Coleman v. Deno
813 So. 2d 303, 2002 WL 100550 (2002)
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Rule of Law:
A physician's decision to transfer a patient, even if influenced by economic factors, generally constitutes a medical malpractice claim under the Louisiana Medical Malpractice Act (MMA), not an intentional tort outside its scope, as such a decision is considered treatment-related and involves professional medical judgment.
Facts:
- On June 7, 1988, Louis Coleman, 32, first visited JoEllen Smith Hospital (JESH) emergency room, complaining of chest pain, and was examined by Dr. Ivan Sherman, diagnosed with costochondritis, and discharged.
- Coleman returned to JESH on June 8, 1988, complaining that his left arm had started aching and swelling, and was examined by Dr. Richard Deno, who documented swelling, bullous lesions, and track marks on his left arm.
- Upon receiving elevated white blood count results (27.1), Dr. Deno diagnosed left arm cellulitis and determined that Coleman required inpatient intravenous antibiotic treatment.
- Dr. Deno decided to transfer Coleman to Charity Hospital in New Orleans (CHNO) for inpatient admission, citing Coleman's lack of insurance to afford private hospitalization at JESH and CHNO's superior resources as a Level I Trauma Center better equipped for complicated infections.
- Dr. Deno telephoned a CHNO charge resident who accepted Coleman for admission, and Coleman signed a discharge sheet instructing him to go 'directly' to CHNO, although Coleman testified Dr. Deno approved going home first to get belongings.
- Coleman was discharged from JESH at 10:00 p.m. on June 8th but did not arrive at CHNO until about 12:30 a.m. on June 9th; CHNO initiated intravenous antibiotic treatment at 8:00 a.m. on June 9th, over seven hours after his arrival.
- On June 10th, CHNO recognized the need for a surgical consult but did not request it until June 11th; Dr. Clyde Redmond, a surgical resident, first saw Coleman at 1:00 p.m. on June 11th, found a much more advanced infection with crepitus, and performed an emergency amputation of Coleman's left arm at 4:10 p.m. due to necrotizing fasciitis and compartment syndrome.
Procedural Posture:
- On April 17, 1989, Louis Coleman requested a medical review panel under the Medical Malpractice Act against Dr. Sherman, Dr. Deno, and JoEllen Smith Hospital (JESH).
- Also on April 17, 1989, Coleman filed a request for a medical review under the Medical Liability for State Services Act against Charity Hospital in New Orleans (CHNO).
- Pre-trial, Coleman settled his claim against CHNO for $25,000.
- On May 1, 1990, the medical review panel found that none of the private providers (Dr. Sherman, Dr. Deno, JESH) breached the standard of care.
- On July 27, 1990, Coleman filed suit against Dr. Sherman, Dr. Deno, and JESH.
- On March 27, 1991, Coleman filed a supplemental and amending petition alleging violations of federal anti-dumping provisions.
- Pre-trial, Coleman settled his claim against JESH for $10,000 and dismissed JESH from the suit.
- In March 1999, the matter was tried before a jury.
- During the trial, the trial judge granted Dr. Deno's peremptory exception of no cause of action and motion in limine, precluding any reference to the federal dumping claim (EMTALA) or Coleman's lack of insurance/finances.
- The jury found Dr. Deno 80% at fault and Dr. Sherman 20% at fault, awarding substantial damages; it found neither Coleman nor CHNO were at fault.
- The trial court granted Dr. Sherman's motion for judgment notwithstanding the verdict (JNOV), dismissing the claim against him, and granted remittitur on the loss of consortium award. The court found Dr. Deno solely at fault and applied the MMA to limit the damage award against him to $100,000.
- On appeal, a divided five-judge panel affirmed in part, amended in part, and reversed in part. It held that Coleman's amended petition stated an intentional tort cause of action for improper patient transfer against Dr. Deno outside the MMA and affirmed the JNOV for Dr. Sherman. The appellate court affirmed the jury's finding of fault as to Dr. Deno's breach of care and the jury's finding that CHNO did not breach its standard of care. It allocated $4,400,000 of the damages to the intentional tort claim and $500,000 to the malpractice claim.
