Court Opinion

ID: 9486962
Source: CourtListenerOpinion
Date Created: 2023-08-05 12:05:00.331219+00
Date Added: 2024-06-11T17:52:01.987169
License: Public Domain

MIKVA, Chief Judge,
dissenting:
Trial Judge Oberdorfer found that State Department omissions proximately caused Nyenpan Tarpeh-Doe’s illness. To overturn that finding under a “clearly erroneous” standard of review, the majority must conclude that the finding was not based on a “plausible account” of the evidence viewed in its entirety. See Anderson v. Bessemer City, 470 U.S. 564, 574, 105 S.Ct. 1504, 1511, 84 L.Ed.2d 518 (1984). The majority cannot reach such a result on this record. I dissent.
I.
The trial court’s conclusion that State Department omissions were a “substantial factor” in causing Nyenpan Tarpeh-Doe’s injuries is a finding of fact; it must be upheld unless it is “clearly erroneous.” See, e.g., Daniels v. Hadley Memorial Hospital, 566 F.2d 749, 756 (D.C.Cir.1977). This is a highly deferential standard. “A finding is clearly erroneous when although there is evidence to support it, the reviewing court on the entire evidence is left with the definite and firm conviction that a mistake has been committed.” United States v. United States Gypsum Co., 333 U.S. 364, 395, 68 S.Ct. 525, 542, 92 L.Ed. 746 (1948) (emphasis added). “In applying the clearly erroneous standard to the findings of a trial court sitting without a jury, appellate courts must constantly have in mind that their function is not to decide factual issues de novo. ” Zenith Radio Corp. v. Hazeltine Research, Inc., 395 U.S. 100, 123, 89 S.Ct. 1562, 1576, 23 L.Ed.2d 129 (1969). “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.” Anderson v. Bessemer City, 470 U.S. 564, 574, 105 S.Ct. 1504, 1511, 84 L.Ed.2d 518 (1985). Judge Oberdorfer found that State Department omissions were a substantial factor in causing Nyenpan’s illness and/or impeding his recovery. Because that finding was based on a “plausible account” of the evidence viewed in its entirety, it should be upheld.
II.
In reaching the opposite conclusion, the majority understates Dr. Lefton’s negligence and misconstrues the trial court’s findings as to its likely effect on Nyenpan’s condition. A recitation of those findings and their eviden-tiary basis is thus in order:
Dr. Lefton’s negligent action and omissions proximately caused Nyenpan’s injuries. Dr. Lefton did not administer or in any way supervise or check on any gynecological, prenatal, or obstetrical care to Linda Wheeler Tarpeh-Doe despite her manifest need for such care. Instead, he referred her to a local gynecologist and obstetrician for care for a period of over nine months without advising her that she should or could call him if she needed advice, without arranging to see her even once to determine whether she was receiving adequate local care, and without inquiring about her care of her treating physicians. He did not inform her of the known risks of delivery and post-natal care of a child, particularly a first child, in disease-ridden Monrovia. He never alerted her to the conditions of the various clinics and *127hospitals in Monrovia, some of which were evidently notorious. He did not visit her upon or after her delivery. When she became sick on Thursday, June 3, and needed prompt attention at 10:00 p.m. he was unavailable for unexplained reasons— the likely inference being that he refused to make a housecall as he had refused several times in the past. When Tarpeh-Doe visited Dr. Lefton for treatment for mastitis on Friday, June 4, Dr. Lefton did not examine, or even ask about the child. He advised her at that time to resume breast feeding. That advice, if followed, could have caused or increased the child’s exposure to infectious bacteria. When the Tarpeh-Does came to Dr. Lefton on June 5, he did not administer any tests. Dr. Lefton considered, but decided against, attempting to evacuate the child by commercial airplane. He did not request the services of a MAC flight for evacuation. He handed over all care to Dr. Van Reken, a physician to whom he had never referred a patient before. He permitted Dr. Van Reken to admit Nyenpan into a local hospital with deplorable conditions at a critical point in the baby’s care — against the baby’s parents’ vehement objections. He was not familiar with conditions at JFK, despite his duty to be aware of conditions at local health facilities in order to advise State Department and AID employees where to safely obtain services. He did not visit or inquire about his American charges at JFK hospital during the initial afternoon of June 5, nor did he visit or inquire that night or the next morning. He never evaluated its facilities for himself to determine whether the parents’ pronounced fears were justified. He did not check to see whether medications, or oxygen, or 24-hour care by doctors or other trained medical attendants, would be available there. He did not contact the Office of Medical Services immediately to request advice or support from a neonatologist or an expert in bacterial spinal meningitis in the United States. When he did cable the Office, he did not inform persons there that he had not examined the child since June 5 nor that he had turned over care to Dr. Van Reken, nor did he request assistance or advice. He did not visit Tarpeh-Doe until June 12. After the June 5 visit to him at the Embassy health clinic, he did not examine the baby at all. He did not authorize evacuation either upon the parents’ repeated requests or upon Dr. Van Reken’s approval of evacuation.
