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Procaccini v. Lawrence and Memorial Hospital, Inc.

Court of Appeals of Connecticut

August 22, 2017

JAMES M. PROCACCINI, ADMINISTRATOR (ESTATE OF JILL A. PROCACCINI)
v.
LAWRENCE AND MEMORIAL HOSPITAL, INC., ET AL.

          Argued March 21, 2017

         Procedural History

         Action to recover damages for medical malpractice, and for other relief, brought to the Superior Court in the judicial district of New London, where the action was withdrawn as against the named defendant et al.; thereafter, the plaintiff filed an amended complaint as against the defendant Emergency Medicine Physicians of New London County, LLC; subsequently, the matter was tried to the jury before Hon. Joseph Q. Koletsky, judge trial referee; verdict for the plaintiff; thereafter, the court denied the motions to set aside the verdict and for a directed verdict filed by the defendant Emergency Medicine Physicians of New London County, LLC, and rendered judgment in accordance with the verdict, from which the defendant Emergency Medicine Physicians of New London County, LLC, appealed to this court. Affirmed.

          Daniel J. Krisch, with whom were Frederick J. Trotta, Sr., and, on the brief, Logan A. Forsey and Jennifer S. Mullen, for the appellant (defendant Emergency Medicine Physicians of New London County, LLC).

          Matthew E. Auger, with whom, on the brief, was Eric W. Callahan, for the appellee (plaintiff).

          Prescott, Mullins and Beach, Js.

         Syllabus

         The plaintiff administrator of the estate of the decedent sought to recover damages from the defendant E Co. for medical malpractice inconnection with the death of the decedent by a methadone overdose. On November, 29, 2008, the decedent was found unresponsive and was brought to a hospital emergency department, where she was treated for a suspected drug overdose by M, the attending emergency department physician. After the decedent's vital signs improved and stabilized, she was discharged and returned to the home of a friend, where she was found unresponsive the next morning and pronounced deceased. The plaintiff alleged that E Co. was vicariously liable for the medical malpractice of M in treating the decedent for a suspected drug overdose. The plaintiff claimed that M's discharge of the decedent after only four and one-half hours of observation was premature in that M should have kept the decedent under medical monitoring for twenty-four hours, which is the period of time during which the fatal side effects of methadone toxicity may occur, and that if the decedent had remained under medical monitoring for the full twenty-four hours, the fatal overdose side effects she experienced after her discharge would have been treated and her eventual death from methadone toxicity would have been averted. The jury returned a verdict for the plaintiff, and the trial court rendered judgment in accordance with the verdict, from which E Co. appealed to this court. E Co. claimed, inter alia, that there was no direct evidence as to when the decedent consumed the fatal dose of methadone, and that the undisputed scientific evidence established that if she had actually overdosed on methadone on November 29, 2008, she would have had a recurrence of overdose symptoms before she was discharged from the hospital's emergency department. Held:

         1. There was sufficient evidence to support the jury's finding that E Co.'s negligence caused the decedent's death:

         a. The jury had before it sufficient evidence from which it could have inferred, without resorting to speculation, that the decedent had consumed the fatal dose of methadone before she was brought to the emergency department on November 29, 2008: although the jury was presented with conflicting expert testimony as to how soon a methadone overdose patient would experience recurring overdose symptoms after receiving a certain medication that is used as an antidote for opiate and opioid overdoses, the jury was free to believe the opinion of the plaintiff's expert witness, S, on the standard of care, that delayed, recurring respiratory depression can occur in methadone overdoses, even if such a phenomenon defied certain undisputed and settled toxicology principles, and to disbelieve those portions of the testimony of E Co.'s expert witness, P, on causation, that attempted to refute that phenomenon, and E Co.'s claim that it was improper for the jury to consider S's testimony concerning the concept of delayed, recurring respiratory depression as it related to causation was unavailing because even if S's testimony was offered strictly for standard of care purposes, E Co. failed to pursue any preemptive or remedial measures that would have precluded or limited S's testimony on the issue of delayed, recurring respiratory depression, and the court never instructed the jury that it should disregard S's testimony thereon or that it should consider such testimony only for standard of care purposes, and, therefore, the evidence regarding delayed, recurring respiratory depression was before the jury to use for any purpose, including causation; moreover, the fact that the decedent did not immediately experience recurring overdose symptoms one hour after the overdose medication was administered did not require the jury to conclude that the decedent's overdose on November 29, 2008, was caused by a narcotic other than methadone, as the jury could have concluded, instead, that the delayed, recurring respiratory depression that the decedent eventually experienced was consistent with her ingestion of a toxic dose of methadone before her visit to the emergency department on November 29, 2008.

