Court Opinion

ID: 6322444
Source: CourtListenerOpinion
Date Created: 2022-03-11 19:00:38.594884+00
Date Added: 2024-06-11T09:20:50.456102
License: Public Domain

Case: 21-50149      Document: 00516234627         Page: 1    Date Filed: 03/11/2022

              United States Court of Appeals
                   for the Fifth Circuit                           United States Court of Appeals
                                                                            Fifth Circuit

                                                                          FILED
                                                                    March 11, 2022
                                   No. 21-50149
                                                                     Lyle W. Cayce
                                                                          Clerk
   Denice Lee, as next friend JS, a toddler,

                                                            Plaintiff—Appellant,

                                       versus

   United States of America,

                                                            Defendant—Appellee.

                  Appeal from the United States District Court
                       for the Western District of Texas
                            USDC No. 5:18-CV-605

   Before Owen, Chief Judge, and Higginbotham and Elrod, Circuit
   Judges.
   Per Curiam:*
          This is a medical malpractice case brought under the Federal Tort
   Claims Act (FTCA). Denice Lee Lopez claims that Dr. Richard Switzer
   breached his duty of care to toddler J.S. causing J.S. significant vision loss.

          *
            Pursuant to 5th Circuit Rule 47.5, the court has determined that this
   opinion should not be published and is not precedent except under the limited
   circumstances set forth in 5th Circuit Rule 47.5.4.
Case: 21-50149         Document: 00516234627               Page: 2   Date Filed: 03/11/2022

                                            No. 21-50149

   Because the district court did not clearly err in failing to find the requisite
   causation, we affirm.
                                                 I
          J.S. was born on December 2, 2015 to Lopez and Kendall L. Smith.
   During her pregnancy, Lopez received prenatal care through CommuniCare
   S.A. CommuniCare is a private health center with a campus in San Antonio.
   At all times relevant to this case, CommuniCare received federal funds under
   the Federally Supported Health Centers Assistance Act of 1992.
   CommuniCare employees are considered federal employees for purposes of
   the FTCA. 1
          Smith has a heritable form of retinoblastoma (RB), and one of his eyes
   was removed due to RB. If a parent has RB, the child should be immediately
   referred to a specialist.         A child with a family history of RB has an
   approximately fifty percent chance of developing RB tumors. RB tumors
   damage the retina and cause vision loss. CommuniCare was aware of the
   family history of RB.
          Dr. Switzer is a pediatrician employed by CommuniCare.                    On
   December 3, 2015, Dr. Switzer conducted his first physical examination of
   J.S. while J.S. was still in the hospital.                During pediatric medical
   appointments, physicians routinely conduct red reflex tests. These tests can
   detect irregularities in the retina, which may indicate RB. The red reflex test
   is currently the only non-invasive test that is widely available, though
   physicians largely agree that it is unreliable. Dr. Switzer performed a red
   reflex test on J.S., and the result was normal.

          1
              See 28 U.S.C. § 1346(b)(1).

                                                 2
Case: 21-50149      Document: 00516234627            Page: 3   Date Filed: 03/11/2022

                                     No. 21-50149

          J.S. saw Dr. Switzer again on December 11, 2015. Both parents
   testified that they presented their concerns about J.S.’s eyes to Dr. Switzer,
   who said it was common for babies to have weak eye muscles at this age. Dr.
   Switzer again performed a red reflex test, and the result was again normal.
          J.S. next saw Dr. Switzer on December 16, 2015. Smith testified that
   he voiced concerns about J.S.’s eyes and Dr. Switzer again stated that the
   issues were likely just from a weak eye muscle. Dr. Switzer performed
   another red reflex exam, and the result was again normal.
          J.S.’s next pediatric appointment was on February 10, 2016, this time
   performed by pediatric nurse practitioner, Lisa Jamison. J.S.’s red reflex test
   result was normal once again. J.S. was not referred to a specialist at this time.
   Between J.S.’s December and February appointments, J.S.’s left eye
   appeared to get worse.
          On April 15, 2016, J.S. was seen by pediatrician Dr. Patricia Hughes-
   Juarez. The medical records again indicated a normal red reflex, although
   Lopez testified that Dr. Hughes-Juarez “noticed something” in J.S.’s eyes.
   Based on J.S.’s examination and family history, Dr. Hughes-Juarez referred
   J.S. to an RB specialist, Dr. Amy Schefler.
          Dr. Schefler diagnosed J.S. with bilateral RB.              A common
   classification system for grading RB tumors is on a scale of A (the smallest
   tumors) to E (the largest ones). Dr. Schefler classified J.S.’s tumors as group
   C. The RB was in the center of J.S.’s left eye, but the tumors had not yet
   reached the center of J.S.’s right eye.          Dr. Schefler started treatment
   immediately. J.S. responded well to treatment. However, because of the
   location of the tumor in J.S.’s left eye, his macula and corresponding central
   vision have been irrevocably damaged. The tumors in J.S.’s right eye caused
   a significant blind spot.

