Fatima E. Belhak and Abdellatif Elfila v. Denice Smith, M.D., and Women's Care Specialists, P.C.

IN THE COURT OF APPEALS OF IOWA

No. 22-2048
Filed May 8, 2024

FATIMA E. BELHAK and ABDELLATIF ELFILA,
Plaintiffs-Appellees,

vs.

DENICE SMITH, M.D., and WOMEN’S CARE SPECIALISTS, P.C.,
Defendants-Appellants.
________________________________________________________________

Appeal from the Iowa District Court for Scott County, Jeffrey D. Bert, Judge.

A doctor and her employer appeal a jury verdict finding them liable for

medical malpractice. REVERSED AND REMANDED.

Troy L. Booher and Beth E. Kennedy of Zimmerman Booher, Salt Lake City,

Utah, and Nancy J. Penner of Shuttleworth & Ingersoll, P.C., Cedar Rapids, for

appellants.

Anthony J. Bribriesco and William J. Bribriesco of Bribriesco Law Firm,

PLLC, Bettendorf, for appellees.

Heard by Bower, C.J., and Badding and Langholz, JJ.
2

LANGHOLZ, Judge.

Fatima Belhak and her husband sued her doctor, Denice Smith, and the

doctor’s employer for medical malpractice over the care that she received following

an episiotomy performed during the birth of her first child.1 The court instructed

the jury on three alternative specifications of negligence. And the jury returned a

general verdict that Smith was negligent and her negligence caused damages to

Belhak—awarding $3.25 million in damages.

Smith seeks a new trial, arguing that the court should not have submitted

one of the specifications of negligence—that Smith used the wrong size of

sutures—to the jury because Belhak had failed to present any expert evidence

supporting causation for that theory. She also argues that a new trial is warranted

because Belhak’s counsel made improper statements in closing argument and

asked more than fifty improper leading questions throughout the trial.

Because Belhak’s expert did not testify that the use of smaller sutures was

more likely than not a cause of Belhak’s harm, that specification should not have

been submitted to the jury. And Smith properly preserved error on this issue by

moving for a directed verdict and raising it again in her posttrial motion for a new

trial. It matters not that she agreed to the jury instruction. So she is entitled to a

new trial on this basis alone, and we need not address whether the conduct of

Belhak’s counsel would also warrant a new trial. We thus reverse and remand to

the district court for a new trial.

1 Because the arguments on appeal do not vary between the coplaintiffs and
codefendants, we will generally refer only to Belhak and Smith for simplicity. But
both defendants appealed the verdict against them and both plaintiffs were
awarded damages and have participated in the appeal as the appellees.
3

I.

Belhak and her husband, Abdellatif Elfila, welcomed their first child in

January 2014. Belhak’s regular obstetrician with Women’s Care Specialists was

unavailable when she went into labor, so Smith covered the delivery. As the baby’s

head began crowning, Smith decided she needed to perform an episiotomy

because Belhak’s skin around her vagina was “very tight around the baby’s head,”

impeding the baby’s outward progress. To perform an episiotomy, a doctor makes

a small incision with a special pair of scissors from the vagina into the mother’s

perineum—the area between the vagina and the anus. After performing the

episiotomy, the baby was successfully delivered without issue. And there appears

to be little dispute about the need for the episiotomy or the way it was performed.

The parties’ dispute starts with what happened next.

After the birth, Smith conducted a vaginal examination, which included

checking out the episiotomy incision to see how far it went and how deep it went

towards the anus and rectum. Smith diagnosed a second-degree laceration with

an extension up into the vaginal area. And Smith repaired the laceration with 4-0

vicryl sutures—the suture she “typically” used for vaginal laceration repairs—rather

than larger 3-0 or 2-0 sutures. Smith did not perform a rectal exam. And she did

not diagnose that Belhak had a fourth-degree laceration—an extension of the

laceration into the lining of the rectum.

While still in the hospital, Belhak felt pain in her rectum and noticed small

pieces of stool and blood on her postpartum pad after birth. She reported this to

her medical providers. After a nurse conducted a visual examination and saw

nothing out of the ordinary, the nurse gave her an ice pack to ease the pain.
4

Belhak went home. And a few days later, she self-inspected her vaginal

area. She was still in pain and saw stool coming from her vagina. After calling

Smith and her regular medical provider, she went to the emergency room, which

sent her to the University of Iowa Hospitals and Clinics. The University doctors

diagnosed Belhak with a fourth-degree laceration. They also diagnosed a

rectovaginal fistula—essentially a hole between the rectum and the vagina that

allowed stool and gas to pass from the rectum to the vagina and then come out of

Belhak’s body either or both ways. Because the area became infected—as

typically happens if not repaired within twenty-four hours of the injury—Belhak had

to wait about five months to repair the injuries with reconstructive surgery.

