IN THE SUPREME COURT OF MISSISSIPPI
NO. 2010-CT-00791-SCT
UNIVERSITY OF MISSISSIPPI MEDICAL
CENTER
v.
DONNIE FOSTER AND SHIRLEY FOSTER AS
LEGAL GUARDIANS OF THE MINOR CHILD,
MALIK R. CALDWELL AND ON BEHALF OF
THE WRONGFUL DEATH BENEFICIARIES OF
TAMIKA FOSTER
ON WRIT OF CERTIORARI
DATE OF JUDGMENT: 01/04/2010
TRIAL JUDGE: HON. TOMIE T. GREEN
COURT FROM WHICH APPEALED: HINDS COUNTY CIRCUIT COURT
ATTORNEYS FOR APPELLANT: ROBERT H. PEDERSEN
WALTER T. JOHNSON
JOSEPH GEORGE BALADI
ATTORNEY FOR APPELLEE: DAVID C. DUNBAR
NATURE OF THE CASE: CIVIL - WRONGFUL DEATH
DISPOSITION: THE JUDGMENT OF THE COURT OF
APPEALS IS REVERSED. THE
JUDGMENT OF THE HINDS COUNTY
CIRCUIT COURT IS REINSTATED AND
AFFIRMED - 02/14/2013
MOTION FOR REHEARING FILED:
MANDATE ISSUED:
EN BANC.
DICKINSON, PRESIDING JUSTICE, FOR THE COURT:
¶1. Tamika Foster died after giving birth at the University of Mississippi Medical Center
(UMMC). This wrongful-death suit followed. After a verdict for the plaintiffs, UMMC
appealed, claiming that the plaintiffs produced nothing more than an unreliable autopsy
report to establish medical negligence, and that the trial judge erred in refusing to allow two
doctors to testify about the autopsy. But because we find sufficient evidence in the record
to support the verdict and because UMMC failed to make a proffer of the doctors’ expected
testimony, we reverse the Court of Appeals’ decision and reinstate and affirm the decision
of the Hinds County Circuit Court.
FACTS AND PROCEDURAL HISTORY
¶2. Physicians at UMMC provided prenatal care to Tamika Foster during her high-risk
pregnancy. When she presented with troubling symptoms, her physicians admitted her to
UMMC and diagnosed her with Class I hemolysis, elevated liver enzyme levels, and low-
platelet-count syndrome (HELLP).
¶3. That same day, she delivered her baby – Malik – by cesarean section under emergency
circumstances. After the delivery, she recovered in the intensive care unit and later was
returned to the labor and delivery unit. The following day, she went into respiratory arrest
and died.
¶4. UMMC pathologists performed an autopsy and determined that Foster’s death was
caused by “myocardial ischemia with arrhythmia secondary to Thrombotic
Thrombocytopenia Purpura” (TTP), meaning she died from arrhythmia caused by TTP.
Although HELLP and TTP are both serious complications that cause a decrease in the
number of platelets in the blood, the course of treatment for the two is not the same.
¶5. According to Dr. Charles Greenberg, the plaintiffs’ hematology expert, the
ADAMTS13 is the only laboratory test that could distinguish between TTP and HELLP.
2
Approximately nine hours after Foster died, the pathologists ran an ADAMTS13 test using
a postmortem sample of Foster’s blood. The pathologists considered these results and
Foster’s medical history to conclude that she had died from complications of TTP. Foster’s
death certificate, completed before the autopsy report, did not mention TTP. Instead, it stated
that the cause of death was “undetermined,” but listed HELLP under “other significant
conditions.”
¶6. Foster’s parents, as representatives of Malik, and Foster’s wrongful-death
beneficiaries, sued UMMC under the Mississippi Tort Claims Act,1 alleging Foster died from
TTP, a condition UMMC failed to properly diagnose and treat. At trial, UMMC’s theory of
the case was that Foster had died from HELLP and not TTP. They argued that the reason its
pathologists incorrectly concluded that TTP had caused Foster’s death was because they had
conducted the ADAMTS13 test using postmortem blood which – although once acceptable
– recently has been shown to produce inaccurate results.
