Florez v. Northshore University Healthsystem

2020 IL App (1st) 190465, 166 N.E.3d 208, 445 Ill. Dec. 179

• Court: Appellate Court of Illinois
• Decided: August 21, 2020
• Docket: 1-19-0465
• Status: Published

Opinion

2020 IL App (1st) 190465

FIRST DISTRICT SIXTH DIVISION August 21, 2020

No. 1-19-0465

JULIEN FLOREZ, a Minor, by His Parents and Next of Friends, ) Appeal from the Aimee Florez and David Florez, ) Circuit Court of ) Cook County. Plaintiff-Appellee, ) ) v. ) ) No. 14 L 13348 NORTHSHORE UNIVERSITY HEALTHSYSTEM, d/b/a ) Evanston Hospital; ARMIN MICHAEL DRACHLER, ) M.D.; NORTHSHORE PHYSICIANS GROUP, LLC, d/b/a ) Northshore Medical Group; ELIZA MEADE, M.D.; ) Honorables JENNIFER LESKO, M.D.; and LISA WEGRZYN, R.N., ) Kay M. Hanlon and ) Thomas Donnelly, Defendants-Appellants. ) Judges Presiding.

JUSTICE HARRIS delivered the judgment of the court, with opinion. Presiding Justice Mikva and Justice Cunningham concurred in the judgment and opinion.

OPINION

¶1 Defendants Northshore University Healthsystem, d/b/a Evanston Hospital; Armin Michael

Drachler, M.D.; Northshore Physicians Group, LLC, d/b/a Northshore Medical Group; Eliza

Meade, M.D.; Jennifer Lesko, M.D.; and Lisa Wegrzyn, R.N. (collectively “defendants”) appeal

the judgment of $50.3 million entered in favor of plaintiff after a jury trial. On appeal, defendants

contend (1) the trial court erred in striking defendants’ supplemental disclosures of their previously

disclosed expert witnesses, where the disclosures were made in response to plaintiff’s

supplemental filing, (2) the trial court abused its discretion in excluding all evidence of Julien

Florez’s autism diagnosis, and (3) opposing counsel’s remarks during closing argument for the No. 1-19-0465

jury to “make a statement” concerning the preciousness of children’s lives constituted reversible

error. For the following reasons, we reverse and remand for a new trial.

¶2 I. JURISDICTION

¶3 On October 9, 2018, after a jury trial, the trial court entered judgment on the verdict in

favor of plaintiff. Defendants filed a motion for a new trial, which the trial court denied on

February 7, 2019. Defendants filed their notice of appeal on March 6, 2019. Accordingly, this

court has jurisdiction pursuant to Illinois Supreme Court Rule 301 (eff. Feb. 1, 1994) and Rule 303

(eff. July 1, 2017), governing appeals from final judgments entered below.

¶4 II. BACKGROUND

¶5 A. Pretrial

¶6 Plaintiff filed a complaint against defendants, alleging medical negligence regarding the

birth of Julien on March 22, 2009. Defendants responded, and discovery commenced with an

original trial date of May 15, 2018. On March 16, 2018, 59 days before trial, plaintiff sought to

disclose a new witness, Dr. Allecia Wilson, and to supplement disclosures provided by various

expert witnesses. The trial court granted plaintiff’s request over defendants’ objection.

¶7 On May 10, 2018, defendants received Julien’s medical records from treatment in

Michigan spanning a period of six months. Defendants moved to continue the trial date, but the

court denied the motion. The case was assigned to another judge for trial, but that judge had a

scheduling conflict. She informed the parties that she could either continue the trial or return it for

reassignment to another judge. She indicated that if she retained the case, she would allow

defendants to take limited discovery of the newly disclosed medical records. Defendants chose to

have the case reassigned, and the trial date was moved to September 18, 2018.

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¶8 On July 25, 2018, 56 days before trial, plaintiff supplemented his answers to written

discovery with “a copy of the June 25, 2018 Psychological Evaluation for Julien Florez from the

Center for Neuropsychology and Behavioral Health.” The evaluation was conducted by Dr. Crystal

Young, one of Julien’s treaters in Michigan. Dr. Young’s report stated that Julien was referred to

her for a cognitive assessment and “evaluation of possible Autism Spectrum Disorder (ASD).” Dr.

Young performed five tests: Wechsler Intelligence Scale for Children, Peabody Picture

Vocabulary Test, Autism Diagnostic Observation Schedule, Developmental Disability—

Children’s Global Assessment Scale, and Vineland Adaptive Behavior Scales. She also conducted

a clinical interview and reviewed records.

¶9 Dr. Young concluded that the “[t]est results are suggestive of Moderate Intellectual

Disability” and most individuals in this category “will not exceed an early elementary level of

acquired academic skill development.” She noted that “Mrs. Florez’[s] description of Julien’s

current ability to recognize some printed words, add, and count to 100, also appears broadly

consistent with these expectations.” She further concluded that “[f]rom a social and emotional

perspective, Julien meets full diagnostic criteria for Autism Spectrum Disorder.” She stated in her

report that ASD “is a childhood developmental disorder characterized by severe and pervasive

impairment in reciprocal social interaction skills and communication as well as the presence of

restricted repetitive and/or stereotyped patterns of behavior, interests, and activities.”

¶ 10 Defendants forwarded the report to their experts and filed their supplemental disclosures

on August 9, 2018. Defendants’ experts opined that Julien’s autism diagnosis supported the

conclusion that his disabilities resulted from a chronic condition rather than an acute injury

occurring at birth. Defendants also sought to supplement its answers to disclose Dr. Young as a

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witness. Plaintiff moved to strike the supplemental disclosures, arguing that defendants were

“trying to inject this new issue into the case.” They also argued that the disclosures were untimely,

since they were filed less than 60 days before trial.