From February until the reconstructive surgery in June, Belhak had to bathe

for thirty minutes in a sitz bath after every bowel movement to disinfect the wound.

Even after her reconstructive surgery, she suffers pain. She has trouble walking,

carrying heavy objects, and sitting or sleeping in certain positions. Sometimes this

pain radiates from her pelvis down her legs. She does physical therapy and at-

home exercises to alleviate the pain as much as possible. She cannot be around

other people too long for fear of uncontrollable bowel movements and gas, and

she has to restrict her diet to avoid accidents. Her relationship with her husband

has struggled because of her injury. And he has taken on more responsibilities in

raising their children, caring for Belhak, taking her to appointments, and helping

her with therapy.
5

In 2016, Belhak and her husband sued Smith and Smith’s employer over

her care following the episiotomy.2 Belhak claimed that Smith’s care was medical

malpractice that caused her physical and mental injury and pain and suffering. And

her husband claimed loss of consortium.

The case was eventually tried to a jury in March 2022—after the first attempt

a couple of years earlier ended with a mistrial during jury selection. Over seven

days, the jury heard from Belhak and her husband, Belhak’s original obstetrician

who could not make the birth, and Smith. The jury also heard from two competing

expert witnesses—one testifying for Belhak and the other for Smith. Belhak’s

expert was Dr. Gregory Chen, an experienced obstetrician and gynecologist who

also served on the clinical faculty of Northwestern University.

After the close of Belhak’s case, Smith moved for a direct verdict on the

specification of negligence that Smith used the wrong size of sutures, arguing that

“there has not been any testimony that the use of 4-0 vicryl sutures caused any of

the injuries to the plaintiffs.”3 The court denied the motion, reasoning that Smith

“has put forth sufficient evidence on both of those issues to make this a jury

question.”

The court then submitted the case to the jury with a marshaling instruction

that included three specifications of negligence, instructing that “[t]he plaintiffs

must prove” that Smith was “negligent in one or more of the following ways:”

2 Belhak originally filed two suits—one against Smith and a second against Smith’s

employer, Women’s Care Specialists. The cases were consolidated together with
all filings after consolidation made in the case originally brought only against
Women’s Care Specialists.
3 Smith also made a second motion for directed verdict applicable to all the

specifications of negligence that is not at issue on appeal.
6

(1) “by failing to perform a rectal examination after an episiotomy; or” (2) “by failing

to recognize a fourth-degree laceration; or” (3) “by using 4-0 Vicryl sutures to repair

the episiotomy.” Smith agreed that the second and third specifications “should be

submitted.” But she argued that the first specification—and others the court

decided not to submit—were “duplicative” and “unduly emphasized plaintiffs’

case.”

The jury found that Smith was negligent and her negligence caused

damages to Belhak.4 And the jury awarded $3.25 million in damages. The verdict

form did not require the jury to specify which of the three specifications of

negligence were proved.

Smith moved for a new trial for a host of reasons. Among other arguments

not relevant to this appeal, she again argued that the suture specification of

negligence should not have been submitted to the jury because there was

insufficient evidence of causation. Smith also argued that Belhak’s counsel made

at least six arguments during closing argument that constituted misconduct and

prejudiced Smith. And she argued that Belhak’s counsel’s repeated use of leading

questions during the trial—over fifty in total that Smith successfully objected to—

was also prejudicial misconduct because “the jury was left with the impression that

defense counsel was attempting to withhold relevant evidence from its

consideration by having to make repeated objections.”

The court denied Smith’s motion. The court held that Smith had failed “to

preserve error” on her argument that the suture specification should not have been

4 While the verdict form mentioned only Smith, the parties agreed that her employer

was also liable for any verdict.
7

submitted to the jury, reasoning that “[w]hile another objection to preserve error is

unnecessary, a party cannot agree to specification, only to later argue it was given

in error.” Alternatively, the court concluded that “a review of the record shows

sufficient evidence regarding harm to Fatima Belhak to allow the jury to decide

causation without speculation,” pointing mostly to evidence of the many harms

Belhak has suffered since the episiotomy.