¶7. Hinds County Circuit Judge Tomie Green, after hearing the evidence without a jury,
found that UMMC’s failure to properly diagnose and treat Foster for TTP proximately caused
her death. Judge Green awarded the plaintiffs $1,230,965, which she reduced to the statutory
limit of $500,000.
¶8. UMMC timely appealed, alleging that Judge Green unreasonably relied on the autopsy
report, and that she committed reversible error by refusing to allow UMMC’s experts to
1
Miss. Code Ann. §§11-46-1 to 23 (Rev. 2012).
3
testify about the autopsy report. The Court of Appeals, agreeing with UMMC on both
arguments, reversed and rendered the judgment. The Fosters petitioned this Court for a writ
of certiorari, which we granted.
ANALYSIS
¶9. UMMC raises two issues on appeal: whether Judge Green’s finding that Foster died
from TTP was supported by substantial evidence; and whether Judge Green committed
reversible error by failing to allow UMMC’s expert witnesses to “comment about the content
of the autopsy report.”
¶10. UMMC’s argument challenges the sufficiency of the evidence. We have held that
“‘[a] circuit court judge sitting without a jury is accorded the same deference with regard to
his [or her] findings as a chancellor,’ and his [or her] findings are safe on appeal where they
are supported by substantial, credible, and reasonable evidence” in the record.2
¶11. Because we “will not disturb those findings unless they are manifestly wrong, clearly
erroneous or an erroneous legal standard was applied” 3 we now look to see whether Judge
Green had substantial medical evidence before her to conclude that Foster died of TTP.4
The record contains substantial evidence to support Judge Green’s
finding that Foster died from TTP.
2
City of Jackson v. Perry, 764 So. 2d 373, 376 (Miss. 2000) (citations omitted).
3
Id.
4
See Univ. of Miss. Med. Ctr. v. Pounders, 970 So. 2d 141, 147 (Miss. 2007).
4
¶12. The factual dispute upon which this issue turns is whether, as the plaintiffs claim,
Foster died of undiagnosed and untreated TTP; or whether, as UMMC claims, she had
HELLP, and was properly diagnosed with, and treated for, HELLP. Commenting on this
issue, the Court of Appeals stated that “there was no expert testimony which supported to a
reasonable degree of medical certainty the notion that Foster had TTP,” and that it could find
no “testimony directly linking Foster to having had TTP. . . .” 5 After reviewing the record,
we reach a different conclusion.
The autopsy report
¶13. Three days following Foster’s death, two UMMC pathologists performed an autopsy
and concluded that her cause of death was myocardial ischemia with arrhythmia secondary
to TTP. The autopsy report – which included the pathologists’ opinions as to Foster’s cause
of death – was admitted into evidence without objection.
¶14. UMMC now finds itself in the unusual position of challenging the reliability and
sufficiency of the opinions of its own pathologists, who clearly are capable of making
admissions on behalf of UMMC. Neither of the pathologists testified at trial, and no
evidence was introduced that they had changed their minds, or that Foster’s cause of death
was anything but TTP. Even if they had, UMMC cites no authority – and we know of none
– for the proposition that a party’s admissions cease to be admissions simply because the
party later recants or denies them.
5
Univ. of Miss. Med. Ctr. v. Foster, 2010-CA-00791-COA (¶¶17-18), 2011 WL 6157338,
*5 (Miss. Ct. App. Dec. 13, 2011).
5
¶15. A strong argument could be made that the admissions of the two UMMC pathologists,
without more, sufficiently supported Judge Green’s finding that Foster died of TTP. But we
need not consider that argument because there is more.
Dr. James Martin’s article
¶16. One of Foster’s treating physicians was Dr. James Martin, chief of maternal fetal
medicine and obstetrics at UMMC. In a scholarly article, Dr. Martin described Foster as “a
patient considered to have [HELLP] syndrome, but later determined to have [TTP].” 6 In its
brief to this Court, UMMC says Dr. Martin made no admission in the article that Foster had
died from TTP. We disagree.
