Copsey v. Park

REED, J. This case involves a medical malpractice action by the wife, minor daughters, and mother of Lance Copsey, deceased, against John S. Park, M.D. The appellants assert that Dr. Park negligently misread Mr. Copsey’s MRI/MRA six days before he suffered a massive, and ultimately fatal, stroke. Over the appellants’ objections, the trial court permitted Dr. Park to present evidence of negligence by subsequent treating physicians and instructed the jury on superseding cause. In ¹¹⁰ the end, however, the jury did not reach the question of superseding cause because they found Dr. Park’s reading of the MRI/MRA non-negligent (i.e., that Dr. Park was not an actual, much less a proximate, cause of Mr. Copsey’s death). Appellants timely appealed and present a single question for our review, which we rephrased: 1 1.

Did the circuit court err in admitting evidence of the negligence of subsequent treating physicians and instructing the jury on superseding causation? For the following reasons, we answer this question in the negative. Therefore, we affirm the judgment of the circuit court. Factual And Procedural Background On February 4, 2010, Mr. Copsey presented to the emergency room of the Anne Arundel Medical Center following an incident on a racquet ball court in which he fell and hit the back of his head.

He did not lose consciousness in connection with the fall, but nevertheless complained of nausea and headaches. He was released after being treated and undergoing a head CT scan, which was reported as normal. Mr. Copsey presented to the Anne Arundel Medical Center emergency room again on May 26, 2010. He indicated that he had been experiencing intermittent, minutes-long episodes of dizziness since that morning.

Another CT scan was performed on his head, but again the results were normal. Therefore, he was instructed to call his internal medicine physician the next day to schedule a “close” follow-up appointment and to return to the emergency room should his symptoms worsen. ¹¹¹ Mr. Copsey was seen by his primary care physician, Aditya Chopra, M.D., on June 1, 2010. In addition to complaining of difficulty walking, nausea, and headaches, he indicated that the vertigo he began experiencing on the day he last presented to the emergency room had not gone away. Dr. Chopra prescribed Meclizine and a Z-Pack, suggested a follow-up with an ear, nose, and throat doctor should the symptoms not improve, and advised consulting an ophthalmologist.

In accordance with Dr. Chopra’s advice, Mr. Copsey consulted ophthalmologist Ross D. Elliott, M.D., on June 2, 2010. Dr. Elliott determined there was no ophthalmological etiology for Mr. Copsey’s symptoms and, in turn, recommended both a neurologic consultation and a neuroradiologic evaluation. These were performed on June 4, 2010, by Dr. Chopra, who found multiple abnormalities consistent with central nervous system involvement and sent Mr. Copsey promptly to the emergency room. Per Dr. Chopra’s advice, on the afternoon of June 4, 2010, Mr. Copsey presented back to the emergency room of the Anne Arundel Medical Center.

He complained of vertigo of approximately a week’s duration and also reported experiencing numbness in the right side of his face, right arm, and right leg, headaches, mild shortness of breath, minutes-long episodes of double vision, and trouble walking. Mr. Copsey’s initial emergency room evaluation was performed by Charles Iliff, M.D., who then consulted with neurologist Larry Blum, M.D. It was decided that a head CT scan and a brain MRI/MRA would be performed. The CT scan and MRI/MRA were interpreted on June 4, 2010, at 4:02 p.m. and 6:45 p.m., respectively, by the named appellee, John S. Park, M.D. Dr. Park’s impressions were of a normal non-contrast head CT and brain MRI and a normal intracranial MRA. Specifically, regarding the CT scan, MRA, and MRI, correspondingly, he found: There is no evidence of acute intracranial hemorrhage, infarction, mass effect, or midline shift.

No abnormal extra-axial fluid collections are identified. The ventricles, sulci, ¹¹² and cisterns are normal. There is no acute injury to the skull base or calvarium. There is normal anatomy of the circle of Willis with no evidence of aneurysm, anteriovenous malformation, or abnormal vessel cut-off.

No hemodynamically significant stenosis is identified. Incidental note is made of fenestration of the left vertebral artery. There is no evidence of acute intracranial hemorrhage, infarction, mass effect, or midline shift. No abnormal extra-axial fluid collections are identified.

The ventricles, sulci, and cisterns are normal. The flow voids at the skull base are normal. There is no acute injury to the skull base or calvarium. Dr. Blum later reviewed the MRI and MRA images interpreted by Dr. Park and confirmed they did not reveal any abnormalities.

In fact, Dr. Blum suspected Mr. Copsey’s symptoms were merely sequelae of migraine equivalents. Mr. Copsey was diagnosed with migraines, cluster migraines, vertigo, hypercholesterolemia, and mildly elevated blood pressure, but it was also noted on his discharge summary dated June 6, 2010, that he was “otherwise doing fine.” Mr. Copsey was seen by Dr. Chopra for an outpatient evaluation on June 7, 2010. Mr. Copsey reported having no chest pain, dizziness, shortness of breath, cough, nausea, vomiting, diarrhea, constipation, aches or pains, headache, or burning urination. Dr. Chopra noted no neurological deficit and instructed Mr. Copsey to return to the emergency room and/or follow up with Dr. Blum should his symptoms return, which they did the very next day.