On Smith’s claims of misconduct during closing argument, the court agreed

that Belhak’s counsel engaged in three instances of misconduct. But the court

concluded that these improper arguments—standing alone or collectively—did not

warrant a new trial. The court reasoned that it had given curative instructions to

the jury, Belhak’s “evidence could be characterized as strong,” and “[n]one of the

alleged misconduct surrounded [the] central factual dispute.” The court also

rejected Smith’s argument based on Belhak’s counsel’s leading questions during

trial, explaining that it was “not convinced the questioning by [Belhak’s] counsel

was part of a concerted plan to require defense counsel to object” and that “not all

of defense counsel’s objections were sustained.” Smith now appeals.5

5 The parties’ appellate filings suggest some confusion about whether Smith has

been dismissed from this appeal by the supreme court. So to be clear, both Smith
and her employer—Women’s Care Specialists, P.C.—properly appealed the
verdict against them and remain as appellants. Because the appellants at first
attempted to appeal from both the consolidated district court proceeding—in which
the verdict was entered—and the dormant case that had been originally filed
against Smith alone, our supreme court dismissed the appeal from the dormant
case for lack of jurisdiction. And the supreme court also dismissed a second
independent appeal that Smith then filed—again from the dormant case—for lack
of jurisdiction. See Belhak v. Smith, No. 23-0246 (April 14, 2023). But the court
never dismissed Smith from the appeal. Indeed, it noted as much in the second
dismissal, stating that Smith “is pursuing an appeal in appeal number 22-2048,
which was taken from Scott County case number LACE127225, within which all
the proceedings below had been consolidated.”
8

II.

As with any claim, to submit a particular theory of negligence—often called

a specification of negligence—to the jury, there must be substantial evidence in

the record supporting the specification. See Alcala v. Marriott Int’l, Inc., 880

N.W.2d 699, 708 (Iowa 2016). For a medical malpractice specification, that means

evidence that establishes “the applicable standard of care, a violation of that

standard, and a causal relationship between the violation and the injury.” Susie v.

Fam. Health Care of Siouxland, P.L.C., 942 N.W.2d 333, 337 (Iowa 2020). And

when multiple specifications are submitted to the jury and “[t]he jury return[s] a

general verdict without specifying which” specifications the plaintiff proved, “[a]

new trial is required . . . if the evidence was insufficient to submit one of” them.

Alcala, 880 N.W.2d at 710. We review the decision to submit a specification to the

jury for correction of errors at law. Id. at 707–08.

Smith argues that a new trial is required because Belhak failed to present

sufficient evidence of causation for one of her three specifications of negligence—

that Smith used sutures that were too small for the repair of Belhak’s episiotomy.

But before we can reach the merits of that argument, we must decide whether

Smith has preserved error for our consideration of this issue on appeal. Belhak

contends that Smith did not because Smith agreed to the jury instruction containing

the suture specification and did not adequately argue the issue in her posttrial

motion for a new trial. We disagree.

“It is a fundamental doctrine of appellate review that issues must ordinarily

be both raised and decided by the district court before we will decide them on

appeal.” Meier v. Senecaut, 641 N.W.2d 532, 537 (Iowa 2002). Moving for a
9

directed verdict on a specification of negligence is a proper way to raise the issue

that a plaintiff has introduced insufficient evidence supporting the specification.

See James ex rel. James v. Burlington N., Inc., 587 N.W.2d 462, 464 (Iowa 1998).

And when the district court denies a directed verdict, the party need not object

again to the jury instruction submitting the specification to the jury. See id. Indeed,

this has been the rule in Iowa for nearly a century. See Heavilin v. Wendell, 241

N.W. 654, 658 (Iowa 1932) (“[T]o the end that there may be no misunderstanding

about this matter, we now fix the ruling to be that, where a party makes a motion

for a directed verdict and the court overrules the same, the person against whom

such ruling is made does not waive the error, if there is one, in the court’s ruling

on a motion to direct a verdict by asking instructions which correctly state the law

of the case as fixed by the court’s ruling on the motion to direct a verdict.”).

