Badawi v. Ohio State Univ. Wexner Med. Ctr.

[Cite as Badawi v. Ohio State Univ. Wexner Med. Ctr., 2023-Ohio-2654.]

IN THE COURT OF CLAIMS OF OHIO

MOHAMED BADAWI, Admr. Case No. 2019-00122JD

Plaintiff Judge Patrick E. Sheeran

v. DECISION

THE OHIO STATE UNIVERSITY

WEXNER MEDICAL CENTER

Defendant

I. Introduction

{¶1} Plaintiff Mohamed Badawi, Administrator of the Estate of Malak Badawi, has

brought a civil lawsuit against Defendant The Ohio State University Wexner Medical

Center.1 Plaintiff’s lawsuit stems from the death of Malak Badawi (daughter of Mohamed

Badawi [“Badawi”] and Sara Elshazli [“Elshazli”]) who died on June 8, 2018, at Nationwide

Children’s Hospital in Columbus, Ohio, after Malak was transferred to Nationwide

Children’s Hospital following her birth by emergency Cesarean section (C-section) on

June 7, 2018, at The Ohio State University Wexner Medical Center (OSUWMC). A

Supplementary Medical Certification lists Malak Badawi’s cause of death as hypoxic

ischemic injury due to uterine rupture. (Joint Exhibit M.)

{¶2} Upon careful consideration of all the evidence (including witness testimony

and exhibits admitted into evidence), the parties’ arguments, as well as post-trial filings

by the parties, the Court holds that Badawi has proven claims of negligence and wrongful

death by a preponderance of the evidence. The Court further holds that Badawi is entitled

to damages in the amount of Two Million, Seven Hundred Fifty Thousand Dollars (USD

1 Mohamed Badawi’s Complaint is accompanied by a copy of an entry of the Franklin County (Ohio)

Probate Court in which the Probate Court appointed Badawi as Administrator of the Estate of Malak Badawi.

In Defendant’s Answer, Defendant has admitted that Mohamed Badawi was appointed Administrator of

Malak Badawi’s estate by the Franklin County (Ohio) Probate Court. (Answer, ¶ 2.) Thus, there is no

dispute that Mohamed Badawi is the Administrator of the Estate of Malak Badawi.

Case No. 2019-00122JD -2- DECISION

$2,750,000.00), plus Twenty-Five Dollars (USD $25.00) (the cost of the filing fee) and

post-judgment interest.

II. Procedural History

{¶3} Badawi has brought claims of negligence, wrongful death, and survivorship

against The Ohio State University Wexner Medical Center. (Complaint.) Badawi also

has brought a claim seeking a determination under R.C. 2743.02(F) that each of the

physicians, attending physicians, residents, interns, fellows, therapists, nurses, and

others who provided care to Sara Elshazli, during the labor and delivery admission of

June 6-7, 2018, were acting within the course and scope of their employment while

rendering care. (Complaint, ¶ 31.)

{¶4} In Defendant’s Answer, Defendant has admitted that, at all times relevant,

Defendant “employed certain physicians[,] * * * nurses and other providers who were

acting in the course and scope of their respective employment in the treatment of Malak

Badawi” (Answer, ¶ 5), and that, at all times relevant, Defendant employed certain

physicians, nurses and other providers who were acting in the course and scope of their

respective employment in the treatment of Elshazli and Malak Badawi. (Answer, ¶ 6, 7.)

Defendant’s admissions resolve whether Defendant’s medical providers who cared for

Elshazli and Malak Badawi were Defendant’s employees and whether their actions were

in the course and scope of their employment.

{¶5} The case proceeded to a bench trial on issues of liability and damages as to

Badawi’s claims of negligence, wrongful death, and survivorship. After Badawi’s opening

statement, pursuant to Civ.R. 50, Defendant, through counsel, moved for a partial

directed verdict. The Court denied Defendant’s motion.

{¶6} After Badawi presented his case-in-chief, Defendant moved for a directed

verdict, which the Court granted in part, and denied in part. The Court granted

Defendant’s motion for a directed verdict on claims that Defendant failed to gain informed

consent, as alleged in the Complaint at paragraph 28(c) and that Defendant failed to

properly train resident physicians and nurses on the indications of an ongoing uterine

rupture, as alleged in the Complaint at paragraph 28(k). The Court further granted

Defendant’s motion for a directed verdict on claims of (i) loss of support from reasonably

Case No. 2019-00122JD -3- DECISION

expected earning capacity of Malak Badawi, as alleged in the Complaint at paragraph

33(d), (ii) compensable funeral expenses and burial expenses, as alleged in the

Complaint at paragraph 33(e), (iii) compensable expenses based on medical bills, and

(iv) a failure to prove the Survivorship Claim, as alleged in the Complaint at paragraph

34.

{¶7} The Court denied Defendant’s motion for a directed verdict on the claim that

Defendant failed to initiate the chain of command, as alleged in the Complaint at

paragraph 28(n). The Court initially deferred a final ruling whether a directed verdict was

proper on the claim that Defendant improperly administered Pitocin, as alleged in the

Complaint at paragraph 28(d). Later, however, the Court granted Defendant’s motion for

a directed verdict as to Defendant’s alleged improper administration of Pitocin, as set forth

in the Complaint at paragraph 28(d).

{¶8} The gravamen of Badawi’s remaining allegations concern whether, on June

7, 2018, Defendant, through its medical team who cared for Elshazli and her unborn child,

breached a duty of care to Elshazli and her unborn child, whether injuries in this case are

the proximate result of the breach, and what damages, if any, should be awarded. Badawi

essentially maintains that, on June 7, 2018, Kara L. Malone, M.D. (attending physician),

Erin Walker, M.D., (a first-year resident at that time) and Elizabeth Miller, R.N. (a nurse

with about 1½ years’ experience as a labor and delivery nurse at that time) were negligent

in their care of Elshazli and her unborn child. The negligence alleged against Dr. Malone

is, in part, based on her absence from Elshazli’s room between the hours of 0840 and

1240, because it was during those times that key events relevant to a determination

whether to perform a C-section are claimed to have occurred.2

{¶9} Defendant denies liability, essentially contending that its employees’ actions

were within the standard of care and that Malak Badawi’s injuries were not the proximate

result of any medical negligence by Defendant’s medical team. Moreover, Defendant

contends that evidence gleaned from pathology findings conclusively shows that Malak’s

injuries occurred well before her birth on June 7, 2018.

2 What occurred, or did not occur, on June 7, 2018, between 0700 and 1313 hours will be discussed

in detail infra.

Case No. 2019-00122JD -4- DECISION

III. Relevant Background

{¶10} Badawi and Elshazli moved to the United States from Egypt. Badawi, who

holds a Ph.D. in Pharmaceutical Research from The Ohio State University (OSU), is the

son of a pharmacist and a pediatrician. After Badawi earned his Ph.D. from OSU, he

participated in a post-doctoral fellowship at OSU. Elshazli holds a degree in accounting

and is a certified public accountant.

{¶11} Badawi and Elshazli met in 2011 and were married in 2013. The couple

wanted a large family and planned to have several children. Their first child, Laila, was

born in January 2015. Laila was delivered by Cesarean section at OSUWMC. Although

Elshazli preferred to have Laila delivered vaginally, the course of her delivery did not

permit that. The Cesarean section was performed because Laila exhibited signs of fetal

distress, as her condition was charted as “nonreassuring fetal well-being.” As a result,

medical providers at OSUWMC recommended an immediate Cesarean section, and

Elshazli agreed. Laila was successfully delivered with no complications.

{¶12} Over two years later, Elshazli became pregnant again. Elshazli wished to

deliver her second child through a vaginal birth, if possible, instead of by Cesarean

section. Elshazli discussed her wishes with Andrea Snyder, M.D., Ph.D., whom Elshazli

saw for prenatal care at OSUWMC. Dr. Snyder explained Elshazli’s delivery options to

her. Understanding this, Elshazli decided to undergo a trial of labor, known as TOLAC

(trial of labor after Cesarean section), with a desired result of having spontaneous labor

and a vaginal birth, known as VBAC (vaginal birth after Cesarean section). The plan

discussed and approved by both Dr. Snyder and Elshazli was for Elshazli to undergo a

Cesarean section on June 8, 2018, if, by that time, Elshazli had not begun her labor.

{¶13} On June 6, 2018, Elshazli began to experience symptoms of spontaneous

labor. Elshazli went to OSUWMC where she was admitted that day to the labor and

delivery unit. Elshazli initially came under the care of Katherine Stafford, M.D., who

served as Elshazli’s attending physician, along with a team of other medical providers.

