Kimberly F. v. Mary Hitchcock ( 1993 )


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  • USCA1 Opinion









    December 3, 1993 [NOT FOR PUBLICATION]

    UNITED STATES COURT OF APPEALS
    FOR THE FIRST CIRCUIT
    ____________________

    No. 93-1438

    KIMBERLY F. AND JOHN F.,

    Plaintiffs, Appellees,

    v.

    MARY HITCHCOCK MEMORIAL HOSPITAL AND
    HITCHCOCK CLINICS, INC.,

    Defendants, Appellants.


    ____________________

    APPEAL FROM THE UNITED STATES DISTRICT COURT

    FOR THE DISTRICT OF NEW HAMPSHIRE


    [Hon. Clarence C. Newcomer, Senior U.S. District Judge]*
    __________________________

    ____________________

    Before

    Cyr, Circuit Judge,
    _____________
    Bownes, Senior Circuit Judge,
    ____________________
    and Boudin, Circuit Judge.
    _____________

    ____________________

    Bradford W. Kuster, with whom Cordell A. Johnston, and Orr
    __________________ ___________________ ___
    and Reno, P.A. were on brief for appellants.
    ______________
    Francis G. Murphy, Jr., with whom Nixon, Hall & Hess, P.A.
    _______________________ _________________________
    were on brief for appellees.

    ____________________

    ____________________

    ____________________

    *of the Eastern District of Pennsylvania, sitting by designation.


















    BOWNES, Senior Circuit Judge. This is an appeal by
    BOWNES, Senior Circuit Judge.
    ____________________

    defendants-appellants, the Mary Hitchcock Memorial Hospital

    and the Hitchcock Clinic, Inc., from a jury verdict finding

    them liable to plaintiffs-appellees, Kimberly F. and her

    husband, John F., because of negligent care given Kimberly F.

    while she was a patient at the Mary Hitchcock Memorial

    Hospital. John F.'s suit was for loss of consortium. We,

    therefore, treat the plaintiffs as one. The Hitchcock

    Clinic, Inc. is an incorporated association of physicians and

    surgeons, some of whom treated Kimberly F. while she was at

    the hospital. Because of the nature of Kimberly F.'s injury,

    it was agreed that she and her husband could use pseudonyms

    to keep some degree of anonymity.

    Kimberly F. was admitted to the obstetrical unit of

    the hospital on August 2, 1986. She gave birth to a son on

    August 3. The child was full term. There were no birth

    complications, and she was discharged on August 5. One week

    later, on August 13, Kimberly F. was diagnosed as having an

    outbreak of genital herpes. She subsequently sued the

    defendants alleging that she was infected with herpes while

    at the hospital and that defendants negligently failed to

    protect her from such infection. Plaintiff also brought a

    count for failure to obtain informed consent.1 The jury


    ____________________

    1. Plaintiff and her husband had moved from New Hampshire to
    another state before this action, based on diversity
    jurisdiction, was brought.

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    found defendants not liable on this count and there has been

    no appeal from this finding.

    Defendants raise three issues before us: that, as

    a matter of law, there was insufficient evidence for the

    jury's finding of negligence; that testimony was improperly

    admitted; and that the closing argument of plaintiff's

    counsel on pain and suffering was improper. We discuss the

    issues seriatim.

    I.
    I.

    SUFFICIENCY OF THE EVIDENCE
    SUFFICIENCY OF THE EVIDENCE
    ___________________________

    In ruling on an appeal from the denial of a motion

    for a directed verdict, we conduct a plenary review of the

    evidence. Our review of the evidence and all reasonable

    inferences therefrom is made in the light most favorable to

    the non-moving party. American Private Line Services, Inc.
    _____________________________________

    v. Eastern Microwave, Inc., et al., 980 F.2d 33, 35 (1st Cir.
    _______________________________

    1992); Gallagher v. Wilton Enterprises, Inc., 962 F.2d 120,
    _________ ________________________

    124 (1st Cir. 1992). The denial of a motion for judgment

    n.o.v. is also subject to plenary review. The standard of

    review is whether the evidence and all reasonable inferences

    therefrom could lead a reasonable person to but one

    conclusion: that the moving party was entitled to judgment.

