Court Opinion

ID: 9477502
Source: CourtListenerOpinion
Date Created: 2023-08-05 06:25:12.062883+00
Date Added: 2024-06-11T17:45:54.913868
License: Public Domain

DAVID A. NELSON, Circuit Judge,
concurring.
I agree that the judgment in favor of the plaintiff must be affirmed, but I think it can be affirmed without resort to any legal presumptions. Accordingly, and because I am unclear as to what effect the Kentucky courts might give to the hospital’s negligent destruction of the skull flap, I would not hold that the hospital’s negligence in that respect created any presumption as to the existence of a causal relationship between the hospital’s earlier negligence and the medical disaster that ensued.
None of the findings of fact made by the district court was clearly erroneous, in my view, and in light of those findings it seems to me that the plaintiff would have been *1250able to carry her burden of proof as to both negligence and proximate cause even if the bone had been subjected to an examination showing that the bone infection itself was not of long standing. I do not view this as a situation where the defendant’s negligent destruction of evidence made it impossible for plaintiff to prove an essential element of her case, in other words, and I therefore consider it unnecessary to speculate on what the Kentucky courts might do in a case actually presenting that sort of situation.
The district court expressly found that acts of negligence occurring “during July, August and September 1980” were substantial factors in causing the catastrophe that occurred in October. There is substantial evidence directly supporting that finding.
When plaintiffs decedent had his brain surgery on June 9, 1980, the hospital knew that a pre-surgical test had “indicated problems with liver disease.” Yet notwithstanding that fact, notwithstanding the seriousness of the June 9 operation, and notwithstanding that plaintiff's decedent returned to the hospital twice in July, once in August, and once in September complaining of headaches, nausea, sweating, and fever, no one at the hospital took the patient’s temperature after he went home on July 3, no one did a blood count, and no one did a neurological examination. Against this background, the testimony of the neurosurgeon who was the attending physician during the decedent’s two hospital admissions makes it clear that, in the words of the court, decedent’s “temperature should [have been] taken and other studies, such as blood count should have been done.” If the hospital had done what it ought to have done in July, August and September, it would not have been taken by surprise in October.
But there is more. When the decedent returned to the hospital on the morning of October 10, the hospital still did not take his temperature. He was rushed back to the hospital at 8:30 that evening, at which time he was found to have a temperature of 102.8°. (As the district court noted, “all hospital records indicate that this was the first time that his temperature had been taken since Mr. Welsh left the hospital on July 3, 1980.”) The government’s own medical expert, Dr. Noble, conceded that the E. coli infection had to have been present, in some form, on the morning of October 10 — and he conceded that “the earlier you got the treatment started the better off you’d have been.”
Dr. Noble explained that the infection constituted “a very serious illness,” with the count of E. coli doubling “every twenty to thirty minutes.” Once the infection gets into the blood stream or into the cerebro-spinal fluid, Dr. Noble testified, “things go very quickly” — which is why avoidance of delay is “so important in dealing with infections in the brain.” In failing to detect any infection on the morning of October 10, the hospital could well be found to have been guilty of negligence that produced tragic consequences.
The trial court having found that the negligent acts that began as early as July and continued to the morning of October 10 “were substantial factors in causing the tragic coma and subsequent death of the decedent,” I would affirm the judgment on that basis. Judge Merritt finds three problems with this approach, but to my mind the problems are far from insoluble.
First, the district judge did not see any logical inconsistency between his finding that “the E. Coli infection seeded in decedent’s brain ... from the gall bladder or liver, or a combination,” and his finding that there was a causative link between the series of negligent acts that began in July and the tragic events that occurred in October. I see no inconsistency either. The defendant ought to have made a record, for future reference, of the significant complaints voiced by Mr. Welsh at his scheduled visit to the clinic on July 18, and it ought to have recorded the even more serious complaints made, as the judge found, during the unscheduled visit on August 22. The trial judge expressly found that “as a result [of the defendant’s failure to pay sufficient attention to these complaints] Dr. Guidry had an inadequate record on Sep*1251tember 25_” The infection — wherever it originated and however long it had been lurking somewhere in Mr. Welsh’s body— had formed an abscess in Mr. Welsh’s head “sometime prior to September 25,” the judge concluded, and given those facts, I am at something of a loss to understand why it should be deemed impermissible for the trial court to conclude that there was a causative link between the failure to record the telltale complaints in July and August and the failure, on September 25, to look for and detect the infection that had reached Mr. Welsh’s head by that time.
