Fitzpatrick v. Univ. of Md. St. Joseph Med. Ctr., LLC

Decision Date26 May 2021
Docket NumberNo. 2407,2407
CourtCourt of Special Appeals of Maryland

Circuit Court for Baltimore County

Case No. 03-C-18-009564


Graeff, Kehoe, Shaw Geter JJ.

Opinion by Shaw Geter, J.

*This is an unreported opinion, and it may not be cited in any paper, brief, motion, or other document filed in this Court or any other Maryland Court as either precedent within the rule of stare decisis or as persuasive authority. Md. Rule 1-104.

Appellants, Rebecca Morris and Charles Fitzpatrick are the parents of appellant, Peter Fitzpatrick. In 2018, appellants filed a medical malpractice claim in the Circuit Court for Baltimore County against appellees, University of Maryland St. Joseph Medical Center, LLC, and co-defendants, Capital Women's Care, LLC and Michael Giudice, M.D. for failure to admit Ms. Morris and deliver Peter on August 6, 2015. Appellees' filed a Motion for Summary Judgment, and at the conclusion of a hearing, the court granted appellees' motion.1 Appellants timely appealed and present the following question for our review:

1. Did Plaintiffs present sufficient evidence to create a jury question on the issue of whether St. Joseph's breach of the standard of care caused Plaintiffs' injuries?

For the reasons set forth below, we reverse and remand for further proceedings consistent with this opinion.


In late 2014, Ms. Morris became pregnant with Peter and she began receiving prenatal care at Capital Women's Care, LLC ("Capital") from Michael Giudice, M.D. ("Dr. Giudice"), a treating obstetrician-gynecologist who also has admitting privileges at University of Maryland St. Joseph Medical Center, LLC ("St. Joseph"). At her initial prenatal visit, Ms. Morris' blood pressure was 142/83 and the ultrasound presented positive fetal heart tones and normal findings. Ms. Morris' subsequent prenatal visits with Capital from February 2015 through July 7, 2015, showed normal fetal movement and heart rate.At those visits, Ms. Morris' blood pressure was normal, and her urine was negative for protein.

At Ms. Morris' prenatal visit on July 21, 2015, she reported decreased fetal movement. She also had an initial elevated blood pressure of 145/88. A repeated check of her blood pressure showed a normal reading of 107/68. On August 6, 2015, she returned for a routine prenatal visit where she again reported decreased fetal movement. On that date, her pregnancy was "full term" at 37 weeks and 1-day gestation. A nonstress test ("NST") was performed by Monica Buescher, M.D. ("Dr. Buescher"), which was found to be nonreactive with moderate variability and two areas of gradual decelerations in the fetal heart rate. Ms. Morris had an initial elevated blood pressure of 146/94. Her blood pressure was taken again with her laying on her left side, which resulted in a reading of 107/70. A urine dipstick reading indicated 1+ protein in her urine. Due to these findings, Dr. Buescher sent Ms. Morris to St. Joseph for further evaluation, including prolonged fetal heart rate monitoring. Dr. Giudice testified that on August 6, 2015, Ms. Morris "complained of decreased fetal movement" and had "an almost reactive NST which had accelerations but did not meet [the] criteria for a reactive NST which is why she was sent to the hospital."

Ms. Morris arrived at St. Joseph's at approximately 2:00 p.m. on August 6. Her care was assumed by Dr. Giudice and Carol Ator, R.N. ("Nurse Ator"), a labor and delivery nurse employed by St. Joseph. Ms. Morris' blood pressure was taken four times between 2:34 p.m. and 3:49 p.m. Her blood pressure readings were, successively, 137/89, 133/92, 144/96, and 144/100, which indicated that her blood pressure was increasing. In hisdeposition, Dr. Giudice testified that the 144/100 reading was not brought to his attention, nor was it "documented with the rest of her vital signs." He also testified that "typically . . . the nurse on labor and delivery" is responsible for documenting blood pressure. Nurse Ator testified that she was aware of the 144/100 blood pressure. Dr. Giudice conducted a urinalysis at 3:43 p.m., which revealed trace protein in Ms. Morris' urine. There are three methods of measuring proteinuria: urine dipstick or urinalysis; 24-hour urine collection; and protein/creatine ratio examination. Dr. Giudice testified that he did not order a 24-hour urine collection, which was available at St. Joseph at the time, and that protein/creatine ratio examination was not available at the hospital then. Nurse Ator testified, in her deposition, that "trace protein on a urine is pretty much not reliable" and that she knew that prior to Ms. Morris' discharge, Dr. Giudice had not ordered a 24-hour urine sample.

