Court Opinion

ID: 4675699
Source: CourtListenerOpinion
Date Created: 2021-04-08 16:13:36.090687+00
Date Added: 2024-06-11T08:03:27.093396
License: Public Domain

J-A08032-19

NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT I.O.P. 65.37

 ANN SMITH, AS EXECUTRIX OF THE         :   IN THE SUPERIOR COURT OF
 ESTATE OF DALE SMITH, DECEASED,        :        PENNSYLVANIA
 ON BEHALF OF HERSELF                   :
 INDIVIDUALLY, SURVIVING SPOUSE         :
 OF THE DECEDENT, AND THE NEXT          :
 OF KIN OF DALE SMITH, AND ON           :
 BEHALF OF THE ESTATE OF DALE           :
 SMITH, DECEASED                        :
                                        :   No. 1166 WDA 2018
                    Appellants          :
                                        :
                                        :
              v.                        :
                                        :
                                        :
 MARC CORDERO, M.D. AND UPMC            :
 MCKEESPORT, A DIVISION AND             :
 HOSPITAL OF THE UNIVERSITY OF          :
 PITTSBURGH MEDICAL CENTER AND          :
 UPMC WOUND HEALING SERVICES            :
 AT UPMC MCKEESPORT, A DIVISION         :
 OF UPMC MCKEESPORT AND THE             :
 UNIVERSITY OF PITTSBURGH               :
 MEDICAL CENTER                         :

               Appeal from the Order Entered August 7, 2018
     In the Court of Common Pleas of Allegheny County Civil Division at
                          No(s): GD-14-014061

BEFORE: PANELLA, P.J., STABILE, J., and McLAUGHLIN, J.

MEMORANDUM BY McLAUGHLIN, J.:                       FILED: APRIL 8, 2021

      This case has returned to us on remand from the Pennsylvania Supreme

Court. We conclude Smith waived her challenge to the jury selection process

and the court did not abuse its discretion in permitting UPMC’s expert to

testify. We therefore affirm.
J-A08032-19

      This is a medical malpractice case brought by Ann Smith, as Executrix

of the Estate of Dale Smith, deceased, on behalf of herself individually, the

next-of-kin of Dale Smith, and on behalf of the Estate (“Smith”). Dale Smith

(“Decedent”), who suffered from diabetes, kidney disease, and other ailments,

sought treatment from Marc Cordero, M.D., for leg wounds/ulcers. Dr. Cordero

allegedly misdiagnosed the leg wounds as venous, not arterial, and this

misdiagnosis allegedly caused Decedent to have his leg amputated. The

amputation in turn allegedly caused a series of events that ultimately resulted

in Decedent’s death. Smith then instituted this suit against Dr. Cordero, UPMC

McKeesport, a division of the University of Pittsburgh Medical Center, and

UPMC Wound Healing Services at UPMC McKeesport, a division of UPMC

McKeesport and the University of Pittsburgh Medical Center (collectively

“UPMC”).

      Jury selection commenced in March 2018. A court clerk, not the trial

judge, conducted the voir dire. The voir dire proceeding before the court clerk

was not transcribed. Smith made motions to challenge for cause Jurors No.

25, 37, and 45. The parties appeared before the trial judge for a hearing on

the motions. The hearing before the trial judge as to the challenges was

transcribed.

      The motions to challenge for cause related to the jurors’ affirmative

answers to two questions:

         [1.] Do you have any feelings or opinions about whether
         medical malpractice lawsuits affect the cost, availability and
         other medical services[?]

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                                      ...

         [2.] Do you have any feelings or opinions as to whether
         there should be a minimum or maximum amount of money
         that can be awarded to an injured party?

N.T., 3/26/18-4/3/18, at 4-5. Counsel explained to the court the responses

and reaction of the jurors.

      The trial judge noted his options, which included conducting a voir dire

of the jurors:

         THE COURT: So I got a couple choices. I could deny all the
         motion[s]. You want them all stricken for cause. I could
         grant them all or if I think that it’s somewhere in the middle,
         I could actually voir dire them myself and with you guys
         there and then make a decision. I’m basically going to ask
         the same questions . . . , except it’s the Judge come down
         to my office and I’m not have my robe on and I will be asking
         them these questions.

Id. at 12. The trial judge did not conduct a voir dire, and neither party

requested that he do so.

      The trial court granted the motion as to Juror No. 37, but denied it as

to Jurors No. 25 and 45:

         If I heard you guys correctly, for me I don’t seem to have a
         problem with denying -- and again, this is the story that you
         guys told me -- your motion Counsel, for number 25 and
         45, I will deny those.

