Duval v. United States Department of Veterans Affairs ( 2023 )

United States Court of Appeals
For the First Circuit
No. 21-1650
DENISE DUVAL, Administrator of the Estate of Wilfred Duval,
Plaintiff, Appellant,
v.
UNITED STATES DEPARTMENT OF VETERANS AFFAIRS,
Defendant, Appellee.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MASSACHUSETTS
[Hon. Leo T. Sorokin, U.S. District Judge]
Before
Kayatta, Howard, and Thompson,
Circuit Judges.
Traver Clinton Smith, Jr., with whom Law Offices of Traver
Clinton Smith, Jr., was on brief, for appellant.
Michael L. Fitzgerald, Assistant United States Attorney, with
whom Rachael S. Rollins, United States Attorney, and Eve A.
Piemonte, Assistant United States Attorney, were on brief, for
appellee.
June 1, 2023
HOWARD, Circuit Judge. Denise Duval, as the
administrator of her father's estate, urges us to conclude that
the district court abused its discretion by declining to strike
expert witness testimony at a bench trial, testimony that she
contends fell outside the scope of an expert's pretrial
disclosures. She consequently asks that we vacate the judgment of
the district court in favor of the government and remand for a new
trial. Finding that any ostensible error committed by the district
court was harmless, we affirm the judgment.
I.
In this case, our review follows a bench trial, and so
"[o]ur recitation of the facts is drawn from the [d]istrict
[c]ourt's findings of fact and conclusions of law." Emhart Indus.,
Inc. v. U.S. Dep't of the Air Force, 988 F.3d 511, 515 n.1 (1st
Cir. 2021); see Duval v. United States, No. 18-10405, 2021 WL
5701770 (D. Mass. July 20, 2021) (district court opinion). Our
focus is trained principally on the portions of the record most
relevant to Duval's argument on appeal that the government violated
expert discovery rules by introducing an allegedly previously
undisclosed theory on the fifth day of trial -- namely, that a
suture used by medical providers on her father migrated from its
intended location.
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A.
This appeal arises from a medical malpractice action
that Duval brought against the U.S. Department of Veterans Affairs
under the Federal Tort Claims Act ("FTCA"), 28 U.S.C. §§ 1346(b),
2671-2680. Duval alleged that providers at the West Roxbury
Veterans Affairs Medical Center ("VA") negligently performed a
percutaneous coronary intervention ("PCI") on her father, Wilfred
Duval, in March 2015. Wilfred Duval died just under a year after
the operation; his daughter brought this action as the
administrator of his estate.
Wilfred Duval, then an 84-year-old resident of
Claremont, New Hampshire, was hospitalized in February 2015 after
suffering a heart attack. He was diagnosed with
"severe . . . coronary artery disease" after a cardiac
catheterization procedure and was then transferred to the VA for
further evaluations. Because of his age and multiple
comorbidities, medical providers at the VA recommended -- and
Wilfred Duval agreed to -- the following two-step process to treat
his coronary artery disease: first, a "minimally invasive direct
coronary artery bypass" procedure ("MIDCAB"), and then a PCI. The
MIDCAB procedure was completed without complications and is not at
issue in this appeal.
Dr. Ioannis Chatzizisis and Dr. Sammy Elmariah performed
the PCI approximately a week after the MIDCAB. As the district
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court explained, "[a] PCI is a procedure used to reestablish normal
blood flow to the heart. The procedure involved inserting a
catheter into Mr. Duval's right femoral artery[,] . . . guiding
the catheter towards the heart, and deploying a stent in Mr.
Duval's left main coronary artery." Both parties agree that the
providers successfully deployed the stent. Instead, the crux of
Duval's medical malpractice claim stems from the providers' use of
a Perclose Proglide device to suture the hole through which they
inserted the catheter for the procedure. The district court
credited Dr. Elmariah's testimony that he and Dr. Chatzizisis
followed "the proper steps for deployment of the device." Indeed,
the district court noted that the providers found no external
bleeding around the site of the insertion point -- the presence of
which could have indicated improper deployment of the suture --
and Wilfred Duval more generally "appeared stable at the end of
the procedure."
