Midland State Bank v. United States

634 F.Supp.3d 498

MIDLAND STATE BANK, as guardian of the minor childrenand independent administrator of the Estate of Julia Castellanos, deceased, Plaintiff, v. UNITED STATES of America, Defendant.

No. 18-cv-02775

United States District Court, N.D. Illinois, Eastern Division

Signed September 30, 2022

Gary D. McCallister, McCallister Law Group, LLC, Chicago, IL, Judson Michael Graham, Judson Graham Firm LLC, Chicago, IL, Marc Emery McCallister, Cavanagh Law Group, Chicago, IL, Eric I. Unrein, Cavanaugh, Biggs, and Lemon, Topeka, KS, for Plaintiff.

Megan Elizabeth Donohue, Assistant United States Attorney, Chicago, IL, AUSA, Prashant Kolluri, Virginia Ovitz Hancock, Michael D. Claus, United States Attorney's Office, Chicago, IL, for Defendant.

MEMORANDUM OPINION AND ORDER

Franklin U. Valderrama, United States District Judge

On the afternoon of November 16, 2015, Julia Castellanos (Julia), 27 years old and 38 weeks pregnant, was shopping with her sister Gloria Castellanos (Gloria) for baby supplies when she noticed that she was bleeding. Gloria drove Julia to Mount Sinai Hospital, where Julia underwent an emergency Cesarean (C-section) procedure performed by Dr. Lemuel Shaffer (Dr. Shaffer). Disastrously, Julia's anesthesia provider, Certified Registered Nurse Anesthetist (CRNA) Mary Kammann (CRNA Kammann), intubated Julia in the esophagus rather than in the trachea, causing a deprivation of oxygen to Julia's brain. So, while the surgical team was delivering Julia's baby, Julia's vital signs plummeted, and she died a few days later. Plaintiff Midland State Bank (Midland), as guardian of Julia's minor children and independent administrator of her estate, filed this wrongful death and survival action against the United States of America (United States) pursuant to the Federal Tort Claims Act, 28 U.S.C. § 2671, et seq., the Illinois Wrongful Death Act, and the Illinois Survival Act. R. 30, Am. Compl.¹ Midland alleges that Dr. Shaffer was negligent for, among other things, failing to be aware of Julia's vital signs during the C-section operation.

The Court held an eight-day bench trial beginning December 7, 2021, during which both fact and expert witnesses testified. See R. 132-39. Having considered the trial evidence and the parties' post-trial submissions, see R. 58, Defendant's Proposed Findings of Fact and Conclusions of Law (DPFFCL); R. 59, Plaintiff's Proposed Findings of Fact and Conclusions of Law (PPFFCL), the Court enters the following findings of fact and conclusions of law. See Fed. R. Civ. P. 52(a)(1) ("In an action tried on the facts without a jury or with an advisory jury, the court must find the facts specially and state its conclusions of law separately."). These findings are informed by the Court's credibility assessment of witnesses and the Court's weighing of the evidence. See Johnson v. United States, 65 F. Supp. 3d 595, 598 (N.D. Ill. 2014). As detailed below, the Court finds that Midland has not met his burden of proof on liability and enters judgment in favor of the United States.

I. Findings of Fact

"In a bench trial or hearing without a jury, the district court judge acts as both gatekeeper and factfinder." Goodpaster v. City of Indianapolis, 736 F.3d 1060, 1068 (7th Cir. 2013). The following findings of fact are based on the evidence submitted at trial and the parties' stipulated facts. See Bernal v. NRA Group, LLC, 2017 WL 4948544, *4 (N.D. Ill. 2017). To the extent that any findings of fact may be considered conclusions of law, they shall be deemed conclusions of law. The same is true with respect to conclusions of law which may be deemed findings of fact. See id. See also In re. Lemmons & Company, Inc., 742 F.2d 1064, 1070 (7th Cir. 1984) ("The labels of fact and law assigned by the trial court are not controlling.").

a. The Parties

Plaintiff Midland is a citizen and resident of Yorkville, Kendall County, Illinois and is the duly appointed Guardian of the Minor Children and Independent Administrator of the Estate of Julia Castellanos, deceased, pursuant to the orders of the Circuit Court of Cook County, Illinois, Probate Division dated January 13, 2017. R. 106, Stip. ¶ 1.

The defendant is the United States, which is statutorily deemed to have employed Dr. Lemuel Shaffer because Dr. Shaffer worked at Access Community Health Network, a federally qualified healthcare center. Stip. ¶ 2.

b. Julia

Julia is the daughter of Jose and Alba Castellanos, and she was a first-generation American born into a family with proud Guatemalan heritage. Tr. 923-24, 1051-52, 1067. Julia grew up in the Chicagoland area and attended Lane Tech High School, where she participated in, among other activities, Acapella Choir and a dance club that would perform folkloric dance in the community. Tr. 492-94; Pl. Exh. 57; Pl. Exh. 58. Julia was a member of the Reserve Officer Training Corps (ROTC) all four years of high school and entered numerous competitions. Tr. 494. In November 2015, Julia lived with her sisters, Albita and Gloria, her parents, Alba and Jose, her 22-month-old son, Daniel, Jr. (Junior), and her long-term partner, Daniel Klein (Klein) in a three-flat home in Cicero, Illinois. Tr. 63-64, 67.

