On June 15, 2020, the Inside Medical Malpractice podcast released a three-episode series featuring an extended conversation between host Chris Rokosh and Paul. The series walks through three of Paul’s medical malpractice trials in turn, each episode dedicated to a single case. The three episodes together run a little over two and a half hours and cover the trial work, the medicine, and the courtroom craft on three different fact patterns.
Chris Rokosh is the founder of Connect MLX, the legal nurse consulting and medical-legal education service that hosts the Inside Medical Malpractice podcast. The podcast format is conversational and pitched at lawyers, healthcare providers, and patients who want to understand how medical malpractice cases are actually built and tried. The three Paul episodes are unusual in that they sit together as a sustained look at one plaintiff lawyer’s recent trial work, rather than offering single-episode snapshots of separate cases.
Episode 1: Hacopian-Armen Estate v Mahmoud
The first episode (48 minutes) covers a fatality case arising from the delayed diagnosis of uterine cancer. The patient, Ms. Hacopian-Armen, presented to the defendant gynecologist in 2009 with several risk factors for diseases of the uterus, including being over 40, experiencing abnormal uterine bleeding, and never having given birth. The gynecologist conducted a routine swab but did not perform an endometrial biopsy. Two years later, in 2011, an endometrial biopsy was performed and revealed Stage IV uterine leiomyosarcoma (uLMS), an aggressive cancer that originates in the muscular outer layer of the uterus. The patient died later that year. The action was brought by her family as an estate claim.
Paul’s theory at trial was straightforward. When a patient presents to a gynecologist with abnormal vaginal bleeding and risk factors for uterine pathology, an endometrial biopsy is the basic step a reasonably prudent gynecologist takes. The procedure is short, in-office, and produces tissue that can be examined for malignancy. Without the biopsy, a cancer like uLMS can sit undetected for years. By the time symptoms become severe enough to drive further investigation, the window for curative treatment may have closed.
The podcast was recorded after the trial but before the trial reasons were released. The trial decision, Hacopian-Armen Estate v Mahmoud, 2020 ONSC 4946, was released later that summer by Justice Carole J. Brown of the Superior Court of Justice, who found for the plaintiffs. The defendant’s appeal was dismissed by the Court of Appeal for Ontario in Hacopian-Armen Estate v Mahmoud, 2021 ONCA 545, which became a leading appellate decision on foreseeability and legal causation in medical negligence. The plaintiffs were represented by Christopher I.R. Morrison and Paul, both now of Davidson Cahill Morrison LLP.
Episode 2: O’Neill-Renouf v Ibrahim
The second episode (46 minutes) covers an obturator nerve injury that occurred during a transvaginal tape (TVT) procedure. The plaintiff was a relatively young woman who underwent what was meant to be a routine procedure for stress urinary incontinence. She awoke from anesthesia with symptoms in the territory of the obturator nerve, a nerve that lies outside the intended surgical field for a TVT procedure. The case proceeded to trial on the question of whether the injury was a recognized complication, as the defence argued, or the consequence of improper needle placement outside the surgical field, as the plaintiff argued.
What Paul calls in the podcast the “backwards perspective” was the central challenge of the case. The operative report was clean; the surgeon’s record described a procedure that had gone as it was supposed to. The plaintiff’s task was to demonstrate, working backwards from the nature and location of the injury, that something had in fact gone wrong despite what the record said. The court accepted the plaintiff’s theory. The decision is reported as O’Neill-Renouf v Ibrahim, 2019 ONSC 4369.
Paul returned to this case in detail in his May 2026 OTLA Spring Conference paper, “Liability Considerations in Surgical ‘Never Events’ or Recognized Complication Cases,” where the O’Neill-Renouf trial functions as the worked example of circumstantial proof succeeding in surgical negligence work. The OTLA paper traces the doctrinal architecture, the three factors that carried the case (immediate symptom onset, anatomical specificity, elimination of alternatives), and the relationship between the dissent the Supreme Court adopted in Armstrong v Ward and the kind of reasoning that succeeded in O’Neill-Renouf. The June 2020 podcast episode is the earlier, more conversational treatment.