         b. E Co. could not prevail on its claim that because the plaintiff failed to present evidence demonstrating that the decedent would have been admitted to the hospital had M not discharged her from the emergency department, the jury could not reasonably have found that E Co. caused the decedent's death: although the plaintiff's expert, S, initially testified that the standard of care applicable to possible methadone overdoses required M to admit the decedent to the hospital for continuous monitoring, S subsequently clarified that the applicable standard of care required only that M monitor the decedent for twenty-four hours for signs of recurrent opiate overdose, and the jury reasonably could have accepted that portion of S's testimony indicating that monitoring was required and rejected that portion of his testimony suggesting that admittance was required; accordingly, to prove causation, the plaintiff needed to show only that the decedent could have been monitored sufficiently for twenty-four hours, and the jury reasonably could have inferred that from the evidence presented.

         2. The trial court did not abuse its discretion in denying E Co.'s motion to set aside the jury's award of $150, 000 in damages for the destruction of the decedent's capacity to carry on and enjoy life's activities; the jury reasonably could have forecast the decedent's life expectancy from its own knowledge and from the substantial evidence presented by the plaintiff of the decedent's age, health, physical condition and habits, all of which were relevant to determine life expectancy, and, therefore, the jury's award of damages for the destruction of the decedent's capacity to carry on and enjoy life's activities was not unreasonable or speculative.

          OPINION

          MULLINS, J.

         In this medical malpractice action, the defendant[1] Emergency Medicine Physicians of New London County, LLC, appeals from the judgment of the trial court, after a jury trial, rendered in favor of the plaintiff, James M. Procaccini, administrator of the estate of Jill A. Procaccini (decedent). On appeal, the defendant claims that there was insufficient evidence supporting the jury's verdict and award of noneconomic damages. Specifically, it claims that the plaintiff failed to present sufficient evidence for the jury (1) to find that the defendant's negligence caused the death of the decedent, and (2) to award $150, 000 in damages for the destruction of the decedent's capacity to carry on and enjoy life's activities. We affirm the judgment of the trial court.

         The following facts, as reasonably could have been found by the jury, and procedural history are relevant to this appeal. On November 30, 2008, the decedent, who was thirty-two years old, died from a methadone overdose. In the years leading up to her death, the decedent had struggled with polysubstance abuse.

         After achieving a period of sobriety early in 2008, the decedent relapsed on November 16, 2008. On that date, the decedent admitted herself to Saint Francis Hospital and Medical Center in Hartford (Saint Francis), seeking treatment for a heroin overdose. On the next day, November 17, 2008, the decedent was transferred to Cedarcrest Hospital, Blue Hills Substance Abuse Services (Blue Hills), in Newington.

         The decedent remained at Blue Hills from November 17, 2008, until her discharge on November 28, 2008. During her stay at Blue Hills, the decedent was administered varying doses of methadone for treatment of her opiate withdrawal symptoms. Methadone, an opioid, [2]frequently is used by clinicians to alleviate the withdrawal symptoms that patients experience while undergoing opiate detoxification. Although methadone commonly is used in the clinical setting and, thus, administered under a clinician's supervision or pursuant to a prescription, it also can ‘‘be purchased [illegally] on the streets as street methadone.'' The decedent's last dose of methadone, five milligrams, was administered at Blue Hills at 7:45 a.m. on November 21, 2008. The decedent was discharged from Blue Hills on November 28, 2008.

         After leaving Blue Hills on November 28, 2008, the decedent made at least two phone calls. One of those calls was to a person from whom the decedent had purchased drugs in the past. Another call was to Charles Hope, a substance abuse counselor and a recovering drug addict with whom the decedent was friendly. Hope agreed to let the decedent stay at his house in New London on the condition that she not use drugs. Hope picked up the decedent from West Hartford on the evening of November 28, 2008, and brought her to his home in New London. Upon their arrival at Hope's home, Hope and the decedent talked briefly and then retired for the night. Hope heard the decedent use the microwave in his kitchen at some point during the night.

         On the morning of November 29, 2008, Hope woke up the decedent and noticed that she was ‘‘feeling a little sick.'' Hope left his home sometime in the late morning or early afternoon of November 29. Hope later called the decedent sometime that afternoon and had a conversation with her. When Hope returned to his home at approximately 6:45 p.m., however, he found the decedent lying unconscious on his living room couch. Hope began performing cardiopulmonary resuscitation, which restored the decedent's breathing. At approximately 6:47 p.m., Hope called 911.

