Della Sumrall v. Singing River Health System ( 2015 )

IN THE COURT OF APPEALS OF THE STATE OF MISSISSIPPI
NO. 2014-CA-01139-COA
DELLA SUMRALL AND ROY SUMRALL APPELLANTS
v.
SINGING RIVER HEALTH SYSTEM APPELLEE
DATE OF JUDGMENT: 05/05/2014
TRIAL JUDGE: HON. ROBERT P. KREBS
COURT FROM WHICH APPEALED: JACKSON COUNTY CIRCUIT COURT
ATTORNEY FOR APPELLANTS: ROBERT W. SMITH
ATTORNEYS FOR APPELLEE: JOSHUA WESLEY DANOS
ROY C. WILLIAMS
BRETT K. WILLIAMS
NATURE OF THE CASE: CIVIL - MEDICAL MALPRACTICE
TRIAL COURT DISPOSITION: JUDGMENT IN FAVOR OF APPELLEE
DISPOSITION: REVERSED AND REMANDED-11/10/2015
MOTION FOR REHEARING FILED:
MANDATE ISSUED:
EN BANC.
GRIFFIS, P.J., FOR THE COURT:
¶1. Della and Roy Sumrall filed a medical-malpractice claim against Singing River Health
System (Singing River). After a bench trial, the trial court entered a judgment in favor of
Singing River. The Sumralls appeal the judgment and argue that: (1) Singing River’s expert
witness should not have been allowed to testify on the nursing standard of care; (2) the court
erred in denying the Sumralls’ motion for partial summary judgment on the standard of care;
(3) the trial court applied the wrong burden of proof; (4) the judgment was against the
overwhelming weight of the evidence; and (5) cumulative error necessitates reversal. We
find reversible error and remand this case to the Circuit Court of Jackson County for further
proceedings.
FACTS AND PROCEDURAL HISTORY
¶2. On February 23, 2012, Della was admitted to Ocean Springs Hospital1 with a
complicated case of acute cholecystitis, or inflamation of the gallbladder. Dr. Edward
Dvorak, a general surgeon, recommended removal of Della’s gallbladder and subsequently
ordered a central line be placed in her external jugular vein. A “central line” refers to a
central venous access device placed into a large vein in the patient. It is used to provide the
patient with medicine, nutrients, fluids, or blood products. Della’s treatment was completed
without further complications.
¶3. On February 29, 2012, Della was scheduled for discharge. Prior to her discharge,
Chequita Steele, an OSH registered nurse, monitored Della. Nurse Steele testified that Della
had previously complained of the inability to breathe when lying flat on her back and
preferred to sit up. In addition to her problem with her gallbladder, Della had chronic
pulmonary obstruction disease (COPD) and a partially collapsed lung, among other health
problems.
¶4. Nurse Steele testified that Della had been reclining in a chair in her hospital room at
an angle of less than ninety degrees–specifically “somewhere in between 30 [degrees] and
45 [degrees]. Probably closer to 45 [degrees].” Nurse Steele talked with Della about the
1
Singing River is the owner and operator of Ocean Springs Hospital (OSH). For
purposes of this appeal, both will be referred to with the understanding that Singing River
and OSH are the same legal entity.
2
need to remove the central line and the removal process. Thereafter, Nurse Steele removed
the dressing that covered the insertion site and cut the sutures holding the line in place.
Nurse Steele then instructed Della to perform the Valsalva maneuver while Steele applied
pressure to the site with gauze and removed the central line. The Valsalva maneuver requires
the patient to take a deep breath, hold it, and bear down.
¶5. Nurse Steele then testified that she held pressure on the exit site for approximately one
minute. At that point, Della began gasping for breath, and she said, “I can’t breathe.” Della
then became unresponsive.
¶6. Della was given emergency treatment in her room. Then, she was taken to the OSH
intensive-care unit. Della suffered anoxic brain damage and permanent impairment. Della
was discharged from OSH on March 29, 2012. The discharge instructions included
information on treating a stroke.
¶7. On May 18, 2012, the Sumralls filed a medical-malpractice claim against Singing
River and OSH. The complaint alleged that Nurse Steele improperly removed Della’s central
line, which caused an air embolus, cardiopulmonary arrest, and anoxic brain damage.
¶8. Because Singing River is a governmental entity, the Mississippi Tort Claims Act
governs the Sumralls’ claims. As required, the trial court held a bench trial from December
9 through December 11, 2013. On April 29, 2014, the trial court entered its findings of fact
and conclusions of law. The trial court ruled in favor of Singing River and found that there
was no nursing standard of care in the removal of a central line. Thus, the trial court
concluded that Singing River did not violate any standard of care. On May 4, 2014, the trial
3
court entered a final judgment. It is from this judgment the Sumralls now appeal.