Therefore, on June 9, 2010, Mr. Copsey returned to Dr. Blum for a follow-up evaluation. At his follow-up on June 9, Mr. Copsey reported the return of his diplopia, or double vision, and headaches, and also indicated that he had begun experiencing hiccups and trouble swallowing for the first time. The onset of the latter two of these symptoms was particularly concerning to Dr. Blum. ¹¹³ Therefore, he ordered another brain MRI, this time requesting an urgent interpretation. Mr. Copsey proceeded directly to the Anne Arundel Medical Center where this, the second MRI of his brain, was performed.

Vijay Viswanathan, M.D., interpreted the image and concluded the following: 1. Ill-defined new band-like signal abnormality within the right lateral medulla which is nonspecific but is concerning for acute infarction. This is a new finding since the prior study dated June 4, 2010. 2. This could be suggestive of lateral medullary syndrome/Wallenberg syndrome. 3.

Left vertebral artery abnormal flow void which is nonspecific. It is difficult to appreciate the connection between right medullary abnormality and left vertebral artery abnormality. Clinical correlation advised. 4. No evidence of intraorbital pathology.

Dr. Viswanathan interpreted the MRI at 4:02 p.m. and dictated his report at approximately 4:42 p.m. However, he did not notify the on-call neurologist, Damanhuri Alkaitis, M.D., of his findings until approximately 10:30 p.m. Dr. Blum recounted this delay in a hospital note dated June 10, 2010, the day after the MRI was performed, as follows: “I had noted in my requisition that I requested an urgent call-back from the radiologist, but that did not transpire.” Dr. Blum could have, however, accessed Dr. Viswanathan’s impression earlier either by logging into the Medical Center’s computer database or following up with the radiology department. Instead, he opted to review the MRI films himself, which he did at approximately 6:00 p.m.

His interpretation of the films was that “[t]he MRI scan did not disclose [any] abnormalities.” Therefore, he sent Mr. Copsey home for the night. Mr. Copsey had already been sent home by the time Dr. Viswanathan notified Dr. Alkaitis of the MRI results at 10:30 p.m. on June 9, 2010. Dr. Alkaitis did not take any action regarding the results that night, nor did anyone advise Mr. Copsey that a lateral medullary infarct had been discovered. ¹¹⁴ At approximately 4:00 a.m. on June 10, 2010, Mr. Copsey awoke to use the bathroom and suffered a major stroke. His wife found him lying on the floor unable to get up and had him rushed to the Anne Arundel Medical Center emergency room, where he arrived at approximately 5:44 a.m.

A promptly-performed brain CT scan showed a right medullary hypodensity indicative of an acute stroke. Mr. Copsey’s already poor condition deteriorated considerably at approximately 11:00 a.m. on June 10, 2010. He was subsequently transferred to Johns Hopkins Hospital, where, on the morning of June 11, 2010, after receiving an angioplasty and stent in his right vertebral artery, he became unresponsive with pinpoint pupils, no corneal or gag reflexes, and lack of movement in his extremities. He passed away on June 13, 2010, at 6:20 p.m.

On September 27, 2011, the appellants filed survival and wrongful death actions in the Circuit Court for Anne Arundel County against Drs. Park, Viswanathan, Blum, and Alkaitis. The appellants alleged that between June 4 and June 10, 2010, each of the four doctors “negligently failed to timely diagnose [Mr. Copsey’s] evolving stroke and refer him for timely and appropriate treatment.” The appellants sought to hold all four defendants jointly and severally liable. However, the appellants entered into pre-trial settlements with Dr. Blum and Dr. Alkaitis and, on September 17, 2014, the day after the trial began, voluntarily dismissed Dr. Viswanathan, leaving Dr. Park to stand trial as the sole defendant.

On August 26, 2014, the appellants filed two pre-trial motions in limine. The first was to preclude Dr. Park from raising as a defense that the negligence of subsequent treating physicians was a superseding cause, while the second was to exclude all evidence relating to Dr. Blum and Dr. Alkaitis’ prior status as defendants or pre-trial settlements. On the first day of trial, after hearing arguments from both sides, the Honorable Paul G. Goetzke denied both motions. The trial lasted seven days.

Finally, on September 24, 2014, the jury returned a verdict in favor of Dr. Park. This timely appeal followed. ¹¹⁵ Discussion I. Admissibility of Evidence of Negligence by Subsequent Treating Physicians (and Properness of the Superseding Cause Instruction) A. Parties’ Contentions The appellants argue the trial court erred in denying both of their pre-trial motions in limine. As for their first motion, which was to exclude all evidence relating to Dr. Blum and Dr. Alkaitis previously being defendants in the case before entering into settlement agreements, the appellants assert the trial court’s denial was based upon unsound reasoning. Specifically, the appellants contend the trial court’s statement that evidence relating to Dr. Blum and Dr. Alkaitis’ prior status as defendants and settlement agreements would be probative on the issue of bias should they be called as witnesses proved inapropos when Dr. Park never called them to testify.

