United States District Court, S.D. California
MEMORANDUM DECISION FOLLOWING TRIAL AND ORDER FOR
ENTRY OF JUDGMENT
Gonzalo P. Curiel, United States District Judge
Annabelle Wright (“Plaintiff or “Ms.
Wright”) brings this medical malpractice action against
Defendant United States of America (“Defendant”)
under the Federal Tort Claims Act (“FTCA”). (Dkt.
No. 1, Compl.) Plaintiff s action arises from heart surgery
that healthcare providers at the Naval Medical Center San
Diego (“NMCSD”) performed on her husband, Wilbur
Wright III (“Decedent” or “Mr.
Wright”) on September 20, 2012. (Id.)
Plaintiff alleges that NMCSD healthcare providers negligently
caused Mr. Wright's death on September 21, 2012.
September 30, 2016, the Court conducted a motion in
limine hearing. (Dkt. No. 78.) On October 3, 4, 5, 6,
11, and 12, 2016, the Court held a bench trial. (Dkt. Nos.
79, 80, 81, 82, 83, 84.) Steven Poliakoff, Esq. and Daniel
Butcher, Esq. appeared on behalf of Defendant United States
of America, and Suzanne Mindlin, Esq., Beth Golub, Esq., and
Robert Weisenburger, Esq. appeared on behalf of Plaintiff
Annabelle Wright. (Id.) Having carefully reviewed
the evidence and the arguments of the parties, as presented
at trial and in their written submissions, the Court makes
the following findings of fact and conclusions of law
pursuant to Rule 52 of the Federal Rules of Civil Procedure.
As discussed below, the Court finds that the healthcare
providers at NMCSD acted with the appropriate standard of
care and concludes that Defendant is not liable for medical
Wilbur Wright III was born on December 15, 1969. Mr. Wright
served in the United States Navy from June 19, 1989 to June
30, 2009, when he was honorably discharged. From June 30,
2009 to early December 2010, Mr. Wright did not work. From
approximately early December of 2010, until approximately
mid-July of 2012, Mr. Wright worked as a supply utility man
in the Military Sealift Command. Mr. Wright died at age 42
and had a life expectancy of 62.79 years per stipulation of
the parties. Mr. Wright and Plaintiff were married for ten
2012, Mr. Wright was diagnosed with a 5.0 cm aneurysm of his
ascending aorta, which is a circumscribed dilation of the
large blood vessel that first takes oxygenated blood from the
heart to the rest of the body, as well as an abnormal aortic
valve. A 5.0 cm ascending aortic aneurysm carries an
approximately 10-12% per year risk of a rupture or
dissection. Instead of having the usual three cusps in his
aortic valve, Mr. Wright only had two. A bicuspid valve like
Mr. Wright's can cause blood flow turbulence, which may
increase the size of the aneurysm.
Wright's heart was twice the normal size for an
individual of Mr. Wright's size, and his left ventricle
was hypertrophied, meaning that the muscle was enlarged and
thickened to the point that blood vessels did not extend all
the way into the heart muscle. These abnormalities meant that
the vessels might not effectively carry cold cardioplegic
solutions, which protect heart tissues during surgery, into
the inferior wall of Mr. Wright's heart. In addition, Mr.
Wright's heart had a left-dominant coronary system,
meaning that the left main coronary artery, which branches
off into the left anterior descending artery and the
circumflex artery, supplied about four-fifths of his heart.
In turn, Mr. Wright's circumflex artery supplied both the
inferior (primarily via the posterior descending artery) and
lateral (via an obtuse marginal branch) walls of Mr.
Wright's heart. Any kinking of the left circumflex artery
would have affected both the inferior and lateral walls of
Mr. Wright's heart.
Theodore Pratt, M.D., a board-certified cardiothoracic
surgeon and then-Chief of Cardiothoracic Surgery at NMCSD,
evaluated Mr. Wright in 2012 and recommended that Mr. Wright
undergo a modified Bentall procedure to remove and replace
both his aortic heart valve and the diseased portion of his
aorta. A modified Bentall procedure is one of the most
complex heart surgeries and carries an approximately 5% risk
of dying. During his pre-operative evaluations, Dr. Pratt
informed Mr. Wright of the risks of this surgery, and Mr.
