2013 IL App (3d) 110374
Opinion filed September 24, 2013
______________________________________________________________________________
IN THE
APPELLATE COURT OF ILLINOIS
THIRD JUDICIAL DISTRICT
______________________________________________________________________________
RITA STEELE, Special Administrator ) Appeal from the Circuit Court
of the Estate of Michelle Koenig, ) of the 21st Judicial Circuit,
) Kankakee County, Illinois,
Plaintiff-Appellee, )
) Appeal Nos. 3-11-0374 and
v. ) 3-11-0375
) Circuit No. 07 L 18
PROVENA HOSPITALS, d/b/a St. Mary's )
Hospital; TIMOTHY MORAN, M.D.; )
and ECHO MANAGEMENT AND )
CONSULTING GROUP, LLC, ) Honorable
) Kendall Wenzelman,
Defendants-Appellants. ) Judge, Presiding.
______________________________________________________________________________
JUSTICE McDADE delivered the judgment of the court, with opinion.
Presiding Justice Wright and Justice Schmidt concurred in the judgment, with opinion.
____________________________________________________________________________
OPINION
¶1 Rita Steele, plaintiff and special administrator for the estate of Michelle Koenig, filed suit
against emergency room doctor Timothy Moran and his employer, Echo Management and
Consulting, for the wrongful death of her daughter, Michelle, due to alleged medical negligence.
She also sued Provena Hospitals, d/b/a St. Mary's Hospital, alleging that Moran acted as its agent
and it was, therefore, vicariously liable for her daughter's death. The jury rendered a verdict
awarding Steele, Todd Koenig, Michelle's father, and Jessica Watts, Michelle's half-sister, $1.5
million. Provena and Moran have both appealed. We reverse and remand on Moran’s appeal
and enter judgment notwithstanding the verdict in favor of Provena.
¶2 FACTS
¶3 I. Michelle's Recent Medical History
¶4 On January 13, 2006, Michelle went to the office of her primary care physician, Dr.
Gregory Trapp, complaining of a sore throat and cough. His nurse-practitioner ordered a throat
culture, which was positive for streptococcus infection. Michelle was prescribed an antibiotic,
amoxicillin, and did not subsequently return to Dr. Trapp’s office.
¶5 On February 9, 2006, Michelle began to feel ill at work. Her symptoms included
difficulty speaking and partial paralysis on her right side. She was picked up from work and
taken home by her mother, but later that day was transported by ambulance to Riverside Hospital
in Kankakee, where she was seen and evaluated by Dr. Trapp, her personal internist. Dr. Trapp
performed a physical examination and initially thought she had suffered a stroke, blood clot, or
cranial bleed. He ordered tests, which he and a consulting neurologist, Dr. Bruce Dodt, thought
supported a diagnosis of multiple sclerosis. He arranged for Michelle’s transfer from Riverside
to the Chicago Institute of Neurology and Neurosurgery (CINN), where she underwent a number
of tests, including a spinal tap requiring a lumbar puncture. The doctors at CINN diagnosed
either presumptive multiple sclerosis (which they described to Dr. Trapp as rapidly progressing)
or lupus. They began a course of steroids while she was hospitalized, and discharged her on
February 13 or 14 with instructions to continue on steroids, starting with a daily dose of 60
milligrams of prednisone and tapering to 40 milligrams per day by February 22. She was to
return to CINN for further treatment.
2
¶6 On Sunday, February 19, Michelle began experiencing severe back pain and a cough. At
the insistence of her mother, Rita, Michelle was taken by ambulance to St. Mary's Hospital for
emergency treatment. Upon arrival at the hospital, Michelle was given a consent-to-treatment
form to sign. Although neither she nor Rita read the form, Rita printed her daughter's name and
directed Michelle to sign it.
¶7 Michelle was treated by Dr. Timothy Moran in the emergency department at St. Mary's.
He was provided with Michelle's medical history, including her current use of steroids and the
recent diagnosis of presumptive multiple sclerosis/lupus and the fact that she had had chicken
pox. Michelle's chief complaint in emergency on February 19 was back pain which limited her
ability to get around. She told Dr. Moran that she had recently undergone a lumbar puncture.
¶8 Dr. Moran performed a physical examination and he treated her back pain with both a
pain medication and a muscle relaxant, which relieved her discomfort enough for Michelle to
walk around and to use the bathroom on her own. Moran also ordered several diagnostic tests,
including blood work, chemistry and metabolic testing, urinalysis and lumbar spine X-rays. He
consulted with Dr. Leonard Cerullo, one of Michelle's physicians at CINN, and learned from him
that the results of her tests at CINN were still incomplete. He also spoke with Dr. Khan, an
internist who was on call for Dr. Trapp but who declined to come to the emergency room, instead
advising that Michelle should see Dr. Trapp in the office the following day.
¶9 During his examination, Dr. Moran observed a rash on Michelle's head, chin, chest and
upper back, which he described as "scattered red papular vesicular lesions." A papular lesion is a
raised lesion or red bump, and a vesicle is a small blister within the skin. Dr. Moran later
testified that he did not think this rash looked like chicken pox because Michelle did not have the
3
dry and crusty lesions he believed she would have exhibited if the virus had developed within the
past 24 hours, and they were not itching.
¶ 10 Results of the testing showed she had no fever, her urinalysis was negative for nitrites,
leukocyte esterase, significant protein and blood. She did have a white blood cell count of
19,000 and her liver enzymes were somewhat elevated. Although Dr. Moran noted the elevated
enzymes, he formed "no opinion" at that time as to the reason for the elevation, nor did he know
that chicken pox could be a cause.
¶ 11 Dr. Moran released Michelle that same night with instructions to continue the pain
medication and muscle relaxant, to follow up with Dr. Trapp the next day (Monday), and with
Dr. Cerullo at CINN as previously scheduled.
¶ 12 Michelle did not see Dr. Trapp during the day on Monday, but at 6:40 p.m. on that
evening, February 20, she again presented for emergency care, this time at Riverside where she
had been evaluated on February 9. She was again complaining of back pain and abdominal
discomfort/nausea.
¶ 13 (The following portion of Michelle's medical history, set forth in paragraphs 14 through
18, was deemed irrelevant to the standard of care and was excluded from the jury by order of the
trial court. The information is summarized from the deposition testimony of Dr. Manczko, Dr.
Trapp, and Dr. Ramani. We include it here because it forms the basis of a significant issue on
appeal.)
¶ 14 At Riverside, Michelle was first seen by emergency department physician Dr. Thaddeus
Manczko. Because he had no independent recollection of these events, his deposition testimony
was drawn from his notes and the hospital’s comprehensive chart. Manczko said Michelle
4
presented with radiating pain in her lower back and abdominal discomfort. He observed residual
right-side weakness, some symptoms of mild dehydration and of infection, bruising around the
lumbar puncture site, and pale skin, and he specifically noted “no skin lesions to suggest
shingles.” He called in Dr. Trapp because, as Michelle’s primary care physician, he would be
able to admit her to the hospital if that became necessary.
¶ 15 Tests were ordered on February 20–some by Manczko and some by Trapp–which showed
a white blood cell count that had more than doubled from the 19,000 finding at St. Mary’s to
39,000 and liver enzymes that had dramatically increased.1 Manczko thought these results were
consistent with infection but could also result from stress, medication, hepatitis, or inflammation
(epidural abscess). He stated he could not base a final or ultimate diagnosis on that information
alone, nor was he, as an emergency room physician, in a position to rule out multiple sclerosis or
viral infection as the cause of her symptoms. In light of the incomplete information available to
him, he made a primary diagnosis of abdominal pain, a secondary diagnosis of low back pain,
and noted a need to rule out an epidural abscess resulting from lumbar puncture.
¶ 16 After being called in, Dr. Trapp assumed the triaging function and primary responsibility
for Michelle’s treatment. He secured consults with three specialists: Dr. Ed Jerkovic
(gastrointestinal), Dr. Bruce Dodt (neurology), and Dr. Ram Ramani (infectious diseases). Dr.