However, Wilfred Duval's blood pressure subsequently
dropped to "concerning[,] if not dangerous[,]" levels in the hours
following the completion of the PCI, and a computerized tomography
("CT") scan later indicated retroperitoneal bleeding -- namely,
"internal bleeding from the site at which the doctors had entered
Mr. Duval's artery with [a] needle." Dr. Naren Gupta then
performed emergency surgery on Wilfred Duval -- having received
his daughter's consent for the operation -- and located the
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Perclose suture not at the hole through which the catheter was
originally inserted, but rather in Wilfred Duval's external
oblique muscle.1 The surgery successfully stopped the bleeding
and "saved Mr. Duval's life."
Wilfred Duval remained at the VA for nearly three months
after the surgery to receive continual care and was discharged to
Whittier Rehabilitation Hospital in late May 2015. Duval and the
government dispute whether her father's condition improved over
the course of the following months; nevertheless, his lower
extremity vascular disease -- a condition from which he suffered
even prior to the heart attack -- had worsened by October and led
to another hospitalization at the VA. Duval testified that her
father's condition steadily worsened thereafter, and he passed
away in February 2016 "from septic shock due to pneumonia and
chronic respiratory failure." Duval claimed that the "improper
deployment of the Perclose device constitute[d] malpractice
because [the] incorrect placement of the Perclose suture led to
1 There is some confusion as to whether Dr. Gupta found the
device in Wilfred Duval's oblique or rectus muscle. Dr. Gupta's
discharge notes stated that he "saw the Perclose device in the
rectus muscle," but he later clarified during his trial testimony
that this was an error and he had actually found the device in the
external oblique muscle. The relevant portion of Dr. Weinstein's
(the government's expert) report accorded with the discharge
notes' recitation of the facts, as did the district court's
opinion, and we accordingly opt not to alter references to the
rectus or abdominal muscle, since this point is far from
dispositive in this appeal.
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Mr. Duval's retroperitoneal bleed as well as other complications
that ultimately caused his death."
B.
Duval filed this FTCA action in March 2018, seeking
$6,000,000 in damages. The parties submitted dueling expert
witness reports that in part addressed the question of whether the
doctors deviated from the applicable standard of care in deploying
the Perclose device. Most relevantly to this appeal, Dr. Joseph
Weinstein -- the government's expert -- opined that "the failure
of the [Perclose] device to deploy was not a deviation in the
standard of care for the average qualified cardiologist in 2015.
The fact that the device was found in the rectus [muscle] by Dr.
Gupta does NOT denote that there was a deviation from the standard
of care." Dr. Weinstein's report also noted that Perclose devices
have a "failure rate of 7%[,]" which more or less accorded with
trial testimony both from Dr. Elmariah and from Duval's expert,
Dr. Tobia Mercuro. Indeed, Dr. Elmariah testified that the
"failure rate is higher . . . for arteries such as [Wilfred
Duval's], where there's a lot of calcium." Neither party deposed
the other's expert witness before trial, despite being entitled to
do so by Rule 26. See Fed. R. Civ. P. 26(b)(4)(A).
As noted, the district court held a six-day bench trial,
during which the district judge heard testimony from ten witnesses
and admitted over two dozen exhibits. The question of whether the
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suture could migrate from its original location surfaced several
times during the proceedings. First, the government indicated to
the district court during its opening statement that the court
would "hear that . . . the fact that the suture was found in the
abdominal muscle does not mean that it was initially deployed
there." Later that day, government counsel asked Duval's expert,
Dr. Mercuro, on cross-examination whether he knew where Drs.
Elmariah and Chatzizisis had deployed the suture, to which Dr.
