Full opinion text
FINDINGS OF FACT AND CONCLUSIONS OF LAW MARCUS, District Judge. THIS MATTER was tried without a jury before this Court on October 20, 23-24, 1995, November 15-17, 20-22, 1995, February 23, 26-28, 1996, April 15-19, 22, and concluded with closing arguments on May 28, 1996. Plaintiff Nathan Wareing, through his Guardian Ad Litem Teresa Wareing (“Plaintiff’) brings this action against Defendant United States of America (“Defendant”) pursuant to the Federal Tort Claims Act, 28 U.S.C. § 2671 et seq. Plaintiff alleges medical malpractice in connection with the birth of Nathan Wareing on May 3, 1985 at the U.S. Naval Hospital in Guam. More specifically, Plaintiff says that the medical treatment that Teresa Wareing received between May 1, 1985 and May 3, 1985 fell below the applicable standard of care, and that the Government’s breach caused Nathan Ware-ing to sustain permanent neurological injuries including, among other things, low I.Q., language disorder, attention deficit disorder, as well as other neurological deficits. Upon a thorough review of the evidence and materials presented at trial, we conclude that Plaintiff has met his burden of demonstrating that Defendant breached a duty owed to Plaintiff, that the Government’s medical staff badly mishandled Teresa Ware-ing’s high risk labor and delivery, that Defendant’s conduct was the cause of Plaintiffs injuries, and that Plaintiff suffered extensive damages. Pursuant to Rule. 52(a) of the Federal Rules of Civil Procedure, the Court makes the following Findings of Fact and Conclusions of Law. ' I. FINDINGS OF FACT 1. Plaintiff Nathan Wareing was born on May 3, 1985 at the U.S. Naval Hospital in Guam. He is presently eleven years old and resides with his mother and Guardian ad litem Teresa Wareing and his father Bruce Wareing in Florida. 2. The United States of America is the Defendant in this action. 3. Bruce Wareing, Nathan’s father, was stationed at Anderson Air Force Base in Guam on active duty with the United States Air Force in 1985. Trial Tr., Test, of Bruce Wareing, November 15, 1995, at 17-18. Teresa Wareing, ‘Bruce Wareing’s wife and Nathan Wareing’s mother, was in the active reserve at this time, and was in- Guam as Bruce Wareing’s dependent. Trial Tr., Test, of Teresa Wareing,' February 27, 1996, at 125-26. 4. Teresa Wareing learned that she was pregnant in August 1984. She received prenatal medical treatment at the United States Air Force clinic through her fortieth week, and thereafter from the United States Naval Medical Center. Id. at 126. Teresa Ware-ing’s medical records reflect that she had regular prenatal appointments between August, 1984 and her admission to the United States Naval Hospital on May 2, 1985. PL Ex. 6, Medical Records, at 15-20. Teresa Wareing’s pregnancy was uneventful, and she testified that she did not have any significant medical problems from August 1984 to May 1985. Trial Tr., Test, of Teresa Ware-ing, February 27,1996, at 130. Her estimated due date was April 8, 1985. Id. at 126. 5. The evidence establishes, however, that from May 1, 1985 until the delivery of Nathan Wareing on May 3,1985, the Plaintiff received substandard medical treatment at the United States Naval Hospital on Guam. Among other things, the Defendant failed to recognize risks attendant to Teresa Ware-ing’s high risk labor and failed to timely deliver her child. At the outset Defendant’s physicians and other health care providers failed to appreciate the warning signs of this high risk pregnancy. According to the testimony of Dr. Oakes, one of Plaintiffs expert witnesses, an obstetrician/gynecologist with a subcertification in maternal fetal medicine or perinatology, the major risks associated with post-term pregnancies are “perinatal asphyxia, meconium aspiration and fetal distress [and] birth trauma.” Trial Tr., Test, of Gary K. Oakes, M.D., February 26, 1996, at 24. Oakes testified that the Defendant failed to establish an adequate pattern of monitoring and surveilling fetal well-being after Teresa reached, her 42nd week. The warning signals were magnified in this case, when at a prenatal examination of Mrs. Wareing on May 1, 1985, an ultrasound test revealed minimal amniotie fluid. Pl.Ex. 17, Dep. of James Ray Beckham, M.D., at 17-19 (“as you scanned over the uterus and looked at the baby there was' a subjective impression that the amniotie fluid was definitely decreased”), Pl.Ex. 6, Medical Records, at 15. Dr. Oakes, the director of perinatology and chairman of obstetrics and gynecology at Memorial Hospital Center in Savannah, testified specifically that the Defendant’s health care providers failed to appreciate the high-risk nature of the Wareing pregnancy and failed to properly monitor it. Particularly after the ultrasound showed minimal amniotie fluid on May 1, 1985, Oakes opined that “she needed to be induced, not two days later as it was scheduled.” That failure, he concluded, was a departure from the standard of care. Trial Tr., Test, of Gary K. Oakes, M.D., February 26, 1996, at 84. Nevertheless, Dr. Beckham, the Navy’s .obstetrician who examined Teresa Wareing on May 1, 1985 concluded that he had a window of some 48 to 72 hours for safe delivery and decided to send Mrs. Wareing home until May 3, when, if needed, he would induce delivery. Pl.Ex. 17, Dep. of James Ray Beckham, M.D., at 20. The Court specifically credits the testimony of Dr. Oakes. 6.Teresa Wareing' began to have contractions at around 10:00 to 10:30 p.m. on the evening of May 1, 1985. Trial Tr., Test, of Teresa Wareing, February 27, 1996, at 140. Thereafter, as the contractions progressed, Mr. and Mrs. Wareing went to the United States Naval Hospital' at around 11:00 a.m. on the morning of May 2, 1985. Id. at 142; Trial Tr., Test, of Bruce Wareing, November 15, 1995, at 26. Upon arrival at the hospital, Teresa Wareing was given an exam and was advised that she was only dilated to ■ one centimeter and that she “should either- go home and rest or go get some lunch, [because] it was going to be a long day....” Trial Tr., Test, of Bruce Wareing, November 15, 1995, at 26-27. Upon returning to the Naval hospital in the afternoon of May 2, 1985, Teresa Wareing was seen by Lieutenant Michael Murphy, M.D., an obstetrician on assignment with the United States Navy, and was admitted as a patient at 3:30 p.m. in the afternoon. Pl.Ex. 18, Dep. of Michael A Murphy, M.D., January 31, 1994, at 25; PI. Ex. 6, Medical Records, at 21. Dr. Murphy was the primary obstetric provider for Mrs. Wareing until his watch was changed at 4:30 p.m., when Lieutenant Commander John Keyes, M.D. assumed the watch. Pl.Ex. 18, Deposition of Michael A. Murphy, M.D., January 31,1994, at 27. Dr. Keyes’s specialty was family practice. Id. at 28. Dr. Murphy backed up the primary care physician, and, upon review of the medical records, he noted that he issued an order at 7:15 p.m. on the evening on May 2, 1985 which directed that “Patient to be monitored, q-2 hours, if ambulating. If no labor, let patient sleep on postpartum. Seconal, 100 milligrams; PO, before sleep if needed tonight.” Id. at 31; Pl.Ex. 6, Medical Records, at 21. Notably, Dr. Murphy agreed with Dr. Oakes’ opinion that decreased amniotic fluid or “oligohydramnios” in connection with a post-date pregnancy “bears concern” and “bears watching” and generally calls for heightened vigilance. Pl.Ex. 18, Dep. of Michael A Murphy, M.D., January 31,1994, at 39. Dr. Keyes also testified in his deposition that a post-date pregnancy raises concern and noted that he watched Mrs. Wareing “very closely” as he “watched all of the ladies on the labor deck closely.” Pl.Ex. 20, Dep. of John Judson Keyes, III, February 11, 1994, at 42, 50. 