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                                                                            Date: 2017.04.20
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             Eid v. Loyola University Medical Center, 2017 IL App (1st) 143967



Appellate Court        LISA EID and MOHAMMED EID, as Special Administrators of the
Caption                Estate of Miranda Eid, Deceased, and LISA EID, Individually,
                       Plaintiffs-Appellants, v. LOYOLA UNIVERSITY MEDICAL
                       CENTER, Defendant-Appellee.



District & No.         First District, Fifth Division
                       Docket No. 1-14-3967


Opinion filed          December 2, 2016
Opinion withdrawn      February 16, 2017
Rehearing denied       February 16, 2017
Filed                  February 24, 2017



Decision Under         Appeal from the Circuit Court of Cook County, No. 13-L-975; the
Review                 Hon. Thomas L. Hogan, Judge, presiding.



Judgment               Affirmed.



Counsel on             Law Offices of Keith L. Davidson, of Chicago (Keith L. Davidson, of
Appeal                 counsel), for appellants.

                       Swanson, Martin & Bell, LLP, of Chicago (Patricia S. Kocour,
                       Catherine Weiler, and Shera D. Wiegler, of counsel), for appellee.
     Panel                    JUSTICE LAMPKIN delivered the judgment of the court, with
                              opinion.
                              Presiding Justice Gordon and Justice Reyes concurred in the judgment
                              and opinion.
                                               OPINION

¶1         After the death of Miranda Eid, a minor, her parents Mohammed and Lisa Eid brought suit
       against Loyola University Medical Center (Loyola), alleging negligent medical treatment of
       Miranda following her pacemaker replacement surgery. Mrs. Eid also sought damages for
       reckless infliction of emotional distress based on Loyola’s nurses leaving medical tubing in
       place when Miranda’s body was released for burial. The jury returned a verdict in favor of
       Loyola, and Mr. and Mrs. Eid appealed.
¶2         On appeal, Mr. and Mrs. Eid argue (1) the jury’s verdict in favor of Loyola on the claims of
       medical negligence and reckless infliction of emotional distress was against the manifest
       weight of the evidence; (2) the circuit court erroneously upheld Loyola’s claim of privilege
       under section 8-2101 of the Code of Civil Procedure (known as the Medical Studies Act) (735
       ILCS 5/8-2101 et seq. (West 2012)) for information that was generated for the use of Loyola’s
       peer review committee when a designee of that committee, pursuant to his authority under
       Loyola’s bylaws, began an investigation of Miranda’s treatment and instructed another
       member of the committee to assemble information concerning the incident; (3) the circuit court
       improperly instructed the jury on the law concerning the claim of reckless infliction of
       emotional distress; and (4) defense counsel’s alleged improper remark during closing
       argument confused the jury, and the additional instructions the circuit court gave the jury did
       not cure the alleged confusion.
¶3         For the reasons that follow, we affirm the judgment of the circuit court.

¶4                                          I. BACKGROUND
¶5         This appeal arises from the death of a two-year-old girl during her recovery from surgery
       that replaced her pacemaker. Miranda Eid was born in 2010 with a chromosomal abnormality
       that resulted in several anatomical defects, including an inverted heart structure and
       dextrocardia, a condition in which the heart is located in the right, rather than the left, chest.
       Miranda also had an atrioventricular block, a condition in which the impulses from the upper
       chambers of the heart are blocked from the lower chambers. To fix the block, Miranda
       underwent surgery when she was six days old to implant a pacemaker.
¶6         Two years later, Miranda needed a new pacemaker. On February 10, 2012, she had surgery
       at Loyola to replace the old pacemaker with a new one. During the surgery, a small laceration
       occurred on the surface of her heart. The laceration was sutured with a single stitch. Prior to
       closing the skin, the surgeons placed a tube in Miranda’s chest to drain fluid. At the conclusion
       of the surgery, Miranda was stable and the surgeons advised Mr. and Mrs. Eid that the
       procedure had been successful.
¶7         Miranda was transferred to the pediatric intensive care unit at 2 p.m. A few hours later,
       Miranda became agitated. Nurse Matz gave Miranda a small dose of Versed, a sedative
       narcotic, to help her relax, as well as a fentanyl drip to help with any pain. About 8:20 p.m.,
       nurse Ghera reported that Miranda appeared fussy and uncomfortable. Nurse Ghera then