Smith urged the district court that Belhak had failed to submit sufficient

evidence of causation on her suture specification in her directed verdict and again

in her posttrial motion for a new trial. Yet when the court considered the jury

instructions—mere moments after considering her argument and denying the

directed verdict—Smith did not again contest including the suture specification in

the marshalling instruction. Rather, she agreed it “should be submitted,” and

instead challenged other specifications as “duplicative” and “unduly emphasiz[ing]

plaintiffs’ case.” Consistent with our century of precedent, Smith preserved error

and was not required to again remind the district court that she still disagreed with

its decision that there was enough evidence to submit the specification to the jury.

Belhak tries to distinguish that precedent because Smith agreed to the jury

instruction rather than merely failing to object to it. But that is a distinction without
10

a difference. We see little daylight between the lack of an objection—which is

functionally agreement—and Smith’s statement of agreement. And the precedent

establishes no such distinction—making clear that there is no waiver from

“agreeing to jury instructions,” Holdsworth v. Nissly, 520 N.W.2d 332, 335 (Iowa

Ct. App. 1994), or even “asking [for] instructions,” Heavilin, 241 N.W. at 657, just

the same as failing to “object to the instructions,” James, 587 N.W.2d at 464.

What’s more, we see nothing in Smith’s challenge to other specifications on other

grounds that could “be taken as an abandonment of [her] clear position that, as a

matter of law, the [specification] should not have been submitted to the jury at all.”

Id.

Belhak also contends that Smith did not properly raise the issue again in

her posttrial motion for a new trial. But Smith had a three-page section of her new-

trial brief devoted to arguing that the district court “erred denying Defendants’

directed verdict motion relating to the use of sutures to repair [Belhak’s] laceration”

and in “submitting a specification of negligence instruction regarding the size of

suture used because that specification required the jury to speculate as to

causation.” While Belhak makes much of the reference to submission of the

specification instruction, this is just another way to say the same thing Smith

argued in the directed verdict motion and now on appeal—that Belhak introduced

insufficient evidence on causation to support a jury verdict on the suture

specification. And the court ruled on Smith’s argument, rejecting it both on the

merits and because the court found it had been waived by failing to object to the

instruction too. Because the issue was raised in and decided by the district court,

it was preserved. So we go to the merits.
11

Causation is a necessary element of a medical malpractice claim. See

Susie, 942 N.W.2d at 337. This will typically require expert testimony to create a

jury question because “a plaintiff needs expert testimony to prove causation unless

the causation is so obvious that it is within the common knowledge and experience

of a layperson.” Doe v. Cent. Iowa Health Sys., 766 N.W.2d 787, 794 (Iowa 2009).

Compare Stickleman v. Synhorst, 52 N.W.2d 504, 507 (Iowa 1952) (holding that

no expert testimony was required on causation where evidence showed that

patient began bleeding profusely from the neck after doctor inserted needle into

the throat, apparently missing the intended mark and hitting a blood vessel), with

Bradshaw v. Iowa Methodist Hosp., 101 N.W.2d 167, 171 (Iowa 1960) (holding

that plaintiff failed to prove causation without expert testimony that his back injury

was caused by fall in the hospital rather than a previous workplace injury).

While the evidence “need not be conclusive,” it “must show the plaintiff’s

theory of causation is reasonably probable—not merely possible, and more

probable than any other hypothesis based on such evidence.” Doe, 766 N.W.2d

at 793 (cleaned up). If the evidence before the jury does not meet this standard,

then there is not substantial evidence supporting submitting the claim to the jury.

See id. at 792–95; see also Susie, 942 N.W.2d at 337–340. “The jury cannot be

left to speculate about the but-for causal link.” Susie, 942 N.W.2d at 338–39.

Smith challenges the causation evidence of only one of Belhak’s

specifications of negligence—that Smith was negligent “by using 4-0 Vicryl sutures

to repair the episiotomy” rather than larger 3-0 sutures. And to be clear, Smith

only challenges the causation link for this specification. She does not challenge

that Belhak presented expert testimony that using smaller 4-0 sutures violates the
12

standard of care for repairing an episiotomy.6 Nor does she challenge that Belhak

presented evidence that Belhak and her husband suffered physical and emotional

injuries after the episiotomy. The narrow question is the causal link between the

two—whether the use of smaller 4-0 suture was the cause of any of Belhak’s

claimed harm.

Because the answer is not “so obvious that it is within the common

knowledge and experience of a layperson,” Belhak needed to provide expert

testimony that the smaller suture was a reasonably probable cause of the harm.

