N.D., a minor by his Guardian Ad Litem, P.D.;  P.D., and B.D., Individually, Plaintiffs–Appellants, v. STEVEN RICHMAN RICHARD MATTERN RICHARD DEMARSICO ESSEX WOMEN HEALTH CENTER (2011)

This is a medical malpractice action involving an infant born with brain damage and other serious deficits.   The infant was delivered a week after his twin sibling, with whom he had shared a placenta, expired in utero.   The infant's parents appeal the trial court's granting of summary judgment to two sets of defendants:  (1) the radiologists who performed and interpreted certain ultrasound studies on the pregnant mother;  and (2) the obstetrician who principally managed the pregnancy and the clinic with which he was affiliated.   The summary judgment order was exclusively based upon the motion judge's conclusion that plaintiffs could not prove that these defendants' alleged deviations from the standards of care could have proximately caused the infant's injuries.

Because the record, when viewed in a light most favorable to plaintiffs, reflects that there are genuine and material disputed issues of fact, including bona fide questions of causation, we vacate the summary judgment order and remand for trial.

I.

To frame our analysis of the issues raised on appeal, we recite several of the facts and disputed contentions that emerged in the pre-trial discovery process.   We do so mindful that several of the critical facts surrounding the pregnancy have yet to be proven or disproven.   Although it is by no means comprehensive, our factual discussion is rather detailed, in recognition of the technical and medical nature of the relevant subject matters.

This case arises out of injuries sustained, in utero, by N.D. (“Neil”),¹ the sole surviving twin in a multiple pregnancy.   The pregnancy, which was considered high-risk due to the mother's age and the presence of multiples, was referred to a maternal fetal specialist shortly after it was diagnosed.   Approximately seven-and-a-half months into the pregnancy, one of the twins expired in utero and the specialist allowed the pregnancy to continue, relying on what was later discovered to be a misdiagnosis concerning the placentation.

On April 30, 2001, N.D.'s mother, B.D., was admitted to the emergency department at Mountainside Hospital with complaints of vaginal bleeding.   The mother was apparently unaware that she was pregnant at that time.   In fact, she was pregnant with twins.   At the hospital, a complete pelvic ultrasound was ordered to rule out fetal demise.

The initial ultrasound was performed on April 30, 2001.   The results of that ultrasound, as dictated by defendant Steven Richman, M.D., a radiologist, in his May 1, 2001 report, revealed the following:

There are twin gestations.   Crown-rump measurements correspond with 12 weeks [,] two days.   Two fetal heart beats are identified.   Placenta is anterior and marginal previa.   There is no adnexal mass or cyst.

IMPRESSION

TWIN GESTATIONS OF 12 WEEKS[,] TWO DAYS. MARGINAL PREVIA.

[Emphasis added.]

During his deposition, Dr. Richman confirmed that the reference in his report to “placenta” was intended to refer to a single placenta.

Following her emergency department visit, the mother was seen by an obstetrician, defendant Richard DeMarsico, M.D., on May 3, 2001.   Dr. DeMarsico ordered a follow-up ultrasound, which was performed by defendant Richard Mattern, M.D., another radiologist, on May 23, 2001.

The results of Dr. Mattern's ultrasound, as dictated in his May 25, 2001 report, revealed the following:

A twin gestation is noted with fetal heart motion seen in both twins.   Twin A has measurements corresponding to approximately 16 weeks and twin B 15.5 weeks with approximate fetal growth since the recent study of 4/30/01.   A membrane is identified.   The placenta is anterior and there is marginal placenta previa, as noted on the earlier study.   Cervical length is normal at nearly 4 cm.   Amniotic fluid volume appears adequate.

IMPRESSION:  VIABLE TWIN GESTATION.   ANTERIOR PLACENTA WITH MARGINAL PREVIA UNCHANGED.

[Emphasis added.]