7.One of the medical providers to Mrs. Wareing at the Naval hospital, Lieutenant Louise M. Therriault, a staff nurse on the labor deck, testified that it was, among other things, part of her duty to monitor the patient’s condition and “report any untoward or suspicious-looking findings to the physician on duty.” Pl.Ex. 21, Dep. of Louise M. Therriault, April 25, 1994, at 27. However, Nurse Therriault observed that it was not her practice to give any more attention to a post-date pregnancy than a non-post-date pregnancy, nor was there any heightened degree of monitoring of a woman who was post-date. Id. at 61-62. 8. Dr. Oakes testified and the evidence supports the finding that the Defendant failed to adequately monitor the information transmitted through the fetal heart monitor. The fetal heart monitor strips were an important piece of evidence presented in the case. Fetal heart monitoring measures the fetal heart rate, and in particular, the variability in the fetal heart'rate, that-is, small regular changes in the lapse of time from beat-to-beat. Good beat-to-beat variability suggests normal neurological function. The deeper the heart rate drops and the longer the deceleration lasts, the greater the risk of possible neurological injury to the fetus. Dr. Oakes testified that careful monitoring of the fetal heart monitor strips was especially important in this case because of Mrs. Ware-ing’s post-term status and the finding of minimal amniotic fluid. Nurse Therriault made a notation at 1:15 a.m. on the morning of May 3, 1985 indicating a deceleration on the fetal heart monitor strip, and additionally noted that Mrs. Wareing was lying on her right side. Id. at 98. Teresa Wareing was thereafter moved to her left side with Nurse Therriault’s assistance. Id.; see also Pl.Ex. 6, Medical Records, at the fetal heart strips 54570-54571. Nurse Therriault testified at her deposition that she did not recall reporting . the deceleration to the physician in charge of Mrs. Wareing’s care. Pl.Ex. 21, Dep. of Louise M. Therriault, April 25,1994, at 105. James E. Short, M.D., an obstetrician/gynecologist and head of the Department of Obstetrics and Gynecology at the Naval Hospital in Guam, testified at his deposition that it would constitute a breach of the standard of care for an obstetrician to fail to communicate or discuss with a family practitioner who was assuming the care of a patient the patient’s medical condition, including whether she is a high-risk, post-term, or whether there is a decreased amount of amniotic fluid. Pl.Ex. 16, Dep. of Dr. James E. Short, M.D., September 28,1994, at 3, 6, 7. 9. At 1:00 a.m. on May 3,1985, Dr. Keyes made a decision to rupture Mrs. Wareing’s bag of waters or membranes (the amniotic sac) in order to stimulate the labor process and in order to attach a fetal scalp electrode so that a better heart rate tracing could be achieved. Pl.Ex. 20, Dep. of John Judson Keyes, III, February 11,1994, at 66-68. Notably, at the time the membranes were ruptured, Dr. Keyes observed thick meconium. Id. at 68. In addition, Dr. Keyes made a notation in the chart indicating “poor variability” which refers “to the baby’s heart beat in the beat-to-beat variability.” This finding was made at approximately 1:00 a.m. in the morning of May 3, 1985. Id. at 69; see also Pl.Ex. 6, Medical Records, at the fetal heart strips 54564-54570. The finding of meconi-um and decreased variability at 1:00 a.m. were unequivocal signs that the fetus was in distress. No action, however, was taken. Dr. Keyes testified that he did not call Dr. Murphy at this time in order to tell him of his findings of thick meconium and poor variability. Pl.Ex. 20, Dep. of John Judson Keyes, III, February 11, 1994, at 72. Dr. Murphy said, however, that he would generally expect a nurse to advise a physician of decreased variability, and that he would expect if a clinical situation presented itself that exceeding the capabilities of a physician the physician would consult another physician with more expertise in the particular area. Pl.Ex. 19, Dep. of Michael A. Murphy, M.D., September 28, 1994, at 9, 16. Dr. Murphy was not notified of Dr. Keyes’ findings regarding the thick meconium and decreased variability prior to approximately 4:00 a.m. Id. at 19-20. Dr. Murphy indicated, however, that if he had been informed of these findings he would probably have proceeded with a cesarian section at that time. Pl.Ex. 18, Dep. of Michael A Murphy, M.D., January 31, 1994, at 75. Dr. Keyes’ failure to contact Dr. Murphy, the obstetrician charged with Mrs. Wareing’s initial care, was a particularly serious breach of the standard of care. 10. Dr. Murphy returned to the Naval hospital’s labor deck at approximately 11:00 p.m. on the evening of May 2, 1985 in order to care for another patient and remained until about 1:30 a.m. in the morning of May 3, 1985. Dr. Murphy did not recall checking on the condition of Teresa Wareing and no notation he examined her during this time period. Pl.Ex. 19, Dep. of Michael A. Murphy, M.D., September 28, 1994, at 4, 11, 12. Although Dr. Keyes knew Dr. Murphy had returned to the hospital, he did not alert him as to his finding of thick meconium and poor variability in Mrs. Wareing’s post-date pregnancy. PlEx. 20, Dep. of John Judson Keyes, III, February 11, 1994, at 73. Indeed, Dr. Murphy testified that it was his recollection that between 7:15 p.m. and 4:30 a.m. he had no contact from the hospital concerning Mrs. Wareing’s condition or care. Pl.Ex. 18, Dep. of Michael A Murphy, M.D., January 31, 1994, at 32. 11. Dr. Oakes opined that the failure of the medical providers to appreciate the significance of the finding of thick meconium was a breach of the standard of care. Trial Tr., Test, of Gary K. Oakes, M.D., February 26,1996, at 40. In addition, the failure of Dr. Keyes to- communicate his findings of thick meconium and decreased variability to Dr. Murphy, the supervising obstetrician until sometime after 4:00 a.m. on the morning of May 3, 1985 likewise was a breach of the standard of care. Id. at 42. Dr. Short also testified that it would constitute a breach of the standard of care for a family practice physician monitoring a patient in labor to fail to advise the on-call obstetrician-gynecologist of a finding of thick meconium and minimal beat-to-beat variability after the rupture of membranes in a patient who is post-term and who had a finding of minimal amniotic fluid. Pl.Ex. 16, Dep. of James E. Short, M.D., September 28,1994, at 4. Dr. Oakes further testified that the findings of thick meconium and decreased variability at around 1:00 a.m. on the morning of May 3, 1985 plainly indicated fetal distress and “when the diagnosis of fetal distress is made, delivery needs to take place. That either needs to take place vaginally or it takes place by Cesarian section. If delivery does not take place in the face of fetal distress, that’s a departure from the standard of care.” Id. at 45. Thus, Dr. Oakes concluded that the standard of care required the calling of a cesarian section sometime between 1:15 a.m. and 1:45 a.m. on the morning of May 3, 1985, and the procedure should be done within thirty minutes after it was called. Id. at 90-91. Dr. Oakes additionally noted that had Nathan Wareing “been delivered at 1:30, he would not have had any permanent sequelae.” Id. at 93. . 