On Dec. 2, 2010, plaintiff’s decedent Teresa Billups, 56, a security guard, underwent surgery to remove her gallbladder via laparoscopy (a laparoscopic cholecystectomy) performed at Kaiser Permanente San Francisco Medical Center. Two days later, after being discharged home, Billups passed away due to post-operative internal bleeding. The bleeding was proven to be caused by Lovenox (a blood thinning, anti-coagulation medication), which Billups received the weeks before and after surgery. The decedent’s widowed husband, Dennis Billups, sued Kaiser Foundation Hospitals; Kaiser Foundation Health Plan Inc.; and the Permanente Medical Group Inc. The decedent’s husband alleged that the defendants negligently monitored his wife’s medication and that this negligence constituted medical malpractice, resulting in the decedent’s wrongful death. The matter proceeded to a binding arbitration, pursuant to Kaiser’s member contract. Plaintiff’s counsel asserted that the defendants mismanaged the decedent’s use of the Lovenox therapy, which led to her death. Counsel contended that the decedent had a very serious medical history with several life-threatening conditions, for which she took many medications. In early 2010, the decedent developed gallbladder disease caused by the development of gallstones. The decedent was ultimately told by her doctor that she should have the gallbladder removed because the trauma of the severe pain attacks put her at risk for life-threatening cardiac complications. At the time her surgery was scheduled, the decedent was taking blood thinning medication and in order for her to have the surgery, she needed to stop taking the blood thinners several days before the surgery to allow the medication to dissipate from her system. In its place, the decedent’s Kaiser physicians prescribed Lovenox, a fast-acting injectable blood thinner. Plaintiff’s counsel contended that the decedent was to take Lovenox until just before her surgery, that way she could benefit from the medication and also have the medication out of her system during and after the surgery, when there is a risk of bleeding. (Experts agreed that this treatment meets with proper standard of care.) However, plaintiff’s counsel asserted that the decedent’s care providers at Kaiser improperly instructed the decedent as to when she should stop her Lovenox injections before the surgery and also as to when she should re-start the injections after surgery. Counsel contended that this misinstruction caused the decedent to take an extra injection of Lovenox the evening before her surgery and caused her to re-start the Lovenox the same day as her surgery. Counsel contended that this prevented the decedent’s blood from coagulating and caused her to bleed internally following her surgery. Thus, plaintiff’s counsel asserted that Kaiser failed to properly plan, communicate, instruct and monitor the decedent’s anti-coagulation protocol, specifically the timing of the Lovenox injections just before and after her surgery. Counsel also asserted that it was a breach of the standard of care for Kaiser to allow the decedent to go home on the night of her surgery since the decedent’s medical problems were severe and she did not have a capable caregiver at home, as her husband was blind. The plaintiff’s internal medicine expert testified that had the decedent stayed in the hospital for one day after her surgery, hospital staff would have assured that the decedent took her Lovenox at the appropriate time. The expert also testified that if the decedent had been held in the hospital until then, the decedent’s blood work would have likely given significant indicators that she was bleeding internally and appropriate care would have been administered to save her life. Defense counsel asserted that the decedent received surgical and anticoagulation treatment that met the standard of care. Specifically, counsel contended that the decedent was instructed not to take her Lovenox injection the day of the surgery and instructed not to restart it until the surgeon or pharmacist in the anticoagulation clinic followed up with her. However, medical records showed that, in fact, the surgeon and the pharmacist followed up the day after the surgery and advised the decedent to restart the Lovenox. Defense counsel also contended that the only documented dose of Lovenox given to the decedent met the standard of care as described by all experts and that the instruction to restart the Lovenox met the standard of care according to all experts. The defense’s expert general surgeon (and former trauma surgeon) testified at arbitration that the decedent’s gallbladder surgery — and perioperative medication management with the use of Lovenox-bridging therapy for outpatient anticoagulation treatment — complied with the standard of care. The expert also testified that based on the patient’s history of atrial fibrillation and rheumatic heart disease, the Lovenox-bridging therapy was appropriate. He further testified that the same-day discharge was appropriate and that an overnight hospitalization was not required in the absence of any surgical complications or medical indications for doing so. In addition, the defense’s expert surgeon testified that because the decedent expired quite suddenly, unexpectedly and unforeseeably two days after her outpatient surgery, these factors, including the sudden onset of severe pain, did not support a hemorrhagic death due to an early resumption of anticoagulation therapy. Instead, the cause of death was more likely than not the result of an embolism in the mesenteric circulation, which had not been examined by the coroner, the expert opined. He further noted that there were no written documents or instructions from the hospital, pharmacists, surgeon, discharge nurse or Anticoagulation Clinic instructing the decedent to begin injecting Lovenox again the same night of the surgery., Two days after the surgery, while home, Teresa Billups cried out in pain, causing her husband to call 911. However, by the time the responders arrived, Mrs. Billups was dead. The decedent’s death was determined to be a result of abdominal bleeding caused by her taking Lovenox on the same day as her surgery, which was 12 hours too early, according to the medical examiner. Mrs. Billups died on Dec. 4, 2010. She was 56. She is survived by her husband. Mr. Billups claimed the couple first met in the early 1970s, while attending college, and were married in 1977. Mr. Billups, being blind his entire life, claimed that in the nearly 33 years of marriage, the decedent learned to care for him and understood his needs in relation to his visual disability. Thus, he claimed the loss of his wife’s care, comfort and society made every-day life incredibly difficult. Mr. Billups claimed he and his wife did everything together and had built a very good life, as they were able to travel/take vacations and socialize with friends and family. He also claimed that he and his wife overcame many of the challenges of his blindness with grace and good humor and that her death was a tragedy that will haunt him for the rest of his life. Thus, Mr. Billups sought recovery of $250,000 (the full MICRA cap) in general damages, but claimed that his loss was worthy many times more than that. He also sought recovery of approximately $300,000 in economic damages, which were eventually excluded from the award on an evidentiary basis. Defense counsel disputed the decedent’s cause of death, asserting that the decedent did not suffer a hemorrhagic death due to an early resumption of anticoagulation therapy, but more likely died as a result of an embolism in the mesenteric circulation.