During his deposition, Dr. Mattern stated that the reference in his report to “the placenta” signified that there was one placenta.

Due to her advanced maternal age and her twin pregnancy, the mother was referred to a specialist, defendant Todd Rosen, M.D., of the Maternal Fetal Evaluation Center at Mountainside Hospital.   According to Dr. DeMarsico, it was his practice to “always refer twin pregnancies to a maternal fetal [specialist].”   Dr. Rosen saw the mother for the first time on May 31, 2001, at which time she was approximately sixteen weeks pregnant.

Dr. Rosen testified at his deposition that he received some medical records from Dr. DeMarsico.   However, Dr. Rosen did not receive any of the ultrasound reports from Dr. DeMarsico even though, according to his deposition, he would have expected the referring physician's office to have supplied “any ultrasounds that had been done to [that] date.”   The first page of Dr. DeMarsico's prenatal record apparently did reflect that the mother had undergone at least one prior ultrasound, but that ultrasound report was not furnished.²  Nevertheless, Dr. Rosen stated at his deposition that he was unaware that prior ultrasounds had been performed on the mother prior to her visiting his office.

Dr. Rosen performed several of his own obstetrical ultrasounds upon the mother, the first one apparently on May 30, 2001.   His three-page “Targeted Ultrasound Report,” dated June 19, 2001, indicates that:  “This is a twin, intrauterine gestation.   We have previously identified this as being a dichorionic, diamniotic gestation.” ³  (Emphasis added).

Dr. Rosen conducted another obstetrical ultrasound on July 17, 2001.   His accompanying report indicated that:  “This is a viable twin intrauterine gestation.   We have previously identified this as a dichorionic and diamniotic placentation.”  (Emphasis added.)

Another obstetrical ultrasound was performed on August 14, 2001 by Dr. Rosen's colleague, defendant Ying Chan, M.D. According to a report concerning that ultrasound, Dr. Chan noted that:  “This is a viable intrauterine twin gestation.   The pregnancy is known to be dichorionic and diamniotic.”   (Emphasis added).

Sadly, the other twin expired in utero, a circumstance which was diagnosed on October 5, 2001, during the thirty-fifth week of the pregnancy.   Dr. Rosen evaluated the mother that day.   Based upon a mistaken belief that the pregnancy was dichorionic, and that the one twin's fetal demise therefore would not affect the other twin, Dr. Rosen recommended that the other twin should remain in utero.   As Dr. Rosen's report indicated:  “We had previously identified this pregnancy as diamniotic and dichorionic.   This suggests that intrauterine fetal demise for Fetus B should not affect Fetus A.” (Emphasis added).⁴

During the week that followed, Dr. Rosen continued to monitor the mother's pregnancy until the surviving twin's status declined.   That twin, Neil, was delivered emergently on October 12, 2001.

The record indicates that Neil now suffers from profound, permanent cerebral palsy.   His parents contend that, although Neil “enjoys a normal life expectancy,” he “suffers from irreparable physical and cognitive limitations that will leave him totally disabled and dependent upon others for the entirety of his life.”

B.D. and Neil's father, P.D., filed this medical malpractice action in April 2006, seeking damages from defendants Dr. Rosen, Dr. Chan, Dr. Richman, Dr. Mattern, Dr. DeMarsico, Mountainside Hospital, Essex Women's Health Center, Maternal Fetal Evaluation Center, Morristown Memorial Hospital, and the Perinatal Diagnostic Testing Center.   The depositions of the parties and fact witnesses were completed prior to the summary judgment motions that form the basis of this appeal.

During discovery, plaintiffs obtained the expert report of a prenatal ultrasound expert, Peter M. Doubilet, M.D., Ph.D., Professor of Radiology at Harvard Medical School and Senior Vice–Chair of Radiology at Brigham and Women's Hospital.   Plaintiffs also obtained the expert report of an obstetrician, Martin Gubernick, M.D., of the Cornell–Weill Medical Center in New York. Finally, plaintiffs obtained the expert report of a maternal fetal medicine expert, Harlan R. Giles, M.D., of Pittsburgh.

