Manning v. BELLAFIORE

• Citation: 991 A.2d 399
• Decision Date: 12 April 2010
• Docket Number: No. 2005-320-Appeal.,2005-320-Appeal.
• Parties: Kathryn MANNING et al. v. Peter J. BELLAFIORE, M.D.
• Court: Rhode Island Supreme Court

991 A.2d 399

Kathryn MANNING et al. v. Peter J. BELLAFIORE, M.D.

No. 2005-320-Appeal.

Supreme Court of Rhode Island.

April 12, 2010.

Michael T. Eskey, Esq., Providence, for Plaintiff.

Joshua E. Carlin, Esq., Providence, for Defendant.

Present: SUTTELL, C.J., FLAHERTY, and ROBINSON, JJ.

OPINION

Chief Justice SUTTELL, for the Court.

The defendant, Peter J. Bellafiore, M.D., appeals from a Superior Court order granting the motion for a new trial sought by the plaintiff, Kathryn Manning.¹ This wrongful death and medical malpractice action arises out of the tragic and premature death of Michael Manning. After a lengthy trial, a jury found in favor of Dr. Bellafiore. The trial justice granted the plaintiff's motion for a new trial, both as a sanction for what he considered Dr. Bellafiore's "flagrant discovery abuses" and because he found the jury's verdict to be against the fair preponderance of the evidence. For the reasons set forth in this opinion, we affirm the order of the Superior Court

I Facts and Travel²

On March 4, 1998, Kathryn Manning's husband fell in his bathroom after losing consciousness. At the time, Mr. Manning was forty years old and the father of four young children. When his wife found him, Mr. Manning was unable to sit up or open his eyes, and he had a mild facial droop on his right side. He was taken to South County Hospital where he was treated by emergency-room personnel. An initial computerized tomography (CT) scan revealed normal blood flow. Doctor Bellafiore, a neurologist who was on call at South County Hospital, examined Mr. Manning several hours after his admission to the emergency room. By that time, Mr. Manning's condition had improved somewhat, and Dr. Bellafiore contacted Donald McNiece, M.D., Mr. Manning's primary-care physician, to obtain his medical history. Although Dr. McNiece was Mr. Manning's admitting physician, he deferred to Dr. Bellafiore in providing Mr. Manning's treatment.

Doctor Bellafiore established a differential diagnosis for Mr. Manning, which is essentially a list of considered causes of a given symptoms or symptoms. Among the sources of Mr. Manning's symptoms contemplated by this differential diagnosis were complex migraine, aneurysm, tumor, and stroke. Doctor Bellafiore recommended that Mr. Manning undergo a magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of the circle of Willis³ to determine whether Mr. Manning was suffering a stroke and, if so, to locate the blockage of blood flow to the brain.⁴ Doctor Bellafiore also prescribed aspirin as an antiplatelet medication.

Mr. Manning first attempted to undergo an MRI/MRA the day he was admitted to South County Hospital. Unfortunately, he had a claustrophobic reaction and became nauseous while inside the closed MRI/ MRA machine, and he was unable to complete the test. Doctor Bellafiore prescribed the antianxiety medication Ativan and the antinausea medication Compazine for Mr. Manning, but his second attempt to undergo an MRI/MRA later that same day also was unsuccessful. In the hope of mitigating Mr. Manning's claustrophobia, Dr. Bellafiore attempted to arrange a so-called "open architecture MRI" for Mr. Manning to undergo at Rhode Island Hospital. Doctor Bellafiore's efforts were frustrated because the MRI machine was being repaired. The radiologist at Rhode Island Hospital initially believed those repairs would be completed by the afternoon of March 5, 1998, but when he called back, Dr. Bellafiore learned that the open MRI machine would be down for repairs indefinitely.

At 3 a.m. on March 6, 1998, Mr. Manning began complaining about a severe headache. He also began experiencing a visual impairment resembling a "white veil." Doctor Bellafiore ordered a second CT scan to determine whether the loss of vision could be attributed to swelling in the brain, and the test results indicated "a new prominent segmental abnormality in the left occipital lobe." This confirmed that Mr. Manning had suffered a stroke two days earlier, but the test did not show any increased cranial pressure.⁵

At approximately 9 a.m. on March 7, 1998, Mr. Manning suffered a second, catastrophic stroke. Mr. Manning was airlifted to Massachusetts General Hospital (MGH), where he was immediately treated by Christopher Putman, M.D. After examining the results of an advanced CT scan,⁶ Mr. Manning's treatment team determined that he had likely suffered a stroke caused by a blockage in the basilar artery in his brain. Doctor Putman performed an angiogram and discovered that Mr. Manning's left vertebral artery was almost completely blocked. He then used several microcatheter treatment balloons to partially expand the artery. Upon reaching the basilar artery, Dr. Putman discovered a clot, which he identified as the cause of the stroke. Doctor Putman attempted to break apart the clot using the clot-buster Urokinase; and, after that was only minimally effective, he inflated several balloons, which dislodged the clot. The clot traveled into another portion of Mr. Manning's brain, and Dr. Putman determined that the risks of further treatment in this region were too great. Unfortunately, Mr. Manning steadily lost brain function and on March 9, 1998, life support was withdrawn and he died.