Wright signed a consent form acknowledging that these risks
included, inter alia, bleeding, heart attack, and
a modified Bentall surgery, the diseased portion of the aorta
and the abnormal valve are removed and replaced with a
mechanical heart valve connected to a tube of woven Dacron, a
synthetic fabric. The combined valve and tube of woven Dacron
are referred to collectively as a valve conduit or, more
simply, a conduit. In order to remove the portion of the
aorta with the aneurysm, the surgeon detaches the left and
right coronary arteries, which supply blood to the heart,
from the aorta within a circular “button” of
adjacent aortic tissue. At the center of each button is the
coronary artery ostium, the opening of the artery itself.
Each coronary artery ostium is surrounded by aortic tissue
from the sinus of Valsalva. The left and right coronary
artery buttons are then reattached, or anastomosed, to the
conduit after the conduit has been attached to the heart.
patient is placed on a heart-lung machine, or cardiopulmonary
bypass (“CPB” or “bypass”), during a
modified Bentall procedure. Bypass is necessary to circulate
oxygenated blood to the brain and rest of the body while the
surgeons remove the diseased heart valve and aorta, replace
them with the conduit, and then reattach the coronary
arteries. Once a patient is placed on bypass, the surgeon
arrests the heart, or stops it from beating, by administering
cardioplegia, a cold solution containing high levels of
potassium, and by placing a clamp across the aorta. CPB
lowers the temperature of blood. Components of the blood,
such as platelets and clotting factors in the blood plasma,
are damaged during bypass. Extended time on CPB can result in
a medical coagulopathy, or a medical bleeding disorder,
wherein the blood loses the ability to clot properly.
Coagulopathy is treated by administering transfusions of
blood and blood products, such as platelets and
September 20, 2012, Mr. Wright underwent a modified Bentall
procedure. Mr. Wright's September 20, 2012 surgery was
performed by Dr. Pratt, who was assisted by CDR Alfredo
Ramirez, M.D., a board-certified cardiothoracic surgeon who
is now the Chief of Cardiothoracic Surgery at NMCSD. Since
2003, Dr. Pratt performed approximately thirty Bentall
procedures as the primary surgeon and was the assistant
surgeon in approximately thirty Bentall procedures. Prior to
September 20, 2012, Dr. Ramirez personally performed an
estimated five to seven Bentall procedures as the primary
surgeon and was the assistant surgeon in approximately
seventy to eighty Bentall procedures.
operation began at approximately 8:39 a.m. Mr. Wright was
given a powerful blood-thinning agent, Heparin, and was
placed on CPB beginning at approximately 9:15 a.m. Mr.
Wright's heart was arrested, and Mr. Wright's blood
was run through plastic tubing and a cardiopulmonary bypass
machine to oxygenate the blood before returning the blood to
Mr. Wright's body.
Pratt removed the aneurysmal portion of Mr. Wright's
aorta and the bicuspid aortic valve, and created the right
and left coronary artery buttons. The operative report states
that Mr. Wright's left “coronary button was noted
to be large and the tissue thinned from the patient's
enlarged sinus.” (Jt. Ex. 4-003.) When creating the
right and left coronary artery buttons, Dr. Pratt and Dr.
Ramirez assessed the integrity of Mr. Wright's aortic
tissue by how it appeared, how it felt when the tissue was
being cut and the coronary artery buttons were created, how
the tissue handled when picked up with surgical forceps, and
how the tissue held sutures when the stitches were done. Dr.
Ramirez testified that the tissue consistency for the left
and right coronary artery buttons was similar, and that while
the tissue used for the buttons “was thinner than
normal, ” it was “by no means . . . thinner than
anything else [he] had seen before, ” and he
“didn't feel . . . that it was not a suitable cuff
to be able to use as a coronary button.” (Tr.
Pratt then performed four anastomoses in the following order:
the proximal suture line, the left coronary artery button,
the distal suture line, and right coronary artery button. Dr.
Pratt attached the conduit to Mr. Wright's heart at the
proximal suture line using interrupted horizontal mattress
sutures with small pledgets of Teflon felt “all the way
along the aortic annulus.” (Jt. Ex. 4-003.) A thin
layer of BioGlue was placed along the suture line.