ANALYSIS
¶9. The Sumralls’ appeal has raised five separate issues. Central to three of the issues is
a challenge to the admission of the opinion evidence of Singing River’s expert – Dr. James
E. Corder. After considering the issues raised, we have combined these issues under the
Sumralls’ challenge that the trial court’s findings were against the overwhelming weight of
the evidence and find this issue dispositive.
¶10. The standard of review for a judgment rendered after a bench trial is well settled. “‘A
circuit court judge sitting without a jury is accorded the same deference with regard to his
findings as a chancellor,’ and his findings are safe on appeal where they are supported by
substantial, credible, and reasonable evidence.” City of Jackson v. Brister, 838 So. 2d 274,
277-78 (¶13) (Miss. 2003) (quoting Maldonado v. Kelly, 768 So. 2d 906, 908 (¶4) (Miss.
2000)). In addition, we must “recognize[] that the trial judge, sitting in a bench trial as the
trier of fact, has the sole authority for determining the credibility of the witnesses.” City of
Jackson v. Lipsey, 834 So. 2d 687, 691 (¶14) (Miss. 2003).
¶11. The trial court ruled in its findings of fact and conclusions of law:
[Della] was set to be discharged from [OSH] on February 29, 2012[,] to a
comprehensive rehabilitation center. Nurse Chequita Steele, an employee of
[Singing River,] was in charge of preparing [Della] for discharge. At a couple
of points in the nursing notes from Nurse Steele, she noted that [Della] was
sitting in a bedside chair in a position less than 90 degrees. Nurse Steele
testified that [Della] was in the same type position when she removed [Della’s]
central line. Nina Musgrove, [Della’s] daughter, disagreed “with Nurse
Steele’s assessment of [Della’s] positioning at the time of the central line
removal.”
4
Nurse Steele explained the central line removal procedure to [Della], [and] had
her take a deep breath and then bear down (the [V]alsalva maneuver) as she
removed the line. It appeared that [Della] understood and complied with the
instructions she was given. Once the line was removed, Nurse Steele applied
pressure to the wound site. Almost immediately after the central line removal,
[Della] began experiencing distress, was gasping for air[,] and became
unresponsive. Nurse Steele called for assistance, and the response team
entered the room to administer care and take [Della] to [the] ICU. Based upon
the testimony and medical records[,] it appears as though there is a
disagreement as to the cause of the [Della’s] distress. It was either an air
embolism or perhaps a cardiac event along with a stroke.
The [Sumralls] presented two experts, Dr. Lidgia Vives and Nurse Crystal
Keller, to offer evidence as to the nursing standard of care regarding patient
positioning during central line removal. Both of [the Sumralls’] experts
testified that the generally accepted standard of care for central line removal
required the following: the nurse should educate the patient about the
procedure; place the patient in the Trendelenb[u]rg position, which is
described as having the patient in a supine position where the site of the central
line insertion is below the heart; have the patient take a deep breath, hold and
bear down (the [V]alsalva maneuver); then, at removal, place gauze with
pressure at the removal site.
Both experts further agreed that if a patient were unable to tolerate the
Trendelenb[u]rg position for whatever reason (breathing difficulty in that
position or intracranial pressure), that a position other than and at less of an
angle was acceptable to perform the central line removal. They did, however,
testify[] that there was no indication that [Della] could not tolerate the
Trendelenb[u]rg position at the time Nurse Steele removed her central line in
preparation for her discharge to the rehabilitation facility[.]
[Singing River] offered the testimony of Dr. Jim Corder. He opined that as to
the applicable standard of nursing care for positioning a patient to remove a
central line, there was none. Based upon his knowledge and experience, the
literature and the fact that hospital policies from across the country on this
issue varied widely, no one position of a patient during central line removal
was so overwhelmingly required, that there truly was no uniformity that would
equate to a standard of care to be followed by nurses. Furthermore, it was
noted in Nurse Steele’s testimony that [Della] was unable to tolerate the
Trendelenb[u]rg position due to some difficulty breathing while in that
position. Based upon the preponderance of the evidence presented for the
Court’s consideration, the Court finds as a matter of fact that there is no
5
recognized applicable standard of nursing care with regard to patient
positioning during the removal of a central line. The widely varying literature
and policies clearly demonstrate that some recline during the removal process
is preferred, but it also depends on the condition and tolerance of the
individual patient.
(Emphasis added).
¶12. While there are additional findings and conclusions, we stop at this point in the trial
court’s findings to begin our consideration. The Sumralls challenge several findings by the
trial court, but we find that there are two that are essential to our review. First, the Sumralls
claim that Dr. Corder should not have been able to testify that there was no applicable
standard of care. Second, the Sumralls contend that Dr. Corder should not have been allowed
to testify that Della suffered a stroke.
¶13. Both in the pretrial expert witness disclosures and at trial, the Sumralls’ expert
witnesses testified that the applicable standard of care for a registered nurse removing a
central line consisted of four key steps:
1. Educate the patient about the procedure;
2. Place the patient in the Trendelenburg position (lying on her back with
her upper torso inclined downward so the central line insertion site is
below the heart);
3. Perform the Valsalva maneuver (have the patient take a deep breath and
bear down);
4. Upon removal, apply pressure and impermeable gauze at the site of
removal.