¶ 11 The motion judge agreed with plaintiff, finding that Illinois Supreme Court Rule 218(c)

(eff. July 1, 2014) requires all discovery to be completed no later than 60 days before trial. On the

day of trial, defendants moved to continue the trial to conduct additional discovery, and to reinstate

the supplemental disclosures stricken by the motion judge. The trial court denied the motions. The

court stated that it “checked the dates” and “didn’t hear anybody say something that raised a red

flag to me misrepresenting the dates.”

¶ 12 Plaintiff subsequently filed motion in limine No. 19 “barring any reference to autism” at

trial. Plaintiff’s motion stated that the record contained references to “a possibility of autism,” and

“[t]he term autism has also come up during the depositions of some treating physicians and

experts.” Plaintiff alleged that no witness would testify for either party that Julien is autistic.

Furthermore, “[n]one of plaintiffs’ or defendants’ experts have offered an opinion—neither in a

discovery deposition nor Rule 213 disclosure—diagnosing Julien Florez with autism.” See Ill. S.

Ct. R. 213 (eff. Jan. 1, 2018). Plaintiff alleged that “autism implies a genetic component to the

brain dysfunction,” and no expert testified that Julien has a genetic condition that led to his brain

injury. Therefore, autism is irrelevant to the issues at trial and mentioning autism would only serve

to confuse the jury. The trial court granted plaintiff’s motion in limine.

¶ 13 B. Trial

¶ 14 Testimony at trial established that Aimee was admitted to Evanston Hospital on March 22,

2009, five days past her due date. All tests and ultrasounds performed prior to her admission

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registered normal. Dr. Jennifer Lesko examined Aimee at 12:24 p.m.; as part of the exam, she

observed the fetal heart rate as indicated by the fetal monitor. Dr. Lesko explained that the fetal

heart rate will accelerate and decelerate. Although accelerations are generally reassuring, there are

two types of decelerations worth noting: variable decelerations, in which the drop in heart rate

lasts less than 30 seconds and has no temporal relationship to uterine contractions, and prolonged

decelerations, where the baby’s heart rate drops for more than two minutes before returning to

baseline. The fetal heart rate is also monitored for fluctuation or variability. Moderate variability,

defined as the fluctuation of the heart rate of more than 6 but less than 25 beats per minute, is a

reassuring sign for fetal health. Conversely, where variability is minimal or absent, this may

indicate a lack of oxygen to the baby.

¶ 15 At around 2:40 p.m., they broke Aimee’s “bag of waters to help with getting contractions

to be a little bit more frequent.” Dr. Lesko stated that “the abrupt release of water *** can

sometimes cause the baby to have a deceleration.” At 2:45 p.m., the monitor showed the baby

experienced a prolonged deceleration. Dr. Lesko testified that the deceleration was consistent with

the breaking of the bag of waters. At 3:45 p.m., Aimee was given an epidural. Dr. Lesko agreed

that the prolonged deceleration noted at this time was “consistent with when her epidural was being

placed.” During her attendance of Aimee, Dr. Lesko noted variable decelerations in the baby’s

heart rate but it always returned to baseline. She assessed the decelerations as moderate.

¶ 16 Around 5:30 p.m., Aimee had not made significant progress in labor, and Dr. Lesko

considered administering Pitocin. Pitocin increases the strength and frequency of contractions to

achieve vaginal delivery. In her notes, Dr. Lesko wrote that she did not start Aimee on Pitocin

because “given [her] remoteness from delivery and frequency of prolonged decels, [she] may not

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make it to have the normal spontaneous vaginal delivery. Patient aware that she may require a c-

section.” Dr. Lesko testified that although she did not recommend using Pitocin at the time, she

wrote that she “would consider it.” Around this time, she communicated with Dr. Drachler, who

was taking over Aimee’s care. In her notes, she wrote that he was “aware and in house.”

¶ 17 Dr. Drachler ordered that Pitocin be administered “slowly” in order to augment Aimee’s

labor. Nurse Wegrzyn testified that at 5:32 p.m., she began administering 2 milliunits of Pitocin to

Aimee. At 6:25 p.m., Dr. Drachler formed a care plan to perform a c-section if one of the following

events occurred: (1) variability in the baby’s heart rate changed from moderate to minimal for

more than 30 minutes or (2) if decelerations recurred. By 6:30 p.m., Nurse Wegrzyn increased the

dose of Pitocin to 8 milliunits. After 7 p.m., the fetal monitor strip showed a prolonged

deceleration. Dr. Drachler ordered a c-section at 9:40 p.m. and Julien was delivered at 10:35 p.m.

Dr. Drachler testified that he monitored Julien’s heart rate throughout the night and noted moderate

variability. He did not believe that the monitor showed minimal variability “until the end.”

¶ 18 Nurse Wegrzyn testified that she attended to Aimee most of the day and through the time

of her delivery. She noted the variable decelerations of the baby’s heart rate, and she testified that

the prolonged decelerations she observed would be concerning “at that moment,” but overall she

was not worried “[b]ecause the variability is still moderate.” Nurse Wegrzyn stated that

“[v]ariables are not super concerning to us. It’s—I mean, a baby could roll on a cord.” She would

not bring all repetitive variable decelerations to the doctor’s attention “because we see those all

the time.” However, she stated that a prolonged deceleration “is different.”

¶ 19 Nurse Wegrzyn testified that she noted minimal variability at 9:10 p.m. and the baby’s

heart rate never improved. They tried certain maneuvers to assist the baby’s heart rate, including

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moving the mother’s positioning, administering oxygen, and ceasing the use of Pitocin. At 9:40

p.m., Dr. Drachler recommended a c-section. Nurse Wegrzyn stated that fetal monitoring ceased

at 10:11 p.m. up to Julien’s delivery. She was in the operating room when Julien was born and

noticed meconium-stained fluid. Previously, she had not observed any fluid that was stained. At

birth, Julien’s Apgar score was “1,” which she agreed was “bad.”