Mrs. Manning filed a civil action against Drs. Bellafiore and McNiece, as well as South County Hospital, alleging negligence and wrongful death. After extensive discovery, trial began on January 4, 2004. At trial, plaintiff contended that the standard of care required Mr. Manning's physicians to conduct an MRI/MRA examination within twenty-four hours of his first stroke. According to plaintiff, Dr. Bellafiore breached this standard of care by failing to accomplish the MRI/MRA examination promptly, and by failing to apprise Mr. Manning of alternative means to accomplish imaging, such as adequate sedation, after it became clear that Mr. Manning's claustrophobia would otherwise prevent him from completing the test in a closed MRI/MRA machine. Moreover, plaintiff contended that if Dr. Bellafiore was unable to complete the MRI/MRA examination at South County Hospital, Mr. Manning should have been transferred to a tertiary care hospital⁷ that performed conventional cerebral angiograms. Additionally, plaintiff argued that Dr. Bellafiore breached the standard of care by failing to administer the clot-buster Heparin after Mr. Manning was admitted.

A great deal of the testimony elicited at trial pertained to Dr. Bellafiore's unsuccessful efforts to obtain an MRI/MRA test for Mr. Manning.⁸ Doctor Bellafiore acknowledged that an MRI was an important diagnostic tool for ruling out possible causes of Mr. Manning's symptoms, as well as for determining whether there was any damage to his brain tissue, which is an indication of an interruption of blood flow. Moreover, an MRA could pinpoint where in the arteries the damage had occurred, which is crucial for determining the cause of a stroke.

Doctor Bellafiore testified that he was involved in the initial efforts to obtain a closed MRI/MRA on March 4, 1998, through the Rhode Island Medical Resonance Imaging Network.⁹ He testified that after Mr. Manning could not overcome his claustrophobia, he presented Mr. Manning with two options to accomplish the closed MRI/MRA several times on both March 5 and March 6. First, he stated that he offered Mr. Manning additional Ativan "to make him a little sleepier to see if he could tolerate the test." Additionally, Dr. Bellafiore testified that he offered his patient intravenous conscious sedation, which achieves a significantly deeper level of sedation.¹⁰ He explained that Mr. Manning could accomplish the MRI/MRA examination by general anesthesia, but he testified that he did not present this option because he felt that the risks outweighed the benefits.¹¹ Doctor Bellafiore vividly described Mr. Manning's refusal of these options stating,

"What he said to me—and I remember it, because I was struck by it. He told me, `I'm sorry, Doc.' I remember it when people call me Doc. It just makes me feel like a doctor. `I know you need me to do this test to figure out what to do, but I just can't do it.' This was on the morning of the 5th after I told him all the things that could be possibly wrong. And I told him about conscious sedation. I told him about Ativan. I told him the open MRI may not give us the answer we need. I basically held— and told him he could have a stroke, he could have a tumor. I was holding a neurological gun to his head."

According to Dr. Bellafiore, after Mr. Manning refused to undergo a closed MRI/ MRA, he had no choice but to recommend an open MRI, even though he considered a closed MRI/MRA to be the "best choice."¹² Indeed, he testified that at that time he did not believe that an open MRI machine was sensitive enough to produce MRA-quality images of the blood vessels.¹³ On a March 5, 1998 assessment and recommendation form, Dr. Bellafiore noted that Mr. Manning could undergo an "MRA as an outpatient." At trial, he explained that such a test would have been performed at a later date in a closed MRI/ MRA machine "if Mr. Manning would agree to * * * that." Despite Dr. Bellafiore's stated preference for the closed MRI/MRA examination, he characterized Mr. Manning's purported choice to wait until the open MRI machine was operational as "a rational decision." He did not document Mr. Manning's alleged refusal to undergo a closed MRI/MRA examination in his treatment notes, nor did he document his intention to order an open MRI for Mr. Manning. Doctor Bellafiore did, however, add the phrase "in an open architecture" to Dr. McNiece's March 5, 1998 order for an "MRI head at Rhode Island Hospital." He also testified that he did not seek the assistance of Mrs. Manning in his attempt to persuade her husband to undergo a closed MRI/MRA with conscious sedation until the evening of March 6, 1998. Doctor Bellafiore testified that Mrs. Manning also was unable...