         Emergency medical technicians (EMTs) from the New London Fire Department arrived at Hope's house on November 29, 2008, at approximately 6:51 p.m. The EMTs found the decedent unresponsive, lying in a supine position in Hope's living room with pinpoint pupils and agonal respirations. Hope told the EMTs that the decedent ‘‘had been on methadone, '' that the decedent ‘‘had a history of addiction, '' and that he was unsure if she used drugs that day. Because she was unconscious, however, the EMTs were unable to obtain any medical history from the decedent. The EMTs administered oxygen to the decedent via an oral airway and bag valve mask. Hope and the EMTs briefly searched Hope's house for drugs, drug paraphernalia, and other evidence of drug use. They did not find any such evidence.

         Shortly thereafter, at approximately 6:55 p.m., paramedics from Lawrence & Memorial Hospital (Lawrence & Memorial) arrived on the scene. The paramedics placed the decedent in their ambulance. At some point between 6:55 p.m. and 7:03 p.m., the paramedics intravenously administered the decedent 1.4 milligrams of Narcan.

         Narcan is used as an ‘‘antidote'' for opiate and opioid overdoses. Narcan, like opiates and opioids, attaches to the opioid receptors located in the body's central nervous system. Narcan, however, does not cause any of the effects that opiates and opioids produce, such as pain relief, a ‘‘high'' feeling, and respiratory depression. Instead, because opioid receptors have a ‘‘stronger affinity for the Narcan molecule than [they do] for [opiates and opioids], '' Narcan ‘‘just knocks [opiates and opioids] out and takes residency in the receptor[s] . . . .'' ‘‘[Once] [t]he Narcan displaces the opiate [or opioid] from the receptor[s] . . . the person's opiate effects evaporate . . . the person wakes up and [he or she is] breathing and . . . alert . . . .'' In other words, ‘‘intravenous administration of Narcan . . . pro- duce[s] a near-instantaneous reversal of the narcotic effect . . . within a minute or two at the most . . . .''

         By the time the ambulance arrived at Lawrence & Memorial at 7:03 p.m., the dose of Narcan had revived the decedent. The decedent was conscious and answering questions asked by the paramedics. The paramedics were able to determine that the decedent was taking several medications, including methadone, Topamax, Seroquel, insulin, and Ambien. In their written report, the paramedics indicated that the ‘‘chief complaint'' was an ‘‘[overdose] on Heroin'' and that the decedent was ‘‘found in respiratory arrest due to [overdose].''

         Upon arriving at Lawrence & Memorial, the decedent was taken to the emergency room, where her condition was triaged. In examining the decedent, the triage nurse, Sarah Zambarano, created an electronic report detailing the decedent's condition at 7:13 p.m. Zambarano indicated in the electronic report that the paramedics informed her that Hope told them that the decedent ‘‘took methadone, ? of heroin.''

         At approximately 7:15 p.m., the decedent was assessed by another emergency room nurse, Pamela Mays. At 7:36 p.m., Mays recorded the following in her treatment notes: ‘‘[the decedent] admits to using heroin to ni[ght] . . . states off methadone for several months after detox . . . now using again.'' Mays also indicated that the decedent ‘‘appear[ed] comfortable'' and was ‘‘cooperative, '' ‘‘alert'' and ‘‘oriented . . . .'' Contrary to May's notes, Hope, who had arrived at the emergency room between 7:30 p.m. and 8 p.m., recalled that the decedent was ‘‘very adamant that she did not take any heroin . . . .'' According to Hope, the decedent told Mays that ‘‘I did not take any heroin, I took methadone.''

         At approximately 7:45 p.m., the attending emergency room physician, Thomas E. Marchiondo, examined the decedent. At the time he began treating the decedent, Marchiondo had access to the paramedics' report, which indicated that the decedent had a suspected overdose on heroin, that the decedent also was taking methadone, and that the decedent had been found in respiratory arrest. Marchiondo detailed his examination of the decedent in his own written report. In his report, Marchiondo noted that the decedent's ‘‘chief complaint'' was an ‘‘unintentional heroin overdose.'' Although the decedent apparently denied any ‘‘other co-ingestion, '' Marchiondo's report indicated that the decedent's ‘‘current medications'' included methadone.

         Marchiondo's report also indicated that a urine toxicology screen had been ordered. The results of the screen, of which Marchiondo was aware when treating the decedent, revealed that the decedent's urine tested positive for the presence of methadone, an unidentified opiate, and unidentified benzodiazepines. Because that screen merely was qualitative, it could not identify the specific type of opiate ingested by the decedent or the exact concentration of that substance or methadone in the decedent's system.

