Providence Hospital v. Willis: DC Court of Appeals Confirms the Med-Mal Causation Standard
A surgeon writes a post-operative order: place sequential compression devices — the inflatable sleeves that keep blood moving through a patient's legs — to prevent dangerous clots. The nurses never put them on. The patient develops deep venous thrombosis, and both of his legs are amputated below the knee.
A District of Columbia jury found Providence Hospital's nursing failure caused that catastrophe and awarded $650,000. Late last month, the D.C. Court of Appeals affirmed the verdict — and in doing so, delivered one of the clearest recent statements of how causation actually works in DC medical malpractice cases. Providence Hospital, Inc. v. Willis, 103 A.3d 533 (D.C. Nov. 20, 2014) (per curiam).
The hospital's argument: prove the negative
On appeal, the hospital did not seriously dispute that its nurses failed to carry out the surgeon's order. Instead, it attacked causation with an argument defense teams love: you can't prove the timing. Perhaps, the hospital urged, the deep venous thrombosis was already "well-established" before the nurses' failure — and unless the plaintiff ruled out that possibility, he had not proven the negligence caused his amputations.
The Court of Appeals rejected that framing. Under DC law as stated in Travers v. District of Columbia, a plaintiff's expert "need only state an opinion, based on a reasonable degree of medical certainty, that the defendant's negligence is more likely than anything else to have been the cause (or a cause)" of the injury. Requiring the plaintiff to also negate every alternative scenario, the court explained, would improperly ratchet the civil burden of proof toward something resembling a criminal-law standard.
The court also emphasized that a jury may draw reasonable inferences from the expert's testimony as a whole. Medicine rarely offers minute-by-minute certainty about when a clot formed. What the law requires is a well-founded expert opinion that the negligence, more likely than anything else, caused (or contributed to causing) the harm — and the jury here had exactly that.
Why this matters
Causation is where medical malpractice cases are won and lost. Negligence is often provable from the chart itself — an order written and never executed, as here. But defendants routinely retreat to causation, where the inherent uncertainty of medicine can be dressed up as reasonable doubt: maybe it was already too late; maybe it would have happened anyway; can you really be sure?
Willis confirms the answer DC law gives: certainty is not the standard. Preponderance is. The patient does not have to disprove every alternative timeline the defense can imagine; he has to show the negligence was more likely than anything else the cause. That is the same more-likely-than-not standard that governs every other civil case, and the Court of Appeals declined the invitation to hold injured patients to something higher.
It is worth pausing on what the hospital's proposed rule would have meant in practice. Prevention failures, by their nature, leave open the theoretical possibility that the harm was already brewing — that is precisely why preventive measures are ordered early and applied continuously. A rule requiring patients to disprove the "it was already too late" hypothesis would make the most negligent omissions the hardest to remedy: the longer prophylaxis is skipped, the murkier the timeline, and the safer the defendant. DC law now clearly forecloses that perverse incentive.
What this means for injured people in DC
- "We can't know for sure" is not a defense. Where a qualified expert ties the negligence to the harm to a reasonable degree of medical certainty, the case belongs to the jury — even if medicine cannot timestamp the injury's progression.
- Nursing failures are hospital failures. This verdict rested on nurses not executing a physician's preventive order. Hospitals are responsible for their nursing staff, and prevention protocols — clot prophylaxis among the most important — exist because the consequences of skipping them are catastrophic.
- DVT and prophylaxis cases deserve careful review. Blood clots remain one of the most preventable causes of serious hospital harm. When compression devices, anticoagulants, or mobilization orders are skipped and a clot follows, the chart usually tells the story.
- Verdicts can be defended on appeal. The jury's award here survived the hospital's appeal intact — a reminder that a well-tried case, built on the correct legal standard, holds up.
- The usual DC med-mal rules still apply. A claim like this one must clear DC's procedural gates — including written notice to each provider at least 90 days before suit under D.C. Code § 16-2802 — and must be supported by qualified experts on the standard of care, breach, and causation. The Willis standard helps at trial; getting to trial takes disciplined preparation from the start.
We try medical malpractice cases in the District's courts, and the Travers standard confirmed in Willis is the backbone of how these cases are proven. If you or a loved one has been hurt, call Posey Lebowitz at (202) 524-0123 or send us a message for a free consultation.
Part of our DMV case law archive, compiled in 2026 to reflect the archive of some of the most important decisions in injury law.