                                          3
Case: 21-50149         Document: 00516234627              Page: 4       Date Filed: 03/11/2022

                                          No. 21-50149

           Lopez filed suit against the United States under the FTCA alleging
   that Dr. Switzer was negligent in failing to refer J.S. for an ophthalmologic
   examination as soon as practicable after birth. She contends that had J.S.’s
   tumors been treated earlier, the outcome would have been better. At the
   bench trial, Lopez called Dr. David Plager and the United States called Dr.
   George Magrath to testify on issues of liability.
           Following the trial, the district court determined that the United
   States breached the standard of care when Dr. Switzer failed to refer J.S. to a
   pediatric ophthalmologist given the family history of RB. But the district
   court concluded that “[b]ecause Plaintiff could not establish through expert
   testimony to a reasonable degree of medical probability (1) when J.S.’s RB
   tumors developed or (2) an established growth rate for RB tumors, it is
   impossible to tell from the medical evidence whether the delay in diagnosis
   exacerbated the damage to J.S.’s vision. . . . Plaintiff did not establish that it
   is more likely than not that earlier detection of J.S.’s retinoblastoma would
   have improved his outcome.”
                                                II
           On appeal from a bench trial, “findings of fact are reviewed for clear
   error and legal issues are reviewed de novo.” 2 “Questions concerning the
   existence of negligence and causation are treated as factual issues subject to
   the clearly erroneous standard.” 3 The district court has committed clear
   error when we are “left with the definite and firm conviction that a mistake

           2
            Luwisch v. Am. Marine Corp., 956 F.3d 320, 326 (5th Cir. 2020) (per curiam)
   (quoting Barto v. Shore Constr., LLC, 801 F.3d 465, 471 (5th Cir. 2015)).
           3
            In re Luhr Bros. Inc., 325 F.3d 681, 684 (5th Cir. 2003) (quoting Avondale Indus. v.
   Int’l Marine Carriers, Inc., 15 F.3d 489, 492 (5th Cir. 1994)).

                                                4
Case: 21-50149           Document: 00516234627              Page: 5         Date Filed: 03/11/2022

                                            No. 21-50149

   has been committed.” 4 “If the district court’s account of the evidence is
   plausible in light of the record viewed in its entirety, the court of appeals may
   not reverse it even though convinced that had it been sitting as the trier of
   fact, it would have weighed the evidence differently.” 5
           Because “[u]nder the Federal Tort Claims Act, liability for medical
   malpractice is controlled by state law,” 6 we look to Texas law. A plaintiff
   alleging medical malpractice under Texas law must prove: “(1) a duty by the
   physician or hospital to act according to an applicable standard of care; (2) a
   breach of that standard of care; (3) an injury, and (4) a causal connection
   between the breach of care and the injury.” 7 “[E]xpert 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.” 8
           The district court determined, and the parties agree, that Dr. Switzer
   breached his duty of care by not immediately referring J.S. to a pediatric
   ophthalmologist. The pertinent inquiry then focuses on causation. In order
   to prove causation, plaintiffs “must show a ‘reasonable medical probability’
   that ‘their injuries were caused by the negligence of one or more defendants.’
   This ‘mean[s] simply that it is more likely than not that the ultimate harm or
   condition resulted from such negligence.’” 9

           4
            Bertucci Contracting Corp. v. M/V Antwerpen, 465 F.3d 254, 258-59 (5th Cir. 2014)
   (quoting Walker v. Braus, 995 F.2d 77, 80 (5th Cir. 1993)).
           5
            In re Luhr Bros., 325 F.3d at 684 (quoting Anderson v. City of Bessemer City, 470
   U.S. 564, 573-74 (1985)).
           6
               Ayers v. United States, 750 F.2d 449, 452 n.1 (5th Cir. 1985).
           7
               Quijano v. United States, 325 F.3d 564, 567 (5th Cir. 2003).
           8
               Guile v. United States, 422 F.3d 221, 225 (5th Cir. 2005).
           9
             Young v. Mem’l Hermann Hosp. Sys., 573 F.3d 233, 235 (5th Cir. 2009) (per
   curiam) (quoting Kramer v. Lewisville Mem’l Hosp., 858 S.W.2d 397, 399-400 (Tex. 1993)).