On June 7, 2018, at 7 a.m. (0700 hours), the normal time for a shift change, Elshazli’s

care was transferred to Kara L. Malone, M.D., who served as Elshazli’s attending

physician, along with a team of other medical providers, including Erin Walker, M.D., a

first-year resident at the time, and Elizabeth Miller, R.N. Nurse Miller was assigned to

Case No. 2019-00122JD -5- DECISION

provide nursing care to Elshazli on a one-to-one basis, since a woman who is undergoing

a trial of labor after a C-section (“TOLAC patient”) is at a higher risk for uterine rupture.

Before Dr. Malone and nurses assumed the care of Elshazli, Dr. Malone and the nurses

were briefed and reviewed Elshazli’s situation.

{¶14} At about 1:13 p.m. (1313 hours) on June 7, 2018, Dr. Malone determined

that Elshazli required an emergency C-section. During the C-section, the OSUWMC team

discovered that Elshazli had sustained a uterine rupture with part of the baby (an arm)

extruding from the uterus. The baby, whom Badawi and Elshazli named Malak, was in

very poor condition. According to the Delivery Summary contained in Elshazli’s medical

record, Malak was assigned the following APGAR scores:

Skin Color 0 0 0 1

Heart Rate 0 1 2 2

Reflex 0 0 0 0

Irritability

Muscle Tone 0 0 0 0

Respiratory 0 0 0 0

Effort

Total 0 1 2 3

1 minute: 0 5 minute: 1 10 minute: 2 15 minute: 3

Apgars

assigned by:

PEDS

(Joint Ex. A 2, p. 150 of PDF.)

{¶15} Apgar scores are based on a measurement of from 0 to 10, with 10 being

the best possible score, and 0 being the worst. As a result of these extremely poor scores,

Malak was quickly transferred to the neonatal intensive care unit at OSUWMC. Malak

was transferred shortly thereafter to Nationwide Children’s Hospital (NCH) for further

treatment due to apparent hypoxic injury. Unfortunately, there was little that NCH could

do, and Badawi and Elshazli faced the agonizing decision whether to terminate the

artificial means that were helping to keep Malak alive, understanding that, even if Malak

were somehow able to survive, she would have devastating developmental

consequences. Badawi and Elshazli opted to remove the life support from Malak, and

Case No. 2019-00122JD -6- DECISION

they spent Malak’s last hours with her. Malak died on June 8, 2018, scant hours after

Badawi and Elshazli consented to the removal of external life supports.

{¶16} Badawi, Elshazli, and Laila later relocated to Illinois. Elshazli became

pregnant again and gave birth to a son, Ali, by Cesarean section in 2020. At the time of

trial, both Badawi and Elshazli were receiving psychological treatment for post-traumatic

stress disorder (PTSD) related to the circumstances of Malak’s birth by emergency C-

section.

IV. Law and Analysis

{¶17} Under Ohio law, Badawi, the Administrator of Malak’s estate, is required to

establish his civil claims by a preponderance of the evidence. See Merrick v. Ditzler, 91

Ohio St. 256, 260, 110 N.E. 493 (1915) (“[i]n the ordinary civil case the degree of proof,

or the quality of persuasion as some text-writers characterize it, is a mere preponderance

of the evidence”); Weishaar v. Strimbu, 76 Ohio App.3d 276, 282, 601 N.E.2d 587 (8th

Dist.1991). A preponderance of the evidence “is defined as that measure of proof that

convinces the judge or jury that the existence of the fact sought to be proved is more likely

than its nonexistence.” State ex rel. Doner v. Zody, 130 Ohio St.3d 446, 2011-Ohio-6117,

958 N.E.2d 1235, ¶ 54.

{¶18} On the trial of a civil case (or criminal case), the weight to be given the

evidence and the credibility of the witnesses is primarily for the trier of the facts to

determine. State v. DeHass, 10 Ohio St.2d 230, 227 N.E.2d 212 (1967), paragraph one

of the syllabus. The Court is the trier-of-facts in this case. The Court therefore must give

appropriate weight to the evidence presented, as it reviews and evaluates the evidence.

The Court is free to believe all, part, or none of the testimony of any witnesses, including

expert witnesses who have testified in this trial. See State v. Green, 10th Dist. Franklin

No. 03AP-813, 2004-Ohio-3697, ¶ 24.

{¶19} Under Ohio law, a specialized hospital should be held to a higher standard

of care because it specializes. Wilburn v. Cleveland Psych. Inst., 126 Ohio App.3d 153,

156, 709 N.E.2d 1220 (10th Dist.1998); see Johnson v. Grant Hosp., 32 Ohio St.2d 169,

178, 291 N.E.2d 440 (1972) (“[a] general hospital, which ordinarily does not and is not

equipped to treat mental patients, should not be held to the same standard of care as a

Case No. 2019-00122JD -7- DECISION

hospital which is operated and equipped to provide care for a patient who has displayed

a tendency to commit suicide”); Sabol v. Richmond Hts. Gen. Hosp., 111 Ohio App.3d

598, 602, 676 N.E.2d 958 (8th Dist.1996) (“[c]rucial to Johnson is the idea that a general

hospital caring for a suicidal patient cannot be held to the same standard of care as a

specialized hospital which routinely deals with such patients”).

{¶20} Here, the evidence shows that Defendant is an academic medical center that

routinely provides care to pregnant women who are undergoing TOLAC/VBAC and that

also provides post-graduate medical education in the field of obstetrics and gynecology.

Under Ohio law, Defendant therefore should be held to a standard of care consistent with

an academic medical center that provides specialized care to women who are undergoing

TOLAC and that provides post-graduate medical education in the field of obstetrics and

gynecology.

{¶21} The Ohio Supreme Court has recognized that, in the medical context,

“because only individuals practice medicine, only individuals can commit medical

malpractice.” Natl. Union Fire Ins. Co. v. Wuerth, 122 Ohio St.3d 594, 2009-Ohio-3601,

913 N.E.2d 939, ¶ 14. But the Ohio Supreme Court also has recognized that, under the

doctrine of respondeat superior, a hospital “is liable for the negligent acts of its

employees.” Berdyck v. Shinde, 66 Ohio St.3d 573, 577, 613 N.E.2d 1014 (1993), citing

Klema v. St. Elizabeth’s Hosp. of Youngstown, 170 Ohio St. 519, 166 N.E.2d 765 (1960).

{¶22} Defendant has admitted that it employed certain individuals who were acting

within the course and scope of their employment when they provided medical care to

Elshazli. (Answer, ¶ 5, 6, 7). Under the doctrine of respondeat superior, Defendant

therefore may be liable for any negligent acts of its employees when they provided

medical care to Elshazli and her unborn child during Elshazli’s hospitalization at

OSUWMC in June 2018.3

3 The Ohio Supreme Court has stated:

“The modern provision of medical care is a complex process becoming increasingly more

complicated as medical technology advances. Large teaching hospitals * * * care for

patients with teams of professionals, some of whom never actually come in contact with

the treated patient but whose expertise is nevertheless vital to the treatment and recovery

of patients.

“* * *

Case No. 2019-00122JD -8- DECISION

{¶23} The Ohio Supreme Court has identified elements to establish negligence of

a hospital employee as follows: “To establish the negligence of a hospital employee, an

injured party must demonstrate that a duty of care was owed to the injured party by the

employee, that the employee breached that duty, and that the injuries concerned were

the proximate result of the breach.” Berdyck v. Shinde, 66 Ohio St.3d 573, 577, 613

N.E.2d 1014 (1993).4

{¶24} The Court concludes that, as a matter of law, Defendant, through its medical

team, owed a duty of care to Elshazli and Malak Badawi that complied with accepted

standards of care. See Mussivand v. David, 45 Ohio St.3d 314, 318, 544 N.E.2d 265

(1989) (“[t]he existence of a duty in a negligence action is a question of law for the court

to determine. * * * There is no formula for ascertaining whether a duty exists”).