    Pontarelli v. Stone, 930 F.2d 104, 113 (1st Cir. 1991);
    __________ _____

    Hendricks & Associates, Inc. v. Daewoo Corp., 923 F.2d 209,
    _____________________________ ____________

    214 (1st Cir. 1991). We have conducted the requisite review



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    and find that the district court was correct in denying the

    motions for a directed verdict and judgment n.o.v.

    A. The Evidence
    A. The Evidence
    ____________

    The evidence viewed in the light most favorable to

    plaintiff was as follows. When she was admitted to the

    hospital on August 2, 1986, plaintiff had no prior history of

    herpes. When plaintiff was examined by defendants on August

    13, she was diagnosed as having an outbreak of genital

    herpes. Such an outbreak is characterized by lesions in the

    infected area. The incubation period for a herpes infection

    is two to twenty-six days. Plaintiff entered the hospital on

    August 2, was discharged on August 5, and the medical

    diagnosis of genital herpes was made on August 13. She was

    well within the herpes incubation period.

    Genital herpes is a life-long affliction and, as is

    true of other types of herpes, is incurable. Outbreaks of

    herpes, manifested by lesions and cold sores, occur from time

    to time during the victim's life. The first attack is

    usually the most severe. The genital herpes outbreak

    diagnosed on August 13 was a primary (first-ever) outbreak,

    i.e., plaintiff never had a herpes outbreak prior to this
    ____

    time. Plaintiff's sexual history was as follows. She had

    sexual intercourse twice in high school; both times her

    partners used condoms. She married for the first time in

    1981. After her first child was born she was divorced. The



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    divorce became final in 1982 or 1983. She met her present

    husband in 1984. She had no sexual relations with other men

    between separating from her first husband and meeting her

    present one. Neither she nor her husband had ever engaged in

    oral sex at any time. Plaintiff's husband has never had any

    herpes symptoms.

    When plaintiff was first admitted to the hospital

    she was put in a birthing room that shared a bathroom with

    another patient. Plaintiff went into the bathroom alone

    because no one had come in response to her pushing the

    nurses' call button. She felt dizzy and sat on the toilet to

    avoid falling. In so doing, she sat on a urine catch basin

    that was in the toilet bowl. The basin contained urine from

    the other patient. As her labor pains increased in

    frequency, a nurse suggested a warm bath might help. She was

    taken to a room with a bathtub. Both she and her husband

    noted that the tub contained some dead bugs. There was an

    open window with no screen. Plaintiff's husband cleaned out

    the tub and she took a bath. During the birthing process, an

    episiotomy was done. This consists of making a surgical

    incision into the perineum and vagina so as to prevent

    tearing during delivery. Prior to delivery, nurses examined

    plaintiff internally to see whether her cervix had dilated.

    Some of the nurses did not wash their hands in the sink in

    plaintiff's room before examining her.



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    After delivery, plaintiff experienced pain and

    discomfort at the site of the episiotomy. Reusable plastic

    ice packs were applied to ease her discomfort. The ice packs

    were wrapped in sterile green surgical cloth. At times, the

    pack was placed over plaintiff's vaginal area in such a way

    that the surgical cloth did not completely cover the plastic

    bag. This resulted in direct contact between the site of the

    episiotomy and the plastic bag. On the day of plaintiff's

    discharge a nurse came in and checked plaintiff's perineal

    area and touched the episiotomy site with her hands. The

    nurse had not washed her hands, nor was she wearing gloves.

    On July 31, a patient was admitted to the

    obstetrics unit of the hospital with a herpes lesion behind

    her right knee. The patient was placed on herpes isolation

    precautions during all of the time she was at the hospital.

