The opinion
[Cite as King-Coleman v. Ohio Dept. of Rehab. & Corr., 2011-Ohio-5318.]
Court of Claims of Ohio
The Ohio Judicial Center
65 South Front Street, Third Floor
Columbus, OH 43215
614.387.9800 or 1.800.824.8263
www.cco.state.oh.us
ANGELIA Y. KING-COLEMAN, Admx.
Plaintiff
v.
OHIO DEPARTMENT OF REHABILITATION AND CORRECTION
Defendant
Case No. 2007-08937
Judge Clark B. Weaver Sr.
DECISION
{¶1} Plaintiff brought this action alleging medical malpractice.1 The issues of
liability and damages were bifurcated and the case proceeded to trial on the issue of
liability.
{¶2} Erick Coleman testified that in June 2005, he underwent a procedure to
repair a gunshot wound in his left femur. As a part of the procedure, metal hardware
and screws were surgically implanted in Coleman’s left leg. On September 20, 2005,
Coleman was admitted into defendant’s care and custody, and on November 21, 2005,
he was transferred to the North Central Correctional Institution (NCCI). Coleman
testified that while at NCCI, he experienced pain and swelling in his leg and knee,
difficulty walking, and that it was necessary for him to ice and elevate his leg whenever
possible. Doctors later discovered that an infection had developed in Coleman’s leg
1
Plaintiff’s May 12, 2010 motion to correct case caption is GRANTED and the clerk is directed to
substitute Angelia Y. King-Coleman, Administratrix of the Estate of Erick Coleman, deceased, in place of
Erick Coleman.
Case No. 2007-08937 -2- ENTRY
requiring removal of the infected hardware. Coleman subsequently learned that he had
developed osteomyelitis in his leg.
{¶3} On September 11, 2006, Coleman was admitted to the Ohio State
University Medical Center (OSU) where doctors removed the infected hardware from
Coleman’s left femur. Subsequent cultures were positive for methicillin-resistant
staphylococcus epidermidis (MRSE). To treat the infection, Coleman was prescribed
vancomycin, an antibiotic which was to be intravenously administered on a long-term
basis.
{¶4} On September 14, 2006, Coleman was transferred to defendant’s
Corrections Medical Center (CMC) where he continued to receive vancomycin.
According to CMC medical records, Coleman developed a low grade fever on
September 26, 2006. (Plaintiff’s Exhibit 3-2.) On September 28, 2006, Martin Akusoba,
M.D., Medical Director at CMC, administered thorazine to Coleman for a case of the
hiccups and ordered blood cultures to determine whether an infection was developing.
CMC medical records indicate that on September 30, 2006, Coleman continued to run a
fever and that he was given Tylenol. (Plaintiff’s Exhibit 3-1.)
{¶5} On October 2, 2006, Coleman continued to run a fever at which time Dr.
Akusoba prescribed the antibiotic, ciprofloxacin. Dr. Akusoba testified that prior to
October 2, 2006, Coleman had not exhibited any sign of an adverse reaction to
vancomycin. Dr. Akusoba explained that he prescribed ciprofloxacin in an attempt to
treat any vancomycin resistant infection.
{¶6} Coleman testified that shortly after taking ciprofloxacin, he began to feel
weak, his eyes began to burn, and he became very itchy. Coleman asserted that the
nursing staff threatened to “put him in the hole” if he refused to take prescribed doses of
ciprofloxacin. Dr. Akusoba testified that CMC does not have a “hole,” or segregation
unit, and that when a patient refuses medication, the patient is allowed to sign a
document recording the refusal of the medication.
Case No. 2007-08937 -3- ENTRY
{¶7} Coleman testified that between October 2 and 4, 2006, his condition
continued to deteriorate. Coleman stated that he began experiencing a severe rash,
vomiting, difficulty swallowing, swollen throat, and blisters on his back, torso, mouth,
nose, and ears, although the first documented blisters occurred at OSU on October 8,
2006. (Plaintiff’s Exhibit 3-1.) Coleman testified that he was not seen by a doctor at
CMC between October 2 and October 6, 2006, despite his rapidly deteriorating
condition; however, according to CMC medical records, Charles Onwe, M.D., a
physician at CMC, examined Coleman on October 4 and 5, 2006. Coleman testified
that on multiple occasions between October 2 and 4, 2006, he reported his deteriorating
condition, including his developing blisters, to CMC nursing staff, but that none of the
nurses examined his blisters. According to a nurse’s note dated October 5, 2006,
Coleman had been complaining of pain and vomiting, but no vomit was observed.
