Pyzyk v. Gateway Psychiatric Grp.

694 S.W.3d 583

Debbie PYZYK, Plaintiff/Respondent,

v.GATEWAY PSYCHIATRIC GROUP, LLC & Gordon Robinson, M.D., Defendants/Appellants.

No. ED 111709

Missouri Court of Appeals, Eastern District, DIVISION ONE.

Filed: June 11, 2024

Motion for Rehearing and/or Transfer to Supreme Court Denied July 18, 2024

Application for Transfer Denied September 3, 2024

Appeal from the Circuit Court of the City of St. Louis, Cause No. 1922-CC00398, Honorable Clinton R. Wright, Judge

FOR APPELLANT: Jeffrey E. Atkinson, 714 Locust Street, St. Louis, MO 63101.

FOR RESPONDENT: John G. Simon, Kevin M. Carnie Jr., Patrick R. McPhail, 800 Market Street, Suite 1700, St. Louis, MO 63101.

Cristian M. Stevens, J.

Introduction

Gateway Psychiatric Group and Dr. Gordon Robinson (collectively, "Appellants") appeal the trial court’s judgment in favor of plaintiff Debbie Pyzyk in a medical malpractice lawsuit following the death of Pyzyk’s daughter, K.P. On appeal, Appellants argue the trial court erred in submitting a verdict directing instruction that improperly included inconsistent alternative theories of negligence, contained more than ultimate facts, and misdirected, misled, and confused the jury. Second, Appellants argue the trial court erred in admitting Plaintiff’s expert’s opinion testimony regarding K.P.’s cause of death because the testimony did not meet the requirements of Section 490.065. Third, Appellants argue the trial court erred in allowing the introduction of K.P.’s death certificate into evidence without limitation because the medical examiner’s conclusion regarding the cause of death was not based on personal knowledge. Finally, Appellants argue the trial court erred in allowing aggravating circumstances damages to be submitted to the jury because there was no evidence of intentional wrongdoing. We affirm the judgment of the trial court.

Factual and Procedural Background

Facts

Dr. Gordon Robinson is a psychiatrist who began treating K.P. on June 25, 2018. K.P. was admitted to Harris House Treatment and Recovery Center for inpatient treatment of alcohol dependence and Adderall abuse. Dr. Robinson continued treating K.P. until her death on March 16, 2016. K.P. suffered from various health conditions, including alcohol dependence, ADHD, amphetamine abuse, generalized anxiety disorder, bulimia nervosa, and anorexia nervosa.

To treat her alcohol abuse, K.P. previously attended a rehabilitation program in California. At that time, K.P. was off Adderall, an amphetamine she had previously abused. Instead, K.P. took the non-addictive Strattera to treat her ADHD. K.P. returned to St. Louis where she relapsed with alcohol. After the relapse, K.P. was admitted to Harris House where she began receiving treatment from Dr. Robinson.

Dr. Robinson learned that K.P. abused Adderall in the past to continue drinking and to keep weight off, but K.P. was not on amphetamines when she came to Harris House. While treating K.P. at Harris House, Dr. Robinson prescribed Vyvanse (Lizdexamfetamine),¹ an amphetamine. Ini- tially, Dr. Robinson prescribed one dose of 50 mg per day. Dr. Robinson changed the prescription to two doses of 50 mg (a total of 100 mg) per day because the effect of the Vyvanse was wearing off in the afternoon.

Pursuant to FDA guidance, the maximum daily dosage of Vyvanse was 70 mg. The FDA provided a black box warning that Vyvanse was an amphetamine and had significant abuse liability, especially when given at a higher dose. On multiple occasions, Dr. Robinson prescribed Vyvanse to K.P. for months without seeing her. K.P was abusing the Vyvanse and taking more than the prescribed amount. At the height of her Vyvanse abuse, K.P. was taking more than two and a half pills per day, roughly equal to 135 mg, a potentially toxic level.

Following the increase in dosage, K.P. lost weight and developed a picking habit. K.P. picked out her entire eyebrow and had scabs she would not leave alone. Also, the change from a single daily dose to two doses caused problems with K.P.’s medical insurance. The insurance covered only one 30-day supply. K.P. had to pay for the second 30-day supply out of her own pocket. This became a source of tension between K.P. and her mother, Debbie Pyzyk, because neither had the money for the prescription.

One evening, K.P. and her mother got into an argument about paying for a Vyvanse prescription. K.P.’s mother did not want to pay for the prescription. K.P. was extremely agitated and screaming. About fifteen minutes after the argument ended, it got quiet. C.M., K.P.’s fiancé who was also at the house, went to K.P.’s bedroom and found her unresponsive on her bed.² Paramedics arrived and took K.P. to the hospital. A few days later, doctors declared K.P. brain dead. She was 35 years old.

