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In Johnson v. Advocate Health & Hospitals Corp., 2025 IL App (1st) 230087, the First District Appellate Court weighed in on two issues with significant implications for medical malpractice defense strategy: the sufficiency of pattern jury instructions in cases involving sole proximate cause, and the treatment of high-low proposals under Illinois’s prejudgment interest statute. Although the court ultimately affirmed the jury’s $20 million verdict, its analysis offers critical guidance for defense attorneys navigating causation theories and post-verdict interest exposure.

The Johnson Case and the Issues on Appeal

The Johnson plaintiff filed suit on behalf of herself and her minor child, alleging that negligent delays during labor and delivery resulted in a brain injury and lasting neurodevelopmental impairments. Advocate defended the case on both standard of care and causation, presenting expert testimony that fetal growth restriction (FGR), a condition identified well before labor, was the cause of the child’s injuries.

After a Cook County jury returned a $20 million verdict in the plaintiff’s favor, the Trial Court entered judgment and awarded prejudgment interest under 735 ILCS 5/2-1303. Advocate appealed, raising two issues:

1. The trial court’s refusal to give a non-pattern jury instruction on sole proximate cause;
2. The award of prejudgment interest despite a high-low proposal made during jury deliberations.

Jury Instructions and the Sole Proximate Cause Defense—A Return to Leonardi

For two decades before August 2021, the Illinois Civil Pattern Jury Instructions included IPI 12.04 and 12.05.  Before August 2021, IPI 12.04 titled “Concurrent Negligence Other than Defendant’s” instructed the jury as follows:

More than one person may be to blame for causing an injury.  If you decide that a [the] defendant[s] was [were] negligent and that his[1] [their] negligence was a proximate cause of injury to the plaintiff, it is not a defense that some third person who is not a party to this suit may also have been to blame.

[However, if you decide that the sole proximate cause of injury to the plaintiff was the conduct of some person other than the defendant, then your verdict should be for the defendant.]

Illinois Pattern Jury Instruction, Civil No. 12.04 (2020).

Similarly, before August 2021, IPI 12.05 titled “Negligence-Intervention of Outside Agency” read as follows:

If you decide that a [the] defendant[s] was [were] negligent and that his [their] negligence was a proximate cause of injury to the plaintiff, it is not a defense that something else may also have been a cause of the injury.

[However, if you decide that the sole proximate cause of injury to the plaintiff was something other than the conduct of the defendant, then your verdict should be for the defendant.]

Illinois Pattern Jury Instruction, Civil No. 12.05 (2020).  These instructions, in part, instructed jurors to find for the defendant if they decided the sole proximate cause of the plaintiff’s injury was someone other than the defendant or something other than the defendant’s conduct. 

These instructions are a product of the Illinois Supreme Court’s decision in Leonardi v. Loyola University, 168 Ill. 2d 83 (1995), which was a medical malpractice action involving a woman who suffered injury during the delivery of her child as a result of a condition called placenta previa and placenta accreta, which negatively impacted her ability to deliver.  Id. at 88-90.  After delivery, the mother suffered respiratory insufficiency, which was ultimately determined to have been caused by a saddle pulmonary embolism.  Id. at 90.  The pulmonary embolism broke into pieces ultimately causing irreversible brain damage. Id.

Subsequently, a lawsuit was filed on behalf of the vascularly compromised mother.  At trial, plaintiff filed motions in limine to prevent the defendant physicians from introducing evidence of a settling defendant’s care and conduct.  Id. at 92.  The Leonardi plaintiff argued that if the defendants were negligent, evidence of any other negligence was not relevant.  Id. at 93.

The Illinois Supreme Court in Leonardi confirmed that the element of proximate cause “is an element of the plaintiff’s case.” Id. Despite proximate cause being an element that a plaintiff must prove, a defendant can “rebut evidence tending to show that defendant’s acts are negligent and the proximate cause” of the injuries.  Id. at 100.  Additionally, a defendant “has the right to endeavor to establish by competent evidence that the conduct of a third person, or some other causative factor, is the sole proximate cause of plaintiff’s injuries.”  Id.  Most importantly, the Leonardi Court concluded:  “[I]f the evidence is sufficient, the defendant is entitled to an instruction on this theory” Id. 

