Court Opinion

ID: 9787701
Source: CourtListenerOpinion
Date Created: 2023-08-31 00:22:33.476274+00
Date Added: 2024-06-11T07:36:59.661183
License: Public Domain

CARPENETI, Justice,
dissenting.
I,. INTRODUCTION
This medical malpractice case raises the question whether a hospital staff exercised care consistent with professional medical standards of restraint and supervision for a psychiatric patient. In such cases, Alaska law requires expert testimony to establish a breach of the standard of care before the plaintiff can recover. Because plaintiff offered no such testimony, even when notified by the trial court that it was required, I would affirm the trial court's decision to dismiss the case.
IIL DISCUSSION
The burdens of proof in a medical malpractice action in Alaska are set out in AS 09.55.540:
(a) In a malpractice action based on the negligence or wilful misconduct of a health care provider, the plaintiff has the burden of proving by a preponderance of the evidence
(1) the degree of knowledge or skill possessed or the degree of care ordinarily exercised under the circumstances, at the time of the act complained of, by health care providers in the field or specialty in which the defendant is practicing;
*231(2) that the defendant either lacked this degree of knowledge or skill or failed to exercise this degree of care; and
(8) that as a proximate result of this lack of knowledge or skill or the failure to exercise this degree of care the plaintiff suffered injuries that would not otherwise have been incurred.
(b) In malpractice actions there is no presumption of negligence on the part of the defendant.
Therefore, it was D.P.'s burden to provide evidence establishing the applicable medical standard of care, the defendants' breach of that standard of care, and that the breach caused her injuries.1 Moreover, as D.P. concedes, this court has previously followed the well-established rule that "[in medical malpractice actions the jury ordinarily may find a breach of professional duty only on the basis of expert testimony." 2
A. D.P.'s Case Was a Medical Malpractice Action as That Term Is Used in AS 09.55.540 and .550.
The court concludes that D.P.'s claims do not raise "'strict' medical malpractice" issues3 and that "[it remains far from clear ... that D.P.'s case should be viewed as a 'medical malpractice action."4 I disagree. Both the broad statutory use of the term "medical malpractice" and the commonly recognized legal definition of "malpractice" favor an application that covers lawsuits like D.P.'s.
The definitions section of the statutory chapter governing medical malpractice claims contains individual definitions indicative of the breadth of services and types of health service providers that the legislature intended that chapter to cover. For instance, AS 09.55.560(4) defines "professional negligence" as "a negligent act or omission by a health care provider in rendering professional services." And AS 09.55.560(5) defines "professional services" to include a "service provided by a health care provider that is within the scope of services for which the health care provider is licensed." Finally, AS 09.55.560(1) defines "health care provider" to include: "a nurse ...; a physician ...; a hospital ...; [and] an employee of a health care provider acting within the course and scope of employment." Taken together, the only conclusion to be drawn from these definitions is that sections 09.55.540 and .550 must apply to a broad range of actions taken in the provision of medical services. These services comfortably include the supervision of psychiatric patients in a hospital.
Similarly, the common definition of "malpractice" is:
Professional misconduct or unreasonable lack of skill. This term is usually applied to such conduct by doctors, lawyers, and accountants. Failure of one rendering professional services to exercise that degree of skill and learning commonly applied under all the cireumstances in the community by the average prudent reputable member of the profession with the result of injury, loss or damage to the recipient of those services or to those entitled to rely upon them.[5]
Given the broad definition commonly applied to "malpractice" and the similarly broad statutory definitions in our statutes on "medical malpractice," I cannot agree that D.P.'s claim is one of "ordinary negligence" and not one of "medical malpractice." Accordingly, to the degree that the court suggests that D.P.'s claim that she was entitled to "reasonable and attentive care, including, ... adherence to physician's orders" was not a claim of medical malpractice, I cannot agree.
B. The Notion of "Ordinary Negligence" Is Not Applicable Within the Context of a Professional Negligence Action.
