Twelve People, Three Hours, A $207 Million Medical Malpractice Verdict

In April 2023 a Philadelphia jury returned a medical-malpractice verdict of roughly $183 million against the Hospital of the University of Pennsylvania. With delay damages the judgment rose above $207 million—the largest reported medical-malpractice award in Pennsylvania history. In July 2025 the Superior Court affirmed (2025 PA Super 142). The Pennsylvania Supreme Court has now agreed to hear the case, focusing on questions of vicarious liability and causation instructions (Mondaq summary).

The size of the number invites a simple narrative: delay, catastrophe, and a jury’s response. The medical and legal record is more complicated. What follows is a walk through the clinical timeline and then an examination of four interlocking problems that sit beneath the verdict: the absence of a clear guideline violation, disputed objective data, the gap created by electronic medical-record documentation, and the way the damages figure itself was constructed.

11:30 a.m.
She is in the ambulance. Heart rate, blood pressure, respiratory rate—all normal. Her temperature is not taken.

11:45 a.m.
She arrives at the Hospital of the University of Pennsylvania and is triaged. The notes record contractions, no vaginal bleeding, no cardiorespiratory distress. On the stand, five years later, the plaintiff’s maternal-fetal medicine expert will characterize this as: she looked healthy.

Then the numbers come in.
Her temperature is 100.9°F. A fetal monitor goes on and the baby’s heart rate is 180. Her blood pressure is elevated. A cervical exam shows her 7 centimeters dilated—active labor. The admission diagnosis, written by the first-year resident and approved by the attending, is chorioamnionitis, “based on her fever and fetal tachycardia as well as maternal tachycardia.”

Every obstetrician reading this knows what that constellation means, and every obstetrician reading this also knows that the diagnosis does not, by itself, mandate an immediate cesarean.

12:00 p.m.
Supplemental oxygen.

12:03 p.m.
IV fluids running.

12:12 p.m.
She is moved from the Pregnancy Emergency Room to Labor and Delivery. In that unit, the fetal heart tracings for every patient are displayed on large screens—in the multipurpose room, at the nursing station, accessible from the patient rooms. This detail will matter later, because it means nobody can say they did not have access to the strip.

Between 12:15 and 12:45 p.m.
Dr. Kirstin Leitner, the attending, sees the patient for the first time. She and the team—the chief resident, the second-year resident, the first-year resident—form a plan. It is, by everyone’s account including the trial court’s, a good plan: attempt vaginal delivery; the tracing is Category II, so continue intrauterine resuscitation with fluids and repositioning; and if the tracing does not improve, proceed to cesarean. (Category I tracings are normal. Category II tracings are indeterminate—neither clearly normal nor clearly abnormal—and are the most common pattern seen in labor; they require continued surveillance and attempts at improvement. Category III tracings are frankly abnormal and generally call for prompt delivery.)

Dr. Leitner will not personally evaluate this patient again until she is on the operating table.

12:30 p.m.
The chart records that Nurse Victoria Kroesche administered Unasyn for the chorioamnionitis. This timing will be fought over, because an anesthesia note records the same medication still infusing at 2:30 p.m. If the dose went in at 12:30, it should have finished by roughly 1:00. HUP’s explanation, offered through Dr. Leitner’s testimony, is that the bag would continue hanging on the IV pole until the next dose was due; the record shows the next dose at 6:53 a.m. the following morning, consistent with standard every-six-hour dosing from a 12:30 p.m. start.

Approximately 1:00 p.m.
The tracing changes. The plaintiff’s expert later testified that variability went from decreased to absent—the line flattened—and that there was a prolonged deceleration. Every treating clinician and the defense expert, by contrast, described minimal or moderate variability and no flat line.

1:08 p.m.
This is the moment the plaintiff’s expert will identify as the point at which an emergency cesarean should have been called.

1:20 p.m.
An epidural is placed for pain. It does not work. The decision is made that general anesthesia will be required for a section.

1:30 p.m.
This is the moment the plaintiff’s expert will testify the baby should have been delivered. Had he been, the expert will say, he would have been born healthy.

1:53 p.m.
Pitocin is started. HUP’s own protocols designate Pitocin a high-risk medication requiring close monitoring. The chief resident will testify it was the team’s plan, that labor had not progressed, and that the patient was in unrelenting pain. She will also testify that the Pitocin was “very quickly turned off”—discontinued after about ten minutes because the strip showed recurrent and prolonged decelerations.

