Danko v. Conyers

2018 COA 14, 432 P.3d 958

• Court: Colorado Court of Appeals
• Decided: February 8, 2018
• Docket: 16CA1383
• Status: Published

Opinion

The summaries of the Colorado Court of Appeals published opinions constitute no part of the opinion of the division but have been prepared by the division for the convenience of the reader. The summaries may not be cited or relied upon as they are not the official language of the division. Any discrepancy between the language in the summary and in the opinion should be resolved in favor of the language in the opinion.

SUMMARY February 8, 2018

2018COA14

No. 16CA1383, Danko v. Conyers — Torts — Professional Liability — Medical Malpractice — Pro Rata Liability

In this medical negligence case, the division considers the

effect of the nonparty at fault statute, section 13-21-111.5, C.R.S.

2017, and Restatement (Second) of Torts section 457 (Am. Law Inst.

1965) (also called the original tortfeasor rule) on the admissibility of

evidence offered by the initial provider that negligence of later

providers caused the harm for which the patient sought damages

from the initial provider. Rather than designating later providers as

nonparties at fault, the initial provider sought to introduce evidence

of their negligence as a superseding cause. The division first holds

that the nonparty at fault statute does not preclude admission of

such evidence. However, the division further holds that the trial

court acted within its discretion in precluding the evidence because the initial provider did not show that treatment by the later

providers, even if negligent, was extraordinary, as required by the

Restatement. Therefore, the judgment against the initial provider is

affirmed. The division also holds that jury consulting fees can be

recovered as costs under the settlement offer statute, section

13-17-202, C.R.S. 2017. COLORADO COURT OF APPEALS 2018COA14

Court of Appeals No. 16CA1383 Boulder County District Court No. 14CV30542 Honorable Norma A. Sierra, Judge

Deborah Danko,

Plaintiff-Appellee and Cross-Appellant,

v.

David J. Conyers, M.D.,

Defendant-Appellant and Cross-Appellee.

JUDGMENT AFFIRMED, ORDER AFFIRMED IN PART, REVERSED IN PART, AND CASE REMANDED WITH DIRECTIONS

Division III Opinion by JUDGE WEBB Graham and Terry, JJ., concur

Announced February 8, 2018

Leventhal & Puga, P.C., Jim Leventhal, Erin C. Genullis, S. Paige Singleton, Benjamin I. Sachs, Denver, Colorado, for Plaintiff-Appellee and Cross-Appellant

Jaudon & Avery LLP, David H. Yun, Denver, Colorado, for Defendant-Appellant and Cross-Appellee ¶1 In a medical negligence case, should the initial provider be

allowed to present evidence that a later provider’s negligence caused

the injury for which the patient seeks to recover damages from the

initial provider? Does the answer depend on whether the initial

provider attempts to apportion fault or seeks complete exoneration

because, even if he or she was negligent, the later provider’s

negligence was a superseding cause of the patient’s injury?

¶2 David J. Conyers, M.D., who performed carpal tunnel surgery

on Deborah Danko, appeals the judgment entered on a jury verdict

in favor of Ms. Danko. According to Ms. Danko, Dr. Conyers

negligently failed to detect an infection resulting from the surgery,

which led to amputation of her forearm. Dr. Conyers challenges

rulings before and during trial excluding his expert testimony that

amputation of Ms. Danko’s forearm by another physician, four

months after she had been discharged from Dr. Conyers’ care, was

unnecessary. Dr. Conyers raised the other physician’s treatment

not as a basis to apportion fault, but as a superseding cause that

relieved him of any liability. He also challenges jury instructions

related to this issue.

1 ¶3 Ms. Danko concedes preservation. She cross-appeals the trial

court’s refusal to award some costs that she incurred.

¶4 We conclude that because Dr. Conyers did not present

evidence that the amputation was extraordinary, the trial court

acted within its discretion in excluding evidence of the other

provider’s negligence. Rejecting Dr. Conyers’ other contentions, we

affirm the judgment. We reverse the cost award in part.

I. Background and Procedural History

¶5 Dr. Conyers, a hand surgeon, performed carpal tunnel release

surgery on Ms. Danko’s right wrist on May 3, 2012. During

post-operative care, he did not order a biopsy to detect possible

infection. In October 2012, he released her from further care,

believing that the wound was healing normally and was not

infected.

¶6 A month later, Ms. Danko sought a second opinion from Dr.

Frank Scott. Dr. Scott performed a minor procedure on Ms.

Danko’s wrist. Three weeks later, Dr. Scott was notified that

cultures taken during the procedure had grown out acid-fast bacilli.

Ms. Danko was diagnosed with a mycobacterium fortuitum (MBF)

infection.

2 ¶7 On January 16, 2013, Ms. Danko saw Dr. Carla Savelli, an

infectious disease specialist. Dr. Savelli recommended long-term

dual therapy involving a regimen of several antibiotics and periodic

surgical debridement of infected tissue. Ms. Danko began taking

antibiotics.

¶8 Two weeks later, Ms. Danko consulted Dr. Bennie Lindeque,

an orthopedic surgeon. Dr. Lindeque recommended amputation of

Ms. Danko’s forearm “due to the severity and level of tendon and

nerve involvement.” He performed the amputation on February 11.

¶9 Ms. Danko sued Dr. Conyers, alleging that because he had

failed to diagnose her MBF infection, he was responsible for the

amputation. Her retained experts opined that had Dr. Conyers

ordered a biopsy in July or August, the MBF infection would have

been detected, dual therapy could have begun, and amputation

would not have been required.

¶ 10 Among other affirmative defenses in Dr. Conyers’ answer, he

raised nonparty at fault under section 13-21-111.5, C.R.S. 2017.

Dr. Conyers obtained an extension for designating nonparties.

Ultimately, he did not do so.