    This entailed strict procedures to prevent the patient's

    herpes infection from spreading to other patients. This

    patient was discharged on the morning of August 2; plaintiff

    was admitted at 11:30 p.m. on August 2.

    A second patient with herpes was in the maternity

    ward at the same time as plaintiff. This patient, "J.D.,"2

    occupied the same room as did plaintiff immediately prior to

    plaintiff being put in the room. The records of J.D. show



    ____________________

    2. This is the case name of the patient, not her actual
    name.

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    that because she had had monthly episodes of herpes outbreaks

    during her pregnancy, she was admitted "at risk," and was

    placed on herpes infection precautions. A herpes culture was

    taken from J.D.'s right labial lesion on July 28. It was

    noted in her records that she was at high risk and herpes

    infection precautions were continued. J.D. gave birth via a

    Caesarean section on July 29. Her records show that the

    reasons for the Caesarean section were that the baby was

    breached and that J.D. was at risk with herpes. On July 30,

    a nurse's note in J.D.'s records stated that she had two

    lesions on the left outer lower labia. A subsequent note on

    the same day states that J.D. continued to have lesions on

    the left lower labia. There is nothing in the record

    indicating that any culture was taken from the lesions on her

    left lower labia. The only culture taken was from the lesion

    on the right labia. The lab report on this culture was

    necessarily a preliminary one; it was negative for herpes. A

    negative culture report on herpes normally includes the

    statement, "these results do not exclude infection with

    herpes simplex virus." This report did not so state. On the

    evening of August 2, the day that plaintiff was admitted to

    the hospital, J.D. was transferred to the second floor.

    Later that evening she told a nurse that she was concerned

    about the fact that she was still on herpes infection

    precautions. The nurse, Linda Morgan, recorded in her chart



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    that J.D. wanted to be taken off herpes infection precautions

    and that she had shown no lesions since July 29. This

    information was given by telephone to Dr. Ketterer and the

    same night, August 2, he gave a verbal order to remove J.D.

    from herpes precautions.

    Nurse Morgan admitted during her testimony that she

    did not tell Dr. Ketterer about the lesions on J.D.'s left

    labial area. Dr. Ketterer admitted that his decision to take

    J.D. off herpes infection precautions was based on incomplete

    information. About two hours after J.D. was taken off

    precautions, plaintiff was admitted to the hospital. She

    spent the next eight hours in labor and delivery on the

    second floor, where J.D. was also located. Both plaintiff

    and J.D. were discharged from the hospital on the same day,

    August 5.

    Two nurses, J.W. and M.W., had herpes and worked in

    the maternity ward of the hospital while plaintiff was a

    patient there. J.W. had a history of genital herpes. She

    gave direct patient care to plaintiff, which included placing

    ice packs on her perineum and physically examining her.

    There was no direct evidence that the other nurse with

    herpes, M.W., had patient contact with plaintiff, but she was

    present on the maternity ward and available to give care to

    all of the patients in the ward.





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    All of the doctors who testified agreed, in effect,

    that it would be a violation of acceptable hospital infection

    precautions for a patient to be infected by herpes while a

    hospital patient.













































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    B. Testimony of Plaintiff's Expert Witness
    B. Testimony of Plaintiff's Expert Witness
    _______________________________________

    Appellants' attack on the sufficiency of the

    evidence focuses on the testimony of plaintiff's expert

    witness, Dr. James Kahn. Their claim is that "no expert

    witness identified any act of negligence that more probably

    than not caused the infection." Appellants' Brief at 9.

    Both sides agree that New Hampshire law controls this issue.

    We will therefore examine New Hampshire law and rule

    accordingly.

