Case Note – When common law medical negligence instruction given, no need for separate failure to consent instruction (Horsley vs. Dr. Kenneth Smith and KS Eyeworks, COA Published, 2/13/2015)

New Adair County Judicial Center, Columbia, Kentucky.

New Adair County Judicial Center, Columbia, Kentucky.

COA affirmed jury verdict in favor of defendant, Dr. Kennth R. Smith and KS Eyeworks in a medical negligence and informed consent claim. The basic facts were that Dr. Smith advised he should have cataract surgery on both eyes, explained the risks, and indicated he would anesthetize the eyes either with eye drops or an injection. Surgery on right eye was successful with Dr. Smith injecting the anesthetic which was his usual practice. Surgery on the second eye did not go so well when the needle ruptured a blood vessel in Horsley left eye resulting in blindness in the left eye.

The allegation in the complaint were common law negligence and informed consent. The informed consent claim was based upon Dr. Smith not explaining the alternative risks of eye drops versus injections.  After a 3-day trial, the jury returned a defense verdict.

The complaint stated:

4. [I]t was the duty of [Dr. Smith] to exercise that degree of learning, skill, ability, care, attention, diligence, prudence, common sense and vigilance ordinarily possessed by physicians, surgeons and ophthalmologists, practicing under the same or similar circumstances and to obtain [Horsley’s] informed consent regarding the surgical procedures to be performed . . . .

5. [Dr. Smith was] negligent in the care and treatment of [Horsley] in that [he] failed to use the same degree of skill, diligence and care as is possessed by prudent, skillful, careful and knowledgeable physicians, surgeons and ophthalmologists under the same or similar circumstances and otherwise deviated from the standard of care applicable thereto.

6. [Dr. Smith] failed to obtain [Horsley’s] informed consent regarding the surgical procedures performed upon [Horsley].

7. As a direct and proximate result of [Dr. Smith’s] negligence, deviations from the standard of care and lack of informed consent, [Horsley] sustained severe, permanent and disabling injuries . . . .

The case culminated in a three-day jury trial. Horsley argued both that Dr.
Smith negligently administered the anesthesia, and that he failed to adequately
explain the anesthesia could have been administered by using numbing drops
instead of injection. Horsley claimed that had Dr. Smith made him aware of these alternative methods, his decision to undergo surgery may have been different.

On cross-examination, Horsley’s counsel presented Dr. Smith with a page
from the American Medical Association (AMA) website. Dr. Smith agreed with
the statement there that, depending on the situation, it is appropriate to inform a patient of alternatives to the proposed course of treatment and associated risks.

Dr. Smith admitted further that although there are several ways to administer
anesthesia before cataract surgery, his standard practice was to perform an
injection. While Dr. Smith recalled discussing with Horsley the different ways of
administering anesthesia, he conceded that he did not give Horsley the option of selecting his choice of anesthesia.

Horsley also tendered a second instruction which he attributed to Palmore,
Kentucky Instructions to Juries, Fifth Ed., § 23.10. The instruction stated: “With
respect to disclosing to [Horsley] the risks of the surgical operation he proposed to perform on him, it was the duty of [Dr. Smith] to exercise the degree of care and skill expected of a reasonable competent practitioner specializing in ophthalmology and acting under similar circumstances.” (Plaintiff’s Tendered
Instruction No. 2). Except for the introductory clause regarding disclosing risks, the two proposed instructions are substantively identical. However, Horsley did
not offer this instruction as an alternative, but in addition to the first instruction.

Largely consistent with Horsley’s first instruction and paragraph 4 of his complaint, the circuit court instructed the jury as follows:

It was the duty of Dr. Kenneth Smith in treating Wilbert Horsley to exercise the degree of care and skill of a reasonably competent ophthalmologist acting under similar circumstances. If you are satisfied from the evidence that Dr. Smith failed to comply with this duty, and further satisfied that such failure was a substantial factor in causing the injuries complained of by Wilbert E. Horsley, then you will find Dr. Smith at fault.

The jury found for Dr. Smith. Horsley’s motions for a new trial or judgment notwithstanding the verdict were denied, and the trial court entered judgment in accordance with the verdict. Horsley now brings this appeal.

The COA disagreed with Horsley’s claim the doctor had a duty to alert his patient to alternative anesthesia methods and then the duty to obtain consent.