Plaintiff's obstetrical expert, Dr. Gubernick, criticized Dr. DeMarsico for not furnishing the prior ultrasounds to Dr. Rosen and for not focusing the specialist's attention upon the fact that those reports apparently indicated a single placenta.   As Dr. Gubernick's report stated:  (1) the April 30, 2001 ultrasound identified that “[the mother] was pregnant with twins and [that] there was a single placenta[,]” and (2) the May 23, 2001 report “clearly states ‘the placenta’ not two placentas.”   Dr. Gubernick concluded that “Dr. DeMarsico saw Dr. Rosen reporting a dichorionic pregnancy on [June 19, 2001], yet the [April 30, 2001] and [May 21, 2001] [sic] ultrasounds performed at the hospital report[ ] conflicting information.  [Dr. DeMarsico] should have resolved this difference with Dr. Rosen by bringing it to his attention[,] and failure to do so was below standards of good and acceptable practice.”

Plaintiff's expert in advanced ultrasound and maternal fetal medicine, Dr. Giles, similarly noted that both the April 30, 2001 and May 23, 2001 radiology reports describe a single placenta:

On April 30, 2001[,] an ultrasound scan revealed a twin gestation of 12+ weeks and a marginal placenta previa[,] which subsequently resolved.   A follow-up scan was performed on May 23, 2001.   Again, a single placenta is described in the report.   The deposition transcripts from both radiologists reaffirmed their opinions as expressed in their reports that this twin pregnancy was characterized by a single placenta.

Dr. Giles concluded “to a reasonable degree of medical probability or certainty, that Dr. Rosen's care fell below the usual and customary standards of medical practice for 2001.”

Meanwhile, plaintiff's obstetrical ultrasound expert, Dr. Doubilet, considered that “three types of errors were made that fell below the expected standard of care[.]”  First, with respect to the hospital radiologists, Dr. Richman and Dr. Mattern, Dr. Doubilet faulted them for:

Failure to report the twin pregnancy as being monochorionic on the 4/30/01 and 5/23/01 sonograms, despite the fact that this was evident from the images.   The report of a twin gestation should always state the chorionicity when it can be determined from the images.

Dr. Doubilet also faulted Dr. Rosen for his subsequent conduct with respect to the later ultrasounds he performed:

Incorrect statements in the reports of the 6/19/01 and 7/17/01 sonograms, stating that the pregnancy had previously been found to be dichorionic.

Erroneous statement in the report of the 10/5/01 sonogram that, because the twins were dichorionic (which they were not), the death of twin B should not affect twin A. In fact, since the twins were monochorionic, the death of twin B can definitely affect twin A via “twin embolization syndrome”, and the effect on twin A includes brain damage resulting in cerebral palsy.

At his deposition, Dr. Rosen did not dispute that this was a monochorionic pregnancy with a single placenta.   He recalled that he “probably did not ask [the mother] if she had had previous ultrasounds.”   He also acknowledged that whether the pregnancy is diamniotic or monochorionic is “clinically significant for [the] management” of a twin pregnancy.   He noted that monochorionic pregnancies are “at extraordinarily high risk for fetal death.”   He added that such mothers are “typically managed as inpatients after a time to try to avoid both—one or both babies dying.”   However, he did not receive the prior ultrasounds performed on B.D., as they had not been forwarded by Dr. DeMarsico's office.⁵

When asked at his own deposition why he had not called to Dr. Rosen's attention the prior ultrasounds or the fact that there was apparently a single placenta for the twins, Dr. DeMarsico stated that he had not been, as he put it, “tuned into” the issue of chorionicity until after Neil's birth.   He also contended that the passages in the radiology reports of Dr. Richman and Dr. Mattern “don't take any position” concerning that issue.   Dr. DeMarsico further stated that he had relied upon the advice of Dr. Rosen, the specialist to whom he had referred B.D., in connection with the mother's care, once the twin pregnancy was identified.