{¶25} With respect to the standard of care that should apply to medical

professionals, the Ohio Supreme Court has instructed that “the standard of care

applicable to medical professionals is to exercise the degree of care that a medical

professional of ordinary skill, care, and diligence would exercise under similar

circumstances.” Cromer v. Children's Hosp. Med. Ctr. of Akron, 142 Ohio St.3d 257,

2015-Ohio-229, 29 N.E.3d 921, ¶ 27, citing Bruni v. Tatsumi, 46 Ohio St.2d 127, 346

N.E.2d 673 (1976), at paragraph one of the syllabus. In Cromer, the Ohio Supreme Court

explained:

Although the standard of care for a medical professional is

heightened, it does not necessarily supplant all consideration of

“Medical professionals may be held accountable when they undertake to care for a patient

and their actions do not meet the standard of care for such actions as established by expert

testimony. *** " (Citations omitted.) * * *.

Lownsbury v. VanBuren, 94 Ohio St.3d 231, 236-237, 762 N.E.2d 354 (2002), quoting Mozingo v. Pitt

Cty. Mem. Hosp., Inc., 331 N.C. 182, 188-189, 415 S.E.2d 341 (1992).

4 Under Ohio law, cause in fact and proximate cause are distinct. See Ackison v. Anchor Packing

Co., 120 Ohio St.3d 228, 2008-Ohio-5243, 897 N.E.2d 1118, ¶ 48. The standard test for establishing cause

in fact is “but for” causation. Ackison at ¶ 48. In Anderson v. St. Francis-St. George Hosp., Inc., 77 Ohio

St.3d 82, 84-85, 671 N.E.2d 225 (1996), the Ohio Supreme Court explained that “a defendant’s conduct is

a cause of the event (or harm) if the event (or harm) would not have occurred but for that conduct;

conversely, the defendant’s conduct is not the cause of the event (or harm) if the event (or harm) would

have occurred regardless of the conduct.” (Emphasis sic). And in Ackison, the Ohio Supreme Court stated,

“Once cause in fact is established, a plaintiff then must establish proximate cause in order to hold a

defendant liable.” Ackison at ¶ 48. In Clinger v. Duncan, 166 Ohio St. 216, 223, 141 N.E.2d 156 (1957),

the Ohio Supreme Court noted: “Ordinarily, the existence of both negligence and proximate cause are, in

a jury trial, questions of fact for the determination of the jury under proper instructions from the court.”

Case No. 2019-00122JD -9- DECISION

foreseeability. As part of their standard of care, medical professionals are

expected to be able to recognize certain symptoms of illness and injury, and

they are expected to be aware of the associated risk of harm. See Berdyck

at 581 (obstetrical staff nurses are expected to recognize symptoms of

major obstetrical complications and take appropriate action to prevent

harm). In other words, they are expected to foresee a risk of harm that a

medical professional of ordinary skill, care, and diligence would foresee

under similar circumstances. And just as with the general negligence

standard, it necessarily follows that we would not expect medical

professionals to guard against a risk of harm that a medical professional of

ordinary skill, care, and diligence would not foresee. See, e.g., Keebler v.

Winfield Carraway Hosp., 531 So.2d 841, 844-845 (Ala.1988), citing

Fernandez v. Baruch, 52 N.J. 127, 244 A.2d 109 (1968) (explaining that a

physician does not have a duty to take measures to prevent a patient from

committing suicide if the patient’s suicide was not reasonably foreseeable

under generally accepted medical standards). Accordingly, foreseeability of

harm is relevant to a physician’s standard of care, and a correct, general

statement of the law regarding the standard of care or the breach of that

standard includes the element of foreseeability.

Cromer at ¶ 28. Here, whether Kara Malone, M.D., Erin Walker, M.D., and Elizabeth

Miller, R.N. were aware of the risk of uterine rupture, and whether Dr. Malone, Dr. Walker,

and Ms. Miller recognized and properly acted upon certain symptoms of uterine rupture

in accordance with the standard of care are squarely before the Court.

{¶26} Whether a standard of care articulated by an expert witness governs a duty

of care is a question of fact, determined from all relevant facts and circumstances. See

Berdyck, supra, at 584; Burton v. Elsea, 4th Dist. Scioto No. 97CA2556, 1999 Ohio App.

LEXIS 6401, at *32 (Dec. 27, 1999), citing Strother v. Hutchinson, 67 Ohio St. 2d 282,

423 N.E.2d 467 (1981) (“disputes as to both the conduct of the parties and the standard

of care are questions for the jury”). The Tenth District Court of Appeals has explained:

With few exceptions, the trier of fact must determine the applicable

standard of care in a medical malpractice case from the testimony of expert

Case No. 2019-00122JD -10- DECISION

witnesses. In Turner v. Children’s Hosp., Inc. (1991), 76 Ohio App. 3d 541,

602 N.E.2d 423, we explained:

Ordinarily, the issue of whether the physician has

employed the requisite care must be determined from the

testimony of experts, unless the standard of care is sufficiently

obvious that laymen could reasonably evaluate the

physician’s conduct. * * * Such expert testimony serves to aid

the trier of fact in determining if there was malpractice. For,

although customary practice is evidence of what a reasonably

prudent physician would do under like or similar

circumstances, it is not conclusive in determining the

applicable standard required. Id. at 548.

Wheeler v. Wise, 133 Ohio App.3d 564, 569, 729 N.E.2d 413 (10th Dist.1999).

{¶27} Here, the evidence shows that, at the time of Elshazli’s admission to

OSUWMC in June 2018, Defendant had a policy governing Vaginal Birth After Cesarean

(VBAC). (Joint Exhibit P.) According to the VBAC policy, “Patients with a prior cesarean

are at increased risk for uterine rupture, placenta previa, placenta accreta, and maternal

or fetal death in a subsequent pregnancy. * * * The complication with the most serious

consequences with regard to TOLAC is uterine rupture, which is associated with both

fetal and maternal risks. When a uterine rupture occurs, maternal risks include

hemorrhage, hysterectomy, operative injury, infection, anemia, and transfusion. Fetal

risks in these circumstances include hypoxic injury and death. It is generally believed

that the risk of uterine rupture during a spontaneously occurring trial of labor is

approximately one in 200 (0.5%). However, the risk of uterine rupture depends on scar

location/type, the number of prior incisions, and the type of labor.” (Joint Exhibit P.)

Through Defendant’s VBAC policy, in June 2018 Defendant, as an academic medical

center, had knowledge of the risk of uterine rupture with respect to a patient who is

undergoing a trial of labor following a C-section, as well as the associated fetal risks and

maternal risks.

{¶28} In June 2018 Dr. Walker, as a first-year resident in obstetrics/gynecology,

and Ms. Miller, as a nurse with about 1½ years of experience in the area of labor and

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delivery, not only had to be prepared to evaluate Elshazli for signs and symptoms of

uterine rupture, but they also had to be prepared to acknowledge it and act upon it, if

appropriate signs of uterine rupture occurred. This is not an easy task for relative

neophytes.

{¶29} Uterine rupture is not a “common” occurrence in TOLAC patients, occurring

in about 1% to 2% of such patients. When a uterine rupture occurs, the risk of death or

serious injury for a TOLAC patient is in the range of 1%. Because the consequences of

a uterine rupture can be so catastrophic, medical providers at OSUWMC must be on the

alert for signs of it.

{¶30} The evidence shows that uterine rupture does not manifest itself in advance.

In other words, confirmation of uterine rupture can only be done by surgical means, which

can only occur after a medical emergency presents itself. Thus, Defendant’s medical

providers are required to be alert for signs of uterine rupture, especially in a TOLAC

patient, since a TOLAC patient already has a scar susceptible of rupturing based on a

prior Cesarean section. What complicates an analysis of the possible existence of uterine

rupture is that the signs that suggest its presence are also signs that can point to other

possible medical diagnoses.

{¶31} The evidence shows that signs of uterine rupture include abnormal fetal

heart rate tracing, abdominal pain, vaginal bleeding, loss of fetal station, maternal

hypotension, maternal tachycardia (and change in contractions). These signs are from

Steven G. Gabbe, M.D., et al., Obstetrics: Normal and Problem Pregnancies, Chapter 20,

452 (7th Ed.2017). Not expressly included in the above signs is “shoulder pain.”5

However, the evidence in this case shows, and this Court so finds, that shoulder pain also

can be a symptom of uterine rupture.

{¶32} None of these signs, if presented, can ONLY come from a uterine rupture.

In other words, abdominal pain (to use just one example) can have different causes and

have different effects; so just because a woman in labor has abdominal pain does not

automatically mean that she is having a uterine rupture.

5 “Classic signs” of a uterine rupture may be described as, an experience of horrible abdominal

pain by a pregnant woman, profuse blood loss, and hemodynamic instability—not shoulder pain, which

results due to irritation of the phrenic nerve.