Specifically, the COA “*conclude[d] that informing the patient of risks and options and obtaining consent to surgery are just a few of the many medical responsibilities expected of physicians who must abide by a standard of care defined by the medical profession itself, the failure of which constitutes the breach of a legal duty. All such medical responsibilities can be adequately addressed in a single duty instruction. They always have been and they were in this case.”*

With but one exception which we shall discuss later [Oghia v. Hollan, 363 S.W.3d 30 (Ky. App. 2012)], we have never deviated from the approach in VanMeter, but followed it through an evolving jurisprudence and despite legislative tinkering (as also discussed infra). As discussed below, we have steadfastly applied the bare-bones approach and stuck with a single instruction defining the whole duty of the physician to his patient whether the breach alleged was a physician’s:

(1) “failure to consider the history given by the patient[,]” Mackey v. Greenview Hosp., Inc., 587 S.W.2d 249, 254 (Ky. App. 1979);

(2) “failure to timely diagnose and treat” the patient’s disease, Dennis v. Fulkerson, 343 S.W.3d 633, 634 (Ky. App. 2011);

(3) “improperly administer[ing] anesthesia[,]” Cohen v. Alliant Enters., Inc., 60 S.W.3d 536, 538 (Ky. 2001) (citing Copeland v. Humana of Kentucky, Inc., 769 S.W.2d 67 (Ky. App. 1989);

(4) “failure adequately to inform the patient” of risks associated with treatment, Keel v. St. Elizabeth Medical Ctr., 842 S.W.2d 860, 862 (Ky. 1992);

(5) “negligence . . . in performing the surgery[,]” Engle v. Clarke, 346 S.W.2d 13, 15 (Ky. 1961).

(6) “improper treatment[,]” Johnson v. Vaughn, 370 S.W.2d 591, 597 (Ky. 1963);

(7) “get[ting] beyond the field of the operation and injur[ing] some sound portion of the patient’s body not involved in the operation,” Fields v. Rutledge, 284 S.W.2d 659, 661 (Ky. 1955); or

(8) “negligence . . . in postoperative care[,]” Engle v. Clarke, 346 S.W.2d 13, 15 (Ky. 1961).

In none of these cited cases did the court give a separate jury instruction, specific to the identified medical responsibility, to supplement the general legal duty instruction. A second, more specific instruction risks improperly “giv[ing] undue prominence to certain facts and issues.” Fields, 284 S.W.2d at 662.

However, Horsley points us to a particular passage in Campanell “that instructions should not blend distinct legal concepts. Liability can be premised separately based on lack of informed consent and deviation from the standard of care.” Id. We interpret this bit of unpublished dicta consistently with established case law and our analysis that lack of informed consent is not a separate tort. At most, this passage is an unartful way of saying what was first said more than a hundred years ago in VanMeter, supra.

The COA spent a significant portion of their efforts in affirming the defense verdict addressing what some refer to as a malpractice crisis and Defendant’s expert Dr. Smith who sent newspaper articles to Horsley anonymously and then testified falsely at trial.  The Trial Court’s sanction of denying a default judgment but ordering the disclosure of the false testimony was admissible at trial.

COA affirmed the defense verdict.

Click on “continued reading” for the full text of the opinion.

Appeals: Preserving error on appeal (instructions, manifest injustice, as applied to judge issues re unjust enrichment and piercing the corporate veil

The following published decision addresses the failure to preserve error on appeal relative to instructions.  The issues surrounded preserving the error, manifest injustice; within the context of unjust enrichment and piercing the corporate veil. 

JAN. 20, 2012

Killian also argues that the trial court erred in allowing a jury instruction on unjust enrichment. Although it is unclear, it appears that Killian is arguing that, by allowing the jury instruction on unjust enrichment, the trial court implicitly pierced the corporate veil, allowing Killian to be held personally liable.

The unjust enrichment jury instruction read as follows: INSTRUCTION NO. 6
Are you satisfied from the evidence that:

a) That SJK, SK Development, LLC and Steven Killian have each benefitted, and have continued to benefit economically by the acquisition of Settlers Trace and that such acquisition would not have been possible unless Tunacakes had agreed to enter into the Consulting Agreement with SJK;
b) That SJK, SK Development, LLC and Steven Killian have each benefitted, and continued to benefit economically by the [sic] purchasing Settlers Trace and that said acquisition would not have been possible unless Tunacakes accepted the Promissory Note from SJK;
c) SJK, SK Development, LLC and Steven Killian, continue to use, possess and/or otherwise enjoy the benefits of an income producing business and property, which would not have been available, but for Tunacakes’ acceptance of the payment terms of the Consulting Agreement and Promissory Note; and
d) To prevent unjust enrichment, SJK, SK Development, LLC and Steven Killian, are jointly and severally liable for full restitution to Tunacakes in amounts now due and owing under the payment terms of the Consulting Agreement and Promissory Note.

