Court Opinion

ID: 4277743
Source: CourtListenerOpinion
Date Created: 2018-05-23 19:00:19.641656+00
Date Added: 2024-06-11T14:34:12.135036
License: Public Domain

United States Court of Appeals
                      For the First Circuit

No. 16-2405

              BARBARA J. BRADLEY and MICHAEL BRADLEY,

                      Plaintiffs, Appellants,

                                v.

                    DAVID J. SUGARBAKER, M.D.,

                       Defendant, Appellee.

          APPEAL FROM THE UNITED STATES DISTRICT COURT
               FOR THE DISTRICT OF MASSACHUSETTS

          [Hon. Denise J. Casper, U.S. District Judge]

                              Before

                Torruella, Thompson, and Kayatta,
                         Circuit Judges.

     Michael Bradley, pro se, with whom Barbara J. Bradley, pro
se, were on brief, for appellants.
     James L. Wilkinson, with whom Philip E. Murray, Jr., Carol
Ann Kelly and Murray, Kelly & Bertrand, P.C. were on brief, for
appellee.

                           May 23, 2018
           TORRUELLA,    Circuit   Judge.      Barbara   Bradley   and   her

husband, Michael Bradley, sued Dr. David Sugarbaker, a thoracic

surgeon   at   Brigham   and    Women's     Hospital   in   Boston,   after

Dr. Sugarbaker performed a surgical biopsy on Ms. Bradley that

resulted in extensive complications.         A trial ensued and the jury

returned a verdict in favor of Dr. Sugarbaker.               The Bradleys

appealed, and we vacated the judgment and remanded on account of

the district court's error in excluding the testimony of the

Bradleys' proffered expert witness.         A second trial followed, with

the jury again returning a verdict in favor of Dr. Sugarbaker.

           The Bradleys appeal to us once more, asserting that, on

remand, the district court erred in: (1) admitting an entry from

Ms. Bradley's diary under Fed. R. Evid. 807's "residual exception"

to the hearsay rule; (2) admitting an excerpt from Ms. Bradley's

medical records from a different hospital under Fed. R. Evid.

803(6)'s "business records" exception to the hearsay rule; and (3)

determining that the Bradleys had waived their medical negligence

claim.    We conclude that, assuming the district court erred in

admitting these two pieces of evidence, those errors were harmless.

We further hold that the district court did not commit prejudicial

error when it found the Bradleys to have waived their negligence

claim.    As a result, we affirm the district court's judgment in

favor of Dr. Sugarbaker.       Our reasoning follows.

                                    -2-
                                    I.

           Because our first opinion pertaining to this dispute

recounts the underlying facts in substantial detail, see Bradley

v. Sugarbaker, 809 F.3d 8, 11-13 (1st Cir. 2015) (Bradley I), we

provide a more succinct summary here.

                                    A.

           On November 9, 2004, Ms. Bradley -- still suffering from

various serious injuries resulting from a car accident two years

earlier -- underwent an MRI.       The MRI revealed the existence of a

potentially cancerous mass at the top of her right lung.            On

December 7, 2004, Ms. Bradley met with Dr. Sugarbaker for the first

time.   He told her that the mass could either be scar tissue from

her car accident-related injuries or a malignant tumor, and that

a biopsy would be necessary to definitively rule out cancer.       Dr.

Sugarbaker further explained that while he had reservations about

whether a fine needle aspiration (FNA) biopsy would be feasible,1

he would request that an interventional radiologist determine

whether an FNA was possible in Ms. Bradley's case.         He referred

this    determination   to   Dr.    Francine   Jacobson,   a   thoracic

radiologist at Brigham and Women's Hospital.         Were an FNA not

1  An FNA biopsy is "an outpatient procedure in which a radiologist
inserts a long, hollow needle through the skin and into the mass
to extract cells," which are then microscopically analyzed.
Bradley I, 809 F.3d at 11 n.1.

                                   -3-
possible, Ms. Bradley would be left with the option of undergoing

a surgical biopsy, a more invasive procedure.         In the interim --

and in anticipation of a potential determination that an FNA was

possible -- Ms. Bradley had an appointment made for an FNA at

Hartford Hospital in Connecticut.

