SIGGINS, J. —
Defendant Alta Bates Summit Medical Center (Alta Bates) appeals from the portion of a judgment awarding plaintiffs Phyllis Keys and
Madeline Knox was the mother of plaintiff Phyllis Keys and the sister of plaintiff Erma Smith. On September 26, 2008, Keys and Smith accompanied Knox to Alta Bates where she underwent surgery on her thyroid. At approximately 6:45 p.m., Knox was transferred from a postanesthesia care unit to a medical-surgical unit. At that time, a nurse noticed Knox's breathing was "noisy," and thought it was stridor, a sound that comes from the upper airway suggesting the airway is obstructed. Because of Knox's respiratory difficulty, at 6:46 p.m., the nurse called the hospital's rapid assessment team to evaluate her. The rapid assessment team is composed of a respiratory therapist and a nurse from the intensive care unit (ICU). Notes taken by the ICU nurse indicated the rapid assessment team arrived at Knox's bedside at 6:48 p.m., and left her room at 6:57 p.m. While there, the respiratory therapist suctioned Knox's mouth, removing some secretions. Dr. Richard Kerbavaz, the surgeon who operated on Knox, was called at 6:50 p.m. and advised about Knox's breathing. Dr. Kerbavaz arrived sometime shortly after 7:00 p.m. At Knox's bedside, Dr. Kerbavaz tried to reposition her and suctioned her mouth and nose. As he removed the bandages and began removing the sutures on her incision to relieve pressure, Knox stopped breathing. Dr. Kerbavaz called a code blue at 7:23 p.m.
Keys saw her mother immediately after surgery while she was on a gurney waiting to be brought to her room. Keys testified that Knox "didn't look herself" and her skin appeared gray. Knox appeared to be very uncomfortable and in distress, and she was sweating. She could not speak and was making a gurgling sound when she breathed. Once they were in her room, the respiratory therapist suctioned Knox twice. Knox had nodded when asked if the suctioning made her feel better, but she still appeared to be uncomfortable. Keys asked the nurse to call Knox's doctor because her condition was not improving. After Dr. Kerbavaz arrived, she watched him begin to
Smith too saw Knox near the nurse's station before she was moved into her room. Knox indicated to her that she had a breathing problem. Knox looked uncomfortable to Smith, and was panting, but she was alert and sitting up. Knox was perspiring and was clammy. The first suctioning performed by the respiratory therapist appeared to provide some relief; Smith asked Knox if she felt better and she nodded. The problem recurred and at Smith's request, the respiratory therapist suctioned Knox again. Smith asked that Dr. Kerbavaz be called. Her sister remained uncomfortable while they were awaiting Dr. Kerbavaz and was not breathing well. After Dr. Kerbavaz arrived, Smith saw him reach toward her sister's neck and her sister's arm go up, and then someone called code blue. Everybody was then moving, and she and Keys were pushed aside. When code blue was called, she left the room immediately but went back to get Keys, who had not moved. Smith believed somebody should have come to help her sister sooner than they did. The lack of a sense of urgency upset her.
Plaintiffs Keys and Smith, along with Key's sister Starlette Settles, filed a complaint for damages against defendant alleging causes of action for wrongful death and NIED. Prior to trial, plaintiffs settled their claims against Dr. Kerbavaz, and the settlement was found to be in good faith. After trial, the jury awarded Keys and Settles $1 million on their wrongful death claims
Defendant filed a timely notice of appeal.
Defendant argues that the verdicts in favor of plaintiffs Keys and Smith on their NIED claims must be reversed because they were unsupported by substantial evidence. We disagree.
In making this argument, defendant relies upon Bird v. Saenz (2002) 28 Cal.4th 910 [123 Cal.Rptr.2d 465, 51 P.3d 324] (Bird). In that case, two events were identified by the California Supreme Court as potential injury-producing events: (1) the negligent transection of the victim's artery and (2) the subsequent negligence by the defendants in failing to diagnose and treat the damaged artery. (Id. at p. 917.) The court ruled that the plaintiffs could not recover for NIED to a bystander for either event. With respect to the negligent transection, the plaintiffs were not present at, nor did they observe the injury-producing event. (Ibid.) As for the defendants' subsequent negligence in failing to diagnose and treat the victim's damaged artery, the plaintiffs did not, and could not, meaningfully perceive the defendants' negligence because "[e]xcept in the most obvious cases, a misdiagnosis is beyond the awareness of lay bystanders." (Ibid.) The court continued, "Even if plaintiffs believed, as they stated in their declarations, that their mother was bleeding to death, they had no reason to know that the care she was receiving to diagnose and correct the cause of the problem was inadequate. While they eventually became aware that one injury-producing event — the transected artery — had occurred, they had no basis for believing that another, subtler event was occurring in its wake." (Ibid.)