12. The Defendant stipulated “that there was a deviation from the medical standard of eare.... Specifically, defendant stipulates that its agents or employees at the Naval Hospital in Guam should have performed the cesarian section prior to 5:37 a.m. on May 3rd, 1985, and that tlje failure to do so constituted a deviation from the medical standard of care.” Defs Stipulation on the Issue of Standard of Care, May 1,1995 [D.E. 94], In fact the record evidence strongly suggests, and this Court finds that the cesarian section should have been called for by approximately 1:15 a.m. 13. The evidence demonstrated the continued failure of Defendant’s physicians and health care providers to properly monitor Teresa Wareing’s pregnancy despite the medical warning signs. Dr. Keyes did not give Mrs. Wareing requested pain medication at 1:45 a.m. PlEx. 6, Medical Records, at 32. Bruce Wareing recalled that they were told that Teresa’s labor was progressing normally and that she was going to have the baby before long and that the nurse “didn’t want to give any pain medication that might slow down the labor.” Trial Tr., Test, of Bruce Wareing, November 15, 1995, at 48. Dr. Keyes testified, however, that he examined Mrs. Wareing at 1:47 a.m. and again at 2:40 a.m. on the morning of May 3,1985 and the labor was not progressing. Pl.Ex. 20, Dep. of John Judson Keyes, III, February 11,1994, at 82. In light of this situation, Dr. Keyes gave Teresa Wareing some demerol and phenergran at 2:40 a.m. to “try to help her to relax.” Id. at 82-83. Bruce Wareing recalled that a nurse told them that Teresa could then have some pain medication because “there [were] other women having babies right at this moment and that they didn’t mind if Teresa’s labor did slow down some because there was only one doctor on duty and he was busy delivering other babies.” Trial Tr.-, Test, of Bruce Wareing, November 15,1995, at 57-58. Dr. Oakes testified that Mrs. Wareing had an arrest of cervical dilation at eight centimeters from approximately 1:00'a.m. until the time of delivery at 5:40 a.m. He added that the failure to take action in view of the complete arrest of cervical dilation for more than four hours also constituted a breach of the standard of care in Dr. Oakes’ opinion. Indeed, the failure of the cervix to dilate for more than two hours demands action because of the heightened risk of fetal injury. Trial Tr., Test, of Gary K. Oakes, M.D., February 26, 1996, at 27-28. Dr. Short agreed that “[a] failure to progress in dilation at two hours during the active phase of labor is a situation which an obstetrician needs to evaluate for intervention and he needs to hear about this_” Pl.Ex. 16, Dep. of Dr. James E. Short, M.D., September 28, 1994, at 9. 14. Furthermore, upon reviewing the fetal heart monitor strips, as the labor wore on, Dr. Oakes opined that there was “ongoing fetal distress” occurring between 1:00 a.m. and 2:45 a.m. on the morning of May 3, 1985. Trial Tr., Test, of Gary K. Oakes, M.D., February 26,1996, at 48-49. The indications of fetal distress during this time frame included several decelerations and a decrease in variability according to the fetal heart monitor strips. Id. at 49. In Dr. Oakes’ opinion, the lack of notations in the medical records concerning the signs of fetal distress during this time period were “profoundly abnormal,” suggesting that the information from the strips was being ignored. Id. at 50. The significance of the failure to take appropriate action in view, of the signs of fetal distress during this approximately hour-and-a-half time frame is that “the longer this goes on, the greater the risk for damage ... brain damage.” Id. at 51. Dr. Oakes testified that the findings from-the fetal heart monitor at 2:45 a.m. were indicative or suggestive of perinatal asphyxia. Id. The evidence further suggests that between approximately 2:45 a.m. and sometime after 4:00 a.m. of May 3, 1985 no medical provider checked Mrs. Wareing’s condition. Dr. Keyes, the physician in charge of the labor deck, testified that he was attending to two other women who were in the process of delivering their children, during this time. Pl.Ex. 20, Dep. of John Judson Keyes, III, February 11, 1994, at 129-143. Dr. Keyes specifically noted that he did not perform any examinations of Mrs. Wareing at this time because he “had to — I was in the labor — I was in the delivery room delivering two babies.” Id. at 93. Nurse Therriault was assisting Dr. Keyes at this time. Pl.Ex. 21, Dep. of Louise M. Therriault, April 25,1994, at 123. And the medical records do not reflect any entries during this time period. Pl.Ex. 6, Medical Records, at 32 and the fetal heart strips 54595-54614. 15. Carol Abrahams, a perinatal clinical nurse specialist called by Plaintiff rendered expert opinions as to the interpretation of fetal heart monitor strips, and the standard of care in obstetrical nursing. Nurse Abra-hams testified that the nursing staff at Guam breached the standard of care by failing to properly monitor the progress of labor and, in particular, by failing to chart several decelerations of the heart rate. Moreover, Nurse Abrahams observed that there was no indication in the medical records that anyone had read or appreciated the significance of the results of the fetal heart monitor strips, notwithstanding that it would have been “hard to miss these profound decelerations,” and it was hard to believe that someone was monitoring the strips but took no action. According to Abrahams, Mrs. Wareing was simply abandoned.by the nursing staff. At about 3:00 a.m. on the morning of May 3, 1985, a deceleration of some five minutes in duration, to as low as 60 beats per minute occurred which was charted on the fetal heart strips, and there is a handwritten notation that Mrs. Wareing was given six liters of oxygen. Pl.Ex. 6, Medical Records, fetal heart strips at 54596-454597. Nurse Abra-hams testified that 60 beats per minute is about as low as an unborn baby’s heart rate can go before death. Nurse Therriault testified that she did not make the notation and did not recognize the writing of the person who did. Nurse Therriault characterized what was happening at this time in the following terms: “[t]his is a rather prolonged deceleration of the fetal heart tone with a very slow return to baseline.” Pl.Ex. 21, Dep. of Louise at 119-120. She agreed that this is the type of finding that should have been communicated to a physician, but she could not recall if this deceleration was in fact communicated to the supervising doctor. Id. at 120. From approximately 3:00 until 4:10 a.m. the heart strips show repeated decelerations and continued lack of beat-to-beat variability in Nathan’s heart rate. Dr. Keyes testified that he did not think the nurses kept him properly informed about the status of Teresa Ware-big’s labor, and that if he had been made aware of the decelerations he would have called Dr. Murphy. 