Court: Louisiana Court of Appeal; December 14, 2004; Louisiana; State Appellate Court
David M. Jones' siblings filed a medical malpractice lawsuit against Doctors John Bick, Ricardo Febry, Nancy Lehman, Hope Cromer, Malcolm Andry, and Christine Smith, alleging that Jones' death in March 1998 resulted from negligent treatment and improper administration of the drug Clozaril. Doctors Febry and Andry responded by citing a statutory medical review panel's conclusion that they met acceptable care standards and requested a maximum recovery of $100,000 contingent upon proving liability. Other defendants, including Doctors Bick, Lehman, Cromer, Smith, and the State of Louisiana, invoked the protections of the Louisiana State Employees Medical Malpractice Act. A motion for summary judgment by Doctors Cromer and Smith was denied by the trial court on September 5, 2003. The trial occurred on September 15-17, 2003, culminating in a judgment on November 10, 2003, which awarded $50,000 in general damages to each plaintiff, $4,264 for funeral expenses to Ruby Jones, and dismissed survival and wrongful death claims against most defendants, except Dr. Bick. The plaintiffs did not appeal but asserted that Doctors Cromer and Smith were also liable. The State and Dr. Bick later appealed after motions for a new trial were denied on January 15, 2004. The judgment was amended to remove Dr. Bick's name and affirmed. Mr. Jones had a history of severe chronic paranoid schizophrenia and was treated with various antipsychotic medications from 1990 to 1997, with limited success. In late 1997, Dr. Smith recommended a trial of Clozaril, which was communicated to Ruby Jones, who was involved in her brother's care. Dr. Smith prescribed Clozaril, starting at 12.5 mg daily in February 1998, with a planned gradual increase, which was slower than the manufacturer’s guidelines. The first prescription was filled on February 6, 2004.
Mr. Jones experienced back pain and was diagnosed with hypertension, leading to a referral to Dr. Ricardo Febry, who noted a family history of heart issues and Mr. Jones' high cholesterol, smoking, and obesity. Dr. Febry initiated treatment for hypertension and conducted a cardiac workup, revealing heart enlargement due to chronic high blood pressure. In March 1998, Mr. Jones was hospitalized for psychiatric care under Dr. Bick due to severe psychosis and possible suicidal ideation, with plans to adjust his Clozaril medication safely.
During hospitalization, Mr. Jones was found to be extremely hypertensive and was referred back to Dr. Febry for his hypertension and back pain. Dr. Febry modified his medication regimen, adding Procardia, which could interact negatively with Clozaril. Mr. Jones exhibited several adverse side effects related to Clozaril, including lethargy and slurred speech. After a report from nursing staff, Dr. Febry questioned the connection between the symptoms and Clozaril, leading him to discontinue the medication and prescribe Benadryl.
Subsequently, Dr. Bick recommended reinstituting Clozaril at a lower dosage, which was agreed upon by the medical team. On March 15, Mr. Jones had stable vital signs after taking Clozaril but later refused lunch. Shortly thereafter, he was found slumped in his chair with signs of hypersalivation, prompting emergency resuscitation efforts, which ultimately failed, resulting in Mr. Jones' death.
The Orleans Parish Coroner’s Office determined the cause of death for Mr. Jones to be an enlarged heart and extensive atherosclerosis. To succeed in their lawsuit, the plaintiffs must establish three key elements by a preponderance of the evidence: (1) the applicable standard of care for Mr. Jones' medical treatment, which reflects the knowledge and skill expected from doctors in Dr. Bick’s practice area in New Orleans; (2) that Dr. Bick deviated from this standard; and (3) that this deviation was the proximate cause of Mr. Jones' death. The law allows for professional judgment to be assessed based on reasonableness at the time of treatment rather than on outcomes or subsequent events.
The trial court's findings regarding the standard of care, breach, and causation will only be overturned if deemed manifestly erroneous. The State and Dr. Bick argue that the trial court improperly applied hindsight in its judgment, asserting that Dr. Bick acted within the standard of care. The plaintiffs counter that the decision was based on Dr. Bick’s failure to acknowledge Mr. Jones' non-compliance with Clozaril administration and overdose symptoms during his final hospital stay.