The chart says the Pitocin administration was continuous. There is no note from her, or from anyone, recording that it was stopped.

2:05–2:11 p.m.
The cesarean is ordered. The chief resident charts the indication as “non-reassuring electronic fetal monitoring tracing”—and will later explain that this was the only preselected option in the dropdown menu. “Category II tracing” was not an available choice. Consent is obtained at 2:11.

2:24 p.m.
Fetal monitoring is removed.

2:36 p.m.
J.H. is delivered. When the section was called, the amniotic fluid was clear. By delivery it is stained with meconium.

He is not breathing. The team ventilates him for nearly five minutes to get him into “a better state.” He goes on CPAP. Within days he is seizing—described in testimony as “constant seizures. The brain is constantly in a state of such abnormal activity that it’s just going haywire.” At the Children’s Hospital of Philadelphia, MRI shows profound hypoxic-ischemic encephalopathy: large areas of brain deprived of oxygen for an undetermined period.

Withdrawal of life support is discussed with his mother.

He survives. He has moderate to severe cerebral palsy. He is nonambulatory. He cannot speak. He has cortical visual impairment and poor limb control. He is fed through a gastrostomy tube. He depends on caregivers to feed, toilet, and clean him, and he faces a lifetime of scoliosis, spasticity, muscle tightness, and joint pain.

Three hours, from ambulance to delivery. That is the whole case.

The jury recorded its decisions on a written verdict slip—the formal questionnaire that breaks the case into discrete yes/no and damages questions. (The verdict slip is distinct from the oral charge, which is the judge’s spoken explanation of the law to the jury, delivered right before deliberations begin.) In this case the slip asked whether the hospital, “acting by and through” the named clinicians, was negligent, and whether that negligence was either a factual cause of the harm or increased the risk of harm.

Under ordinary negligence law a plaintiff must prove factual cause: that the defendant’s conduct more likely than not caused the injury. Pennsylvania also recognizes a more plaintiff-friendly standard. When a defendant’s negligence increases the risk of the harm that occurred and that increased risk was a substantial factor, the jury may treat the negligence as a cause even without finding classic but-for causation. The Hagans verdict slip gave the jury both options in a single combined question. The slip therefore made it impossible to know whether the jury found factual cause or only increased risk. That unknowability is the defect, and is one of the reasons the Pennsylvania Supreme Court agreed to hear the case.

No Clear Guideline Violation

There was no clear clinical practice guideline violation. ACOG’s guidance on intra-amniotic infection states that “intraamniotic infection alone is not an indication for immediate delivery, and the route of delivery in most situations should be based on standard obstetric indications” (ACOG Committee Opinion No. 712). Antibiotics should be started, labor progress should be ensured, and the decision for cesarean should rest on ordinary obstetric grounds. Category II fetal heart-rate tracings are, by definition, indeterminate. Management calls for evaluation of the full clinical picture, intrauterine resuscitation, and continued surveillance. The plaintiff’s theory was never that infection by itself required immediate delivery. It was that the combination of infection plus an evolving Category II tracing, including prolonged decelerations, made continued expectant management unreasonable after a certain point. That is a judgment call under uncertainty, not an obvious protocol breach. Reasonable clinicians can disagree about the precise moment the balance tips.

Plaintiff’s counsel made the structural problem explicit in closing:

“I’m in a Catch-22. If they want to list every individual and say, what did Dr. Leitner do? The answer is nothing. If you look at the record, she did nothing, other than testify that she did everything right. The same thing with the nurse. There is no documentation of anything… [W]hat we are saying is this whole team, on this day, failed this patient. And that is all under HUP. Because we can’t point necessarily to any individual because there is a complete lack of evidence.”
— N.T. 4/20/23 a.m., at 31:8-20

That is not a minor rhetorical flourish. It is an admission that the case could not be proved against any identifiable clinician. The verdict therefore rests on a collective failure whose individual components the plaintiff’s own lawyer said could not be shown. Once a hospital can be held liable on that basis, the ordinary requirement that a plaintiff identify a specific breach by a specific actor begins to dissolve.

The Cord Gas and the Fight Over Mechanism

Important objective data remained in dispute, and the most consequential of those disputes was about mechanism. HUP’s core defense was not that a one-hour delay was acceptable. It was that the brain injury was not hypoxic at all. The claim was that J.H. suffered a fetal inflammatory response downstream of the chorioamnionitis that was already present when the ambulance arrived. On that theory, delivery timing is largely irrelevant; the damage was driven by infection and inflammation that no one caused and no one could have prevented.