I also disagree with the court's conclusion that it is appropriate to allow a jury to *232resolve D.P.'s claim "under an ordinary negligence framework."6 Implicit in this conclusion is the view that the individual acts that in the aggregate comprise any given medical service may be finely parsed into those acts judged under the rubric of ordinary negli-genee and those acts judged under the rubric of professional negligence. California, with its similar statutory scheme for medical malpractice, has rejected this approach.7
Moreover, the logic underlying the parsing approach to acts by health care providers is flawed because "ordinary negligence" is not applicable in a professional negligence case. The court relies on Meier v. Ross General Hospital,8 a California case, for the proposition that "ordinary negligence" can exist in a medical malpractice setting.9 But as the California Supreme Court recently explained in Flowers v. Torrance Memorial Hospital Medical Center,10
whether the cause of action is denominated "ordinary" or "professional" negligence or both, ultimately only a single standard can obtain under any given set of facts and any distinction is immaterial....
... [A] defendant has only one duty, measured by one standard of care, under any given cireumstances.11
That court then went on to further explain that when courts allow seemingly obviously negligent acts to supplant the need for expert testimony to establish the appropriate standard of care, their "reasoning confuses the manner of proof by which negligence can or must be established and the character of the negligence itself."12
The logic of Flowers and the cases that follow it is persuasive. There cannot be two standards of care that apply to one person for the same act at the same time-one "professional" and one "ordinary."
The allegedly negligent act at issue in this case took place during the provision of professional medical services. In these cireum-stances, AS 09.55.540 requires proof of the applicable standard of care and proof of a breach of that standard of care. Because there was no expert testimony, the plaintiff's case was insufficient unless an exception to the rule could be found.
C. Reliance on the Common Knowledge Exception Is Not Appropriate in This Case.
The court finds an exceeption-the "common knowledge exception"-to the rule that expert testimony is needed to establish the standard of care. But that exception is incompatible with our statutory framework. Moreover, even if the common knowledge exception does not conflict with AS 09.55.550, it is inappropriate to apply it on the facts of this case.
1. The common knowledge exception is not compatible with AS 09.55.550.
The common knowledge exception has been explained as applying "when a layperson is able to say as a matter of common knowledge and observation that the consequences of professional treatment were not such as ordinarily would have followed if due care had been exercised."13 That is, the *233type of injury incurred could not have happened in the absence of negligence. But AS 09.55.550 provides, in part, that "[tlhe jury shall be ... instructed that injury alone does not raise a presumption of the health care provider's negligence or misconduct."
The common knowledge exception therefore allows the inference of negligence to be drawn from the proved existence of injury under a broad set of possible cireumstances within the knowledge and observation of the general populace. This is, however, essentially a working definition of "presumption."14 Since AS 09.55.550 explicitly requires the court to instruct the jury that "injury alone does not raise a presumption of . negligence," application of the common knowledge exception is inconsistent with Alaska law.
2. Even if generally applicable, the common knowledge exception should not be applied on the facts of this case.
There are two theories under which the hospital could have become liable to D.P. First, either Dr. McCandless or Dr. Schoet-tle, or both, could have been professionally negligent in prescribing D.P.'s course of treatment and care. But D.P. did not allege any failing by either of her doctors. Accordingly, the hospital and nursing staff are not liable to D.P. for shortcomings attributable to Dr. McCandless's treatment and supervision order,15 unless there were changed circumstances that should have alerted the nursing staff to take appropriate action.16 D.P. therefore cannot rely on any claim that suggests alternative methods of physical, supervisory, or narcotic restraint should have been ordered or implemented because these decisions were within the doctors' exclusive province of professional responsibility.
Second, and relevant to the common knowledge exception, D.P.'s nurses may have been professionally negligent in implementing Dr. McCandless's flexible treatment order. But, as with a doctor's professional Judgments, a failure in care arising out of a nurse's discretionary actions implicates professional negligence. As the court in Sabol v. Richmond Heights General Hospital17 stated:
