D.P. v. Wrangell General Hospital

5 P.3d 225, 2000 Alas. LEXIS 47

• Court: Alaska Supreme Court
• Decided: May 19, 2000
• Docket: S-8024
• Status: Published

Opinions

OPINION

MATTHEWS, Chief Justice.

I. INTRODUCTION

D.P. was diagnosed with schizophrenia and admitted to Wrangell General Hospital. The admitting orders stated that D.P. should remain in the building. Although D.P. remained under periodic observation, she walked out of the hospital. During her brief absence, she had sexual relations with a man whom she delusionally believed was either "Jesus" or "a prophet." D.P. sued the hospital and the duty nurse for negligence, and now appeals the superior court's grant of a directed verdict for both defendants. Because we hold that reasonable jurors could differ concerning whether the defendants breached their duty of care regarding D.P., we reverse the superior court's ruling and remand the case for trial.

IIL FACTS AND PROCEEDINGS

A. Facts

D.P., 48, has a history of auditory hallucinations, delusions, and other schizophrenic symptoms. Medication has generally enabled D.P. to control her condition.

D.P. was treated by Dr. David McCandless, a Wrangell general practitioner, and Kathy Koch and Mark Walker, mental health professionals from Wrangell Mental Health Services. In April 1992 Dr. Ulrich Schoettle, a clinical psychiatrist from Seattle, also began seeing D.P. every other month.

In the spring of 1994, D.P.'s caregivers became concerned that she had stopped taking her medication. By May she was significantly more agitated and began to complain of physical distress from the medication. Despite Dr. Schoettle's recommendation of a new antipsychotic drug, D.P. underwent further deterioration by July and began to experience religious delusions.

Early on July 19, Dr. McCandless admitted D.P. to the hospital, diagnosing her with "schizophrenia, psychotic decompensation." In his hospitalization order, Dr. McCandless wrote in part as follows:

Up as tolerated, should stay in building, under observation/suicide precautions.

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For Agitation/Hallncinations/Danger -to self or Others

-Haldol 5-10 mg + Ativan 1-2 mg IM

Q4° pra[¹] OR AS Needed

-~Restraints prn only if danger to self or others.

When D.P. was admitted she was distraught and delusional. During the day D.P. was observed by four nurses, each on different duty shifts. The nurses' notes show that each nurse regularly checked on D.P. at intervals ranging from a few minutes to two hours. D.P. slept intermittently throughout the day, refusing food and medication. She continued to have delusions and was distraught and agitated. At 4:00 p.m. Nurse Elsie Hansen came on duty. During Hansen's shift, D.P. was noticeably more active and "cheerful," walking throughout the hallways and visiting another room. At 6:50 p.m. Hansen's notes indicate "[D.P. is] out in hallway-states she will walk to ER and then lay down in [her room]." At 6:55 p.m. Hansen went to check on D.P. but was unable to locate her. In the intervening five minutes, D.P. had walked out of the hospital.

Once outside the hospital, D.P. met a temporary forest service worker. In her delusional state, D.P. believed that he was either "Jesus" or "the prophet." D.P. and her new acquaintance spoke for several hours, after which they engaged in sexual relations in a local park. At approximately 10:10 p.m., police officers arrived and returned D.P. to the hospital. The next day, Dr. Schoettle had D.P. involuntarily committed to the Alaska Psychiatric Institute (APT).

B. Proceedings

In June 1995 D.P. sued the hospital and Hansen (collectively defendants) for negligence in failing to provide "reasonable and attentive care, including, but not limited to, adherence to physician's orders, regular monitoring and accurate record-keeping." She sought compensatory damages against both defendants and punitive damages against Hansen individually.

The defendants answered, denying D.P.'s allegations of negligence. D.P. then submitted an interrogatory, requesting that the defendants explain their denial of D.P.'s charge that "[njo effort had been made to restrain" D.P. from leaving the hospital. The defendants replied:

The Hospital's employees understood that [D.P.] was not to be permitted to leave the Hospital facility. The nurse on duty checked on [D.P.] from time to time as the nurse felt it was necessary under the circumstances at any particular time. See the medical records, and in particular the progress notes, which document in part the contacts between Hospital employees and [D.P.]. Had any Hospital employee known that it was [D.P.]'s intention to leave the Hospital facility, she would not have been allowed to do so. Unfortunate ly, D.P. did leave the Hospital, but not as a consequence of any failure on the part of any Hospital employee to exercise reasonable care under the circumstances at that time.