The Louisiana Supreme Court clarified that a physician is not liable for unforeseen consequences stemming from ordinary negligence but is responsible for harm caused by negligent actions. If a physician acts with intentionality, recklessness, or bad faith, they are liable for all resulting damages. The assessment of a physician's conduct must be based on the professional standards and medical knowledge available at the time of treatment, excluding hindsight or later-acquired information.
Dr. Bick contends he could not have reasonably known about pill bottles containing unused Clozaril found by Ruby Jones over five years after Mr. Jones’ death, nor could he have anticipated Mr. Jones dying from a heart attack. The critical issue is whether Mr. Jones’ cardiac failure was a foreseeable consequence of administering Clozaril, based on the knowledge Dr. Bick had at the time of administration on March 14. Evidence of pill bottles discovered later is deemed irrelevant to this determination.
The plaintiffs argue that Dr. Bick was aware of Mr. Jones’ non-compliance with the prescribed 150 mg daily dosage prior to hospitalization, which should impact the assessment of Dr. Bick’s reasonable conduct. The Medical Review Panel found no failure to meet the standard of care, citing proper referrals, diagnostic tests, and medication administration, confirming that Clozaril was appropriate and dosed correctly.
Dr. Kenneth B. Sumner from the Panel testified that a family member assisted Mr. Jones with medication compliance, which is critical to the case. Dr. Bick acknowledged the need for gradual dosage and stated that if Mr. Jones had not complied, he should have received a reduced dosage upon hospitalization. Although Dr. Bick claimed he took responsibility for the residents' actions, he admitted he did not personally verify Mr. Jones’ compliance. Instead, he relied on PHP records indicating compliance, despite acknowledging that this information came from Mr. Jones himself, who was considered an unreliable source. Defense counsel highlighted a note from seven months prior indicating Ruby Jones believed her brother was taking his medication.
Dr. Bick lacked personal knowledge regarding Ruby Jones’ opinion on her brother’s medication compliance and confirmed he did not inquire about it, stating it was not his role. He based his assessment on PHP records indicating family involvement and ongoing medication discussions. Expert psychiatrist Dr. Jose Maldonado noted that the Physicians’ Desk Reference (PDR) stipulates a maximum dose of 12.5 mg of Clozaril twice daily if a patient had missed doses. In contrast, plaintiffs’ expert Dr. William Fann criticized Dr. Bick for assuming Mr. Jones' compliance without concrete evidence and for relying on a social worker’s assessment. Dr. Fann asserted that Dr. Bick should have required production of Mr. Jones' Clozaril prescription bottles upon hospitalization or started treatment at the lowest dosage and adjusted accordingly. The court found credible evidence suggesting Dr. Bick did not adequately verify Mr. Jones' compliance before his hospitalization.
The State and Dr. Bick contended that the trial court incorrectly deemed Clozaril unreasonably dangerous, arguing it was the only viable medication for Mr. Jones, given his severe chronic schizophrenia and non-responsiveness to other treatments. The parties referenced the PDR, which indicates Clozaril is appropriate for patients who have not responded to standard antipsychotics. Dr. Bick testified that Mr. Jones met this criterion, but he acknowledged the drug's significant risks, including sudden death and agranulocytosis. Despite these dangers, he believed Clozaril could substantially improve Mr. Jones’ quality of life. Mr. Jones' medical history raised concerns about heart disease, with risk factors such as high cholesterol and a family history of heart issues, which should have prompted Dr. Bick to exercise caution in prescribing medication. Dr. Febry testified about Mr. Jones’ high risk for cardiac arrest and communicated his concerns to Dr. Bick, who ultimately made the decision based on his experience with Clozaril.
Dr. William Steinman, an expert in internal medicine, stated that each doctor should manage care within their specialty. It was deemed reasonable to expect Dr. Bick to be knowledgeable about the adverse interactions and side effects of Clozaril. Dr. David Hyman, another expert, highlighted Clozaril's dangerous interaction with benzodiazepines, specifically noting that Mr. Jones was prescribed Ativan, which posed risks including sudden heart attack. The PDR's 'black box' warning indicated serious risks associated with combining these medications, including potential respiratory arrest. While no definitive interaction had been established, caution was advised when prescribing Clozaril alongside benzodiazepines or other psychotropic drugs, and Dr. Hyman emphasized the need for careful monitoring of Mr. Jones' medication regimen.
