Breast Cancer Statute of Limitations Case in Iowa

The Iowa Supreme Court reversed a Scott County District Court summary judgment ruling in an important discovery rule medical malpractice ruling.  This case,Rock v. Warhank, is a failure to diagnose breast cancer case, rejecting malpractice defense lawyer claims that Plaintiff should have known of her injury, for purposes of the statute of limitations, just because a doctor made her aware that her breast was not normal.

The History of the Malpractice Discovery Rule

Before we get into this case, let’s look at the history of the medical malpractice discovery rule.

In the early 1930s, courts began recognizing that the general rule of accrual, which meant that a cause of action existed from the time the negligent act was committed, led to ridiculous results in medical malpractice lawsuits. This was just too many injustices where the plaintiff could never be said in human terms to be on notice of claim because no injury or damage became apparent contemporaneously with the negligent act. Courts were blindly following the law and injured parties were losing their right to recovery due to the statute of limitations even before they were aware of its existence.

The unfairness of barring claims of unknowing parties was the linchpin of the discovery rule. The rule was adopted to avoid the unconscionable results that would arise under the general rule in situations where the injured party was not immediately aware of the injury or damage caused by the negligent act.

The state of New Jersey observed that when the discovery rule was first adopted, it seemed rather straightforward.  But here we are in 2008 (now 2023), and lawyers and judges are still grappling with the application of this principle of simple justice to the myriad of circumstances that arise in everyday life.

The rule that evolved was the statute of limitations did not commence to run until the patient discovered, or in the exercise of reasonable care and diligence, should have discovered that they had a cause of action. Many states have adopted this rule without substantial restriction or limitation.

Malpractice Statute of Limitations in Iowa

In Iowa, the statute of limitations for medical malpractice claims, including breast cancer misdiagnosis, is generally two years from the date the patient knew, or should have known, about the injury. There are some exceptions to this rule, most notably the dicovery rule which is the key question in this case,  Rock v. Warhank.  If the malpractice is not discovered within this period, a patient has up to six years from the date of the act or omission causing the injury to file a claim under Iowa’s medical malpractice statute of repose.

Facts of Rock v. Warhank

Typical breast cancer malpractice story.  The plaintiff, who has a direct family history of breast cancer and fibrocystic breast disease, noticed a lump in her left breast. She called her family doctor to have it examined. Her primary care referred her for a bilateral mammogram.

She had a follow-up appointment with primary care the next month.  Her doctor palpated the left breast, located the lump, and told Pamela the mammogram was normal and not to worry about the lump.  Shortly after, the radiologist called and requested she come in for additional views of the right breast. So she additional views of the right breast taken. The technician told her that what they had seen in the earlier mammogram was no longer present, so they did not need an ultrasound.

Plaintiff was concerned at this point that there was confusion over the breast in which the lump existed, and told the technician that the lump was in her left breast and not the right breast. The technician assured Pamela at that time that they did not see anything on the film in the left breast so she shouldn’t worry about it anymore. In addition, her doctor reviewed the radiology report of the right breast and advised Pamela by letter dated that the breast exam did not show any sign of cancer.

Still harboring concerns of a mix-up, the plaintiff felt she needed reexamination of her left breast in September 2002. She saw another doctor who said  the lump was probably benign.  Months later, she had a fine-needle aspiration which was not normal.  She got a biopsy and was diagnosed with breast cancer.

Pamela and her husband Keith filed a petition against the above-named defendants on October 5, 2004, alleging malpractice against Dr. Warhank and Dr. Hartung and loss of consortium. The suit alleged that Dr. Warhank and Dr. Hartung failed to properly examine, diagnose, and treat the cancer in Pamela’s left breast, resulting in the spread of the cancer to six of twelve lymph nodes and in physical disfigurement.

The trial court judge dismissed the lawsuit.  Iowa Code § 614.1(9) provides that a medical malpractice claim must be brought “within two years after the date on which the claimant knew, or through the use of reasonable diligence should have known, or received notice in writing of the existence of, the injury or death for which damages are sought in the action, whichever of the dates occurs first…”   Because she was concerned a mistake was made, the trial judge found the statute of limitations had passed.

Intermediate Appellate Court

The question at hand is whether Rock’s lawsuit was filed within the statute of limitations for medical malpractice claims. The court must determine when the injury occurred and when Rock knew or should have known about the injury and its cause. Under Iowa law, medical malpractice claims must be filed within two years of the claimant knowing or through reasonable diligence should have known about the injury and its cause. The court’s role is to ascertain legislative intent, which is determined by the words chosen by the legislature.

