Springhill Hosps. v. West

Docket NumberSC-2022-0719
Decision Date04 August 2023
PartiesSpringhill Hospitals, Inc., d/b/a Springhill Memorial Hospital v. Patricia Bilbrey West, as personal representative of the Estate of John Dewey West, Jr., deceased
CourtAlabama Supreme Court

Appeal from Mobile Circuit Court (CV-16-901045)

MENDHEIM, Justice.

This appeal stems from a medical-malpractice wrongful-death action commenced by Patricia Bilbrey West ("Mrs. West") the personal representative of the estate of her deceased husband, John Dewey West, Jr. ("Mr. West"), against Springhill Hospitals, Inc., d/b/a Springhill Memorial Hospital ("SMH"). Following an 11-day trial, the jury returned a verdict against SMH and awarded $35 million in punitive damages. The Mobile Circuit Court entered a judgment on the jury's verdict finding SMH liable. In a postjudgment order entered following a hearing concerning a remittitur of the punitive-damages award, the trial court reduced the amount of the award to $10 million. We affirm both the judgment entered on the jury's verdict finding SMH liable and the trial court's order reducing the punitive-damages award.

I. Facts

At the time of the events that precipitated this action, Mr. West was 59 years old. Mr. West was a carpenter who owned his own cabinet shop. On June 4, 2014, Mr. West accidentally sliced most of the tip of his left thumb off when he was using a table saw in his shop. Mr. West drove himself to SMH's hospital emergency room to receive treatment for the injury. Dr. John McAndrew, a board-certified orthopedic surgeon, operated on the thumb. Dr. McAndrew testified that he removed the entire severed portion of the thumb and that the "bone was freshened up. It -- it was not a clean cut, so I freshened it up with the saw." Dr. McAndrew also sutured the exposed wound. The result of the surgery was that Mr. West retained the portion of his left thumb up to the nail bed. Dr. McAndrew stated that the surgery itself "took about 23 minutes" and that Mr. West was in the operating room "52 minutes altogether between when they brought him in the room and when they woke him up from the anesthesia." He further testified that Mr. West tolerated the surgical procedure well. Dr. McAndrew testified that he "wanted to keep [Mr. West] overnight because it was an open wound, and I wanted to give him antibiotics, just to minimize the risk of a bone infection."

Dr McAndrew issued two pain-medication orders for Mr. West's postsurgical care. One order stated that Mr. West should receive an oral dose of Percocet, the brand name for the opioid oxycodone. Specifically, that order stated:

"Oxycodone 10mg/APAP 325 mg Tab 1 tablet(s) PO, every 3 hours PRN Pain, Every 3-4 hours."[1]

The other order stated that Mr. West should receive

"Hydromorphone INJ
(Known as Dilaudid INJ) 4mg (Intravenous), every three hours
increased pain.
(Capitalization in original.)

Dr. McAndrew testified that Dilaudid is the brand name for hydromorphone, which is a concentrated form of morphine that can be administered by IV or by mouth but that "[i]t works, obviously, faster if you give it IV." It is undisputed that Dilaudid is at least seven times more powerful than morphine and that it carries a risk of inducing respiratory depression, sometimes referred to as Opioid Induced Respiratory Depression ("OIRD"), or oversedation, which can be fatal. If a patient has sleep apnea, there is a higher risk that giving the patient Dilaudid could cause OIRD.[3] Dr. McAndrew further explained that "Dilaudid is typically written as an as-needed order, and that's, frankly, the only way I've ever used it is as-needed," not as a "scheduled drug," which is one that is "to be given at a certain time frame on a certain schedule." Dr. McAndrew testified that his intention with the two pain-medication orders was for the nurses to administer Percocet and then for the nurses to

"assess the patient; they would determine, reasonably, what they think, in their judgment, the patient needed to get control of his pain so how severe it was -- and to give up to 4 milligrams of Dilaudid if it was very severe pain that they didn't feel that the Percocet could handle."

On cross-examination, with respect to his order for Dilaudid, Dr. McAndrew admitted that "the verbiage on it is somewhat ambiguous" and that it would have been clearer if it had stated that it was PRN, i.e., as needed. See note 1, supra.