Initially, we note that Killian’s brief fails to include a statement on how he preserved this issue for appeal as required by Kentucky Rule of Civil Procedure (CR) 76.12(4)(c)(v). It is not the burden of the Court to search the record to find proof of the Appellants’ claims. See Phelps v. Louisville Water Co., 103 S.W.3d 46, 53 (Ky. 2003). Having carefully reviewed the record, we note that this issue was not preserved for review because Killian did not timely object to the unjust enrichment instruction. Pursuant to CR 51(3), the time to object to jury instructions is prior to the court instructing the jury. As stated in Harris v. Thompson, 497 S.W.2d 422, 431 (Ky. 1973), “if the appellants were not satisfied with any phase or portion of the instructions the time to speak was before they were given to the jury.” Further, “a general objection without specification is insufficient to preserve the [alleged] error.” Burgess v. Taylor, 44 S.W.3d 806, 814 (Ky. App. 2001).

A review of the record reflects that Killian made an objection to the jury instruction on unjust enrichment, but only argued that Tunacakes had not presented sufficient evidence to support a finding of unjust enrichment. Killian did not argue that, by allowing an unjust enrichment instruction, the trial court would be implicitly finding that the corporate veil should be pierced. Although it does appear that Killian raised this issue in his motion to alter, amend or vacate the judgment, an objection to a jury instruction raised for the first time in a post-trial
motion is not timely. Burgess, 44 S.W.3d at 814. Therefore, this issue is not properly preserved for our review.

Because this issue was not properly preserved, our review is confined to manifest injustice. As set forth in Carrs Fork Corp. v. Kodak Min. Co., 809 S.W.2d 699, 701 (Ky. 1991):
Civil Rule 61.02 provides that palpable error which affects the substantial rights of a party may be considered by the reviewing court even though insufficiently raised or preserved for review and appropriate relief may be granted upon a determination that manifest injustice has resulted from the error. In applying this rule, the palpable error must result from action taken by the court rather than an act or omission by the attorneys or litigants.
Further, manifest injustice exists only if the error “so seriously affected the fairness, integrity, or public reputation of the proceeding as to be ‘shocking or jurisprudentially intolerable.’” Commonwealth v. Jones, 283 S.W.3d 665, 668 (Ky. 2009) (quoting Martin v. Commonwealth, 207 S.W.3d 1, 4 (Ky. 2006)). We believe that the jury instruction on unjust enrichment resulted in a manifest injustice.

First, we note that any jury instruction on unjust enrichment is improper because unjust enrichment is an equitable doctrine, Dodson v. Key, 508 S.W.2d 586 (Ky. 1974), and the application of an equitable doctrine to the facts of a case is a question of law. Daniels v. CDB Bell, LLC, 300 S.W.3d 204, 210 (Ky. App. 2009). Accordingly, the question of whether Killian, SK Development, and SJK Properties were unjustly enriched, if it were an appropriate inquiry, should not have been decided by the jury but by the trial court.

Next, we note that unjust enrichment is not an available remedy to Tunacakes with regard to SK Development and SJK Properties. The doctrine of unjust enrichment “is applicable as a basis of restitution to prevent one person from keeping money or benefits belonging to another.” Haeberle v. St. Paul Fire & Marine Ins., 769 S.W.2d 64, 67 (Ky. App. 1989) (citations omitted). However, when “an express contract is made defining the circumstances under which an obligation may arise with reference to a certain subject matter such contract excludes the possibility of an implied contract concerning the same matter.” Sparks Milling Co. v. Powell, 283 Ky. 669, 672, 143 S.W.2d 75, 76 (1940). Therefore, any recovery must be under the terms of the express contract. Id. In this case, there was a written contract that set forth the obligations of SK Development and SJK Properties to Tunacakes. Thus, unjust enrichment was not an available remedy for Tunacakes as to SK Development and SJK Properties.