¶ 20 Dr. Drachler testified that when he was born, Julien was “in bad shape.” He was lifeless

and blue, and his heart had to be pumped to get circulation to his brain. Bradycardia, or an

abnormally low heart rate, was present. Dr. Dalia Feltman, a neonatologist, handled Julien’s

resuscitation. A tube was inserted in his airway and a ventilator assisted his breathing for the first

55 minutes of Julien’s life. Dr. Feltman testified that lab results showed the presence of metabolic

acidosis, which is one criteria to initiate body cooling. Body cooling is performed by placing the

baby on a cooling blanket in order to lower the body temperature. Dr. Feltman testified that cooling

the baby’s overall temperature “is supposed to slow that further [brain] injury from happening.”

¶ 21 Dr. Feltman stated that before subjecting Julien to body cooling, she also observed his

physical condition. She explained that when the brain does not appear to be “acting normal” at

birth, it could be a sign of hypoxic ischemic encephalopathy, or HIE. Julien exhibited signs of

brain dysfunction, such as lethargy and decreased spontaneous activity, so body cooling was

administered. Within five hours of his birth, Julien showed signs of seizure activity, and he was

given phenobarbital, an antiseizure medication.

¶ 22 1. Plaintiff’s Expert Witnesses

¶ 23 Plaintiff presented Nurse Kathleen Lagana on the issue of whether Nurse Wegrzyn

complied with the standard of care in attending to Aimee prior to Julien’s birth. Specifically, Nurse

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Lagana opined about the use of Pitocin. She explained that contractions reduce the oxygen flow to

the baby, and contractions that are too frequent do not allow the placenta enough time to replenish

the oxygen reserves. As a result, oxygen flow to the baby is reduced. Nurse Lagana stated that

Aimee should not have received Pitocin, given the decelerations observed throughout the

afternoon. They needed to figure out what was causing the decelerations, and they did not want to

“make it worse by making stronger contractions or closer together contractions.” The standard of

care required Nurse Wegrzyn to inform Dr. Drachler that Aimee was not tolerating labor and that

Pitocin was “contraindicated.” Nurse Lagana opined that Pitocin caused an excessive contraction

pattern in Aimee.

¶ 24 Dr. Martin Gubernick testified as plaintiff’s obstetrics expert. Dr. Gubernick reviewed the

fetal monitor strip and noted that following the administration of Pitocin, variability decreased

from moderate to minimal, and accelerations disappeared. The strip indicated a prolonged

deceleration at 7 p.m. Over the next two hours, before Dr. Drachler ordered a c-section, Nurse

Wegrzyn documented repetitive decelerations. He noted that variability in the heart rate remained

minimal for three hours leading up to the c-section. Dr. Gubernick opined that Dr. Drachler

deviated from the standard of care when he started Pitocin and failed to discontinue the drug when

the fetal monitor strip showed a deterioration in the baby’s condition, failed to communicate to

Aimee the signs of fetal distress, and failed to recommend a c-section at least two hours earlier.

¶ 25 Dr. Ronald Gabriel testified as an expert on brain injury. He noted that all measures of the

baby’s condition were normal when Aimee was admitted to the hospital. Bradycardia was

observed at 10:11 p.m., and it persisted “into at least the first five and probably approaching the

first ten minutes of life.” Dr. Gabriel explained that HIE refers to a condition involving “an

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abnormality of the brain” (encephalopathy), resulting from reduced oxygen in the blood (hypoxia)

and reduced blood flow to the organ (ischemia). He agreed that cooling Julien’s body was the

correct procedure to address HIE. Dr. Gabriel opined that Julien’s brain injury occurred “sometime

after *** 10:11 at night.” He came to that conclusion because Julien was bradycardic at birth and

the bradycardia resulted in his brain damage. As additional support for his conclusion, Dr. Gabriel

pointed to an EEG that showed Julien’s brain suffered ischemia as evidenced by “bursts which is

classic for acute lack of oxygen.” An MRI “showed an acute injury to the brain diffuse particularly

in the white matter.”

¶ 26 Dr. Gabriel also pointed to Julien’s present condition as support. Although Julien has

cerebral palsy, his “motor system” significantly benefitted from the cooling and he is much better

than he would have been without the cooling. “The cooling, however, did not have a major impact

on his intelligence or his language. *** He only has about 50 words now approaching ten years of

age and [he’s] barely understandable.” Dr. Gabriel concluded that Julien’s brain injury occurred

shortly before delivery through the first five plus minutes after delivery.

¶ 27 Dr. Robert Zimmerman, a pediatric neuroradiology expert, testified that an MRI taken on

March 27, 2009, showed a hypoxic-ischemic injury of the brain. He opined that the injury occurred

near the time of birth due to the baby’s appearance at birth, and the swelling as shown on the MRI.

A hypoxic-ischemic injury occurring at birth causes damage to brain tissue, which then swells.

This swelling occurs during the acute phase of the injury and only remains visible for five or six

days.

¶ 28 Dr. Allecia Wilson testified as a placental pathologist. She reviewed Aimee’s placental

pathology slides and observed nothing to suggest the placenta contributed to Julien’s brain injury.

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She stated that “the hallmark” of placental insufficiency is growth restriction in the baby. The baby

“will not have the proper weight, the proper length, and the proper head circumference.” Since

Julien’s measurements were normal, Dr. Wilson concluded that Aimee’s placenta was “perfusing

normally.” She did not believe that the weight ratio between placenta and baby was abnormal,

based on Julien’s head circumference, weight, and length.

¶ 29 Evidence presented at trial showed that Julien has global delays; exhibits poor strength,

balance, and coordination; and has significant speech and language deficits. He requires physical,

occupational, and speech therapy. Julien needs help with eating, getting dressed, and for personal

hygiene. He also requires 24-hour supervision. Dr. Gary Yarkony examined Julien and developed

a plan outlining his lifetime minimal care needs and costs of this care. The present value of the

costs of care ranged from $10,489,279 to $11,240,699. The latter amount represented the cost if

Julien attends a private school that includes therapy, as opposed to attending public school and

receiving outside therapy. Since Julien will not be able to work, plaintiff’s vocational expert, David

Gibson, concluded that his future lost earnings ranged from $2,525,775 to $4,335,511.