Since Leonardi, defense attorneys representing medical professionals and institutions have utilized the doctrine of sole proximate cause to defend claims of professional negligence when someone or something other than the defendant’s conduct was the cause of plaintiff’s injury.  See e.g., Bosco v. Janowitz, 388 Ill. App. 3d 450, 466 (1^st Dist. 2009) (finding the long form of IPI 12.04 was appropriate where there was evidence that a neuroradiologist failed to appropriately read an MRI in a post-surgical patient); Ready v. United/Goedecke Services, Inc., 238 Ill. 2d 582 (2010) (finding that the defendant “was entitled to present evidence to support a sole proximate cause jury instruction” and if there is some evidence to support it, the second paragraph of IPI 12.04 should be provided to the jury); Krklus v. Stanley, 359 Ill. App. 3d 471 (1^st Dist. 2005) (arguing that the lethal nature of an aortic dissection or uncontrolled hypertension were “something” other than the conduct of the medical provider defendant that was the cause of the plaintiff’s injury and the long form of IPI 12.05 was appropriate for instructing the jury).

The term “sole proximate cause” was not defined in the civil jury instructions and specifically the word “sole” presented a semantic problem for appellate courts. So, in 2021the Illinois Supreme Court Committee on Jury Instructions withdrew IPI 12.04 and 12.05 and revised IPI 15.01, adding a second paragraph intending to merge the concepts covered in the two withdrawn instructions into the revised IPI 15.01.

Testing the 2021 IPI Changes to Proximate Cause in Johnson

Within this context, the Johnson matter proceeded to trial.  Presenting a sole proximate cause defense at trial, Advocate contended that the child’s brain injury was not the result of any negligent acts by the medical providers, but rather due to fetal growth restriction (FGR)—a prenatal condition that developed well before the patient presented to Advocate’s hospital. This theory was supported by expert testimony that FGR was a known, independent risk factor for neurodevelopmental delay and could cause injury in utero without any deviation from the standard of care.

In Johnson, Advocate proposed a non-pattern instruction directing the jury to find for the hospital if it determined that something other than the hospital’s conduct was the sole proximate cause of the child’s injuries. This language was consistent with the language used in the previously withdrawn IPI 12.04 and 12.05. The Trial Court refused this tendered instruction and gave the revised pattern instruction instead, which instructed the jury to find for the hospital only if they determined the hospital’s conduct was not a cause of the injury. The Johnson court found that this language used in the second paragraph of the revised IPI 15.01 departed from the language used in IPI 12.04 and 12.05. The language used in in IPI 12.04 and 12.05 had long been recognized as accurately stating the sole proximate cause defense. The court noted that the revised 15.01 did not explicitly state the distinct idea of the sole proximate cause defense.

The Johnson Court emphasized the longstanding right of a defendant to present a sole proximate cause defense, as recognized by the Illinois Supreme Court in Leonardi v. Loyola University of Chicago, 168 Ill. 2d 83 (1995). In Leonardi, the Court makes it clear that, when supported by the evidence, a defendant is entitled to an explicit instruction that the conduct of someone other than the defendant or something other than the defendant’s conduct is the sole proximate cause of the plaintiff’s injuries.

In Johnson, the court reiterated and emphasized that a defendant has the right to have the jury instructed on its theory of the case when supported by the evidence. When the pattern instructions do not contain such an applicable instruction, nonpattern instructions may be used. The Johnson court specifically found that IPI 15.01 “does not state the law regarding the sole proximate cause defense with the specificity” required. P 59. Therefore, Advocate was entitled to an instruction on sole proximate cause and IPI 15.01 was not sufficient.

Ultimately, the Court affirmed the jury’s verdict, despite the error, holding that it did not rise to the level of prejudice warranting reversal.

Nonetheless, the appellate court’s decision leaves no doubt: when a defendant presents a sole proximate cause defense, the trial court must ensure the jury is instructed on that theory in clear, accurate terms—even if doing so requires use of a non-pattern instruction. The decision affirms that while pattern instructions are preferred when available and appropriate, they are not immune from scrutiny and do not override a party’s right to a legally sound presentation of its case.