3 ¶ 11 Before trial, Ms. Danko moved to strike the nonparty at fault

defense and to preclude evidence of other providers’ negligence or

fault. The trial court granted the motion. After citing Restatement

(Second) of Torts section 457 (Am. Law Inst. 1965) (hereinafter

Restatement), CRE 401, 402, and 403, the court explained:

In this Court’s opinion, it would result in confusion to jurors were Dr. Conyers to be permitted to muddle the waters by calling into question the service rendered by subsequent doctors, where under [section 457 of] the Restatement of Torts, if the jury finds he was negligent, legally he would be the sole cause of Ms. Danko’s losses.

¶ 12 During trial, the court adhered to this ruling. Still, the court

allowed Dr. Conyers to present evidence as to the standard

treatment of antibiotics and debridement for MBF infections, that

Ms. Danko could have been treated this way even after she left Dr.

Conyers’ care, that she was improving under Dr. Savelli’s

treatment, that post-amputation photographs of the dissected limb

showed healthy nerves and tendons, and that Dr. Conyers’ care did

not cause the amputation.

¶ 13 In depositions and at trial, both Dr. Conyers and his principal

expert acknowledged that failing to diagnose and treat an MBF

4 infection earlier makes further medical treatment foreseeable. They

conceded that an undiagnosed and untreated MBF infection can

lead to amputation of the infected limb.

¶ 14 After Dr. Conyers rested, Ms. Danko moved for a directed

verdict on causation and requested a nonpattern instruction on the

original tortfeasor rule embodied in Restatement section 457. The

trial court denied the motion. Over defense objection, the court

gave the following nonpattern instruction:

The plaintiff, Deborah Danko, is entitled to recover damages to the full extent of injuries and losses suffered as a result of the negligence, if any, of the defendant, Dr. Conyers, even if the injuries and losses she suffered may have been greater due to the course of medical care and treatment she received thereafter.

It also gave a standard instruction on causation.

¶ 15 The court rejected Dr. Conyers’ tendered instructions on

intervening cause. It also rejected a tendered instruction that Dr.

Conyers would be liable for any additional bodily harm (e.g.,

amputation caused by subsequent health care providers), “provided

that you also find that the additional bodily harm resulted from the

normal efforts of health care providers in rendering aid which the

5 plaintiff’s injury reasonably required, irrespective of whether such

acts were done in a proper or negligent manner.”

¶ 16 The jury found Dr. Conyers liable and awarded damages of

$1.5 million.

II. The Trial Court Erred by Relying on Section 13-21-111.5 to Exclude Evidence That Other Providers Caused Ms. Danko’s Injuries ¶ 17 The trial court held that “[b]y failing to designate the [other]

providers as nonparties at fault, Dr. Conyers lost the right to argue

that these providers caused Ms. Danko’s injuries.” It explained that

“[t]his ruling serves to exclude at trial any expert testimony

concerning the standard of care related to the [other] providers.”

¶ 18 The court based this part of its ruling on section

13-21-111.5(3)(b), which provides that the “[n]egligence or fault of a

nonparty may be considered . . . if the defending party gives notice

that a nonparty was wholly or partially at fault within ninety days

following commencement of the action . . . .” According to Ms.

Danko, we must affirm the trial court’s exclusion of evidence related

to other providers’ negligence or fault under this statute.

6 A. Standard of Review

¶ 19 Questions of law concerning the application and construction

of statutes are subject to de novo review. City & Cty. of Denver Sch.

Dist. No. 1 v. Denver Classroom Teachers Ass’n, 2017 CO 30, ¶ 32.

B. Analysis

¶ 20 Ms. Danko asserts that “Colorado law forbids the admission of

evidence of a non-party’s fault where that non-party was not

properly designated.” She relies on cases such as Thompson v.

Colorado & Eastern Railroad Co., 852 P.2d 1328, 1330 (Colo. App.

1993), where the division held that “a court may not allow the

finder of fact to consider the negligence or fault of a nonparty

unless such issue has properly been raised by the defendant in a

pleading which complies with the requirements of [section]

13-21-111.5(3).”

¶ 21 But the supreme court has held that “a defendant may always

attempt to interpose a complete defense that his acts or omissions

were not the cause of the plaintiff’s injuries.” Redden v. SCI Colo.

Funeral Servs., Inc., 38 P.3d 75, 81 (Colo. 2001). In other words,

“[a] defense that the defendant did not cause the plaintiff’s injuries

is not equivalent to the designation of a non-party because it cannot

7 result in apportionment of liability, but rather is a complete defense

if successful.” Id. (citing Staley v. Bridgestone/Firestone, Inc., 106

F.3d 1504, 1512 (10th Cir. 1997)); see Staley, 106 F.3d at 1512

(“[Defendant] can only be held liable if its conduct was a

contributing cause of the injury. It surely must be allowed to

defend itself by showing someone else’s action or inaction was the

sole cause of the injury. That is different from apportionment

between two parties both of whose fault contributed to the injury.”).

¶ 22 Dr. Conyers did not seek to apportion fault between him and

the other providers. Instead, he sought to admit evidence that their

care — not his — had caused Ms. Danko’s amputation. Under

Redden, such evidence is admissible even if a nonparty at fault has

not been designated under section 13-21-111.5. Thus, this portion

of the trial court’s rationale was incorrect.

¶ 23 Still, the trial court did not base its evidentiary ruling solely on

section 13-21-111.5. See URS Grp., Inc. v. Tetra Tech FW, Inc., 181

P.3d 380, 387 (Colo. App. 2008) (“[W]e must next consider whether

the judgment may nevertheless be affirmed on one of the alternative

grounds . . . .”); cf. Foxley v. Foxley, 939 P.2d 455, 458-59 (Colo.

App. 1996) (appellant must challenge all of the trial court’s

8 alternative bases for dismissal). So, we turn to whether excluding

evidence related to the negligence or fault of other providers was

proper under Restatement section 457, sometimes called the

original tortfeasor rule.

