Written By: Brandon Pedersen and Keanin Parish, Student-at-Law
FACTUAL BACKGROUND OF THE CASE
A recent case from the Ontario Court of Appeal shows that doctors may be liable for injuries you sustain even if they were not in charge of the operation.
In Stevenhaagen Estate v Kingston General Hospital, 2022 ONCA 560, Julia Stevenhaagen’s aorta ruptured during an angioplasty procedure – a grave medical emergency which meant that Ms. Stevenhaagen was experiencing severe blood loss. The appellants: Dr. Peter R. McLaughlin, an interventional cardiologist – and Dr. Yaron Sternbach, a vascular surgeon – attended to her rupture.
Dr. McLaughlin used a balloon to tamponade the bleeding, which he testified to be a delicate procedure. To prevent interference with the tamponade process, he decided against moving the patient to an operating room at that time. Dr. McLaughlin then requested the presence of Dr. Sternbach. After his arrival, they decided to attempt an endovascular procedure to stem the bleeding. At 12:35 PM., Dr. Sternbach inserted a ‘Cook stent’ which successfully prevented life-threatening blood loss. However, the Cook stent was not designed for this use. As a result, it obstructed Ms. Stevenhaagen’s aorta, which partially restricted blood flow to her organs. It was not until 2:20 PM. that a cardiovascular surgeon, Dr. Ralph-Edwards, attended to Ms. Stevenhaagen.
At this point, Dr. Ralph-Edwards diagnosed ongoing bleeding from Ms. Stevenhaagen’s aorta and a gathering hematoma in her chest. He opined that surgery was urgently needed and that the patient may have already sustained neurological injury. The patient arrived in the operating room 15 minutes later, during which she underwent an open-heart surgical procedure. After the surgery, she exhibited paraplegia, and a follow-up CT scan confirmed neurological abnormalities. Ms. Stevenhaagen never walked again and required a wheelchair for the rest of her life.
One question at trial was whether Dr. McLaughlin or Dr. Sternbach caused Ms. Stevenhaagen’s injuries by failing to promptly relocate her to the operating room after inserting the Cook stent. On the other hand, the defendants contended that the patient’s injuries were caused by the subsequent open-heart surgery. Drs. McLaughlin and Sternbach were found liable at the trial level for Ms. Stevenhaagen’s injuries. Both doctors appealed the decision.
QUESTIONS ON APPEAL
Firstly, the defendants submitted that the trial judge erred in finding that they failed to meet the standard of care. Secondly, that the trial judge erred in finding that causation had been established. Thirdly, Dr. Sternbach argued that he should not have been found liable at all because Dr. McLaughlin was the doctor making the critical decisions about Ms. Stevenhaagen’s care.
A) STANDARD OF CARE
The trial judge found that Dr. McLaughlin breached the standard of care by failing to consult a cardiovascular surgeon sooner after the aortic tear. He found that the use of the stent was reasonable for the purpose of stemming blood loss from the aortic rupture; however, testimony suggested that surgery was inevitable after its insertion, in part because it was not designed for the thoracic aorta, and because it had caused an obstruction of blood flow. Thus, after the stent’s insertion, Ms. Stevenhaagen should have been immediately moved to the operating room, and Dr. McLaughlin should have consulted with cardiac or thoracic surgery. The trial judge held that this error breached the standard of care owed to Ms. Stevenhaagen.
The trial judge held that ‘but for’ this breach of standard of care, Ms. Stevenhaagen would not have suffered the neurological injuries. On appeal, the defendants referred to Clements v Clements in their contention that the trial judge erred in applying a robust common-sense approach to causation because he held mere possibilities as proof. The appeal judge acknowledged this claim by noting a comment by the trial judge that there was a “possibility” that the aortic rupture itself, and not the stent, caused neurological damage to Ms. Stevenhaagen. However, it was found that the trial judge properly identified the test for causation in Clements v Clements, which asks whether it is ‘more likely than not’ that the defendants’ actions ‘caused or substantially contributed to’ injury. In this case, the plaintiffs are required to prove that Ms. Stevenhaagen’s injuries happened after the final deployment of the Cook stent and before the open-heart surgery began. The trial judge applied the correct standard of proof when he expressed that it was “more likely than not that the instability Ms. Stevenhaagen experienced between the final deployment of the stent and the open-heart surgery caused or substantially contributed to her neurological injuries.”
The appellants also submit that the trial judge did not properly apply the ‘but for’ test. They contend that the trial judge unduly focused on medical causation, rather than factual causation. In other words, the judge failed to ask whether the outcome would have been any different if the doctors had not been negligent. The appellants rely on the decision in Sacks v Ross, which sets out the proper causal reasoning process. That case ruled that triers of fact must consider what would likely have happened had the defendant not breached the standard of care; i.e., if the plaintiff would be injured regardless of the defendants’ acts or omissions, then the defendants did not cause the injury. However, the appeal judge noted that, although the trial judge did not specifically identify this framework, it is clear that the analysis was engaged. Firstly, the trial judge consistently referenced timeframes, such as what happened after the deployment of the Cook stent. This implies the judge understood that circumstances prior to this procedure would not have been the result of the defendants’ negligence. Further, the trial judge noted that if the doctors made the appropriate consultations and immediately moved Ms. Stevenhaagen to the operating room, then she would not have suffered a neurological injury. These findings impute the trial judge’s engagement with the same ‘but for’ causal reasoning process in Sacks, and suggest that the trial judge’s analysis did not unduly focus on medical causation rather than factual causation.
C) STERNBACH’S LIABILITY
Dr. Sternbach submits that the trial judge erred in finding him liable for having merely supported Dr. McLaughlin’s decision not to consult a cardiovascular surgeon. The trial judge found that Dr. Sternbach did not merely support Dr. McLaughlin’s decision, but that the two doctors made the decision together. Despite accepting that Dr. McLaughlin was the “most responsible” – or ‘in charge’ – Dr. Sternbach was sufficiently involved in the negligent treatment of Ms. Stevenhaagen. This finding is on the basis that the two doctors consulted with each other before making the decision. In these consultations, Dr. Sternbach did not disagree with Dr. McLaughlin’s findings, and beyond that, he both supported and facilitated them.
The appeal was dismissed. Dr. McLaughlin and Dr. Sternbach were found to have breached the standard of care by failing to consult a cardiac surgeon and immediately transport Ms. Stevenhaagen to an operating room. On the issue of causation, it was held that this breach of the standard of care caused neurological injury to Ms. Stevenhaagen. Lastly, Dr. Sternbach was found to be liable for his involvement in the decision not to consult with a cardiac surgeon.
WHY THIS MATTERS
This case stands for the proposition that doctors who are not the most responsible for a patient may still be liable for negligence in a malpractice claim. Acts or omissions may give rise to a claim of negligence against you, such as consultations with peers, failing to oppose procedures, or supporting/facilitating them.