PROXIMATE CAUSE-Why Liability for Negligence May Still Exist Even When You Are Not the Primary Cause of the Injury

The Supreme Court of Florida, in the matter of Ruiz v. Tenet Hialeah HealthSystems, Inc. quashed the decision of the Third District Court of Appeal affirming the entry of a directed verdict in favor of Respondent Arturo Lorenzo, M.D., holding that the Third District erred in its decision when it equated the proximate cause of an injury with the primary cause of the injury. In 2009, the Petitioner’s wife, Maria Elena Espinosa, noticed a large mass had developed on the back of her head. She consulted with her primary care physician who diagnosed the mass as a tumor and referred her to a neurosurgeon. The neurosurgeon did not order a biopsy of the tumor, but believed it to be an osteosarcoma and recommended immediate surgery to remove some of the tumor’s mass. The neurosurgeon asked Mrs. Espinosa’s primary care physician to order a battery of laboratory tests to ensure Mrs. Espinosa was medically fit to undergo surgery. An EKG and urinalysis were ordered. The automated interpretation by the EKG machine itself flagged Mrs. Espinosa’s test as abnormal, indicating her heart may have been enlarged and that she also had suffered two myocardial infarctions. The urinalysis results indicated the abnormal presence of protein in her urine. Despite these abnormal test results, Mrs. Espinosa’s primary care physician cleared her for the surgery.

The morning of surgery, Mrs. Espinosa arrived to the hospital. Her assigned anesthesiologist, Dr. Guillermo Velasquez, was running late and her pre-anesthesia evaluation had not yet been performed. As such, Dr. Lorenzo, who was present at the hospital that morning to assist with a different patient’s anesthesia decided to perform Mrs. Espinosa’s pre-anesthesia evaluation himself. Dr. Lorenzo asked Espinosa a series of questions about her medical history and present condition, recording the information she gave him on a pre-anesthesia form/moderate sedation evaluation form in her chart. Dr. Lorenzo also reviewed some, but not all, of the test results in Espinosa’s chart. Dr. Lorenzo read her EKG and, although the readout was blurry, he testified he was able to interpret the EKG with sufficient clarity to conclude her heart was functioning normally. He believed the abnormal result was caused by a malfunction of the EKG machine and not by any problem with her heart. He also reviewed the first page of her urinalysis results, but did not look at the second page of those results where the abnormal results (proteinuria) were displayed. During trial, Dr. Lorenzo admitted the proteinuria reading was something he “would want to know,” but also stated it would not have affected his determination of whether it was safe for Espinosa to undergo anesthesia. After Dr. Lorenzo had completed approximately half of the pre-anesthesia form, Dr. Velasquez arrived and took over from Dr. Lorenzo. Dr. Lorenzo then signed the pre-anesthesia form, introduced Dr. Velasquez to Espinosa, and told Dr. Velasquez, “There is nothing, no major medical problems whatsoever. You may want to look at the EKG.” Dr. Lorenzo then left the room and estimated he saw Espinosa for between three and five minutes. Dr. Lorenzo did not inform Espinosa’s surgeons about the abnormal EKG, which he had reviewed, or about the urinalysis results reflecting abnormal proteinuria, which he had not. Dr. Velasquez later testified that after taking over for Dr. Lorenzo he began the pre-anesthesia evaluation over again from the beginning. Dr. Velasquez reviewed the EKG and the urinalysis results, including the proteinuria reading, but also did not inform Espinosa’s surgeons of these abnormal test results. He also signed the pre-anesthesia form and cleared Espinosa for surgery.

During the surgery, Espinosa lost a large amount of blood and suffered a precipitous drop in blood pressure, which her physicians were unable to reverse. A little over an hour into surgery, she went into cardiac arrest and could not be resuscitated. An autopsy was performed and a pathology test of the tumor tissue revealed that, rather than being an osteosarcoma, the tumor was caused by a type of plasma cell cancer known as multiple myeloma.