Case No. 2019-00122JD -12- DECISION

{¶33} This Court heard the testimony of Christopher J. Robinson, M.D., MSCR,

FACOG. The Court agrees with Dr. Robinson’s testimony that it is necessary for a

medical team treating a TOLAC patient to have “situational awareness.” “Situational

awareness” is vital, because the risks of uterine rupture are so consequential (i.e., the

death of a baby or mother, or both)—that a TOLAC patient must be considered in a very

different light than a patient who has not previously delivered a child by Cesarean section

(or has had some other invasive surgical scar in a similar location). It would not

automatically be a breach of the standard of care to immediately “jump in” with a

Cesarean section at the first hint of sign of uterine rupture, but the showing of a sign or

signs (depending on the particular sign) must be met with an immediate and heightened

awareness of the risks, with further and immediate investigation of just what the symptom

can mean. In other words, the maternal medical team must be aware that uterine rupture

may exist when one or more signs of it become present. The maternal medical team also

must be ready to act if those signs are present. So, if multiple signs of uterine rupture

present, especially over time, with a TOLAC patient, then, given the obvious danger to

mother or child, or both, a medical provider simply cannot afford to wait to see if the

situation resolves itself. Situational awareness demands otherwise. Therefore, for a

TOLAC patient, the standard of care demands considerably more than waiting with the

expectation that the signs that could be uterine rupture resolve themselves. And it is for

this reason, at least, that Defendant has a TOLAC patient sign, as was done here, a

Consent Form that authorizes a delivery by Cesarean section. As one witness

commented, it would be inappropriate for an expectant mother, being rushed to a delivery

room for a Cesarean section delivery, to have to sign a consent form in that time of

emergency.

{¶34} Thus, the main issue in this case, since it is manifest that a uterine rupture

did occur, is to determine, by a preponderance of the evidence, whether Defendant,

through its medical team, acted appropriately when certain signs presented, or whether,

by a preponderance of the evidence, Elshazli should have been transported for a

Cesarean section at any time before 1254 hours. This Court uses that time because it is

the time given by Dr. Robinson as the last possible time for Malak to have been born

without serious risk to her life or health. Thus, in the Court’s view, a Cesarean delivery

Case No. 2019-00122JD -13- DECISION

at 1313 hours was too late, because, despite the very quick and efficient rush of Elshazli

to an operating room for her Cesarean section after the determination that a uterine

rupture had most likely occurred, Malak was born with such natal deficiencies that she

could not survive.

A. The Court rejects Defendant’s theory that the fatal injury to Malak

occurred before Malak’s birth.

{¶35} One of the two defenses presented in this case is Defendant’s contention

that Malak’s death was the result of injury that predated her delivery by days, or even

weeks. This Court rejects, as being against the greater weight of the evidence,

Defendant’s theory that the fatal injury to Malak occurred before Malak’s birth.

{¶36} The autopsy in this case was performed by Peter Baker, III, M.D. and

Christopher Pierson, M.D., Ph.D., both of whom were and are affiliated with The Ohio

State University. They agree on the cause of death being uterine rupture by clinical

history, with the most likely cause of death being extensive acute hypoxic ischemia. While

there was a mistake in the clinical history—the baby was NOT free-floating in the

abdomen—that mistake did not affect the cause-of-death finding.

{¶37} Dr. Baker signed the final Official Death Certificate. This Court notes that

hypoxic ischemia is based on clinical findings, while “hypoxic-ischemic brain injury” is

based on tissue examination. These findings are consistent with each other.

{¶38} Dr. Pierson checked the autopsy report to make sure that its contents were

consistent with his neuropathological findings. They were. Dr. Pierson also testified

regarding “gliosis.” Gliosis may be reasonably defined as a nonspecific reactive change

in the glial cells in response to something occurring in the central nervous system. There

are types of gliosis: myelination gliosis and reactive gliosis. Dr. Pierson did not use either

term in the autopsy. He testified that it “can be very difficult to distinguish an astrocyte

reacting from a normal stimulus, physiologic stimulus, from a pathological stimulus.”

Since he cannot always differentiate between the two, he simply used the term “gliosis.”

{¶39} A red neuron or red cell is an acidophilic or eosinophilic neuron. Red

neurons are signs of irreversible injury and are often seen in association with hypoxic-

ischemic injury. A pyknosis is an irreversible condensation of chromatin in the nucleus of

Case No. 2019-00122JD -14- DECISION

a cell undergoing necrosis. Pyknosis often is used to refer to cells or neurons that

undergo shrinkage.

{¶40} Purkinje cells are a unique type of neuron specific cell to the cerebellar

cortex. Such a cell is a large neuron that takes information out of the cerebellar cortex

and sends it to the deep cerebellar nuclei and white matter. Purkinje cells are sensitive

to a lack of oxygen, although this is mostly so in adults. In this case, Dr. Pierson testified

that he did not see “any evidence of dropout of Purkinje cells, which would be more

indicative of longstanding injury.” Thus, Dr. Pierson does not agree with the defense

contention that the injury is days or weeks old.

{¶41} Contrary to the above, Ady Kendler, M.D., Ph.D. (whose qualifications are

almost entirely identical to Dr. Pierson’s) testified, in effect, that Malak had no acute

neuronal injury; in other words, what killed this infant was days or weeks old. Dr. Kendler

noted the absence of red neurons, which he would have expected had the injury been

“new” (that is, within hours of Malak’s death).

{¶42} But both Dr. Pierson and Hannes Vogel, M.D. testified that they did find red

neurons, even if Dr. Kendler did not. Since the absence of red neurons is critical to

Dr. Kendler’s findings, the greater weight of the evidence is clearly against Dr. Kendler’s

theory.

{¶43} Dr. Kendler was not alone in the belief that what killed Malak was an injury

of longer standing, and not the acute one stated in the autopsy report. Harry T.

Chugani, M.D., adjunct professor of Neurology at New York University, School of

Medicine, agreed with Dr. Kendler’s final conclusion; however, Dr. Chugani took a

different approach in reaching that conclusion. To him, the presence or absence of red

neurons was not relevant. He states that there was a brain stem failure, a failure that is

not explained by the occurrence of a uterine rupture. His clinical analysis is that core

gases provide an informative clue: they give an indication whether there is damage to a

baby’s cells (not just brain cells). Malak’s initial pH was 7.13; low, but not terribly so.

Because the brain reacts to aerobic or anerobic oxidation by producing lactic acid, one

should expect a very different reading: the arterial pH should have been lower, and the

venous pH should have been higher. To Dr. Chugani, the brain damage was considerably

worse than acidosis can explain. But the injury was selective and diffuse, which he

Case No. 2019-00122JD -15- DECISION

testified is not consistent with a hypoxic-ischemic injury. He added that the presence or

absence of red neurons is not relevant, because the injury that killed Malak Badawi

occurred before Malak ever got to the hospital. Thus, the result was inevitable even if an

emergency Cesarean section had been performed at, say, 10 a.m. on June 7th. But Dr.

Chugani admitted that no other doctors treating Malak raised the issues that he, Dr.

Chugani, did. In addition to the doctors noted above, Gordon Sze, M.D. of Yale University

School of Medicine testified that Malak had acute profound prolonged hypoxic ischemia.

To Dr. Chugani, that was wrong.

{¶44} This Court is not convinced that Dr. Chugani’s opinion has merit. For one

thing, Dr. Chugani’s opinion flies in the face of so many other expert opinions. Just as

importantly, as Plaintiff’s counsel noted, Dr. Chugani’s opinions are not directly in his field

of expertise. For example, Dr. Chugani testified that “By definition, gliosis is not normal.”

But Dr. Kendler, Dr. Vogel, and Dr. Pierson all testified that there IS normal gliosis.

{¶45} In summary, the Court finds by a preponderance of the evidence that Malak

Badawi did not die from a longstanding pre-existing injury, but, as stated in the NCH

autopsy report, “[t]he underlying cause of death was uterine rupture (by clinical history).

The most likely immediate cause of death was extensive acute hypoxic ischemic brain

injury.” (Autopsy Report, at 1.)

B. Plaintiff has proven claims of medical negligence by a preponderance of

the evidence.

{¶46} The arguments of counsel basically require this Court to decide whether, and

when, a uterine rupture reasonably should have been suspected in this case. Defendant

maintains that, if a decision is made for Badawi, then a natural consequence of that

decision would be the elimination of the VBAC unit at The Ohio State University Wexner

Medical Center, since (not unlike Chicken Little), a “The Sky is Falling” rationale must

attend each and every TOLAC/VBAC birth.