c. Julia's Admission to Mount Sinai Hospital

On the afternoon of November 16, 2015, Julia, who was 27 years old and 38 weeks pregnant, was shopping with Gloria at Target for diapers when Julia noticed she was bleeding. Tr. 71. Gloria immediately drove Julia to the labor and delivery (L&D) department at Mount Sinai Hospital (Mount Sinai), where Julia had been receiving treatment from her obstetrician, Dr. Shaffer. Tr. 68-69, 71. Julia and Gloria arrived at Mount Sinai at approximately 7:00 p.m., and Julia checked into the L&D department at approximately 7:18 p.m. Tr. 74; Pl. Exh. 71. Coincidently, Dr. Shaffer came in for Mount Sinai's obstetrical service evening shift at 7:00 p.m. Tr. 261, 1143.

After checking in, Julia was taken to a triage room, while Gloria remained in the waiting room on the L&D floor. Tr. 74, 156, 990-91; Joint Exh. 1. At 7:35 p.m., Julia texted Gloria that her contractions were getting closer, and that she was still waiting to see a doctor. Tr. 74-75. At 7:39 p.m., Julia texted Gloria again, saying that she had been informed that the doctor would take a few more minutes to see her. Id.

d. Working Diagnosis of Suspected Placental Abruption

Dr. Kanika Sood (Dr. Sood), the chief obstetrics and gynecology resident at Mount Sinai, was alerted to an "emergent situation," which led her and Dr. Shaffer to assess Julia. Tr. 260, 266-67. When Dr. Sood and Dr. Shaffer arrived at Julia's triage room, Julia was bleeding and Julia's fetal monitor showed decelerations and bradycardic (abnormally low) fetal heart rate. Tr. 267, 1151, 1380-81.

Drs. Sood and Shaffer suspected placental abruption. Tr. 268, 269, 1151. A placental abruption occurs when the placenta prematurely separates from the uterine wall. Tr. 268-69. Because the placenta provides the baby with oxygen from the mother (by way of blood passing from the uterus), placental abruption was a potentially life-threatening condition for the baby. Tr. 808, 1234-36. Placental abruption was also potentially life-threatening for Julia because it is associated with bleeding and hemorrhage. Tr. 1234-36. Dr. Shaffer, as the on-call attending obstetrician, made the call to perform an emergency C-section because of the grave risk that placental abruption presented to Julia and her baby. Tr. 1160, 1234-37 Joint Exh. 1 at JC0108. Dr. Shaffer took Julia to the operating room and the obstetrics department called a "Code Quick," which alerts hospital staff to the fact that there is an emergency, and that assistance is needed at a particular location. Tr. 285-86; Def. Exh. 20 at 20-21. The Code Quick requires certain providers to respond, including nursing staff, obstetrician-gynecologists, and a member of the anesthesia team. Def. Exh. 20 at 20.

e. Emergency C-Section Procedure

The surgical team for Julia's C-section procedure assembled in the operating room. The team included Nurse Yvonne Green, scrub tech Renata Neal, Drs. Shaffer and Sood, and CRNA Kammann. Tr. 189, 193, 203, 260, 1162. In the operating room, CRNA Kammann connected Julia to the anesthesia equipment, which included the "Aespire View," the anesthesia machine, and the "CareScape," a patient monitor. Tr. 105-06, 211. The patient monitor provides the real time parameter data of the patient to the clinician, and it provides both audible and visual alarms if certain limits are exceeded for those parameters. Tr. 589.

CRNA Kammann stood near Julia's head and the patient monitor showing Julia's vital signs. Tr. 392-93, 1242. Drs. Shaffer and Sood stood on either side of Julia's abdomen, with Dr. Shaffer on Julia's left and Dr. Sood on Julia's right. Tr. 290, 297, 1237-41. Neal stood closer to Julia's feet to pass surgical instruments to the surgeons. Tr. 201, 205-06, 209-10, 291. A surgical drape separated Dr. Sood, Dr. Shaffer, and Neal from CRNA Kammann, at the head of the bed. Tr. 209-10, 295-97, 1238-39. The drape was clipped to two IV poles that were on either side of the hospital bed, and it rose to about the height of Dr. Shaffer's eyes. Tr. 209, 296, 387-88, 1238-41. The surgical drape is non-transparent, made of water-resistant material, and used to both keep the operative field sterile and to prevent spatter onto the anesthesia provider. Tr. 205, 213, 298, 1238-39. Due to the surgical drape, the surgeons and Neal were unable to see the anesthesia monitor. Tr. 209, 296-97, 1240-41.

Julia's emergency C-section procedure began at approximately 8:00 p.m. Tr. 302. CRNA Kammann gave Julia 200 milligrams of Propofol, an anesthetic that induces unconsciousness. Tr. 174, 1385; Joint Exh. 1 at JC0209. After administering the Propofol, CRNA Kammann gave Julia 200 milligrams of Succinylcholine, a paralytic that facilitates intubation. Tr. 175, 1326-27, 1385; Joint Exh. 1 at JC0209. CRNA Kammann then intubated Julia...