Ludwig P. Samson, Trustee for the Heirs and Next of Kin of Christine R. Samson, deceased, Appellant,

This opinion will be unpublished and
may not be cited except as provided by
Minn. Stat. § 480A.08, subd. 3 (2016).

STATE OF MINNESOTA
IN COURT OF APPEALS
A17-0721

Ludwig P. Samson, Trustee for the Heirs and Next of Kin of
Christine R. Samson, deceased,
Appellant,

vs.

Jack W. Gordon, M. D.,
Respondent,

Essentia Health d/b/a Virginia Convalescent Center and/or
f/k/a Virginia Regional Medical Center; et al.,
Respondents.

Filed January 16, 2018
Affirmed
Smith, Tracy M., Judge

St. Louis County District Court
File No. 69DU-CV-15-3179

Richard E. Bosse, Law Offices of Richard E. Bosse, Chartered, Henning, Minnesota (for
appellant)

Katherine A. McBride, Rodger A. Hagen, Meagher & Geer, P. L.L.P., Minneapolis,
Minnesota (for respondent Jack W. Gordon, M.D.)

William L. Davidson, Eric J. Steinhoff, Jo ão C. Medeiros, Lind, Jensen, Sullivan &
Peterson, P.A., Minneapolis, Minnesota (for respondent Essentia Health)

Considered and decided by Hooten, Pres iding Judge; Reyes, Judge; and Smith,
Tracy M., Judge.

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U N P U B L I S H E D O P I N I O N
SMITH, TRACY M., Judge
Appellant Ludwig Samson, son of 99-y ear-old decedent Christine Samson,
contends that, in dismissing his medical-malpractice action for failure to comply with the
expert-affidavit requirements in Minn. Stat. § 145.682 (2016), the district court (1) abused
its discretion in determining that the expert affidavit did not suffici ently show a chain of
causation and (2) applied an incorrect standard by requiring appellant to disprove all other
causes of death. We affirm.
FACTS
In 2004, Ms. Samson, who suffered from Alzheimer’s disease and dementia, was
admitted to the Virginia Convalescent Center for long-term care. Four years later, Dr. Jack
Gordon assumed Ms. Samson’s care. In January 2010, Dr. Gordon diagnosed Ms. Samson
with hypothyroidism. 1 Hypothyroidism is characterized by a high thyroid-stimulating-
hormone (TSH) concentration. To treat Ms. Samson’s hypothyroidism, Dr. Gordon started
her on a 25 mcg dose of levothyroxine, a s ynthetic form of thyroid hormone commonly
known as Synthroid.
In March 2010, based on Ms. Samson’s TSH levels, Dr. Gordon increased her
Synthroid dose to alternate between 25 mcg an d 50 mcg per day. A few months later,
Dr. Gordon increased her dose to 50 mcg per day. Ms. Samson’s TSH levels subsequently
normalized.

1 Hypothyroidism occurs when there is in sufficient production of thyroid hormones. The
American Heritage Dictionary 891 (3d ed. 1992).

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In June 2011, endocrinologist Dr. Robert Sjoberg evaluated Ms. Samson. Appellant
expressed concern that his mother’s Synthr oid dosage was making her condition worse.
After reviewing Ms. Samson’s lab results, Dr. Sjoberg concluded that the 50 mcg daily
dosage of Synthroid was appropriate and not harmful.
Eleven months later, Ms. Samson’s family placed Ms. Samson on comfort measures
and no further labs were taken. In Oc tober 2012, Ms. Samson passed away due to
congestive heart failure.
Appellant commenced this medical-malp ractice action against Dr. Gordon and
Essentia Health (Essentia), which does business as Virginia Convalescent Center and was
formerly known as Virginia Regional Medica l Center, based on the allegedly negligent
prescription of Synthroid and subsequent increase in dosage to Ms. Samson, claiming that
this medication contributed to the degenerati on of her health and ultimately caused her
cardiac arrest. Appellant identified Barry Singe r, M.D., as an expert witness and served
Dr. Singer’s affidavit on respondents.
Dr. Singer opined that Dr. Gordon did not co mply with accepted standards of care
when he prescribed Synthroid, which can carry an increased risk of adverse cardiovascular
effects, to Ms. Samson, a woman approaching 100 years of age. Dr. Singer explained that
“[e]lderly patients are more likely to develo p arrhythmias and complications from doses
greater than 25 micrograms.”2 Dr. Singer concluded that Ms. Samson was not a candidate
for synthetic hormone treatment, and that “more likely than not the higher dose of thyroid

2 An arrhythmia is an irregularity in th e force or rhythm of the heartbeat. The American
Heritage Dictionary 102 (3d ed. 1992).