         I have more of a problem with 37 so I’m inclined to strike
         that. So I will allow the other two and sounds like I’ve heard
         enough of number 37, so I would strike her. Grant your
         motion on 37 and I will deny your motions on 25 and 45.

Id. at 13. Smith used a peremptory strike for one of the jurors and the other

juror was an alternate. Smith used all peremptory strikes.

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     Smith filed a motion in limine to preclude the expert testimony of Harold

Brem, M.D., claiming, among other things, that Dr. Brem failed to set forth

any factual basis or a summary of the grounds for multiple opinions on the

issues of standard of care and causation.

     Dr. Brem’s report included the following opinions:

        1. Dr. Cordero provided excellent care. He properly
        diagnosed Mr. Smith and treated his leg ulcer at or above
        the standard of care. Seeing patients with leg ulcers and
        diabetes every two weeks is a common and acceptable
        practice.

        2. Mr. Smith’s leg ulcers were by all criteria to be considered
        venous ulcers. There is no suggestion that they are arterial.

        3. The use of Medihoney gel, has excellent data and is a
        commonly used topical for patients with diabetes and non-
        healing wounds. There is no data or rational to think Santyl
        would be more helpful. The use of the compression device
        (Tubigrip) was a reasonable and prudent measure for the
        care and treatment of venous ulcers.

        4. No event could have prevented Mr. Smith’s amputations.
        It is a direct consequence of the combination of age,
        uncontrolled diabetes, End-Stage Renal Disease, and
        Peripheral Vascular Disease. My opinion is heavily supported
        by the literature and the multiple mechanisms for impaired
        healing. In Mr. Smith’s particular case, his high risk for
        infection was diagnosed and he was successfully treated. He
        lost his right limb because of an exceptionally rare organism
        termed Group A Streptococcus. It occurred because of Mr.
        Smith's diabetes that made him prone to this organism. This
        bacteria or organism is known to cause necrotizing
        infections like Mr. Smith had.

        5. There is no evidence that Mr. Smith had arterial disease
        that could have been corrected and his limb preserved.

        6. Dr. Dreyfuss’ report that these were arterial ulcers is not
        predicated in medical fact. The accusations that this ulcer
        was arterial based in part on the photographs as well that

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       the right leg limb loss was preventable are inaccurate and
       frivolous. Mr. Smith had a very natural outcome from type
       2 diabetes. He lost his left limb unfortunately. Clearly his
       body suffered multiple organ problems from a consequence
       of his multiple co-morbidities. Dr. Dreyfuss’ assertions are
       scientifically unfounded and not substantiated by the
       literature.

       7. The reason the four wounds became one is the natural
       sequence of the underlying pathology. Simply stated, the
       wounds were treated correctly and not just skin deep.

       8. Dr. Diamond, Mr. Smith’s primary MD was involved. He
       was made aware of the results of the wound culture on
       December 23, 2013, and prescribed oral Vancomycin at that
       time. Dr. Cordero appropriately requested that Dr. Diamond
       manage Mr. Smith’s antibiotics due to his End-Stage Renal
       Disease, chronic Cirrhosis, and prior reaction to a prescribed
       antibiotic. This was highly prudent and demonstrates
       another example of excellent comprehensive care and
       expertise by Dr. Cordero and his wound center team.

       9. Dr. Cordero and his team were clearly well trained, as
       manifested by the knowledge shown in their notes and
       attention to detail. Their care was well within the standard
       of care.

       10. Mr. Smith met or exceeded his life expectancy. His loss
       of both limbs was a tragic and unfortunate consequence of
       type 2 diabetes. For not the extraordinary care of his wife
       and the exceptional care of his clinicians, his natural course
       of living would not have been this long. Simply stated, he
       lived a full life expectancy with quality until his last year in
       life. His demise was a consequence of type 2 diabetes
       coupled with multiple other morbidities (i.e., hypertension,
       renal disease and heart disease).

       11. There is no correlation between Mr. Smith's amputations
       and the care provided by Dr. Cordero and the UPMC
       McKeesport Wound Center.

       12. My opinions in this report have been done so with a
       reasonable degree of medical certainty.

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Letter from Harold Brem to UPMC’s Counsel dated February 19, 2018. The

court denied the motion in limine.