(Plaintiff’s Exhibit 3-1.) Coleman asserted that by October 6, 2006, his condition had
deteriorated to the point that he was unable to move or put on his orange jump suit.
{¶8} Dr. Onwe testified that on October 4, 2006, he discontinued ciprofloxacin
after speaking with Coleman. Dr. Onwe explained that he did not discontinue
vancomycin because it had been treating Coleman’s MRSE infection for one month
without an adverse reaction. Dr. Onwe asserted that he did not believe vancomycin
was the offending drug. That same day, Dr. Onwe noted that Coleman was
complaining of itchiness and had a low-grade fever. Dr. Onwe testified that he
observed Coleman’s skin, including his chest and back, and documented some pain
and swelling in Coleman’s left knee. Dr. Onwe further asserted that if Coleman would
have had a rash at that time, he would have documented it.
{¶9} Dr. Onwe testified that on October 5, 2006, he examined Coleman and
documented an elevated temperature and a sore throat but no rash. On October 6,
2006, Dr. Onwe again examined Coleman and documented an erythematous macular
popular rash on Coleman’s upper torso. That same day, Dr. Onwe determined that
Case No. 2007-08937 -4- ENTRY
Coleman was continuing to deteriorate and ordered him to be transported by ambulance
to OSU. Coleman stopped receiving vancomycin on October 6, 2006.
{¶10} According to the medical records at OSU, upon arrival at the emergency
room, Coleman’s entire back and chest area were red and raised with a generalized
rash. (Plaintiff’s Exhibit 3-1.) The records do not identify the existence of any blisters on
October 6, 2006. Coleman testified that he was subsequently diagnosed with Stevens-
Johnson syndrome (SJS). As a consequence of developing SJS, Coleman explained
that he had significant amounts of skin removed and that at the time of trial, he
continued to experience dry skin, sensitivity to sunlight, inability to differentiate between
colors, and inability to properly hydrate his eyes. Ultimately, both vancomycin and
ciprofloxacin were added to Coleman’s allergy list at CMC. (Plaintiff’s Exhibit 3-1.)
{¶11} Plaintiff alleges that defendant was negligent in failing to respond to
Coleman’s complaints of itching, burning sensation, difficulty swallowing, rash, and
blistering and that such negligence proximately caused Coleman to develop SJS and
sustain permanent injuries. Plaintiff urges the court to apply the doctrine of res ipsa
loquitor. Plaintiff further alleges that defendant was negligent in failing to document all
of Coleman’s complaints.
{¶12} Defendant denies liability arguing both that the medical records
contradict Coleman’s version of events and that the doctors and nurses fully complied
with the standards of care. Defendant further asserts that the doctrine of res ipsa
loquitor cannot be applied to this case inasmuch as plaintiff has failed to identify the
instrumentality that caused Coleman’s injury.
{¶13} In order to prevail on a claim of medical malpractice or professional
negligence, plaintiff must first prove: 1) the standard of care recognized by the medical
community; 2) the failure of defendant to meet the requisite standard of care; and 3) a
direct causal connection between the medically negligent act and the injury sustained.
Wheeler v. Wise (1999), 133 Ohio App.3d 564; Bruni v. Tatsumi (1976), 46 Ohio St.2d
Case No. 2007-08937 -5- ENTRY
127. The appropriate standard of care must be proven by expert testimony. Bruni at
130. That expert testimony must explain what a medical professional of ordinary skill,
care, and diligence in the same medical specialty would do in similar circumstances. Id.
{¶14} Plaintiff presented the expert testimony of Tanyanyiwa Chinyadza,
M.D., who is a physician licensed to practice medicine and is board certified in internal
medicine and infectious diseases. Dr. Chinyadza testified that he has treated patients
who have developed both MRSE and SJS. Dr. Chinyadza explained that SJS is a rare
condition in which a patient develops a severe allergic reaction that typically manifests
itself in the form of hives, rash, and an itch. According to Dr. Chinyadza, SJS can cause
permanent damage to the muscular system as well as the skin, mouth, and intestinal
tract. Dr. Chinyadza further explained that SJS can be caused by a “broad range of
things” and that it is often difficult to determine the exact cause of SJS. Dr. Chinyadza
testified that when treating SJS, the standard of care requires the doctor to stop the use
of all suspected agents.
