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Because patients are typically anesthetized during their procedures, and members of the surgical team rarely concede negligence, attorneys representing injured patients are left to reconstruct and reverse engineer the surgery and assemble circumstantial evidence" /> <meta name="robots" content="max-image-preview:large" /> <meta name="keywords" content="anesthetized,attorney,circumstantial evidence,complexity,direct proof,exclusive control,expert review,expert testimony,foreign body cases,inherent risk,intraoperative injury,malpractice,malpractice suits,medical malpractice,medico-legal theory,negligence,patient,remote injury,res ipsa,res ipsa loquitor,surgery,surgical team,unanticipated injury,unconscious" /> <link rel="canonical" href="https://nclawyersweekly.com/2024/09/26/res-ipsa-loquitor-offers-basis-for-many-malpractice-cases/" /> <meta name="generator" content="All in One SEO (AIOSEO) 4.5.7.3" /> <meta property="og:locale" content="en_US" /> <meta property="og:site_name" content="North Carolina Lawyers Weekly |" /> <meta property="og:type" content="article" /> <meta property="og:title" content="Res ipsa loquitor offers basis for many malpractice cases | North Carolina Lawyers Weekly" /> <meta property="og:description" content="By Mark McGrath Patients who wake from surgery with unanticipated and unexplained injuries confront several challenges when they bring malpractice suits. Because patients are typically anesthetized during their procedures, and members of the surgical team rarely concede negligence, attorneys representing injured patients are left to reconstruct and reverse engineer the surgery and assemble circumstantial evidence" /> <meta property="og:url" content="https://nclawyersweekly.com/2024/09/26/res-ipsa-loquitor-offers-basis-for-many-malpractice-cases/" /> <meta property="article:published_time" content="2024-09-26T09:00:49+00:00" /> <meta property="article:modified_time" content="2024-09-25T16:11:08+00:00" /> <meta name="twitter:card" content="summary" /> <meta name="twitter:title" content="Res ipsa loquitor offers basis for many malpractice cases | North Carolina Lawyers Weekly" /> <meta name="twitter:description" content="By Mark McGrath Patients who wake from surgery with unanticipated and unexplained injuries confront several challenges when they bring malpractice suits. Because patients are typically anesthetized during their procedures, and members of the surgical team rarely concede negligence, attorneys representing injured patients are left to reconstruct and reverse engineer the surgery and assemble circumstantial evidence" /> <script type="application/ld+json" class="aioseo-schema"> {"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/nclawyersweekly.com\/2024\/09\/26\/res-ipsa-loquitor-offers-basis-for-many-malpractice-cases\/#article","name":"Res ipsa loquitor offers basis for many malpractice cases | North Carolina Lawyers Weekly","description":"By Mark McGrath Patients who wake from surgery with unanticipated and unexplained injuries confront several challenges when they bring malpractice suits. 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<h2 class="news-page-header">Res ipsa loquitor offers basis for many malpractice cases </h2> <p class="subtitle-text mobile-show" style="font-size: 18px; line-height: 26px;"> </p> <div class="news-publish-info"> <p><a href="https://nclawyersweekly.com/author/nclawyersweeklystarff/"><b>North Carolina Lawyers Weekly Staff</b></a><span>//</span>September 26, 2024<span>//</span><b><span class="bsf-rt-reading-time"><span class="bsf-rt-display-label" prefix=""> </span> <span class="bsf-rt-display-time" reading_time="8"></span> <span class="bsf-rt-display-postfix" postfix="Minute Read"></span></span></b></p> </div> </div> </div> <div class="article-detail-page container">  <div class="row">  <div class="col-sm-9"> <div class="newsdetail-wrapper"> <div class="breadcrumb"> <a href="/">Home</a><span>></span><a href="https://nclawyersweekly.com/category/news/">News</a><span>></span><a