Dr. Hyman criticized the internal medicine specialists for failing to recognize the serious potential drug reactions, particularly in light of Mr. Jones’ hypotension during his final admission, which is a known adverse effect of Clozaril. This hypotension prompted Dr. Febry to discontinue Clozaril, but Dr. Bick later resumed its administration, leading to Mr. Jones’ cardiac arrest. Dr. Fann, a psychiatrist, noted that Mr. Jones’ smoking history could increase Clozaril levels due to nicotine withdrawal, further complicating his condition. He argued that Dr. Bick should have recognized signs of a Clozaril overdose, including weakness and hypotension, as evident in Mr. Jones’ chart. Dr. Fann concluded that had the dose on March 15th not been administered, Mr. Jones would likely have survived. The court found credible evidence supporting the claim that Dr. Bick failed to meet the standard of care by disregarding warnings related to Clozaril and Mr. Jones' medical history.
The trial court admitted medication bottles presented on the trial day without proper foundation and authentication, but this issue is rendered moot following the resolution of the appellants’ first assignment of error. The State and Dr. Bick argue that the trial court did not adequately consider the uncontradicted expert testimony of their pathologist, Dr. Travis Harrison, who stated that Mr. Jones’ death was due to pre-existing heart conditions rather than a sudden drop in blood pressure induced by Clozaril. Dr. Harrison identified severe coronary atherosclerosis and an enlarged, hypertrophic heart as contributing factors, along with Mr. Jones’ family history of heart issues, high cholesterol, and obesity. He concluded that Mr. Jones’ death was sudden and unforeseeable, asserting that Clozaril likely played no role. The appellants reference precedents from the Third and Fifth Circuit Courts of Appeal, which indicate that while uncontradicted expert testimony is not binding on the trier of fact, it should be accepted as true unless its reliability is cast into doubt. However, they emphasize the importance of examining the context of such testimony, as demonstrated in the Arnold case, where the appellate court overturned a trial court's rejection of uncontradicted expert testimony due to a lack of contrary evidence. The Louisiana Supreme Court has affirmed that an appellate court may not uphold a trial court's refusal to accept credible uncontradicted testimony if there are no valid reasons for its dismissal and if legal principles have been overlooked. Thus, while expert testimony is not conclusively binding, it is generally accepted as true unless undermined by the record. The Arnold case further illustrates that corroborating evidence can reinforce expert testimony, unlike the Lovoi case, where uncontradicted evidence was rejected due to broader contextual considerations.
The authenticity of the decedent's will was contested, with expert testimony indicating that the will and an accompanying Army form were authored by different individuals. The expert's conclusion was undermined by the age of the Army document and the fact that most comparisons were between print and script. Two witnesses testified to having observed the decedent writing and signing the will, leading the trier of fact to find these witnesses credible and to dismiss the expert’s opinion as insufficiently convincing. The court found this credibility determination reasonable and not manifestly erroneous.
In a separate matter concerning Mr. Jones' death, expert opinions diverged regarding the cause. Dr. Harrison, the sole pathologist, referenced Mr. Jones' heart condition and family history, suggesting a need for more inquiry into the appropriateness of the prescribed Clozaril. Other experts attributed the death to a Clozaril overdose causing sudden cardiac arrest, while another linked it to unforeseen genetic and lifestyle factors. Under the manifest error standard, the trier of fact has the discretion to choose between these expert interpretations.
The appellants proposed excluding Dr. Bick from the judgment, referencing Detillier v. Kenner Regional Medical Center, which clarified that individual state health care providers can be named as defendants in medical malpractice suits under certain conditions, allowing plaintiffs to benefit from the distinction in terms of discovery and evidence. However, should malpractice be found, judgment would solely be against the state, not the individual provider.
The Louisiana Supreme Court has determined that the trial court's judgment should be modified to remove Dr. John Bick's name. The court concluded that the original judgment was not manifestly erroneous and was supported by sufficient evidence and reasonable credibility assessments made by the trier of fact. Consequently, the judgment is amended to exclude Dr. Bick and is affirmed as amended. Additionally, there is no record indicating how the State became a party to the case; the trial judge initially did not name the State. During the proceedings, the State was identified as "the State of Louisiana through the Louisiana State University Health Sciences Center" by counsel representing the doctors involved. The court infers that Doctors Bick, Lehman, Cromer, and Smith were employees of that institution. The plaintiffs did not address an error raised in the appeal, leading to its abandonment under Rule 2-12.4 of the Uniform Rules of Courts of Appeal.