    In Thorpe v. New Hampshire Department of
    ______ ________________________________

    Corrections, 575 A.2d 351, 353 (N.H. 1990), the court stated:
    ___________

    "The general rule in medical malpractice cases is that the

    proximate cause between the negligence and the injury must be

    established through expert testimony." In Martin v.
    ______

    Wentworth-Douglass Hospital, 536 A.2d 174, 176 (N.H. 1987),
    ___________________________

    the court held that expert testimony was necessary to

    establish the causal link between the injury complained of

    and the health care provider sought to be held accountable,

    and "[t]he quantum of such evidence necessary to survive a

    motion for nonsuit had to be enough to warrant the conclusion

    of a reasonable juror that the causal link probably existed."

    See also Wilder v. Eberhart, 977 F.2d 673, 676 (1st Cir.
    ___ ____ ______ ________

    1992). In Pillsbury-Flood v. Portsmouth Hospital, 512 A.2d
    _______________ ___________________

    1126 (N.H. 1986), the court held:
    In New Hampshire, the plaintiff in a
    medical malpractice action must prove
    that the defendant's negligence caused


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    the patient's injury or loss. See
    ___
    Carrigan v. Sacred Heart Hospital, 104
    ___________________________________
    N.H. 73, 80, 178 A.2d 502, 506-07 (1962).
    "[N]egligent conduct is a proximate or
    legal cause of harm, if the actor's
    conduct is a 'substantial factor in
    bringing about the harm.'" Maxfield v.
    ________
    Maxfield, 102 N.H. 101, 105, 151 A.2d
    ________
    226, 230 (1959) (quoting Restatement of
    Torts 431(a) (1934)). This issue is
    normally one for the trier of fact once a
    prima facie case is established. See
    ___
    id.; W. Keeton, D. Dobbs, R. Keeton & D.
    ___
    Owen, Prosser and Keeton on the Law of
    Torts 41, at 269 (5th ed. 1984)
    (hereinafter cited as Prosser & Keeton).

    Id. at 1129.
    ___

    We now turn to Dr. Kahn's testimony. There was no

    objection to Dr. Kahn's expert qualifications in the field of

    infectious diseases. The crux of his testimony came in the

    answers to a series of questions. Dr. Kahn was asked:

    "Based on your review of all the information, do you have an

    opinion, based on reasonable medical probabilities, as to

    whether or not Mrs. F.'s infection, outbreak of herpes in

    August of 1986 was a primary infection?" He answered: "Yes,

    I continue to feel very emphatically that it was a primary

    infection." In prior testimony Dr. Kahn had explained that

    the term "primary infection" meant a first-ever herpes

    infection. Dr. Kahn had explained the nature of herpes

    infections and how outbreaks of the disease are manifested.

    The next question bearing on the issue was: "Do

    you have an opinion, based on reasonable medical

    probabilities, as to whether or not the hospital was the


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    probable source of -- general source of Kimberly F.'s

    infection in August of 1986?" Dr. Kahn answered that the

    infection was clearly associated with the plaintiff's

    hospitalization. The following question was then asked:

    "What were the possible means of transmission within the

    hospital that could have resulted in her infection?" There

    was an objection based on the use of the word "possible;"

    that "the plaintiffs' burden of proof is probabilities." The

    court denied the objection, pointing out that the main

    question was premised on reasonable medical probabilities,

    and these were the factors the expert considered in arriving

    at his opinion. Dr. Kahn was asked again to state the

    possible sources of plaintiff's infection. He answered:

    "The likeliest, I think, is another patient who at the time

    of your client's hospitalization had what to all intents and

    purposes sounded like a recurrent genital herpes outbreak and

    in at least one instance shared a care giver over a short

    period of time." This answer was followed by a series of

    questions and answers:

    What is your understanding as to whether
    or not there was any potential patient
    source at the hospital?

    A. My understanding from reading the
    record is that there were two patients
    that I'm aware of who had what was either
    diagnosed by somebody else as an active
    herpes infection or to my reading
    certainly compatible with an active
    herpes infection.



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    Q. Were both those patients possible
    sources?

    A. Yes, I think they're both possible
    sources.

    Q. Would you consider health care
    workers as possible sources?

    A. Yes, they're possible sources too,
    yes.

    In his prior testimony Dr. Kahn had discussed

    inanimate objects called fomites such as toilet seats,

    flat surfaces and ice packs, as potential transmission

    sources of herpes. He was asked if he considered fomites as

    a possible infection source.