Ramani did not examine Michelle until Tuesday (February 21), and by then her white blood cell
count had risen to 50,000 and her liver enzymes had escalated still further.2 When asked during
1
On February 19, her AST/SGOT was 80 and her AFT/SGPT was 97.
On February 20, her AST/SGOT was 1,364 and her AFT/SGPT was 986.
2
On February 21, her AST/SGOT was 2,870 and her AFT/SGPT was 1778.
5
his deposition whether he was comfortable with his diagnosis of her at Riverside, Dr. Trapp
responded:
“We were unsure what caused it, but the concern was that the liver
was failing in front of our eyes. Her numbers multiplied by
thousand-fold in 12-15 hours. And she was showing signs of not
just that, but the synthesis or the function of the liver was also
failing.”
¶ 17 All four doctors were extremely concerned by the combination of Michelle’s escalating
liver enzymes and white blood cell count, her “strange” multiple sclerosis diagnosis, and the
declining function of her liver. Dr. Jerkovic insisted that she be airlifted to Northwestern
Memorial Hospital because he believed she needed an immediate liver transplant and she had a
better chance of moving to the top of the transplant list there than at Riverside.
¶ 18 Dr. Ramani, the infectious disease specialist, included in the “impressions” in his report
the need for a Tzanck smear and a "herpes PCR" to rule out herpes. He also considered acute
hepatitis, noting that “liver function rates were normal 2 days ago [February 19]” and suggesting
such hepatitis could be “possibly related to medications and steroids.” The third
“recommendation” in Dr. Ramani’s report was “IV acyclovir to be discussed and decided upon.”
Neither he nor any other of the doctors who examined and treated Michelle at Riverside
diagnosed disseminated varicella zoster or recognized her rash as any form of chicken pox.
¶ 19 (This is the end of the recitation of excluded factual evidence.)
¶ 20 On February 21, 2006, Michelle was transported to Chicago but was dead on arrival at
Northwestern Memorial Hospital. An autopsy determined the cause of death was systemic
6
failure caused by disseminated varicella zoster infection.
¶ 21 II. Procedural History
¶ 22 On July 19, 2007, Rita Steele, as special administrator of Michelle’s estate, filed suit
against Dr. Moran and his employer, Echo Management and Consulting, alleging the wrongful
death of her daughter due to medical malpractice and a survival action. At issue was whether Dr.
Moran breached the standard of care that he, as an emergency room physician, owed to Michelle
and, if so, whether that breach was a proximate cause of her death.
¶ 23 If plaintiff has sustained her burden of proof on this issue, she also has the burden of
proving (1) current and potential damages to the members of Michelle’s family attributable to her
death (wrongful death action), and (2) damages sustained by Michelle and payable to her estate
for pain and suffering attributable to the breach (survival action).
¶ 24 Steele also sued Provena Hospitals d/b/a St. Mary’s Hospital, alleging Dr. Moran was its
agent and it was, therefore, vicariously liable for Michelle’s death. At issue in this claim is
whether Provena held Dr. Moran out as its agent (actual agency) or whether Michelle or someone
lawfully acting as her agent reasonably relied on a reasonably held belief that he was the
hospital’s agent (apparent agency).
¶ 25 In preparation for trial, the parties filed disclosures pursuant to Illinois Supreme Court
Rule 213 (eff. Jan. 1, 2007). Some of those disclosures were the focus of evidentiary challenges
during trial. Dr. Moran’s Rule 213(f)(3) disclosures indicated that he would testify from the St.
Mary’s hospital medical records, and any reasonable inferences therefrom, about his care and
treatment of Michelle on February 19, 2006, and any knowledge and observations he had
surrounding the occurrence of Michelle’s admission to St. Mary’s. Dr. John Segreti, an
7
infectious disease expert proffered by the defendants, included in his Rule 213(f)(3) disclosures
that he would not be rendering an opinion on the standard of care of an emergency room doctor.
Steele’s Rule 213(f)(1) disclosures indicated that she would be providing lay testimony about the
facts and circumstances concerning the care and treatment of Michelle at St. Mary’s on February
19, 2006, and her memory of the events and treatment prior Michelle’s death, including
conversations with medical personnel and observations she made at that time.
¶ 26 Before trial, the court issued the following rulings on specific motions in limine pertinent
to this appeal: (1) barring Steele from eliciting opinions outside those disclosed in her Rule 213
disclosures or expert depositions; (2) barring the defendants from calling subsequent treating
physicians and introducing evidence of subsequent treatment at Riverside Hospital in Kankakee,
specifically the fact that no doctor at Riverside diagnosed Michelle’s chicken pox or
disseminated varicella zoster infection; (3) barring the defendants from presenting testimony
from doctors who treated Michelle at a medical facility in Chicago about the diminished quality
of life of a person with multiple sclerosis; (4) barring testimony from Dr. Moran as to why
Michelle’s liver enzymes were high because such testimony was not presented during his
deposition; (5) permitting testimony about Michelle’s future plans to go to community college;
(6) barring the defendants from presenting a sole proximate cause defense because Moran
presented no evidence to support this theory; (7) permitting certain of plaintiff’s lay witnesses to
testify that Michelle’s rash “looked like chicken pox”; and (8) barring the defendants from
presenting testimony from Michelle’s grandmother that Steele “gave up parental rights of
Michelle Koenig from ages fourteen to eighteen.”
¶ 27 The case was tried to a jury. Dr. Moran was called by both sides. Kristen Bien,
8
Michelle’s friend; Jacqueline Boomsma, the emergency medical technician (EMT) who
transported Michelle to St. Mary’s; and Rita Steele all testified that Michelle had a rash that
“looked like chicken pox.” Steele testified as an occurrence witness to the events surrounding
Michelle’s treatment in the emergency room at St. Mary’s and was also allowed to testify on the
agency issue. She—along with Michelle’s father, Todd Koenig, and her half-sister, Jessica Watts
—provided evidence of their loss-of-society damages resulting from Michelle’s death. Plaintiff
called two experts—Dr. Fred Zar, an infectious disease specialist, and Dr. Robert Mulliken, an
emergency room physician—to testify to the nature and breach of Dr. Moran’s standard of care.
¶ 28 Dr. Moran called as his experts Dr. John Ortinau, an emergency room doctor, who
testified that the standard of care was not breached, and Dr. John Segretti, an infectious disease
specialist, who was offered solely on the issue of proximate cause and who testified that nothing
Dr. Moran did or did not do on February 19 could have led to a different result.
¶ 29 Dr. Moran also made an offer of proof outside the presence of the jury presenting
evidence through live testimony and depositions of (1) Michelle’s subsequent treatment at
Riverside on February 20 and 21 and (2) the fact that none of the several doctors who evaluated
and treated her had diagnosed either chicken pox or disseminated varicella zoster infection. As
part of this offer of proof, Drs. Zar and Mulliken (plaintiff’s experts) testified that they reviewed
Michelle’s February 20 and 21 records from Riverside and learned that no doctor there had
diagnosed her with chicken pox or disseminated varicella zoster. The purpose of the offer of
proof was to preserve for review the trial court’s refusal to allow this evidence to be heard by the
jury.
¶ 30 The jury rendered a verdict in favor of plaintiff and against all defendants in the amount
9
of $1,500,000.
¶ 31 Provena and Moran filed separate appeals which have been consolidated in this court.
Fifteen issues are raised by Moran and six by Provena. Any necessary additional facts will be
presented and discussed in our consideration of these issues.
¶ 32 ANALYSIS
¶ 33 I. Appeal of Dr. Moran, No. 3-11-0375
¶ 34 A. Evidentiary Issues Related to Alleged Medical Negligence
¶ 35 In general, evidence must be legally relevant to be admissible. People v. Kirchner, 194
Ill. 2d 502, 539 (2000). Evidence is relevant if it has a tendency to make the existence of any fact
that is of consequence to the determination of the action more or less probable than without the
evidence. Ford v. Grizzle, 398 Ill. App. 3d 639, 646 (2010). We review a trial court’s ruling on
matters of evidence for an abuse of discretion. Gunn v. Sobucki, 216 Ill. 2d 602, 609 (2005).