Dr. Charles Greenberg
¶17. One of the plaintiffs’ expert witnesses was Dr. Charles Greenberg, a board-certified
hematologist who has served on the faculties of the University of California and Duke
University, and who currently serves on the faculty of the University of South Carolina. Dr.
Greenberg testified that TTP caused Foster’s death:
[I]t’s supported by the medical literature. It’s supported by James George’s7
articles. It’s supported even by Joe Moake’s 8 UMMC hematologist articles.
6
Jonathan F. Rehberg, M.D.; Christian M. Briery M.D.; William T. Hudson, M.D.; James
A. Bofill, M.D.; James N. Martin, M.D., Thrombotic Thrombocytopenic Purpura Masquerading as
Hemolysis, Elevated Liver Enzymes, Low Platelets (HELLP) Syndrome in Late Pregnancy, in 108
Obstetrics & Gynecology, 817-820 (2006) (emphasis added).
7
Dr. George is head of hematology at the University of Oklahoma. According to Dr.
Greenberg, Dr. George is “recognized as a leader for thrombocytotenia . . . including pregnancy and
TTP.”
8
Dr. Moake is a UMMC hematologist who testified by deposition.
6
And I’m still confused about why he doesn’t think it’s TTP. It was TTP that
killed her.9
¶18. Dr. Greenberg’s testimony clearly refutes the Court of Appeals’ finding that the record
contained no “testimony directly linking Foster to having had TTP,” and it refutes UMMC’s
argument that, other than the autopsy report, “no other evidence in the record is sufficient to
support [Judge Green’s] finding that Ms. Foster had and died from TTP.”
¶19. UMMC’s counsel argues that UMMC’s admissions in both the autopsy report and Dr.
Martin’s article concerning the diagnosis of TTP should be disregarded as unreliable. Both
relied on the results of a test that used postmortem blood, which – UMMC argues it has now
learned – produces false results. In support of its argument, UMMC says:
A study published on February 27, 2009 concluded that “[P]ostmortem
ADAMTS13 activity levels may not be valid in establishing a diagnosis of
TTP, and high inhibitor levels in this setting may be related to elevated PFH.
Caution must be used in the interpretation of ADAMTS13 testing in the
presence of hemolysis.”
¶20. UMMC’s counsel cross-examined Dr. Greenberg at length about the validity of using
postmortem blood in ADAMTS13 testing for TTP, presenting him with the 2009 article that
UMMC says calls the practice into question. Dr. Greenberg, however, did not change his
opinion that the test was valid. He testified:
In this article . . . they raised caution and I believe it’s fair to raise caution. It
does not invalidate an autopsy done in 2005, it doesn’t refute the reliability of
that sample. It’s just it raises some caution. It was standard practice, it
probably will remain to be standard practice for a while until we can get a
specific antibody for [sic] perhaps ISA for that.
9
(Emphasis added.)
7
¶21. UMMC based its argument that “new scientific knowledge” made the ADAMTS13
test unreliable – when performed using postmortem blood – on an article from the Journal
of Clinical Apheresis 10 and the testimony of its experts, Doctors Bofill, Moake, and Griffin,
who opined that conducting an ADAMTS13 test with postmortem blood yields invalid
results.
¶22. The Journal of Clinical Apheresis article raised caution in diagnosing TTP
postmortem because “low postmortem ADAMTS13 activity and evidence of inhibitor can
occur in decedents without clinical or histologic evidence of TTP.” The article concluded
“postmortem ADAMTS13 levels may not be valid in establishing a diagnosis of TTP” and
“[c]aution must be used in the interpretation of ADAMTS13 testing in the presence of
hemolysis.” 11
¶23. Dr. Greenberg, however, testified that, as of 2005, an ADAMTS13 test using
postmortem blood was the standard, accepted way to “confirm and diagnose TTP in the
postmortem period.” He further stated that it “does not invalidate an autopsy done in 2005,”
and that “it was TTP that killed her.”