                                                   -2-
       administered a second small dose of Versed. About 8:35 p.m., nurse Ghera noticed that
       Miranda’s breathing became shallow and irregular. Nurse Ghera immediately called nurse
       Matz to the room to assess any changes in Miranda’s condition since nurse Matz had
       administered the earlier dose of Versed.
¶8         Nurses Matz and Ghera began giving Miranda oxygen at approximately 8:45 p.m. and
       called a code identifying an emergent situation with a patient. A code team arrived in less than
       a minute. Nurses Matz and Ghera administered medications and blood, performed
       compressions and tests, and protected Miranda’s airway. Over the next two hours
       approximately 10 to 15 nurses, residents, and physicians conducted tests and worked to
       diagnose Miranda’s adverse symptoms and resolve the problem.
¶9         Blood was drawn around 9:30 p.m. to evaluate Miranda’s blood gas levels. The blood draw
       was tested three times. The first test showed levels so low they were unreadable and the next
       two tests showed abnormally low levels. Extremely low hemoglobin levels could be one
       indication of internal bleeding. The treating physicians, however, believed the test results were
       inaccurate and most likely the result of a sampling error.
¶ 10       A chest X-ray, ultrasound, and echocardiogram were done, and the physicians concluded
       that there was no evidence of blood or fluid around the heart. When a doctor checked
       Miranda’s discharge tube and a nurse felt Miranda’s stomach, the chest tube output was low
       and Miranda’s chest was soft. Those findings corroborated the results of the image tests, which
       indicated no evidence of internal bleeding or fluid or blood around the heart.
¶ 11       The doctors decided not to perform a pericardiocentesis because there was no indication of
       fluid in Miranda’s chest that needed to be withdrawn. The doctors also decided not to place
       Miranda on an extracorporeal membrane oxygenation (ECMO) machine because staff had
       already been performing chest compressions for over 40 minutes and the machine would have
       had little chance of being effective by the time a team was mobilized. Staff continued with
       resuscitation efforts until it became clear those efforts were futile. Miranda was declared dead
       at 10:46 p.m. on February 10, 2012.
¶ 12       Mr. and Mrs. Eid were informed of Miranda’s death. A doctor escorted the Eids to
       Miranda’s room, and nurse Ghera stayed with them to provide support. Mrs. Eid told the
       doctor and nurse Ghera that Mrs. Eid wanted the tubes removed from Miranda’s body. The
       doctor said the tubes would be taken care of after the medical examiner called regarding an
       autopsy. Nurse Ghera said she would remove all the tubes she could take out, bathe Miranda,
       and carry her to the morgue personally.
¶ 13       According to Loyola’s protocol, Miranda’s death was reported to the medical examiner,
       who had the option to either order or waive an autopsy. If the medical examiner waived the
       autopsy, then all the tubes, dressings and tapes were supposed to be removed from the body
       unless a physician requested otherwise because a private autopsy would be conducted. Based
       on her experience, nurse Ghera testified that every child who died within 24 hours of
       admission was sent to the medical examiner for an autopsy. Nurse Ghera learned that the
       medical examiner had waived the autopsy but could not recall when she learned that
       information. Furthermore, the Eids declined a private autopsy when Miranda’s primary
       pediatric cardiologist discussed the matter with them. After Mrs. Eid advised nurse Ghera that
       the private autopsy had been declined, nurse Ghera spoke with her supervisor, nurse Maturin.
       However, nurse Maturin instructed nurse Ghera not to remove the tubes due to some
       uncertainty regarding whether an autopsy would be conducted at another institution.

                                                   -3-
       Consequently, nurse Ghera removed only the smaller tubes as allowed by the protocol
       concerning autopsies. Nurse Ghera placed white cloth tape over the endotracheal tube and
       washed Miranda’s body with warm water. Then nurse Ghera wrapped Miranda’s body in baby
       blankets, placed her in a plastic body bag, and carried her to the morgue around 4 a.m.
¶ 14       The next day, Miranda’s body was transferred to a funeral home and placed in
       refrigeration. To respect the Muslim religious traditions, the male funeral director did not
       uncover or inspect the body. One day later, Mrs. Eid, female friends and family members, and
       female ritual washers arrived at the funeral home to perform a ritual washing. Mrs. Eid was
       crying as Miranda’s body was removed from the body bag. Then Mrs. Eid saw that medical
       tubes were still in place and shouted that nurse Ghera had lied to her. The ritual washers
       removed a nose tube, and there was a little blood on it. When the washers removed the mouth
       tube, blood “began gushing” from Miranda’s mouth. Mrs. Eid fell to her knees, became
       hysterical, and cried uncontrollably. The washers stuffed gauze into Miranda’s mouth to stop
       the bleeding. No attempt was made to remove other tubes.
¶ 15       A few days later, Mrs. Eid contacted Loyola and demanded to speak to nurse Ghera about
       the unremoved tubes. Nurse Ghera explained that her supervisor had instructed her not to
       remove the tubes, so she removed what she could, washed Miranda, and carried her to the
       morgue. Mrs. Eid said she did not believe her.
¶ 16       Kathleen Ostrowski was Loyola’s risk manager and a member of Loyola’s Medical Care
       Evaluation and Analysis Committee (MCEAC), which conducts peer reviews of hospital
       deaths to reduce morbidity and mortality. The morning after Miranda’s death, Ms. Ostrowski
       began contacting individuals to preserve records. Ms. Ostrowski then paged Dr. Robert
       Cherry, the chairperson of the MCEAC, to advise him of the incident. Dr. Cherry returned Ms.
       Ostrowski’s page at 10:51 a.m. and instructed her to investigate the incident on the MCEAC’s
       behalf from a quality perspective.
¶ 17       The Eids sued Loyola for medical negligence and reckless infliction of emotional distress.
       During discovery, Loyola refused to produce 13 pages of documents, claiming privilege under
       the Medical Studies Act. To support their claim of privilege, Loyola submitted the affidavits of
       Dr. Cherry and Ms. Ostrowski. Dr. Cherry averred that he was very familiar with Loyola’s
       bylaws, rules, and polices. He explained that the MCEAC typically met once a week and was
       responsible for evaluating the quality of patient care with the goals of reducing morbidity and
       mortality and improving patient care. To carry out these responsibilities, the MCEAC directed
       and empowered one or more individuals to assemble information about an incident and the
       areas of specialty involved and to report that information back to the MCEAC for its use in
       evaluating and improving the quality of patient care.
¶ 18       Dr. Cherry stated that, as the chairperson of the MCEAC, he frequently, and within the
       scope of his authority and responsibilities, directed and empowered risk manager Ms.
       Ostrowski and other designees of the MCEAC to perform these duties. Typically, the risk
       manager or other MCEAC designee would contact Dr. Cherry to request this directive after
       learning about the occurrence of an event that could have potential for MCEAC review. Dr.
       Cherry then would determine whether an MCEAC investigation was warranted and give the
       directive if indicated. Dr. Cherry averred that this protocol was followed when Ms. Ostrowski
       contacted him about Miranda’s case, he determined that an investigation was warranted, and
       he then directed Ms. Ostrowski to assemble information for the MCEAC’s use. Ms.
       Ostrowski’s affidavit was consistent with Dr. Cherry’s affidavit.

