Procaccini v. Lawrence & Memorial Hospital, Inc.

 JAMES M. PROCACCINI, ADMINISTRATOR
(ESTATE OF JILL A. PROCACCINI)
v. LAWRENCE AND MEMORIAL
HOSPITAL, INC., ET AL.
(AC 38380)
Prescott, Mullins and Beach, Js.
Syllabus
The plaintiff administrator of the estate of the decedent sought to recover
damages from the defendant E Co. for medical malpractice in connection
with the death of the decedent by a methadone overdose. On November,
29, 2008, the decedent was found unresponsive and was brought to a
hospital emergency department, where she was treated for a suspected
drug overdose by M, the attending emergency department physician.
After the decedent’s vital signs improved and stabilized, she was dis-
charged and returned to the home of a friend, where she was found
unresponsive the next morning and pronounced deceased. The plaintiff
alleged that E Co. was vicariously liable for the medical malpractice of
M in treating the decedent for a suspected drug overdose. The plaintiff
claimed that M’s discharge of the decedent after only four and one-half
hours of observation was premature in that M should have kept the
decedent under medical monitoring for twenty-four hours, which is the
period of time during which the fatal side effects of methadone toxicity
may occur, and that if the decedent had remained under medical monitor-
ing for the full twenty-four hours, the fatal overdose side effects she
experienced after her discharge would have been treated and her even-
tual death from methadone toxicity would have been averted. The jury
returned a verdict for the plaintiff, and the trial court rendered judgment
in accordance with the verdict, from which E Co. appealed to this court.
E Co. claimed, inter alia, that there was no direct evidence as to when the
decedent consumed the fatal dose of methadone, and that the undisputed
scientific evidence established that if she had actually overdosed on
methadone on November 29, 2008, she would have had a recurrence
of overdose symptoms before she was discharged from the hospital’s
emergency department. Held:
1. There was sufficient evidence to support the jury’s finding that E Co.’s
negligence caused the decedent’s death:
a. The jury had before it sufficient evidence from which it could have
inferred, without resorting to speculation, that the decedent had con-
sumed the fatal dose of methadone before she was brought to the
emergency department on November 29, 2008: although the jury was
presented with conflicting expert testimony as to how soon a methadone
overdose patient would experience recurring overdose symptoms after
receiving a certain medication that is used as an antidote for opiate and
opioid overdoses, the jury was free to believe the opinion of the plaintiff’s
expert witness, S, on the standard of care, that delayed, recurring respira-
tory depression can occur in methadone overdoses, even if such a
phenomenon defied certain undisputed and settled toxicology princi-
ples, and to disbelieve those portions of the testimony of E Co.’s expert
witness, P, on causation, that attempted to refute that phenomenon,
and E Co.’s claim that it was improper for the jury to consider S’s
testimony concerning the concept of delayed, recurring respiratory
depression as it related to causation was unavailing because even if S’s
testimony was offered strictly for standard of care purposes, E Co.
failed to pursue any preemptive or remedial measures that would have
precluded or limited S’s testimony on the issue of delayed, recurring
respiratory depression, and the court never instructed the jury that it
should disregard S’s testimony thereon or that it should consider such
testimony only for standard of care purposes, and, therefore, the evi-
dence regarding delayed, recurring respiratory depression was before
the jury to use for any purpose, including causation; moreover, the fact
that the decedent did not immediately experience recurring overdose
symptoms one hour after the overdose medication was administered
did not require the jury to conclude that the decedent’s overdose on
November 29, 2008, was caused by a narcotic other than methadone,
as the jury could have concluded, instead, that the delayed, recurring
respiratory depression that the decedent eventually experienced was
consistent with her ingestion of a toxic dose of methadone before her
visit to the emergency department on November 29, 2008.
b. E Co. could not prevail on its claim that because the plaintiff failed
to present evidence demonstrating that the decedent would have been
admitted to the hospital had M not discharged her from the emergency
department, the jury could not reasonably have found that E Co. caused
the decedent’s death: although the plaintiff’s expert, S, initially testified
that the standard of care applicable to possible methadone overdoses
required M to admit the decedent to the hospital for continuous monitor-
ing, S subsequently clarified that the applicable standard of care required
only that M monitor the decedent for twenty-four hours for signs of
recurrent opiate overdose, and the jury reasonably could have accepted
that portion of S’s testimony indicating that monitoring was required
and rejected that portion of his testimony suggesting that admittance
was required; accordingly, to prove causation, the plaintiff needed to
show only that the decedent could have been monitored sufficiently for
twenty-four hours, and the jury reasonably could have inferred that
from the evidence presented.
2. The trial court did not abuse its discretion in denying E Co.’s motion to
set aside the jury’s award of $150,000 in damages for the destruction
of the decedent’s capacity to carry on and enjoy life’s activities; the jury
reasonably could have forecast the decedent’s life expectancy from its
own knowledge and from the substantial evidence presented by the
plaintiff of the decedent’s age, health, physical condition and habits, all
of which were relevant to determine life expectancy, and, therefore, the
jury’s award of damages for the destruction of the decedent’s capacity to
carry on and enjoy life’s activities was not unreasonable or speculative.
Argued March 21—officially released August 22, 2017
Procedural History
Action to recover damages for medical malpractice,
and for other relief, brought to the Superior Court in
the judicial district of New London, where the action
was withdrawn as against the named defendant et al.;
thereafter, the plaintiff filed an amended complaint as
against the defendant Emergency Medicine Physicians
of New London County, LLC; subsequently, the matter
was tried to the jury before Hon. Joseph Q. Koletsky,
judge trial referee; verdict for the plaintiff; thereafter,
the court denied the motions to set aside the verdict and
for a directed verdict filed by the defendant Emergency
Medicine Physicians of New London County, LLC, and
rendered judgment in accordance with the verdict, from
which the defendant Emergency Medicine Physicians
of New London County, LLC, appealed to this court.
Affirmed.
Daniel J. Krisch, with whom were Frederick J.
Trotta, Sr., and, on the brief, Logan A. Forsey and
Jennifer S. Mullen, for the appellant (defendant Emer-
gency Medicine Physicians of New London County,
LLC).
Matthew E. Auger, with whom, on the brief, was Eric
W. Callahan, for the appellee (plaintiff).
Opinion
MULLINS, J. In this medical malpractice action, the
defendant1 Emergency Medicine Physicians of New
London County, LLC, appeals from the judgment of the
trial court, after a jury trial, rendered in favor of the
plaintiff, James M. Procaccini, administrator of the
estate of Jill A. Procaccini (decedent). On appeal, the
defendant claims that there was insufficient evidence
supporting the jury’s verdict and award of noneconomic
damages. Specifically, it claims that the plaintiff failed
to present sufficient evidence for the jury (1) to find
that the defendant’s negligence caused the death of the
decedent, and (2) to award $150,000 in damages for the
destruction of the decedent’s capacity to carry on and
enjoy life’s activities. We affirm the judgment of the
trial court.
The following facts, as reasonably could have been
found by the jury, and procedural history are relevant
to this appeal. On November 30, 2008, the decedent,
who was thirty-two years old, died from a methadone
overdose. In the years leading up to her death, the
decedent had struggled with polysubstance abuse.
After achieving a period of sobriety early in 2008, the
decedent relapsed on November 16, 2008. On that date,
the decedent admitted herself to Saint Francis Hospital
and Medical Center in Hartford (Saint Francis), seeking
treatment for a heroin overdose. On the next day,
November 17, 2008, the decedent was transferred to
Cedarcrest Hospital, Blue Hills Substance Abuse Ser-
vices (Blue Hills), in Newington.
The decedent remained at Blue Hills from November
17, 2008, until her discharge on November 28, 2008.
During her stay at Blue Hills, the decedent was adminis-
tered varying doses of methadone for treatment of her
opiate withdrawal symptoms. Methadone, an opioid,2
frequently is used by clinicians to alleviate the with-
drawal symptoms that patients experience while under-
going opiate detoxification. Although methadone
commonly is used in the clinical setting and, thus,
administered under a clinician’s supervision or pursu-
ant to a prescription, it also can ‘‘be purchased [illegally]
on the streets as street methadone.’’ The decedent’s last
dose of methadone, five milligrams, was administered
at Blue Hills at 7:45 a.m. on November 21, 2008. The
decedent was discharged from Blue Hills on November
28, 2008.
After leaving Blue Hills on November 28, 2008, the
decedent made at least two phone calls. One of those
calls was to a person from whom the decedent had
purchased drugs in the past. Another call was to Charles
Hope, a substance abuse counselor and a recovering
drug addict with whom the decedent was friendly. Hope
agreed to let the decedent stay at his house in New
London on the condition that she not use drugs. Hope
picked up the decedent from West Hartford on the
evening of November 28, 2008, and brought her to his
home in New London. Upon their arrival at Hope’s
home, Hope and the decedent talked briefly and then
retired for the night. Hope heard the decedent use the
microwave in his kitchen at some point during the night.
On the morning of November 29, 2008, Hope woke
up the decedent and noticed that she was ‘‘feeling a
little sick.’’ Hope left his home sometime in the late
morning or early afternoon of November 29. Hope later
called the decedent sometime that afternoon and had
a conversation with her. When Hope returned to his
home at approximately 6:45 p.m., however, he found
the decedent lying unconscious on his living room
couch. Hope began performing cardiopulmonary resus-
citation, which restored the decedent’s breathing. At
approximately 6:47 p.m., Hope called 911.
Emergency medical technicians (EMTs) from the
New London Fire Department arrived at Hope’s house
on November 29, 2008, at approximately 6:51 p.m. The
EMTs found the decedent unresponsive, lying in a
supine position in Hope’s living room with pinpoint
pupils and agonal respirations. Hope told the EMTs
that the decedent ‘‘had been on methadone,’’ that the
decedent ‘‘had a history of addiction,’’ and that he was
unsure if she used drugs that day. Because she was
unconscious, however, the EMTs were unable to obtain
any medical history from the decedent. The EMTs
administered oxygen to the decedent via an oral airway
and bag valve mask. Hope and the EMTs briefly
searched Hope’s house for drugs, drug paraphernalia,
and other evidence of drug use. They did not find any
such evidence.
Shortly thereafter, at approximately 6:55 p.m., para-
medics from Lawrence & Memorial Hospital (Law-
rence & Memorial) arrived on the scene. The
paramedics placed the decedent in their ambulance.
At some point between 6:55 p.m. and 7:03 p.m., the
paramedics intravenously administered the decedent
1.4 milligrams of Narcan.
Narcan is used as an ‘‘antidote’’ for opiate and opioid
overdoses. Narcan, like opiates and opioids, attaches
to the opioid receptors located in the body’s central
nervous system. Narcan, however, does not cause any
of the effects that opiates and opioids produce, such as
pain relief, a ‘‘high’’ feeling, and respiratory depression.