Finally, we conclude that unjust enrichment, as used in this case, imposed personal liability on Killian thereby piercing the corporate veil. As noted by this Court in Daniels, 300 S.W.3d at 211, “piercing the corporate veil” is “the judicial act of imposing personal liability on otherwise immune corporate officers, directors, and shareholders for the corporation’s wrongful acts, . . .” (Quoting 18 C.J.S. Corporations § 14 (2008)). “[T]he decision as to whether to pierce the corporate veil is an equitable one to be decided by the trial court and not the jury.” Id. at 213.

Based on the preceding, Killian could not be held personally liable until the trial court determined that the corporate veil could be pierced. Having carefully reviewed the record, we note that the trial court did not make such a finding. Absent such a finding, the unjust enrichment instruction, which allowed the jury to hold Killian personally liable for the liabilities of SK Development and SJK Properties, resulted in a manifest injustice. Accordingly, we remand this case for the trial court to determine whether the corporate veil can be pierced. If the corporate veil cannot be pierced, then a finding that Killian was unjustly enriched would be inappropriate because Killian cannot be held personally liable. If the trial court determines that the corporate veil can be pierced, then there need not be a determination as to whether Killian was unjustly enriched. Killian would be personally and contractually liable for the wrongful acts of SK Development and SJK Properties. As previously noted, because Tunacakes would have contractual remedies, the equitable remedy of unjust enrichment would not apply.

JURY INSTRUCTIONS: Civil case, separate instructions for past and future pain and suffering; and what about ‘inconvenience’

The following decisions, albeit unpublished, addressed a common thread on pain and suffering, past and future, but bypassed the interesting question and issue as to whether on not the statutory prescription in the no fault act (which includes inconvenience) requires that exact phrase in the instructions as it goes to the jury.   Of course, the side-step is not unwarranted, but judicial clarification has not been a problem before.

See earlier post at the Kentucky Law Review by me entitled:  "Trial Practice: No Pain, No Gain and the Judicial Discounting of Pain and Suffering" back in 2006 and "Zero Pain and Suffering Verdict With Ky AG Candidate on the Defense" from 2007; and "DAMAGES: PTSD and mental anguish resulting from death of a loved one in the same car accident seems to be a noncompensable damage in UIM case even when the claimant has been physically injured from the accident" from 2008.

And, of course, here is KRS 204.39-060(2)(b):

In any action of tort brought against the owner, registrant, operator or occupant of a motor vehicle with respect to which security has been provided as required in this subtitle, or against any person or organization legally responsible for his or her acts or omissions, a plaintiff may recover damages in tort for pain, suffering, mental anguish and inconvenience because of bodily injury, sickness or disease arising out of the ownership, maintenance, operation or use of such motor vehicle . . . . (from 1975!).


Regarding her first assertion of error, Ferguson relies exclusively on McVey v. Berman, 836 S.W.2d 445 (Ky. App. 1992), for this proposition. In McVey, the Court said “[o]f course, it may be appropriate in many cases to give an additional separate instruction on future pain and suffering.” Id. at 450. The language therein is permissive not mandatory. Since Ferguson provides no other Kentucky law mandating separate instructions for past and future pain and suffering and has shown no prejudice resulting from this action by the trial judge, there is no error on the part of the trial judge.

Next, Ferguson argues that the jury instructions should have had the words “inconvenience,” “increased likelihood of future complications,” and “loss of enjoyment of life” in them. Given that we have held that the trial court did not err in failing to grant a motion for directed verdict or a motion for a judgment notwithstanding a jury verdict, clearly any error resulting would be harmless. The jury never deliberated as to damages and, therefore, it is unnecessary for us to go further in our examination of this issue.

STDS of REVIEW: Appellate review of jury instructions in civil case

12/22/2011 COA

With regard to the review of jury instructions, any errors in jury instructions are considered as questions of law and are reviewed by this Court de novo. Hamilton v. CSX Transportation, Inc., 208 S.W.3d 272, 275 (Ky. App. 2006).

Instructions: Missing Evidence Instruction aka Spoliation of Evidence

Questions Presented:
Personal Injury. Jury Instructions. Missing evidence. Issues include propriety of giving spoliation instruction and other evidentiary and instructional rulings.