                                                  -4-
¶ 19       The trial court upheld Loyola’s claim of privilege under the Medical Studies Act for the
       disputed 13 pages of documents. The trial court stated it had reviewed Loyola’s bylaws
       extensively and noted that section 2.1 of the medical staff bylaws specifically indicated that the
       chief medical officer of the hospital was permitted to begin an investigation. At the time of the
       incident at issue here, Dr. Cherry was the chief medical officer of Loyola and the chairperson
       of Loyola’s MCEAC, in addition to other positions he held at Loyola.
¶ 20       The jury trial commenced with opening statements on October 8, 2014, and closing
       argument concluded on November 3, 2014. During the course of the trial, the jury heard
       testimony from multiple experts from both sides, as well as testimony from the nurses and
       doctors who had provided care to Miranda.
¶ 21       The Eids’ experts testified that the standard of care required the doctors to surgically
       reexplore Miranda to stop or prevent internal bleeding or cardiac tamponade, perform a
       pericardiocentesis to remove excess fluid from Miranda’s chest, perform a portable chest
       X-ray to ensure the endotracheal tube remained in the correct place, and have an ECMO
       machine readily available. The Eids medical negligence claim focused primarily on the blood
       samples taken at 9:30 p.m. The Eids’ experts testified that the blood samples indicated
       Miranda was bleeding internally and therefore surgery should have been performed to stop the
       bleeding. For example, Dr. Cooper, the Eids’ pediatric cardiology expert, opined that Miranda
       died from an internal clot and that the images taken did not rule out an internal bleed. Dr.
       Harvey Klein, the Eids’ hematology expert, testified that Miranda likely bled to death.
       However, Dr. Cooper acknowledged there was no documented evidence of a clot or bleeding
       around Miranda’s heart, and Dr. Klein offered no opinion to explain why no blood was seen on
       the echocardiogram. Furthermore, Dr. Cynthia Rigsby, the Eids’ pediatric radiology expert,
       testified that echocardiography (which Loyola’s doctors did use in this case) was the imaging
       “gold standard” to look for fluid around the heart.
¶ 22       Loyola’s expert Dr. Ronald Bronicki, a pediatric intensive care specialist, testified the
       treatment rendered to Miranda was appropriate under the circumstances because there was no
       evidence of excess fluid in her chest or proof of cardiac tamponade and, consequently, the
       other measures suggested by the Eids’ experts would not have helped. Dr. Jonathon Berlin,
       Loyola’s expert in diagnostic radiology, testified there was no evidence of fluid in the chest
       X-ray, and if there was a significant amount of blood or fluid in Miranda’s chest, it would have
       shown up on the X-ray. Dr. Leonard Valentino, Loyola’s expert in pediatric hematology,
       opined there was no evidence in this case of cardiac tamponade because none of the imaging
       indicated any fluid around the heart, and there were no changes in vital signs that indicated
       pericardial tamponade. He also opined that the tested blood samples were not accurate and
       were likely diluted by intravenous fluids given to Miranda.
¶ 23       Concerning Mrs. Eid’s claim of reckless infliction of emotional distress, the testimony of
       her psychologists and psychiatrist indicated she suffered from post-traumatic stress disorder
       and major depression as a result of Miranda’s death and the incident at the funeral home.
       Furthermore, nurse Audrey Berman testified as the Eids’ nursing expert regarding nurse
       Ghera’s actions that resulted in Miranda’s body being released to the funeral home with some
       medical tubes still in place. On cross-examination, nurse Berman acknowledged that it would
       have been inappropriate to remove the tubes if there was some uncertainty about the possibility
       of an autopsy. She also stated that it would have been inappropriate for nurse Ghera to remove
       the tubes after her supervisor had instructed her not to remove all the tubes. Nurse Ghera

                                                   -5-
       testified that her supervisor had some uncertainty about whether an autopsy ultimately would
       be performed at another institution. Nurse Ghera further testified that Loyola’s policy required
       the tubes to remain in place until the issue of whether an autopsy would be conducted had been
       decided.
¶ 24       The jury returned a verdict in favor of Loyola on both the medical negligence and reckless
       infliction of emotional distress claims. The trial court entered judgment on the jury’s verdict
       and denied the Eids’ posttrial motion, and the Eids appealed.