    I did. I considered them, but my own
    judgment is that that's considerably less
    likely. I know there was one instance in
    particular -- I don't know if it's been
    raised before so I don't know if I should
    mention it -- well, I read it so I guess
    I can mention there was some talk about
    an ice pack applied to the perineum.

    My sense of that was that even though
    the ice pack could have been wrapped in
    gauze and therefore, could have held the
    virus in it, it was more consistent with
    what we know about herpes transmission,
    that it was the hand of the nurse
    applying the ice pack rather than the ice
    pack that would have been the likelier
    source of transmission.

    Dr. Kahn was then asked:

    Having considered all of the potential
    sources of infection, did you arrive at
    one that was most likely in your mind?

    His answer was:




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    I think the likeliest explanation is
    the patient who had vaginal lesions with
    a second crop on the left labia, I
    believe, and was taken care of at one
    point by a health care giver who very
    shortly thereafter took care of Kim
    [plaintiff].

    Dr. Kahn identified the patient as J.D. He then

    testified that, in light of the fact that the hospital

    records showed that J.D. had left labial lesions that had not

    been cultured it was imprudent to take her off herpes

    infection precautions. He testified:

    The probability or the possibility of
    her having transmission -- transmissible
    viruses was very high based on her
    history and her presentation.

    On cross-examination Dr. Kahn was asked, "Is the

    best you can say is that J.D. is a possible source of the

    herpes infection in this case?" Then came the following

    exchange:

    A. Comparing her to the other patient,
    I'd say very possible. But again, I
    can't say probable or with definite
    certainty. But a very credible
    likelihood.

    Q. So the best you can say is possible,
    but you cannot say probable, correct?

    A. Slightly high on the possible but not
    probable. "Probable" meaning certainty,
    high possible meaning that's my choice.

    To our knowledge, no New Hampshire case requires

    the incantation of the word "probable" to establish probable





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    causation. In a case involving expert testimony the New

    Hampshire Supreme Court held:

    The possibility that the blasting caused
    the damage could reasonably be found "the
    most probable possibility disclosed by
    the evidence," and blasting the most
    probable cause. Emery v. Tilo Roofing
    _____ _____________
    Company, 89 N.H. 165, 167, 195 A. 409,
    _______
    and cases cited.

    Crocker v. W.W. Wyman, Inc., 110 A.2d 271, 274 (N.H. 1954).
    _______ _________________

    In Emery v. Tilo Roofing Company, 89 N.H. 165, 195 A. 409
    _____ _____________________

    (N.H. 1937), the issue was the cause of a fire to the roof of

    a building. Defendant was hired to re-roof the building.

    There was evidence that defendant's employees were seen

    smoking cigarettes on the roof before the fire started.

    There was no direct evidence that the fire had been caused by

    a cigarette stub. In upholding a verdict for plaintiff the

    court stated:

    That the fire was caused by a cigarette
    stub was the most probable possibility
    disclosed by the evidence and we think
    that the jury were justified in finding
    it to be more probable than otherwise
    that the fire resulted from this cause.
    Staples v. Railroad, 74 N.H. 499. "It is
    _______ ________
    not a case of conjecture between equal
    possibilities, but the ordinary
    determination of a conclusion from
    inferences supported by a balance of
    probabilities." Saad v. Papageorge, 82
    ____ __________
    N.H. 294. Not only was the conclusion of
    the jury as to the cause of the fire
    proper as a direct inference from the
    testimony but the improbability of any
    other explanation "as an exclusionary
    premise may serve to strengthen the force
    of the deduction."



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    Id. at 167.
    ___

    In the case before us the main defense was that

    plaintiff was infected with herpes before she was admitted to

    the hospital. There was no direct evidence of such an

    infection. As with the plaintiff's evidence, it depended on

    expert testimony.

