Court Opinion

ID: 9965593
Source: CourtListenerOpinion
Date Created: 2024-05-02 20:08:42.457981+00
Date Added: 2024-06-11T08:25:15.253668
License: Public Domain

Fitzgerald v Huerta
               2024 NY Slip Op 31523(U)
                     April 29, 2024
           Supreme Court, New York County
        Docket Number: Index No. 805236/2017
                  Judge: Kathy J. King
Cases posted with a "30000" identifier, i.e., 2013 NY Slip
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                       publication.
                                                                                                                     INDEX NO. 805236/2017
  NYSCEF DOC. NO. 120                                                                                          RECEIVED NYSCEF: 04/29/2024

                                   SUPREME COURT OF THE STATE OF NEW YORK
                                             NEW YORK COUNTY
            PRESENT:             HON. KATHY J. KING                                              PART                              06
                                                                                      Justice
            ---------------------------------------------------------------------------------X   INDEX NO.          805236/2017
             JAMES FITZGERALD,
                                                                                                                    02/08/2023,
                                                         Plaintiff,                              MOTION DATE        02/08/2023

                                                 -v-                                             MOTION SEQ. NO.      001 002

             CARLOS J HUERTA, THE DENTAL BOUTIQUE, CARLOS
             J. HUERTA, DMD D/B/A THE DENTAL BOUTIQUE, PAUL J
                                                                                                   DECISION + ORDER ON
             FENYVES
                                                                                                         MOTION
                                                         Defendant.
            ---------------------------------------------------------------------------------X

            The following e-filed documents, listed by NYSCEF document number (Motion 001) 43, 44, 45, 46, 47,
            48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 79, 80, 82, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98,
            113, 117
            were read on this motion to/for                                                  JUDGMENT – SUMMARY                    .

            The following e-filed documents, listed by NYSCEF document number (Motion 002) 59, 60, 61, 62, 63,
            64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 81, 83, 99, 100, 101, 102, 103, 104, 105, 106,
            107, 108, 109, 110, 111, 112, 114, 115, 116, 118
            were read on this motion to/for                                                        DISMISS                         .

                      Upon the foregoing documents, defendants Carlos J. Huerta, DMD, “Carlos J. Huerta,

            DMD d/b/a The Dental Boutique,” and “The Dental Boutique,” (collectively referred to as the

            “Huerta defendants”) move for the following relief:

                      1) summary judgment and dismissal of the plaintiff’s complaint in its entirety pursuant to

            CPLR 3212;

                       2) dismissal of the plaintiff’s complaint with prejudice, pursuant to CPLR 3211(a)(5), with

            respect to all claims concerning treatment prior to December 20, 2014, including March 6, 2014

            and December 11, 2014; or in the alternative,

                       3) partial summary judgment and limitation of the facts for trial of this action pursuant to

           CPLR 3212 (e) and (g);

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                       4) directing the Clerk of the Court to enter judgment accordingly on behalf of the moving

            defendants.1

                      Defendant, Paul J. Fenyves, M.D. moves for the following relief:

                      1) dismissal of the plaintiff’s complaint in its entirety with prejudice, and directing that

            summary judgment be entered in favor of the defendant, pursuant to CPLR 3212;

                      2) directing the Clerk of the Court to enter judgment accordingly on behalf of the defendant.

                      Plaintiff opposes both motions.

                                                        BACKGROUND

                      Plaintiff’s complaint asserts two causes of action sounding in medical malpractice and lack

            of informed consent against the Huerta defendants and Dr. Fenyves, respectively.

                      As to the Huerta defendants, plaintiff alleges that they failed to conform to accepted

            standards of dental care and properly premedicate him prior to rendering treatment in 2014 and

            2015, causing him to develop endocarditis. Plaintiff claims that pre-medication was required based

            on his past medical and surgical history, which included severe aortic valve stenosis, and aortic

            valve replacement surgery in July 2013. It is further alleged that that Dr. Huerta’s failure to order

            antibiotics or confirm that plaintiff had taken antibiotics or discuss antibiotic pretreatment with

            any of plaintiff’s treating physicians caused him to develop endocarditis. Plaintiff also maintains

            that all claims concerning treatment prior to December 20, 2014, which includes the March 6, 2014

            and December 11, 2014 care, should be dismissed as time barred pursuant to the statute of

            limitations.