¶ 25                                            II. ANALYSIS
¶ 26                                    A. Medical Negligence Claim
¶ 27        The Eids argue a new trial is warranted because the jury’s verdict for Loyola on the Eids’
       medical negligence claim was against the manifest weight of the evidence. The Eids contend
       all the credible evidence concerning the treatment rendered by Loyola’s physicians and staff
       supported only a verdict that they violated the standard of care. Specifically, the Eids argue that
       the three blood tests done after 9:30 p.m. were clear and obvious evidence of internal bleeding
       and indicated that reexploratory surgery should have been conducted.
¶ 28        A reviewing court will reverse a jury verdict only if it is against the manifest weight of the
       evidence. Snelson v. Kamm, 204 Ill. 2d 1, 35 (2003). A verdict is against the manifest weight of
       the evidence where the opposite conclusion is clearly evident or where the findings of the jury
       are unreasonable, arbitrary, and not based upon any of the evidence. Id. It is well established
       that the reviewing court may not simply reweigh the evidence and substitute its judgment for
       that of the jury. Id. Furthermore, the weight to be assigned to an expert opinion is for the jury to
       determine in light of the expert’s credentials and the factual basis of his opinion. Wiegman v.
       Hitch-Inn Post of Libertyville, Inc., 308 Ill. App. 3d 789, 799 (1999).
¶ 29        Loyola presented the testimony of the treating physicians to establish the course of action
       they took when Miranda displayed signs of decline. Loyola also presented the testimony of
       three experts, and Dr. Bronicki opined that the treatment rendered by the physicians was
       appropriate under the circumstances. Echocardiography was considered the “gold standard”
       for determining whether there was fluid around the heart, and none of the doctors who
       reviewed the echocardiogram saw any signs of fluid that could cause cardiac tamponade.
       Further, the chest X-ray showed no evidence of fluid that would cause cardiac tamponade or
       indicate internal bleeding. Based on both of those imaging technologies, Loyola’s physicians
       decided not risk either reexploration, which Miranda might not have been able to tolerate, or a
       pericardiocentesis, which potentially could have punctured her heart. Our review of the record
       establishes that Loyola presented more than enough evidence to establish that a verdict in its
       favor would be a reasonable conclusion.
¶ 30        In Snelson, our supreme court affirmed the appellate court’s refusal to overturn a jury
       verdict in a medical negligence claim where there had been opposing testimony among the
       experts. Snelson, 204 Ill. 2d at 36. To support its decision, the supreme court cited the “aptly
       stated” reasoning of the appellate court:
                    “ ‘This case involved a classic battle of the experts. Witnesses qualified in their
                fields stated their opinions and gave their reasons for those opinions. Not surprisingly,
                the plaintiff’s experts did not agree with the defense experts. The jury needed to listen



                                                    -6-
              to the conflicting evidence and use its best judgment to determine where the truth could
              be found.’ ” Id. (quoting Snelson v. Kamm, 319 Ill. App. 3d 116, 145 (2001)).
¶ 31       Similar to Snelson, this appeal involved a jury trial where each side presented expert
       testimony, witnesses, and evidence to support their cases. The jury heard the expert testimony
       from both sides and ultimately decided Loyola was not negligent. We have reviewed the record
       and find that the jury’s verdict is supported by evidence presented at the trial. Accordingly, we
       decline the Eids’ invitation to “usurp the function of the jury and substitute its judgment on
       questions of fact fairly submitted, tried, and determined from the evidence.” Maple v.
       Gustafson, 151 Ill. 2d 445, 452 (1992). We conclude that the jury’s verdict in favor of Loyola
       on the medical negligence claim was not against the manifest weight of the evidence.

¶ 32                            B. Reckless Infliction of Emotional Distress
¶ 33       The Eids argue that a new trial is warranted because the jury’s verdict for Loyola on their
       reckless infliction of emotional distress claim was against the manifest weight of the evidence.
       The Eids argue that Mrs. Eid suffered severe emotional distress when she witnessed the
       removal of medical tubes from Miranda’s body at the funeral home, and this distress occurred
       because nurse Ghera recklessly, and contrary to Loyola’s protocol, left medical tubes in
       Miranda’s body after it had clearly been determined that neither a medical examiner autopsy
       nor a private autopsy would be performed.
¶ 34       For Loyola to be liable for reckless infliction of emotional distress, the Eids had the burden
       to prove that (1) Loyola’s conduct was extreme and outrageous, (2) Loyola knew that there
       was a high probability that its conduct would cause severe emotional distress, and (3) Loyola’s
       conduct in fact caused severe emotional distress. Doe v. Calumet City, 161 Ill. 2d 374, 392
       (1994). Our review of the record establishes that a jury finding in favor of Loyola on either or
       both of the first two elements was not unreasonable, arbitrary, or contrary to the evidence.
¶ 35       Contrary to the Eids’ assertion on appeal, we cannot conclude that it was clearly evident
       that any miscommunication between or among Loyola’s nurses and the Eids concerning the
       removal of the tubes constituted extreme and outrageous conduct. Nurse Ghera testified that
       although Mrs. Eid told her they declined the option of a private autopsy, the supervising nurse
       instructed nurse Ghera to leave the tubes in place because there was still some uncertainty
       regarding whether an autopsy would be conducted at another institution. Although nurse Ghera
       acknowledged that she eventually learned the medical examiner had waived the autopsy, she
       could not remember when she learned that information. Even the Eids’ nursing expert
       acknowledged that it would have been improper for the nurses to remove the medical tubes if
       there was some uncertainty about the possibility of an autopsy. Loyola presented evidence that
       nurse Ghera followed her supervisor’s orders and reasonably believed the orders had a
       legitimate purpose. A jury reasonably could have concluded that the nurses did not engage in
       extreme or outrageous conduct when they exercised caution and left the tubes in place due to
       confusion or uncertainty about the possibility of an autopsy.
¶ 36       Furthermore, there was evidence to support a jury’s determination that Loyola’s nurses did
       not know there was a high probability that their conduct would cause severe emotional distress.
       The Eids were escorted to Miranda’s room shortly after her death and before her body was
       washed and wrapped in blankets. The tubes in Miranda’s body were apparent at that time, and
       Mrs. Eid asked the doctor and nurse Ghera to remove the tubes. Nevertheless, there was no
       evidence indicating that the condition of Miranda’s body in the hospital caused Mrs. Eid severe

                                                   -7-
       emotional distress. Furthermore, there was no evidence showing the nurses were familiar with
       the ritual washing tradition, knew the staff of the funeral home would not tend to the body prior
       to the ritual washing, or knew Mrs. Eid would watch as the ritual washers removed Miranda’s
       unembalmed body from the body bag and removed medical tubes. Accordingly, a jury
       reasonably could determine that the nurses did not know there was a high probability that
       leaving the tubes in place would cause Mrs. Eid severe emotional distress.
¶ 37       The jury heard the testimony of the Eids’ nursing expert and the testimony of nurses Ghera
       and Maturin regarding the uncertainty about the possibility of an autopsy. The issues of fact
       concerning the reckless infliction of emotional distress claim were fairly submitted, tried, and
       determined by the jury, and our review of the record shows that the jury’s verdict in favor of
       Loyola was not against the manifest weight of the evidence.