The appellants also argue the trial court erred in denying their second motion in limine, which, again, was to exclude all evidence relating to the alleged negligence by subsequent treating physicians Blum, Viswanathan, and/or Alkaitis. The appellants assert that this evidence is inadmissible because, pursuant to Martinez ex rel. Fielding v. The John Hopkins Hospital, 212 Md.App. 634 , 70 A.3d 397 (2013), negligence by subsequent treating physicians is insufficient as a matter of law to establish superseding cause. They contend that once Drs.

Blum, Viswanathan, and Alkaitis were no longer parties to the case, evidence of their alleged negligence became unfairly prejudicial and irrelevant as to whether Dr. Park negligently interpreted Mr. Copsey’s head CT scan and brain MRI/MRA on June 4, 2010. The appellants argue that under Maryland law, the actions of joint tortfeasors need not be simultaneous. They point to an abundance of case law, as well as to § 879 of the Restatement (Second) of Torts, 2 as support ¹¹⁶ ing their assertion that Dr. Park was a joint tortfeasor because his negligence combined, albeit not simultaneously, with foreseeable acts of negligence by others to create an indivisible harm. Therefore, the appellants contend he was jointly and severally liable for Mr. Copsey’s death, and that the trial court abused its discretion in allowing him to pursue the superseding cause defense by admitting evidence of the alleged negligence of subsequent treating physicians.

The appellants argue the trial court, by admitting the subject evidence of the motions in limine, invited the jury to draw a number of impermissible inferences, including: That Dr. Alkaitis was solely liable because he had the last chance to save Mr. Copsey’s life; that multi-million dollar settlements had already been obtained against Dr. Blum and/or Dr. Alkaitis; and that the reason why Dr. Blum and/or Dr. Alkaitis were no longer defendants was because they were dismissed by the court for lack of evidence. Because the possibility exists that the jury’s verdict derived from one or more of these inferences, the appellants pray we grant their motion for a new trial. The appellees preliminarily argue the issue raised on appeal — whether the trial judge erred in admitting evidence of the negligence of subsequent treating physicians and instructing the jury on superseding cause — is moot. They point out how the jury, in finding Dr. Park was non-negligent in his reading of the head CT scan and brain MRI/MRA, never decided whether the negligence of Drs.

Blum, Viswanathan, and Alkaitis constituted a “superseding cause” so as to absolve Dr. Park of liability. Therefore, the appellees assert the evidence contested in this appeal is moot because it had no bearing on the jury’s verdict, and that even if the trial court admitted this evidence in error, the error was harmless. On the issue of mootness, we agree with the appellees that, ordinarily, when a jury has found that the defendant did not ¹¹⁷ breach the standard of care, whether the court erred in giving a causation instruction, or in admitting evidence supporting the causation instruction, would be moot. Here, however, the appellants argue that the evidence of negligence by the subsequent treating doctors “contaminated” the jury’s consideration of whether Dr. Park breached the standard of care, which is the one issue the jury actually decided.

This argument is sufficient to remove any problem with mootness. Secondarily, the appellees contend the trial court’s decision to admit the subject evidence of the two motions in limine was proper. They argue it is the province of the jury to weigh evidence and that the jury was free to accept or reject the notion that the negligence of subsequent treating physicians broke the chain of causation between Dr. Park’s reading of the radiological images on June 4, 2010, and the acute, and ultimately fatal, stroke Mr. Copsey suffered six days later. The appellees assert this appeal is predominantly motivated by the appellants’ taking for granted that the jury would be sympathetic to their unfortunate situation and therefore find in their favor.

Ultimately, however, the appellees contend this case came down to a classic “battle of the experts.” They argue the jury trusted their experts more than the appellants’ because their experts reviewed the CT scan and MRI/MRA images blindly, whereas the appellants’ were informed exactly where the abnormalities were before being asked to provide their assessment of whether Dr. Park provided a negligent impression. The appellees assert the jury naturally trusted the experts who viewed the images in the manner Dr. Park would have viewed them over those who viewed the images through the lens of hindsight. Finally, the appellees contend that superseding cause is a question for the jury as long as the facts admit more than one inference regarding whether unforeseeable intervening acts of negligence occurred. The appellees point to Dr. Blum’s failure to follow up on the “urgent” interpretation he requested from the radiology department on June 9, 2010, Dr. Viswanathan’s failure to notify a physician of his critical MRI findings until 10:30 p.m. on June 9, 2010, and Dr. Alkaitis’ failure to do ¹¹⁸ anything after being notified of Mr. Copsey’s possible impending infarct as acts of intervening negligence which a reasonable jury could have determined “unforeseeable.” The appellees take this argument one step further.

They argue Dr. Park was entitled to demonstrate not only that the negligent acts of Drs. Blum, Viswanathan, and/or Alkaitis were superseding causes, but also that this