Mercuro responded that "if it[] [was] found sutured in the rectus
muscle, that's where it had to be initially deployed." Government
counsel then asked Dr. Mercuro if his opinion was "that it cannot
be the case [that] a suture is deployed in one area, and then
subsequently dislodged," to which Dr. Mercuro responded that "the
suture will not migrate." Most significantly, the government's
expert, Dr. Weinstein, and government counsel had the following
colloquy on the fifth day of trial concerning Dr. Gupta's having
found the suture away from the femoral artery:
Q. How, if at all, does [Dr. Gupta's finding]
indicate how the Perclose was deployed?
A. So it doesn't indicate how the Perclose was
deployed. All it indicates is that the
device, at some point, migrated from the
femoral artery to the place where it was found
at the time of surgery, which was, again,
approximately six hours later.
Q. And how can a Perclose device migrate?
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A. A Perclose device can migrate for several
reasons. One, it could have been deployed
appropriately, and then migrated as a result
of the fact that the vessels that it was
deployed in were severely dozed [sic]. It
could have been deployed [sic] due to patient
movement or being not secured appropriately.
It could have been deployed and then moved
because of the fact that the patient
subsequently did have another angiogram, and
a balloon was placed into the femoral artery
to stop bleeding.
Duval urged the district court to strike this testimony on three
occasions. She first asked the district court to do so shortly
after the colloquy above "on the premise that [Dr. Weinstein was
testifying to] possibilities, but he's not testifying to facts,"
but the district court denied this motion. She again moved to
strike this portion of Dr. Weinstein's testimony later that day,
arguing both that "it was pure speculation," and -- most
importantly for the purposes of this appeal -- that she "had no
warning" and "never knew [Dr. Weinstein] was going to testify [to]
that . . . [because] [i]t wasn't disclosed." The district court
denied this motion without prejudice. Finally, in her proposed
findings of fact and conclusions of law, Duval included a passage
striking the relevant testimony.
C.
The district court ultimately found in the government's
favor on Duval's claims because it concluded "that there was no
malpractice." Applying Massachusetts medical malpractice law --
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as is mandated by the FTCA, see 28 U.S.C. § 1346(b)(1) -- the court
concluded that Dr. Elmariah "was skilled, experienced, and
meticulous[,] and that he appropriately supervised Dr. Chatzizisis
during the PCI and in the deployment of the Perclose device."2 See
Parr v. Rosenthal, 475 Mass. 368, 376 (2016) ("To state a claim
for medical malpractice, a plaintiff must demonstrate [in part]
that . . . the defendant physician was negligent, which in medical
malpractice cases means that the physician committed a breach of
the 'standard of care and skill of the average member of the
profession' practicing in his or her specialty." (quoting Bradford
v. Baystate Med. Ctr., 415 Mass. 202, 206 (1993))). While "[t]here
is no doubt that the suture did not successfully and permanently
seal the hole in Mr. Duval's artery," the district court noted
that -- as discussed in Dr. Weinstein's expert disclosures -- "the
Perclose device has a known failure rate . . . [and] Dr. Elmariah
testified that the failure rate is higher for arteries with
substantial calcium deposits, such as Mr. Duval's artery."
Ultimately, the court concluded that Duval did not prove
malpractice with regard to the deployment of the Perclose device
by a preponderance of the evidence because "the evidence
demonstrates that the technique employed (selection of the
2 The district court also rejected Duval's argument that
delays in diagnosing the retroperitoneal bleed in the aftermath of
the PCI deviated from the standard of care, but this aspect of the
court's opinion is not at issue on appeal.
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Perclose device) met the standard of care and that the physicians
complied with the standard of care in their implementation of the
technique (the deployment of the Perclose device)." As further
discussed below, the court also addressed the suture-migration
issue in a footnote to its opinion but did not purport to resolve
the dispute over the legitimacy of the theory.3
Having found that Duval failed to prove a breach of the
standard of care, the district court entered judgment in favor of
the government. This appeal followed.
II.