In short, Dr. Lefton washed his hands of Linda Tarpeh-Doe and her baby and turned his back on them, doing as little as possible to attend to Tarpeh-Doe’s care during pregnancy or to plan for the close medical supervision of mother and child after delivery. He was supposed to be the family doctor. Had Dr. Lefton provided Tarpeh-Doe with gynecological or prenatal care or taken any interest at all in her condition by anticipating and preparing himself and herself for the risks awaiting the mother and child after delivery, he would have visited her or otherwise made himself available so that she would have automatically called or visited him with the child on Friday, or even Thursday, when she first noticed signs of illness. Had she felt that he would willingly, as opposed to reluctantly, attend to her medical needs, she would have sought him out instead of waiting until Nyenpan required emergency care and seeking that care from local, inadequate, facilities. On June 5, had Billie Clement not directed the Tarpeh-Does to the embassy health unit, it is even possible that Nyenpan would have received better care from Dr. Johnson at Cooper’s clinic than he received from Dr. Lefton who permitted Dr. Van Reken to place him in a hospital with roaches and rats and with no medications, no medical attendants during the night, and no oxygen. From Tarpeh-Doe’s arrival in Monrovia throughout her pregnancy, delivery, and most important, from the onset of the post-natal illness of mother and child, Dr. Lefton took none of the initiatives required of him by the State Department directives or by any conceivable standard of care for a physician in his circumstances.
Wheeler Tarpeh-Doe v. United States, 771 F.Supp. 427, 452-53 (D.D.C.1991).
As the foregoing passage makes clear, Judge Oberdorfer based his negligence find*128ing on an array of actions and omissions, particularly Dr. Lefton’s lack of interest in and attention to Linda and Nyenpan throughout her pregnancy and at several critical times during the baby’s illness. Yet, the majority treats any negligence on the part of Dr. Lefton as resulting primarily from misdiagnosis or affirmative mistreatment. As a result, the majority concludes that “Dr. Lefton’s negligence, if any, was ... not preventible by” State Department officials because the State Department was aware only of Dr. Lefton’s poor attitude and penchant for unavailability, not any deficiency in his medical capabilities. Maj. Opin. at 125-26. Properly viewed, however, Dr. Lef-ton’s primary negligence was his almost total abdication of responsibility for Linda and Nyenpan. The consequences of that negligence were surely foreseeable to Washington officials in face of the “unprecedented magnitude” of complaints revealing “widespread discontent with Dr. Lefton’s performance [and] dissatisfaction with Dr. Lefton’s attitude and availability.” And, as discussed below, those consequences may well have been preventible.
Even if Dr. Lefton’s negligence could be characterized as strictly medical, I disagree that the State Department had no duty whatsoever to monitor his medical decisions, particular in emergency cases. First, as the majority indicates, the State Department’s review of Dr. Lefton’s previous activities reported widespread dissatisfaction with his “performance” in general, which reasonably could be taken to include his medical decisions. More importantly, a doctor’s unavailability and poor attitude almost necessarily affect both the level and quality of treatment his patients receive. If a doctor is unavailable to give treatment, it is irrelevant how competent that treatment may have been. And, if a patient has lost confidence in her primary doctor because of his habitual bad attitude, it is foreseeable that she will choose not even to seek treatment or to seek it from less competent sources. The potential consequences of such a crisis of confidence might not be altogether clear were this the ordinary tort action arising in this country. It could be assumed in such a case that the patient would receive quality care elsewhere. In this case, however, the State Department touts its medical services as an inducement for employees to accept employment in isolated and medically substandard outposts around the world. See 771 F.Supp. at 430. As such, State Department medical officials have a heightened duty to foresee the obvious and dire consequences of their doctors’ negligence in places like Liberia. Discharging that duty here involved more that making sure Dr. Lefton was available when Linda Tarpeh-Doe happened to call; it also required Department officials to monitor his continued availability and effectiveness, which necessarily includes some oversight of his medical decisions. In short, State Department officials should have foreseen that Dr. Lefton’s deficiencies were likely to result in the type of illness that befell Nyenpan, and they had a corresponding duty to do whatever was reasonably within their power to prevent that illness. In any event, that is what the trial judge found.
III.
With Dr. Lefton’s negligence and its foreseeability to State Department officials in clearer focus, I fail to see how the trial court’s causation finding is “clearly erroneous” given the deference that the standard affords the finder of fact. Judge Oberdorfer identified four remedial actions that the State Department failed to take that might have prevented or ameliorated Nyenpan’s illness: (1) “directing] Dr. Lefton to focus more attention on his responsibilities and to make himself more available” after hours; (2) imposing additional reporting i*equire-ments on Dr. Lefton so that State Department officials could monitor emergency situations; (3) warning the Ambassador and other embassy medical personnel to notify Washington should emergency treatment situations arise; and (4) requiring Dr. Lefton to adopt plans addressing the care of pregnant mothers and their children, a particularly vulnerable class of patients. 771 F.Supp. at 453-54.
