Opinion
No. 1-429 / 00-0992.
Filed March 13, 2002.
Appeal from the Iowa District Court for Polk County, RICHARD G. BLANE II, Judge.
Plaintiffs appeal from the district court ruling granting the defendants' motions for directed verdict in the plaintiffs' medical malpractice action. REVERSED AND REMANDED.
Lawrence L. Marcucci and John C. Conger of Marcucci Conger, P.L.C., West Des Moines, for appellants.
Roy M. Irish of Patterson, Lorentzen, Duffield, Timmons, Irish, Becker Ordway, L.L.P., Des Moines, for appellee Gronstedt.
Connie Alt and Nancy J. Penner of Shuttleworth Ingersoll, P.L.C., Cedar Rapids, for appellee Lee.
Heard by HUITINK, P.J., and ZIMMER and VAITHESWARAN, JJ.
I. Background Facts and Proceedings.
Bruce Bowman sued Drs. Gary G. Gronstedt and Yasyn Lee for wrongful death damages following his wife Wendy's death. Bowman claims the doctors' substandard care and treatment of Wendy's mental illness caused her death and resulting damages.
The trial record includes the following evidence concerning Wendy's mental health and events preceding her death in October 1996: Wendy first consulted Dr. Gronstedt on September 16, 1996, after she was found wandering disoriented and delusional in an Altoona park on September 4, 1996. At that time Dr. Gronstedt diagnosed Wendy as suffering from a bipolar disorder. He prescribed mood-stabilizing medication and scheduled Wendy for a follow-up appointment in three days. Wendy disappeared for a second time on September 28. After Altoona police found her in a state similar to September 4, she was briefly hospitalized until released by Dr. Gronstedt on October 2, 1996. According to Bruce, he discussed his concerns about Wendy's release with Dr. Gronstedt but was told Wendy would be fine as long as she followed an undisclosed plan for recovery. Other evidence discloses the plan was for Wendy to move out of the Bowmans' home and divorce Bruce. Wendy planned to move to Newton, where she would get a job and also pursue a career as a freelance writer.
Upon her release on October 2, Wendy returned home, gathered her belongings, and disappeared. When she was later found in Dyersville, Wendy was described as confused and incontinent. Police took her to a hospital in Dubuque where she was examined by Dr. Lee. Although Dr. Lee diagnosed Wendy as suffering from bipolar disorder, she did not treat her. Wendy was instead released and instructed to contact Dr. Gronstedt immediately upon her return to Altoona.
After Wendy was released from the hospital in Dubuque on October 5, 1996, she went to live with her parents. Her father, Don Roland, called Dr. Gronstedt to alert him to Wendy's situation and obtain an appointment for her. Dr. Gronstedt told Roland that Wendy already had an October 14 appointment and that would be soon enough for him to see her.
Wendy disappeared for the last time on October 11. Her car was discovered along Interstate 80 in Pottawattamie County on October 12. Approximately twenty quart bottles of water were found in her car, six or eight of which were empty. Five days later, Wendy's body was discovered near the location of her car.
Wendy's autopsy results were inconclusive. Dr. Thomas Bennett, then the state medical examiner, determined the cause of Wendy's death was most probably fatty liver changes, a condition associated with an electrolyte disturbance. In an addendum to his autopsy report, Bennett stated:
The most significant finding at the autopsy was the finding of the fatty liver, which has been associated with sudden death. Fatty liver has numerous causes besides alcohol. For the death of Wendy Bowman, certainly starvation or other undisclosed causes must be considered more likely than alcohol use in her death.
Thus, the cause of death will still be ruled as "sudden death with fatty liver, cause undetermined," and the manner of death would be ruled as "undetermined," also.
Bowman offered expert medical testimony supporting both his malpractice and causation theories. Dr. Daniel Luchins, a psychiatrist, testified Dr. Gronstedt breached the applicable standard of care by discharging Wendy from the hospital on October 2 and his discharge plan for Wendy was also substandard. Dr. Luchins testified Dr. Gronstedt's "plan" did nothing to treat Wendy's mental illness, stating, "You become bipolar because of genetic or biological constitution that makes you bipolar, and you don't get cured from bipolar illness by getting divorced." Dr. Luchins further testified Dr. Lee breached the applicable standard of care because she released Wendy on October 5, 1996, and failed to consult Dr. Gronstedt to ensure that Wendy received the follow-up treatment recommended.
In addition, Dr. Luchins testified a possible cause of Wendy's death was starvation. He noted Wendy was purging herself, either by vomiting or using laxatives, and this would have changed her body chemistry, including a loss of electrolytes. He further testified:
The other abnormality that Wendy has that may have endangered her life was that she drank large amounts of water, and if you drink a lot of water, you can get what's called water intoxication, intoxicated where you — you change your body chemistry and your initial signs are then confusion and delirium, and where you don't know where you are, don't know what you're doing. A little bit similar to what actually Wendy was showing. And if it gets more severe, you change your body chemistry to the point that you get seizures, and if it continues to get more severe, you actually can stop your heart. You just change your body chemistry, and this is — a water intoxication is a fairly common symptom in severe psychiatric illness.