¶14. Here, we are concerned with the second step, i.e., the proper positioning of the patient.
We also note that there was testimony that the removal of a central line may be done by both
6
nurses and doctors. Thus, there was no testimony that the standard of care for the removal
of a central line would be different depending on the type of medical professional. So we
reject the allegation that Singing River failed to present evidence of a separate nursing
standard of care. There was absolutely no evidence that a doctor or a nurse would remove
a central line differently.
¶15. Dr. Vives and Nurse Keller explained that the proper positioning of the patient was
medically necessary because ambient air pressure is greater than venous blood pressure
above the heart, and an open hole can be a pathway for air to enter the venous system. They
also testified that these standards of care were well known and supported by voluminous
medical literature. For example, Johns Hopkins Hospital’s policy and procedure states that
use of the Trendelenburg position for removal of central lines is imperative.
¶16. The Sumralls also offered Della’s medical records while at Singing River, which read:
Nurse Note: 16:45, Katy Lorenzo: rapid response called on 2 East. Patient
sitting up in chair unresponsive to verbal command.
Dr. Rodberg (pulmonologist): Apparently while seated in the chair, the
patient’s central line was removed.
Dr. McShurley (internal medicine): Shortly prior to discharge, the patient’s
central line was removed. Apparently was sitting in a chair and . . . became
unresponsive.
Dr. Rodberg (pulmonologist and employee of Singing River Health System):
Impression: (1) probable air embolus from removal of central line[;] (2) near
respiratory arrest[;] (3) shock secondary to air embolus.
Dr. Karcher (neurologist): It is suspected that she may have had an air embolus
due to removal of the central line. Assessment: possible anoxic brain injury
status post near respiratory arrest yesterday with subsequent myoclonic jerks.
7
Dr. Taylor (pulmonologist and employee of Singing River Health System):
probable air embolism with resultant cardiovascular collapse and possible
anoxic brain injury.
Dr. Roth (internal medicine and employee of Singing River Health System):
She had a little bit of air embolus associated with the venous process resulting
in near cardiopulmonary arrest.
Dr. McShurley (internal medicine and employee of Singing River Health
System): (3/4/12) shock probably due to air embolism resulting in
cardio-vascular collapse secondary to removal of central line in the upright
position.
Dr. Taylor (pulmonologist and employee of Singing River Health System):
probable air embolism with resultant cardiovascular collapse.
(Quotations omitted).
¶17. The Sumralls also point to the testimony of OSH nurse Jenna Blaine. Nurse Blaine
testified that she removed a second central line from Della on March 19, 2012, just twenty
days after the February 29, 2012 incident, while accompanied by a Singing River “patient
care representative” who was present precisely to assure the procedure was done correctly.
Nurse Blaine explained that she placed Della in the Trendelenburg position, removed the
central line, and applied pressure. The Sumralls contend that this was consistent with the
exact steps that their experts and the applicable medical literature stated was the applicable
nursing standard of care.
¶18. The Sumralls introduced the sworn deposition of Dr. John Weldon, a hospitalist and
full-time employee of Singing River. Dr. Weldon was not on duty on February 29, 2012, but
he rendered care to Della during her hospital stay. Dr. Weldon had made a one-line entry in
Della’s voluminous medical record. On March 5, 2012, several days after the central-line
8
incident, he wrote – “I think she had a stroke.” Then, in his deposition, Dr. Weldon
explained that he had no opinion on the etiology of Della’s condition, that the root cause
could well be air embolism, and that his later entry in the medical record referencing a stroke
was simply meant to document that stroke was part of his differential diagnosis. Dr. Weldon
confirmed there were no test results that confirmed a stroke, that he was not offering an
opinion that Della had a stroke, and that he had no opinion as to whether stroke or air
embolism was more probable. He was asked what he would do if he saw a Singing River
nurse getting ready to pull a central line from a patient sitting up in a chair; Dr. Weldon
testified, “I would stop her.” When asked why, he stated, because “that’s not the right way
to do it.”
¶19. To counter the Sumralls’ expert opinions, Singing River called Dr. Corder. Dr.
Corder is board certified in internal medicine and anesthesiology. His practice is as an
intensivist, which he described as a subspecialist in critical-care medicine, basically directing
intensive-care units, and caring for patients in them.
¶20. Over the Sumralls’ objections, Dr. Corder was allowed to testify that Nurse Steele
“did not breach the standard of care,” and that “there is no national standard of care.” He
also was allowed to opine, over an objection, that “Dr. Weldon thought she had a stroke and
I think she had a stroke.” Dr. Corder admitted he had never read Dr. Weldon’s deposition
and did not know that Dr. Weldon stated under oath he had no opinion as to whether Della
had a stroke. The Sumralls’ objection was that Singing River’s pretrial disclosures of Dr.