          The   following    day,   Dr.       Sugarbaker's     physician's

assistant, William Hung, appears to have called Ms. Bradley.

According to an entry in Ms. Bradley's personal diary, Hung relayed

to her that a radiologist had determined that, due to the location

of the mass in her lung, an FNA biopsy would not be possible, and

that she would therefore have to undergo a surgical biopsy.             Ms.

Bradley then called Hartford Hospital to cancel her appointment

for an FNA there.

          Dr.   Sugarbaker   performed    a    surgical   biopsy   on   Ms.

Bradley on December 17, 2004.   Ms. Bradley awoke from the operation

to both good and bad news.    The biopsy had revealed that the mass

in her lung was not cancerous.         But, she found herself in the

hospital's intensive care unit, the procedure having left her lung

with multiple air leaks, which caused her to remain in the hospital

for another week.   Ms. Bradley has since experienced a number of

serious   and   painful   complications       --   including     pulmonary

infections requiring surgery to treat -- that in 2006 forced her

to leave her job as a law librarian.      See id. at 12.

                                 -4-
                                    B.

            The Bradleys sued Dr. Sugarbaker in federal district

court in 2007.     Their Second Amended Complaint alleged medical

negligence, battery, and the failure to obtain informed consent.

Their informed consent claim -- crucially, for our purposes --

revolved around the allegation that "Mrs. Bradley did not have

enough information to "ma[k]e an informed choice [as to] whether

to undergo less intrusive methods for obtaining biopsy tissue than

an open surgical biopsy."          Dr. Sugarbaker moved for       summary

judgment on all of the Bradleys' claims.             The district court

granted summary judgment on the Bradleys' battery claim, denied

summary judgment on their informed consent claim, and did not

expressly render a decision as to their negligence claim.             The

case proceeded to trial, and the jury ultimately returned a verdict

in Dr. Sugarbaker's favor.

            The Bradleys then appealed, asserting that the district

court had erred both in granting summary judgment on their battery

claim and in excluding as irrelevant the testimony of an expert

witness they sought to call at trial.        Id. at 13.     We held that

the district court properly granted summary judgment on the battery

claim.   Id. at 13-17.    But, because we found that the Bradleys'

proffered   expert's   testimony    was   relevant   to   their   informed

consent claim, we vacated the judgment and remanded for a new

                                   -5-
trial.     Id. at 22-23.      Lastly, we took up the Bradleys' related

contention    that   the    expert's    testimony    would   also   have   been

relevant to their negligence claim.           Id.     We observed that "the

negligence claim does not appear ever to have reached the jury:

the verdict form only references Mrs. Bradley's informed consent

claim, and the jury instructions were limited to the elements of

informed consent."         Id. at 23.     Thus, "[i]n light of the poorly

developed record on this issue," we left it to the district court

to consider on remand whether this testimony was also relevant to

any surviving medical negligence claim.             Id.

            On remand, and before a different judge, the district

court clarified that "retrial shall be confined to the claim at

the first trial: informed consent."             The court explained that

"[t]his case from the summary judgment stage through pretrial

phases through trial . . . has been framed and litigated as an

informed consent case."         Therefore, the court held that "to the

extent that Plaintiffs pressed any negligence claim separate and

apart from the informed consent claim, any such claim has been

waived."

            Before the second trial, the Bradleys moved in limine to

exclude as hearsay an entry in Ms. Bradley's personal diary from

December 9, 2004 (the "diary entry").               The entry described her

conversation the day before with Hung, when he informed her of Dr.

                                        -6-
Jacobson's determination that an FNA biopsy was not feasible.   The

diary entry stated, in relevant part:

        We were told by Dr. Zellos . . . that a radiologist
        would need to review the PET Scan to determine if the
        lung biopsy can be done using a needle & a CAT Scan
        or whether surgery will be necessary. The answer to
        this question was received on Wednesday 12/8.      We
        spoke with Bill Hung – the PA – on Wednesday. This
        was after Michael made several calls to the Clinic in
        order to get some answers: Bill explained that the
        radiologist determined that the tumor would be too
        difficult to access via the CAT Scan Procedure &
        surgery would most likely be needed.

