HEALTH CARE LIABILITY UPDATE, 2014 PAULA SWEENEY Slack & Davis 2911 Turtle Creek Boulevard Suite 1400 Dallas Texas 75219 (214) 528-8686 psweeney@slackdavis.com State Bar of Texas ADVANCED MEDICAL TORTS COURSE March 13-14, 2014 Santa Fe, NM CHAPTER 1 This paper has received the State Bar of Texas award for Best Continuing Legal Education Paper and, in 2010, the Texas Judicial Counsel s Award for Best Non-Judicial Paper
TABLE OF CONTENTS TABLE OF AUTHORITIES... VIII MEDICAL MALPRACTICE UPDATE... 1 I. SCOPE OF THE ARTICLE... 1 II. THE GOVERNING STATUTES ARTICLE 4590I AND CHAPTER 74... 1 A. Chapter 74... 1 1. Definitions... 1 B. Article 4590i... 4 1. Definition of Health Care Provider... 4 2. Entities Defined by the Courts as Health care Providers Under Chapter 74 and Article 4590i... 4 3. Definition of Health Care Liability Claim... 6 4. Definition of Physician... 15 5. Chapter 74 Conflict with Other Law... 15 C. Chapter 74 and Sovereign Immunity... 16 D. Chapter 74 - The Deceptive Trade Practices Statute... 16 E. Notice of Claim... 16 F. Ad Damnum Clause... 21 G. Informed Consent, Chapter 74 Subchapter C and Article 4590i, Subchapter F... 22 H. The Bad Result Instruction: Article 4590i, 7.02, and 74.303 (e)(2)... 23 I. Subchapter D, Emergency Care... 23 J. Section 74.154 - New Jury Instruction... 28 K. Res Ipsa Loquitur... 28 L. Statute of Limitations and Repose... 30 1. Limitations Under Article 4590i... 30 2. The Open Courts Exception to the Statute of Limitations Since 1977... 35 3. Tolling of the Statute of Limitations Since 1977... 48 4. Interaction of Article 4590i and Chapter 74 With Other Statutes... 55 5. Tolling Provision and the Effect of Defective Pleadings... 58 6. Statute of Limitations and Its Effect on Derivative Claims... 59 7. Weekends and Holidays Do Not Extend The Statute... 59 8. Minority Tolling and Corporate Dissolution... 59 9. Effect of Plaintiff s Bankruptcy... 59 10. The Effect of Chapter 74, Section 74.251... 60 M. Limitation on Damages - 74.301, 74.302 and 74.303 and Article 4590i, 11.02... 66 1. CPI Adjustment to the Death Cap... 69 2. The Constitutionality of the Damage Caps... 69 3. Article 4590i s Damages Cap and Its Interaction with Other Damages Provisions... 74 4. Unanswered Questions... 77 i
N. Subchapter M, Article 4590i, 13.01 and Subchapter H, Chapter 74, The Expert Report Requirement... 79 1. CPRC Section 74.351, The Expert Report... 79 2. Rule 202 Depositions... 82 3. Deadline is 120 Days... 83 4. Defense Deadline is 21 Days... 83 5. Effect of Challenge... 84 6. Parties May Agree to Extend... 84 7. Court May Grant 30-Day Extension... 84 8. Interlocutory Appeal... 85 9. Is the Deposition of the Defendant Physician Precluded Prior to the Filing of the 120-day Report?... 85 10. What is Service Under Chapter 74?... 85 11. One Service is Enough... 90 12. CVs... 90 13. Are Magic Words Required Regarding Causation?... 90 14. Inconsistent Statements Within the Report.... 91 15. If the Court Can Determine the Basis of Plaintiff s Complaint, the Report is Adequate.... 91 16. Good Faith Efforts is the Standard.... Error! Bookmark not defined. 17. How Many Reports Are Required?... 91 18. A Report Cannot Be Entirely Conclusory.... 92 19. The Four Corners Rule.... 93 20. The Standard of Review.... 94 21. No Good Cause Accident or Mistake is Required.... 94 22. In Emergency Room Cases, the Report Need Not Speak to Willful and Wanton Negligence... 94 23. Expert Reports in Res Ipsa Loquitur Cases.... 