¶ 38                                     C. The Medical Studies Act
¶ 39       Next, the Eids argue the trial court erred by finding that the privilege pursuant to section
       8-2101 of the Medical Studies Act (Act) (735 ILCS 5/8-2101 (West 2012)) applied to 13 pages
       of documents created by Ms. Ostrowski. Loyola responds that the privilege applies because the
       plain language of the Act provides that the privilege covers all information of peer review
       committees or their designees, except the patient’s medical records, used in the course of
       internal quality control to reduce morbidity or mortality, or to improve patient care. Loyola
       argues that its bylaws authorized Dr. Cherry to start the investigation on behalf of the MCEAC
       and instruct Ms. Ostrowski, a member of the MCEAC, to gather information concerning
       Miranda’s treatment from a quality control perspective for the use of the MCEAC as part of its
       peer review process. Based on our review of the plain language and purpose of the Act and the
       relevant case law, we affirm the trial court’s ruling that the Act’s privilege covered the
       disputed documents.
¶ 40       In this appeal, different standards of review apply to the two questions before this court on
       this issue. The legal determination of whether the privilege under the Act applies to
       information generated by designees of a peer review committee is a question of law, which we
       review de novo. See Niven v. Siqueira, 109 Ill. 2d 357, 368 (1985). However, we review under
       the manifest weight of the evidence standard the trial court’s factual determination that the
       specific communications at issue here—i.e., the information Ms. Ostrowski generated after Dr.
       Cherry determined that an investigation was warranted and directed her to begin the
       investigation on behalf of the peer review committee—were part of a peer review study
       covered by the Act. See id. The burden of establishing the applicability of an evidentiary
       privilege rests with the party who seeks to invoke it. Roach v. Springfield Clinic, 157 Ill. 2d 29,
       41 (1993).
¶ 41       Initially, we consider de novo whether the Act applies to information generated by a
       designee of the peer review committee for the use of the peer review committee in the course
       of internal quality control. In answering this question, we are guided by the rules of statutory
       construction. The primary goal of statutory construction is to ascertain and give effect to the
       intent of the legislature, and the most reliable indication of the legislature’s intent is the plain
       language of the statute. Metzger v. DaRosa, 209 Ill. 2d 30, 34-35 (2004). When the statute’s
       language is clear, it will be given effect without resort to other aids of statutory construction.
       Id. at 35. This court will not depart from the plain language of a statute by reading into it


                                                    -8-
       exceptions, limitations, or conditions that conflict with the express legislative intent. Petersen
       v. Wallach, 198 Ill. 2d 439, 446 (2002).
¶ 42       The Act provides, in pertinent part:
               “All information, interviews, reports, statements, memoranda, recommendations,
               letters of reference or other third party confidential assessments of a health care
               practitioner’s professional competence, or other data of *** committees of licensed or
               accredited hospitals or their medical staffs, including Patient Care Audit Committees,
               Medical Care Evaluation Committees, Utilization Review Committees, Credential
               Committees and Executive Committees, or their designees ***, used in the course of
               internal quality control or of medical study for the purpose of reducing morbidity or
               mortality, or for improving patient care *** shall be privileged, strictly confidential
               and shall be used only for *** the evaluation and improvement of quality care ***.”
               (Emphases added.) 735 ILCS 5/8-2101 (West 2012).
       The Act further provides that such privileged material “shall not be admissible as evidence ***
       in any court or before any tribunal, board, agency or person.” 735 ILCS 5/8-2102 (West 2012).
¶ 43       In 1995, the legislature amended the Act to add the phrase “or their designees” to modify
       the entities, including peer review committees, that could create or generate information
       protected by the Act’s privilege. Pub. Act 89-393, § 15 (eff. Aug. 20, 1995). A correct
       grammatical reading of the plain language of the statute indicates the legislature intended to
       include within its scope information generated by a designee of the peer review committee for
       that committee’s use in the course of internal quality control. See Merriam-Webster’s
       Collegiate Dictionary 313 (10th ed. 1998) (defining designee as “one who is designated,” and
       designate as “to indicate and set apart for a specific purpose, office, or duty”). As such, the
       information generated by the investigation—commenced by Dr. Cherry’s directive, on behalf
       of the MCEAC, to Ms. Ostrowski to gather information on the incident from an internal quality
       control perspective—may fall within the scope of the Act if Loyola met its burden to establish
       that Dr. Cherry and Ms. Ostrowski properly constituted designees of the MCEAC.
¶ 44       Accordingly, the next question before us is whether the trial judge’s finding that Dr. Cherry
       and Ms. Ostrowski were designees under the Act was against the manifest weight of the
       evidence. This court has held that the Act protects against disclosure of the mechanisms of the
       peer review process, including information gathering and deliberations leading to the ultimate
       decision rendered by a peer review committee, but does not protect against the discovery of
       information generated before the peer review process begins or information generated after the
       peer review process ends. See Roach, 157 Ill. 2d at 40 (where the committee involved consists
       of members of a hospital’s medical staff, the committee must be engaged in the peer review
       process before the statutory privilege is applicable); Grandi v. Shah, 261 Ill. App. 3d 551, 557
       (1994) (the Act’s privilege did not apply to the conversations of the hospital administrator with
       the treating physician and treating nurse to investigate a patient’s complaint because, even if
       those conversations were part of the hospital’s internal review process, the evidence failed to
       establish that the administrator was acting on behalf of any peer review committee when he
       spoke with the treating physician and nurse).
¶ 45       The purpose of the Act “is to ensure that members of the medical profession will
       effectively engage in self-evaluation of their peers in the interest of advancing the quality of
       health care.” Roach, 157 Ill. 2d at 40. The Act was never intended to shield hospitals from
       potential liability. Id. at 42 The Act does not protect any information of a hospital’s medical