Following K.P.’s death, the St, Louis County Medical Examiner’s Office determined K.P.’s cause of death was an "intraventricular hemorrhage secondary to acute Lisdexamfetamine toxicity." This cause of death was listed on K.P.’s death certificate.

Procedural History

Plaintiff Debbie Pyzyk filed a wrongful death lawsuit alleging that Dr. Robinson was negligent in treating K.P. The case proceeded to trial.

Motion to Strike F.D.’s Testimony

Prior to the start of trial, Appellants filed a motion to strike the testimony of Plaintiff’s expert, F.D. Appellants argued F.D.’s testimony did not meet the requirements of Section 490.065.2 because F.D.’s "opinions are neither supported by sufficient facts or data, nor the product of reliable admissible principles or materials."³ More specifically, Appellants alleged F.D. had never encountered or reviewed a case in which a person had a stroke and died from Vyvanse use. Plaintiff responded that F.D. used the presumptively admissible "differential diagnosis" methodology to conclude K.P.’s stroke and death were caused by Vyvanse.

On January 7, 2023 Appellants filed a renewed motion to strike the expert testimony of F.D. Appellants advanced the same arguments and further challenged the factual basis for F.D.’s opinion. Shortly before F.D.’s trial testimony, Appellants raised their renewed motion to the trial court. Following oral argument, the trial court denied the motion.

Admission of K.P.’s Death Certificate

The medical examiner’s conclusions in K.P.’s death certificate first came up during the trial testimony of C.M., K.P.’s fiancé. Plaintiff’s counsel specifically asked about the death certificate and elicited testimony that C.M. had heard the cause of K.P.’s death was a brain bleed due to Vyvanse use. Appellants did not object to the admission of this testimony.

Then, during Pyzyk’s testimony, Plaintiff’s counsel offered K.P.’s death certificate into evidence. Appellants objected and said the death certificate was not admissible because the medical examiner lacked personal knowledge of K.P.’s cause of death. The trial court initially sustained the objection to the death certificate’s admission. Thereafter, Plaintiff’s counsel asked Pyzyk if she had seen K.P.’s death certificate. Counsel then elicited from Pyzyk that she "saw the words on the death certificate that said the cerebral hemorrhage was secondary to Lizdexamfeta-mine—meaning Vyvanse." This testimony was admitted without objection.

During a recess at the conclusion of Pyzyk’s testimony, Appellants again objected to the admission of K.P.’s death certificate. Appellants argued the medical examiner "did not have any independent knowledge of the case. The cause of death is a conclusion on her part. It’s an absence of her having had any … personal knowledge." In response, Plaintiff’s counsel cited Johnson v. Missouri Board of Nursing Administrators, 130 S.W.3d 619 (Mo. App. W.D. 2004), for the proposition that "a certified copy of a death certificate is prima facie evidence of the facts stated therein and is generally admissible both to prove death and to offer some evidence as to the immediate cause of death." Plaintiff argued that K.P.’s death certificate was certified and thus admissible. On these grounds, the trial court admitted the death certificate.

Aggravating Circumstances

Shortly before trial, Appellants moved to strike Plaintiff’s claim for aggravating circumstances damages for failure to allege sufficient facts to state a claim. Appellants argued that Plaintiff’s claims amounted to only negligence and "there [was] simply no evidence of intentional wrongdoing."

After Appellants rested their case-in-chief, they orally raised their motion to strike the claim for aggravating circumstances damages. Appellants argued the testimony and exhibits did not demonstrate willful, wanton, or malicious conduct by Dr. Robinson when he prescribed Vyvanse to K.P. In response, Plaintiff argued that Dr. Robinson knew of K.P.’s prior amphetamine and alcohol abuse and still prescribed Vyvanse to K.P. Plaintiff also argued that Dr. Robinson knowingly prescribed more than the maximum daily dosage of Vyvanse suggested by the FDA and that Vyvanse’s manufacturer warned Dr. Robinson not to exceed the maximum daily dosage. Finally, Plaintiff pointed to Dr. Robinson’s admission that he changed K.P.’s medical records a few years after she died.

The trial court denied Appellants’ motion to strike and submitted aggravating circumstances damages to the jury. The jury rendered a verdict 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. Ultimately, the jury declined to award aggravating circumstances damages.

Instruction 9

At the instruction conference, Appellants proposed a verdict directing instruction regarding Dr. Robinson’s alleged negligence to replace Instruction 9, the verdict directing instruction submitted by Plaintiff. Appellants argued that Instruction 9, as drafted, contained impermissible evidentiary detail instead of containing only ultimate facts for the jury’s decision.

Instruction 9, as submitted by Plaintiff,...