¶24. Dr. Martin’s article – co-authored by Dr. Bofill and three other members of the
Department of Obstetrics and Gynecology at UMMC – reexamined Foster’s case and course
of treatment after her death. In this article, they accepted, rather than challenged, the
10
D.M. Dwyre, et al., Value of ADAMTS13 Activity and Inhibitor in the Postmortem
Diagnosis of Thrombotic Thrombocytopenic Purpura, in J. Clinical Apheresis (Feb. 27, 2009).
11
Id.
8
pathologists’ finding that TTP had caused Foster’s death, based on the results from the
ADAMTS13 test and Foster’s signs and symptoms of TTP.
¶25. As already stated, Dr. Greenberg testified that, based upon the signs and symptoms
documented in Foster’s medical records and the ADAMTS13 test results finding both low
ADAMTS13 activity and presence of antibody inhibitor, she died of TTP. He also pointed
out that Foster’s tissue samples showed the presence of microthrombi. Dr. Bofill admitted
– and the lab results reported in the Journal of Medical Apheresis article showed – that the
presence of microthrombi in the tissue samples is consistent with TTP.
¶26. The experts’ testimony in this case conflicts considerably, and we consistently have
held that the trier of fact is to resolve conflicting testimony.12 We ordinarily will not disturb
those findings merely because the judge adopts the testimony of one party’s experts over the
views expressed by another party’s experts.13
Judge Green did not refuse “to allow UMMC’s expert and UMMC’s
treating physician to comment about the content of the autopsy report,”
as claimed by UMMC.
¶27. UMMC next argues that the trial court erred by excluding testimony of Dr. Baha
Sibai’s and Dr. Martin. We first must determine what testimony, if any, Judge Green
excluded so we can fairly decide if it should have been admitted. But, first, we review what
actually happened at trial.
12
Univ. Med. Ctr. v. Martin, 994 So. 2d 740, 746 (Miss. 2008).
13
Id. at 748.
9
Dr. Baha Sibai
¶28. In its designation of experts, as supplemented, UMMC designated Dr. Sibai as an
expert in obstetrics and gynecology to “give general testimony about the care given to
Tamika Foster and the rationale behind the treatment.” The designation also disclosed, in
general terms, that Dr. Sibai was expected to testify about HELLP and TTP, but it never
mentioned any expected opinions related to the autopsy report or the pathologists’ opinions.
¶29. During Dr. Sibai’s direct testimony at trial, UMMC’s counsel began questioning him
about the autopsy report findings. Plaintiffs’ counsel objected to Dr. Sibai’s “commentary
about the autopsy and the findings of the autopsy,” arguing that they were outside his area
of expertise. Judge Green sustained the objection, stating to the witness: “[Y]ou can’t testify
to the pathology report as to physicians who are pathologists, and that’s outside your area of
expertise.”
¶30. When Dr. Sibai’s testimony continued, UMMC’s counsel asked: “[a]nd TTP patients,
what type of things would you expect to see in the patients who you’ve treated for TTP who
died and you reviewed the report. What would you see?” Plaintiffs’ counsel again objected.
Although Judge Green never ruled on the objection, a discussion ensued, ending with Judge
Green asking: “[W]hy are we going through the autopsy report?” UMMC’s counsel
answered: “I’m not going to continue going through it if I could just ask two questions.”
Judge Green responded: “If you would ask those two questions, then we will be on our way.”
After the above exchange, UMMC’s counsel asked several more questions, without objection
10
and tendered the witness. And it appears to us that the trial judge ultimately allowed
UMMC’s counsel to ask Dr. Sibai the questions he wanted to ask.
Dr. James Martin
¶31. UMMC also designated Dr. James Martin as an expert in obstetrics and gynecology.
According to UMMC, Dr. Martin was expected to testify about Foster’s medical condition,
her treatment, and his opinion that she had HELLP syndrome. The designation mentions
neither the pathologists’ opinions nor the autopsy report.
