SANCHEZ v. SECRETARY OF HEALTH AND HUMAN SERVICES

United States Court of Federal Claims·Decided October 24, 2024·No. 11-0685V·Unpublished

Opinion

In the United States Court of Federal Claims OFFICE OF SPECIAL MASTERS

********************* TRYSTAN SANCHEZ, by and * through his parents, GERMAIN * No. 11-685V SANCHEZ and JENNIFER * Special Master Christian J. Moran SANCHEZ, * * Filed: August 14, 2024 Petitioners, * v. * * SECRETARY OF HEALTH * AND HUMAN SERVICES, * * Respondent. * ********************* Lisa A. Roquemore, Law Offices of Lisa A. Roquemore, Rancho Santa Margarita, CA, and Richard Gage, Richard Gage, P.C., Cheyenne, WY for petitioners; Jennifer L. Reynaud, United States Dep’t of Justice, Washington, DC, for respondent.

PUBLISHED ORDER DENYING MOTION FOR PROTECTIVE ORDER 1

Based upon the evidence available to the Federal Circuit, the Federal Circuit found that Mr. and Ms. Sanchez, the petitioners, are entitled to compensation and remanded to determine the amount of damages to which they as guardians for their child, Trystan, are entitled. Sanchez v. Sec’y of Health & Hum. Servs., 34 F.4th

1 Because this order contains a reasoned explanation for the action in this case, the undersigned is required to post it on the United States Court of Federal Claims' website in accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic Government Services). This means the order will be available to anyone with access to the internet. In accordance with Vaccine Rule 18(b), petitioners have 14 days to identify and move to redact medical or other information, the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, the undersigned agrees that the identified material fits within this definition, the undersigned will redact such material before posting the decision. 1350 (Fed. Cir. 2022). As the Sanchezes were documenting the scope of their compensation, they produced documents that should have been produced during entitlement. The Secretary obtained full copies of records from four providers, and identified numerous other documents which should have been produced earlier. These include, in chronological order:

• Handwritten Subjective, Objective, Assessment and Plan (SOAP) notes taken by PA Luna during a February 17, 2009 urgent care visit reporting Trystan’s cough symptoms but not mentioning arm contortions; • A March 8, 2010 record from the Inland Counties Regional Center assessment noting Trystan had a seizure episode on August 8, 2009; • A June 3, 2010 email from Ms. Sanchez to James. F. Gusella, Ph.D., providing a chronology suggesting that Trystan’s arm contortions began after he recovered from an upper-respiratory illness; • A record from a November 5, 2010 occupational therapy evaluation mentioning arm contortions beginning after Trystan’s illness; • A record of an August 6, 2011 visit to Dr. Valencia memorializing Ms. Sanchez’s request to “change” a PA’s notes regarding onset of Trystan’s symptoms; • A record from Dr. Brown dated August 19, 2011 stating that Ms. Sanchez asked him “to write a clarifying letter” about his appointment with Trystan in May 2009. Dr. Brown stated that he did not believe Trystan had unusual arm movements in May 2009, as he would have documented such and ordered additional testing. Dr. Brown stated that he faxed and mailed this record to Ms. Roquemore.

The Secretary is seeking a reopening of entitlement pursuant to an August 16, 2023 motion, which remains pending. Mr. and Ms. Sanchez oppose reopening.

As part of the process regarding reopening, the Secretary is seeking oral testimony at a hearing to be held in California, the state where Mr. and Ms. Sanchez live. A purpose of the hearing is to question the witnesses about why the identified documents were not produced during the entitlement phase of this case.2 Mr. and Ms. Sanchez maintain that this testimony is not appropriate and are

2 Another potential topic could be the meaning of the recently produced documents, providing an opportunity for direct testimony and cross-examination that could have been given during the original fact hearing if the relevant documents had been produced before then.

2 seeking a protective order. Pet’rs’ Mot., filed June 21, 2024. The Secretary contends that the Sanchezes have not justified the entry of a protective order.

For the reasons explained below, the anticipated oral testimony is reasonable and necessary. The Sanchezes have not established that a hearing is overly burdensome. Thus, their motion for a protective order is denied.

I. Factual Events in the Life of Trystan Sanchez3

Mr. and Ms. Sanchez are the parents of Trystan Sanchez, who was born in 2008. At age six months, on February 5, 2009, Trystan received a dose of the diphtheria-tetanus-acellular pertussis (“DTaP”) vaccine. Mr. and Ms. Sanchez alleged---and the Federal Circuit found---that the DTaP vaccination caused an aggravation of Trystan’s previously unmanifested Leigh’s syndrome. “Leigh's syndrome is a severe neurological disorder that often presents in the first year of life, is characterized by progressive loss of mental and movement abilities, and typically results in death within ‘a couple years.’” Sanchez, 34 F.4th 1350, 1352 (Fed. Cir. 2022) (citing record).

Throughout this litigation, the parties have disputed when Trystan first began to manifest unusual movements. Via written affidavits and oral testimony, Mr. Sanchez, Ms. Sanchez, and other family members averred that Trystan started having seizures by February 16, 2009, a date that is Ms. Sanchez’s birthday. Mr. and Ms. Sanchez maintain that Trystan continued to have seizures until he was seen by a physician’s assistant, Micaela Marin-Tucker, who worked in the office of a pediatrician Rainilda Valencia. During this appointment, which occurred on August 17, 2009, Ms. Marin-Tucker documented that Ms. Sanchez stated that Trystan began to lose skills “2-3 months ago.” Exhibit 1 at 54. The Secretary did not agree with the testimonial assertions of Mr. Sanchez, Ms. Sanchez, and other family members. The Secretary pointed out that during the time when Trystan was allegedly having abnormal movements, medical professionals saw Trystan and failed to document any complaint about abnormal

3 The pending motion for a protective does not rely upon any particular event in Trystan’s life. Thus, Trystan’s medical history is summarized to provide a context for the Secretary’s motion to reopen, which underlies the motion for protective order. For a more thorough description of Trystan’s medical history, see Decision on Remand, 2020 WL 5641872 (Aug. 26, 2020), mot. for rev. denied, 142 Fed. Cl. 247 (2019), rev’d, 34 F.4th 1350 (Fed. Cir. 2022).

3 movements. Examples of medical professionals who saw Trystan during the critical months of February to May included Jonathan Luna, a physician’s assistant (February 17, 2009); Dr. Nabil Seleem, a pediatrician (April 29, 2009) ; and Dr. Philip Brown, a pediatrician (February 5, 2009 and May 13, 2009). The Secretary reasoned that if Trystan were having seizures, Ms. Sanchez would have reported the seizures or abnormal movements to medical professionals and the medical professionals would have documented (and investigated) that complaint. To the Secretary, the absence of a notation in the medical records of these providers during the relevant period of time within which the Sanchezes have maintained that Trystan was having abnormal arm movements suggestive of seizure activity indicates that Trystan was not have seizures. The Sanchezes, in turn, maintain that they consistently informed medical professionals about Trystan’s abnormal movements but these professionals did not document their concerns. Presently, the parties agree that Trystan suffers from Leigh’s syndrome.

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