The Verdict - Law Journal

This is the first article of our series discussing practical and evidentiary issues in medical malpractice. Each article will examine recent medical malpractice case law and focus on the practical and evidentiary issues within them. The goal is to provide some useful insight into the obstacles that occurred in hopes that future cases can adapt and develop new ways to overcome these challenges.

In medical malpractice cases, where cases may come to trial long after the incident in question and the defendants may have seen hundreds of patients in the interim, witnesses’ memories can often be hazy. In these cases other sources of evidence, including the medical chart and a medical provider’s standard practice, can be critical pieces of evidence. Ensuring that the plaintiff’s theory of the case incorporates, is consistent with or explains any departures from these sources of evidence is vital to the success of the case.

Facts of the Case

This article examines the case of A.G. (Litigation guardian of) v. Rivera,¹ a case that involves a premature infant who failed to receive medications intended to reduce the risks and injuries of premature delivery and suffered several medical complications as a result. A.G.’s mother Li Qu, attended hospital on November 30, 2014. Her baby was 25 weeks and 1 day gestational age. Ms. Qu attended hospital with concerns about vaginal bleeding and was assessed. Dr. Rivera did a test to confirm that her membranes had not ruptured, and ordered an ultrasound. The ultrasound reported that her cervix was shorter than expected, a concerning sign indicative of a risk of preterm labour. Ms. Qu was less concerned about a report of shortened cervix as she had been told she had the same issues during her first pregnancy and carried that baby to full term. Ms. Qu reported some irregular cramping in the previous days that had since resolved. There was significant debate at trial about the remainder of that visit. There was also some confusion with the dating of Ms. Qu’s pregnancy. Ms. Qu and the defendants were under the impression that the gestational age of her baby was 23 weeks and 4 days, although was in fact over a week more developed. The mistake’s relevance related to the exponentially increasing risks to a fetus for each additional week of prematurity. Survival rates are only 20% for babies at 23 weeks but increase to 80% by 25 weeks. These realities affect treatment recommendations. The decision always rests with the mother, after being fully informed by her physician, but at earlier gestations some practitioners discourage attempts of resuscitation with a focus on palliative care whereas at 25 weeks, most practitioners would recommend full resuscitation of the infant. Regardless of the correct gestational age, the experts agreed Ms. Qu should have been given

This is the final installment of our series aimed at providing a detailed examination of the challenges and pitfalls in different areas of medical negligence lawsuits, and approaches to overcoming them. Each article has focused on specific injuries and highlighted the obstacles a plaintiff faces in bringing their case to a successful conclusion. Our next series, which will debut in the Winter 2024 edition of The Verdict, will focus on practical and evidentiary issues in medical malpractice.

This article concludes our current series by considering one of the most critical and costly aspects of any medical malpractice lawsuit: the client’s care plan. It will proceed by describing the principles of autonomy, choice, and independence that underpin all cost of future care analyses, as repeatedly reiterated by the Supreme Court of Canada; flagging proposals for care that are commonly found in defence submissions and the case law, which contravene these principles; and providing specific advice on how to develop and present a care plan successfully in mediation and at trial.

Few aspects of a medical malpractice lawsuit are as important to both counsel and client as the life care plan. For plaintiff’s counsel, the care plan is the evidentiary basis for the assessment of costs of future care. When properly presented, “the life care plan can be a powerful tool of persuasion, whether persuading the defence to settle the case or persuading [the court] to award a fair amount of damages.”¹ For the critically injured client and their family, who are often facing a scary and uncertain future, the care plan serves as a source of reassurance and empowerment, particularly when it is crafted with their input².