Pratt then anastomosed the left coronary button to the
conduit using a single layer of sutures. To avoid twisting or
kinking the arteries when he anastomosed the buttons to the
conduit, Dr. Pratt placed orienting sutures on the buttons so
that “twelve o'clock” on the buttons
corresponded to “twelve o'clock” on the
Pratt then performed the distal suture line anastomosis,
using two layers of Teflon felt pledgets for reinforcement
and running continuous sutures to connect the conduit to the
aorta. A thin layer of BioGlue was placed along the suture
line. Finally, Dr. Pratt performed the right coronary artery
button anastomosis in the same manner as the left coronary
artery button anastomosis, using a single layer of sutures.
All of Mr. Wright's anastomoses, whether they were to the
heart, the remaining aorta, or between the coronary artery
buttons and conduit, were pressure-tested twice to ensure, as
best as possible before the bypass was discontinued, that
they would not leak.
the procedure was completed, a period of time was allowed for
the heart to recover from being kept cold and not beating,
and Mr. Wright's heart was gradually weaned from bypass.
The surgery, up until attempted weaning, proceeded
attempting to wean Mr. Wright from CPB at approximately 12:04
p.m., Dr. Pratt observed bleeding coming from the area behind
the conduit in the region of the left coronary artery button.
Dr. Pratt attempted to identify the precise source of the
bleeding, but was unsuccessful. The precise source of the
bleeding could not be identified without placing undue
traction on the aorta and the newly created anastomoses
between the conduit graft, the aorta, and the coronary artery
buttons. In order to identify the specific site of bleeding,
it was necessary to place Mr. Wright back on bypass, reapply
the cross clamp, and re-arrest the heart, so that the conduit
could be opened and the anastomoses inspected directly.
Mr. Wright was placed back on CPB. Dr. Pratt cross-clamped
the aorta, arrested the heart, opened the conduit
transversely, and inspected the left coronary artery button
anastomosis. The left coronary artery button suture
line was checked for tension, and Dr. Pratt placed additional
sutures where needed to adjust the tension of the suture
line. Dr. Pratt examined the outside of the
graft as well while he made these repairs. Dr. Pratt then
closed the conduit with sutures and removed the aortic
attempt at weaning from bypass was undertaken. In this second
attempt to wean Mr. Wright from CPB, Dr. Pratt observed
bleeding from the inferior edge of the left coronary artery
button, where it appeared that the tissue of the coronary
button had begun to tear along the suture line. (Jt. Ex.
4-004.) Dr. Pratt then placed a single stitch over a pledget
of pericardium to stop the bleeding. (Id.) After Dr.
Pratt made this repair, no further bleeding was observed from
the left coronary artery button. Mr. Wright was taken off CPB
at 3:05 p.m, and the blood-thinning agent Heparin was
reversed. Following separation from bypass, Mr. Wright's
heart was noted to have a stable rhythm, and his vital signs,
including pulmonary artery pressures, were noted to be
Pratt and Dr. Ramirez testified that at no point during the
surgery did they observe or detect bleeding from the proximal
suture line. Because bleeding in the proximal suture line
area is difficult to visually detect, Dr. Pratt tested for
bleeding by using white gauze pads and a white hemostatic
powder, so that any bleeding would stain the white gauze or
powder. The left coronary artery button was the only site of
bleeding Dr. Pratt and Dr. Ramirez observed, and no bleeding
was observed from the left coronary artery button after Dr.
Pratt's second repair.
Wright had been on bypass from 9:15 a.m. until 3:05 p.m. (Jt.
Ex. 2:004, 2:010.) While modified Bentall procedures normally
take between four and a half to six hours, Mr. Wright's
case was prolonged by the bleeding that was encountered and
the procedures that were necessary to stop the bleeding. Dr.
Stuart W. Jamieson, Defendant's designated expert in
cardiothoracic surgery, testified that “[b]leeding is a
major risk in heart surgery” that “[e]very
experienced surgeon” has encountered in a Bentall
procedure, and the fact that bleeding occurs does not
indicate that there was a breach in the standard of care.