The Johnson decision also redemonstrated the high bar that must be met on appeal to establish “serious prejudice” to the defendant when a jury instruction that did not accurately reflect Illinois law was given.  The Johnson Court, despite acknowledging that the IPI instructions did not reflect the law regarding sole proximate cause, did not conclude that there was “serious prejudice.”  The Appellate Court instructed that in order to prove the prejudice, a special interrogatory should have been given to force the jury to “specify what it found to be the cause” of the injury.  Johnson, 2025 IL App (1st) at ¶69. 

If forced into a situation where a trial court refused the former IPI 12.04 or 12.05 to appropriately instruct a jury on sole proximate cause, Johnson makes clear that in order for the defense attorney to adequately meet the burden of establishing a “serious prejudice” if sole proximate cause instructions are rejected.  Specifically, “serious prejudice” will not be found unless a special interrogatory is tendered to force the jury “specify what it found to be the cause” of the plaintiff’s injury.  Id. 

Prejudgment Interest and the Limits of High-Low Agreements

The Johnson court also addressed whether a high-low proposal made during jury deliberations qualifies as a “settlement offer” under the Illinois Prejudgment Interest Act. Advocate had proposed a high-low agreement with a $6 million floor and a $20 million ceiling. The plaintiff declined. After the jury returned a $20 million verdict, the trial court awarded prejudgment interest based on an earlier $5 million settlement offer.

On appeal, Advocate argued that the high-low proposal should bar the interest award. The First District disagreed. It held that a high-low agreement is not a settlement offer within the meaning of the statute because it does not resolve the case or result in a dismissal. Instead, it preserves the verdict and simply brackets the risk of exposure.

The court distinguished high-low proposals from true settlement offers by emphasizing that a settlement offer, if accepted, terminates the litigation. In contrast, a high-low allows the case to proceed to verdict and binds the parties only to abide by the resulting award within the negotiated range. The appellate court also cautioned that allowing high-lows to qualify as settlement offers under section 2-1303 could invite strategic behavior—such as low-value “floor” proposals designed to shield against interest exposure without truly advancing resolution.

Accordingly, the court affirmed the trial court’s award of prejudgment interest.

Strategic Takeaways for Illinois Medical Malpractice Defense Counsel

Johnson underscores several important lessons for defense attorneys managing complex causation disputes and statutory interest risks:

• Pattern Instructions Are Not Always Enough. If you’re advancing a sole proximate cause defense, review the current pattern instructions closely. The 2021 version of IPI 15.01 omits language that may be essential to your theory. Prepare a legally accurate, tailored instruction and preserve any objections on the record if it is refused.
• High-Low Proposals Do Not Bar Prejudgment Interest. A high-low agreement—particularly one proposed during deliberations—will not qualify as a settlement offer under the statute. To limit interest exposure, defendants should consider extending a formal offer to settle that complies with section 2-1303.
• Preserve the Instructional Record. While Advocate did not prevail on appeal, the court’s opinion makes clear that the jury instruction issue was well-preserved and well-argued. This serves as a reminder that thoughtful instructional practice is not just procedural—it’s strategic.

Conclusion

In Johnson v. Advocate, the First District reaffirmed key principles of Illinois law that matter to defense counsel and healthcare clients alike: accurate jury instructions are essential, and statutory interest can become a costly post-trial surprise. The case offers both a caution and a strategy blueprint for litigators seeking to protect the integrity of the defense narrative and manage long-tail financial exposure. Trial success often depends on making the record—not just making the argument.

[1] It is 2025.  According to a study published by the ABA in 2024, 41 percent of all attorneys in the United States are women; the number of women in law school outnumber men at 56.2 percent; “a majority of the 44,000 general lawyers in the executive branch of the federal government have been women” since 2020.  “New ABA report spotlights rise of women in the law” ABA News (Nov. 18, 2024), https://www.americanbar.org/news/abanews/aba-news-archives/2024/11/2024-profile-of-the-profession.  Why are we as attorneys still accepting and being told to use gender exclusive jury instructions?