As noted, the sole challenge Duval advances on appeal
concerns the admission of Dr. Weinstein's challenged testimony in
the context of the government's expert witness disclosure
obligations. We review the admission of expert testimony for abuse
of discretion. Gay v. Stonebridge Life Ins. Co., 660 F.3d 58, 61
(1st Cir. 2011). "Pursuant to that standard, 'embedded findings
of fact are reviewed for clear error, questions of law are reviewed
de novo, and judgment calls are subjected to classic abuse-of-
discretion review.'" Martínez v. United States, 33 F.4th 20, 27
3 The court also stated in its opinion that "[n]either party
objected to expert testimony on this matter as beyond the scope of
the expert reports." This observation appears to be inconsistent
with Duval's second motion to strike and her proposed findings.
But Duval does not advance any argument in her briefs on appeal
that the district court erred in making the statement, and has
therefore waived any argument to that effect.
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(1st Cir. 2022) (quoting Lawes v. CSA Architects & Eng'rs LLP, 963
F.3d 72, 90 (1st Cir. 2020)).
But our inquiry does not end there. Even "[i]f we
determine that the testimony was erroneously admitted, we [still]
then review that admission for harmless error." Gay, 660 F.3d at
62. "Our harmlessness inquiry is whether . . . [the] admission of
the evidence affected plaintiff's substantial rights. The central
question is whether this court can say with fair assurance that
the judgment was not substantially swayed by the error." Dusel v.
Factory Mut. Ins. Co., 52 F.4th 495, 512 (1st Cir. 2022) (ellipsis
in original) (quoting Gay, 660 F.3d at 62); see also Fed. R. Civ.
P. 61 ("Unless justice requires otherwise, no error in admitting
or excluding evidence -- or any other error by the court or a party
-- is ground for granting a new trial . . . . At every stage of
the proceeding, the court must disregard all errors and defects
that do not affect any party's substantial rights.").4
4 Duval at least partly predicates her arguments against
harmlessness on Rule 37(c)(1)'s instruction to district courts
that "[i]f a party fails to provide information or identify a
witness as required by Rule 26(a) or (e), the party is not allowed
to use that information or witness to supply evidence on a motion,
at a hearing, or at a trial, unless the failure was substantially
justified or is harmless." The government contends that Rule
37(c)(1) is "inapposite" because "the district court found no
violation of Rule 26(a), and therefore had no occasion to consider
sanctions under Rule 37."
The government has the better of the argument. Our cases
suggest that the standard prescribed in Gay controls in appeals
like Duval's of alleged abuses of discretion in admitting expert
testimony. This standard originates from Kotteakos v. United
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III.
A.
"Recognizing the importance of expert testimony in
modern trial practice, [Rule 26] provide[s] for extensive pretrial
disclosure of expert testimony." Lawes, 963 F.3d at 90
(alterations in original) (quoting Thibeault v. Square D Co., 960
F.2d 239, 244 (1st Cir. 1992)). "Plaintiffs and defendants alike
must identify their expert witnesses and produce their experts'
States, 328 U.S. 750, 765 (1946) ("But if one cannot say, with
fair assurance, after pondering all that happened without
stripping the erroneous action from the whole, that the judgment
was not substantially swayed by the error, it is impossible to
conclude that substantial rights were not affected." (emphasis
added)), and is rooted in the Federal Rules of Civil and Criminal
Procedures' harmless-error provisions, id. at 757 n.9. By
contrast, the factors we incorporate into our review of a district
court's decision to order preclusion under Rules 26 and 37 differ
from the standard prescribed in Gay. See, e.g., Martínez, 33 F.4th
at 34 (noting that factors we assess in reviewing a district
court's decision to order total preclusion of an expert's testimony
based on failure to comply with discovery obligations include "(1)
the history of the litigation; (2) the sanctioned party's need for
the precluded evidence; (3) the sanctioned party's justification
(or lack of one) for its late disclosure; (4) the opponent-party's
ability to overcome the late disclosure's adverse
effects[;] . . . and (5) the late disclosure's impact on the
district court's docket" (quoting Esposito v. Home Depot U.S.A.,
Inc., 590 F.3d 72, 78 (1st Cir. 2009))); Lawes, 963 F.3d at 92
("As to [appellant's] quarrel with the district court's sanction
[of preclusion], the question 'is not whether we would have imposed
the same sanction. Rather, the question is whether the district
court's action was so wide of the mark as to constitute an abuse
of discretion.'" (quoting Macaulay v. Anas, 321 F.3d 45, 51 (1st
Cir. 2003))). We nevertheless note that at least the D.C. Circuit
has incorporated harmlessness under both Rule 37 and Rule 61 into
its analysis in a similar scenario. See, e.g., Muldrow ex rel.