{¶47} This Court respectfully disagrees.

{¶48} It is undisputed that, between the hours of 0840 and 1240, Dr. Malone

(Elshazli’s attending physician) did not see or observe Elshazli. And while Defendant is

a teaching and academic hospital, and this Court gives some deference to that situation,

Case No. 2019-00122JD -16- DECISION

it must be said that leaving a TOLAC patient to be attended by a first-year resident (and

a registered nurse with only slightly more experience), presents risks of its own. This is

not to say that at every moment, Dr. Malone (or, say, experienced physicians in the field

of obstetrics and gynecology, such as a Steven Gabbe, M.D., or a Mark Landon, M.D., of

The Ohio State University Wexner Medical Center) must be present. That swings things

to the opposite extreme. But situational awareness is not limited to evaluating signs and

symptoms of (for example) uterine rupture; it includes the possibility that, however brilliant

a first-year resident is (and this Court certainly notes that there is ample evidence that Dr.

Walker has become an outstanding physician), such a person while in first year residency

still has a very great deal to learn. The Court notes, for example, the commentary on the

level at which Dr. Gabbe’s text was written—for the medical student and the resident—

as opposed to more experienced doctors.6 Therefore, it is evident that a first-year

resident (even one approaching the end of that first year) is not that far along in one’s

training. This Court understands and accepts this premise, because it is also very true

regarding the practice of law.

{¶49} On June 7, 2018, Elshazli credibly communicated to a nurse, that she had

no problem switching to a Cesarean section. One reason for this is that during the birth

of Laila, Elshazli believed that that delivery was rushed. And although the medical records

do not entirely support that belief, it is true that Laila’s birth by Cesarean section was due

to concern over Laila’s “nonreassuring fetal well-being.” In that sense, the Cesarean

section was promptly done, which, considering the time-period for the possible vaginal

delivery to that point, was considerably shorter in time. Unfortunately, there is nothing in

the medical record that indicates that Elshazli’s preference concerning Malak’s birth was

communicated to Dr. Walker or Dr. Malone. It should have been. Elshazli testified that,

after her “water broke,” a nurse informed her that meconium was present. Elshazli

explained to the nurse, that if there was any risk to her baby, then she was fine with having

a C-section. According to Elshazli, the nurse informed her that “No, no, no, it’s fine” and

that the presence of meconium meant that a physician should be present in the room at

delivery. Since the position of OSUWMC is that the patient has the right to make her own

6 No differentiation is made, in this context, between a first-year resident and a fourth-year resident,

although, clearly, there is in fact a difference.

Case No. 2019-00122JD -17- DECISION

medical decisions, Elshazli’s request should have been followed, or, at a minimum,

discussed in more detail with her. Again, this did not happen.

{¶50} In this instance, several signs were present to Defendant’s medical team.

Dr. Robinson, who favorably impressed this Court with his testimony, noted that the first

decel occurred around 0915, with bradycardia at 0922. He testified that Nurse Miller did

the correct thing IF this were a regular pregnancy, but, of course, it wasn’t: Elshazli was

a TOLAC patient. Nurse Miller noted the late decels, and the strip was reviewed at 1024

by Dr. Malone.

{¶51} Dr. Robinson noted that at 1100, Elshazli experienced shoulder pain.

Shoulder pain that involves irritation of the diaphragm is a definite sign of uterine rupture,

and the irritation which leads to the shoulder pain can be caused by either fluid or by gas.

It is a rare sign of uterine rupture, but it clearly is a sign, as Robert Small, M.D., an

attending anesthesiologist at OSUWMC, seemed to recognize. Dr. Robinson testified

that the ‘judicious call’ is to get the baby delivered. During this time, Malak was not having

enough accels; that is, she was not getting enough blood delivered. During this time

Elshazli’s contractions were much flatter.

{¶52} These factors called for situational awareness. Again, at 1240 (when Dr.

Malone arrives at Elshazli’s bedside), Elshazli is on her hands and knees, and she has

bradycardia. Given two bradycardias and the shoulder pain, waiting, and trying to do a

vaginal delivery as 1313 approaches was a large mistake, according to Dr. Robinson,

since, according to Elshazli’s medical record, dilation was completed at 1158 on June 7th.

(Joint Ex. A2, p. 150 of PDF.) At trial Dr. Robinson noted that once a sign (or signs) of

uterine rupture occurs, rupture can literally come with the next contraction. This is the

medical reason that situational awareness must take into account; yet, it was not done

here.

{¶53} Defense experts were critical of Dr. Robinson’s testimony, especially when

considering the notion of air getting to the diaphragm to cause irritation. Their testimony

was to the effect that the uterus is a closed system, so it cannot admit air, therefore, there

was no possible way for air to have caused the diaphragmatic irritation referenced by Dr.

Robinson. The Court might ordinarily accept that criticism as valid, except that after the

water broke (at 0240), the system was no longer closed. Furthermore, there were

Case No. 2019-00122JD -18- DECISION

examinations that involved internal checking of Elshazli by the medical team, to ascertain

the station of the baby, which again refute the notion of a “closed system.” And this Court

accepts the testimony that not a great deal of air (“only a bubble”) is needed to cause

such irritation.

{¶54} Yet another reason advanced by those critical of this portion of Dr.

Robinson’s testimony bears more discussion: whether a uterine rupture must be

“sudden.” Dr. Gabbe’s text on uterine rupture, Chapter 20 (written by Dr. Landon, of The

Ohio State University, and Dr. William B. Grobman), states that “Uterine Rupture can be

catastrophic, sudden, and unpredictable.” (Emphasis added). Counsel have repeatedly

brought this sentence to the attention of the Court, and, after careful consideration of the

testimony, and a review of that portion of the Chapter, this Court interprets this sentence

to mean that uterine rupture does not have to be sudden, although it certainly can be. It

is painfully evident that uterine rupture can be catastrophic (again, this is not always so),

and it is also clear that uterine rupture is unpredictable. That unpredictability is noted in

the sentence immediately following the above quoted sentence, which reads as follows:

“Persons who care for women undergoing TOLAC should be familiar with electronic FHR

patterns that may be associated with uterine rupture as well as the potential need for

emergent delivery.” A sentence preceding the above two quoted sentences reads as

follows: “Studies that have examined fetal heart rate (FHR) patterns before uterine

rupture consistently report that nonreassuring signs, particularly prolonged

decelerations or bradycardia, are the most common signs of uterine rupture.”

(Emphasis in the original). And in addition to the above quoted text, other testimony in

this case clearly confirms the unpredictability of uterine rupture, as well as pointing out

the relative importance of fetal heart rate patterns. And no other testimony (or textbook

information) gives the slightest hint that uterine rupture is predictable. There are

indicators, or signs, but nothing that can directly predict a uterine rupture.

{¶55} Having noted the foregoing, the Court looks to the sentence from Dr.

Gabbe’s text as an indicator that a uterine rupture need not necessarily happen all at

once. By “complete” this Court means that the rupture need not completely rip open the

entire length of the scar that exists from the prior Cesarean delivery. A uterine rupture

exists when a through and through opening occurs at any location along the scar from

Case No. 2019-00122JD -19- DECISION

the previous Cesarean section. Uterine rupture must also be distinguished from uterine

scar dehiscence. In the latter, the tear is not complete: part of the uterus is still intact. A

uterine rupture, once occurring, can be extended in length as further pressure is exerted

on the tear, in other words.

{¶56} In the context of this case, neither Dr. Walker nor Nurse Miller had anything

other than theoretical experience/exposure to cases of uterine rupture. Dr. Malone, who

had more familiarity, was physically absent during the critical four-hour period noted

above.

{¶57} Defendant contends, however, that Dr. Malone, Dr. Walker, and Nurse Miller

did not deviate from the standard of care. In this regard, Defendant presented Anthony

Sciscione, D.O., whose testimony ran directly counter to that of Dr. Robinson. This Court

does not find Dr. Sciscione’s testimony in this case to be as credible as Dr. Robinson’s.

There are several reasons for this. First, Dr. Sciscione was reluctant to acknowledge

prolonged decels in this case. He initially testified that he thought the FHR in the 0920

time frame was a “variable deceleration.” This Court is clearly a rank amateur in

assessing FHR strips, but when the Court pointed out to Dr. Sciscione that there was “a

squiggle” at about 0925:20 to 0925:27, and that that mark was around the “80” range—

Dr. Sciscione then agreed that this time frame did, in fact, present as a prolonged decel,

“although it’s hard to interpret.”. Other witnesses clearly indicated that this was a

prolonged decel. This Court was, and is, reluctant to give much weight to the FHR

interpretations of Dr. Sciscione.