The following passages from Dr. DeMarsico's deposition illuminate his position:

Q. Whenever it was that you read the June 19th[, 2001] report where Dr. Rosen says he [sic] previously determined this to be dichorionic, were you aware of the fact that the original ultrasounds done back in April and May [2001] suggested this was a monochorionic pregnancy?

[Objections]

Q. Were you aware of the fact that there was a potential inconsistency between what [Dr.] Rosen was saying and what the prior ultrasound reports were saying?

[Objections]

A.  I have no recollection of what I though about it to be honest with you.

Q. Okay. So you don't know if you were3/434 can we agree that there was a potential inconsistency?

A. I don't see it that way.

Q. Okay.

A. Just reading those reports, because they don't make a diagnosis either way of mono or di from these ultrasounds.   Those—the wording does not, to me, at least as a clinician, you know3/434 if anything, they would3/434 I would think, and my experience since [B.D.] because—

Q. Tuned into it?

A. I'm really tuned—well, I have been tuned into it in the recent past to be honest with you.   I can't help it.   They—most radiologists generally when they do it, look at it, think it, write it—or see it and write it.

Q. Okay.

A. Okay. So by it not being there doesn't mean to me there is a conflict.

Q. Okay. And I presume that you relied on Dr. Rosen to analyze this issue and you were going to rely on them?

[Objection]

A.  Yes.

Q. Okay. So if I understand correctly, the reason why you think there may not be a potential inconsistency is that those radiology reports really don't take a firm position?

A. They don't take any position.

Q. Okay. Certainly not a position that would alert you to a potential inconsistency?

A. Yes. As a generalist ․ reading that report, I just know we have a twin pregnancy that both have heart beats and the second one, that the fetuses have grown appropriately.

To support his defense that he adhered to the standards of care, Dr. DeMarsico ⁶ retained two obstetrical experts:  Ruby P. Huttner, M.D., a clinical professor for Obstetrics/Gynecology and Reproductive Sciences at the University of Medicine and Dentistry of New Jersey, and Corey S. Bosin, M.D., a Diplomate of the American Board of Obstetrics and Gynecology.   In his expert report, Dr. Huttner concluded that “Dr. DeMarsico did not deviate from the standard of care expected of him nor was he negligent in providing the appropriate treatment to [the mother] anticipated from a generalist obstetrician.”   Although Dr. Huttner agreed with plaintiffs' experts that “chorionicity should be established in all multiple gestations, and although it is not entirely clear that the erroneous decision regarding chorionicity was the proximate cause of [Neil]'s injury,” he found that “it was obvious that Dr. DeMarsico relied on the assessment made by his maternal fetal medicine consultant in the treatment that he rendered.”

Dr. Huttner disagreed with plaintiff's expert, Dr. Gubernick, in that “[t]here [was] no evidence in the records that the initial reports established chorionicity and hence were monochorionic.   Thus, Dr. DeMarsico could not and would not have seen an inconsistency with Dr. Rosen's conclusions.   There simply is no conflict between the radiologist's report and Dr. Rosen's conclusions.”

The other defense expert, Dr. Bosin, reached the same conclusion, opining in his report that “Dr. DeMarsico followed acceptable standards of care.   The management of care was based on ultrasounds by radiologists and by maternal-fetal medicine specialists.”   Dr. Bosin explained that “[t]he sole description of the single placenta is not reliably diagnostic of a monochorionic placenta without documenting the presence (or absence) and thickness of a dividing membrane and/or the presence (or absence) of a lambda sign.” ⁷

Following factual discovery and the exchange of these expert reports, Dr. Richman and Dr. Mattern (the “radiologist-defendants”) moved for summary judgment, on the ground that plaintiffs could not prove causation as to them.   The radiologist-defendants argued that there was no genuine issue of material fact as to whether any alleged deviations on their part caused plaintiff's injuries.