                      As to Dr. Fenyves, an Internist and plaintiff’s primary care physician, plaintiff claims that

            Dr. Fenyves failed to timely diagnose endocarditis, an infection of the heart’s inner lining, usually

            1
             The claims made against Dr. Huerta and Huerta Dentistry, P.C. are identical, and there are no separate claims
            against Huerta Dentistry, P.C.
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            involving the heart valves during two office visits on June 16, 2015 and June 29, 2015.

            Specifically, plaintiff alleges that the blood test results on June 16, 2015 showed that he had a

            severe bacterial infection, and based on his medical history of heart valve replacement, he required

            immediate hospitalization, consultation by an Infectious Disease specialist, blood cultures, and

            intravenous antibiotics. Plaintiff alleges that Dr. Fenvyes’ failure to diagnose was a departure

            from good and accepted medical standards which proximately caused his injuries.

                   Plaintiff also claims lack of informed consent as to both the Huerta defendants and Dr.

            Fenyes .

                                           STATEMENT OF FACTS

                   On November 7, 2012, plaintiff presented to non-party Mark Schlesinger, DDS, for

            evaluation of tooth #3, whereby Dr. Schlesinger recommended extraction and implant placement.

            The tooth was extracted by Dr. Schlesinger on November 14, 2012, and an implant was placed at

            the site of the tooth on April 25, 2013. Plaintiff presented to cardiothoracic surgeon Dr. Leonard

            Girardi on July 3, 2013with a diagnosis of severe aortic stenosis. Dr. Girardi found that plaintiff

            was in need of aortic valve replacement surgery, which Dr. Girardi performed on July 16, 2013.

            The records show that Dr. Girardi advised plaintiff of the need for lifelong pre-procedure therapy

            for any invasive procedures.

                   On October 24, 2013 plaintiff returned to Dr. Schlessinger, whom he had not treated with

            since April 25, 2013. Dr. Schlessinger took an x-ray of tooth #3 and found that the implant was

            secure in the bone and ready to be restored. Plaintiff requested a recommendation for a general

            practitioner to restore the implant and Dr. Schlesinger referred him to Dr. Huerta. Plaintiff’s first

            visit to Dr. Huerta was on March 6, 2014. A patient intake form indicated that plaintiff underwent

            an aortic valve replacement on July 16, 2013, and had a dental history of bleeding gums. Dr.

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            Huerta charted that "Pt had aortic heart valve replacement July 2013. Will premedicate in case

            need to remove [gum] tissue from around cover screw (mostly exposed)" and "Medical conditions:

            aortic valve replacement July 2013. Will need pre-med until cardiologist recommends otherwise."

                   During the March 6, 2014 visit, an x-ray was taken, and no dental treatment was performed.

            Plaintiff was told that he should take prophylaxis medication before the next visit in case Dr.

            Huerta needed to remove any gum tissue in the process of removing the healing abutment. At his

            deposition, Dr. Huerta testified that it is his custom and practice for every patient that has a valve

            replacement to discuss prophylaxis for endocarditis with medication and how to do so if a

            procedure warranted it.

                    On December 11, 2014, plaintiff returned to Dr. Huerta. He removed the healing abutment

            of the implant and placed an impression coping into the implant to create an impression of the

            abutment. The healing abutment was then reinserted using a driver to screw it back onto the

            implant. Dr. Huerta testified that prior to the procedure he would have questioned plaintiff as to

            whether he had pre-medicated, and that he would not have performed the procedure if plaintiff had

            not pre-medicated. During the care provided on December 11, 2014, Dr. Huerta did not cut the

            gum, use any instruments around the gum line nor did he use any sharp objects in plaintiff's mouth.

                   Plaintiff returned to Dr. Huerta on January 15, 2015, at which time he removed the healing

            cap and placed the abutment and permanent crown, which had been fabricated by the laboratory.

            Although Dr. Huerta did not cut or remove any gum tissue on January 15, 2015, he testified that

            he would have advised plaintiff to pre-medicate in case it was necessary to cut or remove gum

            tissue. Dr. Huerta determined that the crown needed shade changes, so the abutment was left in

            place on the implant and a temporary crown was inserted.