Accordingly, Bird does not categorically bar plaintiffs who witness acts of medical negligence from pursuing NIED claims. "This is not to say that a layperson can never perceive medical negligence ... or that one who does perceive it cannot assert a valid claim for NIED." (Bird, supra, 28 Cal.4th at p. 918.) Particularly, a NIED claim may arise when, as in Ochoa, caregivers fail "to respond significantly to symptoms obviously requiring immediate medical attention." (Bird, supra, 28 Cal.4th at pp. 919-920.)
The evidence here showed that plaintiffs were present when Knox, their mother and sister, had difficulty breathing following thyroid surgery. They observed inadequate efforts to assist her breathing, and called for help from the respiratory therapist, directing him at one point to suction her throat. They also directed hospital staff to call for the surgeon to return to Knox's bedside to treat her breathing problems. These facts could be properly considered by the jury to demonstrate that plaintiffs were contemporaneously aware of Knox's injury and the inadequate treatment provided her by defendant.
The jury was instructed under CACI No. 1621 as it provided at the time of trial that in order to find defendant liable for NIED it had to find that plaintiffs were present when the injury occurred and "aware that Madeline Knox was being injured." The dissent considers it material in this case that CACI No. 1621 has been modified since the time of trial to include a specific paragraph elaborating on the causation requirement for a NIED claim. We do not. As the dissent points out, CACI No. 1621 provides the jury is to determine: "That [name of plaintiff] was then aware that the [e.g., traffic accident] was causing [injury to/the death of] [name of victim]." (CACI No. 1621 (2014) vol. 1, p. 878.) Here, if the court had this version of the instruction available, the jury would be told it had to determine: "That Ms. Keys and Ms. Smith were then aware that the inadequate treatment of Ms. Knox's compromised airway was causing her injury." The evidence and the record in this case lead us to conclude that they were and that the jury made such a determination.
We have no reason to question the jury's conclusion that Keys and Smith suffered serious emotional distress as a result of watching Knox's struggle to breathe that led to her death. The jury was properly instructed, as explained in Thing, that "[s]erious emotional distress exists if an ordinary, reasonable person would be unable to cope with it." (See Thing, supra, 48 Cal.3d at p. 668, fn. 12.) The instructions clarify that "Emotional distress includes suffering, anguish, fright, ... nervousness, grief, anxiety, worry, shock...." Viewed through this lens there is no question that Smith and Keys's testimony provides sufficient proof of serious emotional distress.
Smith said she was scared and upset following her sister's code blue episode in the recovery room. She prayed for her recovery, would not agree to the characterization that she was able to cope with the mental and emotional stress of the events in the recovery room, and "went to pieces" when she learned her sister had died.
Keys was more descriptive of her feeling in the recovery room while her mother struggled to breathe. She testified, "I felt wow, whew. I felt very helpless because there was nothing — I couldn't do anything but stand there wishing something could be done — could be done to her. Nothing was done. She looked very — her face was just gray. She was perspiring a lot. Helpless. Looked in pain and there's nothing I could do but just stand there. And I was just — devastation, devastated that everything that happened to her." When the code blue was called, Keys described her reaction as "very emotional and shocked," and she was crying.
The judgment is affirmed.
McGuiness, P. J., concurred.
POLLAK, J., Dissenting. —
I do not question for a moment the emotional distress plaintiffs must have endured while observing their mother and sister struggle to breathe, and the unsuccessful efforts that were made to remedy her distress. I also acknowledge reservations about the logic and wisdom of the standard that has evolved from the decisions of our Supreme Court as to when a bystander may recover for experiencing such emotional distress.
The negligence in this case was the misdiagnosis of the cause of Madeline Knox's compromised ability to breathe and resulting stridor, noisy breathing indicative of airway obstruction. This was not a situation as in Ochoa v. Superior Court (1985) 39 Cal.3d 159 [216 Cal.Rptr. 661, 703 P.2d 1], where the authorities ignored obvious signs of distress and did nothing to treat the conditions for almost two days. Here, medical personnel responded immediately to Knox's stridor, promptly summoning the hospital's rapid assessment team and then the surgeon who had performed Knox's operation, twice suctioning secretions from Knox's mouth and nose, and removing bandages and sutures to relieve pressure. Plaintiffs observed that these steps were "inadequate" — as the majority opinion points out several times — but they observed only that they were inadequate in the sense that they did not correct the problem. Plaintiffs observed that Knox continued to have trouble breathing, but they could not observe and did not know that the surgeon and staff had not correctly diagnosed the cause of the stridor.
Plaintiffs' expert testified and the jury apparently found that the medical staff failed to recognize that Knox's breathing difficulties were being caused by a hematoma, requiring a higher level of care from an intensivist care physician or anesthesiologist. That, in the opinion of plaintiffs' expert, was the cause of Knox's injuries and eventual death. Plaintiffs did not know that the treatment they were witnessing was inadequate because the medical staff had misdiagnosed the cause of Knox's breathing difficulty.
