IV Case in Point
Illustrated Verdict shares case examples from our archives to show how a visual strategy can support the defense effort. We hope that it is of value in your practice as you develop your defense strategies on behalf of health care providers. Please feel free to forward it to colleagues or clients.

About Us
IV is a leading provider of demonstrative evidence for the defense of medical malpractice claims. Our team of medical illustrators consults with defense teams to educate the lay jury audience about the complexities of medical care. We do this by developing a visual strategy with expert witnesses including high-quality case-specific medical illustrations, x-ray enhancements, and multimedia presentations. IV receives judgment for the defense in over 94% of the cases we participate in, as compared to the national average of 73%. Additionally, insurers who supply us with their trial list enjoy a win rate of up to 97%.
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Case In Point Library
Click to view other editions:

Case In Point Library Page

Pregnancy and Delivery:
Fetal Assessment 2009v1
Shoulder Dystocia 2009v3
MVA Leads to Fetal Demise 2010v4
Fetal Descent Stalled 2010v5
Shoulder Dystocia / Erb's 2011v4
Fetal Tracings / Hypoxic Injury? 2013v1

Coronary Artery Disease 2009v5
CAD / Recurrent MI 2010v1
Aortic Valve Replacement 2011v1

Stroke After Lung Surgery 2009v2
PE / Infection 2010v3
PE Following Roux En Y 2012v1
Intubation / Macklin Effect 2012v4
Lung Cancer vs. Infection 2015v3

Female Pelvis:
Hysterectomy / Fistula 2011v9
Hysterectomy / Ureter Injury 2010v2
Hysterectomy / Kinked Ureter 2010v8
Diag Lap / Bowel Injury 2012v3
Cervical Cancer 2013v3
Endometrial Cancer 2014v1

Male Pelvis:
Bladder Cancer 2013v2

Digestive System:
Gastric Bypass 2009v6
Recurrent Hiatal Hernia 2009v8
Right Colectomy / Leak 2010v7
Gastric Bypass / Volvulus 2011v2
Nissen Fundoplication 2011v3
Large Hiatal Hernia 2013v5
Necrotizing Enterocolitis 2013v7
Arrest during ERCP 2015v4
Diverticulitis Complications 2015v5

Spleen Injury and Bleed 2009v4
Bleed Following Lithotripsy 2012v2
Lap Cholecystectomy 2012v5
Bowel Injury Lap Ovarian Cyst Removal 2013v6
LapChole - Hepatic Duct Injury2015v1

Partial Hip Replacement 2010v6

tPA Infusion 2009v7
Vertebral A. Coil Embolization 2015v7

Head and Neck:
Bell's Palsy 2013v4
Tongue Cancer 2014v2
Chiari I - Vision Loss 2015v2

Judgment for the Defense
Delay in Diagnosis of Bladder Cancer


Plaintiff presented to the defendant in October 2001 with complaints of a lengthy history of urinary urgency, frequency, urge incontinence, and urinary stress incontinence. He was seen by a urologist and a neurologist in early November 2001. Later in November, the defendant performed a flexible cystoscopy and found that the plaintiff was negative for bladder tumors. His diagnosis was partially due to neurogenic bladder (lack of bladder control due to nerve condition). The plaintiff was then referred to a neurosurgeon and it was discovered during an MRI in December 2001 that he had a tethered spinal cord, which he underwent surgery to correct.

In February 2002, there were reports of improvement in urinating. The plaintiff then failed to follow up three months later. In 2003, the plaintiff presented to a different physician with complaints that the medication he was using was not effective. That physician adjusted the medication, and later that year, performed an office cystoscopy and found a sessile appearing lesion on the right posterior wall of the bladder. The plaintiff underwent a more thorough cystoscopy and a transurethral resection of his bladder tumor. The pathology report revealed high-grade carcinoma with invasion of the muscular bladder wall. At that point, he had a radical cystectomy with creation of an ileal conduit. The pathology from this cystectomy reported invasive transitional cell carcinoma. There was lymphatic vessel invasion of the tumor. He unfortunately passed in September 2005 at the age of 56.



The plaintiff claimed that there was a delay in diagnosis of bladder cancer. The plaintiff's family believed that if urine cytologies (tests to look for abnormal cells in urine) and more thorough cystoscopies were performed at any point between 2001 and 2003, that the cancer would have been detected at an earlier stage. They also thought that the defendant should have recognized the patient's higher risk for bladder cancer due to his history of smoking, continuous elevated post-void residuals (amount of urine left in bladder after urination), presentation of persistent hematuria (blood in urine), and persistent WBCs in urine despite negative urine cultures.


The treatment that the plaintiff received from the defendant was within the standard of care. A month after the first appointment with the defendant, the plaintiff had an in-office flexible cystoscopy which was negative for bladder tumors. One issue with trying to detect this particular tumor in this patient with a cystoscopy was that the plaintiff’s tumor grew vertically into the muscular wall of the bladder, when typically they will grow horizontally, becoming more visible over time. Even if they had done a cystoscopy after the office cystoscopy in 2001, the results would have been the same, negative for tumors.



Collaborating with the defense attorney and experts, IV created a visual strategy that helped explain that the defendant actions were within the standard of care.

The first diagram was of normal anatomy of urogenital system and a cross section of the bladder wall.

The next diagram illustrated a flexible cystoscopy.

A diagram of patterns of tumor growth was used to explain the different types of growth of bladder tumors.

Another diagram also showed patterns of growth, focusing on the invasive papillary carcinoma and invasive flat carcinoma.

The final diagram was a timeline from October 2001-November 2002, of the care the patient received from the defendant.

This series of visuals helped the defense successfully convey the following key points to the jury:

  • There are cases where growth of a tumor can affect whether or not there can be early detection.
  • Early cystoscopies are not always going to show tumors or abnormalities.
  • The timeline helped to display the consistent involvement of the defendant in the patients care.

The jury found in favor of the defense. 

“We won. As always, the visuals were extremely helpful. Thanks.”

- Attorney George Wakeman, Esq., Adler, Cohen, Harvey, Wakeman and Guekguezian LLP, Boston, MA