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replacement contributed to her overall deterior ation of the cardiac status” and caused her
to have congestive heart failure.
Respondents moved for dismissal of th e action under Minn. Stat. § 145.682,
subd. 6(c), on the ground that the expert affi davit failed to comply with the substantive
requirements of the statute. Appellant re sponded with a supplemental affidavit from
Dr. Singer to bolster his showing of violation of the duty of care and the chain of causation,
including by describing recent medical studies that discussed the normalcy of elevated TSH
levels in elderly populations and warned about the adverse effects from artificial hormone
over-replacement. After a hearing, the dist rict court granted respondents’ motion to
dismiss. This appeal followed.3
D E C I S I O N
A plaintiff in a medical-malpractice case must submit two affidavits when expert
testimony is required to establish a prima facie case. Minn. Stat. § 145.682, subd. 2. First,
when serving the summons and complaint, a pl aintiff must include an attorney affidavit
stating that the plaintiff’s attorney has reviewed the facts of the case with “an expert whose
qualifications provide a reasonable expecta tion that the expert’s opinions could be
admissible at trial.” Id., subds. 2(1), 3(a). Second, the plaintiff must, within 180 days after
commencement of discovery, serve an affidavit, signed by each expert who is expected to

3In addition to its motion to di smiss, Essentia also moved for summary judgement. The
district court did not find it necessary to rule on Essentia’s su mmary-judgment motion
because appellant’s claim was dismissed. Because we conclude that the district court acted
within its discretion in dismissing appe llant’s medical-malpractice action for
noncompliance with the statutory expert-discl osure requirements, we need not consider
Essentia’s arguments for summary judgment.

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testify, containing the substanc e of the facts and opinions to which the expert plans to
testify, and summarizing the grounds for those opinions. Id., subds. 2(2), 4(a). The expert
affidavit must also include “specific details” about “the applicable standard of care, the
acts or omissions that plaintiffs allege violated the standard of care and an outline of the
chain of causation that allegedly resulted in damage to them.” Sorenson v. St. Paul Ramsey
Med. Ctr., 457 N.W.2d 188, 193 (Minn. 1990). If the plaintiff fails to satisfy these affidavit
requirements, the plaintiff’s malpractice clai m must be dismissed w ith prejudice. Minn.
Stat. § 145.682, subd. 6(c).
We must resolve whether the district court abused its discretion when it determined
that Dr. Singer’s expert affidavit failed to establish a sufficient chain of causation between
the administration of Synthroid to Ms. Samson and her death. To establish causation, the
expert affidavit must illustrate the “how” and “why” that connects the alleged malpractice
to the injury. Teffeteller v. Univ. of Minn. , 645 N.W.2d 420, 429 n.4 (Minn. 2002).
Conclusory statements do not satisfy this requirement. Stroud v. Hennepin Cty. Med. Ctr.,
556 N.W.2d 552, 556 (Minn. 1996). It is not enough for the plaintiff to merely state “that
the defendants ‘failed to properly evaluate’ and ‘failed to properly diagnose’” because such
statements “are empty conclusions which, unl ess shown how they follow from the facts,
can mask a frivolous claim.” Sorenson, 457 N.W.2d at 192-93 (citation omitted).
Dr. Singer’s overarching conclusion was that “the original administration of
Synthroid and later the increased dosage led to [Ms. Samson’s] cardiac arrest resulting in
her death.” To support this conclusion, appella nt argues that he es tablished, through his
expert affidavit, the following chain of causation:

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[1] There was an administration of Synthroid to an elderly
person approaching 100 years
[2] Synthroid is known to cause cardiac arrest, heart failure and
death
[3] Synthroid caused cardiac arrest and heart failure
[4] Cardiac arrest and heart failure caused the death of
Christine R. Samson