                                                   5
Case: 21-50149           Document: 00516234627             Page: 6   Date Filed: 03/11/2022

                                            No. 21-50149

           Evidence in the record reflected that even with prompt treatment, RB
   tumors necessarily cause damage to the retina. Lopez therefore needed to
   show that J.S.’s vision loss was exacerbated as a result of the delay in
   treatment. 10 Plaintiffs must differentiate between what injury would have
   occurred regardless of breach and what injury occurred as a result of the
   breach. 11 “[W]hile it may be facially appealing to infer additional pain and
   suffering resulted from the alleged delay in diagnosis, the trial court is not
   permitted to rely on such speculation.” 12
           Lopez failed “to provide any baseline from which the trial court could
   conclude the delay caused the results.” 13 Lopez argues that the “baseline”
   in this case is the red reflex test. She contends that the red reflex test does
   not return a normal result if a child has RB in the center of the eye.
   Therefore, she concludes, J.S.’s central vision was not yet damaged when Dr.
   Switzer and Nurse Jamison examined him and when he should have been
   referred to a specialist. However, Lopez concedes that Dr. Hughes-Juarez
   also recorded a normal red reflex test before referring J.S. to a specialist.
   Because the red reflex test returned a normal result even when the tumor was
   allegedly impeding J.S.’s central vision, it is hard to understand how the red
   reflex test could provide a baseline in this case. Even assuming it is a close

           10
              Cf. Tenet Hosps. Ltd. v. Bernal, 482 S.W.3d 165, 170 (Tex. App.—El Paso 2015,
   no pet.) (“Any recovery for pain and suffering in a medical malpractice case is limited to
   the additional pain and suffering caused by the improper medical treatment.”).
           11
              See Jones v. King, 255 S.W.3d 156, 159-60 (Tex. App.—San Antonio 2008, pet.
   denied); see also Texarkana Mem’l Hosp., Inc. v. Murdock, 946 S.W.2d 836, 840 (Tex. 1997)
   (“[A] plaintiff should recover only for medical expenses specifically shown to result from
   treatment made necessary by the negligent acts or omissions of the defendant, where such
   a differentiation is possible.”).
           12
                Jones, 255 S.W.3d at 160.
           13
             See id.; see also Murdock, 946 S.W.2d at 840 (concluding that there was no
   evidence that linked the complained-of conduct to any dollar amount of medical expenses).

                                                 6
Case: 21-50149         Document: 00516234627                Page: 7       Date Filed: 03/11/2022

                                           No. 21-50149

   call whether the red reflex test could provide a baseline, this court will not
   reverse a close call on clear error review. 14
           Additionally, the medical experts could not predict to a reasonable
   degree of medical probability when an RB tumor will form, nor could they
   estimate how long an already-formed tumor had been growing. Even if a child
   has the RB gene, doctors still need to wait for a tumor to form to perform
   treatment, and no test can predict whether a tumor will indeed form. In the
   absence of evidence attesting to harm from the delay, the district court could
   not infer a causal link. 15
           It is unclear what additional pain and suffering J.S. suffered as a result
   of Dr. Switzer’s breach. 16 Although there was conflicting evidence, the
   district court’s finding is “plausible in light of the record as a whole.” 17 We
   therefore decline to find clear error.

           14
              See Bertucci Contracting Corp. v. M/V Antwerpen, 465 F.3d 254, 258-59 (5th Cir.
   2014) (quoting Anderson v. City of Bessemer City, 470 U.S. 564, 574 (1985)) (“Where there
   are two permissible views of the evidence, the factfinder's choice between them cannot be
   clearly erroneous.”).
           15
              See Tenet Hosps. Ltd. v. Bernal, 482 S.W.3d 165, 171 (Tex. App.—El Paso 2015,
   no pet.) (“[W]e cannot infer causation . . . by filling in missing gaps.”).
           16
            See Columbia Med. Ctr. of Las Colinas, Inc. v. Hogue, 271 S.W.3d 238, 246 (Tex.
   2008) (“Proximate cause cannot be satisfied by mere conjecture, guess, or speculation.”).
           17
               See Seahawk Liquidating Tr. v. Certain Underwriters at Lloyds London, 810 F.3d
   986, 990 (5th Cir. 2016) (quoting Manderson v. Chet Morrison Contractors, Inc., 666 F.3d
   373, 376-77 (5th Cir. 2012) (“[O]ur court may not find clear error if the district court’s
   finding is plausible in light of the record as a whole, even if this court would have weighed
   the evidence differently.”); Ayers v. United States, 750 F.2d 449, 456 (5th Cir. 1985) (“[I]t
   is not the role of the Court of Appeals to second guess the district court’s credibility choices
   among differing pieces of testimony, even those coming from the same witness or
   witnesses, unless the Court of Appeals is left with the definite and firm conviction that a
   mistake has been committed.”).

                                                  7
Case: 21-50149      Document: 00516234627           Page: 8   Date Filed: 03/11/2022

                                     No. 21-50149

                                 *        *         *
                 The judgment of the district court is Affirmed.

                                          8