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                   On March 3, 2015, Dr. Huerta removed the temporary crown, and “tried in” the shade-

            adjusted crown. He found that the crown needed further darkening, so it was removed, and the

            temporary crown was re-cemented. Dr. Huerta testified that there was no need for prophylactic

            antibiotics because he was not cutting into or manipulating the gum line.

                   On April 22, 2015, the permanent crown was cemented into place by Dr. Huerta. No

            antibiotic prophylaxis was done prior to this procedure because there was no manipulation of the

            gum line. The margins, contact, occlusion, and color were checked and were satisfactory. Floss

            was used to check the contacts between the teeth. The floss only goes through the contact point

            and not down to the gum line. No anesthesia was used and there was no bleeding and plaintiff

            indicated he was happy with the outcome.

                   On June 16, 2015, plaintiff presented to Dr. Fenyves, his primary care physician, with

            complaints of, inter alia, fatigue for two weeks, unintended weight loss, sore throat, body aches

            and intermittent headaches. Plaintiff was afebrile. Blood tests were done, which indicated that

            plaintiff’s white blood count and neutrophils were elevated, and lymphocytes were depressed.

            Blood cultures were ordered by Dr. Fenyves and on June 30, 2015, plaintiff tested positive for

            streptococcus oralis the bacteria that causes Bacterial Endocarditis in heart valve patients after

            dental procedures. Based on the positive blood cultures, which were reported to Dr. Fenyves on

            July 1, 2015, Dr. Fenyves instructed plaintiff to go to the Emergency Room. On July 3rd, a Brain

            MRI and CT scan confirmed that he suffered an embolic stroke following complaints of visual

            changes reported the previous day. Plaintiff was hospitalized for 15 days with bacterial

            endocarditis of the artificial heart valve, during which time he developed bacterial emboli which

            traveled to his brain, causing various injuries.

                                                       DISCUSSION

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                   It is well settled that a party moving for summary judgment “must make a prima facie

            showing of entitlement to judgment as a matter of law, tendering sufficient evidence to

            demonstrate the absence of any material issues of fact” (Alvarez v Prospect Hosp., 68 NY2d 320,

            324 [1986]). The “facts must be viewed in the light most favorable to the non-moving party”

            (Vega v Restani Constr. Corp., 18 NY3d 499, 503 [2012] [internal quotation marks and citation

            omitted]). Once the moving party has met this prima facie burden, the burden shifts to the non-

            moving party to furnish evidence in admissible form sufficient to raise a material issue of fact

            (Alvarez, 68 NY2d at 324). The moving party’s “[f]ailure to make such a prima facie showing

            requires a denial of the motion, regardless of the sufficiency of the opposing papers”.       “In a

            medical malpractice action, plaintiff must show, through a medical expert, both a deviation from

            accepted standards of medical care and that the treatment rendered by the moving defendant was

            a proximate cause of plaintiff’s injuries (see e.g., Kaffka v New York Hosp., 89 NY2d 913 [1996];

            Ferrara v South Shore Orthopedic Assoc., 178 AD2d 364 [1st Dept 1991]). In the absence of

            evidence that defendant’s conduct was a proximate cause of plaintiff’s injury, summary judgment

            must be granted to defendant as a matter of law.

                   In support of their motion, the Huerta defendants submit the expert affirmations of Victor

            Badner, D.M.D (“Dr. Badner”), who is board certified in Public Health Dentistry, and William

            Mandell, M.D. (“Dr. Mandel”), who is a board certified Internist and Infectious Diseases

            physician. Both experts base their opinions on a review of the plaintiff’s medical records and the

            parties’ deposition testimony, and opine with a reasonable degree of medical certainty that the

            Huerta defendants complied with the standard of care in providing medical treatment to plaintiff.

                   Dr. Badner and Dr. Mandel concur that Dr. Huerta properly assessed plaintiff’s antibiotic

            needs prior to proceeding with dental care and obtained a proper dental and medical history from

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            plaintiff, including that plaintiff had undergone valve replacement surgery in July 2013. Both Drs.

            Badner and Mandel opine that the treatment rendered by Dr. Huerta did not place the plaintiff at

            higher risk for the introduction of bacteria into the bloodstream, and that day-to-day life activities

            such as aggressive flossing/brushing, and plaintiff’s self-acknowledged history of bleeding gums,

            may have been the source of infection.