Instead, because opioid receptors have a ‘‘stronger
affinity for the Narcan molecule than [they do] for [opi-
ates and opioids],’’ Narcan ‘‘just knocks [opiates and
opioids] out and takes residency in the receptor[s]
. . . .’’ ‘‘[Once] [t]he Narcan displaces the opiate [or
opioid] from the receptor[s] . . . the person’s opiate
effects evaporate . . . the person wakes up and [he or
she is] breathing and . . . alert . . . .’’ In other words,
‘‘intravenous administration of Narcan . . . pro-
duce[s] a near-instantaneous reversal of the narcotic
effect . . . within a minute or two at the most . . . .’’
By the time the ambulance arrived at Lawrence &
Memorial at 7:03 p.m., the dose of Narcan had revived
the decedent. The decedent was conscious and answer-
ing questions asked by the paramedics. The paramedics
were able to determine that the decedent was taking
several medications, including methadone, Topamax,
Seroquel, insulin, and Ambien. In their written report,
the paramedics indicated that the ‘‘chief complaint’’
was an ‘‘[overdose] on Heroin’’ and that the decedent
was ‘‘found in respiratory arrest due to [overdose].’’
Upon arriving at Lawrence & Memorial, the decedent
was taken to the emergency room, where her condition
was triaged. In examining the decedent, the triage
nurse, Sarah Zambarano, created an electronic report
detailing the decedent’s condition at 7:13 p.m. Zambar-
ano indicated in the electronic report that the paramed-
ics informed her that Hope told them that the decedent
‘‘took methadone, ? of heroin.’’
At approximately 7:15 p.m., the decedent was
assessed by another emergency room nurse, Pamela
Mays. At 7:36 p.m., Mays recorded the following in her
treatment notes: ‘‘[the decedent] admits to using heroin
toni[ght] . . . states off methadone for several months
after detox . . . now using again.’’ Mays also indicated
that the decedent ‘‘appear[ed] comfortable’’ and was
‘‘cooperative,’’ ‘‘alert’’ and ‘‘oriented . . . .’’ Contrary
to May’s notes, Hope, who had arrived at the emergency
room between 7:30 p.m. and 8 p.m., recalled that the
decedent was ‘‘very adamant that she did not take any
heroin . . . .’’ According to Hope, the decedent told
Mays that ‘‘I did not take any heroin, I took methadone.’’
At approximately 7:45 p.m., the attending emergency
room physician, Thomas E. Marchiondo, examined the
decedent. At the time he began treating the decedent,
Marchiondo had access to the paramedics’ report,
which indicated that the decedent had a suspected over-
dose on heroin, that the decedent also was taking meth-
adone, and that the decedent had been found in
respiratory arrest. Marchiondo detailed his examination
of the decedent in his own written report. In his report,
Marchiondo noted that the decedent’s ‘‘chief complaint’’
was an ‘‘unintentional heroin overdose.’’ Although the
decedent apparently denied any ‘‘other co-ingestion,’’
Marchiondo’s report indicated that the decedent’s ‘‘cur-
rent medications’’ included methadone.
Marchiondo’s report also indicated that a urine toxi-
cology screen had been ordered. The results of the
screen, of which Marchiondo was aware when treating
the decedent, revealed that the decedent’s urine tested
positive for the presence of methadone, an unidentified
opiate, and unidentified benzodiazepines. Because that
screen merely was qualitative, it could not identify the
specific type of opiate ingested by the decedent or the
exact concentration of that substance or methadone in
the decedent’s system.
As a result of his review of the drug screen results,
as well as his examination of the decedent and review
of the treatment notes prepared by the nurses and emer-
gency responders, Marchiondo concluded that the dece-
dent had ingested both methadone and heroin.
Regarding the methadone, although he could not deter-
mine specifically when or in what manner the decedent
ingested it, Marchiondo concluded that the decedent
ingested some quantity of methadone ‘‘within the past
couple of weeks.’’ In so concluding, Marchiondo relied
on the fact that methadone was listed as a medication
in her medical history, which caused him to believe
that the decedent was taking the methadone ‘‘under a
doctor’s prescription . . . .’’ Marchiondo consequently
‘‘would have expected [methadone] to come out posi-
tive in her urine.’’ Accordingly, he concluded that the
overdose symptoms that the decedent was experiencing
‘‘were due to a heroin overdose’’ and agreed with a
statement by the plaintiff’s counsel that the decedent’s
symptoms ‘‘[were] in no way related to the methadone
that was in her system.’’3
The decedent remained in the Lawrence & Memorial
emergency room from 7:13 p.m. to approximately 11:53
p.m. on November 29, 2008. ‘‘All throughout her stay
. . . [the decedent] remained awake, alert, and aware,
nontoxic. And through time . . . her vital signs had
improved.’’ Hope, who had stayed with the decedent
at her bedside, also observed that, although initially the
decedent seemed, as characterized by the defendant’s
counsel, ‘‘sluggish,’’ her condition continued to improve
and she was ‘‘laughing and making jokes.’’ During her
hospitalization at Lawrence & Memorial, the decedent
was not administered any Narcan. Marchiondo had
determined that it was not necessary to treat the dece-
dent with Narcan because her vital signs had improved
while she was at Lawrence & Memorial.
Throughout her stay, the decedent was monitored by
Mays, who noted in her report that the decedent’s vital
signs improved and stabilized. At approximately 8 p.m.,
the decedent was ‘‘awake and alert and asking to leave
. . . [but was] told that she was here for the night.’’ At
this point, the decedent’s respiration rate had improved
to sixteen breaths per minute, and her oxygen satura-
tion level had risen to 99 percent. These levels were
‘‘basically normal.’’ The decedent also had been taken
off supplemental oxygen.
At 9 p.m., the decedent was ‘‘resting soundly’’ and
her ‘‘[respiration was] easy/even.’’ Her respiration rate
and oxygen saturation level had not changed since 8
p.m. At 10 p.m. and 11:30 p.m., the decedent’s respira-
tion rate still was sixteen breaths per minute, and her
oxygen saturation level still was 99 percent. At some
point between 11:35 p.m. and 11:53 p.m., the decedent
was discharged and was provided instructions for a
‘‘narcotic overdose,’’ which advised the decedent to
‘‘[r]eturn to the ER if [her condition] worse[ned].’’
Upon being discharged from Lawrence & Memorial,
the decedent left with Hope. Hope and the decedent
stopped for food and coffee before returning to Hope’s
home. At Hope’s home, Hope and the decedent con-
versed until approximately 1:30 a.m. on November 30,
2008, at which point, Hope went to bed. When Hope left
the decedent to go to bed, the decedent was kneeling on
the corner of the bed in Hope’s guest bedroom, watch-
ing television and looking at photographs. Hope did not
hear any activity during the night.
After waking up at approximately 9:45 a.m. later that
morning, Hope found the decedent unresponsive. The
decedent’s body was ‘‘frozen stiff’’ and kneeling in the
same position in which she had been on Hope’s guest
bed when Hope last saw her at 1:30 a.m. earlier that
morning. Hope called 911 at approximately 10:39 a.m.
New London police, accompanied by New London
Fire Department EMTs, arrived at Hope’s home on
November 30 at approximately 11 a.m. The decedent
was pronounced deceased by the EMTs at approxi-
mately 11:05 a.m. Thereafter, Hope assisted the police
in searching his entire house for drug paraphernalia
and other evidence of drug use. Neither Hope nor the
five law enforcement officers searching the scene found
anything relating to drug activity.
At approximately 1:34 p.m., Penny Geyer, an investi-
gator with the Office of the Chief Medical Examiner,
arrived at Hope’s home. At the scene, Geyer performed
an external examination of the decedent’s clothed body.
She did not find any illicit drugs or drug paraphernalia
on or around the decedent’s body, and she did not
observe any signs of drug ingestion on the decedent’s
body, such as needle marks or residue in the decedent’s
nose or mouth.
Deputy Chief Medical Examiner Edward T. McDo-
nough III performed the decedent’s autopsy on Decem-
ber 1, 2008. A toxicology screen ordered by McDonough
detected the presence of methadone in the decedent’s
blood. Specifically, the report indicated that the concen-
tration of methadone in the decedent’s blood was 0.39
milligrams per liter. The postmortem toxicology screen
did not detect any opioids or opiates other than
methadone.
As a result of his review of the toxicology report and
his examination of the decedent, McDonough con-
cluded that the final cause of the decedent’s death was
‘‘methadone toxicity.’’ In so concluding, McDonough
determined that the postmortem concentration of meth-
adone in the decedent’s blood, 0.39 milligrams per liter,
was ‘‘within the fatal range.’’ McDonough also deter-
mined that the decedent died sometime between 5 a.m.
and 7 a.m. on November 30, 2008, although this was
merely a ‘‘crude’’ approximation because the time of
death could have been ‘‘much earlier.’’
In November, 2010, the plaintiff, acting as the admin-
istrator of the decedent’s estate, brought this medical
malpractice action seeking damages for the decedent’s
death. The plaintiff’s initial complaint asserted one
count against Marchiondo, one count against Law-
rence & Memorial Hospital, Inc., and Lawrence &
Memorial Hospital Corporation, and one count against
the defendant. Following the plaintiff’s withdrawal of
the separate counts against Marchiondo and Law-
rence & Memorial Hospital, Inc., and Lawrence &
Memorial Hospital Corporation; see footnote 1 of this
opinion; the plaintiff amended his complaint to seek
recovery from only the defendant.
The plaintiff’s operative complaint alleges that the
defendant is vicariously liable for the medical malprac-
tice that its employee,4 Marchiondo, committed in treat-
ing the decedent for a suspected drug overdose on
November 29, 2008. The gravamen of the plaintiff’s com-
plaint is that Marchiondo’s discharge of the decedent
after only four and one-half hours of observation at
Lawrence & Memorial was premature. According to
the plaintiff, because the decedent presented with a
possible methadone overdose, Marchiondo should have
kept her under medical monitoring for twenty-four
hours, which is the period of time during which the
fatal side effects of methadone toxicity may occur.
Accordingly, the plaintiff alleges, if the decedent had
remained under medical monitoring for the full twenty-
four hours, the fatal overdose side effects she experi-
enced after her discharge would have been treated and
her eventual death from methadone toxicity would have
been averted.
In his complaint, the plaintiff sought both economic
and noneconomic damages resulting from the dece-
dent’s death. The claim for economic damages included
medical expenses and funeral costs, and the claim for
noneconomic damages sought compensation for the
decedent’s permanent loss of her ability to carry on
and enjoy life’s activities.
After the plaintiff rested, the defendant moved for a
directed verdict. Specifically, the defendant argued that
‘‘the plaintiff [had] not submitted sufficient evidence to
establish a prima facie case with respect to causation.’’
(Emphasis added.) The defendant did not challenge the
sufficiency of the evidence regarding the appropriate
standard of care and the defendant’s breach thereof.
The court reserved decision on the defendant’s motion
for a direct verdict.