         As a result of his review of the drug screen results, as well as his examination of the decedent and review of the treatment notes prepared by the nurses and emergency responders, Marchiondo concluded that the decedent had ingested both methadone and heroin. Regarding the methadone, although he could not determine specifically when or in what manner the decedent ingested it, Marchiondo concluded that the decedent ingested some quantity of methadone ‘‘within the past couple of weeks.'' In so concluding, Marchiondo relied on the fact that methadone was listed as a medication in her medical history, which caused him to believe that the decedent was taking the methadone ‘‘under a doctor's prescription . . . .'' Marchiondo consequently ‘‘would have expected [methadone] to come out positive in her urine.'' Accordingly, he concluded that the overdose symptoms that the decedent was experiencing ‘‘were due to a heroin overdose'' and agreed with a statement by the plaintiff's counsel that the decedent's symptoms ‘‘[were] in no way related to the methadone that was in her system.''[3]

         The decedent remained in the Lawrence & Memorial emergency room from 7:13 p.m. to approximately 11:53 p.m. on November 29, 2008. ‘‘All throughout her stay . . . [the decedent] remained awake, alert, and aware, nontoxic. And through time . . . her vital signs had improved.'' Hope, who had stayed with the decedent at her bedside, also observed that, although initially the decedent seemed, as characterized by the defendant's counsel, ‘‘sluggish, '' her condition continued to improve and she was ‘‘laughing and making jokes.'' During her hospitalization at Lawrence & Memorial, the decedent was not administered any Narcan. Marchiondo had determined that it was not necessary to treat the decedent with Narcan because her vital signs had improved while she was at Lawrence & Memorial.

         Throughout her stay, the decedent was monitored by Mays, who noted in her report that the decedent's vital signs improved and stabilized. At approximately 8 p.m., the decedent was ‘‘awake and alert and asking to leave . . . [but was] told that she was here for the night.'' At this point, the decedent's respiration rate had improved to sixteen breaths per minute, and her oxygen saturation level had risen to 99 percent. These levels were ‘‘basically normal.'' The decedent also had been taken off supplemental oxygen.

         At 9 p.m., the decedent was ‘‘resting soundly'' and her ‘‘[respiration was] easy/even.'' Her respiration rate and oxygen saturation level had not changed since 8 p.m. At 10 p.m. and 11:30 p.m., the decedent's respiration rate still was sixteen breaths per minute, and her oxygen saturation level still was 99 percent. At some point between 11:35 p.m. and 11:53 p.m., the decedent was discharged and was provided instructions for a ‘‘narcotic overdose, '' which advised the decedent to ‘‘[r]eturn to the ER if [her condition] worse[ned].''

         Upon being discharged from Lawrence & Memorial, the decedent left with Hope. Hope and the decedent stopped for food and coffee before returning to Hope's home. At Hope's home, Hope and the decedent conversed until approximately 1:30 a.m. on November 30, 2008, at which point, Hope went to bed. When Hope left the decedent to go to bed, the decedent was kneeling on the corner of the bed in Hope's guest bedroom, watching television and looking at photographs. Hope did not hear any activity during the night.

         After waking up at approximately 9:45 a.m. later that morning, Hope found the decedent unresponsive. The decedent's body was ‘‘frozen stiff'' and kneeling in the same position in which she had been on Hope's guest bed when Hope last saw her at 1:30 a.m. earlier that morning. Hope called 911 at approximately 10:39 a.m.

         New London police, accompanied by New London Fire Department EMTs, arrived at Hope's home on November 30 at approximately 11 a.m. The decedent was pronounced deceased by the EMTs at approximately 11:05 a.m. Thereafter, Hope assisted the police in searching his entire house for drug paraphernalia and other evidence of drug use. Neither Hope nor the five law enforcement officers searching the scene found anything relating to drug activity.

         At approximately 1:34 p.m., Penny Geyer, an investigator with the Office of the Chief Medical Examiner, arrived at Hope's home. At the scene, Geyer performed an external examination of the decedent's clothed body. She did not find any illicit drugs or drug paraphernalia on or around the decedent's body, and she did not observe any signs of drug ingestion on the decedent's body, such as needle marks or residue in the decedent's nose or mouth.