                                                   -9-
       staff that is used for the purposes of peer review; rather, the Act protects the information of the
       peer review committees or their designees. See id. at 39; 735 ILCS 5/8-2101 (West 2012). The
       simple act of furnishing a peer review committee with earlier-acquired information is not
       sufficient to cloak that information with the statutory privilege, otherwise a hospital would be
       able to effectively insulate from disclosure virtually all adverse facts known to its medical
       staff, except for those matters actually contained in the patient’s medical records. Roach, 157
       Ill. 2d at 41-42. Consistent with the Act’s purpose to reduce hospital morbidity and mortality
       and improve patient care, a designee of a peer review committee who is authorized to gather
       information for the committee’s use can act expeditiously, while the matter is still fresh in the
       minds of the participants, without waiting for the whole committee to convene to formally
       declare the start of an investigation.
¶ 46        In Roach, the plaintiffs alleged, inter alia, that the hospital negligently delayed providing
       adequate anesthesia to the expectant mother for her emergency cesarean section. The hospital
       argued that certain statements concerning the delay between the treating nurse anesthetist, the
       hospital’s chief of anesthesiology (chief), and a nursing supervisor in the obstetrics department
       were privileged under the Act. Id. at 36-38. Specifically, the chief spoke with the obstetrics
       nursing supervisor a few times in the 7 to 10 day period after the incident, and then the chief
       momentarily stopped the treating nurse anesthetist in the hallway and remarked that the delay
       occurred because new secretaries did not know the proper way to page the anesthesia team. Id.
¶ 47        There was no dispute that the chief’s discussions with the obstetrics nursing supervisor
       “had nothing to do with any physician peer-review committee,” and the court found that the
       chief’s remarks to the treating anesthetist, which occurred before the monthly meeting that
       apprised the department of the incident, “were not ‘information of’ any committee,
       peer-review or otherwise.” (Emphasis omitted.) Id. at 40. The court explained that the
       information the chief obtained from his conversations with the obstetrics nursing supervisor
       “was not transformed into ‘information of’ the anesthesiology department merely because [the
       chief] reported the incident to that body sometime later.” Id. at 41. The court also rejected the
       notion that the chief’s “investigation was tantamount to an investigation by ‘a committee,’
       itself.” Id. at 42. Specifically, the court noted that the hospital’s bylaws contained no provision
       conferring on someone in the chief’s position, or any individual, the authority to act for the
       department in conducting interviews or investigations preliminary to the review process. Id. at
       43.
¶ 48        After Roach was issued in 1993, the legislature amended the Act to add the phrase “or their
       designees” to modify the entities, including peer review committees, that could create or
       generate information protected by the Act’s privilege. Pub. Act 89-393, § 15 (eff. Aug. 20,
       1995). This amendment has somewhat qualified Roach’s discussion about the type of
       information that may constitute “information of” a peer review committee because, since
       August 1995, the plain language of the statute provides that the Act’s privilege applies to
       information generated by a designee of a peer review committee for the use of the peer review
       committee in matters concerning morbidity, mortality, and the improvement of patient care.
¶ 49        The Eids cite Roach and several post-1995 appellate court cases that followed Roach to
       support the proposition that the Act’s privilege does not apply to information generated before
       the peer review committee, acting as a whole, either became aware of the incident at issue or
       was already engaged in the peer review process. However, the Eids’ reliance on those cases is
       misplaced, because the statute was amended after Roach was issued, and the cases citing