{¶58} A second reason is that Dr. Sciscione testified that he disagreed with the

statement that uterine rupture is the principal risk that presents with a TOLAC patient.

The quotation, taken from the Gabbe text, was affirmed by every other medical

professional who testified in this case. It is also in the Policy Statement of Defendant.

{¶59} A third reason is that, unlike every other doctor who testified, Dr. Sciscione

testified that shoulder pain has absolutely no connection with uterine rupture. This Court

was startled to hear this, and so directly asked Dr. Sciscione about it, and in no uncertain

terms Dr. Sciscione reiterated that same answer to the Court.7

7 “The Court: ‘Basically, what I understand you to say is that shoulder pain has absolutely no

connection with uterine rupture. Is that a fair statement?’

Case No. 2019-00122JD -20- DECISION

{¶60} Further, while Dr. Sciscione testified that based on the information provided

to him that Dr. Walker had participated in 157 births, which, as he noted, was a very high

number, he failed to mention, or distinguish, that NONE of these births involved a TOLAC

patient. In fact, as the record indicates, Elshazli was Dr. Walker’s first TOLAC patient.

Even the word “participation” is fraught with ambiguity. To this Court, Dr. Sciscione

appeared to be inflating Dr. Walker’s qualifications.

{¶61} Moreover, Dr. Sciscione has given the same type of testimony relating to

cause of death in ten other cases of this type, arguing that a pre-existing injury occurred

that caused the baby’s death. While this consistent similarity was not further explored, it

certainly raised a significant question mark with this Court.

{¶62} In short, Dr. Sciscione provided a number of reasons (and the above is not

necessarily a complete list) for this Court to discredit the salient points of his testimony.

{¶63} The record is clear that for four hours, from 0840 to 1240, Dr. Malone was

not present in the same room as Elshazli. This, in and of itself, is not a breach of the

standard of care. However, when warning signs of uterine rupture present—as they did

here—her absence left Elshazli with two persons essentially responsible for her care: Dr.

Walker and Nurse Miller. Dr. Walker had never treated a TOLAC patient before, and she

was a first-year resident at the time. This Court believes that had Elshazli not been a

TOLAC patient, the care provided by Dr. Walker and Nurse Miller would have been

sufficient to meet the standard of care.

{¶64} But Elshazli was a TOLAC patient, and the record that presents is clear that

this difference made all the difference in finding that Dr. Malone, Dr. Walker and Nurse

Miller failed to meet the standard of care in this case. Certainly, ambiguity existed as to

each purported sign of uterine rupture, but this Court notes that that is always the case,

because uterine rupture simply cannot be confirmed until after the event takes place.

{¶65} Summarily stated, there were signs of uterine rupture from 0920 right up to

1313 on June 7, 2018: First, there was a significant prolonged decel starting around

A: ‘Yes, Judge, because it makes no sense physiologically.’” Defense counsel attempted to walk this back,

indicating that Dr. Sciscione was merely referring to this case, but this Court did not and does not read his

testimony that way.

Case No. 2019-00122JD -21- DECISION

0920:52, or at least by 0921:12 to 0921:20, and this decel lasts until about 0925:10. That

is approximately four minutes in length, about twice as long as the basic definition of a

prolonged decel. Second, although the prolonged decel come back to the baseline, a

return to baseline is a part of the definition of a prolonged decel.

{¶66} Plaintiff argues that there was another prolonged decel at starting at 1056:07

to 1057:50. This Court disagrees, as that does not (quite) fit the 2-minute requirement of

having a FHR at least 15 bpm under the baseline. It is close, to be sure, but if one accepts

the definition of a prolonged decel as noted above, this does not qualify.

{¶67} However, there is no doubt to this Court that there were significant prolonged

decels occurred from 1234:55 to 1237:50, and from 1239:50 (at least) to 1244:47 (almost

five minutes).8 Yet another prolonged decel occurred at 1305:00 to 1307:15. Finally, a

lengthy prolonged decel took place from 1312:48 on.9 The FHR monitor was

disconnected just after 1318.

{¶68} There were also a significant number of recurrent decels. These took place

between 0910 and 0950; 10:30 to 10:50; 1220 to 1240; and 1300 to 1318. As Dr. Stafford

noted, “It would definitely be—it would be reasonable—I’m sorry—to have a heightened

suspicion [of uterine rupture], especially with the second one you circled there.”

{¶69} Based on the foregoing, there was certainly a reason to give significant

consideration to the possibility of uterine rupture. However, there is more.

{¶70} One of the most contentious issues in this case involved the issue of

shoulder pain. It is undisputed that Elshazli experienced shoulder pain at around 1040.

But the question arises whether that pain was a symptom of uterine rupture.

{¶71} Despite not being a symptom of uterine rupture expressly stated in Dr.

Gabbe’s text, the medical professionals in this case (with the exception of Dr. Sciscione)

were in agreement that shoulder pain definitely could be a symptom of uterine rupture

8 The Court notes that for much of this time, the FHR monitor has a great deal of “skips” in it.

However, none of the markings—when present—show anything that approaches a return to baseline. And

while Elshazli was being repositioned during this time, from being on her back to ‘hands and knees’, when

there ARE markings, as noted above, nothing presents as a return to baseline. It is much more likely,

certainly much more than a preponderance of the evidence, that the FHR remained far below the baseline.

9 Dr. Malone testified that the decel occurred from about 1312:45 to 1316:55 (she circled the

parameters on a copy of the chart).

Case No. 2019-00122JD -22- DECISION

due to irritation of the phrenic nerve, which controls the diaphragm. Having said that,

shoulder pain is not an exclusive sign of uterine rupture, and it is a sign that is considered

to be rare. The irritation caused by fluid or gas causes shoulder pain. This Court accepts

the testimony of Dr. Robinson that air (or fluid) can escape the uterus during labor—the

uterus is not as closed a system as the defense argues. The defense argues, however,

that this presentation of shoulder pain was reproducible, something that should not be the

case with diaphragmatic irritation. This Court respectfully disagrees. As Elshazli is being

moved from side to side, the gas will go to the higher point of the body (much like air in a

bottle of water). This of course could cause the pain to reproduce. While this is a closer

call than other signs of uterine rupture (as noted, shoulder pain is a rare sign of uterine

rupture), the existence of the shoulder pain is something that, in conjunction with all other

symptoms, should have resulted in a situational awareness that there was a growing

chance of uterine rupture.

{¶72} The connection between shoulder pain and uterine rupture was noted by

Dr. Small, an anesthesiologist. He understood that this was not an issue of anesthesia,

and this Court agrees. Defendant’s argument that three doctors were evaluating Elshazli

sounds good, but in context, one was a first-year resident, the second was an

anesthesiologist in training, and the third was Dr. Small, an anesthesiologist. With all due

respect, this is not as comforting a thought as would appear on the surface, especially

since an obstetrician is said to be on call 24 hours/7 days a week.

{¶73} There is also sufficient evidence of maternal tachycardia from 1040 on. This,

too, is a warning sign of uterine rupture.

{¶74} All these signs, combined with the absence of Dr. Malone from 0840 to 1240,

lead this Court to the conclusion that, by a preponderance of the evidence, Dr. Malone

(by her absence), Dr. Walker (a first-year resident), and Nurse Miller breached the

standard of care in regard to Elshazli. A Cesarean delivery should have been ordered

well before 1313.

{¶75} The next issue is whether such negligence was the proximate cause of

Malak’s death. In Jeffers v. Olexo, 43 Ohio St.3d 140, 143, 539 N.E.2d 614 (1989), the

Ohio Supreme Court discussed the concept of proximate cause:

Case No. 2019-00122JD -23- DECISION

“Proximate cause is a troublesome phrase. It has a particular meaning in

the law but is difficult to define. It has been defined as: ‘That which

immediately precedes and produces the effect, as distinguished from a

remote, mediate, or predisposing cause; that from which the fact might be

expected to follow without the concurrence of any unusual circumstance;

that without which the accident would not have happened, and from which

the injury or a like injury might have been anticipated.’ 65 C.J.S. § 103

Negligence pp. 1130-1131. * * *” Corrigan v. E. W. Bohren Transport Co.