{¶15} After reviewing both CMC and OSU medical records and obtaining a
detailed history of events from Coleman, Dr. Chinyadza opined that defendant had
deviated from the standard of care by failing to discontinue the use of both antibiotics,
vancomycin and ciprofloxacin, on October 4, 2006, and that such deviation proximately
caused Coleman’s permanent injuries. Dr. Chinyadza stated that vancomycin had been
prescribed to inhibit osteomyelitis, an infection in Coleman’s bone tissue later diagnosed
as MRSE; and that such infection developed around the hardware used to treat
Coleman’s gunshot wound. Dr. Chinyadza testified that the administration of a long-
term antibiotic, as had been prescribed in this case, was appropriate and that Coleman
seemed to tolerate vancomycin well until his skin rash and blistering developed on or
around October 4, 2006.
{¶16} According to Dr. Chinyadza, Coleman’s symptoms of fever, hiccups,
and sore throat were indications of a developing infection, and doctors should have
Case No. 2007-08937 -6- ENTRY
discontinued the use of vancomycin on October 4, 2006, when Coleman first developed
a rash. He conceded, however, that the medical records fail to reveal a deviation from
the standard of care on that date inasmuch as a rash was not reported until October 6,
2006. Dr. Chinyadza also acknowledged that although Coleman suffered a drug-
induced SJS there is no way to establish with certainty that SJS was caused by
vancomycin. He also admitted that if Coleman had been allowed to discontinue his
antibiotics on October 4, 2006, the severity of his symptoms would have decreased but
he would still have contracted SJS.
{¶17} Defendant’s expert, Bruce Farber, M.D., a board certified physician in
internal medicine and infectious disease, testified that defendant did not breach the
standard of care. Dr. Farber explained that SJS is an unpredictable reaction to some
foreign agent. Dr. Farber asserted that doctors do not currently understand why or how
SJS develops, but that it can be caused by a respiratory infection, a wide variety of
drugs, or an allergic reaction the body produces to fight a foreign antigen. Dr. Farber
testified that vancomycin is the drug of choice when treating an MRSE infection and that
administration of such a drug was within the standard of care in this case. Dr. Farber
based his testimony solely upon the medical records at CMC and OSU.
{¶18} Dr. Farber stated that the addition of ciprofloxacin to extend antibiotic
coverage on October 2, 2006, is common in such cases and that such added treatment
was reasonable in Coleman’s case. Dr. Farber testified that discontinuing ciprofloxacin
but continuing vancomycin on October 4, 2006, was also within the standard of care
inasmuch as Coleman’s complaints of itching developed shortly after the introduction of
ciprofloxacin. At that point, vancomycin had been administered on a long-term basis
with no signs of an adverse reaction. Dr. Farber testified that it was reasonable and
appropriate to continue vancomycin for the treatment of the MRSE infection.
{¶19} Dr. Farber testified that when Coleman arrived at OSU on October 6,
2006, he did not have typical SJS. Dr. Farber explained that in a typical case of SJS
Case No. 2007-08937 -7- ENTRY
the patient first develops a rash and then a fever, and that on October 6, 2006, Coleman
had an erythematous macular popular rash, which is similar to a sunburn that involves
bumps over the body. According to Dr. Farber, SJS is characterized by big blisters
involving the eyes and rectum and that Coleman’s blisters were not documented by
OSU until October 8, 2006. Dr. Farber opined that the mere fact that CMC included
vancomycin on Coleman’s list of possible allergies does not mean that it caused
Coleman’s SJS. On cross-examination, Dr. Farber admitted that if he were to accept
Coleman’s version of events, it would probably change his opinion regarding whether
defendant met the standard of care.
{¶20} Upon review of the testimony and evidence adduced at trial, the court
finds that defendant’s conduct did not fall below the standard of care. The court is
persuaded by the testimony of Dr. Onwe regarding the care he rendered to Coleman on
October 4 and 5, 2006. Coleman’s insistence that he was not seen by a doctor during
that time period conflicts with the timing of events as documented in both the CMC and
OSU medical records. Specifically, Coleman testified that he developed a rash and
blisters between October 2-4, 2006, but the medical records reveal that Coleman’s rash
did not develop until October 6, 2006, and the blistering did not begin until October 8,
2006. Moreover, plaintiff’s expert, Dr. Chinyadza, conceded that based solely upon the
medical records, defendant’s care complied with the standard of care.
