Causation: Barnes v. GBMC 2

The Baltimore Medical Malpractice Blog continues with part two of this series on a Maryland appellate opinion in a medical malpractice case. The case is Barnes v. Greater Baltimore Medical Center, Inc. (GBMC), 210 Md. App. 457 (2013). It is a reported opinion by the Court of Special Appeals of Maryland (now the Appellate Court of Maryland). This post focuses on the sufficiency of expert witness testimony on the issue of causation in this medical malpractice case. Specifically, whether an injured party provided enough evidence to prove that emergency department delays directly caused a severe stroke.

In part 1, I discussed how prior sworn testimony saved a lawsuit from late challenges regarding expert certificates.

After a jury awarded over $1.12 million to an injured individual and spouse, the trial judge set aside the verdict by granting a Judgment Notwithstanding the Verdict (JNOV). However, the Court of Special Appeals reversed that decision and reinstated the complete jury award. This post breaks down how expert medical testimony connects systemic delay to preventable brain injury.

Factual Background

A patient experienced sudden right-side weakness, numbness, and grip failure on January 26, 2005. Recognizing signs of a transient ischemic attack (TIA) or mini-stroke, a primary care physician instructed the individual to go to the hospital right away. The primary doctor gave the family a note ordering an urgent “stroke work up”.

Upon arrival, an initial triage nurse noted the life-threatening risk, marked the patient as priority one, and attached the doctor’s note. However, a second triage nurse altered the routing form. This nurse lowered the priority rating to four and sent the individual to urgent care instead of the main emergency room.

In urgent care, an emergency physician failed to read the note and misdiagnosed the condition as carpal tunnel syndrome. The facility discharged the individual. Shortly after, a vigilant staff nurse realized the mistake, leading the facility to recall the patient.

The individual returned hours later for testing. The second attending doctor recommended hospital admission for complete evaluation. However, administrative delays prevented an official admission, and the facility discharged the individual after midnight. Later that afternoon, the individual suffered a catastrophic, disabling stroke.

Lawsuit

The family sued the hospital, the first emergency doctor, and the medical group. At trial, the jury awarded $1,123,000 in total damages. Afterwards, the trial judge overturned the verdict by granting a JNOV to the defense, ruling that the evidence failed to prove causation. The injured party promptly appealed.

Timeline of Key Events:

• Primary Visit: Primary care doctor orders urgent stroke workup, and the patient is sent immediately to the hospital.
• First ER Arrival: Initial nurse assigns Priority 1, but a second nurse downgrades the patient to Priority 4, routing them to urgent care.
• Urgent Care Evaluation: Emergency doctor misses TIA signs, diagnoses carpal tunnel syndrome, and discharges the patient home.
• Hospital Recall: Staff catches the error and recalls the patient hours later, but an incomplete workup occurs and no admission is made.
• Following Afternoon: Patient suffers a severe, permanent stroke. A lawsuit is filed, and the jury awards $1.123M.

Parties’ Arguments

The appeal focused entirely on whether the evidence showed a direct link between the medical delays and the ultimate harm.

• The Medical Providers’ Arguments: The hospital and doctor argued that the initial triage delay did not alter the outcome. They claimed two emergency doctors eventually evaluated the patient anyway. Additionally, the defense argued that the patient could not be admitted without authorization from a specific insurance doctor. Since that specific doctor was unavailable, the defense argued that admission was impossible during the first visit. Thus, they claimed the initial delay did not cause the stroke.
• The Injured Parties’ Arguments: The injured party argued that the initial downgrade prevented doctors from recognizing the medical emergency early. They presented expert witness testimony showing that proper routing would have led to immediate admission. Furthermore, their expert explained that standard inpatient care—such as flat bed rest, oxygen, IV fluids, and prompt surgery—would have prevented the stroke.

Court’s Ruling on Causation in Medical Malpractice

The Court of Special Appeals reversed the trial court’s JNOV and reinstated the full jury verdict. The court emphasized that a judge reviewing a JNOV must evaluate the evidence in the light most favorable to the non-moving party. In Maryland, a plaintiff only needs slight evidence rising above speculation to send a case to the jury.

Key Stages of Appellate Review:

1. Trial Court Action: The trial judge granted JNOV and canceled the $1.12M jury verdict.
2. Appellate Court Review: The appellate panel evaluated all trial evidence in the light most favorable to the injured party.
3. Key Findings on Appeal: Expert testimony established a greater than 50% chance of stroke prevention, the triage downgrade hid critical urgency from doctors, and conflicting evidence had to be resolved by the jury.
4. Final Legal Outcome: The appellate court reversed the JNOV and reinstated the full $1.123M verdict.

The appellate panel found that the medical expert provided a solid foundation for causation. The expert testified that any hospital following proper protocols would have admitted the patient right away. She also explained that basic steps like laying the patient flat, giving IV fluids, and performing a timely procedure had a greater than 50% chance of preventing the stroke.

Furthermore, the court rejected the defense claims regarding insurance restrictions. The expert testified that emergency doctors possessed the authority to admit acute neurological cases directly. The panel noted that when evidence conflicts, the jury holds the sole right to choose which witnesses to believe. Therefore, the trial court erred when it overturned the jury’s factual decision.

Commentary by Baltimore Medical Malpractice Lawyer Mark Kopec on Causation in Medical Malpractice

This appellate ruling re-affirms the role of the jury in complex medical cases. Trial judges must not replace a jury’s evaluation of witness credibility with their own views. When an expert witness offers clear, sound testimony based on established medical facts, the jury holds full power to accept those opinions.

From a legal perspective, causation does not require absolute certainty. Instead, a plaintiff must prove that harm was more likely than not caused by the medical departure. Here, the expert clearly explained how early bed rest, hydration, and prompt surgical intervention would have protected blood flow to the brain. This logical medical chain provided exactly what the law requires.

Additionally, the decision prevents hospitals from hiding behind administrative complexity. A facility cannot excuse emergency delays by pointing to insurance approval rules when a patient faces a life-threatening TIA. The court recognized that emergency care standards override procedural obstacles. By reinstating the verdict, the court affirmed that negligent emergency delays carry real accountability.

You can read additional Blog posts on issues involving causation. These include:

• Expert Causation: Kaylor v. Arrisueno
• Causation Expert: Dackman v. Fisher
• Nurse Causation: Adventist v. Mattingly 2
• Paramedic Causation: Coit v. Nappi 2
• ER Causation: Estate of Newton v. Javid

Additionally, you can read verdict reports on other stroke cases:

• Stroke Misdiagnosis $70.8 Million
• Stroke Mismanagement $40 Million

Mark Kopec is a top-rated Baltimore medical malpractice lawyer. Contact us at 800-604-0704 to speak directly with Attorney Kopec in a free consultation. The Kopec Law Firm is in Baltimore and helps clients throughout Maryland and Washington, D.C. Thank you for reading the Baltimore Medical Malpractice Lawyer Blog.