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Failure to Review MRI Leads to Ten Year Delay in Brain Cyst Diagnosis


A patient with a history of nausea and vomiting presented to a Georgetown University Hospital pediatric neurologist with severe headaches. The pediatric neurologist told her to arrange an EKG and an MRI through her primary-care physician. The MRI revealed a 3–5 mm supersellar cyst behind her left eye—likely a Rathke's pouch cyst. At the time, the cyst was not pressuring her pituitary gland, hypothalamus, or her optic chiasm. Neither her primary care physician nor the pediatric neurologist ever saw the results of this MRI during the time relevant to this proceeding. Years later, she was diagnosed with gastroparesis, a condition that makes it more difficult for the stomach to empty properly.

 

The patient’s symptoms worsened. About ten years after the first MRI, she presented to George Washington University Hospital (“GWU”) complaining of vertigo and double vision. At that time, GWU doctors ordered an MRI. Like the earlier MRI, this new test showed a cyst-like mass behind the patient's left eye. The cyst had visibly grown and was causing mass effects on the patient's optic chiasm.

 

After her discharge from GWU Hospital, the patient saw a neurosurgeon at Georgetown University Hospital. The neurosurgeon asked the patient to undergo another MRI. While examining the results of this MRI, the neurosurgeon discovered the MRI from ten years before. Comparing the two MRIs, he noted that the patient's cyst had progressed during the intervening decade, becoming bigger. The neurosurgeon then performed surgery to remove the cyst, without complication.

 

The patient brought a medical malpractice action against Georgetown University Hospital, based on its respondeat superior liability for the pediatric neurologist's alleged negligence, and her former primary care physician in connection with their failure to discover the cleft cyst behind her left eye. At trial, the patient's expert witnesses, relying on relevant medical literature and on case studies appearing in that literature, testified that there was a causal link between her Rathke's cleft cyst and her gastroparesis. The patient's damages expert testified that a lump-sum payment of $780,550 would fully compensate the patient for her future medical costs.

 

During closing arguments, the patient’s counsel stated:

You know, the jury system in our country exists to protect the community. And in this medical malpractice case, you will decide what standards doctors must meet in the community when they provide care and treatment to patients. You will decide what standards doctors must meet to protect patient health and safety.... Remember, the standards ... in the medical community exist for a reason. They have been developed by doctors for doctors. They exist to promote patient safety. They exist to protect patient health. They're to provide a medical care system that above all prevents harm that's avoidable. And what these standards are in this community is what you will be deciding when you go back to the jury room.

 

The verdict form asked the jury to answer at least one question regarding a discrete factual issue, while still deciding the ultimate issue of liability. The jury returned a verdict for the patient. The jury awarded her $505,450.37 in past medical expenses, $800,000 in future medical expenses, and $1,200,000 in noneconomic damages, for a total of $2,505,450.37.

 

The District of Columbia Court of Appeals affirmed in part and remanded with instructions. Specifically, because the jury awarded $19,450 more than the record supported, the court remanded with instructions that the trial court amend its order to reduce the award in that amount. In all other respects, the court affirmed. The court first held that the defendants waived their objection to any alleged inconsistency in the verdict by failing to raise the issue before the jury was discharged. Second, the court held that the patient was not required to show that her experts' opinions were generally accepted in the medical science community. Third, there was no impropriety in comments by the patient's counsel during closing argument regarding the standard of care. Fourth, the jury's award of an additional $19,450 in future medical costs beyond the $780,550 that the patient's damages expert testified would fully compensate the patient for such costs was not supported by the evidence, thus requiring a remittitur.

 

The court determined, regarding the first issue, that the jury's verdict was not a “special verdict” involving only the determination of factual questions. The verdict form asked the jury to answer at least one question regarding a discrete factual issue, while still deciding the ultimate issue of liability. A party waives its objection to any alleged inconsistency in a general verdict, with or without interrogatories, if it fails to object before the jury's discharge. The jury verdict was either a standard general verdict or a general verdict with interrogatories, as opposed to a “special verdict” involving only the determination of factual questions. Special verdicts do not require the jury to determine ultimate liability, or reach any legal conclusions whatsoever. Thus, the defendants waived their objection to any alleged inconsistency in the verdict by failing to raise the issue before the jury was discharged.

 

Also, the trial court did not err by permitting the patient's expert witnesses to testify that there was a causal link between her Rathke's cleft cyst and her gastroparesis. The patient was not required to show that her experts' opinions were generally accepted in the medical science community, but, rather, that her experts' methodology was a generally accepted method for forming an opinion regarding medical causation. Her experts relied on relevant medical literature and on case studies appearing in that literature. This was a generally accepted method for forming an opinion regarding medical causation. The requirement for admissibility of expert testimony, that the state of the pertinent art or scientific knowledge permits a reasonable opinion to be asserted by an expert, focuses not on the acceptance of a particular conclusion derived from the methodology, but rather on the acceptance of the methodology itself.

 

The court, in addition, reasoned that there was no impropriety in comments by the patient's counsel during closing argument regarding standard of care. The Court of Appeals will reverse on the basis of improper comments by counsel only when it is likely that the comments left the jurors with wrong or erroneous impressions, which were likely to mislead, improperly influence, or prejudice them to the disadvantage of the defendant. The trial court's conclusion, that counsel's statements “related to the determination the jury was being asked to make regarding the standard of care,” was rational. Counsel did not urge the jury to penalize the defendants based on irrelevant considerations or to return a verdict that would “send a message.”

 

The court found that the jury's award of an additional $19,450 in future medical costs beyond the $780,550 that the patient's damages expert testified would fully compensate the patient for such costs was not supported by the evidence, thus requiring a remittitur. Plaintiffs are not required to prove their damages precisely or with mathematical certainty, but must provide some reasonable basis upon which to estimate damages. The jury may not award damages based solely on speculation. The patient's damages expert testified that a lump-sum payment of $780,550 would fully compensate the patient for her future medical costs. The jury rounded the damages expert's figure up and awarded the patient $800,000 for future medical expenses—a sum $19,450 in excess of the amount the damages expert indicated was necessary. The additional award was not supported by the evidence and was based on speculation.

 

See: President, Directors of Georgetown College v. Wheeler, 2013 WL 5271567 (D.C. Cir., September 19, 2013)(not designated for publication).

 

See also Medical Law Perspectives, October 2013 Report (to be published Oct. 2, 2013): Brain Aneurysm and Subarachnoid Hemorrhage: Failure to Diagnose, Delayed Diagnosis, Misdiagnosis

 

See also Medical Law Perspectives, October 2012 Report: Mistakes in Diagnosing Cancer: Liability Concerns for Misdiagnosis, Failure to Diagnose, and Delayed Diagnosis

 

See also Medical Law Perspectives, June 2012 Report: Too Much, Too Little, Too Late: Injuries from Delays and Failures to Perform CT Scans or Overexposure to Radiation

 

 

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