In Luppold v. Hanlon, the Massachusetts Supreme Judicial Court affirmed a $28.8 million verdict involving emergency-department care that failed to identify and address vascular compromise in time to prevent an amputation. The opinion highlights several issues that continue to shape medical malpractice litigation: expert testimony, causation standards, high-low agreements, and prejudgment interest. While the underlying facts are tragic, the decision also illustrates how modern malpractice trials are built around sequences of missed opportunities and the ability of experts to explain clinical decision-making in a coherent and legally relevant manner.
The case arose after Steven Luppold visited the emergency department at Lowell General Hospital on March 7 and March 13, 2015, with severe foot pain and visible discoloration. Despite classic symptoms of possible vascular compromise, imaging was not performed. After the second visit, his condition continued to worsen. On March 17, at a different hospital, imaging revealed advanced arterial thrombosis and deep vein thrombosis. On March 18, an above-knee amputation was performed. The record reflects a series of clinical encounters where escalating symptoms were documented, yet the underlying vascular pathology remained unidentified long enough to become irreversible.
The plaintiff sued several providers who participated in his care, including a registered nurse, a physician assistant, and a nurse practitioner. A jury concluded that each acted negligently and contributed to the delayed diagnosis, awarding $20 million in damages and $8.9 million in prejudgment interest. On appeal, the primary defendant argued that the trial court improperly restricted cross-examination, misstated the causation standard in jury instructions, and erred in awarding prejudgment interest on future damages.
The Supreme Judicial Court rejected each argument. In doing so, it reaffirmed core principles underlying medical malpractice litigation while simultaneously providing clarification in areas that frequently generate appellate disputes.
One of the central legal questions involved the causation standard under Doull v. Foster, the leading Massachusetts case that reaffirmed the “but-for” test in medical malpractice and other tort claims. The “substantial factor” standard is now largely eliminated from most negligence cases, leaving plaintiffs to demonstrate that, but for a defendant’s negligent act or omission, the harm would not have occurred. In Luppold, the Court determined that the trial judge’s instructions aligned with this requirement and that the jury was properly guided regarding causation.
This aspect of the decision reinforces the importance of expert testimony when several providers are involved at different points in a patient’s care. In many modern malpractice actions, negligence arises not from a single catastrophic mistake but from incremental failures to act, communicate, or escalate. Establishing causation under Doull therefore requires connecting each provider’s conduct to the outcome in a way that makes sense medically and legally. That connection typically cannot be inferred without expert testimony explaining how an earlier intervention would have altered the course of events.
Another issue examined by the Court was the existence of a high-low settlement agreement with one of the defendants. The defendant argued that she should have been permitted to cross-examine the co-defendant regarding that agreement to show potential bias. The trial court limited the questioning, reasoning that revealing the agreement could distort how jurors perceived the co-defendant’s role or create confusion about settlement arrangements that are ordinarily inadmissible.
The Supreme Judicial Court agreed, concluding that the trial judge acted within discretion to prevent unfair prejudice. While the decision does not create a blanket rule against referencing high-low agreements at trial, it demonstrates judicial caution around disclosure. Counsel must therefore be prepared to litigate admissibility in pretrial motions and consider whether the probative value of such information is likely to outweigh the risk of jury confusion.
The opinion also addressed prejudgment interest on future damages. The defendant contended that awarding interest on damages not yet incurred was improper. The Court rejected this argument, observing that interest in Massachusetts attaches when the cause of action accrues, not when individual components of damages are realized. The practical result is that in catastrophic injury cases with long-term medical needs or permanent disability, interest can add substantial exposure. From a litigation-management perspective, this financial reality may influence settlement evaluation and trial strategy, particularly in cases where liability is sharply contested but potential damages are severe.
Beyond doctrinal issues, the decision illustrates several broader trends in modern malpractice litigation. First, clinical narratives now frequently involve multiple providers operating at different decision points, sometimes across several facilities. Making sense of those interactions for a jury requires expert analysis that explains not only what should have happened but also how cumulative choices reduced the range of viable medical options.
Second, expert testimony now serves a dual purpose: establishing standard of care and illuminating the medical consequences of delay. Vascular emergencies, strokes, sepsis, and certain oncologic or neurologic conditions progress in ways that are unfamiliar to lay jurors. Expert witnesses often contextualize symptoms, timelines, and decision points in a manner that transforms what might appear to be routine triage into a critical missed opportunity. In Luppold, experts helped the jury understand how earlier imaging or referral could have prevented the amputation. Without that narrative, jurors would have been left with isolated clinical facts rather than a causal chain.
The case also reminds litigators that negligence in the emergency department can arise from failures to escalate or consult, not simply from misdiagnosis. When symptoms fall within a differential diagnosis that includes high-risk conditions, failure to rule out those conditions can constitute negligence even if the more serious diagnosis is statistically uncommon. Expert testimony is often decisive in explaining what a reasonably prudent provider should have done under the circumstances.
Finally, Luppold underscores how important it is to educate jurors about medical decision-making without overwhelming them with clinical detail. Juries do not need to become experts in vascular surgery, but they must understand how delayed imaging left the patient without meaningful treatment alternatives. Expert testimony served that role, linking clinical timelines to legal causation in a way that aligned with existing tort standards.
Taken together, the Supreme Judicial Court’s decision demonstrates that the traditional negligence framework continues to govern malpractice litigation, even as medicine grows more complex. Expert testimony remains indispensable in showing how particular decisions influenced the outcome, why earlier intervention would have changed the clinical trajectory, and how multiple providers can collectively contribute to a single preventable injury. With this decision, the Court affirms that thorough expert analysis remains central to both trial strategy and appellate review in medical malpractice cases.