      During Dr. Brem’s testimony, Smith objected, arguing the court should

preclude the opinion that the wounds were not misdiagnosed because the

report did not provide a basis:

         [Smith’s Counsel]: Well, he can’t come in here and [say] it’s
         venous with nothing more. He did not give a basis. He can’t
         come in and testify that it’s venous versus arterial. There is
         no bases in his reports and just testify on the stand that it’s
         just his evaluation. He does go onto say that it’s based on
         many, many factors to justify venous versus arterial.
         Nowhere whatsoever does he give a basis for venous versus
         arterial.

N.T., 3/26/18-4/3/18, at 668, 678. The court overruled the objection.

      Dr. Brem testified about his opinions, and the basis for them, including

the factors for determining whether a wound is venous or arterial. On cross-

examination, Smith’s counsel questioned him about the application of those

factors. Dr. Brem further testified as to the reasons to perform a debridement

and that the procedure in this case was within the standard of care. Id. at

686-88. This testimony contradicted Smith’s expert, who had testified that

debridement was not proper here. Id. at 427.

      Further, during Dr. Brem’s testimony, he made an unspecific reference

to “literature,” at which point Smith objected. The trial court overruled the

objection:

         [Dr. Brem:] He developed what they call necrotizing fasciitis
         or otherwise known as a man-eating flesh. It’s when you
         have a rapid progressing infection classically. And someone
         of his age with diabetes -- it could happen to anybody – it’s

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         happened to children; but it’s very classical in diabetes. The
         literature shows that --

         [Smith’s counsel]: Objection.

         THE COURT: We can do it in one word and if not, let’s go up
         there.

         [Smith’s counsel]: The reference is to the literature.

         THE COURT: Overruled.

Id. at 705.

      The jury found in favor of UPMC. Smith filed post-trial motions, which

were denied, and Smith timely appealed. She raises the following issues:

         1. Whether the trial court erred in violation of Shinal v.
         Toms, 162 A.3d 429 (Pa. 2017) by denying two of
         Appellant’s jury challenges for cause without personally
         witnessing the voir dire process and failing to evaluate the
         demeanor of the challenged jurors?

         2. Whether the trial court erred in permitting testimony
         from Appellee’s expert, Dr. Harold Brem, where Dr. Brem’s
         expert report failed to set forth the grounds upon which his
         opinions were based in direct violation of Pa.R.C.P. 4003.5,
         and where his testimony went well beyond the four corners
         of the report?

Smith’s Br. at 5.

      Smith maintains the trial judge erred in denying the motions to strike

the potential jurors, noting the judge did not witness voir dire and therefore

did not see the jurors’ conduct and demeanor. We previously issued an opinion

vacating the judgment in reliance on our decision in Trigg v. Children’s

Hospital of Pittsburgh of UPMC, 187 A.3d 1013 (Pa.Super. 2018), vacated,

229 A.3d 260 (Pa. 2020). UPMC sought further review, and the Pennsylvania

Supreme remanded this case for further proceedings consistent with its

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decision in Trigg. See Smith v. Cordero, 223 A.3d 268 (Pa.Super. 2019),

vacated, No. 262 WAL 2019, 2020 WL 2537060 (Pa. May 19, 2020).

      In Trigg, the plaintiffs alleged that the “Allegheny County Civil Division’s

jury selection process deprived them of their right to a fair trial.” 187 A.3d at

1015. They alleged the failure to strike three prospective jurors for cause was

error and that the error was prejudicial. Id. at 1016. This Court described the

voir dire practice for civil cases in Allegheny County, as used in that case.

According to the Trigg court, the court clerk and parties’ attorneys met with

the potential jurors. Id. If an attorney sought to challenge a potential juror

for cause, the clerk noted the challenge and, after interviewing all jurors, the

clerk and attorney returned to the courtroom of the calendar judge. Id. The

judge would then read the transcript and rule on the challenges for cause. Id.

In Trigg, after the above process, the trial judge denied a motion to strike

three jurors for cause. Id. The plaintiffs then used three of their four

peremptory strikes to remove the jurors. Id.

      This Court in Trigg first addressed the deference we owe to the trial

court where the trial judge was not present for the juror questioning during

voir dire. Stating that the trial judge “possess[ed] no greater skill at

interpreting a transcript than an appellate court,” the Court applied a de novo

standard of review to rulings on motions to strike jurors for cause where the

trial judge was not present during juror questioning. Id. at 1018. The Court

then concluded that failing to strike one juror due to her predisposition was

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error and that the error was not harmless, as the plaintiffs were forced to use

their peremptory challenges. Id. at 1019.

