News: A man suffering from complex regional pain syndrome (CRPS) in his ankle underwent surgery, but the procedure was complicated by a broken drill bit. The patient was informed about the potential for additional surgery and the need for X-rays. When the patient went for X-rays, hospital staff hit his ankle against a desk. X-rays revealed a dislodged surgical screw.
The patient sued the hospital for the dislodged surgical screw, claiming that the staff “ramming” his ankle into the desk caused the dislodging. The patient failed to present an expert to support his claim, and the defendants filed a motion for summary judgment. The motion was granted, then reversed, then reinstated upon multiple appeals.
Background: In May 2015, a man was diagnosed with CPRS in his left ankle. On Dec. 14, 2015, the patient underwent surgery to create an osteotomy, which was aligned and fixed with two screws. However, the surgery did not go as planned: The drill bit broke as the surgeon was drilling a hole in the bone for one of the screws, and shards scattered in the ankle. There was insufficient bone to create a hole for the second screw, but one screw was placed, and the physician hoped that would be sufficient. Following the surgery, the patient was informed about the possibility of additional surgery. No X-rays were taken that day, although the physician informed the patient that X-rays were needed to confirm alignment.
On Dec. 17, the patient returned for a follow-up visit. The physician examined the patient’s ankle but was unable to perform X-rays. The physician informed the patient multiple times that X-rays were needed. The patient was prescribed pain medication, and he went to a hospital for X-rays the following day.
At the hospital, the patient suffered an incident where his extended left ankle contacted a desk. The patient claimed his ankle was “rammed” into the desk, while hospital staff claimed it was a “slight bump.” X-rays showed a lateral displacement in the osteotomy — the fracture was not correctly aligned. A second surgery was performed on Dec. 24.
Approximately one year later, the patient filed a lawsuit against the hospital, claiming that the impact of his left ankle with the desk caused the displacement and dislodged the surgical screw placed during the first surgery. During the litigation, the patient identified two experts, including the physician who performed both surgeries and the patient’s treating physician before the surgeries. Neither physician was designated to testify on the cause of the patient’s injuries. The surgeon referred to the patient’s displacement as “hardware failure” and refused to opine on the cause. The treating physician similarly stated he could not testify that the impact caused the patient’s hardware shift.
Before trial, the defendant hospital filed a motion for summary judgment, claiming that the patient failed to provide expert testimony as to causation, a necessary element of his case. The patient opposed and claimed that no such expert testimony was necessary, and he nevertheless identified his prior experts. The trial court agreed with the defendant hospital that expert causation testimony was required, and that the patient failed to provide any such testimony.
The patient appealed, and the appellate court reversed the trial court’s decision. The appellate court ruled that the patient’s injuries did not require a medical expert because a layperson could determine the cause-and-effect relationship. The defendant hospital appealed that decision to the Supreme Court of Kentucky. The supreme court agreed with the defendant hospital and the trial court, ruling that causation was not within lay knowledge, thus an expert is required. As a result, the patient’s failure to provide expert testimony supported the trial court’s grant of summary judgment for the defendant hospital.
What this means to you: An important lesson from this case focuses on a critical aspect of medical malpractice cases: causation. Generally, the legal standard is that the care provider’s conduct must have been a substantial factor in causing harm such that a reasonable person would consider the conduct to have contributed to the harm. If the conduct is too remote or trivial, it will not be considered a substantial factor. At the same time, conduct does not need to be the only cause of the harm. Different jurisdictions may apply somewhat different standards or describe them differently, but the general application is the same: If the harm would have occurred without the care provider’s conduct, then the conduct is not a substantial factor.
Causation provides an opportunity for defendants to explore the basis for the patient’s injury. If there are alternative sources, care providers could point to those as the source of the patient’s harm. In this case, there were at least two different possibilities for the source of the patient’s injury. There was no dispute that the patient was injured — the imaging revealed the displacement of the screw. But what caused the displacement was heavily disputed. The patient claimed that his ankle being “rammed” into a desk by hospital staff was the source, while the defendant hospital pointed to the patient’s initial surgery, which likewise indisputably had gone awry.
Fortunately for the defendant hospital, the patient failed to provide an expert to support his theory of causation. The patient argued that he was not required to provide an expert because the injury was obvious, and the cause required no expertise to determine — lay knowledge was sufficient. The trial court and state supreme court both disagreed and noted that the question of causation in the medical context almost always requires expert testimony. There are rare cases where the injury “speaks for itself” and could only have happened based on wrongful conduct. This was not one such case, as the defendant hospital argued and presented expert testimony supporting its argument that the initial surgery could have caused the displacement.
This case also shows the importance of appeals — and even the importance of appealing appellate decisions. At the trial court level, the court agreed with the defendant and granted summary judgment, dismissing the matter against the hospital. However, the patient appealed, and the intermediate appeals court reversed the decision. As a result, the defendant hospital then appealed that reversal, and the Supreme Court of Kentucky agreed with the first determination, reinstating the hospital’s dismissal. This chain of events certainly is not typical, but it does show the multiple steps and appellate options. A defendant who believes that a trial court committed an error, or even that an appellate court committed an error, should consider with counsel the options for initial or further appellate review. Appeals can be a time-consuming and arduous process, but in this case, the defendant hospital’s decision to appeal the intermediate appellate review was effective: The hospital was again dismissed from the case, a successful defense decision in the absence of a jury.
Finally, note that the initial issue that started the chain of events involved medical equipment failure. The investigation around that fact might have added to the plaintiff’s story. Had the drill bit not broken and the surgeon successfully placed two screws, the patient’s ankle would have had more stability, and some or all the liability may have laid with the manufacturer.
REFERENCE
- Decided Jan. 18, 2024, in the Supreme Court of Kentucky, Case Number 2022-SC-0302-DG.
An important lesson from this case focuses on a critical aspect of medical malpractice cases: causation. Generally, the legal standard is that the care provider’s conduct must have been a substantial factor in causing harm such that a reasonable person would consider the conduct to have contributed to the harm.
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