¶ 30 2. Defendants’ Expert Witnesses

¶ 31 Nurse Marcia Patterson opined that Nurse Wegrzyn met the standard of care for an

obstetrical nurse. She noted the tracings on the fetal monitor strip but disagreed that the

decelerations observed in the afternoon were concerning. Julien’s heart rate always returned to

baseline which indicated further monitoring rather than a c-section. Although several variable

decelerations occurred that evening, Julien’s heart rate returned to the baseline, which indicated

moderate variability. She testified that a c-section was ordered because although the baby’s heart

rate showed moderate variability, Aimee’s labor was not progressing and a prolonged deceleration

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occurred in the evening. Nurse Patterson also opined that the use of Pitocin was appropriate here

because Aimee needed assistance to move along her labor. She stated that the amount of Pitocin

administered was within standard practice, and it helped to bring the rate of Aimee’s contractions

under control. In reviewing the fetal heart tracings, Nurse Patterson did not find any indication of

excessive contractions connected to the use of Pitocin.

¶ 32 Dr. Julie Jensen, an obstetrician and gynecologist, testified that Julien’s heart rate

throughout the afternoon was not concerning because it always returned to its baseline with

moderate variability. Furthermore, the decelerations correlated with routine procedures, such as

breaking the bag of waters, applying an epidural, and changing the mother’s position. She stated

that Julien’s condition was “very stable.” She opined that defendants properly monitored the

situation and took appropriate measures such as providing Aimee with oxygen, changing her

position, and increasing her intravenous fluids.

¶ 33 Dr. Jensen disagreed with Dr. Gubernick and Nurse Lagana’s interpretations of the fetal

monitor tracings. She testified that the tracings showed a normal baseline with moderate variability

and that the heart rate did not drop to minimal variability until after the prolonged deceleration at

9:24 p.m. She observed, however, that even then Julien’s heart rate returned to baseline. Dr. Jensen

also disagreed with plaintiff’s experts that Dr. Drachler should have ordered a c-section prior to

this prolonged deceleration because nothing on the strip supported a reason to call for one. Dr.

Jensen opined that Dr. Drachler complied with the standard of care when he ordered the c-section

at 9:30 p.m.

¶ 34 Dr. Alan Bedrick and Dr. Michael Scher testified as to the cause and timing of Julien’s

brain injury. Both stated that the tracings on a fetal monitor strip are only “one part of the puzzle”

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in determining whether an HIE injury occurred at birth. Rather, “it’s critical to look at the cord

blood gases and the tracing together, and not just the tracing [by] itself.” Dr. Bedrick testified that

the examination of the cord blood gases did not support plaintiff’s theory that Julien experienced

minimal variability leading to bradycardia, which led to HIE injury at birth.

¶ 35 They also agreed that the evidence showed Julien was already significantly injured by

March 22, and nothing happened during labor that exacerbated the injury. Dr. Scher explained that

HIE can have both acute and chronic causes. In his opinion, Julien’s condition was chronic due to

the small size of the placenta which, as a result, could not supply Julien with sufficient oxygen. He

stated that the fetal-placenta ratio should be 5:1 or 6:1, but, in Julien’s case, it was 10:1, which

indicated a big baby and that the “placenta was super small.” He believed Julien suffered from

chronic asphyxia in utero, which caused his brain damage. Although Julien continued to grow, the

placenta did not, and that caused injury to his brain, lungs, and heart “over a long period of time

in the womb.”

¶ 36 Dr. Bedrick testified that an echocardiogram showed the blood vessels in Julien’s lungs

were thickened and such a condition takes weeks or even months to develop. Julien’s inability to

breathe on his own at delivery, and his bradycardia, supported this conclusion because they

indicated that Julien’s brain and lungs were too damaged to make that transition. Dr. Scher testified

that the thickened blood vessels in Julien’s lungs were caused by lack of blood flow and oxygen.

The echocardiogram also showed that Julien suffered from severe arterial hypertension, which

thickens the heart muscles. The condition indicates that the heart is not pumping blood well. Dr,

Scher testified that this thickening develops weeks before a baby is born and does not occur soon

after birth.

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¶ 37 Both doctors testified that the fact Julien experienced seizures within five hours of birth

supported their conclusion that he did not suffer an acute hypoxic event shortly before birth. Such

seizures typically take 12 to 36 hours to develop after an injury. Since Julien had seizures within

five hours of delivery, it is more likely that the injury occurred prior to labor. Dr. Bedrick also

noted that Julien was limp when he was born, and if his neurological problem resulted from

something that happened shortly before his birth, he would be limp and “stay limp.” In this case,

however, Julien developed very rapid onset of hypertonia (high muscle tone) within 24 hours of

being born *** and that is much more consistent with a brain injurious event occurring before.”

¶ 38 Dr. Edwina Popek testified about the condition of the placenta. She explained that one

umbilical vein takes oxygenated blood from the placenta to the fetus and two umbilical arteries

take deoxygenated blood and waste back to the placenta. She stated that there was evidence of

inflammation within the umbilical cord and “the only cause that we have is the presence of

meconium.” Meconium-laden macrophages found in the layers of the placenta meant that “some

time has gone by since the meconium got into the amniotic cavity.” The umbilical artery also

showed evidence of injury associated with exposure to meconium. Dr. Popek believed “it takes

approximately 16 hours of heavy exposure to meconium” to observe such an injury.

¶ 39 Dr. Popek also remarked on the size of the placenta in relation to Julien, noting that it was

small. She stated that babies can continue to grow with a small placenta because the organ has

about a 30 percent reserve capacity. The baby may be fine for a while, but then “the placenta

doesn’t have enough oomph to get the baby through those last stages of the pregnancy.”

¶ 40 Dr. Richard Towbin testified regarding the timing of Julien’s injury. Based on the MRI, he

determined that Julien’s injury must have occurred at least seven days earlier, between March 12

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and March 20, 2009. He explained that there are three phases of brain injury. The acute phase of

the injury “is where the dominant feature is swelling.” The swelling peaks a few days after the

injury and, as it subsides, fluid takes its place. This second, subacute phase can last for weeks or

months. The last phase, chronic, is reached when these injury-related changes end. Dr. Towbin

testified that the MRI showed Julien’s brain was already transitioning from the acute to subacute

phase, which could not happen if he had been injured at or around his birth. He disagreed with Dr.