Episode 3: Woods v Jackiewicz
The third episode (59 minutes) covers Paul’s $11.5 million jury verdict in Woods v Jackiewicz. The case arose from a 1991 twin pregnancy in which twin-to-twin transfusion syndrome (TTTS) developed and was not recognized in time. The pregnancy ended in an emergency Cesarean section at 27 weeks, and one of the twins, Kelsey Woods, sustained the severe brain injury that became cerebral palsy. The jury found three specific failures by the community obstetrician and entered a unanimous verdict on damages that had been agreed before trial at $11.5 million.
The podcast was recorded with the trial verdict in hand but the appeal not yet decided. The Court of Appeal for Ontario dismissed the defendant’s appeal a few weeks later in Woods v Jackiewicz Estate, 2020 ONCA 458, a unanimous decision. The Court held that the jury’s verdict was reasonable on the expert evidence at trial and that the defence’s contrary expert evidence was for the jury to weigh.
The substantive discussion in the third episode is about jury communication. The challenge in Woods was that the trial took place in 2019 on conduct from 1991, with all the difficulties of establishing the 1991 standard of care nearly three decades after the events. The medicine was technically demanding, the timeline was complicated, and the expert evidence was contested. Paul’s approach, as he describes it in the episode, was to distill the case to the elements the jury could see clearly: what the defendant did, what a reasonable obstetrician would have done, and what the difference would have meant for the family. The framing is something Paul has returned to in other settings (the LSO Motor Vehicle Litigation Summit, the OTLA conferences) but the Woods discussion is the most extended treatment of the approach in a single conversation.
Across the three episodes
Three things connect the conversations.
The first is the role of circumstantial proof in plaintiff-side medical malpractice work. O’Neill-Renouf succeeded because the nature and timing of the injury supported an inference of negligence that the operative record could not displace. Hacopian-Armen Estate turned on the inference, drawn backwards from the eventual Stage IV cancer, that the cancer had been there at the 2009 appointment and would have been detected by the biopsy that should have been done. Woods turned on the inference that, but for the failures the jury found, the pregnancy could have been carried longer with appropriate intervention and the brain injury avoided. The doctrinal architecture differs across the three cases, but the underlying technique of building cases on inference rather than direct evidence runs through all three.
The second is the relationship between the operative or contemporaneous record and what actually happened. In each of the three cases, the records produced by the treating physicians were clean. The plaintiff’s task was to demonstrate that the records, however neat, did not tell the whole story. The “backwards perspective” Paul describes in the O’Neill-Renouf episode is one expression of that work; the timeline reconstruction in Hacopian-Armen Estate and the SFH and ultrasound omissions in Woods are others.
The third is the importance of communicating complex medicine clearly. The cases involve gynecologic oncology, urogynecology, and maternal-fetal medicine respectively. The juries and judges who heard them had to understand the medicine well enough to follow the standard of care and causation analysis. The discipline of distillation, of taking complex medicine and presenting it in a form a non-medical decision-maker can follow, is something all three episodes return to.
Where to listen
The three episodes are available on Spotify:
- Episode 1: Hacopian v Mahmoud (48 minutes)
- Episode 2: O’Neill-Renouf v Ibrahim (46 minutes)
- Episode 3: Woods v Jackiewicz (59 minutes)
More information about Inside Medical Malpractice and the work of Connect MLX is available at connectmlx.com.
Context
At the time the episodes were recorded and released, Paul was a partner at Will Davidson LLP. The firm restructured later, and Paul is now a partner at Davidson Cahill Morrison LLP. Each of the three cases discussed has its own fuller treatment on this site or in conference papers Paul has subsequently published.