CASE NOS. 2007-CA-000018-MR AND 2007-CA-000133-MR

We granted discretionary review in this matter to examine when it is
proper for the trial court to give a missing evidence instruction, and whether it was permissible here to hold an employer liable for punitive damages based upon the gross negligence of an employee. University Medical Center, Inc. d/b/a University of Louisville Hospital ("University Hospital"), appeals from an opinion of the Court of Appeals which affirmed a judgment entered by the Jefferson Circuit Court in favor of Appellee, Michael G. Beglin. 1Based upon a jury verdict, the trial court entered judgment awarding the following
compensatory damages: $1,922,102.00 for the destruction of Jennifer Beglin's power to labor and earn money; 367,358.09 for her medical expenses; 7,543.00 for her funeral and burial expenses; and $3,000,000.00 for her children's loss of parental consortium. The jury also awarded $3,750,000.00 in punitive damages, resulting in a total award of $9,047,003.09.


University Hospital first argues that the trial court erred by giving the missing evidence instruction in connection with the unexplained disappearance of the occurrence report that Cantrall testified she prepared immediately following the operation pursuant to normal hospital procedures. Although University Hospital had exclusive care, custody, and control of the report (if it existed), it is unable to offer any explanation to account for its disappearance. University Hospital contends that it was fundamentally improper and contrary to Kentucky law for the trial court to give the missing evidence instruction when -there was no evidence to show that it had intentionally and in bad faith lost or destroyed the document. It further argues that the instruction improperly influenced both the general verdict of liability and the punitive damages award by insinuating that the hospital covered-up adverse evidence. For the reasons stated below, we conclude that the instruction was properly given.

Following the form approved in Sanborn v. Commonwealth, 754 S.W.2d 534, 539-540 (Ky. 1988), overruled on other grounds by Hudson v. Commonwealth, 202 S.W.3d 17 (Ky. 2006), the trial court gave, over the hospital's objection, this missing evidence instruction:
If you find from the evidence that an incident report was in fact prepared by Nurse Barbara Cantrell recording material information about Mrs. Beglin's surgery, and if you further find from the evidence that University Medical Center, Inc. d/b/a University of Louisville Hospital, intentionally and in bad faith lost or destroyed the incident report, you may, but are not required to, infer that the information recorded in the incident report would be, if available, adverse to University Medical Center and favorable to the plaintiffs.

This remains the approved instruction in both criminal and civil cases.    See Monsanto Co. v. Reed, 950 S.W.2d 811, 815 (Ky. 1997) ("Where the issue of destroyed or missing evidence has arisen, we have chosen to remedy the matter through evidentiary rules and 'missing evidence' instructions.") All agree that the Sanborn instruction accurately sets forth the elements necessary to permit a jury to draw an adverse inference from missing evidence. 6

Standards of Review: Appellate review of jury instructions

From Harstad v. Whiteman, COA, Published 3/4/2011:

“Alleged errors regarding jury instructions are considered questions of law that we examine under a de novo standard of review.” Hamilton v. CSX Transp., Inc., 208 S.W.3d 272, 275 (Ky. App. 2006). Kentucky follows the “bare bones” rule of jury instructions and gives latitude for attorneys to flesh out the details in their arguments. Cox v. Cooper, 510 S.W.2d 530, 535 (Ky. 1974).

From Leighton v. CSX, COA, Published 3/11/2011

Alleged errors regarding jury instructions are questions of law that we examine de novo. Reece v. Dixie Warehouse & Cartage Co., 188 S.W.3d 440, 449 (Ky. App. 2006). The purpose of an instruction is to furnish guidance to the jury in their deliberations and to aid them in arriving at a correct verdict. If the statements of law contained in the instructions are substantially correct, they will not be condemned as prejudicial unless they are calculated to mislead the jury. Ballback’s Adm’r v. Boland-Maloney Lumber Co., 306 Ky. 647, 652-53, 208 S.W.2d 940, 943 (1948).

Stds of Review: Jury instructions

From Stamper v. Hyden, COA, Published, 2/18/2011

The Kentucky Supreme Court has addressed appellate review of instructional error as follows: The rule is that generally an erroneous instruction is presumed to be prejudicial to appellant, and the burden is upon appellee to show affirmatively from the record that no prejudice resulted; and when the appellate court cannot determine from the record that the verdict was not influenced by the erroneous instruction, the judgment will be reversed. Drury v. Spalding, 812 S.W.2d 713, 717 (Ky. 1991), quoting Prichard v. Kitchen, 242 S.W.2d 988, 992 (Ky. 1951) (internal quotation marks omitted.).