16. After Dr. Murphy returned to the hospital, he examined Mrs. Wareing and the fetal heart rate tracing and decided to do a cesarian section sometime at or after 4:00 a.m. on the morning of May 3, 1985. Dr. Murphy testified that his examination of the fetal heart strips revealed that “[tjhere was low variability, and she had an episode of bradycardia.” Pl.Ex. 18, Dep. of Michael A Murphy, M.D., January 31, 1994, at 53-54. The Court finds that there was a breach of the standard of care by failing to perform an immediate cesarian section even at this late hour. The medical records indicate that Bruce and Teresa Wareing signed a consent form for the cesarian section procedure at 4:10 a.m. in the morning of May 3, 1985. Pl.Ex. 6, Medical Records, at 66. Dr. Oakes opined that according to the promulgated standard applicable in 1985 from the American College of Obstetrics and Gynecology (“ACOG”) a cesarian section should actually be performed within 30 minutes of the decision to do the procedure. Trial Tr., Test, of Gary K Oakes, M.D., February 26,1996, at 16, 46. And the failure to perform a cesarian section within thirty minutes of the decision being made would also constitute a breach of the standard of care. Id. Dr. Short and Dr. Murphy both testified that they attempted to comply with the ACOG standards in the course of their practice at the Naval Hospital. Pl.Ex. 16, Dep. of Dr. James E. Short, M.D., September 28, 1994, at 14; Pl.Ex. 18, Dep. of Michael A Murphy, M.D., January 31, 1994, at 44. Dr. Short added that the hospital in general also tried to meet the requirements of the ACOG standards. Id. at 15-16. 17. The medical records are equivocal as to the time the cesarian section was “called.” The procedure may have been called as early as 4:10 a.m. on the morning of May 3, 1985, which was the time the Wareing’s signéd the consent form. PI.Ex. 6, Medical Records, at 66. Alternatively, the procedure may have been called at 4:25 a.m., when there was a note that Teresa Wareing was catheterized. Id. at 32. Finally, the cesarian section may have been “called” as late as 4:40 a.m. according to Dr. Murphy’s note. Id. at 28. Even assuming the procedure was called at the latest time indicated in the medical records, however, the medical records reflect, and there is no dispute among the parties that Nathan Wareing was delivered by cesarean section at 5:40 a.m. Id. Thus, the procedure was not completed for at least an hour, and perhaps as much as an hour-and-a-half past the time it was “called.” This length of time constitutes a breach of the thirty minute ACOG standard of care. Trial ■Tr., Test, of Gary K. Oakes, M.D., February 26,1996, at 16, 46. 18. Nurse Therriault noted in the chart that at 5:00 a.m. on the morning of May 3, 1985 Teresa Wareing was-taken to the operating room. PI.Ex. 6, Medical Records, at 32. Dr. Oakes testified that from 5:00 a.m. until delivery “there is no fetal assessment done whatsoever ... and the fetal monitoring strips stop,” thereby making it impossible to assess his condition. Trial Tr., Test, of Gary K. Oakes, M.D., February 26, 1996, at 58. 19. Bruce Wareing testified that when Nathan was eventually delivered the doctor told him that “it was a boy and he had red hair” but that thereafter “things started going wrong.” Trial Tr., Test, of Bruce Ware-ing, November 17,1995, at 19. Mr. Wareing observed the pediatrician “talking a little faster” and saying “stat,” and, after working on Nathan for a few minutes after birth, “took off running down the hall with the baby on a gurney and they took [him] to the nursery.” Id. at 18. Some time later, after the delivery, Mr. Wareing saw Dr. Rick Weisser, a pediatrician, who, after examining Nathan, was the first physician to speak to Bruce Wareing. Dr. Weisser “explained to me that Nathan’s blood gases w[ere] very far off and that he was very sick. And his words to me w[ere] that he didn’t think Nathan was going to live, and if he did live, that he would probably be a vegetable.” Id. at 21. Mr. Wareing observed Nathan in the nursery and noted that he had ace bandages on his legs, and I.V.s in his stomach, umbilical cord, and hand. He also saw that Nathan’s hand was twitching, which was later explained to him as seizures. Id. at 24-25. In fact Nathan was near death when finally delivered at 5:40 a.m. „ According to Mr. Wareing, the physicians in charge of Nathan’s care had made a decision to medivae Nathan to a hospital in the Phillippines, the Navy Regional Medical Center at Clark Air Base. Id. at 23, 32. Dr. Yoder, a neonatologist, had flown in from the Phillippines and began to care for Nathan in Guam. Thereafter Dr. Yoder took Nathan on the plane, accompanied by Mr. Wareing, to the Phillippines about ten to twelve hours after Nathan was born. Id. 27. Immediately upon arrival in the Phillippines, Nathan was taken to the neonatal intensive care ward. Id. at 32-33. 20.The Defendant has not disputed that Nathan Wareing is neurologically impaired, or that brain damage is indeed evident in his radiological scans, or finally that delivery by cesarian section was untimely. Rather, it has vigorously contested that its negligence caused the Plaintiffs injuries, positing instead, principally through the testimony of its expert, Dr. Chalub, that one or more unidentified injuries or developmental defects in útero and prior to the 38th week of gestation caused Plaintiffs problems. Based upon a thorough review of all the evidence presented, however, the Court finds that Plaintiff has established by a preponderance of the evidence that Plaintiffs injuries were caused by the negligence of the Defendant’s physicians and other health care providers who rendered care during Teresa Wareing’s labor and delivery in Guam. We find that Plaintiffs injuries were sustained because of Defendant’s failure to properly monitor and timely deliver the baby in view, of the emerging fetal distress. The Plaintiffs injuries, were, more likely than not the result of an acute hypoxic ischemic insult to the brain, i.e., a period of reduced oxygen and reduced blood flow which occurred while the mother was in labor, in the early morning of May 3, 1985. Moreover, the Court finds that if the Defendant had complied with the standard of care, the Plaintiff would not have sustained any permanent neurological damage and would not now suffer from the extensive cognitive, behavioral, psychological and neurological impairment he exhibits. 21. To establish causation the Plaintiff presented, among others, the expert testimony of Dr. Dieter Enzmann, á neurologist and expert in the diagnosis of brain injuries in infants, especially hypoxic insults and damage to the premature brain, and Dr. Ronald Coen, a neonatologist with extensive experience in caring for high-risk sick newborns. The Court found their opinions to be credible, persuasive, and particularly helpful in reaching its findings about causation. Dr. Enzmann, a board certified radiologist, and Professor of radiology at Stanford Medical Center, who has taught and written extensively in the interpretation of radiological brain scans, and in connection with the imaging of hypoxic ischemic cerebral damage, explained that neuroradiology is a subspeeialty of radiology which employs various imaging techniques to investigate the brain and spine, including computed tomography (“CT”), magnetic resonance imaging (“MRI”), X-rays, ultrasound, and like technologies. Trial Tr., Test, of Dieter Enzmann, M.D., October 14,1995, at 53-54. Dr. Enzmann reviewed a number of medical records in this case, including a MRI scan dated 10/29/91 from Miami Children’s Hospital, a CT scan dated 6/26/87 from the U.S. Air Force Base Keesler, a radiology report of a head ultrasound scan dated 5/20/85, and clinical summaries of care from Guam and Clark Air Force Base, as well as a number of letters from other physicians