href="https://nclawyersweekly.com/category/news/commentary/">Commentary</a><span>></span><p>Res ipsa loquitor offers basis for many malpractice cases</p> </div>  <div class="slideshow desktop-show"> <div class="news-image"> <img fetchpriority="high" width="875" height="463" src="https://nclawyersweekly.com/files/2024/06/McGrath_Mark_Web-875x463.jpg" class="attachment-article-detail-thumb size-article-detail-thumb wp-post-image" alt="Mark McGrath" decoding="async" srcset="https://nclawyersweekly.com/files/2024/06/McGrath_Mark_Web-875x463.jpg 875w, https://nclawyersweekly.com/files/2024/06/McGrath_Mark_Web-304x162.jpg 304w, https://nclawyersweekly.com/files/2024/06/McGrath_Mark_Web-120x62.jpg 120w, https://nclawyersweekly.com/files/2024/06/McGrath_Mark_Web-50x26.jpg 50w" sizes="(max-width: 875px) 100vw, 875px" /> <p class="image-caption">Mark McGrath</p> </div> </div> <h1 class="news-page-header">Res ipsa loquitor offers basis for many malpractice cases </h1> <p class="subtitle-text desktop-show" style="font-size: 18px; line-height: 26px;"> </p> <div class="row"> <div class="col-sm-9 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Email"><img src="https://nclawyersweekly.com/wp-content/themes/hello-elementor/images/email.svg" alt="email"></a></li></ul> </div> </div> <div class="news-detail"><div id="bsf_rt_marker"></div><style>#ra-player {margin-bottom: 1em;} .ra-button {padding: .3em .9em; border-radius: .25em; background: linear-gradient(#fff, #efefef); box-shadow: 0 1px .2em gray; display: inline-flex; align-items: center; cursor: pointer;} .ra-button img {height: 1em; margin: 0 .5em 0 0;}</style> <div id="ra-player" data-skin="https://assets.sitespeaker.link/embed/skins/default"><div class="ra-button" onclick="readAloud(document.getElementById('ra-audio'), document.getElementById('ra-player'))"><img decoding="async" src="https://assets.sitespeaker.link/embed/skins/default/play-icon.png"/> Listen to this article</div></div> <audio id="ra-audio" data-lang="en-US" data-voice="Amazon Joanna" data-key="9a894192b5d95537bb1afa80262745f5"></audio> <script data-cfasync="false" src="/cdn-cgi/scripts/5c5dd728/cloudflare-static/email-decode.min.js"></script><script> </script><p style="text-align: center"><strong>By Mark McGrath</strong> <p>Patients who wake from surgery with unanticipated and unexplained injuries confront several challenges when they bring malpractice suits. Because patients are typically anesthetized during their procedures, and members of the surgical team rarely concede negligence, attorneys representing injured patients are left to reconstruct and reverse engineer the surgery and assemble circumstantial evidence into a compelling medico-legal theory and a tenable narrative of what occurred in the operating room. <div class="box success alignleft" style="width:35%"><div class="box-inner-block"><i class="tieicon-boxicon"></i> <div class="article_dfp_ads"> <div id="div-gpt-ad-in_content_300x250_a" class="div-gpt-ad-in_content_300x250_a in_content_300x250_a dfp_ad_pos"> <script type='text/javascript'> googletag.cmd.push(function () { googletag.display('div-gpt-ad-in_content_300x250_a'); googletag.pubads().collapseEmptyDivs(true); }); </script> </div> </div> <p><em>As in all things that might come up in a malpractice case, there are complexities, advantages and disadvantages to such a [res ipsa loquitor] claim.</em> <p> </div></div> <p>Consider the following scenario: A patient undergoes knee surgery but emerges from the procedure with numbness and weakness in her left hand. Diagnostic tests indicate an ulnar nerve injury to the left elbow and arm. The operative report indicates a textbook procedure with no unexpected events or complications. Members of the surgical team are at a loss to explain the injury. In this scenario, what options are available to plaintiff’s counsel to establish negligence by the patient’s providers? <p style="text-align: center"><strong>Res ipsa loquitor</strong><div class="article_dfp_ads"> <div id="div-gpt-ad-in_content_300x250_b" class="div-gpt-ad-in_content_300x250_b in_content_300x250_b dfp_ad_pos"> <script type='text/javascript'> googletag.cmd.push(function () { googletag.display('div-gpt-ad-in_content_300x250_b'); googletag.pubads().collapseEmptyDivs(true); }); </script> </div> </div> <p>In the example, res ipsa loquitor immediately comes to mind as a potential basis for recovery. As in all things that might come up in a malpractice case, there are complexities, advantages and disadvantages to such a claim. <p>North Carolina courts have traditionally been reluctant to apply res ipsa loquitor to medical negligence cases. For example, the courts have held that res ipsa is not available in the typical malpractice case because most medical treatment involves inherent risk and is of a scientific nature (<em>Bluitt v. Wake Forest Univ.</em> (2018)). Trial courts have been admonished to remain vigilant and cautious about providing res ipsa loquitor as an option for liability in medical malpractice cases other than in those where it has been expressly approved, namely foreign body cases and injuries to a part of the patient’s anatomy outside of the surgical field (<em>Hayes v. Peters</em> (2007); <em>Howie v. Walsh</em> (2005)). Courts also have held that res ipsa malpractice claims must allege facts from which a layperson could infer negligence based on common knowledge and ordinary human experience (<em>Smith v. Axelbank</em> (2012)). <p>Because the viability of a res ipsa claim turns upon the application of common knowledge and ordinary human experience, the use of experts to establish such a claim is disfavored (<em>Diehl v. Koffer</em> (2000)). As a result, where there is a divergence of expert testimony as to the mechanism of an intraoperative injury the doctrine is unavailable to the patient (<em>Bowlin v. Duke University</em>). Moreover, res ipsa loquitor is not available to a plaintiff who offers direct proof of her injury (<em>Yorke v. Novant Health</em> (2008)). Given these limitations, the North Carolina courts have consistently found that res ipsa is inappropriate in the usual medical malpractice case, where the question of injury and the facts in evidence are peculiarly in the province of expert opinion (<em>Robinson v. Duke University Health Systems</em> (2013)). Taken as a whole, the courts have observed that in medical malpractice cases, the doctrine of res ipsa loquitor should be restrictively applied because the average juror is unfit to determine whether a given injury would rarely occur in the absence of negligence (<em>Rowell v. Bowling</em> (2009)). <p style="text-align: center"><strong>Older precedents</strong> <p>Earlier cases, which are still good law, were more receptive to such cases. In <em>Pendergraft v. Royster</em> (1932), the North Carolina Supreme Court allowed a retained foreign object case to go to the jury on a res ipsa instruction. In so holding, the court observed that in operations like the present, the patient is unconscious from the administration of anesthetics. If the principle of res ipsa loquitur did not apply in an action like the present, the patient would be remediless. <p>The North Carolina Court of Appeals in <em>Parks v. Perry</em> (1984) reached a similar conclusion. In <em>Parks</em>, the plaintiff underwent a hysterectomy. Following surgery, she immediately complained of numbness and weakness in the fingers on her right hand. The evidence showed that the patient went into surgery with no neurological defects in her right hand. During her subsequent care and treatment, her physician determined that the plaintiff’s neurological deficits were caused by ulnar nerve damage in her right elbow. Plaintiff’s expert testified that the numbness was the result of improper positioning and monitoring during the plaintiff’s surgery. <p>Citing <em>Pendergraft</em>, the court recognized that the applicability of res ipsa loquitur in a malpractice case, as in all res ipsa loquitor cases, required the plaintiff to establish three elements: <ul> <li>The direct cause of the injury is not available.</li> <li>The instrumentality was under the exclusive control of the defendant.</li> <li>The injury is of a type that does not ordinarily occur in the absence of some negligent act or omission.