D.P. interpreted this answer as an "ironclad" admission of the existence of a duty of care, the standard of care, and the breach of a duty of care. Therefore, D.P. did not designate any expert witnesses, choosing instead to rely solely on the defendants' interrogatory answer.

At a pretrial hearing held January 24, 1997, the superior court ruled that expert testimony was required to establish the standard of care and the breach of a duty of care. At trial on January 27, the court approved D.P.'s request to call defendants' expert witness, Dr. Schosttle, to testify regarding these issues.

D.P. experienced difficulty eliciting information favorable to her case from Dr. Schoettle. She attempted to show that Hansen breached a duty of care by violating Dr. McCandless's "cut and dried" order to keep D.P. in the hospital. Dr. Schoettle testified that a physician's orders should be viewed holistically. He explained that, as a whole, the specific instructions that D.P. should remain in the building, under observation, and with suicide precautions reflected a directive to "be attentive" to the patient, requiring "general observation and supervision."

Dr. Schoettle further testified that hospitals should maintain an "open door policy" for voluntary psychiatric patients, attempting to normalize the patient's environment rather than imposing artificial controls and restraints. He testified that the "Inlormative community standards in hospitals for observations of psychiatric patients are checking every 15[] minutes to a half hour." Dr. Schoettle later clarified that only acutely suicidal patents require observation every fifteen minutes.

After D.P.'s examination of Dr. Schocttle, the defendants moved for a directed verdict under Civil Rule 50, arguing that D.P. had failed to establish either the standard of care or a breach of duty. D.P. argued that Dr. Schoettle's testimony proved that, although some flexibility existed regarding the extent of supervision necessary, none existed regarding whether to permit her exit from the building.

Although the superior court concluded that Dr. Schoettle's testimony had not established a breach, it allowed D.P. to reopen her direct examination of Dr. Schoettle to make this inquiry. After further questioning, Dr. Schoettle testified that the nurses had executed Dr. McCandless's orders within the "norm of community standards." He stated:

I don't see in-in my professional opinion that there was a miscommunication, a negligence, a nursing decision where somebody made it on their own and-and had some wild idea or-or did anything different than I would have expected any nurse to do. Sometimes patients walk out.

Dr. Schoettle also testified that the nurses had observed D.P. with adequate frequency. But Dr. Schoettle acknowledged that the "fact that the patient went out implies [negligence]," although he did not believe that the nurses were negligent. Dr. Schocttle explained that an order to stay in the building is actually "an assumed" order for any patient, psychiatric or otherwise. He noted that even in psychiatric wards, doors are often left unlocked or open, and patients are allowed to commingle.

The court concluded that Dr. Schocttle's testimony had established the standard of care but failed to show a breach of duty by either the hospital or Hansen. It therefore directed a verdict for the defendants and dismissed D.P.'s claims.

III STANDARD OF REVIEW

In reviewing the superior court's decision to grant a directed verdict, we view the evidence in the light most favorable to the nonmoving party.² We will affirm a directed verdict only where reasonable jurors could not reach different conclusions.³

Whether expert testimony is required to show a breach of a duty of care represents a question of law to which we apply our independent judgment. We will adopt the rule of law most convincing in light of precedent, reason, and policy.⁴

IV. DISCUSSION

A. It Was Error to Require D.P. to Present Expert Testimony as to the Breach of a Duty of Care.

The general rule in medical malpractice actions provides that "the jury ordinarily may find a breach of professional duty only on the basis of expert testimony."⁵ "The primary limitation to this rule is that expert testimony is not needed in non-technical situations where negligence is evident to lay people."⁶ $5 D.P. relies on this exception.

The defendants rely primarily on cases discussing whether the health care provider failed to recognize the suicidal or elopement tendencies of the patient or failed to order appropriate precautions.⁷ 'These cases, however, are distinguishable from the present situation because D.P. does not allege that defendants failed to appreciate her mental health status, to recognize a risk of harm to her, or to order reasonable precautions. She instead faults the defendants' failure to follow the ordered precautionary measures.