The district court held that the diary entry was admissible as

non-hearsay to the extent that it bore on Ms. Bradley's state of

mind.   It further held that the diary entry was also admissible

for the truth of the matter asserted under the residual exception

to the hearsay rule found in Fed R. Evid. 807.

          So too did the Bradleys object to an excerpt from Ms.

Bradley's records from Hartford Hospital (the "Hartford record")

that Dr. Sugarbaker sought to introduce at trial.   That proffered

exhibit indicated that Ms. Bradley had called Hartford Hospital to

cancel her FNA appointment there.    The exhibit also included a

post-it note affixed to that page of her medical records.       The

post-it note bore a hand-written message, dated December 10, 2004,

stating that "Brigham & Women's . . . radiologists said it doesn't

look possible to [biopsy] the lesion."    The district court held

that the note was substantively admissible under the business

                               -7-
records exception to the hearsay rule.                     See Fed. R. Evid. 803(6).

At trial, counsel for Dr. Sugarbaker introduced both the diary

entry    and        the    post-it       note       into     evidence         during   his

cross-examination of Ms. Bradley.

              The    second      trial   similarly         concluded    with     the   jury

returning a verdict in favor of Dr. Sugarbaker.                        The Bradleys now

appeal once more, this time arguing that the district court erred

both in admitting the diary entry and the Hartford record, and in

finding their negligence claim waived.

                                           II.

                                           A.

              We begin with the Bradleys' claims of evidentiary error.

We review the district court's interpretation of the Federal Rules

of Evidence de novo, but its application of those Rules for abuse

of discretion.2           United States v. Muñoz-Franco, 487 F.3d 25, 34

(1st Cir. 2007).          When a district court has committed evidentiary

error,   we    will       only    overturn      a   verdict     if     that    error   has

2  We note that our case law is not perfectly clear as to whether
we review a district court's application of the residual exception
for clear error or abuse of discretion. Compare Brookover v. Mary
Hitchcock Mem'l Hosp., 893 F.2d 411, 419 (1st Cir. 1990); United
States v. Doe, 860 F.2d 488, 491 (1st Cir. 1988) with United States
v. Burdulis, 753 F.3d 255, 263 (1st Cir. 2014); United States v.
Sposito, 106 F.3d 1042, 1046 (1st Cir. 1997); United States v.
Trenkler, 61 F.3d 45, 57 (1st Cir. 1995). However, in light of
our ultimate conclusion that the district court's evidentiary
error was harmless, we need not take up this issue here.

                                           -8-
compromised a party's "substantial rights."                      Cham v. Station

Operators,    Inc.,    685 F.3d 87,    99     (1st    Cir.    2012)   (quoting

Torres-Arroyo v. Rullán, 436 F.3d 472, 480 (1st Cir. 2000)).                   This

means that the verdict will stand unless we determine that the

trial's outcome was "substantially swayed by the error."                     Gay v.

Stonebridge Life Ins. Co., 660 F.3d 58, 62 (1st Cir. 2011) (quoting

Rubert-Torres v. Hosp. San Pablo, Inc., 205 F.3d 472, 480 (1st

Cir. 2000)).

            Before embarking on this analysis, however, we find it

useful to place the Bradley's evidentiary arguments in context.

They claim that Dr. Sugarbaker failed to obtain Ms. Bradley's

informed consent to a surgical biopsy because he did not discuss

alternatives    to    that   procedure     with    her.      Thus,    that    claim

required a showing that Dr. Sugarbaker had no reasonable basis to

believe that no alternative to the surgery existed.                 And, somewhat

curiously, Brigham and Women's Hospital has no record of anybody

making the determination that it would not be possible to perform

an FNA on Ms. Bradley.       Thus, the Bradleys stress, the diary entry

and Hartford record are crucial pieces of evidence because they

bear   on   whether    Dr.   Sugarbaker     reasonably       believed     that   no

alternative to a surgical biopsy existed about which he should

have counseled Ms. Bradley.