Iowa Supreme Court Ruling in Rock v. Warhank

The Iowa Supreme Court held that the plaintiff could not have known and would not have known of her cancer or that her breast cancer was misdiagnosed until she was actually diagnosed with cancer.

Rathje v. Mercy Hospital

Previous Iowa cases held that the statute of limitations begins to run as soon as the plaintiff knew or should have known of the physical or mental harm for which damages are sought. However, in Rathje v. Mercy Hospital, the court revised this interpretation, concluding that the statute of limitations for medical malpractice claims does not begin to run until the plaintiff knew or should have known through reasonable diligence of both the physical or mental harm and its cause in fact. The court held that the plaintiff must have known or should have known through reasonable diligence that the medical care caused or may have caused the injury. The standard for summary judgment is whether a reasonable fact finder could conclude that Rock filed her claim within two years of when she first knew or should have known of her injury and its cause.

When Did the Injury Happen?

The court cannot answer the first question of when the injury occurred without expert testimony, which is not present in the record. However, the court can answer the second question of when Plaintiff knew or should have known of her injury and its cause. The defendants claim that she knew or should have known of her injury and its cause when she discussed the lump with her doctor. This is absurd in human terms and the Supreme Court rejected this argument, stating that she could not have known, and should not have known, of her injury and its factual cause until the day she was diagnosed with cancer at the earliest.

The court also rejected the defendants’ alternative argument that Rock knew or should have known of her injury when her doctor told her the fine-needle aspiration was not normal. The court held that it is inconsistent with the plain language of the statute to charge her with knowledge of facts before Dr. Congreve, an expert, knew these she had breast cancer or conveyed that fact to her.

If the court were to hold the statute of limitations begins to run at the start of an investigation into the existence of a possible injury, then the statute would always be triggered prior to the date the plaintiff gained actual knowledge of the injury unless the injury was immediately apparent.

The court concluded that the record establishes as a matter of law that Rock could not have known, and would not have known through reasonable diligence, of her injury (the spread of cancer) and its cause (the misdiagnosis) more than two years prior to filing this action. Therefore, summary judgment was improperly granted, and the court must consider the question of when the injury occurred with expert testimony.

Logical, Human Conclusion

This makes sense, right?  A lump in the breast alone does not put the patient on notice that she has breast cancer when a doctor is telling her she is fine.  In this case, the medical records are clear that the belief is that the lump is benign and is not a cause of concern. So the court’s reasoning is that this woman was not on notice of the need to bring a claim until the day she was diagnosed with cancer.  While the misdiagnosis might have occurred earlier, the statute of limitations in Iowa and most states require that the plaintiff know or have reason to know of the tort.  You don’t know you have been misdiagnosed until you are given a diagnosis.

Congratulations to Plaintiff’s medical malpractice lawyers Robert Gallagher and David Millage in Davenport, Iowa, who stayed with this case through adverse rulings both at trial and before the Iowa Court of Appeals.

You can find the Iowa Supreme Court’s opinion here.

Iowa Discovery Rule Cases

  • Borchard v. Anderson (542 N.W.2d 247 (Iowa 1996). Plaintiff claimed her ex-husband had repeatedly abused her, even while she was pregnant, and had even terrorized her with a gun. They got divorced in 1981. In 1993, she was diagnosed with PTSD from the abuse. She tried to sue her ex-husband for intentional harm in 1993, but the court said it was too late to do anything about it. Borchard argued on appeal that she didn’t realize the connection between the violence and her emotional problems until she was diagnosed with PTSD, and that’s when she invoked the common law discovery rule.  The court said she knew her husband’s behavior was not okay and it hurt her, even though she might not have understood exactly how it was affecting her. The law doesn’t need victims to have a medical degree to understand the nuances of how they are harmed to begin the running of the statute, just that she knew there was some harm.
  • Woodroffe v. Hasenclever, 540 N.W.2d 45, 47 (Iowa 1995). In civil cases, the statute of limitations starts running once the injured party has knowledge, either actual or imputed, of the facts that could support a legal claim, as per the discovery rule. This case is known for embracing the concept of “inquiry notice” as a means to determine the outer time limit for bringing a cause of action.  The court defined inquiry notice as being “aware of facts that would prompt a reasonably prudent person to begin seeking information as to the problem and its cause.” Id. So that moment of awareness begins the running of the statute of limitations.
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