The jury returned a plaintiff’s verdict and awarded
$12,095 in economic damages and $500,000 in noneco-
nomic damages. The award consisted of $350,000 for
the decedent’s death and $150,000 for the destruction
of the decedent’s capacity to carry on and enjoy life’s
activities.
After the jury returned its verdict, the defendant
renewed its motion for a directed verdict.5 As in its
initial motion, the defendant challenged the sufficiency
of the evidence only with respect to causation: ‘‘[T]he
evidence presented by the plaintiff during his case-in-
chief [was] insufficient to support a conclusion that any
alleged negligence on the part of the defendant was the
cause in fact of the death of [the decedent].’’ Specifi-
cally, the defendant argued that there were ‘‘two miss-
ing links in the plaintiff’s chain of causation: (1) that
[the decedent] overdosed on methadone on [November
29, 2008]; and (2) that [the decedent] met the criteria
for admission to [Lawrence & Memorial].’’
Regarding the first ‘‘missing link,’’ the defendant con-
tended that ‘‘the jury had no basis—other than conjec-
ture—to find that [the decedent] overdosed on
methadone on November 29, [2008]. To the contrary,
science and the chronology of events point only to the
‘reasonable hypothesis’ that [the decedent] took the
lethal dose of methadone after Dr. Marchiondo dis-
charged her.’’ (Emphasis in original.)
Regarding the second ‘‘missing link,’’ the defendant
contended that ‘‘the jury could only guess about another
critical piece of the puzzle: admission to [Lawrence &
Memorial]. . . . [T]here was no evidence about [Law-
rence & Memorial’s] criteria for admission, or whether
[the decedent] met those criteria.’’ According to the
defendant, the applicable standard of care required
Marchiondo to admit the decedent to Lawrence &
Memorial. Thus, the defendant posited, the plaintiff
could not prove that Marchiondo’s breach of that stan-
dard of care caused the decedent’s death without evi-
dence that the decedent likely would have been
admitted to Lawrence & Memorial.
After holding a hearing on the defendant’s renewed
motion for a directed verdict, the court denied the
motion. This appeal followed. Additional facts will be
set forth as necessary.
I
SUFFICIENCY OF EVIDENCE ON CAUSATION
The defendant’s first claim on appeal is that the plain-
tiff failed to present sufficient evidence from which the
jury reasonably could have found that the defendant
caused the decedent’s death. Specifically, the defendant
argues that ‘‘there are two gaping holes in the evidence:
(1) proof that the decedent consumed the fatal dose of
methadone before her discharge from the emergency
room on November 29, [2008], and (2) proof that she met
the criteria for admission to [Lawrence & Memorial].’’
two causation challenges seriatim.
A
In its first challenge to the sufficiency of the evidence
on causation, the defendant contends that there ‘‘was
no direct evidence [regarding] when the decedent con-
sumed the fatal dose of methadone. . . . [O]nly cre-
ative guesswork supports the jury’s inference that the
decedent did so before, and not after, her discharge
from the emergency room.’’ (Emphasis added; internal
quotation marks omitted.) In particular, the defendant
argues that the jury’s finding regarding causation is
inconsistent with ‘‘time and science, i.e., the mechanical
details disclosed by the evidence . . . .’’ (Internal quo-
tation marks omitted.) According to the defendant, the
‘‘undisputed’’ scientific evidence presented at trial dem-
onstrated that ‘‘[i]f the decedent had actually overdosed
on methadone on November 29, [2008], she would have
had a recurrence of overdose symptoms long before
she was discharged [from Lawrence & Memorial].’’
(Emphasis added.) Thus, because the decedent did not
experience recurring overdose symptoms ‘‘long before’’
her discharge, she had not consumed a toxic amount
of methadone on November 29. We disagree.
The following additional facts and procedural history
guide our resolution of this claim. A substantial part of
the evidence presented by both parties at trial came in
the form of expert testimony. Both parties presented
expert testimony on the issue of causation. McDonough,
who was disclosed as the plaintiff’s causation expert,
also was the medical examiner who performed the dece-
dent’s autopsy. He testified that the postmortem level
of methadone in the decedent’s blood, 0.39 milligrams
per liter, was a toxic concentration and caused her
death. He further testified that the specific ‘‘mechanism
of death’’ probably was respiratory depression, in which
the methadone intoxication would have ‘‘[shut] down
[the decedent’s] breathing.’’ McDonough’s determina-
tion of the cause of death called into doubt Marchi-
ondo’s diagnosis of the decedent, which was that she
had overdosed on heroin, not methadone.
Dr. Steven Pike, the defendant’s expert on causation,
initially testified that he could not determine within a
reasonable degree of medical probability whether the
decedent’s cause of death was methadone toxicity. He
later testified, however, that ‘‘it’s probably more likely
than not’’ that methadone toxicity was the cause of the
decedent’s death.
The defendant’s strategy in contesting causation
essentially was to demonstrate that the decedent
ingested the fatal dose of methadone after she was
discharged from Lawrence & Memorial. According to
the defendant, if the plaintiff could not establish that
the decedent ingested the fatal dose before her dis-
charge, there would be no causal connection between
the allegedly negligent treatment she received at Law-
rence & Memorial and the methadone toxicity to which
she eventually succumbed. Critically, during the defen-
dant’s cross-examination of McDonough, McDonough
conceded that he could not rule out the possibility that
the fatal dose of methadone was ingested after the
decedent’s discharge.
Without direct evidence of when the decedent con-
sumed the fatal dose, the parties largely relied on indi-
rect evidence from which the jury could infer the timing
of the decedent’s ingestion of methadone. In turn, such
indirect evidence required the application of the toxico-
logical concepts and biochemical processes that govern
how the human body absorbs, metabolizes, and
excretes Narcan and various opiates and opioids. The
following evidence relating to those scientific principles
was presented through the parties’ expert testimony.
For the most part, the parties’ experts were in
agreement on several fundamental toxicological con-
cepts and biochemical processes. The first important
concept about which the experts provided testimony
was half-life. A half-life is the time it takes for the con-
centration of a drug in a person’s system to be reduced
by one-half. It takes approximately the lapse of five
half-lives for a drug to be eliminated completely from
a person’s system. Because the body does not start to
eliminate a drug until it is absorbed, the first half-life
of a drug will not begin to run until after the drug
is absorbed.
The second concept about which the parties’ experts
testified was duration of effect. Although related to the
concept of half-life, duration of effect ‘‘is not equivalent
to the half-life of the drug. In some cases, it may be
less than the half-life of the drug. In some cases, it may
be longer than the half-life of the drug.’’ While half-life
refers to the rate at which an absorbed drug is elimi-
nated from the body, duration of effect refers to how
long a drug produces physiologic effects.6 To illustrate
this distinction, it is possible that a small concentration
of a drug still is in the body after several half-lives,
yet that small concentration has ceased producing any
effects. The converse also applies in the case of some
drugs: ‘‘[A drug] may go through a couple half-lives,
[but] still be producing some effect . . . .’’
The parties’ experts also generally agreed regarding
the half-lives and durations of effect of Narcan, long-
acting narcotics, and short-acting narcotics. The half-
life of Narcan, approximately thirty to eighty minutes,
is much shorter than the half-lives of both long-acting
narcotics and short-acting narcotics. Additionally, the
half-lives of short-acting narcotics are shorter than the
half-lives of long-acting narcotics. For instance, the
plaintiff’s expert testified that the half-life of metha-
done, a long-acting narcotic, ranges from fifteen to fifty-
five hours, and the defendant’s expert testified that it
could range from eighteen to sixty hours. In contrast,
according to the plaintiff’s expert, the half-life of heroin,
a short-acting narcotic, is two to five hours, and the
defendant’s expert stated that it is three to four hours.
The durations of effect of Narcan, short-acting nar-
cotics, and long-acting narcotics largely were undis-
puted as well. The duration of Narcan’s antidotal effect
begins almost instantaneously upon administration and
lasts for thirty to ninety minutes.7 Generally, Narcan
‘‘wears off much sooner than . . . [opiates and opioids
such as] heroin . . . or methadone.’’ Heroin ‘‘has an
effect of four to six hours,’’ while methadone produces
‘‘a[n] . . . effect of twelve to twenty-four hours.’’
The parties’ experts also noted, however, that there
are some ‘‘interindividual’’ variations in those durations
of effect and half-lives because ‘‘each individual metab-
olizes materials differently.’’ Furthermore, the method
of administration, the dosage size, and the individual’s
tolerance for the drug all affect how quickly after inges-
tion the drug will begin to produce effects. In particular,
because intravenous administration delivers the drug
directly into the bloodstream, it causes an individual
to absorb the drug faster than oral administration and,
therefore, produces effects sooner than oral administra-
tion. For instance, because oral administration of meth-
adone is ‘‘not an instantaneous absorption,’’ ‘‘it takes
time for the methadone to be absorbed . . . .’’ Thus,
it could take as long as two and one-half hours after
ingestion for orally administered methadone to be
absorbed fully and to reach a peak concentration in
the blood.
Having agreed that the effects produced by long-act-
ing and short-acting narcotics generally outlast Nar-
can’s antidotal effects, the parties’ experts also agreed
that overdose symptoms, including respiratory depres-
sion, may return after Narcan wears off. In other words,
if the concentration of a narcotic still is at a toxic level
after Narcan wears off, there will be ‘‘a recurrence of
the symptoms that prompted . . . [the initial dose of]
Narcan.’’ The overdose symptoms reappear because
Narcan only temporarily displaces the narcotic from
the body’s opioid receptors. Once the Narcan has worn
off, the remaining concentration of the narcotic reatta-
ches to the opioid receptors.
Despite their agreement on the foregoing principles,
the parties’ experts disagreed on a critical point. Specifi-
cally, their testimony differed with respect to the issue
of how soon recurring overdose symptoms return after
the administration of Narcan. When asked by the defen-
dant’s counsel what happens to ‘‘patients if they still
have a toxic or rising dose of opiate or opioid after the
Narcan wears off,’’ Pike answered: ‘‘[A]n hour after
Narcan, they’re going to have a recurrence of the symp-
toms that prompted the paramedics or . . . physician
to give the Narcan.’’ (Emphasis added.) Regarding meth-
adone overdoses in particular, Pike further testified that
‘‘patients who do overdose on methadone . . . have to
be admitted because you’re going to be standing there
administering Narcan every hour, hour and a half . . . .
[T]hey need a continuous infusion of Narcan . . . until
they get below that concentration that was causing the
overdose effects, and that could take as long as a
day . . . .’’
In applying those principles to the decedent’s case,
Pike made the following three observations. First, if a
methadone overdose had caused the initial respiratory
depression the decedent was experiencing when Hope
found her on November 29 at 6:45 p.m., then the respira-
tory depression should have returned ‘‘at about 8
o’clock,’’ i.e., approximately one hour after the para-
medics administered Narcan. This conclusion was pred-
icated on the assumption, acknowledged by both
parties’ experts, that methadone is a long-acting nar-
cotic that has a long half-life and duration of effect.