(C.A. 6, 1968), 408 F. 2d 301, 303.

Accord Aiken v. Indus. Com., 143 Ohio St. 113, 117, 53 N.E.2d 1018 (1944) (noting that

in the field of torts “the proximate cause of an event is that which in a natural and

continuous sequence, unbroken by any new, independent cause, produces that event

and without which that event would not have occurred”). See Dobbs, Hayden, and

Bublick, The Law of Torts, Section 198, 681 (2d Ed.2011) (“proximate cause rules are

among those rules that seek to determine the appropriate scope of a negligent

defendant’s liability” (footnote omitted)).

{¶76} Based on the previously discussed analysis of events that took place on

June 7, 2018, relative to the negligence claim, this Court is convinced by a preponderance

of the evidence that the negligence of Defendant’s medical professionals was the

proximate cause of the death of Malak Badawi. Dr. Malone’s absence from Elshazli’s

room between the hours of 0840 and 1240—a time that key events occurred relevant to

a determination whether a C-section should have been performed—coupled with

Defendant’s medical team’s collective lack of situational awareness whether Elshazli may

be experiencing a uterine rupture during the hours of 0840 and 1240 proximately caused

Malak to sustain extensive acute hypoxic ischemic brain injury and such collective

negligence is sufficient to impute liability to Defendant by a preponderance of the

evidence.

{¶77} Before moving to the issue of damages, some additional comments are

necessary. First, Badawi credibly testified that Dr. Malone kept saying, “This is normal,”

and “We’re far away from this being an emergency,” in reference to what was occurring

from 1240 to 1313. This presents to the Court the notion that what Dr. Malone preferred

Case No. 2019-00122JD -24- DECISION

to achieve in this case was a successful vaginal delivery. While, in one sense, that is to

be commended (in the abstract), it simply is not in accord with situational awareness of

what happened between 0840 and 1240.

{¶78} Second, this Court wishes to add to its ruling that limited the testimony of

Stephen Thung, M.D. Dr. Thung performed an act of kindness when, upon seeing a

person crying, went to provide comfort and find out if there was anything he could do.

Upon learning of this tragedy, Dr. Thung stated that he would try to find out what

happened in reference to Malak’s death. This is entirely praiseworthy.

{¶79} But what happened after that is that Dr. Thung became a critical part of the

Review Committee, which exists to determine what happened in any particular case, so

as to review the actions of a doctor whose patient did not have a desirable outcome. The

work of such a review committee is rightly protected as confidential and non-discoverable

by law.

{¶80} But by being an integral part of the Review Committee, Dr. Thung would be

absolutely prohibited from disclosing anything relative to the merits of the case to Badawi

and Elshazli. And it puzzles the Court as to why Dr. Thung would assure a grieving parent

that he would try to find out what happened, yet then be in a position to be absolutely

unable to tell them anything of substance about what the Review Committee did.

{¶81} The first thing Dr. Thung testified to when he took the stand was to say “I

don’t know why Malak died.” When considering that statement, this Court realized that

Dr. Thung was testifying as someone who was a part of the Review Committee; indeed,

a most valued participant. That testimony, coupled as it was with the privileged nature of

his investigation, caused this Court to take a very dim view of letting him testify on the

merits of this case. This is because his initial statement was fraught with possible waiver.

Had Plaintiff pressed the issue, this Court may well have found that by that statement (“I

don’t know why Malak died”), Dr. Thung waived the privilege concerning the Committee’s

work. So rather than address the issue of waiver, the Court opted to strictly limit his

testimony. There was no other option, especially given the staunchly protective mode of

defense counsel during Dr. Thung’s deposition.10

10 The Court is not saying that it disagrees with the legal position taken during that deposition.

Case No. 2019-00122JD -25- DECISION

V. Plaintiff is entitled to damages for mental anguish and loss of consortium.

{¶82} In an action for wrongful death, the personal representative is a nominal

party, and the statutory beneficiaries are the real parties in interest. Damages for wrongful

death are awarded to the decedent’s family to compensate for the injury they suffered as

a result of the decedent’s untimely death. Perry v. Eagle-Picher Industries, 52 Ohio St.

3d 168, 170, 556 N.E. 2d 484 (1990) (internal citations omitted). In this case, the real

parties in interest are Mohamed Badawi, Sara Elshazli, and Laila Badawi. Ali Badawi,

born in 2020, is a family member, but is not a party in interest in this case. Mohamed

Badawi has not included Ali Badawi in the Complaint or requested an award of damages

for him.

{¶83} R.C. 2125.02 pertains to damages in a wrongful death action. R.C.

2125.02(D) provides:

Compensatory damages may be awarded in a civil action for

wrongful death and may include damages for the following:

(1) Loss of support from the reasonably expected earning capacity of the

decedent;

(2) Loss of services of the decedent;

(3) Loss of the society of the decedent, including loss of companionship,

consortium, care, assistance, attention, protection, advice, guidance,

counsel, instruction, training, and education, suffered by the surviving

spouse, dependent children, parents, or next of kin of the decedent;

(4) Loss of prospective inheritance to the decedent’s heirs at law at the time

of the decedent’s death;

(5) The mental anguish incurred by the surviving spouse, dependent

children, parents, or next of kin of the decedent.

Compare R.C. 2125.02 (D)(3) (loss of consortium) with (D)(5) (mental anguish). See

Black’s Law Dictionary 1133 (11th Ed.2019) (defining “loss of consortium” as “1. A loss

of the benefits that one spouse is entitled to receive from the other, including

companionship, cooperation, aid, affection, and sexual relations. * * * 2. A similar loss of

benefits (minus sexual relations) that one is entitled to receive from a parent or child”).

Case No. 2019-00122JD -26- DECISION

{¶84} In the Complaint, specifically in Count III, Wrongful Death, at paragraph

33(a), Plaintiff requests damages for “Mental anguish incurred by the parents by reason

of the death of the infant.” (Emphasis added.) In subparagraph (b), Plaintiff requests

damages for “Loss of the society, companionship, comfort, love, solace, assistance, and

care to the parents of the deceased.” In short, this is a request for damages for loss of

consortium.

{¶85} “‘The cardinal principle of damages in Anglo-American law is that of

compensation for the injury caused to plaintiff by defendant’s breach of duty.’ 2 F. Harper

& F. James, Law of Torts § 25.1, p. 1299 (1956) (emphasis in original).’” (Footnote

omitted.) Carey v. Piphus, 435 U.S. 247, 254-255, 98 S.Ct. 1042, 55 L.Ed.2d 252 (1978).

Accord Fantozzi v. Sandusky Cement Prods. Co., 64 Ohio St.3d 601, 612, 597 N.E.2d

474 (1992) (“[t]he fundamental rule of the law of damages is that the injured party shall

have compensation for all of the injuries sustained”). The Ohio Supreme Court has

explained:

Compensatory damages are intended to make whole the plaintiff for the

wrong done to him or her by the defendant. * * * Compensatory damages

are defined as those which measure the actual loss, and are allowed as

amends therefor. For example, compensatory damages may, among other

allowable elements, encompass direct pecuniary loss, such as hospital and

other medical expenses immediately resulting from the injury, or loss of time

or money from the injury, loss due to the permanency of the injuries,

disabilities or disfigurement, and physical and mental pain and suffering. *

* * Other elements such as pain and suffering are more difficult to evaluate

in a monetary sense. The assessment of such damage is, however, a

matter solely for the determination of the trier of fact because there is no

standard by which such pain and suffering may be measured. In this regard,

this court has recognized that “no substitute for simple human evaluation

has been authoritatively suggested.” Flory v. New York Central RR. Co.

(1959),170 Ohio St. 185, 190, 10 O.O.2d 126, 128, 163 N.E.2d 902, 905.

Fantozzi, 64 Ohio St.3d at 612, 597 N.E.2d 474 (1992).

Case No. 2019-00122JD -27- DECISION

{¶86} The Tenth District Court of Appeals has remarked that appellate review of

the adequacy of a trial court’s award for noneconomic damages, such as mental anguish

or loss of consortium, “is difficult because no specific yardstick, or mathematical rule

exists for determining pain and suffering.” Hohn v. Ohio Dept. of Mental Retardation &

Dev. Disabilities, 10th Dist. Franklin No. 93AP-106, 1993 Ohio App. LEXIS 6023, at *10

(Dec. 14, 1993), citing Fantozzi at 612; Carter v. Simpson, 16 Ohio App.3d 420, 423, 476

N.E.2d 705 (10th Dist.1984). The Tenth District Court of Appeals stated in Hohn that “[i]n

reviewing the reasonableness of a pain and suffering award, a court may consider awards

given in comparable cases as a point of reference, see Hancock v. Norfolk & Western

Ry. Co. (1987), 39 Ohio App.3d 77, 85, 529 N.E.2d 937, but ultimately must evaluate

each case in light of its own particular facts. Id.” Hohn at *10.