Estate of Muldrow v. Re-Direct, Inc., 493 F.3d 160, 167-68 (D.C.
Cir. 2007).
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reports by court-approved deadlines." Id. (citing Fed. R. Civ. P.
26(a)(2)(A)-(B)). Most relevant to this appeal is Rule
26(a)(2)(B)(i), which requires expert witness reports to include
"a complete statement of all opinions the witness will express and
the basis and reasons for them."
As noted above, Duval contends that Dr. Weinstein's
report ran afoul of the "complete statement" requirement by
omitting the migration theory that surfaced at trial. She points
us to the district court's statement in its opinion that "[n]either
expert report discussed whether a Perclose suture can migrate post-
deployment" as evidence for this proposition. More specifically,
she argues that Dr. Weinstein's statement in his report that "the
failure of the device to deploy was not a deviation in the standard
of care for the average qualified cardiologist in 2015" could not
have alerted her to the theory that the suture had migrated post-
deployment, as subsequently discussed at trial. For its part, the
government counters with the subsequent sentence in Dr.
Weinstein's opinion, which read, "[t]he fact that the device was
found in the rectus sheath by Dr. Gupta does NOT imply that there
was a deviation from the standard of care." Citing to our decision
in Gay for the proposition that experts are entitled to
"reasonabl[y] elaborat[e]" on previously disclosed opinions at
trial, 660 F.3d at 64, the government argues that Dr. Weinstein's
migration-focused testimony merely constituted "a reasonable
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explanation of his opinion that the location of the suture did not
imply negligence in its deployment."
B.
Despite the parties' ample briefing on the subject, this
dispute need not detain us. We ultimately conclude that, even
assuming that Duval is correct in her contention that the district
court erred in admitting Dr. Weinstein's migration-focused
testimony, any error was harmless. As noted above, the focus of
our harmlessness inquiry at this juncture is to ensure ourselves
that "the judgment was not substantially swayed by the error."
Gay, 660 F.3d at 62 (quoting Rubert–Torres v. Hosp. San Pablo,
Inc., 205 F.3d 472, 480 (1st Cir. 2000)). This review is meant to
provide "a check upon arbitrary action and essential unfairness in
trials," and not a "multiplicity of loopholes which any highly
rigid and minutely detailed scheme of errors . . . will engender
and reflect in a printed record." Kotteakos, 328 U.S. at 760; see
also Shinseki v. Sanders, 556 U.S. 396, 407 (2009) ("We have
previously warned against courts' determining whether an error is
harmless through the use of mandatory presumptions and rigid rules
rather than case-specific application of judgment, based upon
examination of the record.").
Here, we are unconvinced that any ostensible error in
admitting Dr. Weinstein's testimony "substantially swayed" the
judgment below. Duval contends that "[t]he Government offered no
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other expert testimony on negligence than the 'migration' theory,
and therefore offered no negligence defense other than [that]
theory." But, as noted above, our harmlessness inquiry focuses on
the district court's reasoning, and we do not have any indication
that the court relied on Dr. Weinstein's challenged testimony in
a way that would fundamentally call its bottom-line conclusion
(i.e., that Drs. Elmariah and Chatzizisis did not breach the
standard of care) into question. Cf. Dusel, 52 F.4th at 512 ("In
this case, we can say with such assurance that neither the district
court's judgment nor our de novo review was affected by any alleged
error as neither court relied on the evidence that [appellant]
disputes.").