The principal tool for distinguishing acute intrapartum hypoxia from a subacute inflammatory process is the umbilical cord blood gas. It is drawn at delivery, it is objective, and it is not reconstructed from memory. A markedly acidotic arterial gas supports an acute hypoxic insult. A near-normal gas substantially undercuts it.

J.H.’s cord gas was essentially normal (pH approximately 7.23). The 2014 ACOG/AAP task force report Neonatal Encephalopathy and Neurologic Outcome (2nd ed.) sets out the neonatal signs consistent with an acute peripartum or intrapartum event: Apgar score less than 5 at 5 and 10 minutes; umbilical artery pH less than 7.0 and/or base deficit ≥12 mmol/L; a characteristic MRI/MRS pattern; and multisystem organ failure. An arterial pH of 7.23 does not merely fail to be “concerning.” It fails the threshold outright, by a wide margin.

Plaintiff’s neonatologist, Dr. Erin Zinkhan, conceded on the stand that the result was, by itself, “not terribly concerning.” She then offered the argument that neutralized it: the sample was not arterial but venous. In a hypoxic fetus, she explained, a relatively reassuring venous gas can coexist with a far more abnormal arterial gas. That single reinterpretation waved away the strongest objective piece of exculpatory evidence HUP and their team of physicians had—and dismissed a result that, under the profession’s own consensus criteria, affirmatively excluded the mechanism the plaintiff alleged.

Defense maternal-fetal medicine expert Dr. Laura Goetzl called the venous claim purely speculative and testified that the values were consistent with an arterial sample. The jury was left with a swearing contest between two retained experts about which vessel a needle had entered five years earlier, and the only person who was there who might have shed light on the matter, Dr. Leitner, was not allowed to expand on it.

When defense counsel turned to the cord gas, plaintiff’s counsel objected that she was a fact witness, that the gas was drawn after delivery and therefore could not have informed any decision she made, and that her views would simply be repeating evidence the jury had already heard from the defense expert. The trial court agreed with the plaintiff and sustained the objection. The Superior Court then affirmed it.

So on a matter that could potentially decide a case one way or another, the treating attending physician was not allowed to expand on the cord gas for the jury to hear. The attending got one sentence in. When the defense tried to build on it, it was cut off. As a result, the jury heard the cord gas explained by four paid experts and by one treating physician in a single clause. The dispute that decided the case was resolved between people who were not in the operating room, and that outcome was as much the defense’s doing as the court’s.

It pertains to the formal evidence rule the court uses as a standard. In this case, a treating physician is generally limited to what she knew and did at the time she was caring for the patient. Anything she later learned from the chart, or any opinion she formed while preparing for trial, is treated as expert testimony. If she was never designated as an expert, that later opinion is usually kept out. But the medical and common-sense point about whether the blood came from the umbilical artery or the umbilical vein is not really an “opinion formed in anticipation of litigation.” It is a question about a physical act that occurred in the operating room: which vessel did someone stick the needle into? In principle, a physician who was present (or who supervised the people who were present) could be asked about the usual practice, the labeling, or even what she observed or was told at the time. That is not a forensic interpretation or a retelling of expert testimony. From the appellate record it appears the defense offered Leitner’s testimony as commentary on what the values meant, not as direct observation of the draw. Once it was framed that way, the court treated it as post-hoc expert opinion and excluded it as both improper (she was not designated as an expert) and cumulative (Goetzl had already given the defense interpretation).

The evidentiary ruling left the jury without percipient testimony—testimony from someone who actually observed the draw—on the single piece of data most capable of distinguishing a hypoxic insult that was preventable from an inflammatory injury that was not.

The Documentation Gap

The electronic medical record left a gap between what was charted and what actually happened in real time. Multiple defense witnesses leaned on “what we would normally do” rather than detailed contemporaneous notes of observations and decision-making. Charting around the timing of antibiotics and whether Pitocin was promptly stopped after decelerations contained inconsistencies about when medications were started and finished infusing. A chief resident testified she charted “non-reassuring electronic fetal monitoring tracing” because it was the only preselected option in the dropdown menu. There was no option for Category II tracing. In a case that turns on the reasonableness of clinical judgment over a specific window of hours, that documentation gap becomes consequential. Incomplete records give juries and motivated plaintiffs room to reconstruct the sequence in the light most favorable to liability. Poor documentation never helps the defense.