Corder’s opinions did not state that Dr. Corder would (a) identify the nursing standard of
9
care, (b) testify that Della had a stroke, or (c) testify that Della had a heart attack.
¶21. After the objection, the trial court took a recess to review Singing River’s expert
designation and disclosures. The trial court then sustained the objection to Dr. Corder
testifying that Della had a heart attack, but allowed Dr. Corder to testify that he thought “she
had a stroke” and that Nurse Steele did not breach the nursing standard of care. The Sumralls
argue that this was further confused by Dr. Corder’s testimony that there was “no national
standard of care for positioning or for removal of a central line,” and that the procedures used
by Nurse Steele in removing the central line from Della were simply “techniques to optimize
removal of a central line.”
¶22. The Sumralls challenge the decision by the trial court to allow Dr. Corder’s testimony
that was not consistent with his pretrial disclosures. The standard of review for the
admission or exclusion of evidence, such as expert testimony, is abuse of discretion. Barrow
v. May, 107 So. 3d 1029, 1034 (¶10) (Miss. Ct. App. 2012). This Court will not overturn the
trial court on an evidentiary issue unless the trial court abused its discretion or was clearly
erroneous. Worthy v. McNair, 37 So. 3d 609, 614 (¶13) (Miss. 2010).
¶23. In Canadian National/Illinois Central Railroad v. Hall, 953 So. 2d 1084, 1097 (¶¶43-
44) (Miss. 2007), the supreme court ruled:
[O]ur rules of civil procedure require that a party must disclose the name of
each expert expected to be called as a witness at trial, the subject matter on
which each expert is expected to testify, the substance of the facts and
opinions to which the expert is expected to testify[,] and a summary of the
grounds for each opinion. M.R.C.P. 26(b)(4)(A)([i]). When a discovery
violation occurs, one of the sanctions available under our rules of civil
procedure is “an order refusing to allow the disobedient party to support or
oppose designated claims or defenses, or prohibiting him from introducing
10
designated matters in evidence.” M.R.C.P. 37(b)(2)(B). This Court has stated
that “[a]n expert should not be allowed to testify concerning a subject matter
which is not included in the response to the interrogatory,” and allowance of
such would be reversible error. Buskirk v. Elliott, 856 So. 2d 255, 264 [(¶25)]
(Miss. 2003).
Compliance with the rule involves a fact-intensive comparison between the
subject matter contained in discovery responses and the subject matter of the
testimony given by the expert at trial. Id. This Court has found discovery
violations and subsequent exclusion of expert testimony to be proper when the
experts testified as to a subject matter different from the subject matter
contained in discovery responses. See, e.g., Coltharp v. Carnesale, 733 So. 2d
780, 786 [¶(27)] (Miss. 1999) (trial court committed reversible error by
admitting expert testimony supporting additional theory of plaintiff's injury not
revealed during discovery); T.K. Stanley Inc. v. Cason, 614 So. 2d 942, 950-51
(Miss. 1992) (trial court erred in admitting expert testimony regarding
permanent disability, as it was a separate subject matter from causation).
However, this Court has established that “where the stated subject matter in the
response necessarily includes the subject matter testified to at trial, it is an
abuse of discretion to exclude the expert’s testimony.” Buskirk, 856 So. 2d at
264 [(¶25)].
¶24. We have carefully examined Singing River’s pretrial disclosures about Dr. Corder’s
testimony. According to the disclosure, Dr. Corder was to testify “that Nurse Steele’s
removal of [Della]’s central line was within the applicable nursing standard of care.” It was
also disclosed that he would testify “regarding the policies and procedures of Singing River
Health Systems in the placement and withdraw of central lines.”
¶25. The disclosure indicated that Dr. Corder would testify that the removal of the central
line was “within the applicable nursing standard of care.” This implies that there is an
“applicable . . . standard of care.” If Dr. Corder was to testify as to a standard of care that
was different from the standard of care claimed by the Sumralls, Rule 26(b)(4)(A)(i) required
that Singing River state the substance of the facts and opinions to which the expert was
11
expected to testify and a summary of the grounds for each opinion. Dr. Corder’s disclosure
certainly did not state, as he testified, that “there is no national standard of care.” As such,
we find Dr. Corder’s testimony to be in conflict with the disclosures, and we conclude it was
error to allow Dr. Corder to testify that “there is no national standard of care” for patient
positioning for the removal of a central line.
¶26. Likewise, the disclosure also stated that Dr. Corder would testify “regarding the
policies and procedures of Singing River Health Systems in the placement and withdraw[al]
of central lines.” Yet, in his testimony, Dr. Corder did not testify as to or offer any such
policy or procedure for Singing River. Thus, we find his testimony was not consistent with
the disclosures, and the disclosures did not state the substance of the facts and opinions to
which the expert was expected to testify and a summary of the grounds for each opinion as
required by Rule 26(b)(4)(A)(i). As such, we conclude it was error to allow Dr. Corder to
testify that “there is no national standard of care” for patient positioning for the removal of
a central line.