¶ 36 1. Lay testimony that rash "looked like chicken pox"
¶ 37 We consider first Dr. Moran's challenge to the trial court's decision to allow three lay
witnesses—Rita Steele, Kristen Bien, and Jacqueline Boomsma—to testify that Michelle's rash
"looked like chicken pox." He contends the testimony was tantamount to a medical judgment,
was unwarranted, and was unfairly prejudicial. He also challenges allowing plaintiff's counsel to
comment on that testimony in a later examination, over his objection, and in closing argument.
¶ 38 Steele argues that Dr. Moran did not properly preserve this issue for appellate review and
it is, therefore, forfeited.
¶ 39 For the reasons that follow, we find that the issue has not been forfeited and that the
decision to allow the testimony as framed was reversible error.
10
¶ 40 With regard to the forfeiture issue, a party may not rely on a court's ruling on a motion in
limine to preserve an error for appellate review. Cunningham v. Millers General Insurance Co.,
227 Ill. App. 3d 201 (1992). Thus the party contesting the testimony must object the first time
the testimony is introduced. Cunningham, 227 Ill. App. 3d at 206. In the absence of a proper
objection, the matter is forfeited. Illinois State Toll Highway Authority v. Heritage Standard
Bank & Trust Co., 163 Ill. 2d 498, 502 (1994).
¶ 41 Here the record indicates that before Bien and Boomsma testified, Dr. Moran renewed his
objection to any mention that Michelle's rash looked like chicken pox. On the day that Steele
testified, the court stated that its prior rulings remained in effect concerning the motions in limine
and that if the parties felt it necessary "to step up and put it in the record again, that [was] fine."
We understand the court’s statement to be a reiteration of its ruling that it would allow that
testimony in. On these facts, we find this issue has not been forfeited for purposes of appellate
review.
¶ 42 Similarly, Dr. Moran objected repeatedly to the use of the testimony of these witnesses
that the rash “looked like chicken pox” in the examination of one of his experts, Dr. Ortinau.
¶ 43 However, with regard to Dr. Moran's complaint that plaintiff's counsel expressly and
improperly characterized this testimony as a "diagnosis" of chicken pox during closing argument,
we find that no contemporaneous objection was made and that this claim has been forfeited. We
note that the trial court later attempted to cure the improper argument by instruction to the jury.
¶ 44 Turning now to the merits of the issue which was preserved, we consider first the nature
of the testimony. Each of the three women was allowed to testify that the rash "looked like
chicken pox." We believe this decision was error for three reasons.
11
¶ 45 First, we question the relevance of their testimony to any element of the negligence claim.
The conclusion of three witnesses, without medical training, that the rash “looked like chicken
pox” is irrelevant to a determination of the proper standard of care, Dr. Moran’s possible breach
of that standard, or whether any breach by Dr. Moran was the proximate cause of Michelle’s
death. While their contention that the rash “looked like chicken pox” has little or no probative
value, it does pose a substantial risk, just standing alone, of unfair prejudice.
¶ 46 Second, defendant challenges the testimony as tantamount to a medical diagnosis;
plaintiff responds that it is merely a description of the rash. We believe defendant's
characterization of the testimony to be more accurate.
¶ 47 A "description" of the rash would be, for example, it was flat or raised, pink or red,
blistery or solid, clustered or isolated, hot or cool to the touch, etc. Instead, each witness's
attestation that it "looked like chicken pox" was, in essence, an assurance to the jurors that (1)
she knew what chicken pox rash looked like, and (2) she was able to conclusively distinguish it,
as indicative of chicken pox, as opposed to the myriad other rashes which can appear on the
human body. Such implicit assurances were clearly without basis with regard to two of the
witnesses in light of Bien's admission that, other than having had chicken pox as a child, she had
never seen a rash like that one and Boomsma's affidavit that she had no training in diagnosing
diseases.
¶ 48 We note that these witnesses were neither tendered nor qualified as experts by plaintiff;
they were lay witnesses. A lay witness may offer opinion testimony provided that it is helpful to
a clear understanding of her testimony or a determination of a fact at issue. Freeding-Skokie
Roll-Off Service, Inc. v. Hamilton, 108 Ill. 2d 217, 222-23 (1985) (citing Fed. R. Evid. 701(b)).
12
The opinion testimony of a lay witness must also be rationally based on the witness's perception.
Hopkinson v. Chicago Transit Authority, 211 Ill. App. 3d 825, 846 (1991). However, a lay
witness may not offer testimony pertaining to a specific medical diagnosis unless he or she is
properly qualified as an expert to give such testimony. See Robinson v. Wieboldt Stores, Inc.,
104 Ill. App. 3d 1021, 1026-27 (1982).
¶ 49 Because we find that the testimony is the functional equivalent of a medical diagnosis, we
conclude that the trial court erred in allowing the witnesses to frame their testimony in this
manner.
¶ 50 Third, in addition to the testimony itself, the record shows that plaintiff was allowed, over
multiple objections by defendant, to mischaracterize that description when examining defendant's
expert, Dr. Ortinau. Plaintiff’s counsel finessed their testimony as a diagnosis not only of
chicken pox, but also “varicella zoster virus” and “disseminated varicella zoster virus” (emphasis
added) well before closing argument, as follows:
"Q. You recall Ms. Steele saying the rash looked like chicken pox,
correct?
A. Yes.
Q. It turns out that Ms. Boomsma, Ms. Bien, and Ms. Steele are
correct that, in fact, Michelle did have a varicella zoster virus rash
on February 19th, 2006. True?
[Defense counsel objected to this question, but the court overruled
the objection.]
A. Um, based on the fact that we know what ultimately happened
13
to Ms. Koenig, that is a true statement. That's correct.
Q. All three of them were correct in their description of the rash in
terms of looking like chickenpox, true?
A. Well, I don't know if they're correct in what they said about the
rash. What is correct is that this woman had disseminated
varicella." (Emphases added.)
¶ 51 In describing the rash in terms of the specific disease that is at issue in this case, the
testimony not only implied that it was chicken pox, it was transmuted by counsel into a diagnosis
of varicella zoster virus. The implicit suggestion that "if we, without any training in medical
diagnosis, could see that this was chicken pox, Dr. Moran was clearly deficient when he could or
did not" was made explicit when counsel asked Dr. Ortinau:
"Q. He [Dr. Moran], unlike the three lay people, failed to recognize
that this was a chickenpox rash caused by disseminated varicella
zoster virus. Correct?
[Defense counsel again objected, but was overruled.]
A. Two lay people and a paramedic thought that this was a
varicella zoster rash. That's correct." (Emphases added.)
We find that the testimony was without probative value and was inherently and unfairly
prejudicial, that its prejudicial impact was enhanced by counsel's misuse of it with another
witness, and that the court abused its discretion in both admitting the testimony and allowing its
mischaracterization over objection.
¶ 52 2. Barring of evidence of later treatment
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¶ 53 Dr. Moran also asserts that the trial court erred in barring evidence, by both direct
testimony and through cross-examination of plaintiff’s experts, of Michelle’s later treatment at
Riverside Hospital.
¶ 54 From February 9, when Michelle was first seen at Riverside and transported to CINN, to
February 21, when she died while being airlifted to Northwestern Memorial Hospital, twelve
days elapsed. During that brief time she was examined at CINN by neurological specialists and
diagnosed tentatively with either multiple sclerosis or lupus, and was released on large doses of
prednisone. Five days later, she presented at St. Mary’s Hospital complaining of severe back
pain which made it difficult to walk and which she suggested might be a result of a lumbar
puncture done in connection with her treatment at CINN. She made no complaint related to the
rash that Dr. Moran noted on her upper body. Tests ordered by Dr. Moran showed her white
blood cell count and liver enzymes were somewhat elevated. He attempted, without success, to
consult with her personal physician (see supra ¶ 8), but did assertedly succeed in discussing her
case with the neurological surgeon at CINN, who informed him of her treatment plan and, among
other things, that final results of Michelle's tests were still not available.
¶ 55 Plaintiff’s experts testified Dr. Moran breached the standard of care by (1) failing to
recognize Michelle was immunosuppressed, (2) failing to diagnose Michelle’s rash as chicken
pox, (3) failing to diagnose an extremely rare variant of chicken pox – disseminated varicella
zoster infection, and (4) failing to call in the appropriate experts for consultation.
