Third-party cases pose liability risks to doctors

A column analyzing the impact of recent court decisions on physicians

By Alicia Gallegoscovered legal, antitrust, fraud and liability issues during 2010-13. Connect with the columnist: @legal_med  —  Posted Sept. 26, 2011.

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The Utah Supreme Court is reviewing whether the children of a patient can sue their father's physician for medication mismanagement after the patient shot his wife to death. In a similar case, the Supreme Court of Georgia has ruled that a psychiatrist can be sued for medication negligence after a patient fatally attacked his mother.

The cases raise concerns about doctors' potential liability for criminal actions committed by their patients and what duty, if any, physicians owe to nonpatients. Experts say the cases remind doctors to take note of circumstances that could increase their liability risk to third parties.

In the Georgia case, the father of Victor Bruscato filed a lawsuit on behalf of Victor against psychiatrist Derek O'Brien, MD. He alleged that the doctor's discontinuation of Bruscato's two antipsychotic medications aggravated his son's violent tendencies. After the drugs were stopped, Bruscato, a mentally ill patient with a history of violence, stabbed his mother to death.

Dr. O'Brien had ordered two of Bruscato's medications stopped for six weeks to rule out the possibility that Bruscato was developing neuroleptic malignancy syndrome, according to court documents. A trial court dismissed the case in favor of Dr. O'Brien, ruling that public policy does not allow the Bruscatos to benefit from any wrongdoing, namely the killing of Lillian Bruscato. The appeals court reversed the decision.

In its Sept. 12 opinion, the Supreme Court affirmed, allowing the lawsuit to proceed. Though public policy prevents profiting from a wrongdoing in court, an exception exists if a mentally ill patient isn't aware of what he is doing, the court said. Bruscato was never found guilty of a crime; instead, he was ruled incompetent to stand trial and committed to a state mental hospital.

In the Utah case, a guardian for David Ragsdale's children sued family physician Hugo Rodier, MD; nurse Trina West; and Pioneer Comprehensive Medical Clinic in 2010. He claimed that medical staff improperly administered medication to Ragsdale, leading to the killing of his wife, Kristy Ragsdale, in 2008.

West allegedly prescribed Ragsdale various psychotropic drugs, antidepressants and steroids without consulting Dr. Rodier or warning Ragsdale of the side effects, according to the lawsuit. In general, nurses in Utah have prescribing rights under certain circumstances.

Attorneys for the doctor argued that the children had no standing to sue because of no patient relationship with medical personnel. In addition, Ragsdale pleaded guilty, precluding the family from proving that he killed his wife due to his medication, they said.

Dr. Rodier never saw the patient nor was he asked to consult about the medications, said Vaun Hall, the doctor's attorney. Dr. Rodier denied any wrongdoing. West also claimed no wrongdoing, said Stephen Owens, her attorney.

A lower court found in Dr. Rodier's favor. The family appealed. Because of the public policy issues at stake, the Utah Supreme Court agreed to hear the case, bypassing an appellate review. Oral arguments are scheduled for Nov. 2.

Foreseeable dangers

If the Ragsdale family is allowed to sue, the decision could change the way physicians treat patients, said Hall, attorney for Dr. Rodier.

"There is well-established law -- and this is iron clad throughout the country -- that the physician's first and foremost duty is to his patient and to do what's in the best interest of that patient," he said. Requiring a duty to third parties "would change the type of care [doctors] render, because now they would have to worry about all the others impacted by their care."

Tyler Young, attorney for the plaintiffs, said the case is not about changing the law but clarifying who is allowed to sue for medical negligence.

"If the plaintiffs are not able to sue, then the message is: Doctors can go ahead and do things that have an effect on a third party, and no matter how extreme the treatment, that third party will never have a right to sue because of your poor care," he said.

State laws differ on situations in which physicians are responsible to third parties. But most say doctors owe a duty to nonpatients only if it is foreseeable they are endangered, said Phillip J. Resnick, MD, psychiatry professor and director of the Division of Forensic Psychiatry at Case Western Reserve University in Ohio.

For example, if a physician provides a sedative to a patient and fails to warn about the risk of operating a vehicle, the doctor could be held liable if the patient drives and another motorist is injured, he said.

The same goes for a doctor who fails to report to authorities a patient with a communicable disease. If another person contracts the disease, the physician faces potential liability, he said.

Generally, doctors also have a responsibility to nonpatients in cases of wrongful death. Heirs can sue a doctor believed to have caused the patient's death.

Most mental health specialists are bound by stricter regulations, called Tarasoff duties. These duties stem from a 1976 California Supreme Court case that established a legal duty to protect third parties from a psychiatric patient's foreseeable violence. They require mental health workers who hear patients making explicit threats about an identifiable person to take steps to warn that person.

"If your patient is at risk of harming another person, whether it be from a communicable disease or from being sleepy at the wheel, the doctor has a duty not only to his patient, but can be sued if a third person is harmed," Dr. Resnik said. "The question is: How far does the doctor's responsibility go out? It can't be stretched so far that the doctors are getting stuck with something they couldn't really foresee."

Relationship at risk?

The Litigation Center for the American Medical Association and the State Medical Societies along with the Utah Medical Assn. filed a joint friend-of-court brief in the Ragsdale case, expressing concern about its potential consequences.

"Recognizing the duty to nonpatients advocated by appellants would divert health care providers' focus from their patients and would vastly increase the number of potential litigation adversaries," the brief said. "Health care providers would undoubtedly be dissuaded from treating certain patients or conditions because of the tremendous uncertainty and potential for exposure. This would negatively affect the provision of health care ... and be particularly harmful to under-served groups of patients."

A ruling for the plaintiffs also would clash with the fundamental precepts of medical ethics and treatment, said Mark Brinton, general counsel for the UMA.

"It would create conflicts with physician-patient privacy by giving nonpatients rights to patients' records to pursue their claims. Furthermore, it would reduce the availability of health care resources in the state while increasing the cost of health care and the burden on the courts," he said.

The AMA is not involved in the Georgia case. An attorney for Dr. O'Brien declined to comment. The Medical Association of Georgia was not involved in the case but said it was "disappointed" in the ruling.

"This is now another avenue for increased litigation," said Donald Palmisano Jr., executive director of MAG. "By allowing this case to proceed, you're going against longstanding public policy in Georgia. What's going to prohibit others from following the same course?"

In the Georgia case, William G. Quinn, the lawyer for the Bruscatos, said he hopes the ruling will reinforce the importance of recognizing unstable patients and making knowledgeable treatment decisions.

"If you have a violent patient, the standard of care is going to require you to seriously look at your medication adjustments and make prescribing decisions in a reasonable fashion," he said. "When you are dealing with a complex case and violent history, you've got to know the patient, know the history, know the likely results. So that you've covered your bases, it never hurts to seek a collegial assessment with a more experienced colleague."

A patient has a right to be protected, Quinn said, "even from himself."

Alicia Gallegos covered legal, antitrust, fraud and liability issues during 2010-13. Connect with the columnist: @legal_med  — 

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External links

Vito Bruscato v. Derek O'Brien, Supreme Court of Georgia (link)

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