                                     -9-
                                    1.

            The     Bradleys   contend    that   the   diary   entry   was

inadmissible hearsay, and that the district court therefore erred

in admitting it substantively -- that is, as evidence of the truth

of what it asserted.       As Fed. R. Evid. 801(c) explains, hearsay

is any out-of-court statement that a party seeks to introduce as

proof that what the statement asserts is true.           And, under Rule

802, hearsay is inadmissible unless it fits within a recognized

exception.        Also relevantly, Rule 805 provides that "hearsay

within hearsay" is admissible only when each level of hearsay would

be individually admissible.

            The diary entry effectively asserts that Ms. Bradley

said that Hung said that the radiologist said that an FNA was not

possible.    In other words, the entry contains three layers of

information: (1) that Hung told Ms. Bradley that Dr. Jacobson had

determined that an FNA could not be performed; (2) that Dr.

Jacobson had told Hung that an FNA could not be performed; and (3)

that Dr. Jacobson had, in fact, determined that an FNA could not

be performed.      The district court found the first of these layers

admissible under Rule 801(d)(2).          That rule allows a party to

introduce an opposing party's own statements against him or her.

Fed. R. Evid. 801(d)(2).

                                   -10-
            The   district   court    also       found   the    diary   entry's

remaining   layers   of   information       to   be   admissible    under   the

"residual exception" to the ban on hearsay.                    That exception,

enshrined in Rule 807, provides, in relevant part, that:

       (a) In General. Under the following circumstances, a
       hearsay statement is not excluded by the rule against
       hearsay even if the statement is not specifically
       covered by a hearsay exception in Rule 803 or 804:

       (1) the statement has equivalent                  circumstantial
       guarantees of trustworthiness;

       (2) it is offered as evidence of a material fact;

       (3) it is more probative on the point for which it is
       offered than any other evidence that the proponent
       can obtain through reasonable efforts; and

       (4) admitting it will best serve the purposes of these
       rules and the interests of justice.

            We have previously stressed that whether the "proffered

evidence possesses 'circumstantial guarantees of trustworthiness'

equivalent to those possessed by the other listed exceptions to

the hearsay rule" is the most important part of this inquiry.

United States v. Trenkler, 61 F.3d 45, 57-58 (1st Cir. 1995);

accord 2 McCormick on Evidence § 324 (7th ed. 2016).                    And in

conducting that inquiry, we essentially ask this: Do any of the

rationales behind the Federal Rules' enumerated exceptions to the

hearsay rule also support admitting this statement?                 See, e.g.,

Trenkler, 61 F.3d at 58-59; Brookover v. Mary Hitchcock Mem'l

                                     -11-
Hosp., 893 F.2d 411, 420-21 (1st Cir. 1990); see also 2 McCormick

on Evidence § 324.   Lastly, we keep in mind that Congress meant

for trial courts to admit evidence under the residual exception

"very rarely, and only in exceptional circumstances."        United

States v. Benavente-Gómez, 921 F.2d 378, 384 (1st Cir. 1990)

(quoting S. Rep. No. 1277 (1974)).

          In defending the district court's determination that the

diary entry was admissible, Dr. Sugarbaker argues that the diary

entry had circumstantial guarantees of trustworthiness equivalent

to those motivating the exceptions found in Rules 803(1), 803(4),

and 803(5).   We, however, need not resolve this question.     This

is because, even if we assume that the district court erred, that

error would have been harmless.

          But, before discussing why, we briefly highlight a few

factors that support the district court's admission of the diary.

Under the circumstances, it is difficult to think of any plausible

reason why Dr. Jacobson or Hung would have lied.   This absence of

any credible motive to fudge the truth suggests trustworthiness.

Had Hung simply written into Bradley's medical file that Dr.

Jacobson had told him that an FNA would not suffice, such a

statement would have been admissible under Fed. R. Evid. 803(6).