Doe, 766 N.W.2d at 794. And Belhak does not argue otherwise. We thus focus

on the testimony of Belhak’s expert witness, Dr. Chen, to see whether it provides

the jury a basis to find the required causal link without speculation. See Susie,

942 N.W.2d at 338–39.7

Belhak first points us to a general conclusion that Dr. Chen offered at the

opening of his testimony. He was asked, “And we are going to get into more details

later, but as a result of Dr. Smith’s breaches of the standard of care, were they a

cause of permanent harm to Fatima Belhak?” And Dr. Chen answered, “Yes.” But

6 Of course, this does not mean that Smith agrees that using 4-0 sutures violates

the standard of care—her own expert witness provided a contrary opinion.
7 Again, the issue before us is whether Dr. Chen’s testimony provides “substantial

evidence support[ing] the submission of the causal relationship between” Smith’s
use of the smaller sutures and Belhak’s injury. Doe, 766 N.W.2d at 792. It is not—
as Belhak frames it in her brief—whether “Dr. Chen’s expert opinions are
supported by the record.” So Belhak is wrong to try to shift the burden for
developing the causation record onto Smith based on cases challenging the
admissibility of an expert’s opinion. See Mercy Hosp. v. Hansen, Lind & Meyer,
P.C., 456 N.W.2d 666, 671 (Iowa 1990). The burden of presenting substantial
evidence on all required elements of a plaintiff’s claim—so that it may be submitted
to the jury—remains at all times on the plaintiff. See Doe, 766 N.W.2d at 792–93;
see also Iowa R. Civ. P. 1.945 (authorizing motion for directed verdict “[a]fter a
party has rested,” and “no right to relief has been shown, under the law or facts.”).
13

this alone—without any explanation about what standards of care Dr. Chen was

referring to or how any particular breach caused harm—does not move a jury out

of speculative territory. And it is apparent from this introductory comment that

Belhak’s counsel as well understood that “more details” were needed and

expected to come to give a basis for the conclusion.

Dr. Chen then provided those added details for the causation of Belhak’s

other theories of negligence aside from the suture size. He opined that Smith’s

failure to conduct a rectal examination or to recognize a fourth-degree laceration

caused a multi-month delay in properly repairing the episiotomy. And he explained

that this delay resulted in harms—both while waiting for treatment and

permanently. But when it came time to testify about the 4-0 sutures, Dr. Chen was

asked little about the causal link between the 4-0 sutures and Belhak’s harm. And

what he did say does not provide the required support to find that link.

True, in explaining his opinion that using 4-0 sutures violates the standard

of care, Dr. Chen said that he thought using those smaller sutures “would increase

the risk of the wound breaking down or not have enough strength to hold it

together.” But he did not testify that Belhak’s sutures did not actually hold together

or that her wound broke down because of the sutures.

Much of Dr. Chen’s testimony focused on interpreting medical records from

the University of Iowa Hospitals and Clinics when Belhak was treated there by

specialists who diagnosed her with the fourth-degree laceration and observed the

status of Smith’s original repair with the 4-0 sutures. Belhak did not call those

specialists to testify directly, so the medical records and Dr. Chen’s interpretation

of them were the only evidence of their conclusions. One note in those records
14

said that the “vaginal repair site appears broken down.” When asked what this

note means, Dr. Chen answered, “It’s hard to say, exactly. From what my guess

is, they are seeing an opening either in the perineum or in the vagina or both.”

Belhak’s counsel then pressed Dr. Chen further. And because this exchange is

key to understanding our resolution of the case, we quote it in full:

Q. When you are looking at this record, what does it mean to
you? A. So broken down means they may see some intact stitches,
but you will see tissue that is not sutured, but appears to be
separated.
Q. And so, you said, “appears to be separated,” so—
A. Correct, whether it’s a millimeter separated or fa[r]ther, just not
touching each other like they should be; that there is still a defect, I
guess, for lack of a better term.
Q. Within a reasonable degree of medical certainty, that being
more likely true than not, was Dr. Smith’s breach of the 4-0 sutures
that she used a cause of the vaginal repair site breaking down?
A. My interpretation, also, they may think it was broken down,
meaning they assume, for example, a fourth degree was repaired,
and they see a defect in the perineum and don’t see sutures there,
so they are assuming some of the sutures were dissolved versus it
not being repaired at all.
Q. Sure. So you can’t tell whether—which circumstance, but
you know that whatever sutures that this medical provider is looking
at has been broken down? A. Some of the suture, yes.