The law of medical negligence imposes on physicians engaged in the practice of medicine a duty to employ that degree of skill, care and diligence that a physician or surgeon of the same medical specialty would employ in like circumstances. Likewise, nurses are persons of knowledge and skill and must employ that degree of care and skill that a nurse of ordinary care, skill and diligence would employ in similar circumstances."[18]
Thus, to support this theory D.P. had to provide expert testimony establishing the appropriate standard of care of a professional nurse operating under similar cireum-stances,19 unless the proper level of supervision and restraint of a psychiatric patient was peculiarly within the common knowledge of the average citizen. That it was not in *234this case is evident by reviewing Flowers, which makes clear the strictly limited range of the common knowledge exeeption:
In this regard, this court has on numerous occasions articulated the general rule applicable in negligence cases arising out of the rendering of professional services: "The standard of care ... is a matter peculiarly within the knowledge of experts; it presents the basic issue in a malpractice action and can only be proved by their testimony, unless the conduct required by the particular cireumstances is within the common knowledge of the layman." The "common knowledge" exception is principally limited to situations in which the plaintiff can invoke the doctrine of res ipsa loquitur, ie., when a layperson "is able to say as a matter of common knowledge and observation that the consequences of professional treatment were not such as ordinarily would have followed if due care had been exercised." The classic example, of course, is the X-ray revealing a scalpel left in the patient's body following surgery.[20]
This is clearly not such a case. The measures which a nurse might appropriately take to monitor a paranoid schizophrenic patient, and to dissuade such a patient from leaving should that be her obvious intent, and to attempt to restrain her in the event persuasion was unsuccessful, are not obvious to the lay person."21
Moreover, Alaska has legislatively nullified the doctrine of res ipsa loquitur in medical malpractice cases.22 Yet under D.P.'s theory of the case, the fact that she got outside the building indicates that there was a breach of the standard of care. This argument is virtually indistinguishable from res ipsa logui-tur. Moreover, "proof of a bad result or mishap is no evidence of lack of skill or negligence."23 D.P.'s conclusion therefore leaps two steps-the standard of care and breach-when only one is implicated by the fact of her leaving the building. The first step, and the step on which D.P.'s case falters, is the question of the standard of care. What was the applicable standard of care for the nursing staff to protect D.P. from herself? -What was the staff required or permitted to do-and what was it precluded from doing-in fulfilling its duty to her?
Laypersons cannot accurately answer that question without expert assistance. Both Alaska law and the realities of decisionmak-ing lead to that conclusion. Whether Nurse Hansen's checking up on D.P. five minutes after seeing her in the hallway (and discovering she was gone) was commensurate with the professional standards of a nurse in Wrangell General Hospital supervising a psychiatric patient is surely an issue outside the common knowledge of laypersons.
D. D.P.'s Claims Were Properly Dismissed Because She Foiled to Produce Evidence to Support a Breach of the Duty of Care Established by Dr. Schoettle's Testimony.
Finally, D.P.'s negligence claim fails on the alternative basis that even when the evidence is viewed in the manner most favorable to her, it does not support a claim that Nurse Hansen failed to properly supervise D.P. under the standard of care set out in Dr. Schoettle's testimony-the only evidence produced at trial on that subject.
Dr. Schoettle's uncontradicted testimony established that "the nursing notes do not suggest any negligence whatsoever on the part of the nursing staff." Since D.P. did not provide documentary evidence or her own witness (expert or not) to testify on this claim, Dr. Schoettle's testimony established the standard of care and that there was no *235breach of that standard by the nurses' actions. Accordingly, D.P. did not made out a prima facie case of professional negligence against the nursing staff.
III. CONCLUSION
Alaska law required D.P. to present expert testimony to establish that the hospital or its staff violated standards of professional care while she was under their control. Because she did not do so, I would affirm the trial court. I would not allow this medical malpractice case to proceed under an "ordinary negligence" framework. I therefore dissent.