Each of these precautions would have been a reasonable response upon learning that Dr. Lefton was inclined to neglect his patients, and under a plausible account of the facts, *129each could have averted Dr. Lefton’s negligence and changed the course of Nyenpan’s illness. In particular, it is reasonable to infer that had the State Department warned Dr. Lefton to be more attentive, he would have visited mother and child on the night of June 3 when Linda Tarpeh-Doe first sought treatment for her own illness. Had he made that housecall and observed the baby — who Nurse Clement said did not “look right” — an attentive Dr. Lefton would have begun the diagnosis process then, on the first rather than third day of the critical period between June 3 and June 6. Even if Dr. Lefton did not see the baby on June 3, it is surely reasonable to assume that Linda Tarpeh-Doe would have had enough confidence in a duly warned and attentive Dr. Lefton to call upon him on June 4, instead of proceeding to a local clinic, when the baby stopped feeding. Under this scenario, the diagnosis and treatment would have begun one day earlier than it actually did.
Assuming it had occurred, earlier care by a conscientious doctor would have increased the likelihood of proper diagnosis and treatment during the critical June 3-6 period. First, Nyenpan’s doctors would have had more time to identify the type of bacteria that caused Nyenpan’s meningitis. As it was, the doctors tested the baby only for Gram-positive bacteria (staph and strep) during the critical period. 771 F.Supp. at 439. Tests for Gram-negative salmonella, which two experts identified as the cause of the meningitis, were not performed until well after Nyenpan’s condition was beyond hope. Id. at 440.
Earlier care also would have revealed the urgency of Nyenpan’s condition at a time when State Department intervention could have improved the baby’s chances. Had Dr. Lefton or other embassy personnel been required to report emergency situations, and had they actually done so, stateside experts could have assisted Dr. Lefton in making a proper diagnosis. For example, they could have alerted Dr. Lefton of the possibility of Gram-negative infection and recommended a course of treatment. Or, they could have directed Dr. Lefton to forward Nyenpan’s fluid samples for a full battery of tests in the States. Or, they could have intervened in the decision whether to airlift Nyenpan when the seriousness of his illness first became apparent. On this score, I find severely lacking Dr. Lefton’s justification for not evacuating Nyenpan — namely, that lack of oxygen on the plane would have made intubation more difficult. The hospital to which the baby was assigned had a total absence of oxygen available, a fact Dr. Lefton was under a duty to know. The lack of oxygen at the JFK hospital leaves Dr. Lefton no valid reason for preventing prompt evacuation. In any event, the State Department should have known that prompt evacuation from Monrovia might be needed in emergency situations, and it should have provided for safe and effective means to carry it out.
IV.
Admittedly, the causal link between State Department omissions and Nyenpan’s illness is somewhat attenuated: because the exact cause of Nyenpan’s injury is impossible to pinpoint, the effect of the State Department’s inattention to Dr. Lefton’s documented deficiencies is likewise difficult to gauge. But as the majority acknowledges, a plaintiffs burden on causation is lightened when a doctor’s (or his supervisor’s) negligent omissions make it difficult to determine whether the injury would have occurred but for those omissions. In such cases, plaintiffs may prevail so long as the defendant’s inaction creates uncertainty as to whether, had the defendant acted otherwise, the injury would have been averted. See, e.g., Daniels v. Hadley Memorial Hospital, 566 F.2d 749, 757 (D.C.Cir.1977). Judge Oberdorfer found that Dr. Lefton’s almost total abdication of responsibility for mother and child was a substantial factor in causing Nyenpan’s illness and/or lack of recovery. Because that negligence was reasonably foreseeable to State Department medical officials, and because a number of reasonable remedial actions could have been taken in an effort to avert the injury, it cannot be clearly erroneous to conclude that the State Department’s inaction created the requisite uncertainty as to whether Nyenpan would have recovered had the State Department acted otherwise.
*130Indeed, the speculative nature of the causation question makes it even more troubling that the majority overturns the findings of a trial judge under a clear error standard. Whether an omission creates enough uncertainty as to its effect on a patient’s condition to impose tort liability is a largely subjective inquiry. Under the clearly erroneous standard, the question before an appellate judge is not whether he or she would have reached the opposite subjective conclusion. Rather, the question is whether the trial judge’s conclusion is based on a plausible account of the evidence. A finding in favor of the plaintiff should thus be overturned only if the appellate judge can say with confidence that the defendant’s omission was of no or minimal consequence on the plaintiffs condition. By failing to act, the State Department deprived Nyenpan of quality care during the period in which he had a fighting chance of recovery. While no one can be sure that he would have recovered, neither is it certain that he would not have. I would let the trial judge perform the role that precedent has assigned him, and would affirm the trial court’s decision.