95 24. Non-suit and the 120-Day Clock.... 95 25. Nonsuit Does Not Cancel Motions for Sanctions or Interlocutory Appeals... 95 26. Qualifications Must Be Shown Within the Body of the Report... 96 27. Distinction Between Defendants Who Are Individuals and Defendants Who Are Not... 96 28. 74.351(l), 74.351(d) and Interlocutory Appeal... 97 29. Defendant s Failure to Answer or Have a Registered Agent Does Not Vitiate the Duty to Serve a Report But May Result in Tolling of the 120 Day Clock... 99 30. An Expert May Apply the Same Standard of Care to Two Physicians... 99 31. Docket Control Orders...100 32. Must a Report During the Grace Period be from the Same Expert?...100 33. Sanctions and Court Costs...101 34. The Importance of Requesting a Grace Period Extension...101 35. The Expert Report and Damages...102 36. Interplay Between Deficient Report and No Report...102 37. Effect of Amending Claims or Adding Parties...102 38. Threshold Means Threshold...104 39. Constitutionality of the Expert Report Requirement...106 40. Plaintiff s Experts May Rely on Talking with the Patient...108 41. Chapter 74 Report Cannot be Based on Assumptions...108 42. Must Plaintiff s Experts be from Texas?...108 43. Must Use Defendant s Name...109 44. Experts from Different Fields Permitted?...109 45. Plaintiff s Counsel May Write the Chapter 74 Report...110 46. Plaintiff Does Not Forfeit the Opportunity to Cure Deficiencies by Responding to the Objections Made by Defendant...111 47. Reports in Informed Consent and Negligence Per Se Cases...111 48. The Chapter 74 Report in Federal Court...111 49. Daubert Striking of Expert Does Not Invalidate the Report...112 50. Plaintiff Must Have a Specialized Expert to Maintain a Negligent Credentialing Claim...112 ii
51. The Report Requirement When Defendant Defaults...113 52. Vicarious Liability Claims Do Not Require Separate Expert Reports...114 53. Court Must Rule...115 54. Alleged Bias of Expert Not Relevant at Report Stage...115 55. Procedure for Curing a Defective Report...115 56. Effect of Abatement...115 57. Effect of Bankruptcy on 13.01 Requirements...116 58. Mistaken Filing in Federal Court Does Not Toll the Statute...117 59. The 120 Day Report in Tort Claims Cases...117 60. There Must Not Be an Analytical Gap in Plaintiff s expert s reasoning...117 61. Article 4590i and the Expert Report Requirement....117 O. Chapter 74.352 - Discovery Procedures...117 P. Subchapter 1 of Chapter 74 and 14.01 Expert Witnesses...118 1. The General Rule...120 2. Experts Not From Texas...121 3. Case Law...121 4. Instances in Which Expert Testimony May Not Be Required...129 5. Daubert and Its Progeny...131 6. Personal Preference or Opinion...131 7. Expert Opinion Under Rule 704 Admissible On Ultimate Issues of Mixed Law and Fact...132 8. Physician Acting as a Specialist...132 9. The Physician Must Exercise His Skill With Reasonable Care and Diligence...133 10. The Same School Rule...133 11. Evidence-Custom Admissible, But Not Conclusive On the Standard of Care in Medical Malpractice Cases...135 12. Professional Standards...135 13. Basis for Expert s Opinion...135 Q. Arbitration Agreements, Chapter 74, Subchapter J., and Article 4590i, Subchapter O, 15.01....137 1. The Statute...137 2. Case Law...137 R. Payments for Future Losses, Chapter 74, Subchapter K, 74.501 74.507...138 S. A Notable Omission...140 III. THE TEXAS TORT CLAIMS ACT...140 A. Legal Limitations on Liability of