         Deputy Chief Medical Examiner Edward T. McDonough III performed the decedent's autopsy on December1, 2008. A toxicology screen ordered by McDonough detected the presence of methadone in the decedent's blood. Specifically, the report indicated that the concentration of methadone in the decedent's blood was 0.39 milligrams per liter. The postmortem toxicology screen did not detect any opioids or opiates other than methadone.

         As a result of his review of the toxicology report and his examination of the decedent, McDonough concluded that the final cause of the decedent's death was ‘‘methadone toxicity.'' In so concluding, McDonough determined that the postmortem concentration of methadone in the decedent's blood, 0.39 milligrams per liter, was ‘‘within the fatal range.'' McDonough also deter- mined that the decedent died sometime between 5 a.m. and 7 a.m. on November 30, 2008, although this was merely a ‘‘crude'' approximation because the time of death could have been ‘‘much earlier.''

         In November, 2010, the plaintiff, acting as the administrator of the decedent's estate, brought this medical malpractice action seeking damages for the decedent's death. The plaintiff's initial complaint asserted one count against Marchiondo, one count against Lawrence & Memorial Hospital, Inc., and Lawrence & Memorial Hospital Corporation, and one count against the defendant. Following the plaintiff's withdrawal of the separate counts against Marchiondo and Lawrence & Memorial Hospital, Inc., and Lawrence & Memorial Hospital Corporation; see footnote 1 of this opinion; the plaintiff amended his complaint to seek recovery from only the defendant.

         The plaintiff's operative complaint alleges that the defendant is vicariously liable for the medical malpractice that its employee, [4] Marchiondo, committed in treating the decedent for a suspected drug overdose on November 29, 2008. The gravamen of the plaintiff's complaint is that Marchiondo's discharge of the decedent after only four and one-half hours of observation at Lawrence & Memorial was premature. According to the plaintiff, because the decedent presented with a possible methadone overdose, Marchiondo should have kept her under medical monitoring for twenty-four hours, which is the period of time during which the fatal side effects of methadone toxicity may occur. Accordingly, the plaintiff alleges, if the decedent had remained under medical monitoring for the full twenty-four hours, the fatal overdose side effects she experienced after her discharge would have been treated and her eventual death from methadone toxicity would have been averted.

         In his complaint, the plaintiff sought both economic and noneconomic damages resulting from the decedent's death. The claim for economic damages included medical expenses and funeral costs, and the claim for noneconomic damages sought compensation for the decedent's permanent loss of her ability to carry on and enjoy life's activities.

         After the plaintiff rested, the defendant moved for a directed verdict. Specifically, the defendant argued that ‘‘the plaintiff [had] not submitted sufficient evidence to establish a prima facie case with respect to causation.'' (Emphasis added.) The defendant did not challenge the sufficiency of the evidence regarding the appropriate standard of care and the defendant's breach thereof. The court reserved decision on the defendant's motion for a direct verdict.

         The jury returned a plaintiff's verdict and awarded $12, 095 in economic damages and $500, 000 in noneconomic damages. The award consisted of $350, 000 for the decedent's death and $150, 000 for the destruction of the decedent's capacity to carry on and enjoy life's activities.

         After the jury returned its verdict, the defendant renewed its motion for a directed verdict.[5] As in its initial motion, the defendant challenged the sufficiency of the evidence only with respect to causation: ‘‘[T]he evidence presented by the plaintiff during his case-in-chief [was] insufficient to support a conclusion that any alleged negligence on the part of the defendant was the cause in fact of the death of [the decedent].'' Specifically, the defendant argued that there were ‘‘two missing links in the plaintiff's chain of causation: (1) that [the decedent] overdosed on methadone on [November 29, 2008]; and (2) that [the decedent] met the criteria for admission to [Lawrence & Memorial].''

         Regarding the first ‘‘missing link, '' the defendant contended that ‘‘the jury had no basis-other than conjecture-to find that [the decedent] overdosed on methadone on November 29, [2008]. To the contrary, science and the chronology of events point only to the ‘reasonable hypothesis' that [the decedent] took the lethal dose of methadone after Dr. Marchiondo discharged her.'' (Emphasis in original.)

         Regarding the second ‘‘missing link, '' the defendant contended that ‘‘the jury could only guess about another critical piece of the puzzle: admission to [Lawrence & Memorial]. . . . [T]here was no evidence about [Lawrence & Memorial's] criteria for admission, or whether [the decedent] met those criteria.'' According to the defendant, the applicable standard of care required Marchiondo to admit the decedent to Lawrence & Memorial. Thus, the defendant posited, the plaintiff could not prove that Marchiondo's breach of that ...


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