Shortly thereafter, Dr. DeMarsico and the Essex Women's Health Center (“the obstetrician-defendants”) cross-moved for summary judgment on similar grounds.   The obstetrician-defendants likewise argued that there was no genuine issue of material fact with respect to the issue of proving causation as to them.   Plaintiffs opposed the motions, contending that there were genuine and triable issues of causation as to the conduct of both sets of defendants who then remained in the case.

After hearing oral argument, the trial judge granted both motions for summary judgment.   In his oral decision, the judge noted that the statement of undisputed material facts provided by defendants pursuant to Rule 4:46–2(a) asserted that if either Dr. Richman or Dr. Mattern had seen two placentas, they “would have reported [that] there were separate placentas and as to specific findings such as the location of each placenta.”   Because those two particular assertions were not disputed, the judge concluded that plaintiffs had no viable cause of action against the radiologist-defendants.

As to the obstetrician-defendants, the motion judge rejected plaintiff's argument that the radiologist-defendants should have done more to alert Dr. DeMarsico to the monochorionic nature of the pregnancy and that he, in turn, should have done more to alert Dr. Rosen to that condition.   As plaintiff's counsel explained it:

[H]ad the [radiologist-defendant's] reports been clear and definitive as to the doctor[s'] determination of chorionicity, Dr. DeMarsico would have been aware of the determination of mono-chorionic and that when he received the contrary information from Dr. Rosen thereafter, he would have been alerted to the inconsistency or the contradiction, [he] would have notified Dr. Rosen [,] who of course would have taken the proper steps to further investigate and resolve the discrepancy or the contradiction in the two reports.

The motion judge rejected that argument, discerning no legally competent evidence to support the alleged failures in the chain of communications.   The judge determined that it was speculative that Dr. Rosen would have acted differently, even if the documentation preceding his care had been communicated.

The motion judge consequently found that there was no “factual support in the record for a causal connection between the alleged acts or deviations attributed to these doctors and the ultimate injury incurred by the infant plaintiff herein.”   The judge also found that “the evidence, [the] competent evidence[,][was] so one[-]sided that a rational fact-finder could not in any way find and/or resolve the issue ․ in favor of the plaintiff[s] herein.”

Plaintiffs now appeal, essentially contending that the trial judge misapplied the standards for summary judgment, and that he erred in concluding that there are no triable issues of causation respecting the conduct of either the radiologist-defendants or the obstetrician-defendants.

II.

In considering plaintiffs' appeal, we repeat and abide by certain fundamental principles applicable to summary judgment motions.   The court must “consider whether the competent evidential materials presented, when viewed in the light most favorable to the non-moving party, are sufficient to permit a rational factfinder to resolve the alleged disputed issue in favor of the non-moving party.”  Brill v. Guardian Life Ins. Co. of Am., 142 N.J. 520, 540 (1995);  see also R. 4:46–2(c).  The court cannot resolve contested factual issues but instead must determine whether there are any genuine factual disputes.   Agurto v. Guhr, 381 N.J.Super. 519, 525 (App.Div.2005).   If there are materially disputed facts, the motion for summary judgment should be denied.   Parks v. Rogers, 176 N.J. 491, 502 (2003);  Brill, supra, 142 N.J. at 540.   To grant the motion, the court must find that the evidence in the record “ ‘is so one-sided that one party must prevail as a matter of law [.]’ ”  Brill, supra, 142 N.J. at 540 (quoting Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252, 106 S.Ct. 2505, 2512, 91 L. Ed.2d 202, 214 (1986)).