Governmental Entities...140 1. State and County Hospitals...140 2. The Mandatory Election Clause, 101.106....141 3. Relation Back After Dismissal Is Not Necessary...146 4. The 120 Day Report...146 5. Before Government Unit Can Be Liable, Defendant Must be an Employee...146 6. Must Have Use or Misuse of Tangible Property...147 7. Pleading Condition or Use of Property...147 8. What Constitutes Tangible Property Sufficient to Invoke Waiver of Immunity?...147 9. Causal Link Requirement...147 10. Interlocutory Appeal...148 11. Tort Claims Immunity and The Patient Bill of Rights...148 12. Notice Under the TTCA...148 13. No Discovery Rule...149 14. No Tolling For Incompetents...150 15. Minority Does Not Obviate the Notice Requirement...150 iii
16. City Hospitals...150 17. Liability of Health Care Management Contractors...151 18. Hospitals Operated by the Federal Government...151 19. Texas Tort Claims Act Limit On Damages...152 IV. PLEADING AND PROVING THE MEDICAL MALPRACTICE CASE...154 A. Pleadings of Plaintiff...154 1. Notice of Claim...154 2. Ad Damnum...155 B. Pleadings of Defendant...155 1. Limitations Defense...155 2. Lack of Notice...155 3. Damages Limitations...155 4. Contributory Negligence of Plaintiff...156 C. The Cause of Action...157 1. Establishing the Existence of a Duty: The Patient-Physician Relationship...157 2. Liability of Physician for Acts of Hospital Personnel...166 3. Liability for Residents...166 4. Liability of Physician for Acts of Another Physician...166 5. Breach of Warranty...168 6. Theories of Recovery-Negligence...168 7. Battery...170 8. Lack of Informed Consent...170 9. Abandonment...177 10. Fraud...178 11. Contract to Cure...179 12. Texas Deceptive Trade Practices Act...180 13. Malicious Prosecution...180 14. False Imprisonment...182 15. Limitation on Strict Liability...182 16. Unauthorized Disclosure of Confidential Information...182 17. Experimental Medicine...183 18. Unnecessary Surgery...183 19. Prenatal Injuries...184 20. Wrongful Pregnancy or Conception...185 21. Wrongful Birth...185 22. Wrongful Life...185 23. Wrongful Continued Life...186 24. Spoliation...187 25. Wrongful Death and Survival Actions...187 26. Physician - Patient Relationship Requirement for Wrongful Death Action...188 27. Liability for Infection...188 28. Loss of a Chance...188 29. Civil Rights Violation...188 30. Sexual Exploitation...189 31. Negligent Infliction of Emotional Distress...189 32. Bystander Recovery...189 33. Intentional Infliction of Emotional Distress...190 34. Negligent Misrepresentation...190 35. Failure to Consult a Specialist...191 36. Physician Liability Arising from Worker s Compensation Examinations or Care...191 37. Negligence of Dentists...191 iv
38. Liability of Original Tortfeasor for Subsequent Medical Malpractice...192 39. Patient Dumping or the Duty to Treat in the Emergency Room...192 40. Sexual Abuse & Repressed Memories...195 41. Fear of AIDS...195 42. Negligent Disregard of Patient s DNR Directive...196 43. Long-Arm Jurisdiction, Out-of-State Physicians...196 V. PLEADING AND PROVING THE HOSPITAL LIABILITY CASE...196 A. Proving the Plaintiff s Cause of Action...196 1. Vicarious Liability...196 2. Direct Corporate Liability...201 VI. NURSING HOME LIABILITY...207 A. Repeal of Texas Human Resources Code 32.021(1), (k) and Texas Health and Safety Code 242.050...207 B. Changes To The Punitive Damages Statute...209 VII. PRELIMINARY DISCOVERY...209 A. Discovery Tools In Medical