It remains far from clear that D.P.'s case should be viewed as a "medical malpractice" action. Most courts characterize cases in which the plaintiff alleges a failure to adequately supervise and safeguard the patient as involving "ordinary negligence" issues.⁸ Further, in Alaska, medical malpractice actions are governed entirely by statute.⁹ Alaska Statute 09.55.586(a) sets forth specific procedural requirements for medical mal'practice cases. Under this section, either the parties must submit a malpractice claim to arbitration or the court must appoint an expert advisory panel within twenty days of the answer to the complaint. Neither occurred here. Moreover, the superior court recognized that the parties had failed to treat the action as one for medical malpractice.¹⁰

In Clary Insurance Agency v. Doyle,¹¹ we distinguished between medical malpractice issues and those involving ordinary negligence:

Not every act of a professional requires an instruction on the professional standard of care. Meier v. Ross General Hospital[ ¹²] illustrates the point. Meter involved a wrongful death action by the widow of a suicide victim who had jumped through an unbarred second story window of a hospital. The court concluded that the case supported instructions on both ordinary negligence and medical malpractice. Issues relating to improper medical diagnosis and chemotherapy treatment required an instruction on the professional standard of care. But the court concluded that an instruction on ordinary negligence was appropriate on the question of whether it was negligent to allow the decedent, who was depressed and had previously slashed his wrists, to wander freely around a hospital where there were no bars on the windows.! ¹³]

The defendants unpersuasively rely on Nally v. Grace Community Church of the Valley¹⁴ to distinguish Meter. In Nally, a young man who received informal pastoral counseling committed suicide.¹⁵ Nally simply declined to extend a duty of care "to personal or religious counseling relationships in which one person provided nonprofessional guidance to another seeking advice and the counselor had no control over the environment of the individual being counseled."¹⁶

In view of the numerous authorities holding that a jury may readily determine whether patients known to be a risk to themselves have been adequately supervised, we hold that D.P.'s claims do not raise "strict" medical malpractice issues requiring expert testimony.¹⁷ Whether the hospital exercised reasonable care in supervising D.P. represents a factual question for the jury's resolution un-. der an ordinary negligence framework. We therefore hold that it was error to require D.P. to present expert testimony regarding the hospital's alleged breach of its duty of care.

B. It Was Error Not to Let D.P.'s Case Go to the Jury.

D.P. contends that the superior court should have allowed the jury to consider the testimony of Dr. Schoettle and lay witnesses, in determining the issue of breach.

The defendants respond that no reasonable juror could have found that the defendants were negligent. They emphasize that the hospital is not a psychiatric hospital and lacks "any locked or secure patient facil-it[ies], rooms or wards." The defendants also stress that the standard of care did not require "constant observation." They argue that D.P. conceded both that the nurses had flexibility in implementing the physician's orders¹⁸ and that all except Hansen used reasonable care in observing D.P. They further note that Hansen discovered D.P.'s absence within five minutes.

The issues raised by the defendants concerning their use of reasonable care in supervising D.P. warrant resolution by a jury. D.P.'s pleadings and proposed jury instructions raise ordinary negligence issues. Drawing all inferences in favor of D.P. as the non-moving party, reasonable minds might ""differ as to whether the hospital's efforts to supervise D.P. were adequate in view of her known delusional condition. We conclude that the case should properly go to the jury under a theory of ordinary negligence.

C. The Defendants' Interrogatory Answer Is Admissible to Show the Existence of a Duty of Care.

D.P. argues that the superior court erred by refusing to characterize the defendants' interrogatory answer as an admission of both the existence of a duty and the breach of that duty. Specifically, D.P. asserts that the court erred by labeling this evidence as "discovery" rather than "proof," arguing that it should have been "weighed in the analysis of defendants' motion for a directed verdict."

Civil Rule 33(c) provides that answers to interrogatories "may be used to the extent permitted by the rules of evidence." The defendants' answer in the present case bears directly upon the hospital's duty of care and should have been admitted for that purpose. We therefore hold that the interrogatory answer is admissible on the issue of the defendants' duty of care.¹⁹

V. CONCLUSION

We REVERSE the directed verdicts in favor of the defendants and REMAND this case for a new trial utilizing an ordinary negligence framework.

1 . 'Prn'" is medical shorthand for "as needed."

2 . See Fairbanks N. Star Borough v. Lakeview Enters., Inc., 897 P.2d 47, 53 n. 5 (Alaska 1995).

