Dennis Thomas, as Administrator of the Estate of Glenda Thomas v. University Medical Center, Inc. D/B/A University of Louisville Hospital

CourtKentucky Supreme Court
DecidedAugust 17, 2020
Docket2018 SC 000454
StatusUnknown

This text of Dennis Thomas, as Administrator of the Estate of Glenda Thomas v. University Medical Center, Inc. D/B/A University of Louisville Hospital (Dennis Thomas, as Administrator of the Estate of Glenda Thomas v. University Medical Center, Inc. D/B/A University of Louisville Hospital) is published on Counsel Stack Legal Research, covering Kentucky Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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Dennis Thomas, as Administrator of the Estate of Glenda Thomas v. University Medical Center, Inc. D/B/A University of Louisville Hospital, (Ky. 2020).

Opinion

RENDERED: AUGUST 20, 2020 TO BE PUBLISHED

Supreme Court of Kentucky 2018-SC-000454-DG

DENNIS THOMAS, AS ADMINISTRATOR OF APPELLANT THE ESTATE OF GLENDA THOMAS, DECEASED, AND DENNIS THOMAS, INDIVIDUALLY

ON REVIEW FROM COURT OF APPEALS V. CASE NO. 2016-CA-001557-MR JEFFERSON CIRCUIT COURT NO. 09-CI-07333

UNIVERSITY MEDICAL CENTER, INC. APPELLEES D/B/A UNIVERSITY OF LOUISVILLE HOSPITAL; NEUROSURGICAL INSTITUTE OF KENTUCKY, P.S.C.; TODD W. VITAZ, M.D., SARAH C. JERNIGAN, M.D., AND AASIM KAZMI, M.D.

OPINION OF THE COURT BY JUSTICE KELLER

AFFIRMING

Dennis Thomas, in his capacity as Administrator of the estate of his

deceased wife, Glenda Thomas, and in his individual capacity, appeals the

decision of the Jefferson Circuit Court to exclude from evidence a Root Cause

Analysis (“RCA”) and to grant a directed verdict in favor of Neurosurgical

Institute of Kentucky, P.S.C. (“NIK”). The Court of Appeals affirmed the decision

of the Jefferson Circuit Court. Having reviewed the record and considered the

arguments of the parties, we hereby affirm the decision of the Court of Appeals,

though for different reasons. I. BACKGROUND

On August 15, 2008, fifty-year-old Glenda Lee Thomas underwent an

anterior cervical discectomy and fusion procedure, which required a surgical

incision on her neck. The surgery was performed at University Medical Center,

Inc. (“UMC”) by Dr. Aasim Kazmi, a sixth-year neurosurgical resident, under

the supervision of Dr. Todd Vitaz, the attending surgeon.

After the operation, Mrs. Thomas was transported to the post-anesthesia

care unit (“PACU”). She arrived at approximately 2:30 PM. The PACU record

indicates that her breathing was unlabored and regular. At around 5:00 PM

that day, Mrs. Thomas was discharged from the PACU and transferred to the

medical floor. The PACU records indicate that, at the time of discharge, she

was in good condition and oriented, with clear speech and controlled pain.

At approximately 8:00 PM, a nurse noted in Mrs. Thomas’s chart that

she suffered from dyspnea (shortness of breath), labored breathing, and pursed

lips. Soon after, Dr. Sarah Jernigan, a fifth-year neurosurgical resident,

examined Mrs. Thomas. Dr. Jernigan noted swelling in Mrs. Thomas’s neck

and complaints of worsening shortness of breath. However, Dr. Jernigan also

noted that Mrs. Thomas’s speech was fluent, she did not require increased

oxygen, and she was not short of breath during conversation. Dr. Jernigan

further noted that a firm hematoma, three to four centimeters at its largest

diameter, was centered on the neck incision. Dr. Jernigan ordered a steroidal

drug and an x-ray.

2 At approximately 9:00 PM, after the x-rays were completed, Dr. Jernigan

returned to Mrs. Thomas’s bedside. Jernigan noted that Mrs. Thomas was now

wheezing, “having more difficulty breathing,” and could no longer carry on a

conversation. Dr. Jernigan ordered Mrs. Thomas back to the operating room for

wound exploration.