{¶21} Plaintiff argues that the doctrine of res ipsa loquitur should be applied
in this case; however, the court does not agree. The doctrine of res ipsa loquitur is a
rule of evidence which allows the trier of fact to draw an inference of negligence from
the facts presented. Morgan v. Children’s Hosp. (1985), 18 Ohio St.3d 185, 187. The
two prerequisites which must be met to warrant the application of the rule are: “(1) that
the instrumentality causing the injury was, at the time of the injury, or at the time of the
creation of the condition causing the injury, under the exclusive management and
control of the defendant; and (2) that the injury occurred under such circumstances that
Case No. 2007-08937 -8- ENTRY
in the ordinary course of events it would not have occurred if ordinary care had been
observed.” Id., quoting Hake v. Wiedemann Brewing Co. (1970), 23 Ohio St.2d 65, 66-
67.
{¶22} Dr. Farber testified that, in his opinion, SJS can be caused by a wide
range of factors including a respiratory infection, a wide variety of drugs, or an allergic
reaction to a foreign antigen. Furthermore, Dr. Chinyadza admitted that there was no
way to prove that vancomycin proximately caused Coleman’s SJS. Moreover, the
experts agree that, based solely upon the medical records, defendant’s action did not
fall below the standard of care. Additionally, Dr. Chinyadza testified that even if the
doctors had discontinued vancomycin on October 4, 2006, Coleman still would have
developed SJS, although his reaction would have been less severe. Therefore, the
court finds that neither prerequisite for the doctrine of res ipsa loquitur has been met.
{¶23} Finally, to the extent that plaintiff contends that defendant is liable for
failing to accurately document all of Coleman’s complaints, Dr. Chinyadza stated that in
his practice, he refers to the nurses’ notes in addition to directly speaking with the
nurses. Dr. Chinyadza asserted that it would be “normal” for a patient’s major
complaints to be documented, although he did not elaborate as to what would constitute
a major complaint. Dr. Chinyadza testified that the CMC nursing notes do not document
any complaints either of a rash or blisters between the dates of October 2 through 6,
2006, even though Coleman maintains that he made such complaints on those dates.
Dr. Chinyadza admitted that he did not know whether nurses are required to document
every single patient complaint.
{¶24} Plaintiff has failed to persuade the court by a preponderance of the
evidence that defendant’s documentation of Coleman’s complaints while at CMC fell
below the standard of care. Even if the court were to agree that the standard of care
requires nurses to document every patient complaint on each day the patient is seen, as
stated previously, the court is not persuaded that Coleman’s testimony properly
Case No. 2007-08937 -9- ENTRY
chronicles the sequence of events. In short, plaintiff failed to persuade the court by a
preponderance of the evidence that defendant breached the standard of care with
respect to CMC medical records documentation.
{¶25} For the foregoing reasons, the court concludes that plaintiff has failed to
prove her claims by a preponderance of the evidence and that judgment shall be
entered for defendant.
Court of Claims of Ohio
The Ohio Judicial Center
65 South Front Street, Third Floor
Columbus, OH 43215
614.387.9800 or 1.800.824.8263
www.cco.state.oh.us
ANGELIA Y. KING-COLEMAN, Admx.
Plaintiff
v.
OHIO DEPARTMENT OF REHABILITATION AND CORRECTION
Defendant
Case No. 2007-08937
Judge Clark B. Weaver Sr.
JUDGMENT ENTRY
Case No. 2007-08937 - 10 - ENTRY
{¶1} This case was tried to the court on the issue of liability. The court has
considered the evidence and, for the reasons set forth in the decision filed concurrently
herewith, judgment is rendered in favor of defendant. Court costs are assessed against
plaintiff. The clerk shall serve upon all parties notice of this judgment and its date of
entry upon the journal.
_____________________________________
CLARK B. WEAVER SR.
Judge
cc:
Anne B. Strait Mark I. Jacobs
Naomi H. Maletz 241 North Superior Street, Suite 200
Assistant Attorneys General Toledo, Ohio 43604-1253
150 East Gay Street, 18th Floor
Columbus, Ohio 43215-3130
Marvin K. Jacobs
1122 Adams Street
Toledo, Ohio 43604
GWP/dms
Filed August 22, 2011
To S.C. reporter October 13, 2011