Ms. Morris' fetal heart rate was monitored at St. Joseph with results that indicated minimum to moderate variability with no accelerations. Based on these results, Dr. Giudice concluded that Ms. Morris had nonreactive fetal heart rate tracing and ordered a biophysical profile. A biophysical profile measures fetal movement, fetal tone, fetal breathing, and amniotic fluid volume and assigns a score ranging from zero to two to each measurement. Ms. Morris' biophysical profile concluded at 4:35 p.m. and yielded a result of 8/8, which indicated that the fetus was stable "at that moment in time." Ms. Morris' blood pressure was not taken again after her biophysical profile was completed. Dr. Giudice order her to be discharged at 5:24 p.m. Nurse Ator discharged her at 5:39 p.m.

Dr. Giudice testified that he was aware that Ms. Morris' blood pressures qualified for gestational hypertension and preeclampsia. As defined by the Task Force on Hypertension in Pregnancy of the America College of Obstetricians and Gynecologists, the diagnostic criteria for preeclampsia are gestational hypertension with the presence of proteinuria. Gestational hypertension is characterized by new-onset blood pressure elevation (defined as a systolic blood pressure of 140 mm Hg or greater, or a diastolic blood pressure of 90 mm Hg or greater, or both, on two occasions at least four hours apart) after 20 weeks of gestation in the absence of proteinuria. Proteinuria is defined as the excretion of 300 mg or more of protein in a 24-hour urine collection, a urine dipstick reading of 1+, or a protein/creatinine ratio greater than or equal to 0.3.

Ultimately, Dr. Giudice diagnosed Ms. Morris with gestational hypertension. He testified that preeclampsia was on his differential diagnosis at the time of Ms. Morris' discharge. He was "worried that preeclampsia would develop" and "specifically told [Ms. Morris] and discussed with her signs and symptoms of preeclampsia and asked her to call back if she developed any signs or symptoms of preeclampsia."

On August 10, 2015, four days later, Ms. Morris called Capital, complaining of decreased fetal movement. When she reported to Capital for an appointment that day, her blood pressure was 157/99, she had +1 protein in her urine, and a NST showed minimal variability with minimal acceleration. She was then sent to St. Joseph for evaluation, where her fetal heart rate tracing showed minimum variability and, according to Dr. Giudice, "decelerations that were essentially random in nature." Due to these results, Dr. Giudice decided to proceed with delivery and to perform an "urgent" Caesarean section. Peter wasborn at 5:13 p.m. on August 10, 2015, with low Apgar scores of 1, 3, and 6 at one, five, and ten minutes, respectively. Later that day, he was transferred to the University of Maryland Medical Center ("UMMC") for brain cooling. An MRI of Peter's head on August 17, 2015 showed findings most consistent with global hypoxic-ischemic encephalopathy ("HIE"), a brain disorder caused by insufficient oxygen or blood flow during birth. Peter was discharged from UMMC on September 9, 2015 with the following diagnoses: full term liveborn male, small for gestational age (birthweight 2330g less than the 5th percentile), perinatal depression, HIE, metabolic acidosis, and seizures.

On September 25, 2018, appellants filed a complaint against Capital, Dr. Giudice, and St. Joseph in the Circuit Court for Baltimore County. They alleged Dr. Giudice's failure to admit Ms. Morris for delivery on August 6, 2015, and Nurse Ator's failure to initiate St. Joseph's chain of command policy and advocate for Ms. Morris' admission to the hospital, continued evaluation, and delivery were negligent acts that resulted in injuries to Peter.

St. Joseph's chain of command policy states that its purpose is to:

provide a formalized mechanism for staff to follow in resolving administrative, clinical or other patient safety or service issues . . . St. Joseph Medical Center is committed to quality patient care and to the resolution of quality of care or safety issues. Medical Staff, Nursing Staff and other care providers are responsible for ensuring patients receive quality care and should implement the chain of command/communication procedures to address issues where the quality of care or safety of a patient is at question.

The policy "applies to St. Joseph Medical Center employees (staff), contract personnel, agency personnel and practitioners with clinical privileges." The policy "may be initiated to present or report an issue of concern and pass it up the lines of authority until a resolutionis reached." Pursuant to the policy, "[s]taff will "discuss identified concerns regarding patient care with the attending provider."

Employees (staff) should contact a higher level of authority if the first line of authority does not sufficiently resolve the issue or the person contacted does not respond in an appropriate timeframe.

The policy states that an example of when the policy should be initiated is:

[w]hen a nurse or other practitioner believes within his/her clinical knowledge or judgment that implementing a physician order or plan of care may potentially have an

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