¶ 56 In assessing whether Dr. Moran committed medical malpractice, it was the function of the
jury, as the trier of fact, to determine whether the plaintiff had proven all of the following
elements: (1) the proper standard of care against which the defendant physician's conduct is
15
measured; (2) an unskilled or negligent failure to comply with that standard; and (3) a resulting
injury proximately caused by the physician's want of skill or care. Sullivan v. Edward Hospital,
209 Ill. 2d 100, 112 (2004).
¶ 57 Dr. Moran's challenge to the exclusion of evidence of Michelle's treatment on days two
and three of her illness (February 20 and 21) is stated as:
"Whether the trial court erred in barring evidence of decedent's
subsequent treatment when such evidence is relevant and material
to: the liability issue as to whether defendant's [sic] diagnosed
disseminated varicella virus and pivotal to that issue is what
decedent's rash looked like; what material experts relied on; and
proof that the decedent lived several days after discharge from
defendant emergency room." (Emphasis added.)
Because the question is not expressly limited to the determination of the proper standard of care,
but rather appears to sweep more broadly to cover breach of the standard of care and proximate
cause, we consider all three elements of the malpractice claim.
¶ 58 a. Proper standard of care
¶ 59 Generally, the standard of care applicable to Dr. Moran is whether he, as an emergency
room physician, used the skill, knowledge, and care appropriate to a reasonably careful
emergency room physician to treat Michelle Koenig at St. Mary's Hospital on February 19, 2006.
See generally Studt v. Sherman Health Systems, 2011 IL 108182, ¶¶ 33, 34; Loman v. Freeman,
229 Ill. 2d 104, 119 (2008); Advincula v. United Blood Services, 176 Ill. 2d 1, 23 (1996). The
medical experts—armed with knowledge of Michelle’s death, an autopsy report finding
16
disseminated varicella zoster virus to be her cause of death, and having been informed of her test
results and that she had a raised vesicular rash—opined that the standard required, more
specifically, that Dr. Moran diagnose Michelle as immunosuppressed, her rash as chicken pox,
and her underlying condition as disseminated varicella zoster virus requiring the administration
of acyclovir. Defining the standard of care is generally entrusted to medical professionals and it
is, by definition, restricted to the time the defendant doctor was responsible for the patient’s care.
While expert opinion is extremely useful in defining the standard of care, it remains the duty of
the jury to consider all of the opinions and make the final determination. Borowski v. Vol Solbrig,
60 Ill. 2d 418, 423 (1975).
¶ 60 b. Breach of the standard of care
¶ 61 The determination of whether a doctor acted in compliance with the applicable standard
of care is limited, by definition, to the circumstances with which he was confronted at the time
the medical service was rendered. Thus, the focus of the inquiry is what Dr. Moran did while
Michelle was in his care based on what he knew, should have known, or was reasonably able to
determine while Michelle was in his care. One of the questions to be addressed in response to
the inquiry is whether he should have known that the rash was chicken pox. Some evidence of
the answer to that question is the testimony of the experts, including Dr. Zar, who testified that
the rash could only have been chicken pox.
¶ 62 None of the experts had actually seen the rash on Michelle, however. Dr. Moran was the
only medically trained person to see it and he did not diagnose it as chicken pox. As previously
discussed ( supra ¶ 27), plaintiff attempted to exploit this lack of exactly contemporaneous
corroboration by presenting the lay witnesses’s conclusions that on the very day of Dr. Moran’s
17
treatment the rash "looked like chicken pox."
¶ 63 The evidence of the subsequent appearance of the rash that Dr. Moran sought to present,
while clearly not speaking to exactly how the rash looked on February 19, was nonetheless
instructive on how the rash looked and whether it ever looked like chicken pox. It was,
therefore, legally relevant and potentially admissible. See People v. Kirchner, 194 Ill. 2d 502
(2000). Evidence is relevant if it has a tendency to make the existence of any fact that is of
consequence to the determination of the action more or less probable than without the evidence.
Ford v. Grizzle, 398 Ill. App. 3d 639, 646 (2010).
¶ 64 Whether Dr. Moran breached his standard of care by failing to recognize the rash as
chicken pox is certainly a fact of consequence to the determination of the action. The jury should
be able to consider all relevant evidence in resolving that issue. Experts opined from the
advantage of hindsight that Moran should have recognized the rash; the autopsy report had
conclusively determined that Michelle had chicken pox. The excluded evidence represents a
nearly contemporaneous presentation of the rash with the same failure of doctors, including
specialists plaintiff’s experts would presumably find appropriate, to recognize chicken pox and
the underlying disseminated varicella zoster infection and the same failure to provide treatment
with acyclovir. The reasons for the failure of other doctors to diagnose chicken pox and
underlying varicella zoster infection so close in time to Dr. Moran’s treatment of Michelle is
relevant and probative. Assigning the relative weight to be given to the experts and the on-the-
scene doctors is within the proper province of the jury.
¶ 65 For these reasons we find that the trial court erred in excluding, as irrelevant to the
standard of care, evidence of what other doctors saw and concluded on February 20 and 21.
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¶ 66 c. Proximate cause
¶ 67 When the jury, on remand, ascertains the correct standard of care and whether or not Dr.
Moran did, in fact, breach that standard, it must also determine whether any such breach was the
proximate cause of Michelle’s death. We do not see how that particular element of the inquiry
can be addressed and resolved without evidence of the course of her disease and treatment
between the time she came into Dr. Moran's care and the time she died. Our belief in the
relevance of this evidence gains some support from the fact that the experts tendered by both
parties found it helpful, and perhaps necessary, to review the records and testimony of Michelle's
symptoms and treatment on those two days to arrive at salient conclusions of their own.
¶ 68 In barring this evidence altogether, we find the trial court deprived the jury of information
relevant to its determination of whether any breach of his standard of care by Dr. Moran was a
proximate cause of Michelle's death. We find the trial court abused its discretion in this regard
resulting in reversible error entitling Dr. Moran to a new trial.
¶ 69 3. Allowing an infectious disease specialist to address standard of care
¶ 70 Dr. Moran next challenges the trial court's decision to allow Dr. Zar, a doctor specializing
in internal medicine and infectious disease, to testify on the standard of care of an emergency
room physician.
¶ 71 In Sullivan v. Edward Hospital, 209 Ill. 2d 100 (2004), the supreme court reviewed its
earlier decisions on who may provide expert medical testimony on the standard of care. The
court noted that in Purtill v. Hess, 111 Ill. 2d 229 (1986), it had established two foundational
requirements that must be met to demonstrate an expert physician's qualifications and
competency to testify. First, the physician must be a licensed member of the school of medicine
19
about which he proposes to testify. Second the expert witness must show that he is familiar with
the methods, procedures, and treatments ordinarily observed by other physicians in either the
defendant physician's community or a similar community. Purtill, 111 Ill. 2d at 242-43. If the
expert physician fails to satisfy either of these foundational requirements, "the trial court must
disallow the expert's testimony." Jones v. O'Young, 154 Ill. 2d 39, 44 (1992). Once these
foundational requirements have been met, the trial court has the discretion to determine whether
a physician is qualified and competent to state his opinion as an expert regarding the standard of
care. Purtill, 111 Ill. 2d at 243.
¶ 72 The evidence in this case disclosed that both Dr. Moran and Dr. Zar were licensed to
practice medicine and surgery, thus satisfying the first requirement. Further, Dr. Zar testified that
he took his residents to the emergency room as part of a combined residency program to train
doctors in internal medicine and emergency medicine, and that he works with emergency room
physicians on a regular basis. He thereby established his familiarity with emergency room
practice and satisfied the second requirement.
¶ 73 Whether he was otherwise qualified to testify as an expert on the standard of care of an
emergency room physician was left to the trial court's sound discretion. We review its decision
in that regard for an abuse of discretion.
