## Facts

- Virginia Christine Waffen was treated as a patient at the National Institutes of Health (NIH), part of the United States Department of Health and Human Services (HHS).
- While under NIH care, Waffen underwent a chest x-ray.
- A radiologist issued a written report noting an apparent right upper-lobe density consistent with a possible mass lesion and recommending follow-up evaluation.
- NIH personnel misplaced the radiologist’s report so it was not placed in Waffen’s medical file and was not acted on by her treating providers.
- Approximately seven months later, Waffen obtained an x-ray at another hospital, and she was diagnosed with terminal cancer.
- Waffen sued the United States under the Federal Tort Claims Act (FTCA), alleging NIH’s negligent handling of the radiology report delayed diagnosis and treatment and reduced her chance of survival.
- After a bench trial, the district court found NIH was negligent but concluded Waffen failed to prove the delay was the proximate cause of her terminal condition and dismissed the action.
- Waffen appealed.

## Issues

1. Under the FTCA and the applicable state medical-malpractice causation standard, did Waffen prove by a preponderance of the evidence that NIH’s negligent failure to act on the radiologist’s recommendation proximately caused a compensable injury by substantially reducing her chance of survival?
2. Was the district court’s causation finding clearly erroneous on appellate review?

## Decision

- The Fourth Circuit affirmed the judgment for the United States.
- The court treated the effect of the delay on Waffen’s survival chance as a factual question resolved by the district court after weighing conflicting medical testimony.
- Because the record supported the district court’s finding that Waffen did not prove the delay substantially reduced her chance of survival, the finding was not clearly erroneous.
- Without proof of proximate cause, admitted negligence did not establish FTCA liability.

## Legal Principles

- The FTCA makes the United States liable in tort only to the extent a private person would be liable under the law of the place where the act or omission occurred.
- In medical-malpractice claims based on delayed diagnosis or treatment, a plaintiff must prove causation by a preponderance of the evidence; negligence alone is insufficient.
- Where the asserted injury is a reduced chance of survival, the plaintiff must prove the delay caused a substantial reduction in that chance, not merely that a delay occurred.
- In a bench trial, an appellate court reviews factual findings (including medical causation findings based on competing testimony) for clear error and will not reweigh credibility where the district court’s view of the evidence is plausible.

## Conclusion

In *Waffen*, the Fourth Circuit upheld dismissal of an FTCA malpractice claim arising from NIH’s admitted mishandling of a radiologist’s report recommending follow-up for a suspected lung mass. The court affirmed because the district court’s finding—Waffen did not prove the seven-month delay proximately caused her terminal condition by substantially reducing her chance of survival—was supported by the record and therefore was not clearly erroneous.


Waffen v. United States Department of Health & Human Services, 799 F.2d 911 (1986)