And since Bradley herself had no motive to fabricate that Hung

made such a statement, her own diary entry would seem equal to a

                              -12-
business record in terms of trustworthiness.         Nonetheless, as we

will explain shortly, assuming error occurred, it did not result

in prejudice.

                                      2.

            We now consider the Bradleys' arguments concerning the

Hartford record, and, more specifically, the post-it note affixed

to it.    The Bradleys tell us that the district court should not

have admitted that exhibit substantively -- that is, as evidence

that, in fact, "Brigham & Women's . . . radiologists said it

doesn't look possible to [biopsy] the lesion" 3 -- under Rule

803(6).

            Rule   803(6)   excepts    "record[s]   of   an   act,   event,

condition, opinion, or diagnosis" from the ban on hearsay, so long

as:

          (A) the record was made at or near the time by -- or
          from information transmitted by -- someone with
          knowledge;

          (B) the record was kept in the course of a regularly
          conducted activity of a business, organization,
          occupation, or calling, whether or not for profit;

          (C) making the record was a regular practice of that
          activity;

3  The post-it note actually reads that "it doesn't look possible
to bx the lesion." "Bx" is an abbreviation for "biopsy." See,
e.g., Smith v. Naku, No. CIV S–06–2340, 2011 WL 70564, at *7 n.5
(E.D. Cal. Jan. 7, 2011).

                                  -13-
        (D) all these conditions are shown by the testimony
        of the custodian or another qualified witness, or by
        a certification that complies with Rule 902(11) or
        (12) or with a statute permitting certification; and

        (E) the opponent does not show that the source of
        information or the method or circumstances of
        preparation indicate a lack of trustworthiness.

           That    exception,      however,     does     not      extend    to

"statement[s] to [a] business by a stranger to it."             United States

v. Vigneau, 187 F.3d 70, 75 (1st Cir. 1999).                 Such "'outsider'

information, where offered for its truth [is inadmissible] unless

some   other   hearsay    exception   applies    to    the    outsider's   own

statement."    Id. at 76; see also Fed. R. Evid. 805 ("Hearsay within

hearsay is not excluded by the rule against hearsay if each part

of the combined statements conforms with an exception to the

rule.").

           At trial, Ms. Bradley testified that she was the one who

conveyed the substance of that note (that it had been determined

that an FNA was not possible) to Hartford Hospital.               The post-it

note   affixed    to     the   Hartford   record      therefore     contained

categorical "outsider information."           And so, the district court

should not have let it come in substantively under Rule 803(6).

We note, though, that the post-it may have been admissible under

Rule 801(d)(2), which provides that statements offered against an

opposing party are not hearsay, as evidence that Ms. Bradley did

call to cancel her appointment, and of her reason for doing so.

                                   -14-
But the second layer of hearsay contained in the note -- that

"radiologists said" that a biopsy did not appear possible -- would

still have needed to come in       substantively   under a separate

exception, which it could not have.    See Fed. R. Evid. 805.

          Nonetheless, this second layer of hearsay was admissible

not for its truth, but to show why Ms. Bradley had cancelled her

FNA appointment at Hartford Hospital.    Had it come into evidence

for this reason, the jury would have heard through this evidence

(which corroborated what Ms. Bradley said on the stand) that Ms.

Bradley believed that the radiologists at Brigham and Women's said

that an FNA was not possible (putting aside for the moment whether

or not that is true), and acted on this belief in cancelling her

FNA biopsy.

                                 3.

          Neither the diary entry nor the post-it compromised the

Bradleys' "substantial rights" by coming into evidence.   See Cham,
685 F.3d at 99.   For that reason, assuming error occurred, reversal

is unwarranted.

          The Bradleys argue that they suffered prejudice as the

result of these evidentiary rulings because the diary entry and

the Hartford record amounted to the only evidence at trial that

Dr. Sugarbaker reasonably believed an FNA was not an available

alternative to a surgical biopsy.      Therefore, according to the

                                -15-
Bradleys, the jury must have relied exclusively upon this evidence

when answering in the negative to the question on the verdict form

"Did Mrs. Bradley prove . . . that she was not provided with

sufficient    material     information      regarding    .   .   .     available

alternatives . . . ?"          We disagree, however, with the premise of

this argument, as the jury's conclusion that Ms. Bradley failed to

prove as much does find support outside of those two pieces of

evidence.