The anesthesiology resident then made his way to Mrs. Thomas’s room to

perform a pre-operative assessment of Mrs. Thomas. As he arrived on her floor,

Dennis Thomas, Mrs. Thomas’s husband, ran out of her room, stating that

“she can’t breathe.” The anesthesiologist and Dr. Jernigan went immediately to

Mrs. Thomas’s bedside and began using an AMBU bag, a manual resuscitator.

The doctors also called a Code 900 and opened the neck incision to evacuate

the hematoma. The Code team arrived but struggled to intubate Mrs. Thomas.

She was taken to the operating room for a tracheostomy and exploration of the

neck wound.

Unfortunately, Mrs. Thomas suffered from anoxic encephalopathy, or

brain injury from lack of blood flow. She passed away a few days later, after

supportive care was withdrawn.

Dennis Thomas, in his capacity as administrator of his wife’s estate and

in his individual capacity, filed a medical negligence suit against UMC, Drs.

Vitaz, Jernigan, and Kazmi, and NIK, a private neurosurgery practice of which

3 Dr. Vitaz was a member.1 He later added claims of negligent training and

supervision.

During discovery, UMC revealed the existence of a “Root Cause Analysis

and Action Plan.”2 This RCA report consists of a chart, in which a series of

questions are asked and answered. For example, beside a box listed

“Equipment factors” is a question: “How did the equipment performance affect

the outcome?” The response listed on the RCA chart is “None.” When asked if

equipment performance was a “Root Cause,” the response is “N” or no. The

RCA asks a series of similar questions, such as “What factors directly

contributed to the outcome?” and “To what degree was the physical

environment appropriate for the processes being carried out?”

At issue in this case is the response to the question “What human factors

were relevant to the outcome?” The reply to this question states, “Medical

management of airway in postoperative patient.” When asked if this was a root

cause, the response is “N” or no. However, in response to the question “Take

action?” the report references “1,” or Action Plan Item No. 1. The Action Plan is

attached to the RCA. Action Plan Item No. 1 states, under the “Risk Reduction

1 By amended complaint, Thomas added as defendants Drs. Mark Glasgow (the attending anesthesiologist who responded to the Code 900) and Maya Leggett (an attending physician who responded to the Code 900). However, by order entered April 3, 2012, the trial court granted motions for summary judgment filed by both doctors, thereby dismissing them from this case. In August 2012, Thomas filed a second amended complaint, which did not include Drs. Glasgow or Leggett. 2 Throughout the record, the RCA report is sometimes referred to as an “RCA/sentinel event report.” The document itself is titled “Root Cause Analysis and Action Plan,” but for ease of reference, we refer to the entire document as the RCA.

4 Strategies” category, “Respiratory/Airway/Assessment Skills: Inservice

education for nursing staff and surgical resident staff to recognize signs and

symptoms of mechanical airway obstruction.” Under the “Responsible

Person(s)” heading, the response is “Nursing Education Residency Coordinator;

Department of Neurosurgery and Department of Anesthesia.” Under the

“Measures of Effectiveness” heading, the response is “Measure: Inservice

education will be provided in November 2008.” Finally, under the “Evaluation

Schedule” heading, it is noted that “100% of individuals involved in incident

will have inservice education by Nursing Education or Attending-level for

Department of Neurosurgery residents and Anesthesia residents.” Later,

depositions of the individuals involved in Mrs. Thomas’s care revealed that

those individuals did not receive the recommended inservice training.

UMC ultimately filed a motion in limine to exclude the RCA report as a

subsequent remedial measure under Kentucky Rule of Evidence (“KRE”) 407.

By order dated January 19, 2016, the trial court granted that portion of UMC’s

motion relating to the RCA report. The court explained, however, that “in

keeping with KRE 407, the Court recognizes that there may be circumstances

under which information contained in the Root Cause Analysis and Action Plan

may be, or become, admissible.” The trial court directed Thomas’s counsel to

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