    We read Dr. Kahn's testimony to say that the

    probable cause of the infection was one or more acts of

    negligence by the hospital, and find that this conclusion,

    which was rationally supported and explained, is sufficient

    to establish causation even though the doctor could not

    identify a single cause as the more-likely-than-not cause of

    this infection. It follows, therefore, that the jury verdict

    that the plaintiff was infected with herpes while a patient

    at the Mary Hitchcock Memorial Hospital is unassailable on

    causation grounds.

    II.
    II.

    THE ADMISSION OF TESTIMONY
    THE ADMISSION OF TESTIMONY
    __________________________

    Defendant's argument on this issue is stated as

    follows:

    The Trial Court Abused Its Discretion By
    Allowing The Plaintiffs To Ask Nurse Watkins
    Whether She Had Investigated The Source Of
    Kimberly F.'s Infection

    A. Mrs. Watkins's Testimony About Her
    Investigation on Behalf of the Infections
    Committee Was Precluded by the Express
    Terms of the Statute



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    Appellants' Brief at -i-.

    We have scoured the record and can find no question

    by plaintiff's counsel on direct examination of Nurse Watkins

    asking "whether she had investigated the source of Kimberly

    F.'s [plaintiff's] infection." Nor have we been able to find

    any testimony by Nurse Watkins about her investigation on

    behalf of the Infections Committee.

    Nurse Watkins testified that plaintiff's husband

    spoke to her in 1986 about the source of plaintiff's

    infection. At that time he was employed by the Mary

    Hitchcock Memorial Hospital as an echocardiography

    technologist and knew Nurse Watkins as a co-worker.

    Plaintiff's husband knew that Nurse Watkins' special

    responsibility was infection control and transmission of

    infectious diseases. According to Nurse Watkins, when

    plaintiff's husband spoke to her he had three specific

    concerns: the use of ice packs, lack of cleanliness

    generally in the hospital, and the dirty bathtub. Nurse

    Watkins said she would look into it. She denied that the

    husband asked her "to inquire into a few things." She never

    informed the husband about anything bearing on the source of

    plaintiff's infection. Nor did she tell him that she would

    make an investigation for the hospital. Most of the direct

    examination of Nurse Watkins by plaintiff's counsel focussed

    on the infection control procedures used at the hospital.



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    Nurse Watkins was also asked questions about entries in the

    plaintiff's hospital records by the doctors and nurses who

    treated her.

    On cross-examination Nurse Watkins gave the

    following testimony:

    Q. Given your job as [sic] the
    hospital, as nurse epidemiologist, what
    do you generally do when a, a question of
    a hospital-acquired infection is brought
    to you?

    A. Well, it's my job to look into the
    circumstances of the infection, with the
    primary being a focus to identify
    practices which could be improved to
    decrease the risk of similar infections
    in the future.

    I also had the responsibility for
    educating hospital personnel about
    infection risk and transmission again so
    that their practice will decrease the
    risk of transmission.

    Q. Now, did you take those steps when
    Mr. F. came to you and suggested the
    problems he did?

    A. Certainly I looked into the
    situation, yes.

    Q. What did you conclude?

    There was an objection by plaintiff's counsel to the last

    question which was upheld on the ground that it was precluded

    by N.H. Rev. Stat. Ann. ch. 151:13-a (1981).

    Before we discuss the scope of the New Hampshire

    statute we also must point out another serious omission in

    the record. Defense counsel made no objection to any of the



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    questions pertinent to this issue asked by plaintiff's

    counsel. This was a waiver of the issue under Fed. R. Evid.

    103(a)(1).3 Nor is this omission cured because defendants

    had filed a motion in limine at the start of trial.
    __ ______

    Objections to questions must be made when the questions are

    asked. We also point out that there was not even a general

    objection to the line of questioning, although we do not

    suggest that this would have been sufficient to preserve

    defendants' rights.