                   Significantly, Dr. Badner indicates that plaintiff had a standing prescription for

            Amoxicillin, which was to be taken one hour before surgery and that he had been advised following

            his July 2013 surgery that he would require lifelong pre-procedure antibiotic therapy for any

            invasive procedures or potential for significant break in skin integrity. In regards to plaintiff’s

            December 11, 2014 and January 15, 2015 office visits, Dr. Badner notes that Dr. Huerta

            specifically discussed antibiotic prophylaxis for endocarditis and the need to pre-medicate before

            these visits. He also notes that according to Dr. Huertas’ deposition testimony, he would not have

            proceeded with treatment on those dates if the plaintiff did not confirm that he had been pre-

            medicated. Dr. Badner opines that Dr. Huerta’s documentation complied with the standard of care,

            and it was not necessary to specifically document that he had confirmed with the plaintiff that he

            had pre-medicated, as it was his custom and practice not to proceed with the procedure without

            confirming that plaintiff had done so. According to Dr. Badner, the claim that the healing cap and

            transfer coping were negligently tightened has no basis; instead, he opined that the restoration and

            crown placement was performed appropriately and within the standard of care.

                   Dr. Mandell also opines that: 1) there was no possibility of an increased risk of bacteria

            entering the bloodstream on March 3, 2015 and April 22, 2015, as the treatment only involved

            restoration of the crown and no manipulation of gum tissue; 2) there is no evidence, or reason to

            believe that any of the treatment rendered by Dr. Huerta allowed for introduction of bacteria into

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            the bloodstream that caused plaintiff to develop endocarditis, as none of the treatment rendered

            involved manipulation of gum tissue or perforation of the oral mucosa; 3) it is speculative to allege

            that Dr. Huerta caused plaintiff’s endocarditis since the incubation period is approximately one

            month, and plaintiff remained in his usual state of health until early June of 2015; and 4) the

            allegation that Dr. Huerta failed to diagnose an infection of endocarditis is without merit, as

            plaintiff had no such signs and/or symptoms when treating with Dr. Huerta.

                   Based on the affirmations of Drs. Baden and Mandell, the Huerta defendants have

            established that they did not depart from good and accepted standards of medical and/or dental

            care, and did not proximately cause plaintiff’s alleged injuries.

                   Defendant Dr. Fenyves submits the expert affirmation of Michael S. Wein, M.D., a board

            certified Internist, in support of his motion for summary judgment. Dr. Wein opines to a

            reasonable degree of medical certainty that the care and treatment rendered to plaintiff by Dr.

            Fenyves was within the applicable standards of care for Internal Medicine practice, and that there

            is nothing that Dr. Fenyves did or did not do that proximately caused plaintiff’s alleged injuries.

                   Dr. Wein opines that at plaintiff’s June 16th office visit, Dr. Fenyves appropriately

            questioned plaintiff about his medical history and recent procedures after plaintiff had not

            presented to him for care in two years. The records and testimony also confirm that plaintiff only

            reported the 2013 aortic valve replacement surgery and did not inform Dr. Fenyves about his recent

            dental procedures.

                   Further, Dr. Wein opined that the work up initiated by Dr. Fenyves on June 16, 2015,

            appropriately sought to evaluate both viral and/or bacterial causes of plaintiff’s complaints, which

            would include endocarditis. According to Dr. Wein, Dr. Fenyves first learned of plaintiff’s history

            of having an artificial valve on June 16, 2015, and cannot be held accountable for plaintiff’s failure

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            to pre-medicate with antibiotics prior to an invasive surgery or failing to instruct him to do so. As

            a result, Dr. Wein opines that Dr. Fenyves had no responsibility to instruct plaintiff to take

            prophylactic antibiotics prior to undergoing dental work during a time when plaintiff did not

            present to him for ongoing care nor communicate with him about any intention or expectation of

            undergoing an invasive procedure. Dr. Wein cites the medical record to show that on multiple

            occasions plaintiff was instructed by other medical providers that he required prophylactic

            antibiotics before any invasive procedures because of his AVR surgery. Accordingly, Dr. Wein

            concludes that plaintiff’s claim that Dr. Fenyes failed to inform him that he needed to treat with

            antibiotics prior to undergoing dental procedures is meritless and not supported by the record.