Zimmerman’s conclusion that, based on the MRI, Julien’s injury occurred at the time of birth. Dr.

Zimmerman’s opinion did not account for the fact that Julien had been placed on a cooling blanket

which slows the rate of damage to the brain.

¶ 41 Dr. Scott Hunter testified as an expert in the evaluation of children’s cognitive abilities and

their current and future needs. He reviewed Dr. Yarkony’s life care plan for Julien and Dr.

Gibson’s economic plan. He stated that it was too early to assume Julien would never be able to

live independently or be employable. He found that Julien’s nonverbal reasoning ability was

low/average, but with the proper interventions, Julien could have “areas of independence.” Dr.

Hunter believed that Dr. Yarkony’s opinion reflected “a worst-case scenario” for Julien.

¶ 42 Outside the presence of the jury, defendants made several offers of proof. Dr. Bedrick and

Dr. Scher would testify that the autism diagnosis supported their opinion that Julien suffered from

chronic uteroplacental oxygen insufficiency, resulting in injury before birth. Dr. Scher would state

that from his knowledge, autism spectrum disorder is either “a genetic problem at conception or

acquired or both. And the acquired injury fits into the general uteroplacental insufficiency problem

because of the areas of the brain that are injured.” It is “one more piece of evidence” in determining

the timing and cause of Julien’s brain injury. Dr. Scher would opine, to a reasonable degree of

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medical certainty, that an autism diagnosis “is consistent with and supportive of my opinion that

Julien Florez did not suffer from an acute injury at or around the time of labor and delivery.” Dr.

Scher would testify that in his review of the records, he did not find a previous confirmed diagnosis

of autism. The only references to the disorder came from school psychologists without objective

testing to support it. Without an objective test to confirm an autism diagnosis, Dr. Scher could not

offer an opinion to a reasonable degree of medical certainty that Julien had autism, nor could

autism be a basis of his opinion.

¶ 43 Dr. Hunter would testify that the autism diagnosis “provides a much stronger understanding

of *** [Julien’s] neurodevelopmental profile.” Specifically, that his language deficits do not reflect

an intellectual disability; rather, they reflect “a neurodevelopmental disorder that affects

language.” From his experience working in the area of evaluating children’s cognitive abilities and

assessing their current and future needs, Dr. Hunter would find the autism diagnosis “to be a critical

component to understanding both where Julien is now, *** and what he needs to actually allow

him to be successful.” Dr. Hunter would agree with Dr. Scher that the prior references to autism

in the record did not constitute an actual diagnosis. While recommendations for formal testing

were made, Julien did not undergo such testing, or obtain an actual diagnosis, until Dr. Young’s

evaluation. Until that time, Dr. Hunter “had no data that would suggest that [autism] had been

identified or diagnosed.”

¶ 44 In her offer of proof, Aimee would testify that prior to the family moving to Michigan,

none of Julien’s providers, teachers, or doctors had diagnosed him with autism. Although he had

deficits associated with autism spectrum disorder, he was not diagnosed with the disorder in

Florida. She would confirm that no physicians in Florida indicated to her that Julien may be autistic

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and that one physician, Dr. Jeffrey Brosco, told her that Julien was not on the autism spectrum.

Aimee confirmed that Julien now attends a school for autistic children.

¶ 45 Following closing arguments, the jury returned a verdict in favor of plaintiff for $50.3

million. Defendants filed a motion for a new trial, which the trial court denied. The court did not

believe that defendants were “materially prejudiced” by the exclusion of Julien’s autism diagnosis

because “[a]utism doesn’t seem to be material to this case.” It found that autism is “at best, an

alternative. *** Material to me means related to the substance of what your theory of the defense

is. And I just didn’t find that.” This appeal followed.

¶ 46 III. ANALYSIS

¶ 47 Defendants contend that the trial court erred in striking their supplemental disclosures

pursuant to Illinois Supreme Court Rule 213(f) (eff. Jan. 1, 2018) as untimely under Rule 218(c)

and excluding any reference to Julien’s autism diagnosis at trial. The issue here is not simply

whether the trial court properly struck defendants’ supplemental answers because they were filed

less than 60 days before trial. The question we must answer is whether Rule 213(i) and Rule 218(c)

allow defendants to file supplemental answers less than 60 days before trial, where they filed their

answers in response to additional information plaintiff himself filed less than 60 days before trial.

See Ill. S. Ct. R. 213(i) (Jan. 1, 2018); R. 218(c) (eff. July 1, 2014). Although the admission of

evidence pursuant to Rule 213 lies within the sound discretion of the trial court (Sullivan v. Edward

Hospital, 209 Ill. 2d 100, 109 (2004)), interpretation of the supreme court rules is reviewed de novo

(Vision Point of Sale, Inc. v. Haas, 226 Ill. 2d 334, 342 (2007)).

¶ 48 It is well-settled that reviewing courts should interpret the rules “in the same manner as

statutes.” Id. When construing a supreme court rule, our primary goal is to ascertain the intent of

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the drafters as indicated by the language used, given its plain and ordinary meaning. Ferris,

Thompson & Zweig, Ltd. v. Esposito, 2017 IL 121297, ¶ 22. In making this determination, “a court

must consider the rule in its entirety, keeping in mind the subject it addresses and the apparent

intent of the drafters in enacting it.” Id. We interpret the rules so that no part is rendered

meaningless or superfluous, nor will we depart from the plain language of the rule by reading into

it exceptions, limitations, or conditions that conflict with the expressed intent. Id.

¶ 49 Rule 213(f)(3) provides that, upon written interrogatory, each party must disclose the

subject matter, conclusions, and opinions “and the bases therefor,” of controlled expert witnesses

who will testify at trial. Ill. S. Ct. R. 213(f)(3) (eff. Jan. 1, 2018). The purpose of Rule 213(f) “is

to prevent unfair surprise at trial, without creating an undue burden on the parties before trial.” Ill.