III. The Trial Court Did Not Abuse Its Discretion by Relying on Restatement Section 457 to Exclude Evidence of Other Providers’ Fault

¶ 24 The trial court found the following under CRE 401 and CRE

402:

Even if Dr. Conyers can establish that [the] other . . . providers were negligent — an assumption made only for purposes of considering [Dr. Conyers’ position] — the Restatement of Torts [section 457] would hold any injuries flowing from this subsequent care as being causally related to the care provided by Dr. Conyers. Accordingly, the necessity of [the] decision to amputate the arm is irrelevant if it resulted from any negligence on the part of Dr. Conyers to not diagnose the infection.

A. Standard of Review

¶ 25 Dr. Conyers urges us to review this ruling de novo. He argues

that the trial court misinterpreted Restatement section 457 by

disregarding an exception to initial physician liability and thus

applied an incorrect legal standard, which raises a question of law.

See Bd. of Cty. Comm’rs v. DPG Farms, LLC, 2017 COA 83, ¶ 34

9 (“Whether the court misapplied the law in making evidentiary

rulings is reviewed de novo.”). And if the court applied an incorrect

legal standard, Dr. Conyers continues, the court abused its

discretion. Id. (“An abuse of discretion occurs where the trial

court’s ruling . . . was based on a misunderstanding or

misapplication of the law.”).

¶ 26 But this argument must be juxtaposed against a trial court’s

broad discretion to admit or exclude evidence. See Mullins v. Med.

Lien Mgmt., Inc., 2013 COA 134, ¶ 35. Thus, while we review the

court’s application of Restatement section 457 de novo, unless it

misunderstood this section, the decision to exclude the evidence

remains within the court’s discretion.

¶ 27 Colorado has adopted the approach set forth in Restatement

section 457, which provides:

If the negligent actor is liable for another’s bodily injury, he is also subject to liability for any additional bodily harm resulting from normal efforts of third persons in rendering aid which the other’s injury reasonably requires, irrespective of whether such acts are done in a proper or a negligent manner.

10 (Emphasis added.) See Redden, 38 P.3d at 81 n.2 (“We recognize

that Colorado case law does not absolve tortfeasors of liability when

the plaintiff’s injuries result from medical treatment reasonably

sought and directly related to the actions of the original tortfeasor.”

(citing Restatement § 457)).

¶ 28 Under this approach,

[i]f the actor knows that his negligence may result in harm sufficiently severe to require such services, he should also recognize this as a risk involved in the other’s forced submission to such services, and having put the other in a position to require them, the actor is responsible for any additional injury resulting from the other’s exposure to this risk.

Restatement § 457 cmt. b (emphasis added).

¶ 29 In successive medical malpractice cases, Restatement

section 457 applies when a later “physician’s treatment is directed

toward mitigating the harm inflicted by the first.” Basanti v.

Metcalf, Civ. A. No. 11-cv-02765-PAB-NYW, 2015 WL 868758, at

*27 n.50 (D. Colo. Feb. 26, 2015) (quoting Daly v. United States,

946 F.2d 1467, 1472 (9th Cir. 1991)). Under such circumstances,

the initial physician is responsible “for the negligent manner in

which a [subsequent] physician or surgeon treats the case or

11 diagnoses the injuries or performs an operation.” Restatement

§ 457 cmt. c; see Cramer v. Slater, 204 P.3d 508, 514 (Idaho 2009)

(Restatement section 457 “generally applies to any subsequent

medical negligence which is necessary to correct an original act of

medical negligence, thereby making acts of subsequent medical

negligence generally foreseeable.”).

¶ 30 Still, “[t]he relationship between the harm inflicted by the first

physician and the treatment initiated by the second is crucial to

holding the first physician liable for subsequent malpractice.” Daly,

946 F.2d at 1471. For example, the Daly court declined to apply

Restatement section 457 to the first physician where a patient

“sought treatment from a second physician for an underlying

ailment rather than for any harm inflicted by earlier treatment.” Id.

at 1472. Thus, under Restatement section 457, if the jury found

Dr. Conyers negligent in failing to diagnose the MBF infection, and

that the infection required further medical treatment, usually he

would be responsible for the negligent manner in which a later

provider treated the infection.

¶ 31 An exception exists, however, to the liability of initial

physicians — they are “not answerable for harm caused by

12 misconduct which is extraordinary . . . .” Restatement § 457 cmt d.

Simply put, such misconduct constitutes a superseding cause. See

Walcott v. Total Petroleum, Inc., 964 P.2d 609, 612 (Colo. App. 1998)

(“[W]hen it appears to the court in retrospect that it is highly

extraordinary that an intervening cause has come into operation,

the court may declare such a force to be a superseding cause.”

(citing Restatement § 435)).

¶ 32 So, the question becomes this: crediting the evidence cited in

Dr. Conyers’ opposition, did the trial court misunderstand

Restatement section 457 by failing to recognize that the amputation

could have constituted such extraordinary misconduct?

¶ 33 Although Dr. Conyers argued for the exception, the trial court

did not mention it. Instead, the court addressed only the role

played by other providers’ alleged negligence. For example, the

court explained that “[e]ven if [Dr. Conyers] is able to establish that

[other] providers were negligent in the services they rendered to Ms.

Danko, this would not absolve [Dr. Conyers] of ultimate liability for

[Ms. Danko’s] losses.” In saying this much, the court did not

misunderstand Restatement section 457.