Thus, according to Pike, if the concentration of metha-
done was sufficiently toxic to cause respiratory depres-
sion at 6:45 p.m., then it probably still would have been
sufficiently toxic when the Narcan wore off at 8 p.m.
Second, according to Pike, the record revealed that
the respiratory depression in fact did not return when
the Narcan should have been wearing off. To be sure,
the respiratory depression did not return at any point
during the decedent’s hospitalization at Lawrence &
Memorial. On the contrary, the decedent’s vital signs,
including her respiration rate and oxygen saturation
levels, stabilized at normal levels hours before her dis-
charge. Furthermore, the decedent’s condition did not
warrant another administration of Narcan at Law-
rence & Memorial.
Third, Pike inferred from those first two observations
that the decedent’s initial respiratory depression was
caused by a short-acting narcotic, not a long-acting
narcotic. According to Pike, a short-acting narcotic, by
virtue of having a relatively short half-live and duration
of effect, would not have caused a recurrence of over-
dose symptoms after Narcan wore off. That is, there
would have been a ‘‘rapid decay’’ of the short-acting
narcotic’s concentration during Narcan’s period of
effectiveness, leaving a nontoxic concentration after
Narcan wore off. Therefore, the absence of any recur-
ring overdose symptoms after Narcan’s period of effec-
tiveness is consistent with an overdose on a short-acting
narcotic, not a long-acting narcotic like methadone.
On the basis of those three observations, Pike opined
that the decedent had not ingested a fatal concentration
of methadone before she was hospitalized at Law-
rence & Memorial. Pike attributed the positive metha-
done finding in the Lawrence & Memorial drug screen
to the methadone that the decedent was administered
at Blue Hills. He had ‘‘[n]o doubt whatsoever’’ that the
Blue Hills methadone caused the positive methadone
finding on November 29, 2008, notwithstanding the fact
that the last Blue Hills dose was administered to the
decedent on November 21, 2008. Pike reasoned that the
Blue Hills methadone would have been detected on
November 29 because five half-lives had not passed
since the November 21 dose. In so reasoning, Pike
apparently assumed that the Blue Hills methadone’s
half-life was substantially longer than twenty-four
hours, even though he previously had used twenty-four
hours as ‘‘a reasonable estimate’’ of methadone’s
half-life.
Testimony provided by one of the plaintiff’s experts,
Eric Schwam, controverted Pike’s opinion that recur-
ring respiratory depression always presents approxi-
mately one hour after the administration of Narcan. An
emergency medicine physician who opined mainly on
the standard of care,8 Schwam testified that the ‘‘experi-
ence of decades of . . . [caring for] patients [overdos-
ing on] long-acting opiates’’ has shown that ‘‘delayed
respiratory depression can occur . . . .’’ (Emphasis
added.) According to Schwam, ‘‘you don’t know when
[the] return of respiratory depression is going to occur.
One might think that it would occur when the Narcan
wears off, and that’s a widely held misconception
. . . . [T]hat’s a very easy thing to assume if you know
a little bit about opiate toxicology, but decades of expe-
rience have shown that if that’s the way you think and
you discharge a patient, a lot of them will be dead the
next day.’’ (Emphasis added.)
Schwam also described two specific cases of delayed
recurring respiratory depression that he had encoun-
tered in his medical practice. In the first case, ‘‘[a]
patient took an overdose of methadone, was seen in
the emergency department, was monitored for six
hours, was discharged by the physician, thinking that
everything was okay, and the person had recurrence
of respiratory depression. Fortunately, they survived.’’
In the second case, which was ‘‘very similar to [the
decedent’s case],’’ a ‘‘patient was discharged home and
was found dead the next day.’’ According to Schwam,
‘‘these cases . . . have been going on for years, and
apparently, they continue to happen.’’ For these rea-
sons, Schwam testified, the appropriate standard of
care for a suspected methadone overdose is ‘‘monitor[-
ing] . . . for twenty-four hours for signs of recurrent
opiate overdose.’’ (Emphasis added.)
Although Schwam was not a causation expert,9 the
defendant never objected to counsel’s questions per-
taining to delayed recurring respiratory depression on
the ground that they were outside the scope of the
subject matter of Schwam’s testimony.10 Moreover, the
defendant never moved, on that specific ground, to
strike Schwam’s answers regarding delayed recurring
respiratory depression.11
The plaintiff’s other expert, McDonough, also dis-
agreed with Pike’s assertion that the Blue Hills metha-
done caused the positive methadone finding in the
decedent’s drug screen at Lawrence & Memorial. He
opined that the Blue Hills methadone was not the same
methadone that was detected in the drug screen on
November, 29, 2008. McDonough reasoned that the
amount of methadone the decedent received at Blue
Hills on November 21, 2008, ‘‘is basically the smallest
dosage you can have’’ and that the drug screen was
conducted ‘‘eight and one-half days from the last inges-
tion of that five milligram tablet . . . .’’ In so reasoning,
McDonough apparently refused to assume, like Pike,
that the Blue Hills methadone’s half-life was substan-
tially longer than twenty-four hours.
In analyzing the defendant’s first challenge to the
sufficiency of causation evidence, we begin by setting
forth our standard of review. ‘‘A party challenging the
validity of the jury’s verdict on grounds that there was
insufficient evidence to support such a result carries a
difficult burden. In reviewing the soundness of a jury’s
verdict, we construe the evidence in the light most
favorable to sustaining the verdict. . . . Furthermore,
it is not the function of this court to sit as the seventh
juror when we review the sufficiency of the evidence
. . . rather, we must determine . . . whether the total-
ity of the evidence, including reasonable inferences
therefrom, supports the jury’s verdict . . . . [I]f the
jury could reasonably have reached its conclusion, the
verdict must stand, even if this court disagrees with
it. . . .
‘‘Two further fundamental points bear emphasis.
First, the plaintiff in a civil matter is not required to
prove his case beyond a reasonable doubt; a mere pre-
ponderance of the evidence is sufficient. Second, the
well established standards compelling great deference
to the historical function of the jury find their roots in
the constitutional right to a trial by jury.’’ (Citations
omitted; internal quotation marks omitted.) Doe v. Hart-
ford Roman Catholic Diocesan Corp., 317 Conn. 357,
370–71, 119 A.3d 462 (2015).
‘‘[I]t is [the] function of the jury to draw whatever
inferences from the evidence or facts established by
the evidence it deems to be reasonable and logical. . . .
Because [t]he only kind of an inference recognized by
the law is a reasonable one . . . any such inference
cannot be based on possibilities, surmise or conjecture.
. . . It is axiomatic, therefore, that [a]ny [inference]
drawn must be rational and founded upon the evidence.
. . . However, [t]he line between permissible inference
and impermissible speculation is not always easy to
discern. When we infer, we derive a conclusion from
proven facts because such considerations as experi-
ence, or history, or science have demonstrated that
there is a likely correlation between those facts and the
conclusion. If that correlation is sufficiently compelling,
the inference is reasonable. But if the correlation
between the facts and the conclusion is slight, or if a
different conclusion is more closely correlated with the
facts than the chosen conclusion, the inference is less
reasonable. At some point, the link between the facts
and the conclusion becomes so tenuous that we call it
speculation. When that point is reached is, frankly, a
matter of judgment. . . .
‘‘[P]roof of a material fact by inference from circum-
stantial evidence need not be so conclusive as to exclude
every other hypothesis. It is sufficient if the evidence
produces in the mind of the trier a reasonable belief in
the probability of the existence of the material fact. . . .
Thus, in determining whether the evidence supports a
particular inference, we ask whether that inference is
so unreasonable as to be unjustifiable. . . . In other
words, an inference need not be compelled by the evi-
dence; rather, the evidence need only be reasonably
susceptible of such an inference. Equally well estab-
lished is our holding that a jury may draw factual infer-
ences on the basis of already inferred facts. . . .
Finally, it is well established that a plaintiff has the
same right to submit a weak case as he has to submit
a strong one. (Citations omitted; emphasis added; inter-
nal quotation marks omitted.) Curran v. Kroll, 303
Conn. 845, 856–57, 37 A.3d 700 (2012).
We next set forth the legal principles governing medi-
cal malpractice actions. ‘‘[T]o prevail in a medical mal-
practice action, the plaintiff must prove (1) the requisite
standard of care for treatment, (2) a deviation from that
standard of care, and (3) a causal connection between
the deviation and the claimed injury.’’ (Internal quota-
tion marks omitted.) Gold v. Greenwich Hospital Assn.,
262 Conn. 248, 254–55, 811 A.2d 1266 (2002). ‘‘Generally,
expert testimony is required to establish both the stan-
dard of care to which the defendant is held and the
breach of that standard.’’ (Internal quotation marks
omitted.) Id., 255. Likewise, ‘‘[e]xpert medical opinion
evidence is usually required to show the cause of an
injury or disease because the medical effect on the
human system of the infliction of injuries is generally
not within the sphere of the common knowledge of
the lay person.’’ (Internal quotation marks omitted.)
Milliun v. New Milford Hospital, 310 Conn. 711, 725,
80 A.3d 887 (2013).
The defendant does not argue that there is insufficient
evidence supporting the jury’s findings regarding the
appropriate standard of care and Marchiondo’s devia-
tion from that standard of care. Thus, we focus on the
principles pertaining to causation. ‘‘All medical mal-
practice claims, whether involving acts or inactions of
a defendant physician, require that a defendant physi-
cian’s conduct proximately cause the plaintiff’s injuries.
The question is whether the conduct of the defendant
was a substantial factor in causing the plaintiff’s injury.
. . . This causal connection must rest upon more than
surmise or conjecture. . . . A trier is not concerned
with possibilities but with reasonable probabilities.
. . . The causal relation between an injury and its later
physical effects may be established by the direct opin-
ion of a physician, by his deduction by the process of
eliminating causes other than the traumatic agency, or
by his opinion based upon a hypothetical question.’’
(Internal quotation marks omitted.) Sargis v. Donahue,
142 Conn. App. 505, 513, 65 A.3d 20, cert. denied, 309
Conn. 914, 70 A.3d 38 (2013).
‘‘[I]t is the plaintiff who bears the burden to prove
an unbroken sequence of events that tied his injuries
to the [defendants’ conduct]. . . . This causal connec-
tion must be based upon more than conjecture and
surmise.’’ (Citations omitted; internal quotation marks
omitted.) Paige v. St. Andrew’s Roman Catholic Church
Corp., 250 Conn. 14, 25–26, 734 A.2d 85 (1999). A plain-
tiff, however, ‘‘is not required to disprove all other possi-
ble explanations for the accident but, rather, must
demonstrate that it is more likely than not that the
defendant’s negligence was the cause of the accident.’’