Mr. Wright was taken off CPB at around 3:05 p.m., a
transesophogeal echocardiography (“TEE” or
“echo”) probe was placed, and a scan of Mr.
Wright's heart was performed. The TEE scan noted that a
portion of the inferior wall of Mr. Wright's heart
appeared to be hypokinetic, or have decreased contractility.
Decreased contractility after cardiac surgery can have many
causes, such as the patient being on bypass, the length of
time on bypass, the length of time that the aorta is
cross-clamped, the heart being cold, and air remaining in the
heart's circulation. Hypokinesis may also take any time
between minutes to hours to resolve. Mr. Wright's heart
was accordingly given time to recover. During this recovery
period, the surgeons and anesthesiologists adjusted Mr.
Wright's medications and inserted an intra-aortic balloon
pump (“IABP”) at 3:41 p.m. to offload some of the
strain off of the left ventricle, mechanically reduce cardiac
work, and increase cardiac perfusion pressures. (Jt. Ex.
2:013; Jt. Ex. 4:004.)
Wright's heart function was observed for a period of
time. Mr. Wright's cardiac outputs-the stroke volume, or
the amount of blood being pumped out of the heart in liters
per minute-improved during this observation period. From 3:53
p.m. to 4:08 p.m., Mr. Wright's cardiac output was 4.2;
from 4:53 p.m. to 5:08 p.m., it was 4.5;and from 5:38 p.m.
to 5:53 p.m., it was 5.3, a cardiac output which Dr. Robert
L. Shuman, Plaintiff's designated expert in
cardiothoracic surgery, agreed was within normal limits for a
man Mr. Wright's age, and which Dr. Jamieson
characterized as “high.” (Jt. Ex. 2:014, 2:017;
Tr. 342:13-16, 1132:17-18.) Dr. Jamieson testified that even
while the heart is assisted by an IABP, medications, blood,
blood products, and fluids, the cardiac output is ultimately
generated by the heart: “You cannot improve cardiac
output or heart function merely on the basis of fluids and
drugs.” (Tr. 1133:07- 16.) Accordingly, Mr.
Wright's improving cardiac outputs reflected actual
improvement in his cardiac function. (Id.)
Ramirez and Dr. Pratt also observed that the strength and
contractility of Mr. Wright's left ventricle continued to
improve over time. Mr. Wright's pulmonary artery
pressures were stable, signifying improvement. Mr.
Wright's electrocardiogram (“EKG”) showed no
evidence of ST segment changes, meaning that the EKG readings
did not reflect ischemia or a lack of oxygen to a section of
the heart, and did not indicate a myocardial infarction.
Given the improvement in contractility and ventricular
function, Dr. Pratt did not believe that Mr. Wright needed to
undergo the stresses of another major cardiac surgery, such
as a coronary artery bypass grafting (“CABG”)
procedure, which would necessitate further anticoagulation
and time on bypass. Dr. Pratt therefore continued to watch
Mr. Wright in the operating room.
at approximately 6:00 p.m., Mr. Wright began to require
increased dosages of medication, such as norepinephrine,
which was first administered at about 6:06 p.m., to support
his blood pressure. (Jt. Ex. 2:016.) Mr. Wright's blood
pressure dropped significantly; his need for pressor medications
and inotropic support increased; and the decreased
contractility in his inferior left ventricle possibly
persisted. (Jt. Ex. 4:004.) Dr. Pratt hypothesized in the
operative report that these changes in Mr. Wright's
condition may have possibly resulted from the stitch that was
placed at the left coronary artery button to stop the
bleeding at that site. (Id.) Regardless of the
specific cause, Dr. Pratt and Dr. Ramirez determined that Mr.
Wright needed to undergo a CABG procedure to augment the
blood supply to his inferior left ventricle.
order for Dr. Pratt to perform a CABG procedure, the
blood-thinning agent Heparin was administered to Mr. Wright
at approximately 6:30 p.m., (Jt. Ex. 2:016), and bypass was
initiated at 6:46 p.m., (Jt. Ex. 7:004). Dr. Pratt
performed Mr. Wright's CABG procedure by harvesting a
vein from Mr. Wright's leg and performing two coronary
artery bypass grafts. Dr. Christopher Cornelissen, the
attending cardiac anesthesiologist, testified that the
procedure proceeded “expeditiously.” (Tr.