13 ¶ 34 We are unwilling to equate the court’s mere silence as to the

exception with so fundamental a misunderstanding as Dr. Conyers

asserts, especially in the face of his vigorous advocacy and citation

of authority discussing the exception. See People v. Harris, 633

P.2d 1095, 1098 (Colo. App. 1981) (“Where, as here, the objecting

party expressly raises the question of prejudice and the trial court

nevertheless admits the evidence, it cannot reasonably be assumed

that the court neglected to weigh that factor.”); cf. McGill v. DIA

Airport Parking, LLC, 2016 COA 165, ¶ 31 (“We acknowledge that it

would have been helpful for the court to address CRE 403 in its

written order. However, the fact that it did not do so does not

compel the conclusion that it failed to conduct such an analysis at

all.”). Instead, we conclude that the court discussed only

negligence because it had impliedly rejected Dr. Conyers’ evidence

to support the exception. See, e.g., Janicek v. Obsideo, LLC, 271

P.3d 1133, 1138 (Colo. App. 2011) (“While the trial court did not

explicitly reject homeowners’ contractual interpretation argument,

such a finding was implicit in the court’s ruling that homeowners

were not entitled to claim a homestead exemption.”).

14 ¶ 35 So, having discerned no misunderstanding in the trial court’s

application of Restatement section 457, we take up the court’s

evidentiary discretion.

¶ 36 According to Dr. Conyers, the jury should have heard evidence

related to the fault of the other providers because the facts were

disputed as to whether their misconduct was extraordinary. He

primarily relies on deposition testimony of his limb preservation

expert, who testified that dual therapy cures ninety percent of

patients like Ms. Danko. The expert continued that he was

“shocked” by the amputation, which he said was “unnecessary”

after less than two weeks of dual therapy.

¶ 37 But despite Dr. Conyers’ assertion that the jury should have

heard evidence about whether the amputation fell within the

exception for extraordinary treatment, “[i]f the facts are undisputed,

the court is duty-bound to apply the rules to determine the

existence or extent of a negligent actor’s conduct.” Weems v.

Hy-Vee Food Stores, Inc., 526 N.W.2d 571, 574 (Iowa Ct. App.

1994). Put differently, does the record show a factual dispute

sufficient to have allowed evidence of the other providers’ fault? For

the following three reasons, we conclude that the trial court

15 properly rejected Dr. Conyers’ argument that whether the

amputation was extraordinary was disputed.

¶ 38 First, an “unnecessary” amputation does not equate to

extraordinary misconduct. Indeed, Restatement section 457 gives

the following example: “A’s negligence causes B serious harm. B is

taken to a hospital. The surgeon improperly diagnoses his case and

performs an unnecessary operation . . . . A’s negligence is a legal

cause of the additional harm which B sustains.” Restatement § 457

cmt. c, illus. 1 (emphasis added).

¶ 39 Second, although Dr. Conyers established that amputation

under Ms. Danko’s circumstances is rare, especially where dual

therapy has just begun, both Dr. Conyers and his expert conceded

amputation was a foreseeable risk of failure to diagnose — and

hence delay in treating — an MBF infection. See Redden, 38 P.3d

at 81 (“An intervening cause only relieves the defendant of liability if

it was not reasonably foreseeable.”). After all, the expert’s opinion

that ninety percent of patients are cured with dual therapy

recognizes that ten percent are not. Compare Weems, 526 N.W.2d

at 574 (The court rejected the argument that medical treatment that

resulted in a rare side effect was extraordinary, explaining, “[i]t is

16 immaterial in our analysis that the later injury in this case, spinal

meningitis, was a rare side effect of the medical treatment. The

important evidence was . . . that spinal meningitis was a known

risk of the procedure.”), with Corbett v. Weisband, 551 A.2d 1059,

1075 (Pa. Super. Ct. 1988) (Whether a physician’s misconduct was

extraordinary was a question for the jury where testimony showed

the conduct of the physician was “grossly negligent,” “border[ing] on

insanity,” and a thing that “no sane orthopedic surgeon would ever

do.”).

¶ 40 Third, Dr. Conyers did not present any expert testimony that

the amputation constituted extraordinary misconduct, much less

gross negligence. See Bremer v. Gonzalez, No. 2 CA-CV 2011-0064,

2011 WL 6886073, at *5 (Ariz. Ct. App. Dec. 29, 2011) (unpublished

opinion) (“Du-Brook contends, ‘this case involved unforeseeable and

extraordinary events,’ but identifies no extraordinarily negligent act

or omission by Gary’s treating physician. It merely notes Bremer

had alleged the physician fell below the applicable standard of care.

This is insufficient to support a finding of a superseding cause as a

matter of law.”). As in Bremer, Dr. Conyers’ experts only opined

that “substandard medical care” led to the amputation.

17 ¶ 41 Under these circumstances, the trial court acted within its

discretion in excluding evidence of the other providers’ fault

because Dr. Conyers had not presented any evidence sufficient to

invoke the extraordinary misconduct exception.

¶ 42 Yet, perhaps recognizing that the question was close, the trial

court went further and provided another reason for excluding the

evidence. The order explained that even if admissible under CRE

401 and 402, the evidence should be excluded under CRE 403. We

address this reason next.

IV. The Trial Court Acted Within Its Discretion in Excluding Evidence of Other Providers’ Fault Under CRE 403 ¶ 43 The trial court gave two reasons for excluding any evidence

that other providers’ fault had caused Ms. Danko’s amputation

under CRE 403.

¶ 44 First, the court explained that allowing such evidence “would

result in confusion to jurors” if Dr. Conyers was “permitted to

muddle the waters by calling into question the service rendered by

subsequent doctors, where under the Restatement of Torts [section

457], if the jury finds he was negligent, legally he would be the sole

cause of Ms. Danko’s losses.”

18 ¶ 45 Second, the court noted that “[Ms. Danko’s] counsel also

advised . . . as to his concerns that permitting [Dr. Conyers] to

present testimony questioning the decisions of [other] providers

would result in a ‘trial within a trial,’ potentially exceeding the

14-day period set forth for this proceeding.”

