Bennie Joe Poteet, II, Individually and by and Through Evelyn Poteet, as Conservator of Bennie Joe Poteet, II v. National Healthcare of Cleveland, Inc.
Docket: E2009-01978-COA-R3-CV
Court: Court of Appeals of Tennessee; April 19, 2011; Tennessee; State Appellate Court
Bennie Joe Poteet, II, represented by his mother Evelyn Poteet as conservator, filed a medical malpractice lawsuit against Dr. Adam E. Fall and National Healthcare of Cleveland, Inc. after Mr. Poteet suffered a stroke during his hospital stay, resulting in total paralysis from the nose down. The plaintiffs claimed negligence per se related to a bonus incentive plan at the hospital that allegedly affected the ordering of MRIs by Dr. Fall. The trial court granted the hospital's motion for summary judgment on this issue and excluded related evidence before trial. During the trial, a special verdict form directed the jury to disregard questions about the hospital's negligence concerning neurology coverage if Dr. Fall or the nursing staff were not found negligent. The jury ruled in favor of the defendants, leaving the neurology coverage issue unresolved. Following the trial, the hospital sought a directed verdict on the neurology coverage, while the plaintiffs requested a new trial for various reasons. The court denied the plaintiffs' motion and granted the hospital's directed verdict, along with discretionary costs for the defendants. The plaintiffs appealed, but the appellate court affirmed the lower court's judgment and remanded the case.
Mr. Poteet presented to the emergency room with a history of alcohol abuse, having gone over 24 hours without alcohol, and was initially unresponsive with a chief complaint of 'seizure.' Medical records revealed a complex history, including bipolar disorder, depression, DUI, and multiple suicide attempts. Upon examination by Dr. Hugh Caldwell, only a tongue abrasion was noted, with no injuries to the head, neck, or mouth. Significant emergency room findings included generalized shaking, loud snoring respiration, extreme sweating, and decorticate posturing. At 10:55 a.m., Mr. Poteet experienced further seizures and began vomiting, leading to rapid sequence intubation for airway protection.
Dr. Caldwell ordered a CT of the head, which was interpreted as negative for intracranial hemorrhage or abnormalities. Despite the availability of an MRI and diagnostic catheter angiogram at the Hospital, neither was performed due to the need for transport to Erlanger Medical Center for interventional procedures. At 12:15 p.m., after returning from radiology, Mr. Poteet was monitored, and Dr. Caldwell requested Dr. Fall, a hospitalist, to evaluate him. Dr. Fall's assessment at 12:40 p.m. noted anisocoria and acknowledged the challenges of neurological evaluation due to paralysis from medication and ventilation.
The urine drug screen was positive for Benzodiazepines, and Dr. Fall’s primary diagnosis was status epilepticus due to alcohol withdrawal, with a differential diagnosis that included stroke, which he deemed unlikely given the negative CT scan and pupil reactivity. Dr. Fall concluded that no additional diagnostic imaging was necessary at that time.
Dr. Fall conducted an initial evaluation of Mr. Poteet and requested a neurological consult from Dr. Sharon Farber, who was informed of Mr. Poteet's condition and agreed to see him the following day. Dr. Farber did not recommend any immediate diagnostic tests, medication changes, or transfers. Mr. Poteet was admitted to the ICU at 1:40 p.m., where Dr. Fall ordered the withholding of Norcuron to observe any seizure activity. He also consulted Dr. John Jaggers, a critical care specialist.
Dr. Fall examined Mr. Poteet at 2:18 p.m. and noted ongoing seizure activity; thus, he resumed sedation by 3:00 p.m. and instructed ICU nurses to temporarily interrupt sedation daily at 4:00 a.m. Dr. Jaggers evaluated Mr. Poteet at approximately 8:00 p.m. and, despite noting slightly unequal pupils from Dr. Fall's earlier assessment, found no evidence of a stroke or need for an MRI, diagnosing resolved status epilepticus due to alcohol/Xanax withdrawal.
Nursing assessments that evening indicated Mr. Poteet remained unresponsive but showed movement in response to stimuli, with pupils being equal and reactive. The following day, further assessments confirmed similar neurological status. When Dr. Jaggers reviewed the sedation interruption order from Dr. Fall, he clarified that ICU nurses had discretion in following it. He issued a new order to taper sedation instead of abruptly interrupting it, which took precedence over Dr. Fall's earlier instructions.
At 9:40 a.m. on November 12, Dr. Jaggers examined Mr. Poteet, finding no new developments in his neurological status and maintaining a diagnosis of status epilepticus due to alcohol and Xanax withdrawal. Although ICU nurses noted sluggish pupil reaction starting at 7:00 a.m., Dr. Jaggers indicated that the pupils were still reactive, which was not indicative of a critical brain circulation interruption. Dr. Fall assessed Mr. Poteet later that morning, confirming the diagnosis and noting continued pupil reactivity and movement in response to stimuli.