who have cared for Nathan or reviewed the case. Id. at 65. Based upon a review of these materials, Dr. Enzmann formed a clear opinion as to the type of injury that Nathan Wareing suffered — “a hypoxic ischemic injury to the brain.” Id. at 66. “Hypoxic ischemic” means a lower blood flow and lower oxygen delivery to the brain. Id. at 76. A hypoxic ischemic injury, according to Dr. Enzmann, includes infarctions, demyelination, damage to axons, myelin pallor, and necrosis. Id. at 118-119. Dr. Enzmann also formed an opinion as to the timing of the injury sustained by Plaintiff. He observed that “this is an injury pattern indicative of a term infant. In the combination of the image tests with the medical history, I think this damage occurred in the perinatal time period.” Id. at 66. The “perinatal time period” means “the time around birth, starting with labor, including birth and for 24 hours after birth.” Id. Dr. Enzmann added that his review of the MRI and CT scans failed to reveal any evidence.of a developmental disorder. Id. at 66-67. Nor did his review of the scans suggest that Nathan Wareing suffered from a metabolic disorder. Id. at 67-68. Dr. Enzmann additionally opined that there was no evidence of an injury caused by an infection in this case. Id. at 68. 22. Dr. Enzmann explained that he was able to date an injury based upon an MRI scan because brain injuries exhibit two major patterns detectible even years after the injury has been incurred. The first is a premature pattern, in which the injury is dated in the gestational age of twenty-eight (28) to thirty-two to thirty-four (34) weeks. The second pattern is seen in term infants, usually associated with the age range of thirty-eight (38) to forty (40) weeks or even later if the child is post-term. Id. at 69. According to Dr. Enzmann, in cases involving a hypoxic ischemic injury, “the patterns just differ between those two age groups when the injury occurs,” Id. at 69-70. The premature pattern displays periventricular leukomalacia (“PVL”) which “has a very particular pattern” — “abnormal white matter in a distribution right around the ventricles.” Id. at 70. Notably, Dr. Enzmann testified that the MRI scans and the CT scans taken of Nathan Wareing did not exhibit PVL. Id. “[T]he pattern that we see in PVL [] is different from what we see in this patient.” Id. at 77. In reviewing the scans before the Court, Dr. Enzmann stated that “[tjhese lesions are not periventricular.” Id. at 87. Dr. Enzmann noted that “PVL does not involve gray matter.” Id. at 85; see also id. at 112- (noting that majority of brain damage involves the cortex and grey matter “which rules out PVL as far as I am concerned”). The scans reviewed by Dr. Enzmann revealed that Nathan Wareing suffered injuries to both gray and white matter. Id. at 84, 92. According to Dr. Enzmann, a very important diagnostic- criteria indicative of PVL is damage to the fiber track adjacent to the ventricle in the atrial region of the brain. Yet in Nathan Wareing’s case, the fiber track region is undamaged, “so it’s another criteria that is against PVL.” Id. at 88. Dr. Enzmann further suggested that exposure to an intermittent or continual period of hypoxia significant enough to cause a brain injury four to five hours before birth was a clinical picture most consistent with Nathan’s injuries. Id. at 77. Within a reasonable degree of medical probability, Dr. Enzmann concluded that the most probable timing of injury in this case, based upon his review of the scans and the clinical evidence, was some four to five hours before Nathan Wareing’s birth. Id. at 122. Moreover, Dr. Enzmann noted that evidence of atrophy of the brain develops rapidly after incurring a hypoxic ischemic insult, from a day to seven days after the insult. After that time, the atrophy progresses and becomes more obvious. Id. at 78. Dr. Enzmann testified that an ultrasound finding twenty (20) days after birth showing an enlarged left lateral ventricle would likewise be consistent with a hypoxic ischemic injury at the time of birth. Id. 23. Plaintiff also called Ronald W. Coen, M.D., a neonatologist, as an expert witness to testify concerning causation. Neonatology is a subspecialty of pediatries and involves the care of high-risk sick newborns. Upon review of, among other things, various depositions, court testimony, and medical records from Guam, Dr. Coen likewise testified that Nathan Wareing suffered a hypoxic ischemic injury at or near the time of his birth, most likely because of umbilical cord compression caused by the lack of amniotic fluid. Id. at 14-15. Dr. Coen opined that “Nathan as a fetus entered labor in a stable condition. We have no evidence that his brain had been insulted or injured prior to the labor process.” In this connection, Dr. Coen noted that Nathan’s head circumference and weight were normal for the gestational age that was measured, whereas “[a]s a general rule in- . fants who are injured early in pregnancy usually do not grow normally.” Id. at 18. Additional evidence suggesting that Nathan entered labor in stable and good condition included the non-stress test performed in April, 1985, which was within normal limits and “the early fetal heart rate tracings were described as good.” Id. at 20. Dr. Coen stated that the hypoxic injury “began sometime around the 1:00 o’clock hour in the morning on the 3rd and that is when we found the evidence of meconium in the amniotic fluid.” Id. at 39-40. ‘When meconium is present in the amniotic fluid, .this usually means that there has been a stress,-such as hypoxic ischemic stress. The infant in response to the stress — and particularly term infants — will pass stool and begin gasping. This is in útero.” Id. at 21. Dr. C.oen further opined that neither an infection nor a genetic process played any role in Nathan Wareing’s injury. Id. at 38. Upon his review of the medical evidence in this case,. Dr. Coen observed that the early seizures and multi-organ failures after birth also indicate a moderate to severe hypoxic ischemic injury further suggesting a poor long-term neurological outcome. Id. at 49. Coen further explained that the Plaintiffs initial blood gas levels shortly after birth showed that he was significantly “acidotie,” the result of insufficient oxygen, and that he also showed symptoms of damage to the kidneys, lung and heart, and seizures, which are frequently seen after hypoxic insult. The Plaintiffs initial recovery from hypoxia was complicated by meconium in his lungs, as well as persistent fetal circulation, a condition in which the pulmonary arteries fail to switch over to a life outside of the womb. 24. Ronald Cullen, M.D., a pediatric neurologist, was also called by the Plaintiff, to opine as an expert witness in the field of pediatric neurology. Trial Tr., Test, of Ronald Cullen, M.D., February 26, 1996, at 121. Dr. Cullen has treated Nathan Wareing since 1986. Id. at 124. Upon a review of the records and testimony in this case, as well as his own evaluations of Nathan Wareing on a frequent basis since 1986, Dr. Cullen, like Coen and Enzmann, opined that “Nathan has sustained ... a hypoxic ischemic insult in the form of an encephalopathy to the brain, and that has left him over the years with a number of different neurological deficits.” Id. at 127. Dr. Cullen further testified that an hypoxic ischemic insult is a permanent injury, id. at 129, and that the brain injury sustained by Nathan Wareing has affected his