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       Roach for that proposition either failed to acknowledge and analyze the 1995 amendment that
       added the “or their designees” phrase to the statute or did not address a situation involving an
       individual authorized to act on behalf of a peer review committee. See, e.g., Chicago Trust Co.
       v. Cook County Hospital, 298 Ill. App. 3d 396, 402-04 (1998) (no analysis of the 1995
       amendment when addressing the 1996 version of the statute); Pietro v. Marriott Senior Living
       Services, Inc., 348 Ill. App. 3d 541, 550 (2004) (documents containing the statements of an
       assisted living facility’s nurses and staff, which were prepared in conjunction with the peer
       review committee’s proceeding, were not privileged under the Act because there was no
       evidence the committee requested the statements); Anderson v. Rush-Copley Medical Center,
       Inc., 385 Ill. App. 3d 167, 175-76 (2008) (medical journal articles that were not written by or
       for the peer review committee were privileged under the Act because the committee requested
       the articles, which were used as a resource in conducting its review); Kopolovic v. Shah, 2012
       IL App (2d) 110383, ¶ 28 (no acknowledgment or analysis of the 1995 amendment to support
       the determination that an anesthesiologist’s memorandum to the board of directors of a day
       surgery center was not privileged under the Act because there was no evidence the board,
       acting as a whole, knew of the incident or was already engaged in the peer review process).
¶ 50       The Eids also argue on appeal that the trial court erroneously construed the language of the
       bylaws and those bylaws did not authorize an individual in Dr. Cherry’s position to commence
       an investigation on behalf of the MCEAC. According to the transcript of the May 2014 hearing
       on Loyola’s claim of privilege, the trial court stated that it had reviewed the policies and
       bylaws provided by Loyola “extensively over the weekend” and found that section 2.1 of the
       bylaws specifically authorized the chief medical officer of the hospital, which position Dr.
       Cherry held at the time of the incident in question, to begin a peer review investigation.
¶ 51       The Eids have failed to include in the record on appeal a copy of Loyola’s bylaws. In order
       to support a claim of error on appeal, the appellant has the burden to present a sufficiently
       complete record. Foutch v. O’Bryant, 99 Ill. 2d 389, 391-92 (1984). Where the record lacks
       information of evidence presented at a hearing, it is presumed that the court heard adequate
       evidence to support the decision that was rendered unless the record indicates otherwise.
       Skaggs v. Junis, 28 Ill. 2d 199, 201-02 (1963). Accordingly, based on the record before us, we
       presume that section 2.1 of Loyola’s bylaws authorized Dr. Cherry to commence an
       investigation on behalf of the MCEAC and direct a designee of the committee to assemble
       information for the committee’s review.
¶ 52       The Eids also argue the 13 pages of disputed documents generated by Ms. Ostrowski were
       not used by the MCEAC as part of its peer review process. We disagree. The Act protects “the
       nature and content of an internal review process.” Zajac v. St. Mary of Nazareth Hospital
       Center, 212 Ill. App. 3d 779, 788 (1991). Here, the affidavits of Dr. Cherry and Ms. Ostrowski
       established that she reported to Dr. Cherry the information gathered during her investigation as
       a designee of the MCEAC, she also reported that information to another member of the
       MCEAC, and Dr. Cherry recalled that the matter was presented to the full MCEAC. Thus, the
       information generated by Ms. Ostrowski at Dr. Cherry’s directive pursuant to his authority
       under the bylaws as a designee of the MCEAC contributed to the MCEAC’s deliberations in
       that they were obtained as part of the information-gathering process and were considered prior
       to the conclusion of the MCEAC’s review. Any disclosure of those 13 disputed pages would
       have improperly revealed the MCEAC’s internal review process. See Anderson, 385 Ill. App.
       3d at 176 (medical journal articles requested by and submitted to the peer review committee for


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       its use during its deliberations were privileged under the Act, and the disclosure of these
       articles improperly revealed the committee’s internal review process).
¶ 53        The affidavits of Dr. Cherry and Ms. Ostrowski established that Loyola’s MCEAC was a
       peer review committee covered by the Act. Moreover, after Ms. Ostrowski informed Dr.
       Cherry that Miranda’s case might warrant peer review proceedings, Dr. Cherry, at 10:51 a.m.,
       utilized his authority to commence the MCEAC’s investigation and directed Ms. Ostrowski as
       the MCEAC’s designee to gather information from an internal quality control perspective for
       the use of the MCEAC. Loyola already produced the documents Ms. Ostrowski created prior
       to Dr. Cherry’s 10:51 a.m. directive to conduct the MCEAC investigation; Loyola asserted the
       Act’s privilege applied only to the documents generated by Ms. Ostrowski after she obtained
       Dr. Cherry’s directive on behalf of the committee. Consequently, we conclude the trial court’s
       determination that the 13 pages of documents were privileged under the Act was not against
       the manifest weight of the evidence.

¶ 54                                          D. Jury Instructions
¶ 55        The Eids argue the trial court abused its discretion when it gave the jury an instruction,
       which was submitted by Loyola and objected to by the Eids, concerning the definition of
       extreme and outrageous conduct. Specifically, the Eids contend Loyola’s instruction was
       unnecessary and distorted the elements of the reckless infliction of emotion distress tort by (1)
       turning the permissive factors concerning the intensity and duration of the alleged emotional
       distress into controlling factors in the determination of whether the emotional distress was
       severe, (2) making the determination of whether the conduct was extreme and outrageous
       dependent on the determination of whether the conduct caused severe emotional distress, (3)
       including the concept of unendurability to define severe emotional distress, and (4) restricting
       the jurors from exercising common sense to determine whether defendant’s conduct was
       outrageous.
¶ 56        Generally, a trial court’s decision to grant or deny an instruction is reviewed for an abuse of
       discretion, which considers whether, taken as a whole, the instructions fairly and correctly
       stated the law and were sufficiently clear so as not to mislead. Dillon v. Evanston Hospital, 199
       Ill. 2d 483, 505 (2002). However, when the question is whether the applicable law was
       conveyed accurately, the issue is a question of law, and our standard of review is de novo. Studt
       v. Sherman Health Systems, 2011 IL 108182, ¶ 13. We review the Eids’ assertion that the
       disputed instruction was unnecessary for an abuse of discretion and review their challenge to
       the applicable law conveyed by the instruction de novo.
¶ 57        Supreme Court Rule 239(a) requires that “[w]henever Illinois Pattern Jury Instructions
       (IPI) contains an instruction applicable in a civil case, giving due consideration to the facts and
       the prevailing law, and the court determines that the jury should be instructed on the subject,
       the IPI instruction shall be used, unless the court determines that it does not accurately state the
       law.” Ill. S. Ct. R. 239(a) (eff. Jan. 1, 1999). A non-IPI instruction may be used if the court
       determines that the pattern instruction does not accurately state the law. Ill. S. Ct. R. 239(b)
       (eff. Jan. 1, 1999). In a situation where our pattern instructions are inadequate and additional
       instruction is appropriate, a non-IPI instruction is permissible if it is simple, brief, impartial,
       and nonargumentative. Dillon, 199 Ill. 2d at 505. “Where a unique factual situation, or a point
       of law, is presented, a nonpattern instruction may be given if it is accurate and will have no
       improper effect on the jury.” Id. at 505-06.

