Missouri Court of Appeals Affirms Jury Verdict for Plaintiff Despite Concerns Regarding Expert Opinions

Dr. Gordon Robinson is a psychiatrist who began treating K.P. on June 25, 2013 and continued treating her until her March 16, 2016 death. K.P. was admitted to Harris House Treatment and Recovery Center for inpatient treatment for alcohol dependence and Adderall abuse. K.P. suffered from various health conditions, including alcohol dependence, ADHD, amphetamine abuse, generalized anxiety disorder, bulimia nervosa, and anorexia nervosa. While treating K.P. at Harris House, Dr. Robinson prescribed her Vyvanse, an amphetamine. K.P was abusing the Vyvanse and taking more than the prescribed amount. One evening, K.P. and her mother got into an argument about paying for a Vyvanse prescription. About fifteen minutes after the argument ended, K.P. was found unresponsive in her bedroom. She was taken to the hospital and declared brain dead a few days later. The St. Louis County Medical Examiner’s Office determined K.P.’s cause of death was an “intraventricular hemorrhage secondary to acute Lisdexamfetamine toxicity” (the generic name for Vyvanse), which was also identified on the death certificate. K.P.'s mother filed a wrongful death lawsuit alleging that Dr. Robinson’s negligence caused K.P.’s death. At the conclusion of the trial, the jury found in favor of plaintiff and awarded $5 Million in compensatory damages, which the trial court reduced to $801,061 pursuant to the medical malpractice liability limitations in Section 538.210. The jury declined to award aggravating circumstances damages.

Defendants Gateway Psychiatric Group and Dr. Gordon Robinson raised four separate issues on appeal: (1) that the trial court improperly included conflicting theories of negligence in the verdict directing instruction; (2) the expert testimony about K.P.'s cause of death did not comply with legal standards; (3) the death certificate was admitted into evidence without proper foundation; and (4) aggravating circumstances damages were incorrectly allowed as there was no evidence of intentional wrongdoing.

Appellants argued that the trial court erred by including both the ultimate fact and additional evidentiary details in the jury verdict director. They argued that the sole ultimate fact for the jury's consideration should have been whether Dr. Robinson unreasonably prescribed Vyvanse to K.P., while the remaining four disjunctive theories of negligence—prescribing Vyvanse above the recommended dose, failing to weigh risks, not monitoring for side effects, and not discontinuing the medication—were improper evidentiary details. Plaintiff argued that these additional disjunctives represented different theories of negligence, not just evidentiary details, all of which were separate ultimate facts for the jury to consider. The court noted Appellants failed to object to the submission of the verdict director instruction at the instruction conference and instead only proposed an alternative instruction, which was denied. Because they failed to object to the submission, Appellants failed to preserve any claim of error. Nevertheless, the court exercised its discretion to conduct a plain error review and determined that all five disjunctives were proper ultimate facts and denied the Appellants' claim of error, concluding that no manifest injustice occurred.

On their second point on appeal, Appellants argued plaintiff’s expert’s cause of death opinion lacked sufficient factual support, was unreliable, and should not have been admitted. They claimed the expert failed to consider all relevant facts and did not provide physical evidence linking Vyvanse to K.P.’s death. The court cited an "obvious problem" with the expert’s opinion, in that there was no evidence presented of the physical effects of Vyvanse on K.P.’s cardiovascular system, the expert failed to identify all the scientifically plausible causes of death, and the expert ignored uncontested evidence of K.P.’s various comorbid conditions. However, the court found the opinion was supported by substantial other evidence, to which defendants failed to object, including the death certificate, medical examiner’s report, medical records, family testimony, medical literature, and warnings from Vyvanse’s FDA packaging materials. The court concluded that even if the expert’s differential diagnosis methodology was deficient and his opinion unreliable, the overall evidence was sufficient to uphold the judgment, as the error did not materially affect the outcome. Thus, the court denied Appellants' challenge to the expert’s cause of death opinion testimony.

On defendants' third point on appeal, the court found that the trial court acted within its discretion by admitting K.P.'s death certificate into evidence, as it is considered prima facie evidence of the facts it states, including the cause of death. Additionally, the long-form investigative report from the St. Louis County Medical Examiner’s Office, which included the death certificate's information and more details, was also admitted without objection. Since the death certificate’s information was cumulative of other evidence that was admitted without objection, Appellants could not demonstrate that its admission caused them any prejudice.

As mentioned above, the jury awarded plaintiff $5 Million in compensatory damages but chose not to award any damages for aggravating circumstances. In their fourth point on appeal, Appellants argued that the consideration of aggravating circumstances might have tainted the jury’s decision on the amount of compensatory damages awarded. The court did not reject the argument outright, or indicate that the improper submission of a claim for aggravating circumstances damages could not constitute reversible error in a case such as this where the jury awarded only compensatory damages. However, the court found the argument lacked specific factual or legal support and was therefore speculative and noted that the trial court reduced the compensatory damages to $801,061 due to the medical malpractice liability limitations in Section 538.210. Considering the lack of concrete evidence of prejudice, the court found the issue of aggravating circumstances damages moot. The defense does not appear to have cited specific evidence and argument in the record submitted in support of the aggravating circumstances claim or argued that the improper admission of this claim tainted the jury such that it believed compensatory damages were a foregone conclusion and that its only real decision was whether to also award aggravating circumstances damages. This appears to have been information the court was looking for to fully analyze the issue but failed to find any in the record on appeal.