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Issue:
Does a physician's decision to transfer a patient, allegedly motivated by economic reasons (lack of insurance), constitute an intentional tort cause of action outside the scope of the Louisiana Medical Malpractice Act (MMA), or is it a claim of medical malpractice subject to the Act's limitations on damages?
Opinions:
Majority - Lobrano, Justice Pro Tempore
No, a physician's decision to transfer a patient, even if partly motivated by economic factors, constitutes a medical malpractice claim subject to the Louisiana Medical Malpractice Act's limitations, not an intentional tort outside its scope. The court reversed the appellate court's finding of an intentional tort of "patient dumping," clarifying that "malpractice" under the MMA (La. R.S. 40:1299.41A(8)) covers "any unintentional tort or any breach of contract based on health care or professional services rendered, or which should have been rendered." The court distinguished physician liability from hospital liability, noting that federal (EMTALA) and state anti-dumping statutes apply to hospitals, not physicians. Applying a six-factor test, the court concluded that Dr. Deno's decision to transfer Coleman was treatment-related, required expert medical evidence, involved patient assessment, occurred within a physician-patient relationship, was linked to treatment, and was not an intentional tort. The court stated that the MMA's applicability does not depend on a doctor's motives. Therefore, Coleman's claims against Dr. Deno, including the transfer decision, fit within the definition of "malpractice" under the MMA. The court affirmed the judgment notwithstanding the verdict (JNOV) dismissing the claim against Dr. Sherman, as Coleman's arm symptoms had not developed during his visit to Dr. Sherman. However, the court found the jury manifestly erred by not allocating any fault to Charity Hospital, which delayed administering antibiotics and obtaining a surgical consult. The court reallocated fault, finding Dr. Deno 25% at fault and Charity Hospital 75% at fault. The case was remanded to the court of appeal for a meaningful quantum review and for rendering judgment consistent with the MMA's limitations.
Concurring in part and dissenting in part - Johnson, J.
Yes, a physician's decision to transfer an uninsured patient from a private hospital to a public hospital due to inability to pay should be considered an intentional tort outside the scope of the Medical Malpractice Act. Justice Johnson concurred with affirming Dr. Deno's medical malpractice liability but dissented on the "patient dumping" issue. He argued that "patient dumping" falls under general tort law, not the MMA, citing Spradlin v. Acadia-St. Landry Med. Found. The MMA specifically addresses unintentional acts of negligence, whereas a decision to transfer a patient solely due to their inability to pay is an intentional act. Justice Johnson believed Dr. Deno's explanation that he transferred Coleman for superior trauma care was a pretext, and the true motivation was economic, making it a non-medical, intentional decision that should not be subject to the MMA's limitations.
Dissenting in part - Knoll, J.
No, the jury's finding of malpractice against Dr. Deno was manifest error because Coleman failed to prove causation, and Dr. Deno's actions were not negligent. Justice Knoll agreed with the majority that "patient dumping" was not an intentional tort but dissented from the finding of malpractice against Dr. Deno. She argued that Coleman's experts provided conclusory testimony and did not sufficiently explain the link between Dr. Deno's actions and the ultimate loss of Coleman's arm, especially considering the compartment syndrome developed days after Dr. Deno last saw him. Dr. Redmond, the surgeon, testified that the compartment syndrome began only hours before surgery and that earlier antibiotics from Dr. Deno would not have altered the outcome. Justice Knoll also pointed out Coleman's own delay in reporting to Charity Hospital, despite signing instructions to go "directly," as a superseding cause. She concluded that the jury's verdict against Dr. Deno was manifestly erroneous, particularly in light of its "no fault" finding for Charity Hospital despite "overwhelming evidence" of CHNO's fault, suggesting the jury's decision was skewed by the impermissible patient dumping theory.
Analysis:
This case significantly clarifies the scope of the Louisiana Medical Malpractice Act concerning physician liability for patient transfers, reinforcing that decisions involving professional medical judgment, even when intertwined with economic factors, typically fall under malpractice rather than intentional tort law. It underscores the distinction between a physician's individual liability and a hospital's obligations under anti-dumping statutes like EMTALA. The ruling also highlights the appellate court's role in reviewing and, if necessary, reallocating fault when a jury's determination is manifestly erroneous, ensuring that all negligent parties bear appropriate responsibility for patient harm.