¶ 46 A trial court has broad discretion to exclude relevant evidence

“if its probative value is substantially outweighed by the danger of

unfair prejudice, confusion of the issues, or misleading the jury, or

by considerations of undue delay [or] waste of time . . . .” CRE 403;

see Alhilo v. Kliem, 2016 COA 142, ¶ 9.

¶ 47 Restatement section 457 supports the trial court’s concern

over jury confusion. If the jury found Dr. Conyers negligent, then it

would have to decide whether the other providers’ alleged

“substandard care” rose to the level of extraordinary misconduct.

And herein lies the problem: what constitutes extraordinary

misconduct is not so easily defined. Compare Carmichael v. Beller,

914 P.2d 1051, 1058-59 (Okla. 1996) (Extraordinary medical

treatment is “something which may not have been within a normal

19 effort to render aid . . . for the injuries suffered.”), with Deutsch v.

Shein, 597 S.W.2d 141, 145 (Ky. 1980) (if a “divergence of medical

opinion” exists about the misconduct, it is not extraordinary),

abrogated on other grounds by Osborne v. Keeney, 399 S.W.3d 1

(Ky. 2012).

¶ 48 Restatement section 457 provides two illustrations of

extraordinary misconduct relieving the original tortfeasor of liability

for the subsequent misconduct:

 A nurse, unable to bear the sight of the victim’s intense

suffering, disobeys the surgeon’s instructions and gives an

injection of morphine so excessive she knows it might be

lethal. Restatement § 457 cmt. d, illus. 4.

 The victim takes advantage of a hospital stay to have an

unrelated procedure performed, e.g., the victim’s initial injury

is a broken leg, but examination reveals an unrelated hernia

for which surgery is negligently performed. Restatement

§ 457 cmt. e, illus. 6.

Neither of these scenarios would have been useful in instructing

the jury here.

20 ¶ 49 Instead, the court would have had to draw finer lines than the

jury might have understood between inadmissible testimony that

the other providers’ treatment fell below the standard of care and

admissible testimony that their treatment fell so far below that

standard as to be extraordinary. Compare Williams v. Le, 662

S.E.2d 73, 77 (Va. 2008) (“In order to relieve [the physician] of

liability for his negligent act, the negligence intervening between the

[physician’s] negligent act and the injury must so entirely supersede

the operation of the [physician’s] negligence that it alone, without

any contributing negligence by the [physician] in the slightest

degree, causes the injury.” (quoting Atkinson v. Scheer, 508 S.E.2d

68, 71 (1988))), with Puckett v. Mt. Carmel Reg’l Med. Ctr., 228 P.3d

1048, 1069 (Kan. 2010) (“[W]hether the aspiration resulted from

negligence or not, it was a foreseeable consequence of the treatment

alleged to have been necessitated by [the medical providers’] alleged

negligence. Thus . . . this case is not one of extraordinary

circumstances . . . .”).

¶ 50 As well, allowing evidence of the other providers’ fault would

create a trial within a trial. Ms. Danko sought to blame Dr.

Conyers. If he, in turn, sought to blame the other providers, juror

21 confusion could result. See Hopey v. Spear, No. 13-CV-2220, 2016

WL 9665165, at *6 (C.D. Ill. June 23, 2016) (“Such questioning, if

not reasonably and carefully limited by the court, has the potential

to turn into a ‘trial within a trial,’ and prejudice and confuse the

jury as to what is the relevant, actual issue in this case . . . .”). In

other words, allowing evidence of the other providers’ fault could

have shifted the jury’s focus from Dr. Conyers’ care of Ms. Danko to

the other providers’ care. See Manuel v. City of Chicago, 335 F.3d

592, 597 (7th Cir. 2003) (“If that evidence had been admitted by the

district court, the parties would have no doubt argued over the

truthfulness of those allegations, necessarily shifting the focus of

the trial . . . .”).

¶ 51 Given all this, we conclude that the court acted within its

discretion in excluding this evidence, under both Restatement

section 457 and CRE 403.

V. Jury Instructions

¶ 52 Lastly, Dr. Conyers challenges the trial court’s jury

instructions related to the other providers’ fault. Specifically, the

court gave a midtrial instruction that the “necessity of Ms. Danko’s

amputation . . . is not a matter that you will be asked to deliberate

22 upon.” And at the end of the trial, the court gave Ms. Danko’s

tendered nonpattern instruction saying that she was entitled to

damages for the full extent of injuries, “even if the injuries and

losses she suffered may have been greater due to the course of

medical care and treatment she received thereafter.”

¶ 53 Dr. Conyers also challenges the trial court’s rejection of his

jury instruction on Restatement section 457 and his intervening

cause instruction.

¶ 54 We review jury instructions de novo to determine whether the

instructions as a whole accurately informed the jury of the

governing law. Nibert v. Geico Cas. Co., 2017 COA 23, ¶ 8. If they

did, we review the trial court’s decision to give or reject a particular

jury instruction for an abuse of discretion. Id.

¶ 55 Dr. Conyers argues that the instructions given by the trial

court misstated the law and instead emphasized Ms. Danko’s

theory of causation. These arguments fall short.

¶ 56 As to the midtrial instruction, Dr. Conyers’ liability for

damages resulting from the amputation did not depend on whether

23 it was necessary. See Carter v. Shirley, 488 N.E.2d 16, 20 (Mass.

App. Ct. 1986) (“We see no reason why the rule should not apply to

physicians whose original negligence causes the intervention of a

second physician who either improperly diagnoses the case and

performs an unnecessary operation or makes a proper diagnosis

and performs a necessary operation negligently.”); see also

Restatement § 457 cmt. c. Thus, telling the jury it would not

deliberate on the necessity of the amputation was within the court’s

discretion.

¶ 57 As to the nonpattern jury instruction, recall that the trial court

excluded evidence of the other providers’ fault. For this reason, the

instruction accurately described Dr. Conyers’ liability under

Restatement section 457, if the jury found that he had caused Ms.

