475 S.W.3d 162
Mo. Ct. App.2014Background
- Plaintiff Sherry Huelskamp was prescribed Lamictal (an anticonvulsant/antidepressant) by psychiatric NP Cathy Neubauer in November 2008; Neubauer testified she warned Plaintiff Lamictal can cause a rash and to stop it and call if a rash developed, but Plaintiff said she did not remember any warning.
- Plaintiff developed a rash in early December 2008 and called family-practice NP Barbara King (employed by defendant Patients First Health Care, LLC); King knew Plaintiff was on Lamictal but did not investigate Lamictal’s side effects or black-box warning and did not tell Plaintiff to stop Lamictal or to call Neubauer; King treated the rash as antibiotic-related and instructed stopping Amoxicillin.
- Plaintiff’s rash worsened; King prescribed steroids on December 10 and recommended a dermatologist on December 12; dermatologist Dr. Reinberg ordered discontinuation of Lamictal on December 12, after which Plaintiff stopped the drug.
- On December 14 Plaintiff was hospitalized and diagnosed with Stevens–Johnson Syndrome / Toxic Epidermal Necrolysis, with ~98% body involvement; she incurred significant damages.
- Plaintiff sued Defendant for medical malpractice based on Nurse King’s alleged failure to instruct discontinuation of Lamictal or to advise contacting the prescribing provider on December 4; jury awarded $525,000; trial court denied Defendant’s directed verdict, JNOV, and new-trial motions.
- On appeal Defendant challenged (1) causation/submissibility, (2) admission of Plaintiff’s rebuttal testimony, and (3) submission of Instruction No. 7 (alleged roving commission); the Court of Appeals affirmed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Submissible case on causation ("but for") | Huelskamp produced expert testimony that King breached the standard of care and that discontinuing Lamictal on Dec. 4 would have prevented TEN; Huelskamp also testified she would have complied with a discontinuation order. | Patients First argued causation fails as a matter of law because Neubauer had already warned Plaintiff (so other sources made King’s omission not the but‑for cause) and that Plaintiff did not prove she would have stopped Lamictal on Dec. 4. | Affirmed: evidence and reasonable inferences supported a submissible case on both breach and "but for" causation; jurors could credit plaintiff’s testimony that she would have complied and experts that early discontinuation would have prevented TEN. |
| Admission of rebuttal testimony | Huelskamp sought leave to testify in rebuttal that she would have stopped Lamictal or called Neubauer if instructed; this directly countered defense implication she ignored instructions. | Patients First argued the testimony was improperly used to make up a missing element of causation and was prejudicial. | Affirmed: trial court did not abuse discretion; rebuttal testimony was competent to discredit defense evidence suggesting Plaintiff did not follow medical advice and, at most, remedied evidence conflicts. |
| Instruction No. 7 (alleged roving commission) | Instruction paralleled MAI pattern: alleged specific omissions (failed to instruct discontinuation or to instruct to contact prescriber), required breach and causation. | Patients First argued the wording ("failed to") assumed duty, was too general re: timing/"inquire," and improperly assumed Lamictal caused TEN. | Affirmed: instruction correctly submitted ultimate issues (breach and causation), "failed to" language is MAI‑approved, the alleged vagueness did not mislead the jury, and the instruction did not assume causation. |
Key Cases Cited
- Davolt v. Highland, 119 S.W.3d 118 (Mo. App. 2003) (standard for reviewing directed verdict/JNOV and submissible case rule)
- Keveney v. Missouri Military Academy, 304 S.W.3d 98 (Mo. banc 2010) (jury‑verdict reversal standard)
- Washington by Washington v. Barnes Hosp., 897 S.W.2d 611 (Mo. banc 1995) (elements of medical malpractice: breach and causation)
- Harvey v. Washington, 95 S.W.3d 93 (Mo. banc 2003) ("independently sufficient" negligence by another provider can defeat but‑for causation against a different provider)
- Sanders v. Ahmed, 364 S.W.3d 195 (Mo. banc 2012) (focus on whether conduct directly caused or directly contributed to injury in causation analysis)
- Howard v. City of Kansas City, 332 S.W.3d 772 (Mo. banc 2011) (abuse‑of‑discretion review for admission of rebuttal evidence)
- Twin Chimneys Homeowners Ass’n v. J.E. Jones Const. Co., 168 S.W.3d 488 (Mo. App. E.D. 2005) (roving‑commission doctrine and instruction requirements)