S. Ct. R. 213, Committee Comments (adopted Mar. 28, 2002). The information disclosed in a Rule

213(f) answer, or in a discovery deposition, “limits the testimony that can be given by a witness

on direct examination at trial.” Ill. S. Ct. R. 213(g) (eff. Jan. 1, 2018). Each party also has a

continuing duty “to seasonably supplement or amend any prior answer or response whenever new

or additional information subsequently becomes known to that party.” Ill. S. Ct. R. 213(i) (eff. Jan.

1, 2018); Warrender v. Millsop, 304 Ill. App. 3d 260, 265 (1999). The rule’s disclosure

requirements “are mandatory and subject to strict compliance by the parties.” Sullivan, 209 Ill. 2d

at 109.

¶ 50 While Rule 213 provides no specific time limit within which to file supplemental answers,

Rule 218(c) states that the “dates set for the disclosure of witnesses *** and the completion of

discovery shall be chosen to ensure that discovery will be completed not later than 60 days before

the date on which the trial court reasonably anticipates that trial will commence.” Ill. S. Ct. R.

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218(c) (eff. July 1, 2014). Together, Rules 213(f)(3), 213(i), and 218(c) ensure that the “parties

disclose the subject matter, conclusions, opinions, bases, qualifications, and all reports of a witness

who will offer opinion testimony,” no later than 60 days before trial. See Scassifero v. Glaser, 333

Ill. App. 3d 846, 855 (2002); Gee v. Treece, 365 Ill. App. 3d 1029, 1035-36 (2006).

¶ 51 Rules 213 and 218, however, should “be liberally construed to do substantial justice

between or among the parties.” Ill. S. Ct. R. 213(k) (eff. Jan. 1, 2018); R. 218(c) (eff. July 1, 2014).

Accordingly, this court has held that Rule 218(c) does not automatically require the trial court to

bar an expert witness disclosed less than 60 days before trial. Frulla v. Hyatt Corp., 2018 IL App

(1st) 172329, ¶ 27. In Frulla, the trial court set the trial date for March 3, 2017, and ordered

plaintiff to serve supplemental disclosures by November 21, 2016. The order also set January 5,

2017, as the deadline for defendants’ disclosures. Id. ¶¶ 6-7. Plaintiff, however, failed to file his

supplemental disclosures until December 6, 2016.On January 5, 2017, the trial court ordered

defendants to serve their Rule 213(f)(3) disclosures by January 20, 2017. Plaintiff objected,

arguing that he had not waived the requirement that discovery be completed no later than 60 days

prior to trial. Defendants filed their initial disclosures on January 20, 2017, and filed an amended

disclosure on January 23, 2017. Id. ¶ 8.

¶ 52 On appeal, plaintiff argued that the trial court erred in failing to bar defendants’ expert

witnesses for noncompliance with Rule 218(c). He contended that pursuant to the rule’s 60-day

requirement, defendants had an “ ‘affirmative duty’ ” to make their Rule 213(f)(3) disclosures no

later than January 3, 2017. Id. ¶ 24.

¶ 53 This court noted that, in November 2016, plaintiff knew that the court set a schedule for

defendants to make their Rule 213 disclosures by January 5, 2017, past the 60-day deadline, yet

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“plaintiff stood mute” and did not object. Id. ¶ 25. Furthermore, “[p]laintiff was dilatory in making

his own disclosures,” which necessarily delayed defendants’ disclosures because their “experts

typically would need time to review the discovery from plaintiff’s experts in order to formulate

their opinions and prepare their reports.” Id. ¶ 28. We found it “clear that plaintiff is attempting to

enforce the letter of Rule 218(c) to his advantage without regard to its stated purpose while

ignoring his own counsel’s lack of diligence in providing discovery disclosures to defendants’

counsel.” Id. ¶ 29. We held that the trial court did not abuse its discretion when it allowed

defendants “to disclose experts less than 60 days before trial in order to do substantial justice

between the parties.” Id. ¶¶ 28-29; see also Gee, 365 Ill. App. 3d at 1038 (finding that “a

mechanical application of the 60-day deadline under the circumstances presented could encourage

parties to cause delays which might force opposing parties into a late disclosure of alternate

witnesses, thereby unfairly gaining a tactical advantage”).

¶ 54 As in Frulla, we find that the trial court below should have allowed defendants to file their

supplemental answers in order “to do substantial justice between and among the parties” (see Ill.

S. Ct. R. 218(c) (eff. July 1, 2014)). On July 25, 2018, 56 days before trial, plaintiff supplemented

their answers to written discovery with “a copy of the June 25, 2018 Psychological Evaluation for

Julien Florez from the Center for Neuropsychology and Behavioral Health.” The report stated that

Dr. Young performed the evaluation on June 25, 2018, and the “[r]esults and recommendations

were discussed with Julien’s family” on that date. On August 9, 2018, two weeks after defendants

received the report, they filed their supplemental answers to plaintiff’s Rule 213(f) interrogatories.

Rule 213(i) obligates a party “to seasonably supplement or amend any prior answer or response

whenever new or additional information subsequently becomes known to that party.” Ill. S. Ct. R.

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213(i) (eff. Jan. 1, 2018). In those answers, defendants’ experts opined that Julien’s autism

diagnosis is “one more piece of evidence” that “is consistent with and supportive of [their] opinion

that Julien Florez did not suffer from an acute injury at or around the time of labor and delivery.”

Defendants also filed a supplemental answer identifying Dr. Young as an expert witness. Plaintiff

moved to strike the supplemental disclosures, arguing that defendants were “trying to inject this

new issue into the case” and that the disclosures were untimely, since they were filed less than 60

days before trial. The trial court struck defendants’ disclosures, finding that Rule 218(c) required

that all discovery be completed no later than 60 days before trial.