    The pertinent provision of the New Hampshire

    statute provides:

    II. Records of a hospital committee
    organized to evaluate matters relating to
    the care and treatment of patients or to
    reduce morbidity and mortality and
    testimony by hospital trustees, medical
    staff, employees, or other committee
    attendees relating to activities of the
    quality assurance committee shall be
    confidential and privileged and shall be
    protected from direct or indirect means
    of discovery, subpoena, or admission into


    ____________________

    3. Rule 103. Rulings on Evidence
    Rule 103. Rulings on Evidence

    (a) Effect of erroneous ruling. Error
    Effect of erroneous ruling.
    may not be predicated upon a ruling which
    admits or excludes evidence unless a
    substantial right of the party is
    affected, and
    (1) Objection. In case the ruling is
    Objection.
    one admitting evidence, a timely
    objection or motion to strike appears of
    record, stating the specific ground of
    objection, if the specific ground was not
    apparent from the context;



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    evidence in any judicial or
    administrative proceeding, except that in
    the case of a legal action brought by a
    quality assurance committee to revoke or
    restrict a physician's license or
    hospital staff privileges, or in a
    proceeding alleging repetitive malicious
    action and personal injury brought
    against a physician, a committee's
    records shall be discoverable.

    N.H. Rev. Stat. Ann. ch. 151:13-a II. The New Hampshire

    Supreme Court carefully delineated the scope of the statute

    in a case that was the opening chapter to the case before us.

    The parties were the same; the issue concerned only the scope

    of the statute. Justice Souter, then an associate justice of

    the New Hampshire Supreme Court, wrote the opinion, In re
    _____

    "K", 561 A.2d 1063 (N.H. 1989). In the state case the
    ___

    evidence was clear that Nurse Watkins made an investigation

    as to the source of plaintiff's infection, then made a report

    to the Infections Committee and prepared a written report

    which was kept in files in her own office. Plaintiff's

    lawyer requested the hospital, through Nurse Watkins, to

    release the results of the investigation. The hospital

    refused, claiming a privilege under N.H. Rev. Stat. Ann.

    151:13-a. Plaintiff then brought a petition in the New

    Hampshire Superior Court seeking a disclosure order. The

    superior court held the privilege inapplicable and ordered

    disclosure of Nurse Watkins' written report and the relevant

    portion of the minutes of the meeting of the Infections

    Committee at which Nurse Watkins made her report. The


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    hospital appealed. Id. at 1065. After a lengthy explanation
    ___

    and discussion of the legislation, the New Hampshire Supreme

    Court held that the minutes of the Infection Committee

    meeting and Nurse Watkins' written report were insulated from

    disclosure by the New Hampshire statute. Id. at 1065. The
    ___

    court also held:

    Once, however, it is understood that
    the requisite committee structure and
    quality review function are present, our
    traditionally limiting approach to
    privilege claims must be honored by
    recognizing that the privilege does not
    go beyond the records of testimony, as
    such, to which the statute refers. As we
    observed before, a quality assurance
    committee's attention does not place its
    subject matter beyond the bounds of
    discovery or disclosure in the normal
    course; the privilege is confined to the
    records and testimony described in the
    statute. See N.H.S. Jour. 1410-14
    ___ ______________
    (1981). Thus, the ordinary record of a
    patient's treatment remains admissible as
    it always has been, even though a quality
    assurance committee may have studied that
    record and issued a report based on data
    culled from it. And a physician may
    still be obligated to testify about the
    course of a patient's case, and to render
    a professional evaluation of the
    treatment, even though a quality
    assurance committee may already have
    elicited the same testimony on the same
    subject in the course of its own
    proceedings.

    Id. at 1070.
    ___

    We have no difficulty finding that the New

    Hampshire statute was not implicated by the direct

    examination of Nurse Watkins in the case at bar. It was



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    arguably implicated by defendants' cross-examination, but

    that is not an issue before us. It is incredible to us that

    defendants would misstate in their argument the questions

    asked and the testimony given, fail to object at trial to

    questions and answers which they now claim led to a violation

    of the statute, deliberately implicate the statute on cross-

    examination, and still appeal the issue. This not only

    transcends the proper limit of appellate argument, it

    requires a good measure of "chutzpa."



































