Miscellaneous: Kielson, David et al vs. Cooley Dickinson Hospital et al

• 
• 
• 
• 
• 
• 
• 
• 

						
                                
Preview
                                C7

COMMONWEALTH OF MASSACHUSETTS

Hampshire, ss. Superior Court Department
of the Trial Court :
Civil Action No.: 15-00130

DAVID KIELSON, et al.,

Plaintiffs
PROPOSED SPECIAL VERDICT
FORM OF DEFENDANT, BRIAN
D. JOHNSON, M.D.

Vv.

BRIAN D. JOHNSON, M.D., et al.,
Defendants

eed

I, INFORMED CONSENT

 

1. Did Dr. Johnson on October 16, 2013, have a duty to disclose all of the
material risks to Mr. Kielson regarding his anesthesia course of treatment on October 31,
2013?

Yes No
If your answer to Question 1 is “NO,” go no further. If your answer to
Question 1 is “YES,” please continue with Question 2.
2. Was there a failure to disclose a material risk to Mr. Kielson concerning
his anesthesia course of treatment?
YES NO
If your answer to Question 2 is “NO,” go no further. If your answer to

Question 2 is “YES,” please continue with Question 3.

3. If there was a failure to disclose a material risk to Mr. Kielson concerning
his anesthesia course of treatment, did the plaintiffs establish that the undisclosed risk
actually occurred as a result of the anesthesia?

YES NO

If your answer to Question 3 is “NO,” go no further. If your answer to
Question 3 is “YES,” please continue with Question 4.4. If there was a failure to disclose a material risk to Mr. Kielson concerning
his anesthesia course of treatment, have the plaintiffs established that Mr. Kielson would
not have consented to the course of treatment had he known of the material risk?

YES NO.

If your answer to Question 4 is “NO,” go no further. If your answer to
Question 4 is “YES,” please continue with Question 5.

5. If there was a failure to disclose a material risk to Mr. Kielson concerning
his anesthesia course of treatment, has the plaintiff established that a reasonable person in
similar circumstances would not have consented to the course of treatment had he/she
known of the material risk?

YES NO.
If your answer to Question 5 is “NO,” go no further. If your answer to

Question 5 is “YES,” please continue with Question 6.

6. Was the failure to disclose a material risk to Mr. Kielson concerning his
anesthesia course of treatment a substantial contributing cause of the alleged injuries to
Mr. Kielson?

YES NO

If your answer to Question 6 is “NO,” go no further. If your answer to
Question 6 is “YES,” continue to question 7.IL DAMAGES

7. Did Mr. Kielson suffer substantial or permanent loss or impairment of a
bodily function or substantial disfigurement?

YES NO

8. If the answer to Question 6 is “Yes”, what is the amount of money that
will fairly and reasonably compensate Mr. Kielson for the physical and mental pain and
suffering, impairment, disfigurement and/or loss of enjoyment of life that he suffered as a
result of the lack of informed consent?

(if your answer to Question 7 is “NO”, the amount of damages awarded in Question
8 for pain and suffering, both prior to the verdict and in the future, may not exceed
$500,000.00.)

Prior to the verdict:

dollars and cents.
(write out in words)

(s ). (write out in numbers)
In the future:

dollars and cents.
(write out in words)

($. ). (write out in numbers)

If you award future damages in response to this question, please set
forth the period of weeks, months or years over which such future
damages are intended to provide compensation.

(Answer in weeks, months or years)Ill. LOSS OF CONSORTIUM

9. If your answer to Question 6 is “YES,” did Gail Kielson (“Mrs. Kielson”)
lose any society, companionship, love and support of her husband, Mr. Kielson?

YES NO

If your answer to Question 9 is “NO,” go no further. If your answer to
Question 9 is “YES,” continue to question 10.

10. Did the failure to give informed consent to Mr. Kielson cause Mrs.
Kielson to lose any society, companionship, love and support of Mr. Kielson?

YES NO

If your answer to Question 10 is “NO,” go no further. If your answer to
Question 10 is “YES,” continue to question 11.

11. If your answers to both Questions 9 and 10 are “YES,” what amount of
money would fairly and reasonably compensate Mrs. Kielson for her loss of society,
companionship, love and support of Mr. Kielson?

dollars cents
(write out in words)

($. ). (write out in numbers)

Thereby certify that at least 12 out of 14 members of the jury have agreed on each
question.

Date ForepersonDated: November 28, 2017 The Defendant
BRIAN D. JOHNSON, M.D.
By His Attorneys:

     
 

Michael -Burke — BBO No. 065400
Christopher J. Visser - BBO No. 676531
Bulkley, Richardson and Gelinas, LLP
1500 Main Street - Suite 2700

P.O. Box 15507

Springfield, MA 01115

(413) 781-2820; (413) 272-6803 Fax
mburke@bulkley.com
evisser@bulkley.com

Certificate of Service

I, Christopher J. Visser, attorney for the defendant, Brian D. Johnson, M.D., do
hereby certify that a true copy of the above document was served upon the attorney of
record for each party by electronic mail and first class mail on November 28, 2017.

Cm

Christophiér J. Visser