. . . .
And I don't know if that was what caused Wendy's death, but it's a possibility.
Lastly, Dr. Luchins testified Wendy may have suffered from polydipsia, a psychiatric condition which occurs when a person drinks an excessive amount of water. He testified that because Wendy was purging, she could become water intoxicated more quickly, with a resulting risk of seizures or death.
In their motions for directed verdict, the defendant doctors argued that Bowman's evidence was as a matter of law insufficient to establish a causal connection between any theory of malpractice and Wendy's death. In a ruling granting the doctors' motions, the court said, "I would grant the defendants' Motion for Directed Verdict on the lack of proof as to the proximate cause of death being related to the conduct of either of the defendants." As a result, Bowman's claims were dismissed resulting in this appeal.
II. Scope of Review.
We review a district court's grant or denial of a motion for directed verdict for correction of errors of law. Iowa R. App. P. 6.4. We view the evidence in the light most favorable to the nonmoving party and afford them every legitimate inference we can reasonably deduce from the evidence. Nesbit v. Myers, 576 N.W.2d 613, 614 (Iowa Ct.App. 1998). A motion for directed verdict should be denied if there is substantial evidence to support the plaintiff's claim. Hasselman v. Hasselman, 596 N.W.2d 541, 545 (Iowa 1999). Evidence is substantial when a reasonable mind would accept it as adequate to reach a conclusion. Id.
III. The Merits.
A medical malpractice claim premised on negligence requires proof of an affirmative act of negligence, lack of skill or care, or failure to give careful or proper attention to a patient. Lagerpusch v. Lindley, 253 Iowa 1033, 1037, 115 N.W.2d 207, 210 (1962). A prima facie medical malpractice case requires proof establishing the applicable standard of care, the defendant's breach of the applicable standard of care, and a causal relationship between the defendant's breach and the plaintiff's injuries. Daboll v. Hoden, 222 N.W.2d 727, 734 (Iowa 1974). After prima facie evidence of negligence has been established, the remaining question of proximate cause is ordinarily a jury question. Causation, like the standard of care and its breach, requires proof by expert testimony. McCleeary v. Wirtz, 222 N.W.2d 409, 414-15 (Iowa 1974); Cronin v. Hagan, 221 N.W.2d 748, 755 (Iowa 1974); Barnes v. Bovenmyer, 255 Iowa 220, 229, 122 N.W.2d 312, 317 (1963); Bradshaw v. Iowa Methodist Hosp., 251 Iowa 375, 383, 101 N.W.2d 167, 171 (1960); Wilson v. Corbin, 241 Iowa 593, 604, 41 N.W.2d 702, 708 (1950).
The conduct of a party is a proximate cause of an injury when it is a substantial factor in producing the injury and the injury would not have happened except for the conduct. Huber v. Watson, 568 N.W.2d 787, 790 (Iowa 1997). A proximate cause need not be the sole proximate cause in order for a negligent party to be liable to an injured person. Gunnison v. Torrey, 216 N.W.2d 361, 364 (Iowa 1974). Because there may be more than one substantial factor in bringing about a harm, there can be more than one proximate cause of an injury. Johnson v. Interstate Power Co., 461 N.W.2d 310, 323 (Iowa 1992) (citations omitted).
Under Bowman's causation theory, Wendy's mental and physical condition would not have deteriorated to the extent it did, nor would she have disappeared on October 11, had Drs. Lee and Gronstedt promptly intervened by hospitalizing her or otherwise treating her. This theory finds abundant support in the opinion by Dr. Luchins that Wendy's fatty liver changes, the most likely immediate cause of death, resulted from starvation or water intoxication.
Moreover, an expert's opinion on the possibility of a causal connection between negligent conduct and injury can be sufficient to generate a jury issue if there is other testimony connecting the injuries to the negligent act. See Gerst v. Marshall, 549 N.W.2d 810, 818 (Iowa 1996). Here, Bennett's autopsy report listed four possible causes for a fatty liver: starvation, pregnancy, diabetes, and alcohol withdrawal. Bennett's autopsy report noted Wendy was not pregnant and did not have a history of diabetes or alcohol use. Bennett's report therefore supports the conclusion by Dr. Luchins that starvation was a likely factor contributing to Wendy's death.
Contrary to the district court's conclusion, we find sufficient evidence supporting the submission of Bowman's malpractice and causation theories to the jury. By concluding otherwise, the trial court failed to consider the substance of the causation opinion given by Dr. Luchins as well as the fact that Wendy's death could have resulted from more than one proximate cause. Where evidence of a defendant's negligence is not wholly excluded as a contributing cause of a plaintiff's injuries as a matter of law, the issue of proximate cause is a factual question for the jury to determine. Molchon v. Tyler, 546 S.E.2d 691, 696 (Va. 2001) (holding there was a jury question on whether psychiatrist's discharge of patient was proximate cause of patient's suicide shortly thereafter). Because the evidence does not wholly exclude the doctors' malpractice as a substantial factor causing Wendy's death, the resulting fact questions should have been submitted to the jury.
We accordingly reverse the judgment of the district court and remand for a new trial.