            First, during direct examination, Ms. Bradley testified

that she cancelled her FNA appointment at Hartford because Hung

had told her that Dr. Jacobson had determined an FNA to be

infeasible.       Then, Dr. Sugarbaker testified -- with no objection

from    counsel    for   the    Bradleys    --   that   "there   had    been   a

determination by our team that a needle biopsy, based on its

location in that area or some other technical difficulty, was not

advised."    The meaning of the word "advised," is somewhat unclear

here.    However, Dr. Sugarbaker's later testimony clarifies that

his team had concluded that an FNA was not a possible alternative

to surgical biopsy.

            This means that the jury heard the following from sources

other than the diary entry and the Hartford record: (1) it had

been determined that an FNA wasn't possible; (2) this information

had been communicated to Ms. Bradley; and (3) that determination

                                     -16-
was the reason that Ms. Bradley cancelled her FNA at Hartford

Hospital.     Thus,   Ms.     Bradley       and   Dr.   Sugarbaker's       combined

testimony effectively brought to the jury's ears exactly the same

information contained in the diary entry and Hartford record.                   The

Bradleys protest that they only pursued this line of questioning

during Ms. Bradley's direct examination because of the district

court's earlier ruling admitting the diary entry and Hartford

record.     But even if this is so, we cannot ignore that the jury

still heard Dr. Sugarbaker testify that his team had ruled an FNA

out as a possible alternative.            See, e.g., Ohler v. United States,

529 U.S. 753, 755 (2000) ("Generally, a party introducing evidence

cannot    complain    on   appeal     that     the   evidence     was   erroneously

admitted."); Tersigni v. Wyeth, 817 F.3d 364, 370 (1st Cir. 2016)

(plaintiff waived the right to appeal the admission of evidence

after    unsuccessfully      moving    to    exclude    it   in   limine    because

plaintiff introduced the evidence herself during trial).                        And

therein lies the rub.

            Additionally, at oral argument, the Bradleys intimated

that this nonetheless did not amount to harmless error because the

documentary    evidence      that   the     district    court     admitted,   while

cumulative, had the effect of bolstering Dr. Sugarbaker's own self-

serving testimony.         Thus, they say, the diary entry and Hartford

record served to undercut the notion that Dr. Sugarbaker had lied

                                        -17-
about an FNA being infeasible.               This argument, however, fails to

convince us.        We first note the paucity of evidence in the record

suggesting that Hung or Dr. Jacobson had any reason to misrepresent

that   an    FNA    had    been    ruled    out,     or    that    they     in    fact     did

misrepresent as much.          It is also worth noting that Dr. Sugarbaker

testified that a determination as to whether an FNA was possible

for    a    given    patient       would    "[n]ot        usually"    be     documented.

Moreover, one of Dr. Sugarbaker's expert witnesses -- Dr. Jones,

a thoracic surgeon -- offered his conclusion, based on reviewing

Ms. Bradley's medical records, that "the location and rather

diffuse nature [of the mass in her right lung] would have made it

challenging"        to    obtain   a     diagnosis    from    an     FNA.         While    the

Bradleys'     expert       witness       essentially       presented        the    opposite

conclusion -- that an FNA would have been feasible -- Dr. Jones's

testimony nonetheless further erodes the possibility that Ms.

Bradley was incorrectly informed that an FNA had been ruled out.

             In summary, given Ms. Bradley's own testimony at trial

about what Hung told her, the two writings to that effect did

little work because no party challenged Ms. Bradley's testimony

and the writings simply aligned with that testimony.                          Even if the

two writings had not come in for the truth of what the radiology

department      concluded,         the     evidence       would    nonetheless            have

bolstered the conclusion that Dr. Sugarbaker reasonably thought an

                                           -18-
FNA   was    infeasible.      Having    considered      these   two   pieces   of

evidence "in light of the entire record," Zachar v. Lee, 363 F.3d
70, 76 (1st Cir. 2004), we feel confident that the diary entry and

the Hartford record are not what tipped the scales towards the

jury's      ultimate   conclusion.      Because    we    "can   say   with   fair

assurance that the judgment was not substantially swayed by," Gay,
660 F.3d at 62, the assumed error, we hold that the jury's verdict

should stand.