How the $207 Million Was Built

The construction of the $207 million figure itself reveals how catastrophic-injury damages are assembled and how juries resolve uncertainty. The jury’s award broke down roughly as follows: approximately $101 million for future medical and life-care costs, $80 million for noneconomic damages (pain and suffering), a smaller sum for lost earnings, and then delay damages that pushed the total judgment above $207 million (Legal Newsline reporting).

The life-care component rested on sharply different methodologies. Plaintiff’s life-care planner presented detailed cost projections for residential and at-home care scenarios and relied on general population life tables. The economist translated those annual costs into cumulative figures. No plaintiff expert offered a specific opinion that this child would live to age 70; the life-care planner expressly declined to opine on life expectancy. Defense pediatric neurology expert Dr. Mark Mintz projected a substantially shortened life expectancy, with a maximum in the range of age 29 under certain assumptions. Plaintiff’s neurology expert pushed back on the characterization of the child’s functional status and noted that immobility might reduce expectancy by five to ten years relative to population norms. The jury effectively selected a life expectancy of approximately 70 years and awarded future care costs on that basis. The Superior Court later held that the jury was entitled to do so from the evidence presented, including the life tables, and that the resulting figure did not shock the conscience.

The noneconomic award of $80 million was equally large. In closing, plaintiff’s counsel referenced Philadelphia Eagles quarterback Jalen Hurts’ then-reported $51 million annual salary and invited the jury to consider what a lifetime of profound impairment was worth by comparison. Defense counsel did not object contemporaneously, and the Superior Court later treated the issue as waived (post-trial briefing; Expert Institute). The reference functions as a classic form of anchoring: a vivid, locally salient number is placed before the jury as a benchmark against which the child’s losses can be measured.

Taken together, these elements show why a case without a clear guideline violation or an unambiguous cord-gas result can still produce a nuclear verdict. The standard of care turned on clinical judgment under incomplete information. Key data points were contested. The written record did not fully capture the decision-making process. And once liability was found, the quantification of lifelong, total-dependency harm rested on methodological choices—especially life expectancy—that the jury resolved at the high end of the available evidence. Appellate courts have left that resolution intact.

The case now goes to the Pennsylvania Supreme Court, which will focus on the legal framing of vicarious liability and the causation instructions rather than a wholesale re-weighing of these facts. Whatever the Court decides on those technical questions, the underlying medical and damages issues remain a window into how catastrophic birth-injury cases are actually tried and valued.

What the Verdict Teaches

For physicians there are some important lessons and warnings from the case, regardless of how the Supreme Court eventually rules.

The downstream effects of a verdict like this go well beyond one hospital’s balance sheet or Pennsylvania physician malpractice premiums. A $207 million verdict for a “delayed” cesarean in a gray-area case is a signal that every Labor & Delivery unit in the state will hear. Will pregnant women presenting with suspected chorioamnionitis be offered a cesarean earlier in similar clinical settings even though clinical guidelines would suggest a more conservative approach? There is a reason guidelines give latitude to clinicians in these situations—cesareans carry higher rates of infection, hemorrhage, and blood clots, and they increase the risks in future pregnancies. Will more maternal harm be the net result of clinical decisions driven by verdicts like this that treat gray-area judgment-call management of Category II tracings as the basis for nuclear awards? Are you comfortable that your obstetrician is making the best medical decision when you show up in labor at a hospital in Pennsylvania, or are they making a clinical decision that is more legally defensible if something were to go wrong? It is worth repeating that a single Philadelphia jury’s reading of a gray-area case may become the reason the next pregnant woman is steered toward cesarean.

The impact of verdicts of this magnitude will almost certainly not be confined to large academic centers. Smaller and mid-sized regional and community hospitals already operate on thinner margins and thinner specialist coverage. A single nine-figure judgment—or even the credible threat of one—can make the continued provision of obstetric services financially irrational. The predictable result is fewer community hospitals willing to keep labor-and-delivery units open, longer travel times for women in labor, and the quiet disappearance of local obstetric care in places that cannot absorb this level of risk. The same dynamic that could produce defensive cesareans in well-resourced hospitals will simply eliminate the service altogether in less-resourced ones.

The injury suffered by the child in this case is a tragedy. The greater danger is that the response to it will produce a new set of harms: more cesareans in gray-area cases and fewer places left where women can safely deliver.

Anish Koka is a cardiologist who writes on health policy and medicine. Follow him on @X: @anish_koka