¶27. Also, the Sumralls challenge the admission of Dr. Corder’s opinion that “Dr. Weldon
thought she had a stroke and I think she had a stroke.” Dr. Weldon did not testify that Della
had a stroke. Thus, there was no factual basis to support Dr. Corder’s statement on Dr.
Weldon’s opinion. Also, Dr. Corder’s disclosures stated that he would testify “that it is
highly improbable [Della] suffered from an air embolus. Furthermore, Dr. Corder will opine
that, even assuming an air embolus occurred, it is a known complication of central line
12
removal.”2
¶28. Dr. Corder’s designation does not mention that he would opine that Della had a
“stroke.” It does indeed state “that it is highly improbable [she] suffered from an air
embolus,” but it does not disclose he would testify she suffered a stroke. Without mention
of the stroke, we must also determine that – as to the opinion that Della suffered a “stroke”
– the disclosures did not state the substance of the facts and opinions to which the expert was
expected to testify and a summary of the grounds for each opinion as required by Rule
26(b)(4)(A)(i). As such, we find Dr. Corder’s testimony to be in conflict with the
disclosures, and we conclude it was error to allow Dr. Corder to testify, “Dr. Weldon thought
she had a stroke and I think she had a stroke.”
¶29. Therefore, we find that the trial court abused its discretion in allowing Dr. Corder to
testify inconsistent with, outside of, and beyond his designation. First, we find that the trial
court’s finding that “as a matter of fact . . . there is no recognized applicable standard of
nursing care with regard to patient positioning during the removal of a central line” and
“without an applicable standard of care, there can be no breach of such,” was not supported
by substantial, credible, and reasonable evidence. Second, we find that the trial court’s
finding that “[i]t was either an air embolism or perhaps a cardiac event along with a stroke”
was not supported by substantial, credible, and reasonable evidence.
2
In the second amended designation of expert witnesses, Singing River added that
“Dr. Corder will be offered to contradict any opinions on standard of care and/or causation
as stated in the depositions of Plaintiffs’ experts, Dr. Ladgia Vives and Crystal Keller, R.N.”
However, Singing River did not offer any further explanation on the contradictions that were
intended to be part of Dr. Corder’s testimony.
13
¶30. Further, we find that the Sumralls offered expert testimony, supported by extensive
medical literature, to indicate that there was a standard of care for a nurse to remove a central
line. We recognize that the standard of care may include some variation in the proper
positioning of the patient depending upon her condition. However, the trial court’s finding
that there is no standard of care is against the overwhelming weight of the evidence and must
be reversed. Hence, we reverse the trial court’s judgment and remand for further proceedings
consistent with this opinion.
¶31. In addition, we recognize that the Sumralls have also challenged a number of the trial
court’s discovery and pretrial rulings under the issue they refer to as “cumulative error.”
Because we have decided to reverse and remand this case for further proceedings, we find
the issues raised in the cumulative-error section are now moot. Furthermore, we are of the
opinion that the Sumralls have raised these issues only as to the finding of cumulative error
and do not ask this Court to reverse the trial court’s ruling on each of the individual issues.
Had the Sumralls so intended, they would have provided citations to legal authority and
included these as separate issues. As a result, we make no ruling as to these separate issues.
¶32. THE JUDGMENT OF THE CIRCUIT COURT OF JACKSON COUNTY IS
REVERSED, AND THIS CASE IS REMANDED FOR FURTHER PROCEEDINGS
CONSISTENT WITH THIS OPINION. ALL COSTS OF THIS APPEAL ARE
ASSESSED TO THE APPELLEE.
LEE, C.J., IRVING, P.J., BARNES, MAXWELL, FAIR AND JAMES, JJ.,
CONCUR. CARLTON, J., CONCURS IN PART AND DISSENTS IN PART WITH
SEPARATE WRITTEN OPINION. WILSON, J., DISSENTS WITH SEPARATE
WRITTEN OPINION, JOINED BY ISHEE, J.
CARLTON, J., CONCURRING IN PART AND DISSENTING IN PART:
14
¶33. I respectfully concur in part and dissent in part. I agree with the majority’s decision
reversing the judgment of the trial court. However, I would render a judgment in favor of
the Sumralls as to the issue of liability and remand to the trial court to determine damages.
I submit that the findings and judgment of the trial judge in this bench trial were not
supported by credible or substantial evidence in the record. I also submit that the trial court’s
findings were contrary to established Mississippi law. As a result, the judgment is against
the overwhelming weight of the evidence and contrary to the law.