3 . See id.

4 . See Guin v. Ha, 591 P.2d 1281, 1284 n. 6 (Alaska 1979).

5 . Kendall v. State, Div. of Corrections, 692 P.2d 953, 955 (Alaska 1984) (quoting Clary Ins. Agency v. Doyle, 620 P.2d 194, 200 (Alaska 1980)).

6 . Id.

7 . See, e.g., Rudy v. Meshorer, 146 Ariz. 467, 706 P.2d 1234, 1236-38 (App.1985) (requiring expert testimony to show that psychiatrist "was negligent in his determination that [decedent] was not suicidal"); Dimitrijevic v. Chicago Wesley Mem'l Hosp., 92 Ill.App.2d 251, 236 N.E.2d 309, 313 (1968) (requiring expert testimony to determine "whether defendant doctors failed to exercise ordinary skill and care in not characterizing decedent as a suicidal risk"); Kanter v. Metropolitan Med. Ctr., 384 N.W.2d 914, 916 (Minn.App.1986) (recognizing that expert testimony would assist trier of fact in determining whether nurse should have recognized patients' "potential [suicidal] tendencies").

8 . See, eg., Meier v. Ross Gen. Hosp., 69 Cal.2d 420, 71 Cal.Rptr. 903, 445 P.2d 519, 523, 529 (1968) (where decedent leapt from hospital window, alleged failure to supervise involved only "ordinary negligence" issues since it did not concern "the propriety of any controverted medical diagnosis or treatment"); Paulen v. Shinnick, 291 Mich. 288, 289 N.W. 162, 164 (1939) (where patient leapt from window, "whether [attendant] should have locked the screen ... or [] taken some other precaution to prevent plaintiff's escape, is not a question on which a jury requires the advice of trained psychiatrists"); Stallman v. Robinson, 364 Mo. 275, 260 S.W.2d 743, 745, 749 (1953) (where decedent hung herself with her nightgown, expert testimony not required to determine "whether the patient was reasonably safeguarded and protected, in the circumstances in view of her known condition" because case was not "strictly speaking a malpractice case"); Kent v. Whitaker, 58 Wash.2d 569, 364 P.2d 556, 557 (1961) (action was "not a malpractice case" where patient with known suicidal tendencies strangled herself with plastic tubing while unattended in locked room because it did not concern "improper diagnosis or negligent treatment" but rather "failure of the specific duty of exercising reasonable care to safeguard and protect a patient with known suicidal tendencies from injuring herself"). But see Reifschneider v. Nebraska Methodist Hosp., 222 Neb. 782, 387 N.W.2d 486, 488-89 (1986) (where emergency room patient fell from hospital cart, court refused to find that laypersons could determine whether hospital had duty to restrain or supervise patients on carts).

9 . See AS 09.55.530-.560.

10 . The court, however, did rely on AS 09.55.540 in requiring D.P. to present expert testimony.

11 . 620 P.2d 194 (Alaska 1980).

12 . 69 Cal.2d 420, 71 Cal.Rptr. 903, 445 P.2d 519 (1968).

13 . Doyle, 620 P.2d at 200.

14 . 47 Cal.3d 278, 253 Cal.Rptr. 97, 763 P.2d 948 (1988).

15 . Id. 253 Cal.Rptr. 97, 763 P.2d at 950-52.

16 . Id. 253 Cal.Rptr. 97, 763 P.2d at 957.

17 . D.P.'s arguments for the hospital's breach of its duty involve issues of ordinary custodial care of patients, not specialized care that requires the use of medical judgment: Did the hospital monitor the front door properly? Did the staff take reasonable precautions to prevent D.P. from leaving? We note, however, that in so far as D.P. intends to argue issues that involve specialized medical decisions-such as the appropriate level of physical restraints or medication-she can do so only through expert testimony.

18 . D.P. admitted that the nurses have "all the discretion in the world" as to how closely to observe D.P. and what precautions to take, but argued that "[the one issue they: don't have discretion about is keeping her in the hospital or out of the hospital."

19 . See Alaska R. Evid. 402 ("All relevant evidence is admissible" unless otherwise provided); Alaska R. Evid. 401 ("Relevant evidence means evidence having any tendency to make the existence of any fact that is of consequence to the determination of the action more probable or less probable than it would be without the evidence.").