</li> </ul> <p>The court then observed that the application of the doctrine in medical malpractice cases also requires the plaintiff to prove that the injurious result rarely occur standing alone, and that the injury at issue is not an inherent risk of the procedure. <p>The <em>Parks</em> court held that res ipsa loquitor applied to the case. The court cited testimony from the plaintiff’s expert that the injury to the plaintiff’s fingers was caused by prolonged pressure to her ulnar nerve during surgery, and that ulnar nerve injuries were not a risk of hysterectomy surgery. In support of its holding, the court reasoned that there was no direct proof of the cause of the injury in that the plaintiff was unconscious during the procedure, no member of the surgical team could offer direct evidence of how the injury occurred, and the positioning and monitoring of the plaintiff during surgery was under the exclusive control of the operating room nurse. Thus, the court concluded that the doctrine of res ipsa loquitur applied to the case, and that summary judgment had been improperly granted by the trial court. <p style="text-align: center"><strong>Other situations</strong> <p>North Carolina courts have largely limited application of the doctrine to two situations. First, it remains well-established that res ipsa is available in cases arising from a failure to remove foreign objects at the conclusion of surgery. Thus, a failure to remove a surgical sponge from a patient’s body can support such a claim (<em>Fox v. Green</em> (2003)). Second, when a patient emerges from surgery with an injury to a remote part of the body that is outside the surgical field (<em>Grigg v. Lester</em>, (1991)). In another case, one which does not fall within these categories, the Court of Appeals held that res ipsa was available to a plaintiff when the surgeon connected the patient’s bowel to her vagina during a colectomy procedure (<em>Robinson v. Duke</em> (2013)). <p>Application of res ipsa loquitor has been confined to cases where there is no direct proof of negligence available to the injured patient (<em>Yorke v. Novant Health</em> (2008)). Our courts have further ruled that to prevail on a res ipsa loquitor theory a plaintiff must show, without the assistance of expert testimony, that the injury resulted from the defendant’s negligence, and that the injury was of a kind not typically occurring in the absence of negligence (<em>Howie v. Walsh</em> (2005)). <p>Conversely, courts have allowed expert testimony in the form of a theory as to the mechanism of an intraoperative injury where the injury was not an inherent risk of the procedure, the surgery was in the defendant’s exclusive control, the patient was anesthetized and unable to offer direct evidence of the cause of the injury, and no expert testimony is required to prove that the injuries arose from the defendant’s negligence (<em>Robinson v. Duke</em> (2013)). <p>There are divergent applications of these principles. For example, it has been held that res ipsa was available to a patient who suffered a burn to the hand during adenoid surgery (<em>Schaffner v. Cumberland County Hosp. Syst.</em> (1985)). But the Court of Appeals also has held that res ipsa did not apply when a patient undergoing a cardiac procedure suffered a burn to her back (<em>Bluitt v. Wake Forest</em> (2018)). <p>Even within the two categories accepted by the courts, res ipsa has been sparingly applied. For example, the Court of Appeals has held that where a patient underwent hip replacement surgery and awoke from surgery with severe damage to her sciatic nerve, res ipsa did not apply, notwithstanding expert witness testimony that this complication was extremely rare and virtually unheard of (<em>Fuller v. Negron-Medina</em> (2020)). <p style="text-align: center"><strong>Challenging cases</strong> <p>There is no escaping the fact that surgical malpractice cases present challenges for plaintiffs’ counsel. Grounding a medical malpractice case upon the doctrine of res ipsa loquitor presents an attractive