            Additionally, there was no basis for Dr. Fenyves to make any referral to rule out endocarditis on

            June 16, 2015 or suspect that there was any reason to suspect plaintiff was suffering from

            endocarditis because he was not made aware of plaintiff’s recent dental treatment without

            prophylactic antibiotics until July 1, 2015.

                    Defendant Dr. Fenyves has also established entitlement to summary judgment as a matter

            of law through the affirmation of his expert, Dr. Wein, which demonstrates that the medical care

            and treatment rendered to plaintiff from June 16th through June 30th of 2015, was in accord with

            good and accepted medical standards, and was not the proximate cause of plaintiff’s alleged

            injuries.

                    In opposition, plaintiff submits the expert affirmations of an unnamed dentist and Board

            Certified Internist and Cardiologist.

                    The General Dentistry expert opines that the Huerta defendants deviated from accepted

            standards of dental practice, which caused plaintiff to suffer streptococcus oralis endocarditis.

            Plaintiff’s Cardiology expert opines, that Dr. Fenyves departed from good and accepted standards

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            of medical care in treating plaintiff from June 16, 2015 through June 30, 2015, by failing to timely

            diagnose and treat plaintiff’s bacterial endocarditis, which caused plaintiff to develop septic emboli

            to the brain, a stroke and resultant injuries.

                    Specifically, both experts raise issue of fact regarding whether Dr. Huerta properly

            assessed plaintiff's antibiotic needs prior to proceeding with treatment; whether Dr. Huerta failed

            to inform the patient that he must take antibiotics, and to ensure that the patient pre-medicated with

            antibiotics, or failed to follow his own protocol and treatment plan; whether Dr. Huerta failed to

            diagnose endocarditis; whether Dr. Huerta’s records complied with the standard of care in

            recording an appropriate history and whether plaintiff was a candidate for pre-medication; and

            whether the restoration and crown placement, including the level of tightness of the healing cap

            and transfer coping or abutment to the subgingival implant was performed appropriately and not

            negligently tightened.

                    Plaintiffs’ experts also raises an issue of fact as to whether Dr. Fenyves failed to consider

            that plaintiff was suffering from bacterial endocarditis based on his symptoms, blood test results

            and history of heart valve replacement; whether Dr. Fenyes failed to immediately hospitalize

            plaintiff on June 16, 2015; and whether Dr. Fenyes failed to document on June 16, 2015 that

            plaintiff had undergone any medical or dental procedures prior to the onset of symptoms.

                    Based on these expert affirmations, plaintiff has raised triable issues of fact rebutting the

            prima facie showing of summary judgment as to the Huerta defendants and Dr. Fenyves. Summary

            judgment is not appropriate ... [when] the parties [submit] conflicting medical expert opinions

            because [s]uch conflicting expert opinions will raise credibility issues which can only be resolved

            by a jury” (Cummings v Brooklyn Hosp. Ctr., 147 AD3d 902, 904 [2d Dept 2017], quoting

            DiGeronimo v Fuchs, 101 AD3d 933 [2d Dept 2012] [internal quotation marks omitted]; see Elmes

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            v Yelon, 140 AD3d 1009 [2d Dept 2016]; Leto v Feld, 131 AD3d 590 [2d Dept 2015]). Thus, the

            Court finds that the motions of the respective defendants seeking summary judgment on the issue

            of medical malpractice is denied.

                   As to plaintiff’s informed consent cause of action, the Court notes that all moving

            defendants have made a prima facie showing for summary judgment which plaintiff has failed to

            oppose.

                      To recover damages for lack of informed consent, a plaintiff must establish that (1) the

            defendant physician failed to disclose the material risks, benefits, and alternatives to the

            contemplated medical procedure which a reasonable medical practitioner under similar

            circumstances would have disclosed and (2) a reasonably prudent person in the patient’s position

            would not have undergone the procedure if he or she had been fully informed (Rodriguez v. New

            York City Health & Hosps. Corp., 50 A.D.3d 464, 465 [1st Dept 2008]). Here, the record shows

            that plaintiff was properly informed of the risks of infection and antibiotic management given his

            history of valve replacement surgery. Additionally, Drs. Badner and Mandell opine that there is

            no casual connection between the dental care provided and plaintiff’s endocarditis. It is well

            settled that without proximate cause, a claim for lack of informed consent cannot stand (Public

            Health Law §2805-d; Amodio v. Wolpert, 52 A.D.3d 1078 [3d Dept 2008]). Finally, Dr. Badner

            opines that plaintiff’s lack of informed consent claim is without merit as restoration of an implant

            is not an invasive procedure requiring consent, and that in any event, plaintiff was properly

            informed of the risks of infection and the need to pre-medicate, given his history of valve

            replacement surgery. Additionally, it is undisputed that neither the Huerta defendants or Dr.