Danko’s injury by having failed to diagnose and treat the MBF

¶ 58 Still persisting, Dr. Conyers argues that the nonpattern

instruction should have told the jury that the amputation must

have resulted “from the normal efforts of third persons in rendering

aid which the other’s injury reasonably requires.” To be sure, this

language appears in Restatement section 457 and it was accurately

24 quoted in Dr. Conyers’ tendered instruction. But his argument

misapprehends both “normal” and “reasonably requires.”

¶ 59 Restatement section 457 neither defines “normal” nor offers an

illustrative example. However, comment b to Restatement

section 443 explains as follows:

The word “normal” is not used in this Section in the sense of what is usual, customary, foreseeable, or to be expected. It denotes rather the antithesis of abnormal, of extraordinary. It means that the court or jury, looking at the matter after the event, and therefore knowing the situation which existed when the new force intervened, does not regard its intervention as so extraordinary as to fall outside of the class of normal events. When a negligently driven automobile hits a cow, it is scarcely to be regarded as usual, customary, or foreseeable in the ordinary sense in which that word is used in negligence cases, that the cow, after lying stunned in the highway for five minutes, will recover, take fright, and make a frantic effort to escape, and that in the course of that effort it will charge into a bystander, knock him down, and injure him. But in retrospect, after the event, this is not at all an abnormal consequence of the situation which the driver has created. It is to be classified as normal, and it will not operate as a superseding cause which relieves the driver of liability.

Viewed through this lens, “normal” remains subject to the prior

analysis of “extraordinary.”

25 ¶ 60 Nor must the amputation have been “reasonably required.”

See Whitaker v. Kruse, 495 N.E.2d 223, 225-26 (Ind. Ct. App. 1986)

(“The rationale for permitting recovery under this rule is that the

tort-feasor created the necessity for medical care in the first

instance. So long as the individual seeking medical care makes a

reasonable choice of physicians, he is entitled to recover for all

damages resulting from any aggravation of his original injury

caused by a physician’s misdiagnosis or mistreatment.”); Rine v.

Irisari, 420 S.E.2d 541, 545 (W. Va. 1992) (“[T]he aggravation

caused by the negligent or unskillful treatment by a physician of

the original injury would not have occurred if there had been no

original injury.” (quoting Makarenko v. Scott, 55 S.E.2d 88, 93-94

(W. Va. 1949))).

¶ 61 Instead, the phrase “reasonably required” refers to whether

Ms. Danko was reasonable in seeking medical treatment for the

MBF infection and whether that treatment related to an injury

caused by Dr. Conyers. See Redden, 38 P.3d at 81 n.2; Madrid v.

Safeway Stores, Inc., 709 P.2d 950, 951 (Colo. App. 1985)

(“Although Madrid’s experts testified that the initial surgery was

reasonably required, and was necessitated as a result of the injury

26 to her toe sustained in the fall, the evidence on this issue was in

conflict. Safeway produced testimony by four medical doctors that

the original injury was minor and did not require surgery.”).

¶ 62 The evidence was undisputed that Ms. Danko reasonably

sought medical treatment related to the MBF infection. Dr. Conyers

did not argue that further treatment was unnecessary — only that

he did not cause the MBF infection needing treatment. On this

basis, the issue faced by the jury was whether Dr. Conyers caused

Ms. Danko to seek treatment because he was negligent in neither

diagnosing nor treating the MBF infection. See Rine, 420 S.E.2d at

544 (“Many courts have recognized the rule that, in cases of

successive malpractice, the original medical tortfeasor is liable for

subsequent negligent medical treatment which is undertaken to

mitigate the harm caused by the original medical tortfeasor.”). Dr.

Conyers’ tendered instruction misstated this principle.

¶ 63 Turning to the intervening cause instruction requested by Dr.

Conyers, we conclude that the trial court properly rejected it as

well. First, as discussed in Part III above, the court acted within its

discretion in holding that Dr. Conyers’ opposition and his midtrial

proffer did not include evidence creating a dispute whether the

27 amputation resulted from extraordinary misconduct. Second,

treatment by subsequent providers that merely falls below the

standard of care does not constitute superseding cause. See

Weems, 526 N.W.2d at 574 (“[T]he trial court correctly rejected [the

defendant’s] requested jury instruction on superseding cause”

where “[t]he undisputed evidence revealed that medical treatment

rendered to Weems was not an extraordinary or unforeseeable

act.”).

¶ 64 In sum, we conclude that the jury was properly instructed.

VI. Ms. Danko’s Cross-Appeal

¶ 65 On cross-appeal, Ms. Danko challenges the trial court’s denial

of costs totaling $47,530.75. Dr. Conyers does not dispute

preservation. We affirm in part and reverse in part.

A. Additional Background

¶ 66 On October 21, 2015, Ms. Danko made a settlement offer

under section 13-17-202(1)(a)(I), C.R.S. 2017. Dr. Conyers did not

accept the offer. The verdict exceeded the amount of the offer.

¶ 67 The trial court reduced the recoverable costs below amounts

paid by Ms. Danko in four areas. As to Dr. Lindeque, who testified

for Ms. Danko as a nonretained treating physician — although Ms.

28 Danko had initially endorsed him as a retained expert — the court

reduced costs from $45,000 to $15,000. The court reduced the

costs for ReEntry Rehabilitation Services, which prepared a post-

amputation life care plan, from $15,434.60 to $10,280.73. It

disallowed entirely Ms. Danko’s claim for court reporter fees and

transcript costs totaling $2125.75, all of which involved depositions

of her treating physicians taken by Dr. Conyers. The court also

disallowed $7944.14 claimed for a jury consultant and related

travel expenses.