      The Pennsylvania Supreme Court granted review in Trigg, and, in April

2020, it vacated the judgment of this Court and remanded for further

proceedings. The Court concluded the plaintiffs had waived the argument that

the trial court erred by not observing the demeanor and tenor of the

prospective juror. Trigg v. Children’s Hosp. of Pittsburgh of UPMC, 229

A.3d 260, 269 (Pa. 2020). The court noted that the plaintiffs had not made

any “objection in pretrial motions to the trial judge’s absence from the Jury

Assignment Room during voir dire.” Id. Further, “when [the plaintiffs] made

their challenge for-cause to the seating of prospective juror 29, they did not

contemporaneously object to the trial judge’s absence from the room during

voir dire.” Id. Also, the plaintiffs’ challenge during voir dire “was predicated

on the substance of the answers which [the juror] gave.” Id. The Court

concluded that the “record [did] not support [the plaintiffs’] claim that, as part

of their challenge for-cause, they implicitly raised issues concerning the

inability of the trial judge to assess the demeanor of prospective juror 29 as

she gave her answers.” Id. at 270. The Court further concluded that arguing

in post-trial motions that the judge erred in failing to strike the juror because

the judge did not have an opportunity to observe the juror did not preserve

the issue. Id. Rather, in the Court’s view, the failure “to raise with the trial

judge any issue relating to his lack of observation of this juror’s demeanor in

answering voir dire questions,” and to “request that he personally interview

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the juror,” “the trial judge was deprived of any opportunity to address and

resolve the issue before the jury was finally empaneled.” Id.

      Here, as in Trigg, Smith failed to raise in any pre-trial motions, or in

her for-cause challenges during voir dire proceedings, any claim that error

occurred because the trial judge did not observe the questioning of the jurors

or their demeanor. The first time she made such a challenge was in post-trial

motions. Further, although the trial judge noted that he could conduct a voir

dire of the jurors, Smith did not ask him to do so. Accordingly, in accordance

with the Pennsylvania Supreme Court’s decision in Trigg, we conclude that

Smith waived her challenge to the voir dire process.

      Smith next claims the trial court erred by denying her motion in limine

to preclude the expert report of Harold Brem, M.D., and by permitting Dr.

Brem to testify to unsupported and conclusory expert opinions that were

outside the scope of his report. She claims that whether the wounds were

venous or arterial required a multi-factorial analysis, but Dr. Brem’s report

failed to support his conclusion that the wounds were venous with any

discussion of the factors. The court then permitted him to testify extensively

about it. Smith also stated that Dr. Brem testified as to why debridement was

an appropriate treatment, even though his report did not mention this. Smith

claims that “[c]ontrasting Dr. Brem’s bare bones expert report with his lengthy

and detailed trial testimony . . . , [Smith] was ambushed at trial and could not

possibly prepare an informed line of questioning to cross-examine the

witness.” Smith’s Br. at 51. Smith further argued that Dr. Brem should not

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have been allowed to testify that his opinions were supported by “the

literature.” Id. at 52 (citing Aldridge v. Edmunds, 750 A.2d 292 (Pa. 2000)).

      UPMC counters that Dr. Brem’s expert report provided adequate notice

of his expert opinions, and his trial testimony was within the fair scope of the

report. UPMC asserts that his report discussed multiple factors for determining

whether a wound is venous or arterial. According to UPMC, he “analyze[d] the

impact of decedent’s age, uncontrolled diabetes, end-stage renal disease and

peripheral vascular disease on decedent’s leg amputations and ultimate death

by explaining how the consequences of these conditions bear on circulation,

temperature, granulation, drainage and pressure of blood leakage.” UPMC’s

Br. at 32-33. UPMC claims Dr. Brem discussed the location of the wounds and

some appropriate measures to treat the wounds, and that he “opined that

decedent’s comorbidities caused multiple organ problems and prevented the

healing of his wounds or preservation of his legs.” Id. at 33.

      UPMC argues that Dr. Brem’s trial testimony was within the “fair scope”

of his report because in his testimony, he discussed and explained the same

factors. Id. It further argues that the testimony did not surprise Smith, and

“at most, expanded upon his expert report and thus did not hinder [Smith’s]

counsel from being able to prepare a meaningful response.” Id. at 34. UPMC

points out that Smith “extensively cross-examined Dr. Brem . . . regarding

the diagnosis of wounds as venous versus arterial.” Id. It also contends the

trial testimony was “appropriate . . . to rebut the expert testimony put forth

by [Smith] at trial.” Id. at 35.