¶ 55 However, we cannot ignore the fact that defendants’ supplemental disclosures in response

to Dr. Young’s evaluation were untimely only because plaintiff filed Dr. Young’s evaluation less

than 60 days before trial. Plaintiff supplemented written discovery as required by the rules, but

they did so 56 days before trial. Defendants’ answers could not comply with Rule 218(c), even if

they had been filed on the same day defendants received Dr. Young’s report.

¶ 56 Nothing in the language of Rule 213(i) or Rule 218(c) indicates an intent to hold the 60-

day limit above all other considerations. Rather, both rules explicitly state that they should be

“liberally construed to do substantial justice” between the parties. Ill. S. Ct. R. 213(k) (eff. Jan. 1,

2018); R. 218(c) (eff. July 1, 2014). Plaintiff seeks “to enforce the letter of Rule 218(c) to his

advantage without regard to its stated purpose,” while ignoring his own actions that contributed to

defendants’ untimely filing. See Frulla, 2018 IL App (1st) 172329, ¶ 29. Strict enforcement of

Rule 218(c)’s 60-day time limit in this case rendered Rule 213(i) meaningless, and as a result,

defendants’ experts had no way to offer their opinions on Dr. Young’s report or reference Julien’s

autism diagnosis in support of their conclusions. Enforcement of Rule 218(c)’s 60-day time limit

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here did not “do substantial justice between and among the parties.” See Ill. S. Ct. R. 218(c) (eff.

July 1, 2014).

¶ 57 Furthermore, the purpose of discovery rules “is to eliminate surprise and unfairness” and

afford a fair opportunity to investigate. People v. Sutton, 349 Ill. App. 3d 608, 618-19 (2004). As

our supreme court noted, “[d]iscovery is intended as, and should be, a cooperative undertaking by

counsel and the parties, conducted largely without court intervention, for the purpose of

ascertaining the merits of the case and thus promoting either a fair settlement or a fair trial.”

Williams v. A.E. Staley Manufacturing Co., 83 Ill. 2d 559, 566 (1981). The process of discovery

should not be conducted as a “tactical game.” Zagorski v. Allstate Insurance Co., 2016 IL App

(5th) 140056, ¶ 39.

¶ 58 A mechanical application of Rule 218(c)’s 60-day deadline to defendants under these

circumstances would encourage tactical gamesmanship. Dr. Young conducted her evaluation and

prepared a written report on June 25, 2018. She discussed the results with Julien’s family that day.

Approximately one month later, plaintiff’s counsel was given the report and they filed it as

supplemental discovery on July 25, 2018. While we acknowledge that plaintiff’s counsel tendered

the report as soon as they received it, plaintiff gives no reason why they waited a month before

presenting Dr. Young’s report to their counsel. If plaintiff had supplemented their discovery after

receiving Dr. Young’s report on June 25, 2018, defendants would have had time to file their

supplemental answers before the 60-day deadline. Instead, the one-month delay left defendants

with no opportunity to respond within Rule 218(c)’s 60-day time limit.

¶ 59 After the trial court struck defendants’ supplemental answers and their supplemental

disclosure of Dr. Young as an expert witness as untimely, plaintiff moved to strike any reference

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to autism at trial, arguing that “no witness would testify for either party that Julien is autistic,” and

“[n]one of plaintiffs’ or defendants’ experts have offered an opinion—neither in a discovery

deposition nor Rule 213 disclosure—diagnosing Julien Florez with autism.” The trial court granted

the motion. Plaintiff’s actions in filing Dr. Young’s report less than 60 days before trial, filing

motions to strike defendants’ supplemental answers and disclosures as untimely, and after the trial

court granted the motions, filing motion in limine No. 19 to strike any reference to Julien’s autism

at trial, prevented defendants from using the diagnosis as support for their opinions. We emphasize

that, in making our determination, we take no position on the merits of plaintiff’s case. We

determine only that application of the discovery rules below did not serve their purpose, and

condoning such conduct would encourage the same tactical gamesmanship the rules seek to avoid.

Sullivan, 209 Ill. 2d at 109-10. Accordingly, we find that the trial court abused its discretion in

striking the supplemental answers of defendants’ experts pursuant to Rule 218(c).

¶ 60 Plaintiff argues, however, that it was defendants who engaged in improper gamesmanship

by filing their untimely supplemental answers. Plaintiff insists that he had no intention to use the

report with existing experts and defendants’ late attempt to inject autism into the case was aimed

at surprising plaintiff. Plaintiff maintains that Julien’s autism-associated behaviors were “well-

documented” in his medical records “long before the Young report,” and defendants’ experts could

have incorporated autism in their answers well before the 60-day deadline.

¶ 61 We do not agree that Julien’s autism was “well-documented” in the record. In their offers

of proof, Dr. Hunter and Dr. Scher stated that the prior references to autism in the record did not

constitute an actual diagnosis. While there were recommendations for formal testing, Julien did

not undergo such testing, or obtain an actual diagnosis, until Dr. Young’s evaluation. Absent Dr.

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Young’s report, Dr. Hunter stated that he “had no data that would suggest that [autism] had been

identified or diagnosed.” In her offer of proof, Aimee confirmed the lack of an earlier autism

diagnosis. She stated that none of Julien’s providers, teachers, or doctors in Florida had diagnosed

him with autism. Although he had deficits associated with autism spectrum disorder, no physicians

in Florida indicated that Julien may be autistic. In fact, Dr. Brosco told Aimee that Julien was not

on the autism spectrum.

¶ 62 We also disagree that defendants filed the supplemental disclosures in an attempt to

surprise plaintiff shortly before trial. As discussed above, plaintiff filed Dr. Young’s report less

than 60 days before trial. When defendants received the documents showing a professional

diagnosis of autism spectrum disorder for the first time, they filed their experts’ supplemental

answers two weeks later, on August 9, 2018. Their supplemental answers did not disclose a

completely new theory of causation that would have surprised plaintiff. Rather, defendants experts

would opine that the diagnosis is “consistent with and supportive of [their] opinion that Julien

Florez did not suffer from an acute injury at or around the time of labor and delivery.” We adhere

to our holding that the trial court should have allowed defendants to file their supplemental answers

pursuant to Rule 213(i).