The law in Canada concerning care planning in medical negligence cases is clear and well-established. The ultimate goal of an assessment of future care costs is to ensure that the injured plaintiff is adequately cared for. Expenses that further this goal are based on what a reasonable person with ample means would incur.³

With respect to the plaintiff’s living arrangement — the focal point of every care plan, which inherently impacts the provision of all other aspects of care — courts across this country have repeatedly found that it is “difficult to conceive of any reasonably-minded person of ample means who would not be ready to incur the expense of home care.”⁴ Plaintiffs’ counsel need not rely solely on this case law or common sense to support the idea that any reasonable person would choose this model of care over, say, a group home: a recent survey demonstrated that 91% of all Canadians, and nearly 100% of Canadians aged 65 years or older, report that they plan on living independently for as long as possible.⁵

This is the ninth article in our series aimed at providing a detailed examination of the challenges and pitfalls in different areas of medical negligence lawsuits, and approaches to overcoming them. Each article will focus on specific injuries and highlight the obstacles a plaintiff faces in bringing their case to a successful conclusion. By comparing cases involving similar injuries, we hope to illustrate how the plaintiff succeeded, and, when they did not, provide strategies that may have been available to improve their chance of success.

This article will focus on cases where miscommunications have caused or contributed to a plaintiff’s injury. The importance of communication in facilitating Canada’s collaborative, team-based model of healthcare delivery, and the role that complete and accurate communication of patient information plays in defining the standard of care for physicians and nurses, will be explained using a recent obstetrical malpractice judgment of the B.C. Supreme Court as a case study.

Introduction

Healthcare in Canada is delivered through a collaborative, team-based model of care, in which different medical professionals, possessing diverse experience and expertise, respond to patient needs in a synergetic fashion. These teams may operate according to established templates, in the ordinary course of primary healthcare delivery (for example, the informal, two-person teams comprising of family physicians who prescribe medications and pharmacists who fill them), or they may be complex and ad hoc (for example, labour and delivery teams, which often include professionals specializing in obstetrics, pediatrics, nursing, family medicine, neonatology, and anaesthesiology). Under such a collaborative care model, the delivery of safe and effective healthcare is dependent on each team member competently fulfilling their individual duties. As one Manitoba court put it, “the health care system in place in Canada mandates that these professionals work as a team with each individual having a role in the provision of care to a [patient]. Each person must carry out their role within their appropriate standard of care and each of these professionals is entitled to rely upon (and must rely upon) the others to fulfill their respective individual responsibilities.”¹

A duty that is common to all healthcare professionals working collaboratively, which has been affirmed by courts across Canada, is the duty to communicate all relevant patient information in an accurate and complete manner. The failure to do so can have cascading impacts on the performance of the team as a whole, leading to catastrophic outcomes for patients: one review of obstetric malpractice claims conducted by the American College of Obstetrics and Gynecology, for instance, found that 31% of adverse events were attributable to communication problems.²

Although communication errors may not be as obviously disastrous as, say, surgical errors, they can have devastating impacts on patients and their families. In an era where interprofessional communications are increasingly transmitted across new technologies and mediums,³ and in which medical professionals are increasingly reliant on team-based care given staffing shortages during Canada’s ongoing “health human resources crisis,”⁴ the potential impact of miscommunication among medical professionals involved in a patient’s care must be front-of-mind for plaintiff’s counsel when analyzing and arguing their case.

This is the ninth article in our series aimed at providing a detailed examination of the challenges and pitfalls in different areas of medical negligence lawsuits, and approaches to overcoming them. Each article will focus on specific injuries and highlight the obstacles a plaintiff faces in bringing their case to a successful conclusion. By comparing cases involving similar injuries, we hope to illustrate how the plaintiff succeeded, and, when they did not, provide strategies that may have been available to improve their chance of success.

This article will focus on cases where injuries were caused by a delayed diagnosis, and will discuss when a delay in diagnosis constitutes negligence. The unique challenges of proving causation in such claims and the role of the conduct of the plaintiff will be examined in relation to when this can lead to a finding of contributory negligence or even a complete dismissal of the plaintiff’s claim.