¶34. In this case, the record reflects that the Sumralls met their burden of presenting a
prima facie case of medical negligence against Singing River Hospital and its nursing staff.3
3
See McIlwain v. Natchez Cmty. Hosp. Inc., 2013-CA-00572-SCT, 2015 WL
5157499, at *3 (¶15) (Miss. Sept. 3, 2015) (setting forth elements to show medical
negligence of hospital and of its staff). The record reflects that the Sumralls’ expert Dr.
Lidgia Vives, a vascular neurologist, testified that Nurse Steele breached the applicable
standard of care by negligently removing Della’s central line jugular catheter and thereby
caused the devastating and permanent damage alleged in this case. Dr. Vives testified that
Nurse Steele violated the applicable standard of care as follows: by negligently removing
the central line catheter from Della while she sat up in a chair, instead of removing it in the
recommended Trendelenburg position, a supine position that places the catheter site below
the heart to prevent an air embolism; Nurse Steele failed to document the use of the Valsalva
maneuver in the patient chart and that the Valsalva maneuver is required to prevent air
embolisms; Nurse Steele's deposition testimony reflects that Nurse Steele left the site
uncovered; and Nurse Steele removed the central line without a doctor's order to do so. The
record also reflects expert testimony that Nurse Steele removed the central vein without
supportive or intervention care such as a heart monitor, available 100% oxygen for suspected
air embolism, and without monitoring Della's respirations or EKG. The Sumralls’ medical
experts included Dr. Vives, Dr. James Martin, and Crystal Keller, R.N. Dr. Martin was the
medical director of the nursing facility to which Della was admitted for care after her
discharge from Singing River Hospital. Dr. Vivies and Nurse Keller both testified as to the
applicable standard of care, and their testimony was supported by medical literature. The
expert testimony established that the standard of nursing care for removing a central line
requires that a patient be placed in the Trendelenburg position, or a supine position, so that
the central line insertion site in the jugular is at or below her heart to reduce the risk of air
embolus. The standard also requires educating the patient about the procedure and getting
15
The Sumralls met this burden specifically through the testimony of two medical experts
establishing the following evidence of the required elements: (1) the standard of nursing care
applicable in this case; (2) the duty owed to Della in this case to conform to that required
medical standard; (3) the breach of that duty by Singing River as the proximate cause of
Della’s injuries and damages.4 “Recovery in a negligence action requires proof by a
preponderance of the evidence of the conventional tort elements: duty, breach of duty,
proximate causation, and injury (i.e., damages).” Palmer v. Biloxi Reg'l Med. Ctr. Inc., 564
So. 2d 1346, 1354 (Miss. 1990). Singing River, however, failed to present competent
conflicting evidence and therefore failed to rebut the Sumralls’ prima facie case.
¶35. The laws of the state of Mississippi have long recognized that “[a] hospital may be
subject to liability for its own acts of negligence toward patients and others, but also, it may
be liable where the negligence of its health care personnel is imputed to the hospital under
an agency theory.” Boyd v. Lynch, 493 So. 2d 1315, 1319 (Miss. 1986).5 The determination
of whether a duty is owed constitutes a question of law, and is reviewed de novo on appeal.
the patient to perform the Valsalva maneuver, hold pressure, and apply occlusive gauze.
Expert testimony reflects that central venous catheters may be inserted at locations other than
the jugular, like the chest or groin, which may not required not require a supine position to
place the insertion site at or below the heart.
4
See McIlwain, 2013-CA-00572-SCT, 2015 WL 5157499, at *3 (¶15).
5
See Delta Reg'l Med. Ctr. v. Venton, 964 So. 2d 500, 506 (¶¶16-20) (Miss. 2007)
(finding that negligent acts of nursing staff and other employees constituted the proximate
contributing cause of the patient’s injuries and death); DeLaughter v. Lawrence Cnty. Hosp.,
601 So. 2d 818, 824-25 (Miss. 1992); Miss. Baptist Health Sys. Inc. v. Kelly, 88 So. 3d 769,
776-77 (¶¶22, 26) (Miss. Ct. App. 2011).
16
See Scafide v. Bazzone, 962 So. 2d 585, 592-93 (¶¶20-21) (Miss. Ct. App. 2006).6
¶36. In applying a de novo standard of review to the findings and judgment of the trial
court, I submit that the trial court erroneously found that no duty was owed by Nurse Steele,
and hence by Singing River, to Della. Mississippi law has long recognized that nursing
personnel of a hospital owe at the very least a duty to exercise due care to the patients.3 See
Univ. of Miss. Med. Ctr. v. Pounders, 970 So. 2d 141, 148 (¶29) (Miss. 2007). Thus, Singing
River failed to present competent medical expert testimony to rebut the Sumralls’ prima facie
case.4 The trial court therefore erred as a matter of law in its findings, and its resulting
verdict is contrary to the evidence and law. “If a [hospital] chooses to allow a nurse to
perform a non-delegable duty” of a physician to assure that medical treatment is properly
ordered and administered, then “the [hospital] must accept responsibility if that duty is
breached” by a nurse.5 See and compare Sacks v. Necaise, 991 So. 2d 615, 619 (¶9) (Miss.
