Heddleston, M. v. Obstetrical and Gynecological

Citation: Not availableDocket: 443 WDA 2015

Court: Superior Court of Pennsylvania; July 22, 2016; Pennsylvania; State Appellate Court

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Maria Heddleston and her husband, Brian Heddleston, appealed a judgment in favor of the defendants in a medical malpractice case regarding the failure to timely diagnose Maria's breast cancer. The defendants included Obstetrical and Gynecological Associates of Pittsburgh, Dr. Renata D. Hoca, Magee Women’s Hospital-UPMC, Dr. Nancy Brent, and Pediatric Alliance, P.C. The Heddlestons alleged that the defendants were negligent in failing to diagnose breast cancer from September to October 2009, which progressed to Stage IV by November 2010. Testimony indicated that Maria complained of severe breast pain during this period, which experts believed should have prompted diagnostic imaging. The jury found in favor of the defendants with a ten-to-two verdict. The Heddlestons sought a new trial, but the trial court denied their post-trial motion on March 2, 2015. They subsequently filed a notice of appeal, which was followed by cross-appeals from the defendants. The appellate court found merit in some of the Heddlestons' assertions and vacated the judgment, remanding for a new trial, while rejecting the defendants' cross-claims.

Appellants present seven issues for review regarding their entitlement to a new trial or evidentiary hearings, citing several procedural concerns. These include: 1) the undisclosed financial relationship between a juror and the CEO of Pediatric Alliance, P.C., who was present during the trial; 2) juror confusion indicated by a second jury question that was not disclosed to counsel; 3) the trial court's allowance of cross-examination of a lay witness using medical slides from a charity website; 4) the exclusion of testimony from oncology expert Dr. Barry Singer regarding the identification of a tumor; 5) the acceptance of causation testimony from Appellees’ expert, Dr. William Farrar, about mammogram standards; 6) irrelevant cross-examination of Appellants’ standard of care expert, Dr. Robert Hecht; and 7) the exclusion of testimony from Husband regarding advice from a UPMC doctor about accusations of fabrication.

Appellees have filed cross-appeals with three questions: A) whether the trial court erred in denying motions for non-suit or directed verdict due to contradictory expert testimonies; B) whether the trial court erred by not granting these motions when the Plaintiffs' expert failed to establish causation to a reasonable degree of certainty; and C) whether there was sufficient evidence to establish that Defendant Dr. Hoca was the ostensible agent of the other Defendants.

Additionally, Appellees Pediatric Alliance, P.C. and Dr. Nancy Brent raise issues regarding the trial court's denial of motions to exclude and for directed verdicts, challenging the qualifications of Appellants’ standard of care expert and alleging contradictions in the expert testimony that forced jury speculation. They also contend that the testimony from Appellants’ causation expert failed to establish causation or increased risk against them.

The appellate court is reviewing the Heddlestons' appeal, focusing on whether the trial court erred in denying their motion for a new trial. The standard for review involves assessing if the trial court made a legal error affecting the case's outcome or if it abused its discretion, defined as issuing a judgment that is unreasonable, arbitrary, or biased. The court finds merit in the appeal regarding the admission and exclusion of evidence, specifically addressing the trial court's decision to allow the cross-examination of the Wife using slides from the Susan G. Komen website that purportedly showed breast cancer warning signs. 

The Appellants argue that the slides were unauthenticated, constituted hearsay, and violated rules on lay witness testimony. The Appellees contend that the Wife acknowledged the diagrams' accuracy regarding breast cancer symptoms and assert that any objection based on improper testimony was waived by the Appellants. They further argue any potential error was harmless, as the information presented was uncontested. However, the Appellants maintain that proper authentication by a medical professional was necessary for the slides to be admissible. The court notes that the Appellants had objected to the slides at a sidebar, emphasizing the need for expert testimony.

Appellants objected to Wife's qualification to authenticate or provide medical testimony on breast cancer symptoms. They argued this objection was not waived, despite defense counsel attempting to illustrate symptoms to the jury. The trial court allowed defense counsel to ask Wife about the accuracy of slides depicting these symptoms, which she largely denied experiencing, except for one pain that ceased when she stopped pumping. Defense counsel claimed the slides were sourced from the Susan G. Komen website, leading to further questioning about the website's content, which Appellants objected to but were instructed to rephrase. The trial court characterized the slides as demonstrative evidence, but this classification does not exempt it from rules of evidence concerning authentication and hearsay. The lack of a qualified medical expert's opinion on the slides' content rendered the evidence improperly admitted. This admission was significant because it misrepresented the symptoms of breast cancer and contradicted Appellants' claims, which hinged on the argument that Wife's severe pain warranted further testing to rule out cancer. Furthermore, the evidence suggested that Appellees were not negligent, as Wife reportedly lacked warning signs. Appellants argued a second error occurred when the trial court excluded Dr. Barry Singer, an oncologist, from providing crucial causation testimony about what imaging would have revealed had it been conducted in late 2009. Appellants clarified that while they would not ask Dr. Singer to address standard of care, they sought his opinion on the diagnostic test results, emphasizing causation rather than standard of care.