The Duty to Diagnose

One of the many duties of a doctor is the duty to diagnose a patient once they have undertaken the patient’s care. A doctor is not expected to be infallible in diagnosing a patient. They must, however, exercise reasonable care, skill and judgement in coming to a diagnosis. If this is done, they will generally not be held liable even if their diagnosis turns out to be incorrect.¹

The defense of “error of judgment” often comes into play in cases of missed or delayed diagnosis, which argues that the defendant cannot be held liable as long as they were reasonably exercising their clinical judgment, even if their judgment turned out to be an error. But if the physician does not avail themselves of the scientific means available for the collection of the best factual data to arrive at the diagnosis, does not accurately obtain the patient’s history, and/or does not refer the patient to the appropriate specialists, courts have found that the result is not an error of judgment but in fact constitutes negligence.²

In Pinch v Morwood ³, the infant plaintiff sustained a catastrophic brain injury after her mother suffered an eclamptic seizure. Two days before suffering the seizure, Ms. Pinch had attended the emergency department with complaints of neck pain that had kept her up all night. Allegations of negligence were brought against the emergency physician who assessed Ms. Pinch for failing to diagnose and treat her pre-eclampsia, a disorder in pregnancy characterized by high blood pressure, proteinuria, and headaches. If left untreated, pre-eclampsia can cause eclamptic seizures. It was uncontested that if pre-eclampsia had been diagnosed, treatment would have been provided that would have prevented Ms. Pinch’s eclamptic seizures and the resultant brain injury to her unborn child.

This is the eighth article in our series aimed at providing a detailed examination of the challenges and pitfalls in different types of medical negligence lawsuits and approaches to overcoming them. Each article will focus on specific injuries and will highlight the obstacles a plaintiff faces in bringing their case to a successful conclusion. By comparing cases involving similar injuries, we hope to illustrate how the plaintiff succeeded, and, when they did not, strategies that may have been available to improve their chance of success.

This article will focus on wrongful birth cases, including specific issues relating to causation in such claims and the inconsistent approaches taken by courts in determining damages for the cost of care for children born due to medical negligence, either with or without disabilities.

Introduction

Wrongful birth claims involve allegations of negligence by a parent against a medical practitioner for the birth of a child who would not otherwise have been born. Wrongful birth cases typically involve the unwanted birth of a child with disabilities following the defendant’s negligent performance of a medical procedure or provision of medical advice (e.g. failed abortion, failure to offer genetic or other prenatal tests, failure to properly perform or interpret prenatal tests, or failure to inform the patient of the risk of fetal abnormality associated with the results of the prenatal testing).

A wrongful pregnancy claim specifically concerns plaintiff parents who never wanted to be pregnant in the first place, but became pregnant with an unplanned child with or without disabilities as a result of the defendant medical practitioner’s negligence (e.g. failed sterilization, negligence in prescribing contraceptives).¹ For the purposes of this article, we use the term wrongful birth to describe both wrongful birth and wrongful pregnancy claims.

Wrongful life claims are similar to wrongful birth claims, with the difference being that they are brought by the child rather than the parents. In such cases, the child’s claim is that but for the negligence of the defendant, they would not have been born at all. Wrongful life has been rejected as a cause of action by Canadian courts for various reasons, including the fact that as a matter of public policy, any existence should be viewed as preferrable to no existence at all.²

Proving a breach of the standard of care in wrongful birth cases is similar to that of other medical negligence cases, but there are certain unique causation issues that require counsel to gather extensive evidence about the plaintiff’s particular circumstances. And although wrongful birth lawsuits are not new in Canada, with cases dating back to the 1970’s, there is still uncertainty and controversy around the assessment of damages based on each court’s characterization of the loss to the plaintiff parent. Over the years, courts have denied or limited an award for the cost of care based on inconsistent approaches. In particular, the damage limits for children born without disabilities are so exceptional that no such limit is employed in any other area of medical negligence.