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¶ 58       Here, there was no civil IPI instruction defining the tort of reckless infliction of emotional
       distress. The trial court gave the following non-IPI instruction submitted by Loyola:
                   “Under the reckless infliction of emotional distress claim, extreme and outrageous
               conduct means conduct that is so outrageous in character, and so extreme in degree, as
               to go beyond all possible bounds of decency in a civilized community, and is such that
               the intensity and duration of the distress inflicted is so severe that no reasonable person
               of ordinary sensibilities could be expected to endure it.”
¶ 59       The language in this instruction was taken from our supreme court’s opinion in McGrath v.
       Fahey, 126 Ill. 2d 78, 86 (1988) (citing Restatement (Second) of Torts § 46 cmt. j, at 77-78
       (1965)). We hold that the trial court did not err by giving the jury this instruction, which was an
       accurate statement of Illinois law, had no improper effect on the jury and was neither
       misleading nor confusing.

¶ 60                                          E. Closing Argument
¶ 61       Finally, the Eids argue Loyola made improper comments during closing argument that
       confused the jury, and the additional instructions the trial court gave the jury did not cure the
       alleged confusion. Specifically, the Eids argue that Loyola’s counsel blamed unidentified
       hospital employees for failing to remove the tubes from Miranda’s body before it was released
       to the funeral home, and this argument violated the trial court’s ruling prohibiting any
       arguments attributing liability to unidentified Loyola employees.
¶ 62       “Attorneys are afforded wide latitude during closing argument and may comment and
       argue on the evidence and any inference that may be fairly drawn from that evidence.” Zickuhr
       v. Ericsson, Inc., 2011 IL App (1st) 103430, ¶ 72. A new trial based on improper closing
       argument is allowed only when the comments resulted in substantial prejudice to the opposing
       party; generally, however, the court sufficiently cures any prejudice when it sustains a timely
       objection and instructs the jury to disregard the improper comment. Id. ¶ 75.
¶ 63       According to the record, the trial court directed Loyola’s counsel to refrain from arguing
       that anyone at Loyola other than nurses Ghera and Maturin acted recklessly by leaving the
       tubes in place. If Loyola failed to abide by this ruling, then the trial court would give the jury
       two instructions submitted by the Eids concerning causation. Specifically, the trial court would
       instruct the jury that (1) the right to decide whether or not to have a private autopsy of Miranda
       belonged solely to Mr. and Mrs. Eid, and if the jury found the Eids informed Loyola that they
       declined the right to request a private autopsy, then it was no defense that any official or
       department of Loyola or any other person might have wanted any medical tubes or equipment
       to be left in Miranda’s body for purposes of a private autopsy and (2) the right to decide
       whether or not to have a medical examiner’s autopsy belonged solely to the office of the
       medical examiner, and if the jury found that the office of the medical examiner informed
       Loyola that it declined to perform that autopsy, then it was no defense that any official or
       department of Loyola or any other person might have wanted any medical tubes or equipment
       to be left in Miranda’s body for purposes of a medical examiner’s autopsy.
¶ 64       During Loyola’s closing argument, counsel stated that it was an unfortunate mistake that
       Miranda’s body was released from Loyola with the tubes in place, but the nurses neither
       believed the autopsy matter was resolved by the time they went off duty nor anticipated that
       Mrs. Eid would see Miranda’s body with the tubes in place. Further, although counsel did not
       blame the ritual washers, Loyola’s people had no involvement in the chain of events that

                                                   - 13 -
       occurred at the funeral home. Although counsel had no answers for the jury about what
       happened after the nurses went off duty, their efforts did not successfully ensure that the tubes
       would be removed before Miranda’s body was released to the funeral home, so the jury was
       asked to evaluate the conduct only of the nurses and “nobody else’s [conduct] at Loyola.”
¶ 65       Although the trial court overruled the Eids’ objection, the court admonished Loyola’s
       counsel for stating that the people at the funeral home should have done something, asked what
       difference it would have made, and stated that it was not proximate cause. The trial court gave
       the jury the two instructions submitted by the Eids, and their counsel discussed those
       instructions during his rebuttal argument.
¶ 66       Assuming, arguendo, that Loyola’s argument improperly suggested that someone else at
       Loyola other than nurses Ghera and Maturin should have done something to prevent the
       release of Miranda’s body to the funeral home with the tubes still in place, the Eids’ argument
       concerning jury confusion lacks merit. The two additional instructions the trial court gave the
       jury and the rebuttal argument of the Eids’ counsel clarified that Loyola could not claim that
       some potential request for an autopsy was a defense for the nurses’ conduct of leaving the
       tubes in Miranda’s body, if the jury found from its consideration of all the evidence that the
       medical examiner and the Eids had made it known to Loyola that they declined their rights to
       request an autopsy. Based on our review of both attorneys’ entire closing arguments and all the
       jury instructions, we conclude the Eids did not suffer substantial prejudice from the closing
       argument remark of Loyola’s counsel.

¶ 67                                         III. CONCLUSION
¶ 68        We conclude that the jury verdict in favor of Loyola on the claims of medical negligence
       and reckless infliction of emotional distress was not against the manifest weight of the
       evidence; the Act’s privilege applied to the information generated by Ms. Ostrowski after Dr.
       Cherry determined that an investigation by the MCEAC was warranted and directed her to
       investigate the incident on behalf of the MCEAC; the non-IPI jury instruction concerning the
       tort of reckless infliction of emotional distress was accurate, clear, and did not mislead the jury;
       and the Eids did not suffer substantial prejudice from remarks by Loyola’s counsel during
       closing argument. Accordingly, we affirm the judgment of the circuit court.

¶ 69      Affirmed.




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