Our review of an order granting summary judgment must observe the same standards, including our obligation to view the record in a light most favorable to the non-moving parties, here plaintiffs.   See Estate of Hanges v. Met. Prop. & Cas. Ins. Co., 202 N.J. 369, 374 (2010).   We accord no special deference to a trial judge's assessment of the documentary record, as the decision to grant or withhold summary judgment does not hinge upon a judge's determinations of the credibility of testimony rendered in court, but instead amounts to a ruling on a question of law.   See Manalapan Realty v. Manalapan Twp. Comm., 140 N.J. 366, 378 (1995) (noting that no “special deference” applies to a trial court's legal determinations);  612 Assocs., L.L.C. v. No. Bergen Mun. Utils.   Auth., 404 N.J.Super. 531, 536 (App.Div.2009) (same).

We also bear in mind the basic elements of a cause of action for medical malpractice, although only one of those elements3/434 causation3/434 is at issue on this appeal.   A medical malpractice plaintiff bears the burden of proving:  (1) the applicable professional standard of care, (2) that each defendant deviated from that standard of care, and (3) that the deviation was the proximate cause of plaintiff's injuries.  Gardner v. Pawliw, 150 N.J. 359, 375 (1997);  see also Model (Civil) Jury Charges § 5.50A, § 6.10. The plaintiff must provide competent expert testimony in order to establish that each defendant deviated from that applicable standard of care.  Schueler v. Strelinger, 43 N.J. 330, 345 (1964);  Model (Civil) Jury Charges § 5.50A. The plaintiff must also provide competent expert testimony that “the deviation was the reasonably probable cause of the injurious condition arising thereafter.”   Germann v. Matriss, 55 N.J. 193, 208 (1970);  see also Model (Civil) Jury Charges § 6.10.

As noted, the critical issue concerning defendants' summary judgment motions in this case is causation.   In particular, we must consider whether the obstetrician-defendants, by their actions or inactions, deviated from the standards of care in a manner that could have proximately caused the injuries to Neil, or could have made them more severe.   We must similarly consider whether the radiologist-defendants, by their own actions or inactions, deviated from the standard of care in such a way that their conduct could have been a proximate cause of the infant's harm, or a worsening of that harm.

In focusing upon the causation issues here, we must bear in mind that the law contemplates that an injury can be produced by more than one cause.  Conklin v. Hannoch Weisman, 145 N.J. 395, 417 (1996);  Camp v. Jiffy Lube No. 114, 309 N.J.Super. 305, 309 (App.Div.), certif. denied, 156 N.J. 386 (1998).   The Model Civil Jury Charges reflect that recognition of potential concurrent causes:

To find proximate cause, you must first find that [defendant]'s negligence was a cause of the accident/incident/event.   If you find that [defendant] is not a cause of the accident/incident/event, then you must find no proximate cause.

Second, you must find that [defendant]'s negligence was a substantial factor that singly, or in combination with other causes, brought about the accident/incident/event or injury/loss/harm claimed by [plaintiff].   By substantial, it is meant that it was not a remote, trivial or inconsequential cause.   The mere circumstance that there may also be another cause of the accident/incident/event or injury/loss/harm does not mean that there cannot be a finding of proximate cause.   Nor is it necessary for the negligence of [defendant] to be the sole cause of [the] accident/incident/event or injury/loss/harm.   If you find that [defendant]'s negligence was a substantial factor in bringing about the accident/incident/event or injury/loss/ harm, then you should find that [defendant]'s negligence was a proximate cause of the accident/incident/event or injury/loss/harm.

[Model (Civil) Jury Charge 6.12 (emphasis added).]

The possibility of multiple contributing causes is not uncommon in medical negligence actions.   See, e.g., Bendar v. Rosen, 247 N.J.Super. 219, 233–34 (App.Div.1991);  Edwards v. Our Lady of Lourdes Hosp., 217 N.J.Super. 448, 464 (App.Div.1987).   A pivotal question to be decided in such cases is whether the defendant's negligence amounted to a “substantial factor” in producing the injury.   See Model (Civil) Jury Charge 6.12;  see also Dubak v. Burdette Tomlin Mem. Hosp. 233 N.J.Super. 441, 452 (App.Div.), certif. denied, 117 N.J. 48 (1989).