To explain his theory regarding Ms. Sa mson’s death, appellant directs us to
Dr. Singer’s opinions that (1) Synthroid is known to cause cardiac arrest and heart failure,
(2) more likely than not the higher dose of thyroid replac ement contributed to the overall
deterioration of Ms. Samson’s cardiac status, and (3) Synthroid caus ed deterioration of
Ms. Samson’s clinical status and eventually her death. Appellant also points to the
affidavit’s references to a number of studies on natural age-related increases in TSH and
the adverse cardiovascular effects of synthe tic thyroid over-replacem ent, as well as the
manufacturer’s warning label advising against giving a full hormone-replacement dose to
the elderly due to the prevalence of cardiovasc ular disease in this population. Based on
this cited information, appellant asserts:
Synthroid is known in the medical community to cause cardiac
arrest and failure in the elde rly . . . [and] the Respondent
prescribed such medication for over two years when such was
not indicated due to the TSH levels not being over 7.5, thus not
having a diseased thyroid a nd that such medication,
unindicated, more likely than not caused [Ms. Samson’s]
demise or death . . . .

(Emphasis removed.)
The district court found appellant’s explanation deficient, stating, “There is nothing
in Dr. Singer’s expert affidavit that indi cated Ms. Samson’s heart failure was directly
caused by the administration of Synthroid.” The court observed:

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Dr. Singer merely states Dr. Gord on breached the standard of
care by prescribing and admi nistering Synthroid to
Ms. Samson and that as a result her cardiac status deteriorated.
Dr. Singer’s expert affidavit does not assert any opinions or
discussion directly linking Ms. Samson’s deterioration or death
to Synthroid.

We agree with the district court that there is a missing link in appellant’s theory of
causation. Specifically, appellant fails to connect the second link in his chain—that
“Synthroid is known to cause cardiac arrest, heart failure and death”—with the third link—
that, in fact, “Synthroid caused cardiac arrest and heart failure” in this case. Appellant
relies on the discussions in the manufacturer’s warning and the Physicians’ Desk Reference
regarding prescribing Synthroid to elderly patients. As Dr. Gordon points out, however,
neither the manufacturer’s warning, nor the Physicians’ Desk Reference , states that any
specific dosage of Synthroid ca rries an increased probability of cardiac arrest in older
patients. Rather, these sources advise physicians to prescribe lower doses of Synthroid to
elderly patients, because this population has a greater likelih ood of hidden heart disease,
and warn about the possible adverse reactions related to hyperthyroidism
4 due to
therapeutic overdosage, including arrhythmias and cardiac arrest. Yet, there is no evidence
that Ms. Samson ever suffered from hyperthyroidism, which is marked by a patient’s TSH
levels dropping below the normal reference range.
Appellant further appears to suggest th at Ms. Samson was subject to synthetic
hormone over-replacement because Dr. Gordon needlessly placed her on and continued to

4 Hyperthyroidism occurs from pathologically excessive production of thyroid hormones.
The American Heritage Dictionary 889 (3d ed. 1992).

8
administer Synthroid, despite the fact that her TSH levels were in a normal, although
elevated, range for someone of her age group based on recent medical studies. However,
Dr. Singer’s affidavit cites no evidence to su pport this alleged over-replacement theory.
Dr. Sjoberg, an endocrinologist, reviewed Ms. Samson’s dosage levels in 2011 and
concluded that the 50-mcg dosage was approp riate and that her recorded TSH levels
normalized on this dose. Dr. Singer opines that Ms. Samson was “not a candidate for
thyroxine replacement” given her age and TSH levels. But his affidavit never states that
Ms. Samson’s TSH levels dropped below the normal range in the year and a half following
Dr. Sjoberg’s visit and before her death or that Ms. Sams on’s recorded levels were
unacceptable or reflected any over-replacement of hormones that would give rise to
concerns of adverse consequences.
Apart from TSH levels, there is no refere nce in the affidavit to Ms. Samson
suffering any of the side effect s associated with over-replacemen t, such as arrhythmia or
toxic thyroid, during the nearly three years sh e was on Synthroid. In fact, Dr. Singer
specifically notes in his affidavit that there is no evidence of this. And it is hyperthyroidism
caused by over-replacement, and not the administration of Synthroid itself, that Dr. Singer
claims would have put Ms. Samson at an elevat ed risk of adverse cardiovascular effects.
Moreover, we note that the sources cited by Dr. Singer say nothing about an increased risk
of Ms. Samson’s specific cause of death: congestive heart failure.
In sum, while Dr. Singer’s affidavit states that irregular heartbeat and cardiac arrest
can be heightened risks in elderly people, and that these adverse side effects are more likely
to occur with over-replacement of ar tificial thyroid hor mone and resulting

