Claimants’ decedent, Ivy Browne, 34, a homemaker, treated for two years with opioids prescribed to her by her Kaiser primary care physician, Magnolia De Guzman, M.D. Subsequently, on Nov. 13, 2009, the opioids in Browne’s system caused respiratory suppression and a sudden cardiac arrest. At 2 a.m., when claimant Louis Gregory, Browne’s husband, got up to go to the bathroom, he found that his wife was not breathing. He called 911 and performed CPR, but to no avail and Browne died. The coroner concluded that Browne died of acute Oxycodone Toxicity, opiate toxicity. Browne was a Kaiser member and had treated with Kaiser for all of her medical care. Gregory and Browne’s three children, acting individually and as the surviving heirs and successors in interest of the decedent, proceeded to arbitration against De Guzman, Kaiser Foundation Health Plan Inc., Kaiser Foundation Hospitals and Southern California Permanente Medical Group. The claimants contended that De Guzman prescribed increasingly higher levels of opiates, which eventually led to Browne’s death. They also contended that opioids, especially in such high doses, are known to cause respiratory suppression. Prior to her death, Browne suffered from chronic back pain following a work related injury in 2003. De Guzman became Browne’s primary care physician at Kaiser in June 2008. She continued to treat Browne for her chronic back pain from then until Browne’s death on Nov. 13, 2009. De Guzman and all experts who testified agreed that Browne was compliant with her medications, took them as prescribed and never sought early refills or took any medications not prescribed by De Guzman. Between June 2008 and February 2009, De Guzman prescribed, changed and increased her prescriptions for opioids, including Lidoderm, Hydrocodone, Oxycodone, Oxycontin, Fentanyl patch and Norco. In February 2009, De Guzman made a referral to the Kaiser Integrated Pain Management Program, but Browne indicated that she could not attend the program until after she completed her clinical training at High Desert Hospital. When Browne graduated from college in June 2009, she requested the referral to pain management, but she failed to keep her first appointment because of the distance from her home and financial, transportation hardships, as the pain management clinic was 30 miles from her residence. On July 21, 2009, De Guzman made an urgent referral to pain management. Browne attended the pain management orientation, but missed her first pain management session on Sept. 14, 2009. During this time, De Guzman continued to refill the doses of opioid medications. On Oct. 2, 2009, Browne informed De Guzman that she was dropping out of the pain management program because of transportation problems and cancelled all of her appointments related to pain management. On Oct. 13, 2009, Browne visited De Guzman, complaining of back pain. De Guzman’s examination revealed no objective abnormal findings, and the only finding was Browne’s subjective complaint of pain. On Nov. 10, 2009, Browne again visited De Guzman and again the physical examination was within normal limits, as the only finding was Browne’s subjective complaints of pain. As of Nov. 10, 2009, Browne was taking 30-milligrams of Oxycontin/Oxycodone, slow release, two tablets, twice daily for controlled, round-the-clock pain management, and Hydrocodone-Acetimenophen 10-325, one tablet every four hours, as needed for breakthrough pain. Claimants’ counsel contended that in addition to the extreme increase in the already very high opioid dosage, De Guzman erroneously prescribed it “twice daily,” “prn” or “as needed for pain”. Counsel contended that the Slow Release Oxycontin/Oxycodone is engineered with a specific design to release medication over a precise 12-hour period so that there is controlled release. Oxycontin/Oxycodone slow or extended release must be prescribed in precise 12-hour intervals, and not on an as needed basis, counsel noted. However, the claimants’ counsel contended that the label, as prescribed by De Guzman, read two times daily as needed for pain. Counsel asserted that this permitted “stacking,” meaning that the patient, even if being totally compliant with the instructions, could take two doses in less than 12-hour intervals, as long as no more than two doses were taken in a 24-hour period. In addition, claimants’ counsel contended that, on autopsy, it was determined that the amount of Oxycodone in Browne’s system indicated that she had taken two doses of the Oxycodone less than 12 hours apart. Thus, claimants’ counsel asserted that De Guzman did not take a detailed medical, social or psychological history from Browne and continued to treat the patient exclusively with high doses of opioids, which were not working to control her pain. The claimants’ family practice expert testified that the standard of care required that De Guzman refer the patient to pain management. The expert further testified that if the patient was unable to attend the pain management program, De Guzman was required to safely wean her from those high doses of opioids, and was certainly not continue to increase the dosage. The claimants’ pain management expert testified that the purpose of pain management for a chronic pain patient is to achieve pain control from a multidisciplinary approach, using the expertise of psychologists, physical therapists and physical medicine doctors to attempt to define and treat all of the possible underlying cause of chronic pain. He testified that the standard of care required that Browne be weaned from the medications and that pain management required a multidisciplinary approach, a detailed personal medical history and family history, and comprehensive plan of care. The claimants’ pharmacology expert testified that De Guzman’s prescriptions for slow release Oxycontin/Oxycodone violated the standard of care. The expert opined that this violation was the cause of ambiguity, resulting in Browne taking the Oxycontin/Oxycodone slow release in less than the required 12-hour intervals, which was a substantial factor in causing her sudden death. The respondents’ counsel contended that there was plenty of evidence to suggest that Browne knew how to take slow release medications, has taken slow release medications in the past, and was familiar with the intervals. Additionally, counsel contended that Browne had taken similarly labeled prescriptions and had demonstrated good use of that. The respondents’ counsel further contended that Browne was sent to pain management not once, but three times, and that there was no failure to meet the standard of care., Browne died of acute Oxycodone Toxicity, opiate toxicity. She died on Nov. 13, 2009, at the age of 34. Browne was a devoted wife and mother of three teenage children. Browne’s family sought recovery of wrongful death damages, including loss of society, loss of consortium and loss of parental guidance.