(Emphasis added.) Rawls v. Progressive Northern Ins.
Co., 310 Conn. 768, 782, 83 A.3d 576 (2014). ‘‘[T]he issue
of causation in a negligence action is a question of fact
for the trier . . . .’’ (Internal quotation marks omitted.)
Burton v. Stamford, 115 Conn. App. 47, 87, 971 A.2d
739, cert. denied, 293 Conn. 912, 978 A.2d 1108 (2009).
With the relevant legal framework in mind, we turn
to the present case. As an initial matter, we highlight
that the parties’ dispute regarding causation revolves
around the issue of when the decedent ingested the
fatal dose of methadone. That issue, in turn, depends
principally on the application of the toxicological princi-
ples governing the relative half-lives and durations of
effect of Narcan and long-acting and short-acting nar-
cotics. Thus, we begin by reviewing the expert evidence
relating to those toxicological principles.
The thrust of the defendant’s argument is that the
undisputed ‘‘physical facts of human biology’’ and ‘‘set-
tled scientific principles’’ ‘‘permit[ted] only one conclu-
sion: If the plaintiff had consumed the fatal dose of
methadone before her discharge from the emergency
room, there would have been some sign of the drug’s
resurgent effect before 1:30 a.m.’’ The fundamental flaw
in this argument is that the relevant ‘‘physical facts’’
and ‘‘scientific principles’’ were disputed at trial. Our
review of the record reveals that, although the parties’
experts concurred on much of the relevant science,
their testimony diverged on a crucial point. As pre-
viously explained in considerable detail, the parties’
experts disagreed as to how soon after receiving Narcan
a methadone overdose patient experiences recurring
overdose symptoms.
The defendant’s causation expert, Pike, testified that
recurring methadone overdose symptoms should pre-
sent, if at all, one hour after the administration of Nar-
can. This testimony, however, was contradicted directly
by the testimony of Schwam, the plaintiff’s standard of
care expert. In particular, Schwam testified that
‘‘delayed respiratory depression can occur’’ in cases of
overdoses on long-acting narcotics and that ‘‘you don’t
know when [the] return of respiratory depression is
going to occur.’’ (Emphasis added.) According to
Schwam, ‘‘[o]ne might think that [the return] would
occur when the Narcan wears off, [but] that’s a widely
held misconception . . . .’’ (Emphasis added.)
Schwam recalled from his experience two cases in
which delayed recurring respiratory depression
occurred. Although the defendant correctly points out
that these two cases may not be exactly analogous to
the decedent’s case, they still, nonetheless, are illustra-
tive of the broader point that delayed recurring can
occur in cases of methadone overdose.
Despite some testimony suggesting that delayed
recurring respiratory depression violates certain scien-
tific principles, Schwam testified that it is a medical
phenomenon that actually has been observed in prac-
tice. Indeed, Schwam opined not only that the phenome-
non can occur, but that it occurs despite what the
defendant characterizes as ‘‘undisputed’’ and ‘‘settled’’
scientific principles. Specifically, Schwam testified that
‘‘a little bit [of knowledge pertaining to] opiate toxicol-
ogy’’ has given rise to the ‘‘widely held misconception’’
that recurring overdose symptoms return ‘‘when the
Narcan wears off . . . .’’ (Emphasis added.) In other
words, the evidence did not establish, as the defendant
suggests, that delayed onset of recurring respiratory
depression was scientifically impossible. On the con-
trary, the jury heard expert testimony that delayed
recurring respiratory depression can occur in metha-
done overdoses, even if such a phenomenon seems
to defy the ‘‘undisputed’’ and ‘‘settled’’ toxicological
principles of half-life and duration of effect.
‘‘Conflicting expert testimony does not necessarily
equate to insufficient evidence.’’ (Internal quotation
marks omitted.) Dallaire v. Hsu, 130 Conn. App. 599,
603, 23 A.3d 792 (2011). Rather, ‘‘[w]here expert testi-
mony conflicts, it becomes the function of the trier of
fact to determine credibility and, in doing so, it could
believe all, some or none of the testimony of either
expert.’’ (Internal quotation marks omitted.) DelBuono
v. Brown Boat Works, Inc., 45 Conn. App. 524, 541, 696
A.2d 1271, cert. denied, 243 Conn. 906, 701 A.2d 328(1997). It is axiomatic that in cases involving ‘‘conflict-
ing expert testimony, the jury is free to accept or reject
each expert’s opinion in whole or in part.’’ (Internal
quotation marks omitted.) Shelnitz v. Greenberg, 200
Conn. 58, 68, 509 A.2d 1023 (1986).
In the present case, the jury certainly was free to
believe and accept the opinion of the plaintiff’s expert
that the phenomenon of delayed recurring respiratory
depression can occur in methadone overdoses. Like-
wise, it was free to disbelieve and reject the parts of
the testimony of the defendant’s expert that attempted
to refute that phenomenon. Therefore, contrary to the
defendant’s assertion, the fact that the decedent did not
immediately experience recurring overdose symptoms
one hour after Narcan was administered did not require
the jury to conclude that the decedent’s overdose on
November 29, 2008, was caused by a short-acting nar-
cotic rather than methadone. The jury could have con-
cluded, instead, that the delayed recurring respiratory
depression the decedent eventually experienced was
consistent with her ingestion of a toxic dose of metha-
done before her visit to Lawrence & Memorial on
November 29, 2008.
Notwithstanding our conclusion that the parties pre-
sented conflicting expert testimony on the concept of
delayed recurring respiratory depression, the defendant
argues that it is improper to consider Schwam’s testi-
mony in reviewing the evidence on that concept. Specif-
ically, the defendant argues that ‘‘Schwam testified as
an expert on the standard of care, not causation. [Thus]
[the jury] had no basis to transplant that standard of
care testimony to the foreign soil of causation—and no
guidance from an expert on how to make it grow there
if [it] did.’’ According to the defendant, ‘‘[t]he plaintiff
put on Dr. Schwam for one purpose; his testimony can-
not be used for another and totally different purpose.’’
(Internal quotation marks omitted.) We find this argu-
ment unpersuasive.
As an initial matter, we note that it is unclear from
the record whether Schwam’s testimony was offered
solely for standard of care purposes. The plaintiff’s dis-
closure of Schwam’s testimony indicated that Schwam
would testify on a wide range of subject matter, includ-
ing how delayed recurring respiratory depression
caused the decedent’s death.12 Additionally, the record
is silent as to how the plaintiff actually offered the
testimony and if at that time he in fact limited his offer
to standard of care purposes.
Notwithstanding the ambiguity surrounding the plain-
tiff’s proffer of Schwam’s testimony, the parties appar-
ently agree that Schwam’s testimony was offered only
for standard of care purposes.13 Schwam, nonetheless,
was an emergency medicine physician who had experi-
ence treating overdose patients and reviewing overdose
cases in his capacity as a hospital’s director of quality
assurance. Thus, his testimony regarding delayed respi-
ratory depression was an ‘‘expert’’ opinion in the sense
that it was based on his expertise and experience in
practicing emergency medicine, a field apparently
requiring knowledge of the toxicological and pharmaco-
logical properties of narcotics. The fact that the parties’
dispute over the standard of care and causation both
centered primarily on those properties reveals that the
issues of standard of care and causation clearly were
intertwined in the present case.
Even if Schwam’s testimony was offered strictly for
standard of care purposes, the defendant failed to pur-
sue any preemptive or remedial measures that would
have precluded or limited Schwam’s testimony on the
issue of delayed recurring respiratory depression. The
defendant did not file a motion in limine on that issue;
it did not object to questions on that issue asked of
Schwam by the plaintiff’s counsel;14 it did not move to
strike Schwam’s testimony regarding that issue;15 and
it did not request a limiting instruction directing the
jury to consider Schwam’s testimony on that issue only
for standard of care purposes. See State v. Dews, 87
Conn. App. 63, 69, 864 A.2d 59 (rejecting claim that trial
court, sua sponte, should have ‘‘stricken . . . testi-
mony and offered a limiting instruction as to its use’’
because ‘‘defendant did not object to . . . testimony,
he failed to seek to have the testimony stricken . . .
he did not request a limiting instruction . . . [and] he
[did not] take exception to the court’s failure to give a
limiting instruction’’), cert. denied, 274 Conn. 901, 876
A.2d 13 (2005).
Accordingly, the court never instructed the jury that
it should disregard Schwam’s testimony on delayed
recurring respiratory depression or that it should con-
sider such testimony only for standard of care purposes.
In the absence of any such instruction from the court,
the evidence regarding delayed recurring respiratory
depression was before the jury for it to use for any
purpose, including causation. See Curran v. Kroll,
supra, 303 Conn. 863–64 (‘‘We also are not persuaded by
the . . . argument that the Appellate Court improperly
concluded that evidence of the decedent’s telephone
call to [the defendant physician] would support an infer-
ence that the decedent would have called [the defen-
dant] about her leg pain if she had been warned about
it because the evidence was not presented for that pur-
pose . . . . This evidence was admitted in full, without
limitation. In the absence of any limiting instruction,
the jury was entitled to draw any inferences from the
evidence that it reasonably would support.’’ [Emphasis
added.]); see also State v. Carey, 228 Conn. 487, 496, 636
A.2d 840 (1994) (‘‘If [inadmissible] evidence is received
without objection, it becomes part of the evidence in
the case, and is usable as proof to the extent of the
rational persuasive power it may have. The fact that it
was inadmissible does not prevent its use as proof so far
as it has probative value. . . . This principle is almost
universally accepted. . . . The principle applies to any
ground of incompetency under the exclusionary rules.’’
[Internal quotation marks omitted.]).
The defendant also argues that, even if the jury could
consider Schwam’s testimony for causation purposes,
the combined expert testimony of Schwam and McDo-
nough still was insufficient to establish causation. Spe-
cifically, the defendant argues that ‘‘[e]ven if the
plaintiff could dress up standard of care testimony in
causation clothes, Dr. Schwam did not opine that
delayed respiratory depression caused the decedent’s
death. No [expert] witness did.’’ (Emphasis altered.)
The defendant also contends that McDonough’s opinion
as to the decedent’s cause of death was inadequate
because McDonough could not determine if the dece-
dent consumed the fatal dose of methadone before her
discharge from Lawrence & Memorial. Thus, the grava-
men of the defendant’s challenge to the expert evidence
on causation is that the opinions of McDonough and
Schwam were deficiently unspecific. We are unper-
suaded.
The defendant correctly states that a plaintiff in a
medical malpractice action generally must prove causa-
tion with expert testimony. See Milliun v. New Milford
Hospital, supra, 310 Conn. 725. We disagree with the
defendant, however, that the cumulative effect of the
expert evidence and other evidence presented in this
case did not establish a causal connection between the
defendant’s negligence and the decedent’s death.