The line of bystander emotional distress cases from our Supreme Court, most recently summarized and restated in Bird v. Saenz (2002) 28 Cal.4th 910 [123 Cal.Rptr.2d 465, 51 P.3d 324] (Bird), make clear that in order to permit recovery, it is not enough that the plaintiff bystanders observe the injured person's suffering. The plaintiffs must "`experience a contemporaneous sensory awareness of the causal connection between the negligent conduct and the resulting injury.'" (Id. at p. 918.) There must be "`contemporaneous awareness the defendant's conduct or lack thereof is causing harm.'" (Id. at p. 919.) While the court rejected the notion "that a layperson can never perceive medical negligence" (id. at p. 918), the court made clear that recovery is possible only in extreme cases (such as observation of the amputation of the wrong limb), "[b]ut the same cannot be assumed of medical malpractice generally" (ibid.). In Bird, the court makes clear that to permit recovery, the bystander plaintiff must observe not only the negligent act and the injury, but also must be aware of the causal connection between the two. There must be "contemporaneous, understanding awareness of the event as causing harm to the victim." (Id. at p. 920.)
The Bird opinion discusses approvingly several other cases in which NIED recovery was denied because of the bystanders' lack of awareness of a misdiagnosis, even though they were aware that treatment was failing to correct the patient's physical problem. I quote from the Supreme Court opinion: "In Wright v. City of Los Angeles (1990) 219 Cal.App.3d 318 [268 Cal.Rptr. 309], a relative who watched a paramedic conduct a cursory medical examination that failed to detect signs of sickle cell shock was permitted to sue for wrongful death but not for NIED. While the relative was `present at the scene at the time the injury-producing event occurred,' there was no evidence `he was then aware [that the decedent] was being injured by [the paramedic's] negligent conduct.' (Id. at p. 350.) Likewise, in Breazeal v. Henry Mayo Newhall Memorial Hospital (1991) 234 Cal.App.3d 1329 [286 Cal.Rptr. 207], a plaintiff who observed ultimately unsuccessful efforts to restore her son's breathing with a tracheostomy and endotracheal tubes was held not to have a valid claim for NIED. [Fn. omitted.] `There was evidence that at some point [the plaintiff] saw [one of the defendant physicians] bent over [her son], with blood on both of them. However, there was no evidence ... that what [the physician] was doing at that moment was "an injury-producing event," rather than an unsuccessful attempt to correct an already existing injury....' (Id. at p. 1342.) Nor was she `contemporaneously... aware that any such event was causing him injury.' (Ibid.) Finally, in Meighan v. Shore (1995) 34 Cal.App.4th 1025 [40 Cal.Rptr.2d 744], the plaintiff wife, who was trained as a nurse, feared that her husband was experiencing a heart attack and believed that he was not being treated appropriately in the emergency room. In fact he was suffering a heart attack, but initial test results were to the contrary and physicians incorrectly misdiagnosed his condition. Citing Golstein [v. Superior Court (1990)] 223 Cal.App.3d 1415,
Plaintiffs' lack of awareness that the cause of Knox's continued suffering was defendant's failure to correctly diagnose the cause of her stridor, under Bird and the cases it cites, thus precludes NIED recovery. The result is not changed by characterizing the injury-producing event, as does the majority opinion, as "lack of acuity." (Maj. opn., ante, at p. 490.)
Moreover, the jury in this case was not properly instructed. The instruction given was based on CACI No. 1621 as it read at the time of trial. (CACI No. 1621 (2013) vol. 1, p. 862.) Based on the then current CACI instruction, the jury was instructed that the third element plaintiffs were required to prove to establish NIED was the following: "That Phyllis Keys and Erma Smith were present at the scene of the injury when it occurred and [were] aware that Madeline Knox was being injured." Although taken from CACI, the instruction was incomplete and erroneous. Subsequent to the trial in this case, CACI No. 1621 has been modified to read as follows: "That [name of plaintiff] was then aware that the [e.g., traffic accident] was causing [injury to/the death of] [name of victim]." (CACI No. 1621 (2014) vol. 1, p. 878.) As it appears, the corrected instruction adds the essential requirement that plaintiffs were contemporaneously aware that the defendant's negligence was causing the patient's injury. The omission of this critical factor from the court's instructions is, of course, understandable because based on the then current CACI form instruction. The jury's verdict is also understandable since it was based on that incomplete instruction. Nonetheless, the omission of this critical factor was contrary to the clear holding of Bird and of the prior cases discussed in Bird.
The instruction that the majority states would have been given under the revised CACI instruction would not have corrected the error because it contains the same misunderstanding of what our Supreme Court has required. It is not sufficient that the bystanders realized the treatment being provided was "inadequate" to correct Knox's breathing difficulty. To recover for NIED they must have realized that Knox was not improving because defendant was not correctly diagnosing the cause of the breathing problem. Plaintiffs must have been aware that defendant's negligence was the cause of the harm.
The revision that has since been made to the standard CACI instruction thus underscores why the judgment in this case cannot properly be affirmed. Although plaintiffs were present and observed Knox's struggle to breathe,
For these reasons, I respectfully dissent.