¶ 74 We can fully understand Dr. Moran's concerns, first, that a specialist in infectious disease
would likely be better equipped to recognize a rare infectious disease than a doctor who, by the
nature and necessities of his job, is more of a generalist, and, second, that a higher or more
exacting standard of care might be imposed upon him by such a specialist. While another judge
might have weighed this risk differently than did the trial court in this case, we note that
20
"[w]hether the expert is qualified to testify is not dependent on whether he is a member of the
same speciality or subspecialty as the defendant but, rather, whether the allegations of negligence
concern matters within his knowledge and observation." Jones, 154 Ill. 2d at 43. Because of Dr.
Zar's qualifications in internal medicine and his experience with emergency room physicians and
residents, he could offer competent, relevant and helpful testimony on the matter of Michelle
presenting in the St. Mary's emergency room with a form of chicken pox. Consequently, we
cannot say that no reasonable person would take the view of the trial court and thus we find that
its decision was not an abuse of discretion. A reasonable person could also conclude that Dr.
Zar's limited experience in emergency rooms goes to the weight rather than the admissibility of
his opinions.
¶ 75 4. Plaintiff's use of two standard of care experts
¶ 76 Dr. Moran next contends that the trial court erred when it denied his motion to bar
Mulliken’s testimony as cumulative. Steele answers that the number of expert witness to testify
for each party is a matter of the trial court’s discretion, and in this case, the court did not abuse its
discretion. We agree.
¶ 77 A trial court has discretion to exclude cumulative evidence, and a ruling in this regard
will not be reversed unless the trial court abuses its discretion. Kozasa v. Guardian Electric
Manufacturing Co., 99 Ill. App. 3d 669, 678 (1981). Within this discretion is a trial court’s
ability to limit the number of expert witnesses a party may present. Dillon v. Evanston Hospital,
199 Ill. 2d 483, 494-96 (2002).
¶ 78 Here, the record does not indicate that the trial court abused its discretion when it
permitted Steele to present expert testimony by both Drs. Zar and Mulliken. As Steele notes, Dr.
21
Zar specialized in internal medicine and infectious diseases and had relevant emergency room
experience, and Dr. Mulliken specialized in emergency care. This case centered on emergency
treatment for a patient who had a variation of the chicken pox virus; thus, it was relevant to
Steele’s case to present expert testimony from a witness who had emergency room experience
and specialized in infectious diseases and another who specialized in emergency care. The
testimony of Drs. Zar and Mulliken was not necessarily cumulative, and the trial court did not
abuse its discretion when it denied Dr. Moran’s motion to bar Dr. Mulliken’s testimony.
¶ 79 B. Evidentiary Issues Relevant to Wrongful Death Action
¶ 80 1. General law about wrongful death
¶ 81 The first section of the Wrongful Death Act recognizes, in pertinent part, that:
"Whenever the death of a person shall be caused by wrongful act,
neglect or default, and the act, neglect or default is such as would,
if death had not ensued, have entitled the party injured to maintain
an action and recover damages in respect thereof, then and in every
such case the person who or company or corporation which would
have been liable if death had not ensued, shall be liable to an action
for damages***." 740 ILCS 180/1 (West 2012).
This section requires Steele to prove that Michelle would have prevailed in an action for
negligent medical treatment asserted against Dr. Moran.
¶ 82 The scope of the pecuniary injuries and the potential beneficiaries of damages are defined
in the pertinent part of section 2:
"Every such action shall be brought by and in the names of the
22
personal representatives of such deceased person, and *** the
amount recovered in every such action shall be for the exclusive
benefit of the surviving spouse and next of kin of such deceased
person. In every such action the jury may give such damages as
they shall deem a fair and just compensation with reference to the
pecuniary injuries resulting from such death, including damages for
grief, sorrow, and mental suffering, to the surviving spouse and
next of kin of such deceased person." 740 ILCS 180/2 (West
2012).
See also Elliot v. Willis, 92 Ill. 2d 530, 540 (1982). In the instant case, Michelle left no spouse or
children and the potential beneficiaries of the wrongful death action were her mother, Rita Steele;
her father, Todd Koenig; and her half-sister, Jessica Watts.
¶ 83 2. Wrongful death issues raised on appeal
¶ 84 Dr. Moran argues that the trial court erred in: (1) refusing to allow evidence or instruction
about plaintiff's health and the effects on her quality of life since she had multiple sclerosis (issue
5); (2) barring defendants from eliciting testimony that the decedent's mother gave up parental
rights for four years when the sole issue of damages is loss of society (issue 7); and (3)
permitting unfounded hearsay conversations between the decedent and her father about her
alleged plans to go to community college when there was no lost wage claim (issue 8).
¶ 85 First, on the issue of Michelle's health, Dr. Moran asserts that the trial court erred when it
did not allow testimony from physicians who treated Michelle at the Chicago Institute concerning
the diminished quality of life of a person with multiple sclerosis, and also erred when it did not
23
instruct the jury to consider Michelle’s health in its determination of damages. Steele argues that
Dr. Moran did not disclose an opinion concerning Michelle’s alleged diminished quality of life or
life expectancy during discovery, and in the absence of such evidence, the court did not abuse its
discretion.
¶ 86 The trial court has wide discretion in the admission or exclusion of evidence. Martin v.
Sally, 341 Ill. App. 3d 308, 314 (2003). Here, the trial court did not abuse its discretion when it
refused to permit Dr. Moran to present testimony about Michelle’s alleged diminished quality of
life or life expectancy. The record does not indicate that any such testimony was disclosed prior
to trial, either through discovery submissions or deposition testimony, and thus, the trial court
cannot be found to have abused its discretion in excluding the medical opinion evidence. Nor is
there any indication in the record that Dr. Moran made an offer of proof as to the contents of this
evidence or what it would establish. See McMahon v. Coronet Insurance Co., 6 Ill. App. 3d 704,
711-12 (1972) (appellate court concluded that a party may not raise an issue concerning the trial
court’s exclusion of certain expert testimony because the party did not make an offer of proof
showing the actual substance of the testimony). We find that Dr. Moran has therefore forfeited
this issue.
¶ 87 For the same reasons, the trial court did not err in refusing to instruct the jury to consider
Michelle’s health in assessing damages.
¶ 88 Second, regarding Steele's alleged relinquishment of her parental rights to Michelle, our
review of the record reveals no factual or legal basis for any contention that she or a court took
action depriving her of parental rights. See 750 ILCS 50/8 (West 2006). There is evidence in the
record that Steele and Todd agreed Michelle should reside in Florida with her father to avoid her
24
continued association with the “wrong crowd of kids.” We note Michelle lived five years after
the end of the separation and was apparently living with her mother at the time of her death. The
decision of what to do with this contradictory proffered testimony rests in the discretion of the
trial court and we cannot say, on this record, that allowing the warring contentions to go to the
jury—the finder of fact—was an abuse of discretion.
¶ 89 Third, turning to Dr. Moran's complaint concerning any discussions of Michelle's intent
to enroll in community college, we again find no error on the part of the trial court. Steele
contends that this testimony was only relevant to Michelle’s relationship with her mother and
father and to an understanding of Michelle’s life at the time of her death. The testimony
indicated that Michelle had personal aspirations and that she shared her goals and dreams with
her parents. We note that plaintiff did not seek lost wages or any other damages related to
participation in or completion of any degree granting program. Nor did either party present
evidence that Michelle applied to or had been accepted by any post secondary institution. We
find no evidence in the record that the testimony was offered for or relevant to anything other
than Michelle's relationship with her parents, and therefore, its admission was not an abuse of
discretion.
¶ 90 C. Evidentiary Issues Related to Discovery
¶ 91 Dr. Moran raises the following specific issues pertaining to alleged violations of Illinois
Supreme Court Rule 213 (eff. Jan. 1, 2007): (1) whether the trial court erred in barring defendant
from testifying that the decedent’s liver enzymes were high since such testimony is a logical
corollary to defendant’s disclosed opinion that he would testify as to his findings (issue 6); (2)
whether the trial court erred in allowing undisclosed expert testimony as to why the alleged
25
chicken pox did not itch (issue 9); and (3) whether the trial court erred in allowing plaintiff to
improperly question defendant’s proximate cause expert about standard of care opinions outside
the scope of direct examination and Rule 213 disclosures (issue 10).