Ct. App. 2007). The expert testimony presented by the hospital’s expert, Dr. Corder, and the
6
See also Belmont Homes Inc. v. Stewart, 792 So. 2d 229, 232 (¶11) (Miss. 2001)
(whether a duty is owed is a question of law that is reviewed de novo).
3
Dr. Corder's testimony conflicts with established law that reflects that at the very
least, the hospital owes its patients a duty to exercise reasonable care. Univ. of Miss. Med.
Ctr. v. Pounders, 970 So. 2d 141, 148 (¶29) (Miss. 2007). “When a doctor notifies a
hospital that a patient is at high risk for a particular type of complication, the hospital must
take reasonable precautions to reduce or eliminate the risk, if possible.” Id. (citing Clark v.
St. Dominic-Jackson Memorial Hosp., 660 So. 2d 970, 972-73 (Miss. 1995)).
4
See also M.R.E. 702 (evidentiary criteria for medical experts).
5
See Code Miss. R. 15-16-1:41.30 (hospital policies must comply with professionally
recognized nursing standards and delineate the functions for which the nursing service is
responsible; policies must address orders).
17
trial judge’s related finding that the hospital owed no duty to Della caused “error within the
trial mechanism itself [causing] a legally incorrect or unjust verdict to be rendered.”
Compare Loyacono v. Travelers Ins. Co., 168 So. 3d 981, 983 (¶8) (Miss. Ct. App. 2013),
and Bell v. City of Bay St. Louis, 467 So. 2d 657, 659 (Miss. 1985) (verdict reversed and
rendered where jury was instructed contrary to Mississippi law).
¶37. The trial court also erred in its findings and verdict in relying on the medical opinion
testimony of Nurse Steele for opinions falling outside of the scope of her nursing expertise.
The record reflects no physician’s order authorizing nurses, or Nurse Steele, to remove
central venous catheters, or to remove Della’s central catheter. The record does reflect,
however, that upon embarking on Della's gallbladder surgery, her treating physician issued
an order for a physician to insert the right internal jugular central venous line in Della, and
anesthesiologist Dr. Paul Harris inserted her central venous catheter. The record further
reflects that Nurse Steele decided on her own to remove Della’s central venous catheter
without a doctor's order and without even consulting a doctor, and she was allowed to render
medical expert opinion testimony outside of her nursing expertise and competence.
¶38. Singing River argued at trial, and on appeal, that evidence showed that Nurse Steele
assessed on her own that Della's central venous jugular catheter should be removed while
Della sat upright, since Nurse Steele decided that Della could not tolerate a Trendelenburg
position (where a patient with a jugular central line lies on her back with her upper torso
inclined downward, so the central line insertion site is at or below the heart). The testimony
of the Sumralls’ medical expert, Dr. Vives, established that placing the central jugular
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catheter site at or below the heart increased venous pressure on the jugular vein to assist in
preventing an air embolus. The Sumralls’ medical expert testimony also reflects that Della
could have tolerated this positioning, and thus the trial court erred in relying on Nurse
Steele’s testimony asserting that Della could not.6 Nurse Steele lacked the medical
qualifications to engage in removing a central venous jugular catheter without a doctor’s
order, and she also lacked competency to render medical expert testimony and a medical
opinion as to causes of illnesses or how Della would or would not respond to the
Trendelenburg position. Under Mississippi law, nurses are not qualified to medically
diagnose or competent to render an opinion as to medical causation. Vaughn v. Miss. Baptist
Med. Ctr., 20 So. 3d 645, 652 (¶¶20-21) (Miss. 2009) (nurses are not competent to testify on
issues or causation or attest to causes of illnesses), see also Richardson v. Methodist Hosp.
of Hattiesburg Inc., 807 So. 2d 1244, 1247-48 (¶¶14, 19) (Miss. 2002) (finding medical
diagnosis is outside a nurse's scope of practice).7 Since Nurse Steele was not medically
qualified or competent to render expert medical opinion testimony as to whether Della could
or could not medically tolerate the Trendelenburg position, her opinion testimony as to this
6
As noted by the majority, Nurse Steele testified that Della had been reclining in a
chair in her hospital room at an angle of less than ninety degrees, describing the position as
“somewhere in between 30 [degrees] and 45 [degrees]. Probably closer to 45 [degrees].”
The trial judge’s finding and judgment relied upon Nurse Steele’s testimony on that issue,
in finding that Nurse Steele determined Della’s need to sit “in a bedside chair in a position
less than ninety degrees . . . when she removed [Della’s] central line.”
7
See M.R.E. 702 (expert testimony); Mid-S. Retina LLC v. Conner, 72 So. 3d 1048,
1051 (¶10) (Miss. 2011).
19
issue is insufficient to support the verdict and judgment in this case.8 Contrary to Nurse
Steele’s unqualified assertions, the record reflects that the Sumralls’ medical expert, Dr.
