Cleeton v. SIU Healthcare, Inc.

2023 IL 128651, 220 N.E.3d 1050, 468 Ill. Dec. 271
CourtIllinois Supreme Court
DecidedMay 18, 2023
Docket128651
StatusPublished
Cited by9 cases

This text of 2023 IL 128651 (Cleeton v. SIU Healthcare, Inc.) is published on Counsel Stack Legal Research, covering Illinois Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Cleeton v. SIU Healthcare, Inc., 2023 IL 128651, 220 N.E.3d 1050, 468 Ill. Dec. 271 (Ill. 2023).

Opinion

2023 IL 128651

IN THE SUPREME COURT OF THE STATE OF ILLINOIS

(Docket No. 128651)

CAROL CLEETON, Appellant, v. SIU HEALTHCARE, INC., et. al. (Mouhamad Bakir, M.D., Appellee).

Opinion filed May 18, 2023.

JUSTICE NEVILLE delivered the judgment of the court, with opinion.

Chief Justice Theis and Justices Overstreet, Cunningham, Rochford, and O’Brien concurred in the judgment and opinion.

Justice Holder White took no part in the decision.

OPINION

¶1 The plaintiff, Carol Cleeton, as the independent administrator of the estate of Donald Cleeton, the deceased, filed a multiple-count wrongful death action against the defendants SIU Healthcare, Inc.; Charlene Young; Abdullah Al Sawaf; SIU Physicians & Surgeons, Inc., doing business as SIU Medicine; Stephanie Whooley; Sue Ferrill; Ashley Kochman; and Medtronic, Inc. (Medtronic), as well as the respondents in discovery Memorial Medical Center, Mouhamad Bakir, Jessica Farley, Nauman Jahangir, Hannah Purseglove, Natalie Mahoney, Jonathan Roderick Dutt, and Shilpa Chaku. The plaintiff filed a motion pursuant to section 2-402 of the Code of Civil Procedure (Code) (735 ILCS 5/2-402 (West 2018)) to convert a respondent in discovery to a defendant. The Sangamon County circuit court denied the motion, finding that the plaintiff did not present sufficient evidence to convert the respondent in discovery to a defendant. The appellate court affirmed the decision of the circuit court. 2022 IL App (4th) 210284-U, ¶ 35.

¶2 We allowed Carol’s petition for leave to appeal pursuant to Illinois Supreme Court Rule 315 (eff. Oct. 1, 2021). We also allowed the Illinois Trial Lawyers Association to file an amicus curiae brief in support of the plaintiff’s position, and we allowed the Illinois State Medical Society, American Medical Association, and the Illinois Association of Defense Trial Counsel to file amicus curiae briefs in support of the position taken by Dr. Bakir, the respondent in discovery. Ill. S. Ct. R. 345 (eff. Sept. 20, 2010). For the following reasons, we now reverse the judgment of the appellate court and remand the cause to the circuit court for further proceedings consistent with this opinion.

¶3 I. BACKGROUND

¶4 A. Donald’s Medical History and Care

¶5 When he was 17 years old, Donald incurred a cervical cord injury, which left him quadriplegic. To reduce Donald’s involuntary muscle spasms (spasticity from the nerve damage), Dr. Jose Espinosa implanted a Medtronic SynchroMed II Infusion System. The Medtronic device was a programmable pump that delivered doses of baclofen into the intrathecal space of Donald’s spine. The device consisted of two parts: the pump itself, which held and dispersed baclofen, and a catheter, which delivered baclofen from the pump into the intrathecal space of the spine. The pump was managed by the Southern Illinois University Department of Neurology (SIU Neurology) and required regular refills.

¶6 On October 25, 2017, Donald and his mother, Carol, presented at the SIU Neurology clinic for a routine pump refill. Charlene Young, F.N.P., and Ashley

-2- Kochman, R.N., made failed attempts to refill Donald’s pump before Young successfully refilled it. One of Kochman’s attempts resulted in inserting the length of the refill needle into Donald’s abdomen without making contact with the pump.