¶ 92 "The purpose of discovery rules, governing the ‘timely disclosure of expert witnesses,
their opinions, and the bases for those opinions[,] is to avoid surprise and to discourage strategic
gamesmanship.’" Spaetzel v. Dillon, 393 Ill. App. 3d 806, 812 (2009) (quoting Thomas v.
Johnson Controls Inc., 344 Ill. App. 3d 1026, 1032 (2003)). Rule 213 disclosure requirements
are mandatory and command strict compliance from the parties. Sullivan v. Edward Hospital,
209 Ill. 2d 100, 109 (2004).
¶ 93 Faced with a challenge that testimony was not disclosed or exceeds the scope of Rule 213
disclosure, a trial court’s ruling on the admission of evidence is an exercise of its discretion and
will not be reversed absent an abuse of that discretion. Sullivan, 209 Ill. 2d at 109. An abuse of
discretion occurs when no reasonable person would take the view of the trial court. Foley v.
Fletcher, 361 Ill. App. 3d 39, 46 (2005).
¶ 94 The current version of Rule 213 (Ill. S. Ct. R. 213 (eff. Jan. 1, 2007) creates three classes
of opinion witnesses; lay witnesses are only required, in Rule 213(f)(1), to disclose the subject of
the their testimony rather than the detailed disclosure previously compelled by section Rule
213(g). The Committee Comments of March 28, 2002, explain that “applying this detailed-
disclosure requirement to lay witnesses creates a serious burden without corresponding benefit to
the opposing party.”3 Ill. S. Ct. R. 123, Committee Comments (Mar. 28, 2002).
3
Given this change, the disclosures of Rita Steele related to agency that are challenged by
Provena were compliant with the amended rule.
26
¶ 95 Independent expert witnesses have intermediate disclosure obligations set out in Rule
213(f)(2). None of the witnesses in the instant case fall into this category.
¶ 96 Because the third class of witnesses, the controlled experts described in Rule 213(f)(3),
can be counted on for full cooperation, “the amended rule requires the party to provide all of the
details required by the former rule.” Id. Thus, “the requirement that the party identify the
‘subject matter’ of the testimony means that the party must set forth the gist of the testimony on
each topic the witness will address, as opposed to setting forth the topics alone.” Id. The
controlled expert witnesses include Drs. Moran, Zar, Mulliken, Ortinau and Segreti. We
consider Dr. Moran’s discovery challenges in the context of this very brief overview of the
disclosure requirements.
¶ 97 First, Dr. Moran contends that the trial court erred in granting Steele’s motion in limine
barring him from testifying as to why Michelle’s liver enzymes were high because such
testimony was part of his findings during his care and treatment of Michelle. Steele asserts that
the court properly barred this testimony because Dr. Moran did not disclose his reason as to why
Michelle’s liver enzymes were high prior to trial.
¶ 98 An expert’s opinion testimony at trial is limited to "[t]he information disclosed in answer
to a Rule 213(f) interrogatory, or in a discovery deposition." Ill. S. Ct. R. 213(g) (eff. Jan. 1,
2007). While a witness may elaborate on his disclosed opinion as long as it is a logical corollary
to the opinion, and not a new reason for it, "[t]he testimony at trial must be encompassed by the
original opinion.” Foley, 361 Ill. App. 3d at 47 (court affirmed trial court’s determination to
permit expert testimony concerning the standard of care during childbirth because the expert
witness’ disclosure referred to the prenatal period in general, and not only the time before labor).
27
¶ 99 Here, the record indicates that during Dr. Moran’s deposition, he stated that he did not
have an opinion as to why Michelle’s liver enzymes were elevated on February 19. Likewise, at
trial Dr. Moran testified that he had no opinion on the day he treated her as to the cause of
Michelle’s elevated liver enzymes. If he developed such an opinion after submitting his Rule
213 disclosures and giving his deposition, and prior to trial, he had a duty under Rule 213(i) to
supplement his answers. We find no evidence in the record that he did so. Overall, this
testimony cannot be a natural corollary of any disclosed opinion when he twice expressly denied
having such an opinion. The trial court did not abuse its discretion in granting Steele’s motion
in limine barring this testimony.
¶ 100 Dr. Moran next contends that the trial court abused its discretion when it permitted Steele
to cross-examine Dr. Segreti concerning the standard of care of an emergency room physician
because he was only offered and qualified as an expert on proximate cause and his Rule 213
disclosures were limited to causation. On direct examination, Dr. Segreti was only asked for
causation opinions. Steele counters that Dr. Segreti explicitly testified on cross-examination that
he had no opinion as to the standard of care of an emergency room physician.
¶ 101 Initially we note that the issue as framed objects to the questions being allowed, not to the
answers that were or were not given. That Dr. Segreti denied having an opinion on the standard
of care is not responsive to the challenge on appeal.
¶ 102 This issue calls into question the parameters of Rule 213(g), which provides relative to
Rule 213(f) opinion witnesses, in pertinent part:
“g. Limitation on Testimony and Freedom to Cross-Examine. ***
Without making disclosure under this rule, however, a
28
cross examining party can elicit information, including opinions,
from the witness.” Ill. S. Ct. R 213(g) (eff. Jan. 1, 2007).
The meaning of the quoted sentence has been liberally interpreted. Stapleton v. Moore, 403 Ill.
App. 3d 147, 160 (2010) (Rule 213 specifically allows the eliciting of even new, previously
undisclosed opinions on cross-examination.); Jackson v. Reid, 402 Ill. App. 3d 215, 234 (2010)
(the scope of disclosure required by Rule 213(f)(3) does not limit or restrict the scope of cross-
examination when testing the expert’s opinion testimony); Skubak v. Lutheran General Health
Care Systems, 339 Ill. App. 3d 30, 32 (2003) (Rule 213's disclosure requirements do not apply to
cross-examination of an opposing party’s opinion witness); Maffett v. Bliss, 329 Ill. App. 3d 562,
577 (2002) (none of Rule 213's disclosure requirements applies to cross-examining an opposing
party’s opinion witness). However, we have been unable to find a case that presents the situation
with which we are confronted. We find, for the following reasons, that Rule 213(g) does not
authorize the cross-examination challenged here.
¶ 103 As we have previously discussed in paragraph 72, standard of care opinions can only be
rendered by doctors who meet two foundational requirements. Because Dr. Segreti is licensed in
the same school of medicine as Dr. Moran, he clearly satisfies the first; there was, however, no
showing that he was sufficiently knowledgeable of emergency room procedures to satisfy the
second. Absent such qualifications, it was improper, even considering Rule 213(g), to allow him
to be questioned on the standard of care.
¶ 104 Moreover, seeking standard of care opinions from Dr. Segreti plainly exceeded the scope
of direct examination and was not a logical expansion of any questions he had been asked or
answers he had given. We do not believe that the rule is intended to change fundamental and
29
long-standing procedural, as opposed to disclosure, restrictions on cross-examination.
¶ 105 Finally, the purpose of the discovery rules is to avoid surprise and to discourage strategic
gamesmanship. Thomas v. Johnson Controls, Inc., 344 Ill. App. 3d 1026, 1032 (2003).
Plaintiff’s attorney admitted that the goal of his cross-examination of Dr. Segreti was just that,
saying in his brief:
“Plaintiff’s counsel intended to suggest that Segreti conveniently
had no such opinions not because he could not offer standard of
care opinions about emergency room doctors, but rather because
they would have cut against Dr. Moran’s position. [Citation] After
a lengthy argument [citation], counsel asked Segreti whether he
had offered standard of care opinions in similar cases, but he could
not recall.”
It is this use of improper questioning to negatively influence the jury that Dr. Moran contends
was error. The trial court erred in allowing this cross-examination over objection.
¶ 106 Finally, Dr. Moran contends that the trial court erred when it permitted Dr. Zar to testify
that Michelle’s chicken pox did not itch because he had not presented this testimony in his Rule
213 disclosures or in his deposition. Steele contends that the topic of prednisone was explored
during Dr. Zar’s deposition, and thus, his testimony that its ingestion was the reason why the rash
did not itch should not have taken them by surprise. We do not believe that this rationale is
consistent with the disclosure requirements of Rule 213(f)(3) that we have previously discussed.