Counsel for UPMC conceded to a point during the proceedings, and the trial court concurred. During direct examination, Appellants’ counsel inquired of Dr. Singer whether diagnostic imaging conducted in September or October 2009 would have identified a tumor. Appellees objected, claiming Dr. Singer's response constituted standard of care testimony. Appellants’ counsel reminded the court that this question had previously been deemed acceptable in a motion in limine concerning Dr. Singer. Despite this, the trial court upheld the objection, determining the inquiry fell under standard of care testimony. Appellees leveraged this ruling in their closing argument, asserting that the absence of evidence regarding what imaging would have shown created a significant gap in Appellants' case.

Appellees contended that Dr. Singer was not qualified under the MCARE Act to provide standard of care testimony and that their objection was aimed at preventing Dr. Singer from suggesting specific diagnostic tests that should have been conducted. Appellants’ counsel argued, however, that the question posed was about causation, not the standard of care. The exchange at sidebar highlighted differing interpretations, with Appellees maintaining it was standard of care testimony while Appellants insisted it was causation-related. Ultimately, the court sided with Appellees, ruling the testimony inadmissible and sustaining the objection, with an exception noted by Appellants' counsel.

To establish a prima facie case of medical malpractice, a plaintiff must demonstrate four elements: 1) the medical practitioner owed a duty to the plaintiff; 2) the practitioner breached that duty; 3) the breach was a proximate cause or substantial factor in the plaintiff's harm; and 4) damages were a direct result of that harm. Expert testimony is typically required to show that the defendant's actions deviated from accepted medical standards and that this deviation caused the harm.

In this case, Dr. Hecht, a gynecologist, provided testimony indicating that the Appellees failed to meet the standard of care by not ordering imaging studies to rule out cancer. However, to recover damages, an expert must also establish a causal link between the breach and the injury. Dr. Singer was responsible for offering such causal testimony, asserting that the cancer was present in 2009 and could have been detected with imaging studies, thereby reducing its severity. He did not, however, assert that it was standard to order these tests or that failing to do so deviated from the standard of care.

The court found that without Dr. Singer's causation testimony, the Appellants could not prove their case for medical malpractice. The trial court's error in sustaining defense objections to this key testimony was deemed prejudicial, necessitating a new trial. The court identified two reasons for this requirement and did not need to address other issues raised by the Appellants regarding juror relations and jury confusion.

If Dr. Ferrar is called as a defense expert in the new trial, he must avoid commenting on the timing of mammogram screenings or the appropriateness of such a test for the Wife, who was in her thirties. The court also noted that while the defense's questioning of Dr. Hecht concerning irrelevant treatment issues was not prejudicial enough to warrant a new trial, such lines of inquiry should be excluded in retrial. Lastly, the Appellants attempted to introduce testimony from Husband regarding a UPMC physician's advice to hire a lawyer, but the trial court denied this request due to UPMC being a defendant in the case.

The court clarified that while a party could inquire if someone advised obtaining an attorney, they could not ask who made that recommendation. Appellants abandoned this line of questioning and, on appeal, argued it was fair comment and not hearsay since it wasn't offered for the truth of the matter. The court found this evidence irrelevant if not true and agreed with the trial court that mentioning UPMC or identifying the recommending physician would be prejudicial. The trial court indicated that had there been an objection to defense counsel's suggestion of fabrication by Appellants' counsel, it would have been upheld. Appellants failed to demonstrate prejudice from this. 

In the cross-appeals, Appellees contended that Dr. Hecht was unqualified to opine on breastfeeding, that he should not have suggested imaging in 2009, and that a directed verdict was warranted. The court noted that the trial court has discretion in qualifying expert testimony, with a liberal standard applied in Pennsylvania. A reversal of the trial court's decision on expert testimony requires proof of abuse of discretion or legal error. The court agreed with the trial court that Dr. Hecht was qualified to suggest that the Wife's severe pain warranted diagnostic imaging. 

Appellees further argued for a directed verdict based on contradictions between Appellants' expert witnesses, Doctors Singer and Hecht. The court noted that a directed verdict is appropriate when witnesses' testimonies are so contradictory that the jury lacks guidance, but a jury can resolve conflicts unless they are absolute. Upon reviewing the testimonies, the court concurred with the trial court that there was no absolute contradiction or vital disagreement between the experts, thus not warranting the application of the Mudano rule.

Appellees argue in their cross appeals that Dr. Singer’s testimony on causation was insufficient, warranting a directed verdict. The standard of review for both directed verdict motions and judgments notwithstanding the verdict (N.O.V.) is identical, requiring reversal only upon finding an abuse of discretion or a legal error affecting the case's outcome. A judgment N.O.V. can be granted if either the movant is entitled to judgment as a matter of law or if the evidence overwhelmingly supports the movant's position. 

Dr. Singer's testimony indicated that a diagnostic imaging test in fall 2009 could have revealed the presence of breast cancer, which was diagnosed in November 2010 at Stage IV, significantly increasing the risk of death. His testimony, albeit limited, sufficiently supported the Appellants' case against a directed verdict motion. Additionally, Appellees claimed the trial court erred in not dismissing Magee Women’s Hospital of UPMC and UPMC due to insufficient evidence of an agency relationship with Dr. Hoca. This claim was rejected, referencing the trial court's findings that Dr. Hoca had been employed by UPMC since becoming a physician. The judgment was reversed, and the case was remanded for a new trial, with jurisdiction relinquished. Judge Mundy concurred, while Judge Jenkins filed a concurring and dissenting opinion. Judgment was entered on July 22, 2016.