B. Standard of Review and Law

¶ 68 Awarding costs is within the discretion of the trial court, and

the court’s findings as to the reasonableness and amount of costs

will be disturbed on appeal only for an abuse of discretion. Archer

v. Farmer Bros. Co., 90 P.3d 228, 230 (Colo. 2004). A trial court

abuses its discretion when it acts in a manifestly arbitrary, unfair,

or unreasonable manner. Id.

¶ 69 According to section 13-17-202(1)(a)(I),

[i]f the plaintiff serves an offer of settlement in writing at any time more than fourteen days before the commencement of the trial that is rejected by the defendant, and the plaintiff recovers a final judgment in excess of the

29 amount offered, then the plaintiff shall be awarded actual costs accruing after the offer of settlement to be paid by the defendant.

¶ 70 However, merely by making a statutory settlement offer, a

party cannot “compel a trial court to award actual costs no matter

how unreasonable or unnecessary such expenses may have been.

This would lead to the untenable result that a trial court awards

costs for expenses which never should have been incurred.” Scholz

v. Metro. Pathologists, P.C., 851 P.2d 901, 910 (Colo. 1993). Rather,

in considering whether to award such costs,

[t]he trial court has no discretion to deny an award of actual costs under this statute, so long as it determines that those costs are reasonable. Nonetheless, the trial court holds discretion over the amount of costs to be awarded and may disallow certain requested costs as unreasonable so long as the court includes in the record its reasons for doing so.

Bennett v. Hickman, 992 P.2d 670, 673 (Colo. App. 1999),

superseded by statute on other grounds, Ch. 5, sec. 1, § 13-17-202,

2008 Colo. Sess. Laws 8, as recognized in Miller v. Hancock, 2017

COA 141.

¶ 71 The proper exercise of this discretion requires the trial court to

answer two questions:

30 1. Were the expert’s services reasonably necessary to the party’s case?

2. Did the party expend a reasonable amount for the expert’s services?

Clayton v. Snow, 131 P.3d 1202, 1203 (Colo. App. 2006) (citations

omitted). The answers to these questions may lead to reduction in

the amount of costs awarded. See, e.g., Underwood v. Dillon Cos.,

936 P.2d 612, 616 (Colo. App. 1997) (“On cross-appeal, King

Soopers claims that the trial court abused its discretion in awarding

only half of its requested amount of expert witness fees. We

disagree.”).

¶ 72 “A trial court’s award of costs must be supported by findings

that, considered together with the record, are sufficient to permit a

reviewing court to determine the basis for the award.” Miller, ¶ 46.

Specifically, the findings “must include an explanation of whether

and which costs are deemed reasonable.” Id.

C. Application

¶ 73 Dr. Conyers argues that the trial court properly exercised its

discretion because Ms. Danko incurred some of the reduced costs

before the statutory settlement offer. This argument falls short

because the court made no findings on timing. Instead, it

31 articulated other reasons for reducing the costs claimed, which we

address.

1. Dr. Lindeque

¶ 74 The trial court found:

The invoices submitted by Dr. Lindeque do not differentiate between the time he spent in an expert capacity versus that spent as a treating physician. In researching medical literature, Dr. Lindeque billed 69.5 hours. At trial, the Court was struck by Dr. Lindeque’s testimony about the time spent preparing for trial relative to the period of time he spent treating Ms. Danko. His time treating Ms. Danko was very limited, especially when considering the significance of the procedure [he] performed. By contrast, the time he spent preparing for trial exceeded his time with Ms. Danko by more than tenfold. The Court finds that awarding $15,000 for Dr. Lindeque’s preparation and participation at trial is reasonable under the circumstances of this case.

Ms. Danko does not assert that these findings lack record support.

And the findings explain why the court reduced these costs.

¶ 75 Undaunted, Ms. Danko argues that the court should have

allowed the entire $45,000 charge because Dr. Lindeque testified

“in good faith,” he “professionally and diligently performed” his

32 underlying work, and the court did not find his $500 hourly rate

unreasonable. This argument misses the mark in two ways.

¶ 76 First, Ms. Danko reduces the initial Clayton question — “Were

the expert’s services reasonably necessary to the party’s case?” — to

a binary choice. But doing so would deprive trial courts of

discretion to determine that some, but not all, of an expert’s

services were reasonably necessary. See Underwood, 936 P.2d at

616.

¶ 77 Second, at trial Dr. Lindeque did not testify for Ms. Danko as a

retained expert. And as discussed above, the court precluded all

evidence that the amputation was unnecessary. Given these

limitations, the court concluded that his charges were excessive,

without impugning Dr. Lindeque’s good faith, questioning his

professionalism, or commenting on his credibility. Cf. In re

Marriage of Elmer, 936 P.2d 617 (Colo. App. 1997) (finding half of

fee reasonable in light of charges that trial testimony by expert

witness was duplicative and $14,470 in requested costs was

excessive).

¶ 78 On this basis, we discern no abuse of discretion.

33 2. ReEntry Rehabilitation

¶ 79 The trial court found:

Plaintiff seeks $15,434.60 for ReEntry Rehabilitation Services. Helen Woodard assessed Ms. Danko’s vocational rehabilitation. The report completed, and for which billing is included, also includes review of depositions and review of medical records, which are believed to have little relevance to the development of a post-amputation Life Care Plan. This information is then summarized in 12 pages of a 37-page report. The Court finds that approximately two-thirds of the amount requested for Ms. Woodard, or $10,280.73, is reasonable to award as costs. The $400 cost for setting up the file is regarded as necessary and reasonable.

Again, Ms. Danko does not assert that these findings lack record

support.

¶ 80 Instead, she argues that when the trial court concluded

approximately one third of the report had “little relevance” to the

care plan, the court made an improper credibility determination.

But the court did not mention credibility. Nor does Ms. Danko

explain why the deposition and record review were reasonable and

necessary to develop the life care plan.