¶ 107 However, Steele also asserts that any error was harmless because Dr. Moran had already
recognized in his testimony that prednisone may suppress itching. Where testimony is
30
undisclosed pursuant to Rule 213, but is cumulative of other testimony, the opposing party is not
prejudiced by its admission and a new trial is not warranted. Bauer v. Memorial Hospital, 377
Ill. App. 3d 895, 914 (2007). In this case, even if the court erred in permitting Dr. Zar to testify
that Michelle’s chicken pox did not itch because of her use of prednisone, the error was of no
consequence.
¶ 108 D. Disallowance of Dr. Moran’s sole proximate cause defense
¶ 109 Dr. Moran contends that the trial court erred when it granted Steele’s motion in limine
preventing him from presenting evidence that Michelle’s subsequent treatment at Riverside was
the sole proximate cause of her death. Because we have ruled on the admissibility of evidence of
subsequent treatment at Riverside Hospital and have remanded for a new trial, we decline to
further address this issue.
¶ 110 We also decline to address, because of the decision to grant a new trial, alleged errors in
the jury instructions, cumulative errors, denial of the motions for directed verdict, manifest
weight of the evidence, and remittitur of the damages award.
¶ 111 II. Appeal of Provena Hospitals, No. 3-11-0374
¶ 112 When Michelle and her mother arrived at St. Mary’s Hospital on February 19, Michelle
was given a consent form for her signature. Steele took the form, printed Michelle’s name and
then instructed her to sign it. Michelle signed the consent and it was witnessed on behalf of the
hospital.
¶ 113 The form provides in pertinent part:
“Consent to and Conditions for Treatment
The terms and conditions that apply to the care, treatment,
31
and other services provided by or through Provena Health, or
at any of Provena Health’s facilities, are set forth below.
Please read these terms and conditions very carefully.
CONSENT TO TREATMENT
***
I understand that the practice of medicine is not an exact
science. I acknowledge that no guarantees have been made, or can
be made, regarding any care, treatment, or other related services
that may be provided by or through Provena Health, or at any of
Provena Health’s facilities. I acknowledge and understand that
most physicians who provide physician services at Provena Health
are not employees or agents of Provena Health, but instead are
independent medical practitioners and independent contractors. I
understand that each of these medical practitioners exercises his
or her own, independent medical judgment and is solely
responsible for the care, treatment, and services that they order,
request, direct, or provide. I acknowledge that these practitioners
are not subject to the supervision or control of Provena Health and
that the employment or agency status of physicians who treat me is
not relevant to my selection of Provena Health for my care. I also
understand that I will receive, and am solely responsible for
payment of, a separate bill from each of these independent
32
practitioners, or groups of practitioners, for care, treatment, or
services provided.
***
ACCEPTANCE AND SIGNATURE
I represent that I, as either the person identified above or
such person’s legal representative, have read and understand, and
am duly authorized to accept and execute, these terms and
conditions. Any questions that I’ve had have been satisfactorily
answered. I hereby accept and agree to be bound by all of the
above terms and conditions and I agree that a copy of this
document may be used in the place of the original in enforcing any
rights hereunder.” (Emphasis added.)
The document is signed by Michelle Koenig, witnessed by Josephine Johnson and dated. There
are two lines below the signatures for a representative to explain why the patient is unable to
sign. Nothing was written on those lines.
¶ 114 There is no evidence that either Michelle or her mother read the consent form, asked any
questions or had knowledge of its contents. Indeed, Steele affirmatively asserted that neither she
nor Michelle read the consent and, because they did not, it was not binding on them.
Provena responds that long-standing Illinois law clearly holds that a competent adult who signs a
document is deemed to have read it and is bound by its terms. Provena also argues that the
consent form on its face defeats two elements—holding out and reliance—of the three plaintiff
must prove to establish the apparent agency of Dr. Moran.
33
¶ 115 In order to hold a hospital vicariously liable for the acts of an independent contractor, the
plaintiff must plead and prove that he or she acted as the hospital’s apparent agent. York v. Rush-
Presbyterian-St. Luke’s Medical Center, 222 Ill. 2d 147, 183 (2006). The supreme court has
stated:
“[U]nder the doctrine of apparent authority, a hospital can be held
vicariously liable for the negligent acts of a physician providing
care at the hospital, regardless of whether the physician is an
independent contractor, unless the patient knows, or should have
known, that the physician is an independent contractor. The
elements of the action [are] as follows:
‘For a hospital to be liable under the doctrine of apparent
authority, a plaintiff must show that: (1) the hospital, or its agent,
acted in a manner that would lead a reasonable person to conclude
that the individual who was alleged to be negligent was an
employee or agent of the hospital; (2) where the acts of the agent
create the appearance of authority, the plaintiff must also prove that
the hospital had knowledge of and acquiesced in them; and (3) the
plaintiff acted in reliance upon the conduct of the hospital or its
agent, consistent with ordinary care and prudence.’ [Citation.]”
Gilbert v. Sycamore Municipal Hospital, 156 Ill. 2d 511, 524-25
(1993).
¶ 116 The supreme court explained that when a patient is unaware that the treatment provider is
34
not an employee or agent of the hospital, the patient should still have the right to look to the
hospital for financial recovery in an instance involving negligent emergency room care. Thus, “
'[t]he fact that, unbeknownst to the patient, the physician was an independent contractor should
not prohibit a patient from seeking compensation from the hospital which offers the emergency
room care.' ” Gilbert, 156 Ill. 2d at 522 (quoting Pamperin v. Trinity Memorial Hospital, 323
N.W.2d 848, 855 (Wis. 1988)).
¶ 117 In York, the supreme court emphasized the complexity of the issues presented in a case
such as this one, stating:
“In Gilbert, this court recognized that the relationship between a
patient and health-care providers, both physicians and hospitals,
presents a matrix of unique interactions that finds no ready parallel
to other relationships.” York, 222 Ill. 2d at 192.
Because of the variety of these relationships and the efforts of the players to either limit their
exposure to liability or maximize their potential for recovery from the most or the deepest
pockets, a determination of whether the doctrine of apparent agency renders a hospital
vicariously liable for the malpractice of an independent contractor appears to demand a fact-
specific inquiry.
¶ 118 In the instant case, Provena argues that the consent form signed by Michelle is dispositive
of this appeal because it provides legally binding evidence that (1) Michelle was on notice that it
was likely Dr. Moran was an independent contractor and not an employee of the hospital (“most
physicians *** are not employees”), thereby defeating the element of “holding out,” and (2) it
was of no consequence to her whether any doctors who treated her were employees of the
35
hospital or independent contractors, thereby defeating the element of reliance. Provena contends
that the consent form requires judgment in its favor and asks us to find that the trial court erred in
denying its motion for judgment not withstanding the verdict (judgment n.o.v.) and denying it a
new trial.
¶ 119 In addressing those issues, we consider whether Michelle’s failure to read the consent
form that she signed avoids its legal effect; whether the court erred in finding Steele’s reliance
rather than Michelle’s was controlling, and in allowing her attorney to make such an argument in
closing, and/or in so instructing the jury; and whether the consent form defeats one or more
elements of apparent authority.
¶ 120 A. Failure to Read the Consent Form
¶ 121 We look first at whether Michelle’s signature on the consent form binds her to knowledge
of its contents even though she did not read it. Illinois law on this question is long-standing and
consistent. The supreme court held in Black v. Wabash, St. Louis & Pacific Ry. Co., 111 Ill. 351,
358 (1884), that a competent adult is charged with knowledge of and assent to a document the
adult signs and that ignorance of its contents does not avoid its effect. That principle has been
consistently reiterated by the supreme court and by the appellate court. See, for example, recent
decisions in Melena v. Anheuser-Busch, Inc., 219 Ill. 2d 135, 150 (2006); All American
Roofing, Inc. v. Zurich American Insurance Co., 404 Ill. App. 3d 438, 447-49 (2010). Thus, the
terms of Provena’s consent form and Michelle’s assent to them are not negated by her failure to
read the document.