¶32. Dr. Martin testified at length – without objection – about Foster’s medical condition,
her care and treatment at UMMC, his opinion that she died of HELLP, and that UMMC
followed the standard of care in treating her. When UMMC’s counsel began to ask questions
about the autopsy, Judge Green – on her own and not in response to an objection – told
UMMC’s counsel:
I’m going to limit you, counsel, in terms of the autopsy report the same as I did
with Dr. Sibai. So let’s move along. This was done at University by the
pathology department. So let’s don’t get too deep into it.
UMMC’s counsel responded: “I won’t.”
¶33. Following this exchange, Dr. Martin testified – without objection – about the
substance of discussions that took place at an autopsy conference he attended at the request
of the pathology department.
UMMC failed to make a proffer of the testimony it expected from Dr.
Sibai or Dr. Martin.
11
¶34. UMMC alleges in its brief that Judge Green prohibited Dr. Sibai and Dr. Martin from
testifying “about the autopsy report.” We are unable to find any such prohibition in the
record. Judge Green prohibited Dr. Sibai from giving “opinions about” the pathology report,
because, as she put it, “I think that he’s not an expert in pathology, and I wouldn’t let a
pathologist get here and testify to his work.” She later applied the same ruling to Dr. Martin.
¶35. We might view this issue differently, had UMMC’s counsel brought to our attention
some reasonably specific testimony or opinion it wished to elicit from Dr. Sibai and Dr.
Martin. But without a proffer, Judge Green had no opportunity to correct the mistake (if
there was one), and we have no way to judge whether the opinions UMMC claims were
excluded, were sufficiently important to require reversal. Rule 103 of the Mississippi Rules
of Evidence states:
Error may not be predicated upon a ruling which . . . excludes evidence unless
a substantial right of the party is affected, and . . . the substance of the
evidence was made known to the court by offer or was apparent from the
context within which questions were asked.14
¶36. In speaking to this issue, we have said that we will not reverse a judgment unless it
can be shown, upon examining the record, that the “error was actually prejudicial and
harmful to the rights of the complaining party.” 15 And we:
14
Miss. R. Evid. 103.
15
Illinois Cent. R. Co. v. Benoit Gin Co., 248 So. 2d 426, 429 (Miss. 1971) (citations
omitted).
12
must be able to see from the record itself whether the offered testimony would
be material and of benefit to the merits of the case, and whether its exclusion
was actually harmful and prejudicial to the [proponent of the evidence].16
¶37. “In the absence of a meaningful proffer, we cannot place the lower court in error.” 17
Therefore, because UMMC’s counsel failed to make a proffer at trial, or to this Court on
appeal, we affirm the trial court’s ruling.
CONCLUSION
¶38. The Court of Appeals erred in reversing and rendering judgment in favor of UMMC.
The trial judge’s findings were supported by substantial credible evidence, and any error
associated with Judge Green’s ruling on expert testimony was not preserved with an
appropriate proffer of the expected testimony. Therefore, we reverse the judgment of the
Court of Appeals and reinstate and affirm the judgment of the Hinds County Circuit Court.
¶39. THE JUDGMENT OF THE COURT OF APPEALS IS REVERSED. THE
JUDGMENT OF THE HINDS COUNTY CIRCUIT COURT IS REINSTATED AND
AFFIRMED.
WALLER, C.J., RANDOLPH, P.J., LAMAR, KITCHENS, CHANDLER,
PIERCE, KING AND COLEMAN, JJ., CONCUR.
16
Dazet v. Bass, 254 So. 2d 183, 187-88 (Miss. 1971).
17
See Knotts by Knotts v. Hassell, 659 So. 2d 886, 891 (Miss. 1995) (finding no reversible
error when the trial court excluded plaintiff’s expert on the ground that the testimony would be
cumulative when plaintiff failed to make a proffer for court to determine if the testimony would be
different or noncumulative).
13