868:01-05.) Following the CABG procedure, Mr. Wright was
removed from CPB at approximately 9:05 p.m. The hypokinesis
in Mr. Wright's left ventricular inferior wall decreased,
and the contractility of Mr. Wright's heart appeared to
improve between 9:05 p.m. and 10:48 p.m., based on readings
from the TEE probe.
Wright was observed in the operating room between 9:05 p.m.
and 11:13 p.m. During this period of time, Dr. Pratt and Dr.
Ramirez observed Mr. Wright's open chest and did not
observe, visually or through repeated testing with white
gauze and hemostatic powder, evidence of surgical bleeding at
the anastomoses. Mr. Wright was clinically stable and
transported from the operating room at 11:13 p.m. to the ICU.
Dr. Pratt accompanied Mr. Wright to the ICU and remained with
him throughout the night.
Wright arrived in the intensive care unit at approximately
11:20 p.m. on September 20, 2012. After three runs on bypass
and the modified Bentall and CABG procedures, Mr.
Wright's cardiac outputs were low, and he required a
significant amount of inotropic and vasopressor medications
to maintain his blood pressure. Mr. Wright exhibited elements
of cardiogenic shock, or heart pump failure, and medical
coagulopathy. Cardiogenic shock causes leakage of fluid from
the blood vessels into tissue spaces. Dr. Kenneth Serio,
Defendant's expert in critical care medicine and
pulmonary medicine, noted that Mr. Wright “had
dysfunction of multiple elements of the clotting system,
” including platelet dysfunction, fibrinogen
deficiency, and lack of fibrinolysis. (Tr. 926:21-25,
929:17-24.) In accordance with the appropriate treatments for
shock and medical coagulopathy, Mr. Wright received
aggressive inotropic and vasopressor support, and he received
blood, blood products, and platelets. Dr. Serio testified
that the “significant amount of blood product
replacement, to the point that [Mr. Wright] had his entire
blood volume replaced once with that regimen, ” was an
appropriately aggressive treatment measure, given the level
of clotting system dysfunction involved. (Tr. 931:08-15.)
approximately 12:27 a.m. on September 21, 2012, the morning
following surgery, Dr. Pratt removed Mr. Wright's
dressing in the ICU because Mr. Wright's blood pressure
abruptly decreased. After removal of the dressing, Mr.
Wright's blood pressure increased and stabilized. Dr.
Pratt observed bleeding from all tissue surfaces as a result
of Mr. Wright's medical coagulopathy, and continued to
treat Mr. Wright with transfusions of blood, fresh frozen
plasma and platelets, and by keeping Mr. Wright in a warm
before 2:00 a.m., Mr. Wright's vital signs deteriorated,
and his cardiac rhythm changed to ventricular fibrillation. A
cardiac arrest code was called. Dr. Pratt attempted to
resuscitate Mr. Wright for over an hour. At 3:08 a.m. on
September 21, 2012, Mr. Wright was pronounced dead.
autopsy was performed on Mr. Wright's body. The Chief of
Pathology, CAPT Scott Luzi, M.D., examined Mr. Wright's
heart and found a myocardial infarction, or heart attack, in
the posterior wall of the left ventricle. Dr. Luzi testified
that Mr. Wright's heart weighed 750 grams, among the
largest he had seen. Dr. Luzi initially believed there was a
“defect” in the back of the graft conduit as it
anastomosed to the heart.
November 17, 2014, Plaintiffs designated experts in
cardiothoracic surgery and pathology (Robert L. Shuman, M.D.
and John C. Hiserodt, M.D., respectively) and Defendant's
experts in cardiothoracic surgery and pathology (Stuart W.
Jamieson, M.D. and Christopher L. Swalwell, M.D.,
respectively) inspected Mr. Wright's heart. The
examination was video-recorded. Mr. Wright's heart was
examined for anastomotic defects, as well as the
“defect” initially identified by Dr. Luzi. Dr.
Hiserodt, Dr. Swalwell, and Dr. Jamieson all concluded that
there were no defects in any of the anastomoses, and that the
“defect” identified by Dr. Luzi was not present.