First, although McDonough did not testify specifically
that the respiratory depression responsible for the dece-
dent’s death was ‘‘delayed,’’ he did opine that the cause
of death was respiratory depression resulting from
methadone toxicity. McDonough also provided subse-
quent testimony indicating that the ‘‘presumed time to
onset’’ of respiratory depression in methadone over-
doses ‘‘could be quite long’’ because ‘‘the respiratory
depression comes on much later than the pain relief.’’
(Emphasis added.) Furthermore, expert testimony pro-
vided by Schwam, which we presume the jury credited,
described in considerable detail the phenomenon of
delayed recurring respiratory depression in methadone
overdoses. The occurrence of fatal respiratory depres-
sion hours after the decedent’s consumption of metha-
done was consistent with the expert testimony provided
by McDonough and Schwam. Thus, when all of the
expert testimony is considered together, the jury rea-
sonably could have inferred that the decedent suc-
cumbed to delayed respiratory depression.
Second, the fact that McDonough could not deter-
mine the specific time at which the decedent consumed
the fatal dosage of methadone does not render his opin-
ion inadequate. Rather, the specific timing of the dece-
dent’s ingestion of methadone was a fact that the
plaintiff could have proven with circumstantial evi-
dence. See Shelnitz v. Greenberg, supra, 200 Conn. 66(‘‘[in a medical malpractice action] [c]ausation may be
proved by circumstantial evidence and expert testi-
mony’’ [emphasis added; internal quotation marks omit-
ted]). On direct examination, the plaintiff asked
McDonough whether it was his opinion that, if the dece-
dent had consumed methadone before her discharge
but not afterward, the methadone consumed before her
discharge on November 29, 2008, caused the decedent’s
death. McDonough answered that question in the affir-
mative. In answering that question, McDonough clearly
had to assume that the decedent ingested methadone
only before, and not after, her discharge. In other words,
McDonough offered a conditional opinion that the
methadone consumed before the decedent’s discharge
caused her death, the condition being that the plaintiff
prove that the methadone in fact was consumed before,
and not after, her discharge. McDonough’s testimony
was not the exclusive means of proving that fact.
Having determined that the jury reasonably could
have credited expert testimony supportive of the phe-
nomenon of delayed recurring respiratory depression,
we now examine the other evidence relating to when
the decedent consumed the fatal dose of methadone.
Our review of the record leads us to conclude that there
was sufficient evidence from which the jury could infer,
without resorting to speculation, that the decedent con-
sumed the fatal dose of methadone before her dis-
charge.16
In particular, the jury was presented with the follow-
ing relevant evidence. At approximately 6:45 p.m. on
November 29, 2008, the decedent was found to be suffer-
ing from symptoms that are consistent with an opiate
or opioid induced overdose. The decedent’s improve-
ment in response to a dose of Narcan confirmed that
she had been experiencing an overdose on an opioid
or opiate. The paramedics who treated the decedent
were able to determine that the decedent’s ‘‘current
medications’’ included methadone. Hope searched his
home upon finding the decedent overdosing on Novem-
ber 29, and he did not find any drugs, drug parapherna-
lia, or evidence of drug use.
There were conflicting accounts as to whether the
decedent admitted to taking methadone, but the jury
certainly was free to credit the account wherein the
decedent told the emergency room nurses that she took
methadone and not heroin. Critically, a toxicology
screen performed in the emergency room on November
29, 2008, detected the presence of methadone in the
decedent’s urine. The jury heard expert testimony that
the positive finding for methadone in that screen could
not have been caused by the therapeutic doses of metha-
done the decedent received eight days earlier.
From the time she was discharged, 11:53 p.m. on
November 29, 2008, until 1:30 a.m. on November 30,
2008, the evidence showed that the decedent was in
the company of Hope, who did not observe her ingest
any more drugs. At some point between 1:30 a.m. and
9:45 a.m., the decedent experienced another episode of
respiratory depression, which the jury could have found
to be the type of delayed recurring respiratory depres-
sion that Schwam opined is consistent with methadone
overdoses. Hope testified that he did not hear any move-
ment from the decedent between 1:30 a.m. and 9:45
a.m. on November 30, unlike the night of November 29,
when he had heard the decedent use the microwave in
his kitchen. Hope found the decedent’s body in the
same position in which it had been when he last saw
the decedent at 1:30 a.m.
The medical examiner determined that the concentra-
tion of methadone present in the decedent’s blood at
the time of death was at a toxic level. The decedent’s
death occurred approximately seven to fifteen hours
after she initially overdosed on November 29, 2008.
Hope and law enforcement officials searched Hope’s
home on November 30, 2008, and did not find any evi-
dence relating to drug activity. In addition, Geyer, an
investigator with the medical examiner’s office, did not
find any drugs, drug paraphernalia, or signs of drug use
on or near the decedent’s body.
Construing all of the evidence in the light most favor-
able to sustaining the verdict, as we must; Saint Ber-
nard School of Montville, Inc. v. Bank of America, 312
Conn. 811, 834, 95 A.3d 1063 (2014); we conclude that
it is sufficient to support the jury’s finding that the
decedent consumed a fatal dose of methadone before
she was brought to the emergency room at Lawrence &
Memorial on November 29, 2008.
B
In its second challenge to the sufficiency of causation
evidence, the defendant contends that ‘‘there is a
[another] missing link in the plaintiff’s causal chain.
. . . [T]he jury could only guess whether the decedent
would have been admitted to [Lawrence & Memorial]
if Dr. Marchiondo had not discharged her.’’ According
to the defendant, in order to prove that Marchiondo’s
negligence caused the decedent’s death, the plaintiff
was required to present evidence regarding ‘‘[Law-
rence & Memorial’s] admission standards . . . and
whether the decedent met them.’’ Because the plaintiff
failed to present such evidence, the defendant contends,
the jury reasonably could not have found that the defen-
dant caused the decedent’s death. We disagree.
The defendant’s second sufficiency challenge suffers
from the basic flaw of misunderstanding Schwam’s tes-
timony regarding the applicable standard of care. As
the defendant argues, Schwam did testify initially that
the standard of care applicable to possible methadone
overdoses required Marchiondo to ‘‘admit [the dece-
dent] to the hospital for continuous monitoring . . .
for a minimum of twenty-four hours.’’ (Emphasis
added.) Schwam subsequently clarified, however, that
the applicable standard of care only required Marchi-
ondo ‘‘to monitor her. He needed to ideally admit her
to an intensive care unit, but certainly to monitor her
for twenty-four hours for signs of recurrent opiate over-
dose.’’ (Emphasis added.) The jury, of course, could
have accepted the part of Schwam’s testimony indicat-
ing that monitoring was required and rejected the part
suggesting admittance was required.
Consequently, in order to prove causation, the plain-
tiff needed to show only that the decedent could have
been monitored sufficiently for twenty-four hours, not
admitted for that period of time. Zambarano, an emer-
gency room nurse at Lawrence & Memorial, testified
that the decedent was monitored in a room called the
‘‘observation room’’ during her hospitalization. Nurses
assigned to the observation room monitor the vital signs
of patients in that room both in person and through
remote telemetric monitoring displays at a nearby
nurses’ station. Thus, nurses can respond immediately
to a crash in the vital signs of an observation room
patient. According to Zambarano, patients can stay
overnight in the observation room. Alternatively, Zamb-
arano testified, patients can be monitored in less acute
areas, such as hallway beds. With that testimony, along
with the evidence that the decedent was ‘‘told that she
was here for the night,’’ the jury reasonably could have
inferred that it was more likely than not that the dece-
dent could have been monitored medically for twenty-
four hours at Lawrence & Memorial.
Accordingly, in construing all of the evidence in the
light most favorable to sustaining the verdict, as we
must; Saint Bernard School of Montville, Inc. v. Bank
of America, supra, 312 Conn. 834; we conclude that
there was sufficient evidence supporting the jury’s find-
ing that the defendant’s negligence caused the dece-
dent’s death.
II
SUFFICIENCY OF EVIDENCE SUPPORTING
JURY’S AWARD OF DAMAGES
The defendant’s second claim is that the plaintiff failed
to present sufficient evidence supporting the jury’s
award of $150,000 in damages for the destruction of
the decedent’s capacity to carry on and enjoy life’s
activities. Specifically, the defendant contends that a
plaintiff seeking damages for the destruction of a dece-
dent’s capacity to carry on and enjoy life’s activities
must present evidence of the decedent’s life expec-
tancy. According to the defendant, the plaintiff failed
to present evidence of the decedent’s life expectancy
in the present case, and, therefore, the jury’s award of
damages for the destruction of the decedent’s capacity
to carry on and enjoy life’s activities was ‘‘speculative
and unreasonable.’’ We disagree.
The following additional facts and procedural history
are necessary to our resolution of the defendant’s sec-
ond claim. At trial, the plaintiff presented evidence of
the decedent’s (1) age, (2) health, (3) physical condition,
and (4) habits and activities. Regarding the decedent’s
age, a photograph of the decedent’s driver’s license,
which contained the decedent’s date of birth, was
admitted into evidence.
Regarding the decedent’s health, the plaintiff offered
some of the decedent’s medical records. Those records
indicated that, in addition to polysubstance abuse, the
decedent suffered from diabetes, hypothyroidism, high
cholesterol, high blood sugar, anxiety, and depression.
The records also indicated that, since 2000, the dece-
dent had completed several inpatient and outpatient
substance abuse treatment programs and had been hos-
pitalized several times for diabetes related compli-
cations.
Regarding the decedent’s physical condition, McDo-
nough’s autopsy report, wherein he detailed the obser-
vations of his external and internal examinations of
the decedent, was admitted into evidence. McDonough
testified that he observed ‘‘no evidence of acute trauma’’
as a result of his external examination of the decedent’s
body. Furthermore, McDonough’s internal examination
revealed no evidence of disease afflicting the decedent’s
cardiovascular, hepatobiliary, lymphoreticular, gastro-
intestinal, genitourinary, and central nervous systems,
nor was there evidence of disease afflicting the dece-
dent’s head, neck, internal genital organs, or abdominal
and chest cavities. McDonough’s examination did
reveal, however, that the decedent’s thyroid exhibited
signs of chronic inflammation and that her lungs were
congested with fluid.
Regarding the defendant’s habits and activities, as
previously set forth, there was considerable evidence
presented of the decedent’s lengthy struggle with polys-
ubstance abuse and her alternating periods of sobriety
and relapse. In addition to her drug problems, however,
there was evidence presented regarding the decedent’s
other habits and activities. The decedent’s father, James
Procaccini, testified that in the summer of 2008 the
decedent was a ‘‘very happy person’’ who was ‘‘able to
function in life very well.’’ According to her father,
the decedent helped him and his wife with household
chores, submitted ‘‘an awful lot’’ of job applications, and
attended Alcoholics Anonymous meetings. The ‘‘bright
spot in [the decedent’s] life’’ at that time, however, was
helping her father and mother care for her two year
old twin niece and nephew. Prior to the summer of
2008, the decedent had graduated from the University
of Vermont with a bachelor of science degree and had
taken a cross-country trip to Mount Rainier in Wash-
ington.