cognitive and intellectual abilities, his physiological development, his psychological development, as well as his motor functions. Id. at 130-131. In reaching this conclusion, Dr. Cullen stated that he ruled out “a structural or congenital defect in brain.” Further, Dr. Cullen testified that Nathan Wareing’s injury was “not genetic” because chromosomal testing had been done, and “[i]t was not infectious in that the records didn’t reveal any intrauterine infection and the studies done indicated no changes in the brain that you would see with an infection like toxoplas-mosis or rubella,” and “[i]t was not traumatic in that there was no history in the records of severe abdominal trauma,” and “it was not metabolic” in that chemical tests were performed. Id. at 153-54. Moreover, the cause of the hypoxia that Nathan experienced was “related to a compromise of his fetal reserve during the hours of labor, cord compression, since the amhiotic fluid was low and the cord compressed easy and there were variable decelerations, útero placental insufficiency with a decrease in flow of blood from the placenta through the cords of the baby, and then the effects of the meconium, which further comprised that flow of blood. And all of those things were occurring during the intrapartum period.” Id. at 164. Dr. Cullen added that the time Nathan sustained this injury was “between approximately 1:00 o’clock in the morning up through the time of birth in a progressive and more serious fashion during that time.” Id. Dr. Cullen explained that what he meant by “a progressive and more serious fashion” was that “when you get the compromise of fetal reserve and you continue to have repeated insults, that there is a summation effect, so that the second one, the third and the fourth all have a greater impact than if it was only one single episode.” Id. at 164-65. 25. Several of Defendant’s physicians at least implicitly concurred with the conclusions reached by Plaintiffs experts regarding the cause of Nathan Wareing’s injuries. Dr. Hassel, a pediatrician who cared for Nathan Wareing at the Naval Hospital in Guam, as well as Dr. Bell and Dr. Yoder, the neonatol-ogists who treated Nathan in the Phillip-pines, all appeared to agree that the cause of Nathan’s problems was the result of asphyxia during labor. Pl.Ex. 23, Dep. Rhett Hassell, M.D., April 26, 1994, at 45; Pl.Ex. 26, Dep. Richard Bell, M.D., February 1, 1994, at 51, 77; Pl.Ex. 25, Dep. Bradley Yoder, M.D., February 3, 1994, at 18, 66. Both Dr. Bell and Dr. Yoder testified that there was no medical evidence to suggest that Nathan Wareing’s injuries were the result of any other syndromes, such as an infection, or metabolic or traumatic event. Pl.Ex. 26, Dep. Richard Bell, M.D., February 1, 1994, at 87; Pl.Ex. 25, Dep. Bradley Yoder, M.D., February 3, 1994, at 67. Dr. Weisser, who had known the Wareing’s previously through church, met with Bruce and Teresa Wareing and “told them that there were some errors in judgment that were made in the care of her while she was in labor.” Pl.Ex. 2U, Dep. Rick Weisser, M.D., February 1,1994, at 57; Trial Tr., Test, of Brace Wareing, November 17,1995, at 21. Bruce Wareing testified that “Dr. Weisser told us that we had grounds for a lawsuit based upon the way Nathan — the delivery went with Nathan-” Trial Tr., Test, of Bruce Wareing, November 17, 1995, at 49; Trial Tr., Test, of Teresa Wareing, February 28, 1996, at 22-23 (stating that Dr. Weisser told her that “that this should never have happened to Nathan” and explained that “Nathan and I were neglected; that Nathan should not have suffered what he suffered; that Nathan should have been delivered long before that ever occurred, long before he was actually delivered. It was not handled well by the medical staff.... I don’t remember his exact words but our care was just very mismanaged. We were not taken care of.”). 26. Dr. Barry M. Crown, a psychologist, testified for Plaintiff, and was received as an expert in the field of psychology and neurop-sychology. Trial Tr., Test of Barry M. Crown, October 23, 1995, at 1, 7-8. Dr. Crown opined that the cause of Nathan Wareing’s neurological deficits, including attention deficit disorder, was his brain injury. Trial Tr., Test of Barry M. Crown, October 24,1995, at 44. 27. In order to rebut the Plaintiffs theory of causation the Defendant presented testimony from Dr. Chalub, a pediatrician neurologist, who opined that Nathan’s condition was due to one or more causes notably occurring before the thirty-eighth week of gestation rather than during the intrapartum period. Dr. Chalub opined that the severity of the condition called persistent fetal circulation experienced by Nathan Wareing after birth suggested a condition which had been ongoing for at least ten to fourteen days and not three to four hours prior to birth. Dr. Chalub also said that if there was a hypoxic ischemic insult in the intrapartum period he would have expected that Nathan Wareing could not walk or talk, and would have an inability to use his limbs, and manifest severe retardation. He noted that none - of these symptoms are manifested in Nathan Ware-ing. Moreover, Dr. Chalub added that a finding of an enlarged left ventricle of the brain further supported his conclusion that something occurred during the developmental stage of the fetus and the brain rather than four to five hours prior to birth. Dr. Chalub further noted that the uniformly thin corpus callosum in the brain was also indicative of an injury which 'occurred earlier than three to five hours prior to birth. Dr. Cha-lub also said that the scans indicated the presence of periventricular leukomalacia (“PVL”), a condition which is caused by the deprivation of oxygenated blood flow to the brain during the twenty-eighth to the thirty-fifth week of gestation. Dr. Chalub added that the normal level of nucleated red blood cells found at birth suggests that a lack of blood flow to the brain at term was not the cause of the injury. On cross-examination, however, Dr. Cha-lub stated that he did not know if Nathan Wareing suffered from a hypoxic ischemic insult before birth. Dr. Chalub further conceded that he found no chromosomal abnormality, no migrational disorder, and was unable to identify any infectious agent. Although .Dr. Chalub maintained that the medical evidence suggested that Nathan Wareing suffered from a problem in the developmental stage, notably he was unable to say precisely what developmental problem may have occurred and, significantly, did not know the cause of the problem. The Court considers the inability to identify a specific developmental defect, whether genetic, metabolic, traumatic, or infectious, to be significant. Plaintiffs experts, and particularly Drs. Enzmann and Coen, were able to opine, within a reasonable degree of medical probability, that Nathan Wareing’s injuries were caused by a hypokic ischemic insult occurring during the intrapartum- period. Dr. Enzmanris expertise as a neuroradiologist in interpreting the relevant MRI, CT, and ultrasound scans was particularly convincing. Dr. Enzmanris reading and interpretation of the scans indicated a hypoxic ischemic injury at term, not a developmental defect prior to the intrapartum period. Dr. Chalub’s reliance upon a finding of an enlarged ventricle on the left, side of Nathan Wareing’s brain was undermined by Dr. Enz-mann’s testimony on this point too. Dr. Enz-mann observed that a finding of a large ventricle does not indicate the presence of a developmental abnormality, noting that “when you damage brain tissue, the body resorbs that tissue, so the brain shrinks. Something had to take the place of that damaged tissue that is now removed. And what takes its place is water. And the water containing cavities in the brain are the ventricles. So they increase in size and take up the place of damaged brain.” Trial Tr., Test, of Dieter Enzmann, M.D., October 24, 1995, at 75. Indeed, Dr. Enzmann said that he would expect to see a large ventricle following a hypoxic ischemic injury.