Dr. McAndrew assigned Mr. West to the orthopedic floor of the hospital for his overnight care. At 7:19 p.m. on June 4, 2014, Nurse Joann Edwards took Mr. West from the postsurgery area to the orthopedic floor and handed him off to Nurse Jane Elenwa.[4] Mr. West's vital signs were noted to be stable at that time. According to the SMH Medical Administration Record ("the MAR"), at 10:00 p.m. on the night of June 4, 2014, Nurse Elenwa administered a 4-milligram dose of Dilaudid to Mr. West. Nurse Elenwa checked on Mr. West a half-hour later, and he rated his pain as having slightly decreased from before the administration of the Dilaudid. The MAR also indicates that, at 11:51p.m., Nurse Elenwa returned to Mr. West's hospital room and administered a second 4-milligram dose of Dilaudid to Mr. West. It is undisputed that this was equivalent to giving Mr. West 56 milligrams of morphine in a span of less than 2 hours.[5] The MAR states that Nurse Elenwa checked on Mr. West a half-hour later and he rated his pain level as having slightly decreased from before the administration of the second dose of the Dilaudid. None of SMH's medical records reflect that Mr. West was ever given Percocet.

In her video deposition that was shown to the jury, Nurse Elenwa flatly denied having given Dilaudid to Mr. West. She insisted that "[t]he medication I gave him was in a pill form, not an IV." Additionally, Nurse Elenwa testified that if she had given Mr. West 8 milligrams of Dilaudid in less than 2 hours it would have been "egregious and a gross violation of the standard of care."

In its closing arguments at trial as well as in its brief on appeal, SMH admitted that Nurse Elenwa had administered the doses of Dilaudid to Mr. West and that she had not administered any Percocet.[6]SMH's reason for those concessions was that SMH had admitted in its pretrial submissions and pretrial arguments that its medical records were accurate. At the hospital, controlled narcotics, such as opioids, are stored securely in an electronic medication dispenser -- known as the Omnicell Machine - that can be retrieved only by using a biometric fingerprint and/or a passcode. A report is created upon each retrieval of such drugs, showing the identity of the individual retrieving the medication and the time at which the medication was removed from the dispenser. Those reports show that Nurse Elenwa accessed both 4-milligram doses of Dilaudid, and scans of Mr. West's identification bracelet indicate that Nurse Elenwa administered those doses of the opioid to Mr. West.

At 3:45 a.m. on June 5, a nurse's aide returned to Mr. West's room and discovered that he was not breathing and was unresponsive. The aide called Nurse Elenwa into the room.[7] At 3:58 a.m., an emergency code was called, and an SMH code team arrived to perform CPR in an effort to resuscitate Mr. West. Those efforts failed, and Mr. West was pronounced dead at 4:25 a.m. on June 5, 2014.

SMH maintains a "crash cart" that holds emergency medications that may be needed during emergency-code situations. The crash cart used at the time of Mr. West's code contained five .4-milligram doses of Narcan. Narcan's sole purpose is to counteract an opioid overdose. The SMH physician who responded to the code for Mr. West, Dr. Alan Babcock, and the code team's nursing personnel, documented the medications they administered during the code, and there was no documentation of an administration of Narcan. However, SMH's billing invoice for its care of Mr. West charged his account for the administration of all five doses of Narcan.

Mrs. West originally commenced this action against SMH on May 20, 2016. Mrs. West asserted several allegations of negligence against SMH under the Alabama Medical Liability Act ("the AMLA"), § 6-5-480 et seq. and § 6-5-540 et seq., Ala. Code 1975. Relevant to this appeal, Mrs. West alleged that SMH had "negligently departed from the accepted standard of care applicable to similarly situated healthcare providers which was in effect at the time in one or more of the following respects": by failing to assess and monitor Mr. West; by failing to train Nurse Elenwa concerning the dangers of Dilaudid; by failing to formulate and implement policies, procedures, and/or protocols in a timely manner following notification from the Joint Commission for Accreditation of Healthcare Organizations ("JCAHO") for SMH's nursing staff to use standardized screening and monitoring tools when administering opioids by IV for pain management; by failing to identify and correct systematic flaws, hazards, and weaknesses that existed at the hospital with regard to the administration to patients of opioids by IV and the monitoring of those patients; by approving Dr. McAndrew's Dilaudid pain-medication order; and by failing to seek clarification of that order. (Emphasis added.) Regarding some of those allegations, Mrs. West sought to hold SMH vicariously liable for the acts and omissions of SMH's Chief Nursing Officer ("CNO") Paul Read and Nurse Elenwa.

Approximately a month before trial, on January 3, 2022, Mrs. West filed a motion for leave to file a third amended complaint. In part that proposed amendment sought to add allegations that Nurse Elenwa had failed to document in Mr. West's medical records that she gave him Narcan after ...

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