Following the jury’s return of a plaintiff’s verdict, the
defendant filed a motion to set aside the verdict on
the ground that the jury’s award of damages for the
destruction of the decedent’s capacity to carry on and
enjoy life’s activities was ‘‘speculative.’’ Specifically, the
defendant argued that the plaintiff failed to present
evidence of ‘‘[h]ow long the plaintiff likely would have
lived,’’ and, therefore, ‘‘[w]ithout a life expectancy table,
or some other evidence on this topic,’’ the jury’s award
‘‘[could not] stand.’’ The court denied the defendant’s
motion to set aside the verdict.
We begin our analysis by outlining our standard of
review. ‘‘The standard of review governing our review
of a trial court’s denial of a motion to set aside the
verdict is well settled. The trial court possesses inherent
power to set aside a jury verdict which, in the court’s
opinion, is against the law or the evidence. . . . [The
trial court] should not set aside a verdict where it is
apparent that there was some evidence upon which the
jury might reasonably reach [its] conclusion, and should
not refuse to set it aside where the manifest injustice
of the verdict is so plain and palpable as clearly to
denote that some mistake was made by the jury in the
application of legal principles . . . . Ultimately, [t]he
decision to set aside a verdict entails the exercise of a
broad legal discretion . . . that, in the absence of clear
abuse, we shall not disturb.’’ (Internal quotation marks
omitted.) Kumah v. Brown, 160 Conn. App. 798, 803,
126 A.3d 598, cert. denied, 320 Conn. 908, 128 A.3d
953 (2015).
We now turn to the legal principles governing dam-
ages awards in wrongful death actions. ‘‘In actions for
injuries resulting in death, a plaintiff is entitled to ‘just
damages’ together with the cost of reasonably neces-
sary, medical, hospital and nursing services, and includ-
ing funeral expenses.’ General Statutes § 52-555. ‘Just
damages’ include (1) the value of the decedent’s lost
earning capacity less deductions for her necessary liv-
ing expenses and taking into consideration that a pre-
sent cash payment will be made, (2) compensation for
the destruction of her capacity to carry on and enjoy
life’s activities in a way she would have done had she
lived, and (3) compensation for conscious pain and
suffering.’’ (Emphasis added.) Katsetos v. Nolan, 170
Conn. 637, 657, 368 A.2d 172 (1976).
Regarding compensation for the destruction of a
decedent’s capacity to carry on and enjoy life’s activi-
ties, our Supreme Court has stated the following: ‘‘[T]he
parties in a death action are entitled to attempt to pre-
sent an over-all picture of the decedent’s activities to
enable the jury to make an informed valuation of the
total destruction of his capacity to carry on life’s activi-
ties. . . . So, for example, evidence bearing on how
pleasurable the decedent’s future might have been is
admissible . . . as is evidence as to the decedent’s hob-
bies and recreations.’’ (Citations omitted; emphasis
added; internal quotation marks omitted.) Waldron v.
Raccio, 166 Conn. 608, 616–17, 353 A.2d 770 (1974); id.,
617 (evidence of ‘‘decedent’s attachment to his family’’
relevant to claim for destruction of capacity to carry
on and enjoy life’s activities); see also Katsetos v. Nolan,
supra, 170 Conn. 658 (evidence that decedent ‘‘was hap-
pily married,’’ ‘‘had four children,’’ ‘‘was a very happy
person and in good health,’’ ‘‘was a dedicated mother
and homemaker,’’ ‘‘[was] active in many outside activi-
ties,’’ ‘‘was a state-licensed hairdresser,’’ and had
worked in pizza restaurant and office relevant to her
capacity to enjoy life’s activities); cf. Bruneau v. Quick,
187 Conn. 617, 635–36, 447 A.2d 742 (1982) (in personal
injury action for surgeon’s malpractice, evidence that
plaintiff no longer could undertake ice skating, sailing,
ballroom and jazz dancing, and gardening as she had
before botched surgery was relevant to her ‘‘ability to
carry on and enjoy certain activities’’).
A claim for the destruction of a decedent’s capacity
to carry on and enjoy life’s activities requires proof of
the decedent’s life expectancy. See Sims v. Smith, 115
Conn. 279, 286, 161 A. 239 (1932) (‘‘damages based upon
the loss to the estate of a decedent by his death neces-
sarily involves a consideration of the probable duration
of his life’’); cf. Acampora v. Ledewitz, 159 Conn. 377,
384–85, 269 A.2d 288 (1970) (in personal injury action,
trial court erred in allowing jury to consider damages
for permanent pain and suffering because ‘‘no evidence
was introduced as to [plaintiff’s] life expectancy’’).
With respect to the type of evidence that can be used
to prove one’s life expectancy, our Supreme Court has
stated the following: ‘‘A mortality table17 is not the exclu-
sive evidence admissible to establish the expectancy
of life, since age, health, habits and physical condition
may afford evidence thereof.’’ (Emphasis added; foot-
note added.) Johnson v. Fiske, 125 Conn. 445, 449, 6
A.2d 354 (1939). ‘‘[Mortality] tables only give the average
of a large number of lives, and in the individual case
the expectancy may be higher or lower than the average.
While generally held admissible, they are not conclu-
sive, nor are they the exclusive evidence admissible in
proof of that fact, which the jury may determine from
other evidence . . . .’’ (Emphasis added.) Donoghue v.
Smith, 114 Conn. 64, 66, 157 A. 415 (1931); see also
Tampa v. Johnson, 114 So. 2d 807, 810 (Fla. App. 1959)
(‘‘[a] jury is not bound by mortality tables, but these
constitute only one of many factors that may be consid-
ered in estimating life expectancy’’ [emphasis added]);
Glover v. Berger, 72 Wyo. 221, 250, 263 P.2d 498 (1953)
(‘‘[d]irect evidence as to plaintiff’s expectancy of life,
however, is not essential, but the jury may determine
such fact from their own knowledge and from the proof
of the age, health, and habits of the person and other
facts before them’’ [internal quotation marks omitted]).
Use of a mortality table is not the exclusive means of
proving life expectancy because ‘‘our rule for assessing
damages in death cases gives no precise mathematical
formulas for the jury to apply. . . . [T]he assessment
of damages in wrongful death actions must of necessity
represent a crude monetary forecast of how the dece-
dent’s life would have evolved.’’ (Citations omitted;
emphasis added; internal quotation marks omitted.)
Katsetos v. Nolan, supra, 170 Conn. 657. Indeed, ‘‘[t]he
life expectancy of the deceased, for the purpose of
assessing damages in a wrongful death action, is a ques-
tion of fact for the jury to decide . . . .’’ (Emphasis
added.) 22A Am. Jur. 2d 353, Death § 221 (2013).
Consequently, ‘‘jurors may determine such fact from
their own knowledge and from the proof of the age,
health, and habits of the person and other facts before
them.’’ (Emphasis added.) 29A C.J.S. 493, Damages
§ 141 (2012); see also 22A Am. Jur. 2d, supra, § 349, pp.
469–70 (‘‘if age, sex, health, and mental capacity are
proven, the jury is entitled to determine from these
facts and circumstances . . . in its sound judgment
. . . the decedent’s life expectancy, without resort to
mortality tables’’). ‘‘The law does not require the pro-
duction of . . . life expectancy tables whenever there
is an issue of life expectancy, and does not regard them
as essential to the establishment of that issue or to the
recovery of damages based on life expectancy.’’ 29A
Am. Jur. 2d 723, Evidence § 1383 (2013).
Thus, insofar as the defendant argues that the plain-
tiff’s proof of the decedent’s destroyed capacity to enjoy
life’s activities is insufficient because he did not present
‘‘government mortality tables,’’ we disagree. As pre-
viously addressed in considerable detail, the plaintiff
presented substantial evidence of the decedent’s age,
health, physical condition, and habits, all of which are
relevant to determining life expectancy. The decedent’s
age was established by her driver’s license; the dece-
dent’s sundry illnesses were established by her medical
records; the decedent’s physical condition at the time
of her death was expounded in McDonough’s autopsy
report and trial testimony; and the jury was familiar
with the decedent’s enduring drug habits. Moreover,
the jury heard testimony from the decedent’s father
regarding the activities in which the decedent enjoyed
partaking, including her strong attachment to her niece
and nephew. Waldron v. Raccio, supra, 166 Conn.
616–17 (decedent’s ‘‘attachment to his family’’ relevant
to his capacity to enjoy life’s activities). Thus, the jury
reasonably could have made a ‘‘ ‘crude . . . forecast’ ’’;
Katsetos v. Nolan, supra, 170 Conn. 657; of the dece-
dent’s life expectancy from its own knowledge and from
proof of the decedent’s age, health, physical condition,
and habits.
In light of the foregoing evidence that the plaintiff
presented with respect to the decedent’s life expectancy
and activities that she enjoyed, we conclude that the
jury’s award of damages for the destruction of the dece-
dent’s capacity to carry on and enjoy life’s activities
was not unreasonable or speculative. Accordingly we
conclude that the court did not abuse its discretion in
refusing to set aside the jury’s award of damages for
the destruction of the decedent’s capacity to carry on
and enjoy life’s activities.
The judgment is affirmed.
In this opinion the other judges concurred.
1
Lawrence & Memorial Hospital, Inc., Lawrence & Memorial Corporation,
and Thomas E. Marchiondo, a physician, were initially named as defendants
in this action. Prior to trial, the plaintiff withdrew the action as against
Lawrence & Memorial Hospital, Inc., and Lawrence & Memorial Corporation,
and filed an amended complaint naming Emergency Medicine Physicians
of New London County, LLC, as a defendant. After filing this appeal, but
before oral argument was heard, the plaintiff withdrew the claims as against
Marchiondo, who died before trial began. Accordingly, because those three
other defendants are not involved in this appeal, we refer to Emergency
Medicine Physicians of New London County, LLC, as the defendant through-
out this opinion.
2
The jury heard expert testimony explaining the differences between
opiates and opioids. An opiate is a ‘‘naturally occurring’’ narcotic that is
derived from poppy plants. There are four opiates: opium, heroin, codeine,
and morphine. An opioid is a ‘‘synthetic or semisynthetic narcotic . . . .’’
Examples of well-known opioids include oxycodone, hydrocodone, fentanyl,
and methadone.
3
Marchiondo also diagnosed the decedent with pneumonia.
4
The parties stipulated at trial that Marchiondo was ‘‘an employee, agent,
representative, or servant of [the defendant] and acting within and pursuant
to the scope of his employment, agency, representation, and authority with
[the defendant].’’ Accordingly, the court instructed the jury: ‘‘If you find that
. . . Marchiondo’s treatment of [the decedent] was negligent, that is, devi-
ated from the applicable standard of care, and that negligence was a substan-
tial factor in bringing about her death, then [the defendant] is responsible
for . . . Marchiondo’s conduct and, in that event, you should find against
[the defendant].’’
