A Baltimore-based hospital should have been allowed to present evidence of the nurse-midwife standard of care and the role that violation of that standard might have caused in a medical malpractice case involving a baby born with cerebral palsy and other health issues, a Maryland appeals court recently ruled.
In Enzo Martinez and others v. Johns Hopkins Hospital, Maryland's intermediate appellate court reversed the Circuit Court for Baltimore City court and sent the case back for a new trial, ruling that The Johns Hopkins Hospital (JHU) should have been allowed to present testimony about the role the midwife used by Rebecca Fielding and Enso Martinez played in their son Enzo Martinez's injuries.
Fielding went into labor with Enzo on March 25, 2010. She had decided to have a natural birth at home with a woman who was a registered nurse-midwife and a doula. A doula is a labor coach who provides support for a woman in labor. Unfortunately, the baby was not in the proper position, which often leads to the infant not being able to progress through the birth canal. In an attempt to expedite delivery, the midwife took several actions - fundal pressure, intramuscular injections of Pitocin and an episiotomy -- which, did not work. Eventually the midwife decided that Fielding should go to the hospital.
JHU physicians evaluated Fielding and decided that an "urgent" rather than an "emergency" Caesarean section (C-section) was required, in part, because the fetal heart rate monitor indicated that the baby was adequately oxygenated. An urgent C-section is one that must be completed as soon as possible but there is time to have the patient's blood tested, etc. An emergency C-section is one that must be completed immediately; no blood tests or other tests are performed.
Enzo Martinez was delivered, but his condition was poor.
Martinez, by and through his parents, filed a lawsuit alleging that JHU negligently failed to perform a timely C-section. Martinez's lawyers argued that, had the baby been delivered earlier, as the standard of care required, he would not have suffered injury. Martinez also argued that JHU had failed to recognize the signs of fetal distress.
Before the case went to trial, Martinez filed a motion seeking to exclude testimony regarding the standard of care applicable to the midwife and her alleged breach of that standard while treating Fielding. In response, the hospital, argued that presentation of both were relevant to the hospital's defense that it was not negligent and that it was not the cause of Martinez's injuries. In support of its assertion, JHU attached an order from the Maryland Board of Nursing, which had suspended the midwife's certification and license to practice as a nurse-midwife. The order said that the Board had never authorized the midwife to perform home deliveries and concluded that she had violated the Nurse Practice Act based upon the care she provided to Fielding and other patients - the midwife was linked to five other cases, including one which resulted in the death of an infant. In addition, the hospital attached deposition testimony from doctors indicating that the actions taken by the midwife were either no longer used in labor and deliveries and that those actions may have contributed to the baby's health problems.
The trial court granted Martinez's request, ruling that there could be no testimony as to what the standard of care is for midwives. The trial court explained that the issue was whether JHU breached the standard of care, not someone else's breach. As a result, only evidence regarding the physical actions and conduct of the midwife and the reactions of JHU personnel when learning of this conduct was allowed.
After a two week trial, the jury awarded Martinez $4 million for lost wages, $25 million for future medical expenses and $26 million for non-economic damages. JHU filed a motion asking the court for several things: 1) a new trial; 2) to alter the judgment; and/or 3) for a reduction in the jury award. The trial court denied JHU's request for a new trial. It did, however, reduce the jury's award for lost wages from $4 million to $2.6 million and reduced the jury's $26 million award for non-economic damages to $680,000 in line with Maryland's cap on non-economic damages.
Both Martinez and JHU appealed.
JHU argued on appeal that evidence of the midwife standard of care and the midwife's alleged breach of that standard was relevant to its defense that the midwife's negligence was the sole cause of Martinez's brain damage before Fielding arrived at JHU and, therefore, the hospital was not a cause of injury. JHU also contended the evidence was relevant to explaining why the C-section took place when it did. The hospital said it had to undertake additional evaluations to determine the effect of the midwife's negligence on the baby and the mother before performing the C-section.
Martinez argued, among other things, that the trial court acted properly in excluding the evidence and that JHU's defense was not contingent upon a finding that the midwife violated the standard of care.
The Court of Special Appeals reversed, holding that the circuit court made a mistake when it forbade evidence of the nurse-midwife standard of care and in forbidding evidence of a breach of that standard by the nurse-midwife while treating Fielding. The appellate court also ordered a new trial.
The trial judge had reasoned that the standard of care related to the midwife was irrelevant. "While the trial judge's inferences are reasonable, his rationale does not recognize the other obvious possibility; namely, that Midwife [Evelyn] Muhlhan breached her standard of care, and that the breach was the sole cause of Martinez's injuries. This was precisely the defense advanced by the Hospital at trial. Thus, the relevant inquiry on appeal is whether evidence of a non-party's negligence is relevant to a defendant's complete denial of liability," the appeals court said.
Maryland courts have seemingly not decided whether a party may defend itself with evidence of a non-party's negligence. Courts in other jurisdictions have considered the issue related to a non-party's negligence and have decided that such evidence is admissible. In addition, the court observed, those cases supported its analysis that evidence of both negligence and causation attributable to a non-party is relevant where a defendant asserts a complete denial of liability.
Here, the court said, JHU was entitled to try to convince the jury that, not only was it not negligent and not the cause of Martinez's injuries, but that Midwife Muhlhan was negligent and caused the injuries. By precluding such evidence the jury was given a materially incomplete picture of the facts, which denied the hospital a fair trial.
The court also pointed out that other jurisdictions have consistently held that when a defendant was precluded from presenting evidence of a non-party's negligence, the defendant was entitled to a new trial.
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