Second, like Judge Merritt, I cannot bring myself to say that I have a “conviction” that no visit to the VA clinic occurred on September 25. Mrs. Welsh testified that there was such a visit. The Welshes’ son Mitchell — home from college on that day — testified that there was such a visit. The judge who actually heard the testimony found as a fact that “the visit was made.” If that seems a slender reed on which to base liability, I can only observe that on reeds no less slender this court allows people to be sent to jail. The fact that the hospital failed to record the September 25 visit hardly convinces me that the visit could not have occurred; were it not for a single note by a nurse, we should not even have any contemporaneous record of the visit at which the doctors decided, on July 9, that Mr. Welsh (whose status was still that of an inpatient, even though he had been allowed to go home for a few days) could finally be discharged after a month-long hospitalization. The trial judge’s characterization of this VA hospital’s record-keeping practices as “deficient” strikes me as something of an understatement.
Finally, I am not persuaded that the trial judge erred in his interpretation of the testimony given by Dr. Nobel — the government’s expert witness, not the plaintiff’s— on the question of whether discovery of the infection on the morning of October 10 would have made a difference. The significant portion of the court’s colloquy with Dr. Nobel is as follows:
THE COURT: Do you think this disaster could have been averted if — if they had known that morning what was going on?
THE WITNESS: He was infected — well, I don’t know — the sooner that you get the treatment started the better. And I think — whether he would have survived or not or had less damage, I would have to assume that the earlier you got the treatment started the better off you’d have been. He had a very serious illness, that E. coli infection with—
THE COURT: That would have had to have been there that morning.
THE WITNESS: I’m sorry?
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THE COURT: He came for a regularly scheduled visit and an EEG about 10:00 in the morning on the 10th.
THE WITNESS: Apparently he wasn’t hav[ing] symptoms at that — from my reading of the record. At that time he wasn’t having symptoms.
THE COURT: My question was, the infection would have in fact actually had to have been there at that time, now that we know what happened later.
THE WITNESS: It would have had to have been there in some form. But I think what happened — and the way I put this together was I think that he had the infection was in the bone, but it was in the bone for a very short period of time. And I think possibly during this hospitalization maybe something was manipulated. Somehow the infection got into the blood stream or into the cerebrospinal fluid. Once that happens then things go very quickly. The E. coli or any organism in the cerebrospinal fluid is just like plopping a large amount of bugs into a large culture dish. They have no impediment to growth.
And so E. coli doubles about every— every 20 to 30 minutes. And this is a geometric progression. And so — just to give you an example, if you said you had a jar that had E. coli doubling in it, and the E. coli doubled every 60 seconds, and in one hour the jar was full, *1252the question is when is a jar half full? Well, it’s half full at 59 minutes because at 60 it doubled again. So that’s what’s so important in dealing with infections in the brain. The longer you delay the more dangerous it becomes for the patient.”
The trial judge — having seen and heard Dr. Nobel as he spoke, and having prepared written findings of fact and conclusions of law promptly thereafter — expressed himself on Dr. Nobel’s testimony as follows:
“The Court notes the failure to take this patient’s temperature on the morning of October 10, 1980, when according to Dr. Nobel the infection was undoubtedly present, in spite of the patient’s complaints. Dr. Nobel testified that if the infection had been diagnosed at that time, the decedent might have been helped. The Court finds that the failure to diagnose the infection on the morning of October 10, 1980, was negligence.”
The trial court concluded that the hospital’s negligence on the morning of October 10 was a substantial factor in Mr. Welsh’s death. That conclusion was not clearly erroneous, in my opinion.