Dr. Shuman also testified that Dr. Luzi “was incorrect,
” and that the “defect” was in fact
“just a piece of redundant aortic tissue that
hadn't been cut away.” (Tr. 318:21-319:01.)
video-recorded examination from November 17, 2014 was
reviewed by Dr. Luzi prior to his deposition on December 12,
2014. Dr. Luzi testified that being unfamiliar with the
conduit used in the procedure, he had mistakenly identified
as a “defect” the area between the conduit and
the native aortic tissue that remained after the aneurysm was
removed. After reviewing the recorded examination and
listening to both parties' pathologists and
cardiothoracic experts discuss the anatomy of Mr.
Wright's heart and the procedure performed, Dr. Luzi
realized that his probe had merely passed easily into a
“blind space” between the graft and Mr.
Wright's native tissue that remained following removal of
the aneurysm, and that no actual defect was present. (Tr.
allegations of medical malpractice rely on the opinion of Dr.
Robert L. Shuman, who testified that Dr. Pratt and his
surgical team breached the standard of care in the following
1. Failing to reinforce the left coronary artery button;
2. Performing a single-layer closure at the proximal suture
3. Making two attempts to repair the left coronary artery
4. Failing to stop Mr. Wright's bleeding;
5. Delaying Mr. Wright's CABG procedure for three hours;
6. Failing to insert a left ventricular assistive device
(“LVAD”) while Mr. Wright was still in the
expert in cardiothoracic surgery, Dr. Stuart W. Jamieson,
testified that Dr. Pratt and his surgical team did not breach
the standard of care in any of the six ways enumerated above.
Dr. Jamieson supported his analysis with facts, his extensive
knowledge of the standard of care, and his work throughout
the United States and the world.
Jamieson is a preeminent cardiothoracic surgeon. He is
currently the Endowed Chair and Distinguished Professor of
Surgery as well as the Dean of Cardiovascular Affairs at
University of California San Diego (“UCSD”). (Tr.
1075:1-5; Ex. 395.) Dr. Jamieson was formerly a professor and
the director of the heart and lung transplantation program at
Stanford University, where he was involved in the first
successful heart and lung transplant in the world. (Tr.
1078:16-21.) Dr. Jamieson was also formerly a professor and
the chief of heart surgery at the University of Minnesota,
where he performed the first heart and lung, double lung, and
single lung transplants in the Midwest. (Tr. 1078:
Jamieson has performed heart surgery for forty-five years,
worked in major training institutions, lectured throughout
the United States and the world, established heart surgery
programs throughout the world, and done demonstration
surgeries in many countries. (Tr. 1084:23-1085:23.) He is
very familiar with the standard of care in the United States,
the world, and locally. (Id.) Dr. Jamieson has
performed or supervised approximately 50, 000 heart surgeries
and has performed or supervised several hundred Bentall
procedures. (Tr. 1082:12-15.) Dr. Jamieson participates as
the senior surgeon in critical stages of multiple heart
surgeries and trains cardiovascular surgeons in California,
the United States, and throughout the world. (Tr. 1082:18-22,
1085:15-1086:3.) He has authored or co-authored over 500
publications regarding heart surgery and trained
approximately fifty cardiovascular surgeons. (Tr. 1081:17-20,
Federal Tort Claims Act directs the Court to apply the law of
the State of California, which is where the alleged tort
occurred. See 28 U.S.C. § 1346(b)(1); Daly
v. United States, 946 F.2d 1467, 1469 (9th Cir. 1991).
Plaintiff has the burden of establishing by a preponderance
of the evidence all of the facts necessary to prove the
negligence of Defendant and that such negligence was the
cause-in-fact of the complained-of injury. Johnson v.
Superior Court, 143 Cal.App.4th 297, 305 (Cal.Ct.App.
2006); Fein v. Permanente Med. Grp., 38 Cal.3d 137,
152 n.9 (Cal. 1985).
elements for medical malpractice are: “(1) a duty to
use such skill, prudence, and diligence as other members of
the profession commonly possess and exercise; (2) a breach of
the duty; (3) a proximate causal connection between the
negligent conduct and the injury; and (4) resulting loss or
damage.” Johnson, 143 Cal.App.4th at 305.