{¶87} In assessing the proper amount of damages that should be awarded, this

Court notes that Plaintiff opted not to have an economist testify. As a result, the damages

to be awarded in this case solely relate to mental anguish and loss of consortium. Badawi

asks for damages for himself, for Elshazli, and for Laila.

{¶88} First, as to Laila. Although Badawi requests an award of damages for her,

such damages were not requested in the Complaint (“[m]ental anguish incurred by the

parents””).11 Thus, although the Court has heard testimony regarding the effect of Malak’s

death on her, an award of damages is inappropriate, given that Laila was not included in

the Complaint. Therefore, the Court will not grant an award of damages for her mental

anguish.

{¶89} The mental anguish of Malak’s parents was properly pled. In addition to the

mental anguish about the loss caused by Malak’s death, there is the mental anguish over

just how the death of Malak occurred. This is not to say that Malak’s death was

intentional, as it obviously was not. But it was avoidable, and there is a lingering guilt on

the part of the parents (even if undeserved) over what occurred.

{¶90} Badawi was in Elshazli’s hospital room during the crisis point after 1 p.m. on

June 7th. Dr. Malone reassures even then that “This is normal” and “We’re far away from

this being an emergency.” The Court notes this not to necessarily find fault with Dr.

11 Complaint, Paragraph 33 (a).

Case No. 2019-00122JD -28- DECISION

Malone for saying those things (although it disagrees with them), but that they remained

in the memory of Badawi. The guilt, or suffering, comes from feeling so helpless as

Elshazli was taken into the operating room for the emergency C-section; she was crying

intensely as she knew something was now dreadfully wrong. This is also true for Badawi;

who felt so helpless when learning of the horrible result. And, for being so helpless in

terms of his commitment to Elshazli; that he somehow failed not only Malak, but Elshazli

as well. Badawi is trying to find some joy in life again.

{¶91} For Elshazli, the feeling is even worse. She is Malak’s mother. The decision

to go the TOLAC route, although agreed to by both Badawi and Elshazli, was more

Elshazli’s decision than Badawi’s. There will not be a day in Elshazli’s remaining time on

Earth where, as long as she remains in possession of her mental faculties, she is not

reminded of this tragedy, and of her central position in it. The depth of her grief was

testified to by Audra Jorday, R.N., who has experience in this area, and noted that she

had never seen anything like the grief exhibited by Elshazli. Elshazli did not want to eat,

shower, or even leave the hospital. Both Badawi and Elshazli reacted to Malak’s death

as if it had just occurred, even though some days had passed. Both parents told Nurse

Jorday that they were having ‘flashbacks’ to being in the operating room. Elshazli testified

about how greatly the death of Malak affected her, about the pain and the guilt and the

hollowness in her heart that she has to carry with her. She had a good friend who had a

due date close to the time of Malak’s, and that friend delivered a healthy baby. Elshazli

has avoided this friend because of all the things her friend’s baby can do that Malak would

never live to do. Elshazli and Badawi were both diagnosed with PTSD as well.

{¶92} Elshazli has suffered profound guilt because she could not save Malak’s life.

Badawi testified to this as well—about Elshazli’s strong feelings of guilt, and the large

sense of anxiety and loss. Elshazli testified that her heart “cringed” over being unable to

save Malak. Even with Elshazli’s relocation to Illinois, Elshazli is reluctant to socially

engage. When Elshazli is asked about how many children she has, she answers “Two”

then feels badly about this answer, but she does not wish to relate the story of Malak’s

brief life. Badawi noted that Elshazli has become very risk averse; she won’t even ride a

roller coaster now.

Case No. 2019-00122JD -29- DECISION

{¶93} In summary, Elshazli and Badawi’s lives are forever changed as a couple,

as parents, and as individuals.

{¶94} If there is a greater loss than the loss of a child to a parent, this Court does

not know what it is. The photograph of Badawi and Elshazli holding Malak is one that

shows the depth of feeling that they had for the child. Added to that is the terrible anguish

that accompanied Badawi and Elshazli’s decision to remove Malak from life support,

when that never should have had to happen. Plaintiff’s counsel suggested using a

formula to determine the amount of damages. This Court has always been somewhat

wary of using a formula in these circumstances. Mental anguish is not a constant. Some

days, it can overwhelm. On other days, at times, it tends to move towards the

background. But never does the mental anguish go away. No caring parent’s life is ever

the same again, and Badawi and Elshazli are very caring parents. No amount of money

can adequately compensate for such a loss. Having said that, monetary compensation

is the only way that exists in our system of law to give some semblance of justice to the

bereaved. It is unsatisfactory in that sense, but it is all that we have.

{¶95} The Court understands the questions of defense counsel about the cost of

raising and educating a child. Those are expenditures that, tragically, no longer have to

be made in Malak’s case, but certainly would have existed had she survived. But such a

calculation, while necessary in determining a proper award for economic damages, has

little, if anything, to do with mental anguish, and it is the latter, and not the former, that

this Court must address. If economic damages were to be awarded, of course they would

be diminished by the aforementioned costs of raising the child.

{¶96} Likewise, there can be no measure or consideration regarding punitive

damages, or punishment, in determining the measure of damages for pain and suffering.

There is not one member of the medical team who wanted anything other than the delivery

of a healthy and fit baby for Badawi and Elshazli. In truth, there is clearly some anguish

on their part as well. No one wanted this to happen. And while that is not relevant in

determining the appropriate measure of damages for mental anguish for Badawi and

Elshazli, this Court is not without an appreciation of the good intentions of the medical

professionals who attended Elshazli. Again, no one wanted this result. Unfortunately,

however, there was sufficient negligence to have proximately caused this result.

Case No. 2019-00122JD -30- DECISION

{¶97} Based upon the evidence before the Court, and in spending a considerable

amount of time in trying to reach a just and proper amount of damages for mental anguish,

the Court, having reviewed the testimony relevant to the issue, finds that damages for

mental anguish are awarded to Mohamed Badawi in the amount of One Million Dollars

(USD 1,000,000.00). Damages for mental anguish are awarded to Sara Elshazli in the

amount of One Million, Two Hundred Fifty Hundred Thousand Dollars (USD

1,250,000.00). Damages for Loss of Consortium are awarded to Sara Elshazli and to

Mohamed Badawi in the amount of Two Hundred and Fifty Thousand Dollars each (USD

250,000.00) for a total damages award of Two Million, Seven Hundred Fifty Thousand

Dollars (USD 2,750,000.00).

VI. Conclusion

{¶98} For reasons set forth above, the Court holds that Mohamed Badawi, as

Administrator of the Estate of Malek Badawi, is entitled to a judgment in his favor in the

amount of Two Million, Seven Hundred Fifty Thousand Dollars (USD $2,750,000.00), plus

Twenty-Five Dollars (USD $25.00) (the cost of the filing fee) and post-judgment interest.

{¶99} It is so Ordered.

PATRICK E. SHEERAN

Judge

[Cite as Badawi v. Ohio State Univ. Wexner Med. Ctr., 2023-Ohio-2654.]

MOHAMED BADAWI, Admr. Case No. 2019-00122JD

Plaintiff Judge Patrick E. Sheeran

v. JUDGMENT ENTRY

THE OHIO STATE UNIVERSITY

WEXNER MEDICAL CENTER

Defendant

IN THE COURT OF CLAIMS OF OHIO

{¶100} For reasons set forth in the Decision filed concurrently herewith, the Court

holds that Plaintiff has proven claims of negligence and wrongful death by a

preponderance of the evidence. Judgment is entered in favor of Plaintiff. The Court

awards damages in the amount of Two Million, Seven Hundred Fifty Thousand Dollars

(USD $2,750,000.00), plus Twenty-Five Dollars (USD $25.00) (the cost of the filing fee)

and post-judgment interest. Court costs are assessed against Defendant. The Clerk

shall serve upon all parties notice of this judgment and its date of entry upon the journal.

PATRICK E. SHEERAN

Judge

Filed June 14, 2023

Sent to S.C. Reporter 7/31/23