9
hyperthyroidism, the affidavit does not sh ow that Ms. Samson suffered from any such
therapeutic overdosage. The expert affidavit is deficient because it never explains how the
Synthroid dosage given to Ms. Samson directly (and most lik ely) caused her to suffer
congestive heart failure. Therefore, as in Stroud, appellant’s expert affidavit fails to set
forth the complete chain of causation—specif ically a chain that co nnects Dr. Gordon’s
administration of Synthroid to Ms. Samson with her death, as required by the statute. See
556 N.W.2d at 557. Because of this missing li nk, the affidavit fails to “set out a precise
explanation of why respondents’ failure to fo llow the applicable standard of care caused
the death” of Ms. Samson. Cf. Demgen v. Fairview Hosp ., 621 N.W.2d 259, 263 (Minn.
App. 2001), review denied (Minn. Apr. 17, 2001).
Appellant argues that an expert affidav it is fundamentally intended to provide
“meaningful disclosure” and correctly obser ves, “This is not a situation where the
Defendants are required to guess or search out for the Plainti ff[’s] theory of the case.”
However, the Minnesota Supreme Court has made clear that “absence of prejudice to
defendant, [or a] failure of defendant to prove plaintiff’s claim is frivolous . . . will not
excuse or justify an affidavit of expert identification falling short of the substantive
disclosure requirement.” Lindberg v. Health Partners, Inc., 599 N.W.2d 572, 578 (Minn.
1999); see also Broehm v. Mayo Clinic Rochester, 690 N.W.2d 721, 726 (Minn. 2005) (“So
as not to undermine the legislative aim of expe rt review and disclosure, we have stressed
that plaintiffs must adhere to strict compliance with th e requirements of Minn. Stat.
§ 145.682.”).

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Finally, appellant argues that the district c ourt, in evaluating the sufficiency of the
expert affidavit, erroneously required him to “disprove all other [possible causes] of death.”
This claim stems from the follo wing language at the end of di strict court’s memorandum
in its dismissal order: “While Dr. Singer certainly has provided evidence it is possible the
Synthroid caused Ms. Samson’s death, there are also so many othe r possible causes for
cardiac arrest in a 99 year old woman.”
A logical reading of the court’s statement, particularly when considered in context,
is that the district court was referring to th e fact that Dr. Singer failed to demonstrate the
necessary causal link that it was more likely than not that it was Synthroid that caused
Ms. Samson’s death. To explain its decision to dismiss appellant’s case, the district court
stated:
Not only is there no detailed chain of causation linking the
alleged negligence (Dr. Gordon’s administration of Synthroid)
with the claimed injury (M s. Samson’s death), but the
conclusion drawn is a classic logical fallacy. While Dr. Singer
certainly has provided evidence it is possible the Synthroid
caused Ms. Samson’s death, there are also so many other
possible causes for cardiac arrest in a 99 year old woman. There
is no medical evidence to suppor t the conclusion of Dr. Singer
that Synthroid was more likely than not the cause in this case.

Based on this language, rather than improp erly shifting the burden onto appellant to
disprove all other possible causes of death, the district court appears to have been
explaining how appellant’s ch ain of causation is missing a link that would permit the
conclusion that Synthroid more likely than not caused Ms. Samson’s congestive heart
failure.

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Appellant asserts that, as in Pfeiffer ex rel. Pfeiffer v. Allina Health Sys., 851 N.W.2d
626 (Minn. App. 2014), review denied (Minn. Oct. 14, 2014), the district court improperly
acted as a factfinder “when it made its decision that all other causes of death have not been
ruled out when none have b een brought forward by [respon dents].” This argument is
unavailing. To establish causa tion, a plaintiff must show th at the “defendant’s action or
inaction was a direct cause of the injury. . . . A mere possibility of causation is not enough
to sustain a plaintiff’s burden of proof.” McDonough v. Allina Health Sys. , 685 N.W.2d
688, 697 (Minn. App. 2004) (citations omitted). Here the district court determined, within
its discretion, that Dr. Singer’s affidavit failed to show how Ms. Samson’s congestive heart
failure was directly caused by the artificial thyroid hormone she was given for nearly three
years with no recorded adverse side effects and normalized TSH levels, as opposed to the
result of preexisting maladies or old age. Th e district court did not erroneously require
appellant to disprove all other causes of death.
In sum, we conclude that the district court did not abuse its discretion in dismissing
appellant’s medical-malpractice claim.
Affirmed.