            Fenyves performed an procedure that involves invasion or disruption of the integrity of the body

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            for which informed consent is required (see Public Health Law § 2805-d[2]; see generally Lewis

            v. Rutkovsky, 153 A.D.3d 450, 456 [1st Dept 2017]).

                      Similarly, plaintiff does not oppose that branch of Dr. Fenyves’ motion seeking dismissal

            of all claims asserted against him prior to June 16, 2015. Plaintiff’s expert fails to render an

            opinion that Dr. Fenyves, plaintiff’s primary care physician at the time, departed from accepted

            standards of medical care in treating the plaintiff prior to that date. As such, all claims asserted

            against        Dr.      Fenyves        before      June       16,      2015       are       dismissed.

                      Finally, the Court notes that while the Huerta defendants seek dismissal of claims involving

            treatment prior to December 20, 2014, including treatment rendered on March 6, 2014 and

            December 11, 2014 pursuant to CPLR 3211 (a)(5), plaintiff’s malpractice claims as to treatment

            on December 11, 2014 are not time barred under the continuous treatment doctrine. CPLR § 214-

            a provides that a medical malpractice action must be commenced within two and a half years from

            the last treatment where there is continuous treatment for the same condition which gave rise to

            the malpractice (see Lohnas v Luzi, 30 NY3d 752 [2018]; McDermott v Torre, 56 NY2d399

            [1982]; Devadas v Niksarli, 120 AD3d 1000 [1st Dept 2014]).

                      Here, plaintiff has demonstrated that the continuous treatment doctrine tolls the statute of

            limitations because the course of treatment by Dr. Huerta ran continuously from the first (March

            6, 2014) to the last visit (April 22, 2015), and plaintiff’s claim is related to the original, crown

            placement. Other than placement of the crown, no other treatment was contemplated or performed.

            Since the claims against the Huerta defendants occured within two and a half years of the last date

            of treatment, the action was timely commenced on June 20, 2017 and is not time barred.

                      Contrary to plaintiff’s contentions, however, the Court finds that the continuous treatment

            doctrine does not apply to plaintiff’s claim that the Huerta defendants “allowed dogs to come into

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            contact with plaintiff’s body during the procedures, [which] increased the risk of infection.” The

            record demonstrates that this claim arises from the presence of a small therapy dog in the treatment

            room during plaintiff’s office visit on March 6, 2014, and does not relate back to the course of

            treatment for the crown replacement. Therefore, plaintiff’s claim regarding the presence of the

            dog in the treatment room on March 6, 2014 is dismissed.

                    Accordingly, it is hereby

                    ORDERED, that the Huerta defendants motion is granted to the extent of dismissing

            plaintiff’s lack of informed consent cause of action and dismissing the claims relating to the

            presence of a dog in the treatment room on March 6, 2014, and in all other respects the motion is

            denied; and it is further

                    ORDERED, that the motion of defendant Paul J. Fenyves, M.D., is granted to the extent

            of dismissing plaintiff’s lack of informed consent cause of action and the claims relating to the

            care and treatment of plaintiff prior to June 16, 2015, and in all other respects the motion is denied.

                    This constitutes the Decision and Order of the Court.

                    4/29/2024                                                             $SIG$
                      DATE                                                          KATHY J. KING, J.S.C.
             CHECK ONE:                  CASE DISPOSED                 X   NON-FINAL DISPOSITION

                                         GRANTED             DENIED    X   GRANTED IN PART              OTHER

             APPLICATION:                SETTLE ORDER                      SUBMIT ORDER

             CHECK IF APPROPRIATE:       INCLUDES TRANSFER/REASSIGN        FIDUCIARY APPOINTMENT        REFERENCE

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