option in malpractice cases. As Rule 9(j)(3) makes clear, res ipsa claims need not conform to the onerous provisions of Rule 9(j), including presuit expert review and certification. From a cost-saving and streamlining perspective, relying on res ipsa loquitor affords plaintiff’s counsel the opportunity to prosecute a simplified and less costly case. Because counsel relying on res ipsa alone need not comply with Rule 9(j), counsel may not need to retain multiple experts, including nurses, certified registered nurse anesthetists, surgeons and anesthesiologists, and have them review all medical records relating to the negligence of the defendants. <p>These advantages must be weighed against the significant risks inherent in pursuing a res ipsa malpractice case. Our courts have repeatedly emphasized that, while res ipsa can provide a basis for a malpractice case, application of the doctrine should be confined to the narrow scenarios recognized by the courts. As a consequence, counsel who rely solely on res ipsa do so at their peril. Pleading res ipsa as an alternative claim is in most cases the prudent play. <p><em>Mark McGrath is a lawyer with Paynter Law in Hillsborough, where he practices personal injury and medical malpractice litigation.</em> </div> <div class="mobile-specific-data"> <div class="share-links"> <p class="share">Share this!</p> <ul class="social-share-links"><li><a class="twitter" href="https://twitter.com/intent/tweet?text=Res+ipsa+loquitor+offers+basis+for+many+malpractice+cases&url=https%3A%2F%2Fnclawyersweekly.com%2F2024%2F09%2F26%2Fres-ipsa-loquitor-offers-basis-for-many-malpractice-cases%2F" target="_blank"><img src="https://nclawyersweekly.com/wp-content/themes/NCLW/images/twitter.svg" alt="twitter"></a></li><li><a class="facebook" href="https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fnclawyersweekly.com%2F2024%2F09%2F26%2Fres-ipsa-loquitor-offers-basis-for-many-malpractice-cases%2F" target="_blank"><img src="https://nclawyersweekly.com/wp-content/themes/hello-elementor/images/facebook.svg" alt="facebook"></a></li><li><a class="linkedin" href="https://www.linkedin.com/shareArticle?mini=true&url=https%3A%2F%2Fnclawyersweekly.com%2F2024%2F09%2F26%2Fres-ipsa-loquitor-offers-basis-for-many-malpractice-cases%2F&title=https%3A%2F%2Fnclawyersweekly.com%2F2024%2F09%2F26%2Fres-ipsa-loquitor-offers-basis-for-many-malpractice-cases%2F" target="_blank"><img src="https://nclawyersweekly.com/wp-content/themes/hello-elementor/images/linkedin.svg" alt="linkedin"></a></li><li><a class="crunchify-link crunchify-pinterest" href="https://pinterest.com/pin/create/button/?url=https%3A%2F%2Fnclawyersweekly.com%2F2024%2F09%2F26%2Fres-ipsa-loquitor-offers-basis-for-many-malpractice-cases%2F&media=https://nclawyersweekly.com/files/2024/06/McGrath_Mark_Web.jpg&description=Res%20ipsa%20loquitor%20offers%20basis%20for%20many%20malpractice%20cases" data-pin-custom="true" target="_blank"><img src="https://nclawyersweekly.com/wp-content/themes/hello-elementor/images/pinterest.svg" alt="pinterest"></a></li><li><a class="email" href="/cdn-cgi/l/email-protection#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" title="Share by Email"><img src="https://nclawyersweekly.com/wp-content/themes/hello-elementor/images/email.svg" alt="email"></a></li></ul> </div> <div class="right-sidebar-mobile"> </div> </div> </div> <div class="related-content-section"><h2>Related Content</h2><div class="related-content"><div class="content-box"><a href="https://nclawyersweekly.com/2024/10/28/how-to-manage-key-stakeholders/"><div class="rc-wrapper "><div class="rc-img"><img width="304" height="175" src="https://nclawyersweekly.com/files/2024/08/Sullivan_Jay_Agorapulse-304x175.jpg" class="attachment-article-list-thumb size-article-list-thumb wp-post-image" alt="Jay Sullivan" decoding="async" /></div><div class="rc-content-wrap"><div class="rc_title_wrap"><h3 class="rc-img-title">How to manage key stakeholders</h3></div><p class="rc-img-content">By Jay Sullivan On a good day, running a law firm is a juggling act. 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