Vives, testified that Della could have tolerated the Trendelenburg position in her condition,
and that such positioning would have helped Della’s breathing, and not hindered it. The
Sumralls also presented evidence that after being discharged from Singing River to an
assisted nursing center, Della tolerated the Trendelenburg position for a central line removal
without incident. The trial court’s findings and judgment were based upon incompetent
evidence, and were contrary to Mississippi law. Furthermore, the record reflects that Singing
River failed to rebut the Sumralls’ prima facie case of medical negligence with competent
evidence.
¶39. Accordingly, I concur with the majority’s decision to reverse the trial court’s
judgment. I would, however, render a judgment on the issue of liability in favor of the
Sumralls, and remand the case back to the trial court to determine damages.
WILSON, J., DISSENTING:
¶40. I agree with most of the majority opinion. I agree that the Dr. Corder should not have
been allowed to testify that there is no recognized standard of care regarding patient
positioning during the removal of the central line. I also agree that Dr. Corder should not
have been allowed to testify that Della had a stroke. Therefore, I also agree with the majority
that the circuit court’s findings based on this testimony are not supported by substantial
evidence.
8
Vaughn, 20 So. 3d at 651-52 (¶¶20-21) (finding nurses are not competent to testify
on causes of illnesses).
20
¶41. Despite my agreement with the majority on these points, I believe that we are
compelled to affirm because the circuit court’s decision was based on additional,
independent, and sufficient findings of fact that do not rely on any testimony from Dr. Corder
that was beyond the scope of Singing River’s expert disclosures. The majority quotes
extensively from the trial court’s findings of fact but admittedly “stop[s]” in the middle of
those findings. Ante at (¶¶11-12). The next paragraph of the trial court’s opinion, which the
majority does not quote, is critical:
Even if plaintiff had been able to definitively establish the Trendelenberg [sic]
position as the applicable standard of nursing care for [positioning the patient
during] central line removal, the facts also establish that such a standard would
not be absolute, and under the right circumstances, a position other than
Trendelenberg [sic] is acceptable. Here, the defendant presented evidence as
to the plaintiff’s ability to tolerate the Trendelenberg [sic] position. Therefore,
even if that were the standard, the intolerance of the plaintiff to that position
would allow for deviation from the standard without violation of the standard.
The trial court’s finding that “under the right circumstances, a position other than
Trendelenberg [sic] is acceptable” was based not only on Dr. Corder’s testimony but also on
the testimony of Della’s own experts.
¶42. When, as in a case brought under the Tort Claims Act, the circuit judge sits as the
finder of fact, we “are bound by the [circuit] court’s judgment if its judgment was supported
by substantial evidence and was not manifestly wrong.” Amos ex rel. Amos v. Jackson Pub.
Sch. Dist., 139 So. 3d 120, 124 (¶10) (Miss. Ct. App. 2014). “As to the findings of fact and
conclusions of law, the judgment of a circuit . . . court in a non-jury trial is entitled to the
same deference on appeal as a chancery court decree.” Id. (quotation marks omitted).
“Furthermore, if the [circuit] court’s judgment can be sustained for any reason, it must be
21
affirmed, even if the trial judge based it upon the wrong legal reason.” Id. (emphasis added;
quotation marks, ellipsis, and brackets omitted). “The trial judge’s conclusions will not be
disturbed on appeal where there is substantial supporting evidence in the record, even if this
Court might have found otherwise as an original matter.” Scott Addison Constr. Inc. v.
Lauderdale Cnty. Sch. Sys., 789 So. 2d 771, 773 (¶8) (Miss. 2001) (emphasis added) (citing
Murphy v. Murphy, 631 So. 2d 812, 815 (Miss. 1994)).
¶43. The factual question whether Della was able “to tolerate the Trendelenberg [sic]
position” was the subject of conflicting evidence at trial. But there is evidence to support the
circuit court’s finding that she could not tolerate it, including Nurse Steele’s testimony and
Dr. Corder’s testimony. In addition, Della’s experts acknowledged that certain of her
conditions—chronic obstructive pulmonary disease (COPD) and a partially collapsed lung,
which required her to use an oxygen tank—could make it difficult for a patient to breathe in
the Trendelenburg position. I might or might not have reached the same conclusion as the
trial judge, but that is not our standard of review. The question is simply whether there was
substantial supporting evidence in the record to support the above-quoted factual findings.
There was, and those factual findings are sufficient to sustain the judgment independent of
and despite any error committed by the trial judge in overruling Della’s objections to parts
of Dr. Corder’s testimony. See, e.g., Palmer v. Biloxi Regional Med. Ctr. Inc., 564 So. 2d
1346, 1354-55 (Miss. 1990) (holding that there can be no liability in a medical malpractice
case absent a breach of the standard of care). Therefore, I respectfully dissent.
ISHEE, J., JOINS THIS OPINION.
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