¶ 63 Errors in the exclusion of expert testimony warrant a new trial if they are “serious and

prejudicial.” Ayala v. Murad, 367 Ill. App. 3d 591, 601 (2006); see also Fakes v. Eloy, 2014 IL

App (4th) 121100, ¶ 75 (a new trial is warranted if the Rule 213 violation deprived the party of a

fair trial, and that party demonstrates resulting prejudice). The trial court’s denial of a motion for

a new trial is reviewed under an abuse of discretion standard. Graham v. Northwestern Memorial

Hospital, 2012 IL App (1st) 102609, ¶ 39.

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¶ 64 “In any negligence action, the plaintiff bears the burden of proving not only duty and breach

of duty, but also that defendant proximately caused plaintiff’s injury.” Leonardi v. Loyola

University of Chicago, 168 Ill. 2d 83, 93 (1995). Although the burden is on plaintiff to show

proximate cause, if defendants have “evidence that negates causation” they “should [be able to]

show it.” Id. at 93-94.

¶ 65 Here, the critical issue before the jury was whether Julien’s brain injury was proximately

caused by defendants at or near the time of his birth or by other factors that have no connection to

the circumstances of his birth. This was a vigorously contested case, with knowledgeable experts

on one side giving scientific testimony that conflicted with the opinions of knowledgeable experts

on the other side. Defendants’ experts testified in their offers of proof that a diagnosis of autism, a

brain disorder, would have supported their opinion that Julien suffered from chronic uteroplacental

oxygen insufficiency, resulting in brain injury before birth. Dr. Hunter would testify that the autism

diagnosis “provides a much stronger understanding of *** [Julien’s] neurodevelopmental profile.”

Specifically, he would find that Julien’s language deficits do not reflect an intellectual disability;

rather, they reflect “a neurodevelopmental disorder that affects language.”

¶ 66 According to defendants’ experts, an autism diagnosis provides “one more piece of

evidence” in support of their theory that Julien’s brain damage was caused by a chronic condition

and not by the circumstances of his birth. As such, Julien’s diagnosis was material and relevant to

the issue of causation. See Smith v. Silver Cross Hospital, 339 Ill. App. 3d 67, 73-74 (2003) (stating

that relevant evidence has the “ ‘tendency to make the existence of any fact that is of consequence

to the determination of the action more or less probable than it would be without the evidence’ ”).

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¶ 67 Plaintiff contends that a new trial is unwarranted because the exclusion of autism evidence

did not prejudice defendants. He argues that the evidence at trial overwhelmingly favored plaintiff

because “[t]he only logical and reasonable conclusion *** is that Julien sustained a significant

neurologic injury at or near the time of delivery leaving him with profound and permanent

deficits.” We disagree. Evidence on the core issue of causation consisted primarily of expert

testimony. The jury assigns weight to an expert’s opinion in light of the expert’s credentials and

the factual basis of his or her opinion. Snelson v. Kamm, 204 Ill. 2d 1, 27 (2003). While the jury

found in favor of plaintiff, thus giving more weight to the testimony of plaintiff’s experts, we

cannot say to what extent the jury discounted the testimony of defendants’ experts. Both parties

presented qualified and experienced experts, and we find nothing in the record that would cause

the jury to completely disregard the testimony of defendants’ experts.

¶ 68 The jury heard extensive expert testimony on both sides that led to conflicting opinions as

to the cause of Julien’s brain injury. Defendants’ experts would have used Julien’s autism

diagnosis as further support for their opinion that his brain injury resulted from a chronic condition,

in a case where both sides presented ample medical evidence for their positions. It was the jury’s

function to resolve the conflicting expert opinions and determine the cause of Julien’s brain injury

(Vanderhoof v. Berk, 2015 IL App (1st) 132927, ¶ 64), and it was deprived of relevant evidence

in making those determinations.

¶ 69 Exclusion of Julien’s autism diagnosis also prejudiced defendants in the jury’s assessment

of damages. Defendants are only liable for the portion of damages resulting from injuries caused

by them. Voykin v. Estate of DeBoer, 192 Ill. 2d 49, 58 (2000). Therefore, even if the jury had

found that autism had nothing to do with the brain injury caused by defendants, autism may still

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be relevant to the question of damages. Autism spectrum disorder may be relevant to, among other

things, Julien’s speech and language deficits, his need for therapy, his schooling requirements, and

his future employment prospects. Damages calculations included the costs of therapy and

schooling and the loss of future earnings, but defendants were prevented from establishing whether

Julien’s autism diagnosis would reduce their damages. Under these facts, we find that exclusion

of Julien’s autism diagnosis deprived the jury of relevant evidence on the issues of causation and

damages and that defendants were prejudiced as a result.

¶ 70 Due to our findings above, we need not address plaintiff’s argument that defendants were

required to seek leave of court pursuant to Illinois Supreme Court Rule 183 (eff. Feb. 16, 2011)

before filing their untimely answers or defendants’ argument that opposing counsel’s remarks

during closing argument constituted reversible error.

¶ 71 IV. CONCLUSION

¶ 72 For the foregoing reasons, we reverse the judgment entered against defendants and remand

for a new trial.

¶ 73 Reversed and remanded.

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Decision Under Review: Appeal from the Circuit Court of Cook County, No. 2014-L- 13348; the Hon. Kay M. Hanlon and the Hon. Thomas More Donnelly, Judges, presiding.

Attorneys J. Timothy Eaton and Jonathan B. Amarilio, of Taft Stettinius & for Hollister LLP, of Chicago, for appellants. Appellant:

Attorneys Patrick A. Salvi, II, Matthew L. Williams, Brian L. Salvi and for Heidi L. Wickstrom, of Salvi, Schostok & Pritchard P.C., of Appellee: Chicago, for appellee.

Robert G. Black, of Law Office of Robert G. Black, P.C., of Naperville, IL, for appellee.

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