To be sure, Duval's case is distinguishable from Dusel,
a case in which the challenged evidence was duplicative of other
materials in the record, and in any case "neither the district
court's holding nor our . . . review relie[d] on" it. Id. Here,
by contrast, the district court stated that it "considered" Dr.
Weinstein's testimony "that sutures can migrate in certain
conditions . . . in determining Dr. Elmariah's credibility, as
well as in determining whether proper procedure was followed by
Dr. Elmariah and Dr. Chatzizisis in deploying the Perclose device."
But the district court similarly stated that it considered the
testimony of Duval's expert that a suture will not migrate once
deployed as well. And, as the government stresses, the district
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court apparently found no need to resolve that disagreement.
Rather, it focused on the device's failure rate even when properly
used -- noting testimony that "the failure rate is higher for
arteries with substantial calcium deposits, such as Mr. Duval's
artery" -- and highlighted evidence that the device was properly
used in this case, such as the facts that "Mr. Duval did not
display external bleeding after the doctors used the Perclose
device and the doctors did not observe any puffiness or swelling
around his groin area, both of which would have been indicators
that the Perclose device did not correctly deploy." On this
record, we cannot conclude that any error in admitting Dr.
Weinstein's testimony "substantially swayed" the district court's
judgment. Cf. Gay, 660 F.3d at 64 (reasoning that admitting
testimony that allegedly was beyond the scope of an expert report
was harmless when that "testimony [could not] reasonably be
understood as the pivotal evidence that tipped the verdict in favor
of [appellee]").
Duval responds that the district court could not have
concluded that the doctors complied with the standard of care
without also concluding that the suture migrated, given that the
suture was found in the rectus muscle. Duval thus infers that the
district court did in fact conclude that the suture migrated, even
though the court did not explicitly resolve that matter.
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But this inferential reading of the court's opinion
could apply just as well to the expert disclosure made by the
government. In acknowledging where the device was found while
expressly rejecting any claim that that fact meant that the
attempted deployment was negligent, the expert disclosure itself
-- if read in the same way Duval reads the court's opinion --
implied that migration must be possible. All that is to say that
if we read the district court as implicitly accepting that
migration was possible, then we should similarly read the
government's expert disclosure. So Duval's only developed
rejoinder to the government's harmlessness argument would
undermine her argument that she was unfairly surprised by the
migration theory at trial.5 This -- paired with the fact that
plaintiff's counsel expressed no surprise when government counsel
mentioned migration in opening, or even when the migration
testimony was first offered -- further supports our above
5 To be clear, to the extent that Duval meant to use the
relevant portion of her brief as an argument that the court erred
under Massachusetts law in concluding that the doctors' deployment
of the Perclose device did not deviate from the standard of care,
we deem any such argument waived for lack of development. Cf.
United States v. Zannino, 895 F.2d 1, 17 (1st Cir. 1990) ("[I]ssues
adverted to in a perfunctory manner, unaccompanied by some effort
at developed argumentation, are deemed waived."). Duval did not
cite to a single case in support of this proposition in the
relevant section of her brief. See United States v. Freitas, 904
F.3d 11, 21 (1st Cir. 2018) (applying Zannino waiver to an argument
for which appellant "neither cite[d] any precedent nor explain[ed]
the lack of precedent").
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conclusion that any error by the district court in allowing the
testimony did not "substantially sway" the trial's outcome.
IV.
Duval raises the concern that a ruling adverse to her
might encourage misbehavior by litigants in the future. On the
contrary, our decision in this case in no way should be read to
condone Rule 26 violations; the rule's requirements are "an
integral part of the machinery devised to facilitate the management
of pretrial discovery." Lawes, 963 F.3d at 90 (quoting Downey v.
Bob's Disc. Furniture Holdings, Inc., 633 F.3d 1, 5 (1st Cir.
2011)). But, given our harmlessness analysis, we nevertheless
cannot say on the record before us that the alleged error in
admitting Dr. Weinstein's testimony warrants upsetting the
district court's considered judgment. The judgment of the district
court is thus affirmed.
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