¶ 122 B. Legal Effect of the Executed Consent Form
¶ 123 1. Rita Steele’s observations and reliance
36
¶ 124 We next consider whether there is evidence in the record to support the trial court’s
finding that it is Rita Steele’s observations and reliance that are controlling, rather than
Michelle’s assent to the terms of the consent form. We find none.
¶ 125 Michelle was 20 years old and, therefore, an adult when she arrived at St. Mary’s on
February 19. She was conscious upon arrival at the hospital and was able to sign the consent
form when directed by her mother to do so. There was no evidence she had been unconscious in
the ambulance. Although she was in pain, she was able to discuss her symptoms and medical
history and to opine that the pain might be the result of an earlier lumbar puncture. After
receiving medication, she was able to walk around and use the bathroom. We find no evidence
from which to conclude that she was unable to understand or assent to the terms in the consent
form.
¶ 126 Steele did not sign the consent form for Michelle or indicate in the space provided on the
form that Michelle was unable to consent or that there was any reason why Michelle could not
sign it. Moreover, Steele provided no power of attorney or other legal instrument to establish
herself as Michelle’s legal representative or assert any other legally cognizable basis for
recognizing her right to act or otherwise stand in her daughter’s stead.
¶ 127 We find Steele’s claim that Monti v. Silver Cross Hospital, 262 Ill. App. 3d 503 (1994),
and Nosbaum v. Martini, 312 Ill. App. 3d 108 (2000), validate the substitution of her actual or
constructive knowledge for Michelle’s consent to lack merit. In Monti, the patient was
unconscious and unable to act for herself but proved that others responsible for her care,
including her husband, relied on the hospital to provide complete emergency care for her. Monti,
262 Ill. App. 3d at 507-08. In Nosbaum, the patient was a child and the choice was made by her
37
biological father. Nosbaum, 312 Ill. App. 3d at 122. Here, Michelle was a conscious and lucid
adult and was not acting at the direction of any person with authority to act or decide on her
behalf.
¶ 128 York v. Rush-Presbyterian-St. Luke's Medical Center, 222 Ill. 2d 147 (2006), on which
plaintiff also relies, is factually inapposite. Plaintiff, Dr. James York, was alive and he testified
that he relied on his son, Dr. Jeff York, to select the anesthesiologist for his surgery. In addition,
the consent form signed by the York plaintiff was vastly different from that signed by Michelle
Koenig, in that "the treatment consent form nowhere stated that plaintiff would be treated by
independent-contractor physicians***" York, 222 Ill. 2d at 197. The court went on to quote
excerpts from the consent that could "reasonably be interpreted as allowing Rush to select
anesthesiologists." (Internal quotation marks omitted.) York, 222 Ill. 2d at 197.
¶ 129 Because we find no legal basis for supplanting Michelle’s acknowledgments and
understandings with Steele’s beliefs, we hold that the trial court erred in its contrary finding and
in permitting plaintiff’s counsel to argue to the jury that the consent form could be disregarded
and in instructing the jury that plaintiff only had to prove what Steele, and not Michelle, knew or
should have known about Moran’s relationship with the hospital.
¶ 130 2. Binding nature of the consent form Michelle signed
¶ 131 There is no evidence in the record showing that Michelle made any observations or
statements relative to Dr. Moran’s relationship with Provena while at St. Mary’s. Nor, because
of her death, could she provide such evidence on retrial. We therefore find that the executed
consent form is the sole legally-cognizable determinant in this case of whether plaintiff has
proven apparent authority so as to render Provena vicariously liable for Moran’s alleged medical
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negligence. This court has held that such consents are “almost conclusive” in determining
whether a hospital should be held liable for the medical negligence of an independent contractor.
Thede v. Kapsas, 386 Ill. App. 3d 396, 401 (2008). The foregoing findings are sufficient to
entitle Provena to a new trial.
¶ 132 3. Judgment notwithstanding the verdict
¶ 133 But Provena also seeks a judgment n.o.v., claiming that the consent form signed by
Michelle conclusively establishes (1) that Provena did not hold out Dr. Moran as its apparent
agent and (2) that Michelle either knew there was no employee relationship between Provena and
Dr. Moran or it did not matter to her whether such a relationship existed, thereby disclaiming any
reliance on Provena to provide her care.
¶ 134 A trial court should grant a motion for judgment notwithstanding the verdict only in those
limited cases where all of the evidence and the inferences from the evidence, when viewed in the
light most favorable to the nonmovant, so overwhelmingly favors the movant that no contrary
verdict based on that evidence could ever stand. Maple v. Gustafson, 151 Ill. 2d 445 (1992). We
review a trial court's determination on a motion for judgment n.o.v. de novo. Thornton v.
Garcini, 382 Ill. App. 3d 813 (2008). In undertaking its de novo review, an appellate court “has
no right to enter a judgment n.o.v. if there is any evidence, together with reasonable inferences to
be drawn therefrom, demonstrating a substantial factual dispute, or where the assessment of
credibility of the witnesses or the determination regarding conflicting evidence is decisive to the
outcome." Maple, 151 Ill. 2d at 454.
¶ 135 The elements necessary to prove apparent agency in a medical malpractice action as
defined in Gilbert have been set out in paragraph 116.
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¶ 136 Provena does not contest whether Steele met the second apparent authority factor.
Therefore we consider only whether, when we view the evidence in the light most favorable to
Steele, it shows that she satisfied the first (“holding out”) and third (reliance) elements of her
apparent agency claim.
¶ 137 a. “Holding out” of Dr. Moran as an employee
¶ 138 Regarding “holding out,” if a patient has actual or constructive knowledge that the doctor
is an independent contractor, the hospital is not vicariously liable. The hospital prevails on this
element if “the patient is in some manner put on notice of the independent status of the
professionals with whom he might be expected to come into contact.” (Internal quotation marks
omitted.) York, 222 Ill. 2d at 182. The consent form Michelle signed advised that “most
physicians who provide physician services at Provena Health are not employees or agents of
Provena Health, but instead are independent medical practitioners and independent contractors.”
(Emphasis omitted.) See supra ¶ 113. Unlike the situation in Churkey v. Rustia, 329 Ill. App. 3d
239 (2002), where the form also did not say that all of the providers were independent
contractors, the Churkey consent did link the independent providers with practice areas.
Churkey, 329 Ill. App. 3d at 244. Provena’s consent did not.
¶ 139 We acknowledge Provena’s argument that York’s phrase “in some manner put on notice
of the independent status of the professionals with whom she might be expected to come into
contact” (emphasis added and internal quotation marks omitted) (York, 222 Ill. 2d at 182)
suggests some flexibility in the test. However, given the very high standard for entry of a
judgment n.o.v., we find that the consent does not convincingly put plaintiff on notice that Dr.
Moran is an independent contractor and thereby adequately defeat the “holding out” factor.
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¶ 140 b. Reliance on employee relationship
¶ 141 Turning to the reliance factor, we find that the statement, “I acknowledge *** that the
employment or agency status of physicians who treat me is not relevant to my selection of
Provena Health for my care;” in the consent form constitutes a clear disclaimer of Michelle’s
reliance on the hospital for her medical care. We believe that this statement gains still more
weight when taken in conjunction with the additional acknowledgments that “most” of the
providers are independent contractors who function and bill for their services independently of
the hospital, and that “any questions that I’ve had have been satisfactorily answered,” constitute
definitive indicators that Michelle was not relying on Provena or, vicariously, on the employee
status of any of her treaters in seeking emergency care. We, therefore, find that plaintiff failed to
sustain her burden of proving Michelle’s reliance on Provena and that a judgment n.o.v. should
have been granted by the trial court.
¶ 142 CONCLUSION
¶ 143 For all of the foregoing reasons, the verdict in favor of plaintiff is reversed, judgment not
withstanding the verdict is entered for Provena, and the matter is remanded for a new trial on
plaintiff’s claims against Dr. Moran.
¶ 144 No. 3-11-0374, judgment notwithstanding the verdict entered.
¶ 145 No. 3-11-0375, reversed and remanded.
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