- Id. Moreover, the Court is not persuaded by Dr. Chalub’s finding of PVL in light of Dr. Enz-mann’s finding that the scans indicate that the great majority of the injury was sustained in the subcortical white matter, not in the periventricular region. Id. at 111. Finally, Dr. Chalub’s finding of a small corpus callosum as an indicator of a developmental defect prior to birth was answered by Dr. Enzmann who testified that “[a]nything that destroys brain tissue can cause small corpus callosum. So if it’s a premature insult, PVL can cause a small corpus callosum. If it’s an insult at term, that brain damage can cause a small corpus callosum. It’s a secondary phenomenon and related to brain damage.” Id. at 115. Likewise Dr. Chalub’s reliance on the normal finding of nucleated red blood cells taken shortly after birth was belied by the more convincing testimony of Dr. Coen, who opined that infants who are under chronic stress, or stress which has been ongoing for several weeks, will “raise their nucleated red blood cell count. Infants who are under acute stress, such as Nathan, I don’t think had time to mobilize the bone marrow to produce the nucleated red blood cells and give the type of pattern greater than five or seven percent.” Trial Tr., Test, of Ronald Coen, M.D., February 27, 1996, at 113-114. According to Dr. Coen, if Nathan Wareing was suffering from chronic stress occurring weeks before his birth, his nucleated red blood cell count “should have been higher than noted.” Id. at 115. In addition, Dr. Coen observed that medical studies have shown that not all children who experience a term hypoxic ischemic insult suffer from cerebral palsy, spasticity, severe mental retardation, or cortical blindness. 28.In sum, the overwhelming weight pf the evidence including the testimony of Drs. Enzmann and Coen, the fetal heart tracings, the baby’s severely depressed condition at birth, and Nathan’s subsequent clinical course, which included symptoms of multiple organ damage and seizures, leads us to reject the Government’s theory of causation as presented by Dr. Chalub. The greater weight of the evidence demonstrates and this Court finds that Nathan Wareing’s current neurological condition and deficits are causally related to the failure to properly monitor and the delay in performing a cesarian section. We note again, Dr. Cullen testified that “[wjithin reasonable medical probability had he been delivered earlier, his injuries would have been considerably less.” Trial Tr., Test, of Robert Cullen, M.D., February 26, 1996, at 170. Dr. Cullen added that had Nathan Wareing been delivered by cesarian section at 1:30 a.m. in the morning of May 3, 1985, “[wjithin a reasonable medical probability he would not have suffered from a permanent neurological injury and, at most, might show a mild problem in learning.” Id. Dr. Cullen further opined that Nathan Wareing has attention deficit disorder (“ADD”) which was “due to the brain injury that he sustained at the time of birth and the chemical changes that it produced.” Id. at 173. Dr. Crown also testified that the cause of Nathan Wareing’s attention deficit disorder was his' brain injury and noted that ADD is a very common finding among children who are neurologically impaired. Trial Tr., Test, of Barry Crown, M.D., October 24, 1995, at 44. Dr. Cullen testified that Nathan’s attention deficit disorder is a condition that he will continue to suffer from for the remainder of his life. Trial Tr., Test, of Robert Cullen, M.D., February 26, 1996, at 173. Dr. Cullen added that he was of the opinion that Nathan’s “cognitive intellectual level and the range he is functioning at is as a result of the brain damage that he sustained during the intrapartum period at birth.” Id. at 178. Dr. Cullen concluded that had delivery occurred at about 1:30 a.m., Nathan “would be functioning with a normal I.Q.” Id. 29. Having found that Defendant plainly breached a duty of care and that its negligence caused substantial, damages, any fair measure of damages includes a finding that the Plaintiff has suffered permanent neurological injuries that will essentially leave him functioning at the level of a ten to twelve year old level for the rest of his life. Nathan Wareing’s I.Q., language abilities, social skills, attention and functional abilities have all been profoundly affected because of Defendant’s negligence. A. I.Q. Testing 30. An examination of the evidence presented concerning the Plaintiffs I.Q. supports a finding that the Plaintiff sustained substantial neurological damage. Initial I.Q. testing performed on Nathan Wareing in December, 1987 evidenced an I.Q. score of 72 on the Revised Stanford Binet test. Def.Ex. 8, at WH00035-36. This result fell “in the Borderline range, between Low Average and Mildly Mentally Delayed.” Id: Subsequent testing at Miami Children’s Hospital in March, 1988 revealed a one-year language delay on. the Peabody Picture Vocabulary Test. Id. atWH00045. ' '31. Dr. Crown, examined Nathan Wareing on four separate occasions. Trial Tr., Test, of Barry Crown, M.D.,' October 23,1995, at 9. Nathan obtained a full-scale I.Q. of 70 in the first test Dr. Crown gave in May, 1991. Id. at 18-19, 25. Dr. Crown noted that this score — 70—on the full scale I.Q. test placed Nathan Wareing between the second and third percentile, meaning that roughly 97 out of 100 in his peer population would have an I.Q. greater than 70. Id. at 26. The normal range for this test is a score in between 85 and 115. Id. Subsequent tests resulted in full-scale I.Q. scores of 70, 74, and 70 respectively in 1992, 1993, and 1994. Id. at 49. One of Defendant’s experts, Bonnie E. Levin, Ph.D., an neuropsychologist, tested Nathan’s I.Q. in June, 1994 and he received a score of 64. (Dr. Levin, however, questioned the reliability of the score on the test she administered because she indicated that the score should have been similar to the scores obtained by Dr. Crown.) Dr. Crown stated that the current definition of “educable retarded,” according to the American Association of Mental Disabilities is a score of 74 or below on an I.Q. test. Based on this definition, Dr. Crown opined that Nathan’s test scores placed him in the “educable retarded” range. Trial Tr., Test, of Barry Crown, M.D., October 23, 1995, at 27. Dr. Crown concluded that “[t]he pattern that’s emerged is ... that these problems, these impairments, are, indeed, permanent-” Id. at 51. Although Dr. Crown noted that Nathan will be able to acquire new knowledge as he ages, “the application of that knowledge will become more and more difficult for him. He-will have the rote ability to acquire information, but will not have the ability to apply it.” Id. Dr. Crown opined that based on his examination of Nathan he did not believe that the Plaintiff would ever progress beyond the primary grade levels, or the third or fourth grade, in terms of educational achievement. Id. at 54.