California courts require “only that physicians and
surgeons exercise in diagnosis and treatment that reasonable
degree of skill, knowledge, and care ordinarily possessed and
exercised by members of the medical profession under similar
circumstances.” Mann v. Cracchiolo, 38 Cal.3d
18, 36 (Cal. 1985) overruled on other grounds by Perry v.
Bakewell Hawthorne, LLC, 2 Cal. 5th 536 (Cal. 2017);
see also Landeros v. Flood, 17 Cal.3d 399, 408 (Cal.
1976); Meier v. Ross Gen. Hosp., 69 Cal. 2d 420');">69 Cal. 2d 420, 429
(Cal. 1968); Allen v. Leonard, 270 Cal.App. 2d 209,
215 (Cal.Ct.App. 1969). Ordinarily, the standard of care is a
matter solely within the knowledge of experts and can only be
proven through expert testimony unless the negligence is
obvious to a layperson. Johnson, 143 Cal.App.4th at
305; Landeros, 17 Cal.3d at 410.
further acknowledges that there may be more than one
recognized method of diagnosis or treatment, and a physician
is not negligent if, in exercising his best judgment, he
chooses a method which, in hindsight, turns out to be the
wrong choice, or one not favored by other physicians.
Lawless v. Calaway, 24 Cal. 2d 81');">24 Cal. 2d 81, 87-89 (Cal.
1944); Barton v. Owen, 71 Cal.App.3d 484, 501-02
(Cal.Ct.App. 1971); Vandi v. Permanente Med. Grp.,
Inc., 7 Cal.App.4th 1064, 1070 (Cal.Ct.App. 1992).
“A difference of medical opinion concerning the
desirability of one particular medical procedure over another
does not, however, establish that the determination to use
one of the procedures was negligent.” Clemens v.
Regents of Univ. of Calif., 8 Cal.App.3d 1, 13 (Cal.
1970) (citing Meier, 69 Cal. 2d at 420).
prove causation, the plaintiff must establish
“‘that the defendant's breach of duty . . .
was a substantial factor in bringing about the plaintiffs
harm.'” Mayes v. Bryan, 139 Cal.App.4th
1075, 1092-93 (Cal.Ct.App. 2006), as modified (June
21, 2006) (quoting Leslie G. v. Perry & Assocs.,
43 Cal.App.4th 472, 481 (Cal.Ct.App. 1996)). The traditional
“but for” test of causation is necessarily
subsumed under the “substantial factor” test.
Viner v. Sweet, 30 Cal.4th 1232, 1239 (Cal. 2003);
Mitchell v. Gonzales, 54 Cal.3d 1041, 1052 (Cal.
1991) (“‘If the conduct which is claimed to have
caused the injury had nothing at all to do with the injuries,
it could not be said that the conduct was a factor, let alone
a substantial factor, in the production of the
injuries.'” (quoting Doupnik v. Gen. Motors
Corp., 225 Cal.App.3d 849, 861 (Cal.Ct.App. 1990))).
in a medical malpractice action, causation must be proven to
a reasonable medical probability, rather than a
reasonable medical possibility, based upon competent
expert testimony. Jones v. Ortho Pharm. Corp., 163
Cal.App.3d 396, 403 (Cal.Ct.App. 1985) (emphasis added);
Morgenroth v. Pac. Med. Ctr., Inc., 54 Cal.App.3d
521, 533-34 (Cal.Ct.App. 1976). “A possible cause only
becomes ‘probable' when, in the absence of other
reasonable causal explanations, it becomes more likely than
not that the injury was a result of its action.”
Miranda v. Bomel Const. Co., Inc., 187 Cal.App.4th
1326, 1336 (Cal.Ct.App. 2010). Accordingly,
“[c]ausation is proven when a plaintiff produces
sufficient evidence to allow the jury to infer that in the
absence of the defendant's negligence, there was a
reasonable medical probability the plaintiff would have
obtained a better result.” Mayes, 139
Cal.App.4th at 1093 (internal citations and quotation marks
has failed to meet her burden to prove by a preponderance of
the evidence that Dr. Pratt and his surgical team breached
the standard of care. Each alleged ...