club v. Sinclair Refining Co., 59 F.Supp. 911, 915 (N.D.Iowa 1945), and when res ipsa is submitted in a medical malpractice case, the plaintiff is relieved of the burden of showing that specific acts of defendant were below accepted medical standards. The plaintiff still must prove negligence, but he or she does so by convincing the jury the injury would not have occurred absent some unspecified but impliedly negligent act. See Wiles v. Myerly, 210 N.W.2d 619, 624, 627 (Iowa 1973). See also Frost v. Des Moines Still College of Osteopathy and Surgery, 248 Iowa 294, 302, 79 N.W.2d 306, 311 (1956) (The injury was of a kind which ordinarily does not occur in the absence of someone's negligence.). Accord Hale v. Venuto, 137 Cal. App.3d 910, 918, 187 Cal.Rptr. 357, 361-62 (1982) (The doctrine permits the jury to infer negligence from the happening of the accident alone .... The inference of negligence which the doctrine permits to be drawn is one which stems from the happening of the accident itself as distinguished from an inference of negligence drawn from evidence of specific acts of wrongdoing....); Fraser v. Sprague, 270 Cal. App.2d 736, 746, 76 Cal.Rptr. 37, 43 (1969) (Evidence ... need not establish the fact that the actual procedure followed by defendant was negligent; it is sufficient if it supports an inference of negligence from the fact that the injury occurred. The inference of negligence ... is one which stems from the happening of the accident itself ....); Wasem v. Laskowski, 274 N.W.2d 219, 224 (N.D.1979) (Doctrine creates a permissible inference from harmful results that the defendant did not exercise the correct standard of care.). Thus, the jury was asked in the res ipsa instruction to accept or reject an inference of negligence predicated on plaintiff's unexpected injury. Instruction 14B impermissibly conflicted with the res ipsa instruction by telling the jury, in essence, that negligence could not be presumed from an error in defendant doctors' treatment. The defendant medical center casts its lot with the defendant doctors and adopts their arguments with respect to instruction 14B. It does not ask for separate treatment in this case. Nonetheless, instruction 14B by its terms is limited to the doctors' duty and not that of the medical center. Trial court's instructions required the jury to consider the alleged specific acts of negligence against the medical center, and finding no such specific negligence, then to consider the medical center's negligence, if any, under the res ipsa loquitur instruction. We find no ground, in view of our holding in the next division with respect to instruction 14D, to justify a reversal of the judgment in favor of the medical center. The giving of instructions which are conflicting and confusing is reversible error, Hartwig v. Olson, 261 Iowa 1265, 1278, 158 N.W.2d 81, 88 (1968). See also Morse v. Incorporated Town of Castana, 213 Iowa 1225, 1230, 241 N.W. 304, 306-07 (1932) ([E]rror is committed in the giving of inconsistent instructions. ... the giving of such confusing and conflicting instructions is reversible error. (citations omitted)). Because instruction 14B may have deprived plaintiff of the benefit of the res ipsa instruction with respect to the doctors, a new trial is required as to them. See Childers v. McGee, 306 N.W.2d 778, 780 (Iowa 1981) (When a court gives inconsistent instructions and a jury returns only a general verdict, it is impossible to tell which instruction the jury followed.). As the case must be remanded, we discuss those additional issues that may arise upon retrial.