                                        B.

              Lastly, the Bradleys press that the district court erred

in finding their medical negligence claim waived.               We disagree.

              The Bradleys' Second Amended Complaint advanced various

theories of negligence.        Among other things, it alleged that Dr.

Sugarbaker was negligent in representing that a surgical biopsy

was the only option and also that he performed that procedure in

a negligent fashion.         Dr. Sugarbaker moved for summary judgment

on all of the claims in the Second Amended Complaint.             The district

court's summary judgment order, however, only explicitly addressed

the   Bradleys'    battery    and    informed     consent   claims    (granting

summary judgment on the former but not the latter).

              At a status conference before the beginning of the first

trial, the Bradleys highlighted that the district court's summary

judgment order was ambiguous as to whether their negligence claim

                                       -19-
had survived summary judgment.        The Bradleys then explained that

their negligence claim consisted of the contention that failing to

discuss viable alternatives to surgical biopsy amounted to a breach

of   the   standard    of   care.   The    district    court   expressed    its

skepticism that this claim was distinct from their informed consent

claim.     In response, the Bradleys raised the possibility of filing

a motion for clarification of the summary judgment ruling.                  The

district court told them that they could discuss that possibility

with opposing counsel and "see how necessary you think that may

be."       The     Bradleys,   however,    never      filed    a   motion   for

clarification.

             All of this first suggests that -- by failing to continue

to pursue it after this pretrial conference -- the Bradleys waived

any negligence claim not involving Dr. Sugarbaker's failure to

discuss alternative procedures that may have survived summary

judgment.4       See In re Net-Velázquez, 625 F.3d 34, 40-41 (1st Cir.

2010) (finding that plaintiffs had waived claims they failed to

raise during a        pretrial conference     -- which resulted in the

district court omitting those claims from its subsequent pretrial

order -- and explaining that "[a] defense or legal theory may not

4  For example, this would include the claim -- which the Second
Amended Complaint appears to have made -- that Dr. Sugarbaker
performed the surgical biopsy in a negligent manner.

                                    -20-
be preserved by bare reference in a pleading if it is thereafter

abandoned until, freshly discovered on appeal, it is raised anew");

see also Fed. R. Civ. P. 16(c)(2)(A) ("At any pretrial conference,

the court may consider and take appropriate action on [matters

including] formulating and simplifying the issues, and eliminating

frivolous claims or defenses.").

          All of this additionally suggests that, even if the

district court erred in finding that the Bradleys had waived all

of their negligence claims -- for example, because they never

relinquished those involving an "absence of informed consent"

theory of negligence -- prejudice nevertheless did not result.

Like the district judge who oversaw the motions for summary

judgment, we express our skepticism over whether such a theory of

negligence would actually amount to a distinct claim from the

Bradley's informed consent claim.     But even if we assume that

these were distinct claims, we cannot escape the conclusion that

the Bradleys would have lost on this theory of negligence anyway.

This is because, as the Bradleys framed it, their informed consent

claim would effectively constitute a necessary element of their

negligence claim: breach of the applicable standard of care.   And

so, it would have been impossible for the Bradleys to prevail on

that negligence claim while losing on their informed consent claim.

Thus, even if the district court erred in finding such an "absence

                               -21-
of informed consent" negligence claim waived, the Bradleys cannot

have suffered prejudice as a result.     Accordingly, none of the

Bradleys' waiver-related arguments call for reversal.

                                III.

            The Bradleys did not suffer prejudice because of the

district court's decision to admit the diary entry or the Hartford

record.     Additionally, any error the district court may have

committed in finding their negligence claims waived would likewise

have been harmless.     The district court's judgment is therefore

affirmed.

            Affirmed.

                                -22-