Missouri Medical Negligence Cases: Causation and Rebuttal Evidence

A St. Louis area healthcare clinic and its nurse were held responsible for medical negligence by a Missouri jury. Nurse prescribed medication to a patient without proper warning to discontinue use of the medication if a rash resulted which was contained in the “black box” warnings of the medication the nurse should have been aware of or looked up. The patient suffered a known side effect of the medication, a rash, and the nurse treated the patient for the rash without advising her to stop taking the medication that was causing the rash in the first place. The side effects of the original medication progressed into severe rashes and hospitalization.

The personal injury lawsuit resulted in verdict in favor of the patient, the clinic and the nurse appealed the judgment and claimed evidence errors by the court should require a new trial. Essentially, the clinic’s lawyers claimed the Judge in the original Missouri medical negligence case should have never let the case get to the jury in the first place arguing the medical malpractice lawyers did not make a case because:

  1. the Patient did not prove causation and
  2. the Court improperly allowed rebuttal evidence by patient.

The Missouri Court of Appeals denied both arguments and upheld the verdict.


In any personal injury case an injured party must show 1. liability (fault of the defendant) 2. Causation (the actions caused the injury) and 3. damages from the injuries. The appeal in this case was about # 2 causation. Huelskamp v Patients First Healthcare court stated:

“In order for Plaintiff to have made a submissible case on her medical malpractice claim against Defendant, she must have proven that Defendant’s employee, Nurse King, failed to use the degree of skill and learning ordinarily used under the same or similar circumstances by members of her profession, i.e., breached the standard of care [….liability….]and that Nurse King’s negligent act or acts directly caused or directly contributed to cause Plaintiff’s injuries.” [….. causation ….]

The victim testified that had she been told by the nurse to stop taking the medication that caused the rash that she would have. Additionally, the patient also testified that had she been told to contact another nurse about whether or not to continue the medication she would have done that as well.

The defense claimed this is not adequate causation because the other nurse gave the patient the same advice.

“….here there was evidence Plaintiff was unaware of the information about her medical condition (that she should discontinue Lamictal or call Nurse Neubauer in the event of a rash) on December 4, 2008 when she contacted Nurse King. Although Nurse Neubauer testified she had told Plaintiff to stop taking the Lamictal and call Nurse Neubauer if Plaintiff developed a rash, Plaintiff testified at trial that she did not remember Nurse Neubauer giving her any warnings about taking Lamictal.

Defendant’s argument in this portion of its first point on appeal is essentially that Plaintiff should not be able to recover from Nurse King because Plaintiff was at fault for failing to stop the Lamictal on her own. Defendant had an opportunity to raise this issue with the jury by offering a comparative fault instruction but chose not to do so. Additionally, even though Defendant did not offer such an instruction, it argued in closing that Plaintiff was solely at fault for her injuries because she did not follow Nurse Neubauer’s advice. The jury’s verdict concluding that Nurse King’s negligent conduct directly caused or directly contributed to cause Plaintiff’s injuries indicates that the jury rejected Defendant’s attempt to fault Plaintiff.”

Essentially, the defendants’ arguments of no causation were really comparative fault arguments, that the patient was partially or fully responsible for not taking other actions but that the causation was still there. For this reason and the reasons discussed by the court above the verdict was affirmed on the causation argument.

Rebuttal Evidence:

The Patient did not testify about what she would have done if instructed by the nurse until after the defense put on their case. Typically, once a party puts on their evidence and rests they are often done submitting evidence. Unless the defense brings up a new topic and then the Court cam allow the patient to testify again to answer new evidence or arguments brought up by the defense, this is called rebuttal evidence.

Whether or not to allow rebuttal evidence is one of those areas of trial practice that the Court of Appeals with not overturn a case on unless there is an “abuse of discretion” by the trial judge. Essentially, the trial judge has to make a pretty big mistake for the appeals court to correct it.

“To the extent that Plaintiff’s rebuttal testimony should still have been offered in Plaintiff’s case in chief, it was within the trial court’s considerable discretion to admit the testimony. See Aliff v. Cody, 26 S.W.3d 309, 316 (Mo. App. W.D. 2000) (a trial court has considerable discretion in admitting rebuttal evidence which was available and should have been offered in plaintiff’s case in chief).”

The court of appeals grants the trial court broad discretion on how to conduct their trials as they sit through the entire case and are best situated to make on the spot procedural decisions about how the trial proceeds. As long as the decision is not an abuse of the courts discretion the court and unduly prejudice one side, the appeals courts will support the trial judge’s decisions.