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    III.
    III.

    THE CLOSING ARGUMENT
    THE CLOSING ARGUMENT
    ____________________

    At the close of his argument, plaintiff's counsel

    stated:

    I gave a figure to you in the opening,
    that I would suggest that you seriously
    consider as a full, fair, adequate and
    reasonable compensation for what they
    have suffered, what they are suffering
    and what they will suffer. And as I
    promised you then, I will say it again
    now.

    I think I would suggest to you -- not
    I think. What I think doesn't count. I
    would suggest to you that on the
    evidence, one million five hundred
    thousand dollars for Kimberly and one
    million five hundred thousand dollars for
    John is adequate, fair, full and complete
    compensation for their interests.

    In Davis v. Browning-Ferris Industries, Inc., 898
    _____ _________________________________

    F.2d 836 (1st Cir. 1990), we held that, even in a diversity

    case, the question of whether the amount of the ad damnum can
    __ ______

    be disclosed to the jury is a matter of procedure and

    therefore federal law applies. Id. at 837. We went on to
    ___

    hold that such disclosure was improper. Id. at 837-38.
    ___

    Inexplicably, both parties addressed the question

    below as exclusively one of New Hampshire law and,

    unfortunately, persuaded the district judge, a visiting judge

    from Pennsylvania, that New Hampshire law controlled. Just

    prior to final argument defense counsel asked the court that

    it preclude plaintiff's counsel from expressing his opinion



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    about the dollar value of the case or referring to the ad
    __

    damnum in his argument. Plaintiff's counsel had, without
    ______

    objection, stated the amount of the ad damnum in his opening.
    __ ______

    The court therefore asked: "You mean it's all right on

    opening statement but not on closing?" Defense counsel

    stated: "If I knew he was going to say it on opening, I

    would have objected but rather than my saying anything and

    object and make a bigger deal about it, I made the judgment

    not to." The judge stated, after plaintiff's counsel argued

    that under New Hampshire law reference to the ad damnum was
    __ ______

    allowed:

    THE COURT: Coming from the Common-
    wealth of Pennsylvania my ears stood
    straight up when I heard you mention the
    figures in your opening statement, but
    hearing no objection I assumed that
    probably was the practice in this
    jurisdiction.

    The court then asked plaintiff's counsel to supply him with

    authority for his position.

    The court's observation illustrates why counsel

    should object at the time an incorrect statement is made by

    opposing counsel. If an objection had been made to the ad
    __

    damnum disclosure in the opening, there would have been time
    ______

    for some research by the court and counsel prior to closing

    argument, and it probably would have been ascertained that

    there was a First Circuit case that clearly controlled. As

    it was, the court did not make a ruling until after



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    defendants' argument. It ruled that under New Hampshire law

    the ad damnum could be disclosed to the jury in final
    __ ______

    argument.

    We are faced, therefore, with a ruling based on the

    wrong law. This was due primarily to the neglect of both

    counsel. We would think that counsel would be aware of the

    controlling First Circuit cases by the time of trial. That

    plain error was committed is clear, but it is also clear that

    the error was harmless. The ad damnum was in the amount of
    __ ______

    one million five hundred dollars for each plaintiff. The

    jury awarded plaintiff one hundred and twenty-five thousand

    dollars and her husband twenty-five thousand dollars.

    Clearly, the jury paid scant attention to the amount of the

    ad damnum. Under the circumstances, there is no point in
    __ ______

    sending the case back for a new trial.

    CONCLUSION
    CONCLUSION
    __________

    The judgment below is affirmed. Appellees are
    The judgment below is affirmed. Appellees are
    ___________________________________________________

    awarded costs of appeal.
    awarded costs of appeal.
    ________________________

















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