Applying these causation principles here, we conclude that summary judgment was improvidently granted to both the obstetrician-defendants and to the radiologist-defendants.   Viewing the record in a light most favorable to plaintiffs, including the reports of their well-credentialed experts, the record objectively raises genuine issues of causation that warrant a trial.

With respect to Dr. DeMarsico, the record presents significant issues about whether his own failure to appreciate that the mother had a single, monochorionic placenta and to assure that Dr. Rosen received the prior ultrasound reports performed at the hospital, could be reasonably found by a jury to comprise substantial contributing factors to the failure to intervene and deliver Neil sooner, after his twin expired in utero.   The trial judge essentially treated Dr. Rosen's own ultrasound studies and his own failure to make a fuller inquiry as intervening conduct that broke the arguable chain of causation.

We cannot agree, as a matter of law, that Dr. Rosen's handling of the pregnancy would necessarily have been unaffected if he had been provided with the prior ultrasound studies, or if Dr. DeMarsico had, as plaintiffs' expert opined, fulfilled his alleged duty to bring the prior studies to the specialist's attention.   Dr. DeMarsico's testimony in his deposition that he had not been “tuned into” the monochorionic issue at the time poses legitimate factual questions about whether he should have been more attentive to the nature of the placenta, and whether he should have communicated that issue to the specialist, Dr. Rosen.   We cannot presume, at least on the present record, that Dr. Rosen necessarily would have ignored such communications had they been made, or that he would have ignored the prior ultrasound studies had they been contemporaneously supplied.

Although we perceive that the claims against the radiology defendants are weaker, we likewise conclude that summary judgment was also erroneously granted in their favor.   Although the reports of Dr. Richman and Dr. Mattern do refer to the “placenta” in the singular, they do not elaborate further about the chorionicity of the placenta.   Had the reports done so, in conformance with the standard of care as set forth by plaintiffs' radiology expert, that arguably could have averted the adverse outcome in this case.   Greater precision and detail in the radiology-defendants' reports potentially could have prompted Dr. DeMarsico to be more “tuned into” the chorionicity issues and, in turn, the information he passed onto Dr. Rosen also may well have been more definitive and pointed.   All of these realistic possibilities must be sorted out by a fact-finder at trial.

In vacating summary judgment, we are cognizant that the present record does suggest that the most culpable participant in the sequence of events was Dr. Rosen, who has settled out of the case.   However, his apparently central role in the chronology does not rule out plaintiffs' reasonable contentions, which are backed with expert support, that the remaining defendants also deviated from the standard of care, and that their own deviations were potentially consequential, at least in part.

The orders granting summary judgment are reversed and the case is remanded for trial.

FOOTNOTES

FN1. Because this opinion by necessity refers to the minor's medical and neurological deficits and his actual date of birth, we have utilized initials for him and his parents, P.D. and B.D. For ease of reading, we refer to the child by the fictitious name “Neil.”.  FN1. Because this opinion by necessity refers to the minor's medical and neurological deficits and his actual date of birth, we have utilized initials for him and his parents, P.D. and B.D. For ease of reading, we refer to the child by the fictitious name “Neil.”

FN2. The medical record was not provided in the appellate record, but it is alluded to in a report of one of the defense experts..  FN2. The medical record was not provided in the appellate record, but it is alluded to in a report of one of the defense experts.