-We found Dr. Crown’s testimony to be credible. B. Functional Abilities 32. By any measure, the Plaintiff’s level of functioning is significantly impaired. At the age of 10$, he can not tell time, does not know his address or telephone number, and can only occasionally recollect the city in which he lives. Nor can he consistently spell his name. In terms of Nathan’s language abilities, Teresa Wareing testified that Nathan does.not speak in a normal cadence, has fluency problems, and his speech is delayed in the sense that “[h]e has to think about what he is going to say.” Trial Tr., Test, of Teresa Wareing, February 28,1996, at 87-88. He can tie his shoes only loosely and exhibits substantial difficulty with personal hygiene, toiletry and brushing his teeth. He does not know the value of money and cannot tell the difference between a penny, a nickel, a dime or a quarter. In connection with toiletry, Mrs. Wareing testified that “Nathan took a real long time to toilet train,” and, although he was taught the use of the toilet, Nathan remains “really bad” at taking care of himself in the bathroom". Mrs. Wareing said that this meant that Nathan “urinates on ‘the floor. He doesn’t look where he is urinating in the bathroom. His underwear ha[s] a residue of stool most days.” Id. at 90. Mr. Wareing testified that Nathan “doesn’t clean up after himself’ when he uses the toilet and has found that his underwear is frequently soiled. Trial Tr., Test, of Bruce Wareing, November 22,1995, at 8. Mr. Wareing emphasized that both he and Teresa have continually been working with Nathan in order to improve his personal hygiene skills, but-he has not significantly improved over the course of many years. Id. at 9. Mr. Wareing further said that they have to frequently clean up the bathroom because of Nathan’s poor toiletry skills. Id. Mrs. Wareing added that Nathan also has difficulty in the area of dental hygiene. Trial Tr., Test, of Teresa Wareing, February 28,1996, at 90. Bruce Wareing farther testified that Nathan is able to shower and bathe himself, albeit with supervision because [s]ometimes he can go in there and get it done. Sometimes he forgets to, you know, like wash his hair or whatever. A lot of times he will go in the shower or you tell him to go to the shower and you check five or -ten minutes later and he is standing naked in the bathroom playing with something. And then when you get him in the shower, he will sit and play with the fog on the glass and he kind of forgets what he is in there to do. So sometimes he will go in there and he will do fine, and sometimes you got to keep checking on him to make sure that he is doing what he is supposed to be doing. Trial Tr., Test, of Bruce Wareing, November 22, 1995, at 6. Mr. Wareing added that Nathan does not always observe social customs such as closing the door when using the bathroom and will sometimes falter in the area of personal modesty and fail to wear clothes after he comes out of the shower, even if family or company are in the house. Id. at 6-7. 33. Ronni Waldman, a senior teacher at the Easter Seals Society of Dade County, who taught Nathan Wareing in her class in 1994 and 1995, also testified that Nathan cannot write his name consistently because he sometimes leaves letters out. Trial Tr., Test, of Ronni Waldman, October 24, 1995, at 2, 4,10. Ms. Waldman stated that Nathan does not know the value of a penny, a nickel, a dime, or a quarter. Id. at 11. Ms. Wald-man added that Nathan can carry on a conversation, but his conversational skills are impaired inasmuch as “it’s hard for him to stay on topics.” Id. at 12. Nathan has also exhibited memory problems according to Ms. Waldman, who noted that “[w]e have to do many of the skills with constant repetition in order for him to retain information.” Id. Moreover, the Plaintiff gets lost easily and must be watched closely for reasons of personal safety. 34. In connection with Nathan Wareing’s current physical abilities, the evidence indicates that the Plaintiff has difficulty with eye-hand coordination and fine motor skills, and that he cannot keep up with other children his own age in regular sports activities. Bruce Wareing testified that Nathan was unable to keep up with a regular soccer program because the game was too fast for him. Trial Tr., Test, of Bruce Wareing, November 17, 1995, at 68-69. Mr. Wareing added that Nathan, can not run as fast as other boys his age “[a]nd so when he tried to play soccer, he couldn’t run as fast as the other kids, but I think more of a problem than running was trying to figure out where the ball was going. And he has to stop and think about things ■ sometimes, and it just didn’t work.” Id. at 69. 35.Plaintiff also submitted evidence concerning Nathan’s social development and social skills. In this regard, Dr. Crown observed that Nathan “had difficulties with visual memory” and auditory effect which has caused problems in “decoding” or discerning what facial expressions mean. Trial Tr., Test, of Barry Crown, M.D., October 23, 1995, at 36. The effect of this deficit is that “[h]e didn’t necessarily know when someone was angry or happy or sad, or so on.” Id. The ability to decode visual and auditory messages “becomes even more significant as we go on in life because that forms the basis of our social interaction. It’s important when we look at someone to know whether they are responding in' a happy way or a sad way toward us, whether they are angry, whether they are provoked, and so on, to be able to discern feeling, not only in terms of facial expression, but also in terms of language tone and being able to pick up the tonal differences.” Id. Dr. Crown further opined that when fully grown Nathan will only be able to achieve a social level within a pre-adoles-cent range around 10 years of age. This meant, for example, that when Nathan is thirty-five years old, he will still have the social skills of a 10-year old. Id. at 54-55. There was significant credible evidence that Nathan Wareing’s social development has been appreciably delayed, and that he does not act like a child of his age. Lawrence Forman, a rehabilitation/habilitation counselor, called by Plaintiff as an expert in the field of rehabilitation and life care planning, Trial Tr., Test, of Lawrenee Forman, November 15, 1995, at 2, 18, opined that Nathan does not have the social development of a child his age. Trial Tr., Test, of Lawrence Forman, November 20, 1995, at 31. Nathan’s delayed social development was echoed by- his teachers and therapists. Francine Weiner, a learning disabilities teacher with Davie Elementary School, testified that her review of Nathan’s responses as a third grader “are very developmentally younger than many of the kindergartens that I test_” Pl.Ex. 31, Dep. of Francine Weiner, April -27, 1994, at 3 — 4, 136, 142. Lanette Robinson, a speech clinician at Davie Elementary School, added: By now the third grader should be able to write his name without missing a letter. He should be able to count at least to 100 by now. I think Nathan goes from one— The other day it was like one to twenty-four. He is inconsistent, Nathan. A normal third grader should be able to go to a special class and not need a buddy or a partner to go to the office and take his medication. We have to walk him with a messenger. A normal third grader should be able to, after learning going to a new school, find his way from here to there, to the cafe