Malpractice Cases...209 B. Rule 202 Depositions...209 C. Incident, Unusual Occurrence Or Variance Reports...209 D. Compelling Physical and Mental Examinations...210 1. Expert Witnesses...210 2. Depositions of Hospital Corporate Officers...211 3. Photographs...212 4. Financial Condition of a Hospital...212 5. Privileges...212 E. Mandamus as a Remedy...221 VIII. SUMMARY JUDGMENT PRACTICE...222 A. Summary Judgment Practice in Texas...222 1. Adequate Time for Discovery...223 2. How Much Evidence is Enough?...223 3. Applicability of Rule 166A(i)...223 B. Summary Judgment Proof...223 1. Affidavits...224 2. Depositions...225 3. Answers to Interrogatories and Requests for Admissions...226 4. Medical Records...226 C. Determining if Summary Judgment is Proper...227 1. Has the Movant Negated an Essential Element of the Claimant s Claim or Defense?...227 2. Has a Fact Issue Been Raised?...227 3. The Movant Must Raise All Grounds at the Trial Court Level...227 4. Expert Testimony Must Be Sufficient...227 5. Expert Must Be Familiar with the Standard of Care...228 v
6. The Standard of Care Must Be Specifically Stated...228 7. Causal Link Must Be Established...229 8. Fact Issue on Unpleaded Theories is Sufficient...230 9. Respondent s Summary Judgment Proof...230 10. Continuances...231 D. Appealing the Grant or Denial of Summary Judgment...231 IX. CROSS-EXAMINATION OF MEDICAL EXPERTS IN THE MEDICAL MALPRACTICE CASE...232 A. Qualifications of Expert...232 1. Professional Qualifications...232 2. Lack of Medical Specialty Board Certification...232 3. Hospital Medical Staff Privileges...232 B. Use of Medical Treatise and Literature...232 C. Use of Medical Records...233 D. Bias, Prejudice, Reputation or Pecuniary Interest...233 1. Bias and Prejudice...233 2. Financial Interest of Expert in Success or Outcome of Case...233 3. Professional Reputation or Character...233 4. Prior Litigation Testimonial Experience or Expert...233 5. Specific Financial, Accounting and Income Records of Expert Not Discoverable or Admissible for Impeachment Purposes...234 6. Insurance Carriers...234 7. Ex Parte Conferences...234 E. Other Suits...235 F. Prior Complaints Against Experts...235 G. Prior Criminal Record of Expert...235 H. Tampering with Expert Witnesses...236 X. DAMAGES IN MALPRACTICE CASES...236 A. Damages Law in Tort Cases Apply to Malpractice Actions...236 B. Damages Unique to Malpractice Cases...236 XI. THE PLAINTIFF S APPROACH TO THE COURT S CHARGE...237 A. The Court s Charge in Texas...237 1. General Rules and Trend Toward Simplification...237 2. The Charge in Malpractice Cases...237 B. Instructions and Special Issues - Legal Authority...238 1. Negligence Conveying the Legal Standard of Conduct for Physicians to the Jury...238 2. Proximate Cause Definition...240 3. Occasion In Question Definition...240 4. Inferential Rebuttals...241 5. Informed Consent...243 6. Submitting Res Ipsa Loquitur by Instruction...245 7. Damages Limit Instruction...245 vi
8. Bad Result Instruction...245 9. Establishment of Facts: Direct or Circumstantial Evidence...245 10. Burden of Proof: Preponderance of Evidence by Definition...246 11. Instruction on Spoliation...246 12. Disapproved Instructions and Definitions...246 13. Submission of Emergency Room Cases...248 XII. INSURANCE COVERAGE...249 A. Multiple Claims and Defendants...249 B. The Importance Of The Claim Date...249 APPENDIX A...251 APPENDIX B...259 TOLLING OF THE STATUTE OF LIMITATIONS...259 vii