FN3. Twinning is characterized by one of three placentation types, the formation of which depends on the timing of twinning after fertilization.   From earlier division of the zygote to later, placentation may be dichorionic-diamniotic, monochorionic-diamniotic, or monochorionic-monoamniotic, which indicates whether the twins have their own outer sacs (chorions) and their own inner sacs (amnions).   Traci B. Fox, Multiple Pregnancies:  Determining Chorionicity and Amnionicity, Department of Radiologic Sciences Faculty Papers 1–2 (2006), available at http:// jdc.jefferson.edu/rsfp/1. We take judicial notice of these basic medical definitions because they may be helpful to the reader, and because we presume they would not be disputed by the parties.   See N.J.R.E. 201(b).  In doing so, we do not intend to constrain the parties' respective proofs at trial..  FN3. Twinning is characterized by one of three placentation types, the formation of which depends on the timing of twinning after fertilization.   From earlier division of the zygote to later, placentation may be dichorionic-diamniotic, monochorionic-diamniotic, or monochorionic-monoamniotic, which indicates whether the twins have their own outer sacs (chorions) and their own inner sacs (amnions).   Traci B. Fox, Multiple Pregnancies:  Determining Chorionicity and Amnionicity, Department of Radiologic Sciences Faculty Papers 1–2 (2006), available at http:// jdc.jefferson.edu/rsfp/1. We take judicial notice of these basic medical definitions because they may be helpful to the reader, and because we presume they would not be disputed by the parties.   See N.J.R.E. 201(b).  In doing so, we do not intend to constrain the parties' respective proofs at trial.

FN4. Some of the reports refer to Neil as “Fetus A” or “Twin A,” and to his counterpart twin as “Fetus B” or “Twin B.”.  FN4. Some of the reports refer to Neil as “Fetus A” or “Twin A,” and to his counterpart twin as “Fetus B” or “Twin B.”

FN5. Plaintiffs and Dr. Rosen ultimately reached a settlement, which was approved by the trial court after a friendly hearing.   Thereafter, the complaint was voluntarily dismissed against Dr. Rosen, as well as against defendants Dr. Chan, Dr. Shah, Mountainside Hospital, Morristown Memorial Hospital and the Perinatal Diagnostic Testing Center..  FN5. Plaintiffs and Dr. Rosen ultimately reached a settlement, which was approved by the trial court after a friendly hearing.   Thereafter, the complaint was voluntarily dismissed against Dr. Rosen, as well as against defendants Dr. Chan, Dr. Shah, Mountainside Hospital, Morristown Memorial Hospital and the Perinatal Diagnostic Testing Center.

FN6. The summary judgment record apparently did not contain any expert reports on behalf of the defendant radiologists, Dr. Richman and Dr. Mattern.   In any event, we must examine the record in a light most favorable to plaintiffs as the non-moving parties.   See R. 4:46FN⌑7. “In dichorionic twins, the area of fusion between the placentas form a wedge-shaped zone termed the ‘[l]ambda’ or ‘twin-peak’ sign.   In monochorionic twins, this structure is absent[.]”  I. Meizner, Can Ultrasound Determine Chorionicity and Amnionicity in Multiple Pregnancy?   The First World Congress On:  Controversies in Obstetrics, Gynecology & Infertility, Prague, Czech Republic 2 (1999).   Again, we provide this background information simply to aid the reader, and we do not intend to constrain the parties' respective proofs at trial..  FN6. The summary judgment record apparently did not contain any expert reports on behalf of the defendant radiologists, Dr. Richman and Dr. Mattern.   In any event, we must examine the record in a light most favorable to plaintiffs as the non-moving parties.   See R. 4:46FN⌑7. “In dichorionic twins, the area of fusion between the placentas form a wedge-shaped zone termed the ‘[l]ambda’ or ‘twin-peak’ sign.   In monochorionic twins, this structure is absent[.]”  I. Meizner, Can Ultrasound Determine Chorionicity and Amnionicity in Multiple Pregnancy?   The First World Congress On:  Controversies in Obstetrics, Gynecology & Infertility, Prague, Czech Republic 2 (1999).   Again, we provide this background information simply to aid the reader, and we do not intend to constrain the parties' respective proofs at trial.

PER CURIAM