Ruiz filed a medical malpractice action against each physician involved in Espinosa’s treatment, including Dr. Lorenzo. In part, Ruiz alleged Espinosa’s death was caused by the failure to correctly diagnose her condition as multiple myeloma. Ruiz argued multiple myeloma should only be treated through radiation or chemotherapy and that surgery was not appropriate in Espinosa’s case. Had Espinosa been correctly diagnosed at any point, Ruiz claimed, the surgery would have been canceled and Espinosa would have survived. With regard to Dr. Lorenzo, Ruiz alleged he breached the standard of care by (1) not reviewing all the available data in Espinosa’s chart, (2) not ordering a second EKG to reconcile the abnormal results of the first EKG, and (3) not reporting the abnormal lab results-some of which he did not review-to Espinosa’s surgeons. Ruiz contended that, had Dr. Lorenzo adhered to the standard of care, either Dr. Lorenzo or the surgeons would have realized Espinosa was suffering from multiple myeloma and the surgery would have been canceled.

The trial court granted a directed verdict in favor of Dr. Lorenzo, holding that, even assuming Dr. Lorenzo was negligent in his care of Espinosa, he did nothing more than place her in a position to be injured by the independent actions of third parties—namely, the surgeons. The trial court analogized Dr. Lorenzo to “the cab driver who drove [Espinosa] to the hospital.” Ruiz appealed and the district court affirmed the trial court’s ruling, concluding that no competent, substantial evidence in the record would allow a reasonable factfinder to conclude Dr. Lorenzo was the “primary” cause of Espinosa’s death. Ruiz v. Tenet Hialeah Healthsys., 224 So. 3d 828, 830 (Fla. 3d DCA 2017).

The Florida Supreme Court disagreed with the Third District Court of Appeal and explained that “the law does not require an act to be the exclusive or even the primary cause of an injury in order for that act to be considered the proximate cause of the injury; rather, it need only be a substantial cause of the injury.” Opinion at 8. The Supreme Court relied on its prior opinion, Sardell v. Malanio, 202 So. 2d 746, 746-47 (Fla. 1967) where the Court held that a young boy who threw a football to his friend could be held to have proximately caused the injuries sustained by a passerby with whom his friend collided as he tried to catch the ball. The district court in Sardell had reasoned that Malanio, who threw the ball, “had no ‘physical control over the pass catcher’ and had no reason to expect the collision with the plaintiff,” and therefore “held that the alleged negligence of the catcher effectively isolated the initial alleged negligence of the passer” such that Malanio’s act of throwing the football could not be the proximate cause of the plaintiff’s injuries. Id. at 747 (quoting Sardell v. Malanio, 189 2d 393, 394 (Fla. 3d DCA 1966). On that basis, the district court affirmed the trial court’s dismissal of the complaint against Malanio. Id. The Supreme Court quashed that decision, explaining that “[t]o preclude liability of the initial negligent actor, the alleged intervening cause must be efficient in the sense that it is independent of and not set in motion by the initial wrong.” Id. The Court reasoned that the act which injured the plaintiff-that is, the attempt to catch the ball-“was merely a direct, natural, and continuous sequel to the initial act of the passer Malanio.” Id. Indeed, the catcher “would not have acted at all had it not been for the initial act of Malanio, who threw the ball and thereby initiated the series of events which in natural sequence allegedly produced the ultimate injury.” Id. Thus, although the primary cause of the plaintiff’s injury was the collision with the catcher, Malanio substantially contributed to causing the plaintiff’s injury by throwing the football without due care.

The Supreme Court concluded the district court erred when it affirmed the trial court’s entry of a directed verdict on causation in favor of Dr. Lorenzo where the trial court found the record evidence established he was not the primary cause of Espinosa’s death. It further stated that its precedent makes clear that “Dr. Lorenzo cannot prevent Ruiz from establishing proximate cause merely by showing his actions or omissions were not the primary cause of Espinosa’s death. Instead to foreclose liability on the grounds of causation, Dr. Lorenzo’s acts or omissions must not have substantially contributed to Espinosa’s death as part of a natural and continuous sequence of events which brought about that result.” Opinion at 11. To obtain a directed verdict on this basis, Dr. Lorenzo must show there is no competent, substantial evidence in the record which would permit a reasonable factfinder to reach such a conclusion at all.” Id. (citation omitted).

To read the Supreme Court’s full opinion on the Ruiz case, click here.