. See AS 09.55.540.

. Kendall v. State, Div. of Corrections, 692 P.2d 953, 955 (Alaska 1984) (ellipsis omitted) (quoting Clary Ins. Agency v. Doyle, 620 P.2d 194, 200 (Alaska 1980)).

. Op. at 229.

. Op. at 228.

. Black's Law Dictionary 959 (6th ed.1990) (defining malpractice").

. Op. at 229.

. See Bellamy v. Superior Court, 50 Cal.App.4th 797, 57 Cal.Rptr.2d 894, 900-01 (1996);
Some ... tasks may require a high degree of skill and judgment, but others do not. Each, however, is an integral part of the professional service being rendered. Trying to categorize each individual act or omission, all of which may occur within a space of a few minutes, into "ordinary" or "professional" would add confusion in determining what legal procedures apply if the patient seeks damages for injuries suffered at some point during the course of the examination or therapy. We do not see any need for such confusion or any indication the Legislature intended MICRA's applicability to depend on such fine distinctions. (Footnote omitted.)

. 69 Cal.2d 420, 71 Cal.Rptr. 903, 445 P.2d 519 (1968).

. Op. at 228-229.

. 8 Cal.4th 992, 35 Cal.Rptr.2d 685, 884 P.2d 142 (1994) (in bane).

. See id. 35 Cal.Rptr.2d 685, 884 P.2d at 146 (footnote omitted).

. Id. 35 Cal.Rptr.2d 685, 884 P.2d at 147.

. Id. (footnote and internal quotation marks omitted) (quoting Engelking v. Carlson, 13 Cal.2d 216, 88 P.2d 695 (1939)).

. See Blacks Law Dictionary 1203 (7th ed.1999) {defining "presumption" as "(al legal inference or assumption that a fact exists, based on the known or proven existence of some other fact or group of facts"); see also Commentary to Alaska Rule of Evidence 301(a), second paragraph (defining presumption").

. See Dimitrijevic v. Chicago Wesley Mem'l Hosp., 92 Ill.App.2d 251, 236 N.E.2d 309, 314 (1968) (holding that hospital was under no duty to take precautions not ordered by the attending physician); State v. Washington Sanitarium and Hosp., 223 Md. 554, 165 A.2d 764, 766 (1960) (stating that "(ilt was not incumbent upon the nurses and attendants to apply restraints or supervision which the attending physician" did not order); Sabol v. Richmond Heights Gen. Hosp., 111 Ohio App.3d 598, 676 N.E.2d 958, 960 (1996) (holding that the hospital was not Hable where its staff provided the protective measures ordered by the aitending physician to prevent suicide).

. See Washington Sanitarium, 165 A.2d at 766.

. 111 Ohio App.3d 598, 676 N.E.2d 958.

. Id. at 960 (emphasis added) (citations omitted).

. See Hitch v. Ohio Dep't of Mental Health, 114 Ohio App.3d 229, 683 N.E.2d 38, 45 (1996); Payne v. Milwaukee Sanitarium Found., Inc., 81 Wis.2d 264, 260 N.W.2d 386, 390-91 (1977) ("Where the patient requires professional nursing or professional hospital care, then expert testimony as to the standard of that type of care is necessary.") (citation omitted).

. 35 Cal.Rptr.2d 685, 884 P.2d at 147 (emphasis added) (footnote and citations omitted).

. See Baker v. United States, 226 F.Supp. 129, 132 (S.D.Iowa 1964) ("It is particularly recognized in the treatment of mental patients that diagnosis is not an exact science.... Further the objective is treatment not merely incarceration. Treatment requires the restoration of confidence in the patient. This in turn requires that restrictions be kept at a minimum. Risks must be taken or the case left as hopeless.") (emphasis added) (citations omitted), aff'd, 343 F.2d 222 (8th Cir.1965).

. See Priest v. Lindig, 583 P.2d 173, 175-76 & n. 7 (Alaska 1978) (citation omitted).

. Dimitrijevic v. Chicago Wesley Mem'l Hosp., 92 Ill.App.2d 251, 236 N.E.2d 309, 312 (1968).