After starting to ask another follow-up, Belhak’s counsel then instead moved on to

covering other topics.

It is tough to know what Dr. Chen was trying to say during this exchange.

His answer as to whether the use of 4-0 sutures was “a cause of the vaginal repair

site breaking down” was particularly “cryptic” and “confusing.” Susie, 942 N.W.2d

at 338. And he never agreed that the 4-0 sutures were likely the cause of

anything—the breakdown of the repair site or otherwise. Indeed, from the

exchange it is not clear that he even agreed it is more likely than not that the

observed breakdown was of the 4-0 sutures rather than just the fourth-degree
15

laceration that he believed Smith had missed diagnosing—which, again, was one

of the alternative specifications of negligence not challenged here. This testimony

thus improperly left the jury to speculate about the but-for causal link. See id. at

338–39.

But there is another problem. Even if Dr. Chen had answered the question

and agreed that the 4-0 sutures caused a breakdown at the repair site, that

testimony still would not have completed the causal link between the sutures and

Belhak’s harm. Dr. Chen was never asked—and thus never explained—whether

any breakdown in the repair site caused by the sutures in turn caused Belhak harm.

Unlike his testimony on the other alleged acts of negligence, he never opined that

the use of the sutures caused the multi-month delay in properly repairing the

episiotomy or the related concrete harms from that delay. For example, he never

opined that the sutures likely caused the fourth-degree laceration or that they likely

made any harm Belhak suffered worse. So any attempt to complete that last

causal link would require improper speculation by the jury too. See id. at 338–39.

Without any evidence from which a jury could conclude that Smith’s use of

smaller sutures was a cause of Belhak’s injury, it was error for the district court to

submit the suture specification of negligence to the jury. And because the general

verdict does not tell us which of the specifications the jury found to be proven,

Smith is entitled to a new trial. We thus reverse the district court judgment and

remand this case for a new trial consistent with this opinion.

III.

Because a new trial is required due to the improper submission of the suture

specification, we need not decide whether the conduct of Belhak’s attorney during
16

closing arguments also warrants a new trial. But since the new trial will again

require the parties’ counsel to engage in proper closing arguments, we find it

appropriate to offer some guidance to prevent these issues from arising again.

The district court concluded that Belhak’s counsel engaged in three

instances of misconduct during closing arguments. Belhak’s counsel improperly

attacked defense counsel by accusing him of “character assassination” of Belhak

during defense counsel’s questioning of Dr. Chen. He improperly attacked the

defense’s expert witness by suggesting—without any basis in evidence—that the

expert had violated his Hippocratic oath when performing episiotomies in

Honduras. And he improperly mischaracterized Belhak’s medical records from the

University of Iowa Hospitals and Clinics by saying, “The University of Iowa said

that the fourth-degree laceration was there at the time of delivery,” when that

conclusion is nowhere in the records or any other trial evidence.

“Attorneys have a duty to refrain from crossing the admittedly hazy line

between zealous advocacy and misconduct.” Kinseth v. Weil-McLain, 913 N.W.2d

55, 73 (Iowa 2018). And our decision not to decide whether this conduct would

independently warrant a new trial should not be interpreted as any disagreement

with the district court’s well-reasoned conclusions that this conduct by Belhak’s

counsel crossed that line.

“When attorneys approach the jury box to present their closing arguments,

they carry with them an immense responsibility.” Id. While “[w]e presume juries

follow [their] instruction and do not consider closing statements to be evidence,”

we recognize that they “will inevitably take [their] cues from attorneys during their

respective closing arguments.” Id. And so, “we observe a heightened sensitivity
17

to inflammatory rhetoric and improper statements, which may impress upon the

jury that it can look beyond the facts and law to resolve the case.” Id. Engaging

in unwarranted personal attacks against opposing counsel and the opposing

party’s expert witness and misstating key evidence are violations of this

responsibility we entrust to Iowa attorneys as officers of the court.

Of course, “attorneys may occasionally make one or more isolated missteps

during closing arguments,” particularly in the heat of zealous advocacy. Id. But

we caution that “repeated” and “deliberate” misconduct is another matter entirely—

more likely to require a new trial. Id. And so, Belhak’s counsel would be wise to

take care that his misconduct does not repeat.

REVERSED AND REMANDED.