¶7 On October 29, 2017, Donald arrived at the Memorial Medical Center emergency room complaining that since his pump was refilled, he had a headache, abdominal pain, and increased spasms. Donald also reported that he had recently suffered from a urinary tract infection. Donald was evaluated by Dr. Richard Austin, who, inter alia, consulted the on-call neurology resident, Dr. Nauman Jahangir, who recommended having a Medtronic representative interrogate the device or test it for proper pump function. The interrogation revealed that the pump was functioning properly and delivering the correct dosage. Donald’s emergency room notes contained a sepsis and acute urinary tract infection diagnosis. Dr. Austin admitted Donald to the hospital and transferred his care shortly before midnight. In transferring Donald’s care, Dr. Austin spoke with Dr. Nichole Mirocha.

¶8 On October 30, 2017, Dr. Mirocha called pulmonary critical care specialist Dr. Bakir to have Donald transferred to the intensive care unit (ICU) to address tachycardia, altered mentation, and possible seizures. Dr. Mirocha shared Donald’s medical history with Dr. Bakir, including the interrogation of his baclofen pump in the emergency room. Around 10 a.m., Donald was transferred to the ICU, where Dr. Bakir became Donald’s managing physician. A pulmonary medicine fellow, Dr. Keivan Shalileh, and Dr. Hannah Purseglove, a resident, were also working in the ICU that day. Dr. Bakir was aware of baclofen; however, the baclofen pump was not part of his intensive care and pulmonology practice.

¶9 Prior to October 30, 2017, Dr. Bakir had never treated a patient who was potentially experiencing baclofen withdrawal syndrome (BWS). Dr. Bakir reviewed Donald’s chart, examined him, and spoke with Carol, who informed him of the challenges with Donald’s pump refill on October 25, 2017. Because of Donald’s heart rate, Dr. Bakir immediately consulted cardiologist Momin Siddique, who ordered tests to investigate a possible pulmonary embolism as well as Donald’s elevated troponin level. Dr. Bakir also consulted neurology, neurosurgery, and the baclofen pump team.

¶ 10 After receiving a request for troubleshooting assistance with Donald’s pump, at 10:44 a.m., a Medtronic employee faxed the emergency procedures for baclofen

-3- withdrawal to Memorial Medical Center. At 6:44 p.m. on October 30, 2017, the Medtronic emergency procedure documents were incorporated into Memorial Medical Center’s electronic medical records for Donald. Dr. Bakir testified during his deposition that the Medtronic emergency procedure documents were never provided to him while he was caring for Donald.

¶ 11 Dr. Abdullah Al Sawaf, a neurologist, and Dr. Shilpa Chaku, a neurology resident, examined Donald around 11:15 a.m. on October 30, 2017. Dr. Al Sawaf’s differential diagnosis for Donald was “mild-moderate baclofen withdrawal vs sepsis (urine source).” Specifically, Dr. Al Sawaf noted that Donald’s “[n]ormal tone argues against baclofen withdrawal, but the timeline of events and dysautonomia supports that possibility.” Dr. Al Sawaf also found that sepsis could present similarly. He also asked Young to interrogate Donald’s pump to rule out failure, and Young reported that the pump was working as expected. Dr. Al Sawaf found that Donald’s episodes where his eyes would roll back and flutter were not seizures but were likely a dysautonomia phenomenon. After examining Donald, Dr. Al Sawaf and his team spoke with Dr. Bakir and the ICU team about Donald’s case. During the discussion, Dr. Bakir and Dr. Al Sawaf expressed a lack of familiarity with BWS. Dr. Al Sawaf stated he did not think it was BWS because Donald’s tone was normal. There was no discussion about a possible pump catheter malfunction.

¶ 12 Around 12:07 p.m. on October 30, 2017, a code blue was called for Donald because of a lack of pulse. Dr. Espinosa recommended intrathecal administration of baclofen, which was given by Dr. Todd Knox at 2:05 p.m. Donald was pronounced dead at 3:06 p.m. after three hours of resuscitation efforts. Later tests revealed that the catheter for Donald’s pump contained holes.

¶ 13 B. Circuit Court Proceedings

¶ 14 In February 2019, Carol filed a wrongful death action against SIU Healthcare, Inc.; Young; and Dr. Al Sawaf. She named, as respondents in discovery, the following: Memorial Medical Center, Dr. Austin, Dr. Knox, Dr. Bakir, Medtronic, Dr.

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Bluebook (online)
2023 IL 128651, 220 N.E.3d 1050, 468 Ill. Dec. 271, Counsel Stack Legal Research, https://law.counselstack.com/opinion/cleeton-v-siu-healthcare-inc-ill-2023.