5
The court reserved decision on the defendant’s renewed motion for a
directed verdict when it granted the defendant’s motion for an extension
of time to file other postverdict motions. Subsequent to the court’s granting
of the motion for an extension of time, the defendant filed a motion to set
aside the jury’s verdict, wherein the defendant again renewed its motion
for a directed verdict. The trial court denied both the motion to set aside
and the motion for a directed verdict, the latter of which was denied nunc
pro tunc.
6
Throughout trial, it appears that the parties, and even their expert wit-
nesses, occasionally blurred the distinction between half-life and duration
of effect. Indeed, although he warned against ‘‘confus[ing] duration of effect
with half-life,’’ Pike himself provided a definition of ‘‘half-life’’ that seemingly
incorporated the concept of the duration of effect: ‘‘half-life . . . has . . .
to do with how long th[e] physiologic response that the drug is producing
will be effective . . . .’’ (Emphasis added.) As another example, when asked
by the defendant’s counsel to provide the ‘‘durational effect’’ of Narcan,
McDonough replied: ‘‘It would be similar to the half-life of thirty to eighty
minutes.’’ (Emphasis added.)
Nevertheless, it is of little importance whether the technical scientific
distinction between half-life and duration of effect was preserved consis-
tently at trial. As explained previously in greater detail, the crucial issue at
trial pertained to Narcan’s relative effectiveness as compared to both long-
acting and short-acting narcotics. The parties’ experts agreed that ‘‘[Nar-
can’s] effectiveness is much shorter than the effect of the longer-acting
[and] even short-acting narcotic[s] . . . .’’ (Emphasis added.) Moreover, as
also explained previously in greater detail, it was undisputed that the half-
lives and durations of effect of short-acting narcotics are shorter than those
of long-acting narcotics.
7
The defendant, but not the plaintiff, asserts that the ‘‘parties stipulated
that the maximum effective duration of the Narcan given to the decedent
was ninety minutes.’’ (Emphasis added.) Although the record reveals that
the plaintiff offered to stipulate that the effective duration of Narcan is
‘‘twenty to ninety minutes,’’ neither the defendant nor the court accepted
this proposed stipulation. Furthermore, the court never submitted any such
stipulation to the jury.
8
Although the defendant does not challenge the jury’s finding with respect
to the standard of care, we note that Schwam opined that Marchiondo’s
treatment of the decedent deviated from the appropriate standard of care
for a possible methadone overdose. Schwam testified that Marchiondo
improperly ruled out methadone as a potential cause of the decedent’s
overdose because there was ‘‘sufficient evidence to at least raise the possibil-
ity that the overdose was . . . partly methadone.’’ Consequently, having
wrongly excluded methadone, Marchiondo also failed to provide the dece-
dent with the appropriate care for a methadone overdose, which is ‘‘monitor[-
ing] . . . for twenty-four hours for signs of recurrent opiate overdose.’’
9
The plaintiff conceded at oral argument before this court that Schwam’s
testimony was offered only for standard of care purposes.
10
The defendant did file two motions in limine regarding the scope of
Schwam’s testimony. The second, which sought to preclude Schwam from
testifying on the ‘‘effective duration of Narcan,’’ effectively was granted
when the court stated that it would sustain any ‘‘objection that fairly impli-
cates . . . [the] effective duration of Narcan.’’ The first motion sought to
preclude Schwam from testifying regarding the standard of care with respect
to Marchiondo’s diagnosis of pneumonia. The plaintiff agreed to not elicit
any testimony from Schwam regarding the pneumonia diagnosis. Neither
of those two motions, however, sought to preclude or limit in any respect
Schwam’s testimony regarding delayed recurring respiratory depression.
11
The defendant did move to strike the following testimony from Schwam’s
direct examination: ‘‘Well, [the belief that respiratory depression would
return when Narcan wears off is] a very easy thing to assume if you know
a little bit about opiate toxicology, but decades of experience have shown
that if that’s the way you think and you discharge a patient, a lot of them
will be dead the next day.’’ The court, however, denied the motion to strike.
Critically, the defendant’s stated ground for the motion to strike was that
Schwam’s answer was not responsive to the question asked by the plaintiff’s
counsel. At no point did the defendant move to strike Schwam’s testimony
on the ground that it was outside the scope of the plaintiff’s offer of Schwam’s
testimony for standard of care purposes.
12
Specifically, the plaintiff stated in the disclosure that Schwam would
testify as to (1) ‘‘all subject matter arising from his expertise in the field
of emergency medicine, including the treatment of patients suspected of
suffering from drug overdose’’; (2) ‘‘all subject matter arising from his educa-
tion, training, and experience’’; (3) ‘‘the care and treatment [the decedent]
received from the defendant during her emergency department admission
on November 29, 2008’’; (4) ‘‘the decedent’s medical history, her presenting
symptoms, the course of treatment she received by the defendant, the diagno-
sis provided, the laboratory results, and the medical course that could and
should have occurred, but did not’’; and (5) ‘‘certain aspects of the testimony
provided by the defendant’s experts.’’
In outlining the subject matter of Schwam’s testimony, the disclosure also
stated: ‘‘Please see the attached five page opinion letter . . . that capture[s]
the expected subject matter of his expected testimony.’’ In the attached
opinion letter, Schwam opined, among other things, that (1) ‘‘when Narcan
is administered to counteract methadone, the Narcan usually wears off long
before the methadone, and patients may seem well for several hours, only
to relapse and become unconscious much later’’; (2) ‘‘when the effects of
Narcan [administered to the decedent] wore off, the effects of methadone
returned and she suffered unresponsiveness and fatal respiratory depression;
and (3) ‘‘to a reasonable medical certainty, it can be determined that the
delayed toxic effects of the methadone caused [the decedent’s] death.’’
13
See footnote 9 of this opinion.
14
See footnote 10 of this opinion.
15
See footnote 11 of this opinion.
16
The defendant’s reliance on Paige v. St. Andrew’s Roman Catholic
Church Corp., supra, 250 Conn. 14, is unavailing. The defendant cites Paige
as support for its position that the jury in the present case resorted to
improper speculation in finding that the defendant caused the plaintiff’s
death. We are unpersuaded by the defendant’s reliance on Paige because
it is distinguishable from the present case.
In Paige, our Supreme Court held that there was insufficient evidence
supporting the jury’s finding that the defendant caused the plaintiff’s injuries.
Id., 17. The plaintiff in Paige was cleaning a boiler located in the defendant’s
church when someone activated the boiler, causing the plaintiff to sustain
serious burn injuries. Id., 16–17. There was no direct evidence presented at
trial that affirmatively established that the person who activated the boiler
was an employee, servant, or agent of the defendant. Id., 34. Thus, the
plaintiff’s case relied principally on two alternative theories of negligence:
(1) the defendant failed to supervise and instruct its employees, servants,
and agents with respect to the boiler’s operation; and (2) the defendant
failed to restrict public access to the boiler’s controls. Id., 27.
In returning a plaintiff’s verdict, the jury answered several interrogatories
regarding the plaintiff’s theories of negligence. Id., 26–27 n.13. Its responses
to the interrogatories indicated that it had found that the defendant was
not negligent in failing to restrict public access to the boiler’s controls. Id.,
27–28. It did find, however, that the defendant was negligent in failing to
supervise and instruct its employees, agents, and servants with respect to
the boiler’s operation. Id., 27. Notwithstanding its finding that the defendant
negligently supervised and instructed its employees, agents, and servants,
the jury indicated in another interrogatory that the defendant’s custodian
was not the person who activated the boiler. Id., 27 n.13.
The jury’s responses to the interrogatories were central to our Supreme
Court’s analysis of the sufficiency of the evidence on causation. Id., 28–31.
Specifically, the court reasoned that those responses indicated that the jury’s
finding of negligence ‘‘was limited to the manner in which [the defendant]
dealt with its own employees, servants and agents.’’ (Emphasis added.) Id.,
28. Therefore, ‘‘[i]n order for there to have been a causal connection between
the defendant’s negligent conduct and the plaintiff’s injuries . . . it would
have had to have been an employee, agent or servant of the defendant who
activated the [boiler]. . . . [T]he converse [was] equally true . . . . [T]he
defendant’s conduct [could not have been] causally linked to the plaintiff’s
injuries if the [boiler] was activated by a person who was not an employee,
agent or servant of the defendant.’’ (Emphasis in original.) Id., 28–29.
In reviewing the sufficiency of the evidence on causation, the court in
Paige examined only the evidence relating to whether the person who
activated the boiler was an employee, servant, or agent of the defendant.
The plaintiff’s evidence unquestionably suggested that there was only one
employee, agent, or servant of the defendant who was near the boiler con-
trols at the time of the accident and who knew how to use those controls—
the defendant’s custodian. Id., 24, 34. As previously explained, however, the
jury’s response to an interrogatory indicated that it specifically found that
the defendant’s custodian was not the person who activated the boiler. Id.,
27 n.13. Thus, the Supreme Court held that the ‘‘jury could not have con-
cluded that it was an employee of the defendant who had activated [the]
boiler . . . .’’ Id., 34.
The defendant argues that Paige guides our resolution of its sufficiency
claim. Specifically, it contends that ‘‘[l]ike the possibility that a member of
the public may have turned on the church boiler [in Paige], nothing . . .
in this case [eliminated] the possibility that the decedent took the fatal dose
[of methadone] after she left the emergency room.’’ We are not persuaded
by the defendant’s analogy.
We conclude that Paige presented a distinct situation involving a logical
inconsistency in the jury’s verdict. In responding to a set of highly detailed
and specific interrogatories, the jury revealed that its finding of negligence
was based solely on the defendant’s conduct with respect to its employees,
agents, and servants. Yet, its responses to those interrogatories also revealed
that it exonerated the only employee of the defendant who, according to
the plaintiff’s evidence, could have activated the boiler. There are no jury
interrogatories in the present case that reveal a similar inconsistency in the
jury’s verdict, nor is any such inconsistency otherwise apparent. Further-
more, the plaintiff in Paige failed to present any evidence from which the
jury reasonably could infer that the person who activated the boiler was
an employee, agent, or servant of the defendant. In the present case, however,
there is ample evidence from which the jury could infer that the decedent
consumed the lethal dose of methadone before her discharge. In particular,
there was evidence that the decedent exhibited opioid overdose symptoms
prior to her discharge, that her urine tested positive for methadone at the
time of her hospitalization, and that the delayed respiratory depression she
experienced after her discharge was consistent with the consumption of a
toxic dose of methadone prior to her discharge.
17
A mortality table, also termed an ‘‘actuarial table,’’ is ‘‘[a]n organized
chart of statistical data indicating life expectancies for people in various
categories . . . .’’ Black’s Law Dictionary (10th Ed. 2014).