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      The “admission of expert testimony is a matter within the sound

discretion of the trial court, whose rulings thereon will not be disturbed absent

a manifest abuse of discretion.” Woodard v. Chatterjee, 827 A.2d 433, 440

(Pa.Super. 2003) (quoting Walsh v. Kubiak, 661 A.2d 416, 419 (Pa.Super.

1995) (en banc)).

      “[E]xpert[] testimony on direct examination is to be limited to the fair

scope of the expert’s pre-trial report.” Whitaker v. Frankford Hosp. of City

of Phila., 984 A.2d 512, 522 (Pa.Super. 2009) (quoting Coffey v. Minwax

Co., Inc., 764 A.2d 616, 620 (Pa.Super. 2000)). See also Pa.R.C.P.

4003.5(c) (providing “[t]o the extent that the facts known or opinions held by

an expert have been developed in discovery proceedings . . . , the direct

testimony of the expert at the trial may not be inconsistent with or go beyond

the fair scope of his or her testimony in the discovery proceedings . . .”).

      “In applying the fair scope rule, we focus on the word ‘fair.’” Whitaker,

984 A.2d at 522 (quoting Coffey, 764 A.2d at 620-21). “Departure from the

expert’s report becomes a concern if the trial testimony ‘would prevent the

adversary from preparing a meaningful response, or which would mislead the

adversary as to the nature of the response.’” Id. (quoting Coffey, 764 A.2d

at 621). We will find reversible error only if the opposing party is prejudiced

as a result of the testimony going beyond the fair scope of the expert’s report.

Id.

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      The trial court found the admission of the testimony proper, reasoning

that the report contained a sufficient summary of the grounds for his opinion

and the testimony was not an unfair surprise:

         Dr. Brem’s report satisfied Pa.R.C.P. 4003.5 in that the
         report sufficiently stated the facts and opinions on which
         Brem eventually testified and likewise contained a sufficient
         summary of the grounds for his opinions. Additionally,
         Brem’s testimony was consistent with, and was within the
         fair scope of, his report. Daddona v. Thind, 891 A.2d 786,
         805 (Pa.Cmwlth. 2006); Pa.R.C.P. 4003.5. Nothing about
         Dr. Brem’s testimony constituted unfair surprise or other
         error. See Daddona, 891 A.2d at 805 (indicating purpose
         of Pa.R.C.P. 4003.5 is to avoid unfair surprise). Admission
         of his testimony was proper.

Trial Court Opinion, filed Aug. 9, 2018, at 2.

      The trial court did not abuse its discretion in admitting Dr. Brem’s

testimony. Although Dr. Brem’s expert report did not detail all the factors

considered to determine that the wound was venous, he noted that it was a

multi-factorial test. Indeed, he explicitly said that the ulcers were by “all

criteria” – i.e., more than one criterion – venous ulcers. The report further

discusses, among other things, the location of the wound, and Smith’s various

illnesses, including diabetes and kidney disease, which he noted contributed

to the healing issues and infections. At trial, Dr. Brem provided more

discussion and explanation of the factors for determining whether wounds are

venous or arterial. Smith was readily able to cross-examine Dr. Brem about

those factors. She was not surprised by or unprepared to respond to the

testimony.

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      In   her   brief,   Smith   also   challenges   Dr.   Brem’s   discussion   of

debridement. Smith did not object to that testimony at the trial, and therefore

waived the claim. Pa.R.A.P. 302 (“Issues not raised in the lower court are

waived and cannot be raised for the first time on appeal.”). Moreover, even if

she had not waived it, we would find no error. Dr. Brem’s discussion of

debridement followed the testimony of Smith’s expert, as well as that of Dr.

Cordero, regarding debridement, and the discussion caused no surprise to

Smith.

      Smith also challenges Dr. Brem’s reference to “literature.” Although, Dr.

Brem referenced “literature” during his testimony, no textbooks or other

materials were admitted into evidence. Further, the single, vague reference

to “literature” in the abstract, in the context of the extensive expert testimony

in this case, did not prejudice Smith. See Aldridge v. Edmunds, 750 A.2d

292, 297-98 (Pa. 2000) (concluding that “judicious use of learned treatises

may be made on direct examination of an expert witness in appropriate

circumstances for the limited purpose of explaining the basis for the opinion,”

but finding error where excerpts were enlarged on poster board and the expert

was guided through a series of leading questions regarding the texts).

      Judgment affirmed.

President Judge Panella joins the memorandum.

Judge Stabile concurs in the result.

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Judgment Entered.

Joseph D. Seletyn, Esq.
Prothonotary

Date: 4/8/2021

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