Kayla Butts v. United States, 930 F.3d 234

Background

Infant A.F. born at Berkeley Medical Center (no NICU) showed immediate respiratory distress and low Apgar scores; placed on oxyhood and transferred to Berkeley’s Max Care Nursery.
Dr. Sarah Hardy (on call pediatrician) arrived, ordered tests, started antibiotics, placed A.F. on oxygen, then returned to office while monitoring by phone; later decided to transfer A.F. but consulted newly arrived neonatologist Dr. Avinash Purohit.
Dr. Purohit, a board-certified neonatologist hired to establish a NICU but without an operational NICU, told Dr. Hardy he could manage A.F. at Berkeley; Dr. Hardy transferred care to him that afternoon.
A.F.’s condition worsened over the next 24 hours; Dr. Purohit eventually transferred A.F. to Winchester NICU the following afternoon, but A.F. suffered irreversible brain injury from hypoxia.
Butts sued multiple providers; United States substituted for Dr. Hardy under the FTCA. After a bench trial, the district court found Dr. Hardy breached the standard of care and awarded >$7M; the United States appealed.
The Fourth Circuit held the district court’s finding of breach was clearly erroneous because Butts’ own experts testified that transferring A.F. to Dr. Purohit (a neonatologist with capability to intubate) was an acceptable alternative to immediate NICU transfer.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Dr. Hardy breached the applicable standard of care by failing to transfer A.F. to a NICU the afternoon of birth	Butts: A.F. needed NICU-level care (CPAP or intubation) that Berkeley lacked; Hardy should have transferred to Winchester NICU immediately	U.S.: Hardy transferred care to Dr. Purohit (board-certified neonatologist) who had ability to provide needed interventions at Berkeley; transfer satisfied standard	Held: No breach — experts conceded transfer to higher care at Berkeley to Dr. Purohit was an acceptable method of treatment
Whether expert testimony established breach with sufficient specificity	Butts: Experts opined NICU transfer was required and that Hardy’s actions caused harm	U.S.: Experts’ testimony was qualified and inconsistent; neither clearly defined precise standard requiring immediate NICU transfer	Held: Plaintiff’s experts did not provide testimony showing Hardy violated the standard of care
Effect of transferring responsibility to another physician on Hardy’s liability	Butts: Transfer to Purohit did not absolve Hardy because Berkeley lacked a NICU and Purohit lacked NICU resources	U.S.: Transfer to a board-certified neonatologist who committed to care satisfied the standard; subsequent decisions by Purohit determine next transfer timing	Held: Transfer to Purohit was adequate; Hardy not liable for later decisions by Purohit
Standard of review for bench-trial factual findings	Butts: District court’s factual findings should stand	U.S.: Even under clear-error deference, record lacks substantial evidence to support breach finding	Held: Applying clear-error review, the Fourth Circuit concluded the district court’s breach finding was clearly erroneous and reversed

Key Cases Cited

Equinor USA Onshore Properties Inc. v. Pine Res., LLC, 917 F.3d 807 (4th Cir. 2019) (standard for mixed review of bench-trial judgments)
Anderson v. City of Bessemer City, N.C., 470 U.S. 564 (U.S. 1985) (clarifies scope of clearly erroneous standard)
United States v. Wooden, 693 F.3d 440 (4th Cir. 2012) (discusses limits of clear-error review)
United States v. United States Gypsum Co., 333 U.S. 364 (U.S. 1948) (source on "definite and firm conviction" test for clear error)
Miller v. Mercy Hosp., Inc., 720 F.2d 356 (4th Cir. 1983) (reviewing court may reverse if findings not supported by substantial evidence)
Bellomy v. United States, 888 F. Supp. 760 (S.D.W. Va. 1995) (medical-malpractice standards regarding acceptable methods of treatment)