¶ 81 Of course, the court’s one-third reduction of the costs claimed

was an approximation based on the portion of the report the court

34 questioned. But “[t]he trial court’s goal when awarding attorney

fees and costs ‘is to do rough justice, not to achieve auditing

perfection.’” Estate of Casper v. Guarantee Tr. Life Ins. Co., 2016

COA 167, ¶ 70 (citation omitted) (cert. granted June 26, 2017).

¶ 82 For these reasons, we cannot say the trial court abused its

discretion in reducing the ReEntry Rehabilitation costs.

3. Court Reporter Fees and Transcripts

¶ 83 The trial court found:

An objection is also presented for the deposition fees totaling $2,125.75 for a number of Plaintiff’s treating physicians, as these were taken when Plaintiff objected to informal discovery by Defendant. The Court agrees that Plaintiff could have cooperated with Defendant’s approach on this point, and this amount of $2,125.75 is disallowed from Plaintiff’s bill of costs.

Here, too, Ms. Danko does not assert that these findings lack record

¶ 84 Rather, she asserts that “[r]egardless of the precipitating

factors for Defendant’s decision to take depositions of Plaintiff’s

treating physicians,” the record does not show that the related

“transcription and reporter fees actually expended were

unreasonable.” But this assertion begs the question of whether, as

35 the court found, Ms. Danko could have avoided these costs. After

all, to recover deposition costs, a party must show “the taking of the

deposition and its general content were reasonably necessary.”

Cherry Creek Sch. Dist. No. 5 v. Voelker, 859 P.2d 805, 813 (Colo.

1993).

¶ 85 Thus, the findings support the discretionary decision to

disallow these costs.

4. Jury Consulting

¶ 86 The trial court found:

Defendant objects to an expense of $6,474.57 for a jury consultant, plus travel expenses of $1,469.57 for travel on short notice. The Court agrees with Defendant that these two expenses are unnecessary to Plaintiff’s counsel [sic] presentation of the case to a jury, and are disallowed.

Unlike the three other findings discussed, this finding does not

involve any factual questions resolvable by record examination.

¶ 87 The parties have not cited, nor have we found, Colorado

authority addressing jury consulting expenses as recoverable costs.

Dr. Conyers cites several unpublished decisions from the United

States District Court for the District of Colorado. Ms. Danko

responds that federal law defines recoverable costs more narrowly

36 than does Colorado law, citing Crawford Fitting Co. v. J.T. Gibbons,

Inc., 482 U.S. 437, 441-42 (1987). She is correct.

¶ 88 Although section 13-17-202(1)(b) does not mention jury

consulting expenses, use of “including” in the statute “means that

the items of ‘actual costs’ listed are illustrative rather than

exhaustive.” Catlin v. Tormey Bewley Corp., 219 P.3d 407, 416

(Colo. App. 2009).

¶ 89 On the one hand, authority in other states is sparse. Citing

federal precedent, one state has held that such expenses are not

recoverable as costs. Delmonico v. Crespo, 127 So. 3d 576, 579

(Fla. Dist. Ct. App. 2012) (“We agree with other jurisdictions which

have held that costs and fees associated with jury consultants are

not recoverable.”); see also City of Shreveport v. Chanse Gas Corp.,

794 So. 2d 962, 979 (La. Ct. App. 2001) (“Here, the District Court

viewed the mock trial and jury consultant as overhead items which

cannot be reimbursed. Given that these exercises were strictly to

aid the attorneys and yielded only marginal results, we cannot say

the District Court abused its great discretion in denying these items

as costs.”).

37 ¶ 90 On the other hand, we recognize that “[r]ising costs of

increasingly specialized lawyers, the need to deploy expensive

experts, jury consultants, and all the associated expenses have

priced some parties out of the market.” Marc Galanter, The

Vanishing Trial: An Examination of Trials and Related Matters in

Federal and State Courts, 1 J. Empirical Legal Stud. 459, 517

(2004) (footnote omitted), cited with approval in State ex rel. Crown

Power & Equip. Co. v. Ravens, 309 S.W.3d 798, 804 (Mo. 2009).

¶ 91 Balancing this limited authority against the concern over

rising litigation expenses leads to considering the policy underlying

our settlement offer statute. “The intent of section 13-17-202 is to

encourage settlements by imposing costs upon a rejecting party in

the event the final result is less favorable to that party than the

offer.” Hall v. Frankel, 190 P.3d 852, 866 (Colo. App. 2008). In

other words, “[t]he purpose of section 13-17-202 is to encourage the

settlement of litigation by increasing the cost of proceeding with a

lawsuit after the opposing party has made a reasonable settlement

offer.” Lawry v. Palm, 192 P.3d 550, 565 (Colo. App. 2008).

¶ 92 These statements of purpose and intent tip the scales in favor

of recovery of jury consulting expenses by a party who made a

38 statutory settlement offer, which was rejected, and did better than

the offer at trial.

¶ 93 Nor would allowing Ms. Danko to recover the jury consulting

expenses contravene the trial court’s discretion over

reasonableness. Recall, the court did not find these expenses

unreasonable, in whole or in part. Rather, the court found them

“unnecessary to Plaintiff’s counsel [sic] presentation of the case to a

jury.”

¶ 94 But the statute does not impose a necessity requirement on

recovery of “actual costs accruing after the offer.” And while

reasonableness has been implied as a precondition to recovery,

reasonableness is a lower standard than necessity. Thus, the

court’s finding of “unnecessary” does not support disallowing this

cost.

¶ 95 In sum, the trial court’s cost award is reversed as to the

$7944.14 jury consulting and related travel expenses. In all other

respects, the award is affirmed.

39 VII. Conclusion

¶ 96 The judgment is affirmed. The trial court’s cost award is

affirmed in part and reversed in part. On remand, the trial court

shall increase the costs awarded to Ms. Danko by $7944.14.

JUDGE GRAHAM and JUDGE TERRY concur.