By 2:00 p.m., Dr. Farber, a neurologist, found the pupils reactive but did not document their size and did not order further tests, agreeing with the existing diagnosis of seizures. On November 13, ICU nurses observed a change in pupil size, although they remained reactive. By 1:00 p.m., Dr. Fall noted one pupil was non-reactive, prompting a 'STAT' CT scan, which identified a basilar artery stroke. After consultation with Dr. Devlin, an MRI was ordered, revealing a clot in the basilar artery, leading to Mr. Poteet's transfer to Erlanger at 8:10 p.m.
Dr. Devlin ordered an emergency angiogram upon Mr. Poteet's arrival at Erlanger to locate the stroke. Dr. Steven Quarfordt, an interventional radiologist, then inserted a catheter into Mr. Poteet's arteries and administered tissue plasminogen activator (tPA) to dissolve the clot, alongside an angioplasty to expand the basilar artery. Although this treatment prevented death, Mr. Poteet suffered severe consequences, including a diagnosis of 'locked-in' syndrome after being taken off mechanical ventilation on November 15. Locked-in syndrome leaves patients paralyzed but aware, allowing limited communication through eye movements. Mr. Poteet now resides in a nursing home requiring constant care.
The Plaintiffs filed a malpractice lawsuit against Dr. Fall and the Hospital on April 27, 2007, alleging negligence in Mr. Poteet's treatment from November 11-13, 2004. The Hospital sought to dismiss the suit based on earlier federal proceedings, but the trial court denied this motion. It ruled that issue preclusion did not apply because the prior federal partial summary judgment was not a final judgment, lacking an express determination and failing to adjudicate all claims. Thus, the trial court allowed the Plaintiffs to pursue claims of direct liability against the Hospital.
The federal district court had previously granted the Hospital's partial summary judgment, dismissing all claims except for vicarious liability concerning Dr. Fall, whose alleged failure to consider a stroke or order an MRI is central to the Plaintiffs' claims. They argue that an MRI could have identified the stroke's early stages, necessitating timely transfer to a facility capable of providing the examination.
On March 24, 2008, the Hospital sought partial summary judgment against the Plaintiffs' claim of negligence related to a bonus incentive plan that tied Dr. Fall's annual bonus to the reduction of MRI orders. The Hospital also moved for summary judgment on all other claims by the Plaintiffs. Four days later, the Plaintiffs filed a motion for partial summary judgment regarding their negligence per se claim based on the same bonus plan. The trial court denied the Hospital's summary judgment on January 21, 2009, but granted the Plaintiffs' motion concerning the bonus plan. The court concluded that the Plaintiffs failed to demonstrate a genuine issue of material fact regarding the implementation of the bonus proposal and the assertion that Dr. Fall's clinical decisions were influenced by it during Mr. Poteet's November 2004 admission. Consequently, the court found the Hospital's evidence negated essential elements of the claim and dismissed the Plaintiffs' punitive damages claim related to the bonus incentive.
Prior to the trial, multiple motions in limine were filed, with the court ruling to exclude evidence of the bonus incentive plan while allowing testimony from Dr. Patrick Lyden, a neurology expert for the Plaintiffs. The jury trial commenced on March 17, 2009, lasting twelve days. Testimony from Dr. Barrow, the Hospital's radiologist, indicated that if a clot had been present, it would likely have been detected by an MRI. He elaborated that ischemia or thrombosis would typically show positive CT findings after a minimum period of three to twelve hours, but it could take longer. Bernadette DePrez, the Chief Nursing Officer, acknowledged discussions aimed at increasing the Hospital's profitability and emphasized the importance of reporting changes in patient pupil observations. Susan Lewis, a nurse and trial representative for the Hospital, stated that a 2004 Joint Commission review found no issues with neurology coverage at the Hospital during that period.
Janice Beerman, a nursing expert, testified that changes in pupil reactivity are significant indicators of neurological status and require nurses to notify physicians. On November 12, 2004, at 7:00 a.m., a nurse documented that Mr. Poteet's pupils were sluggish, which Beerman acknowledged could indicate a change in neurological status; however, she found no record of any nurse notifying a physician of this change. Throughout that day, Mr. Poteet's pupils remained sluggish, with a slight enlargement noted by 5:00 p.m., but again, there was no documentation of physician notification. On November 13, 2004, Beerman noted further changes in pupil size, indicating neurological changes, yet found no record of a nurse informing a physician about these developments. She emphasized that nurses did not follow the physician's standing order to interrupt Mr. Poteet's sedation at 4:00 a.m., constituting a breach of the standard of nursing care. Gary A. Salzman, a medical expert, opined that Dr. Fall's failure to act upon the unequal and sluggish pupils was also a breach of medical standard of care, suggesting that he should have ordered an MRI or transferred the patient to a stroke center given the concerning signs.
Dr. Fall had a duty to assess Mr. Poteet’s pupils on November 13, 2004, as part of the standard of care. Dr. Salzman opined that Mr. Poteet should have been transferred to a stroke center immediately upon noting the nonreactive pupil and a 2-millimeter change. He indicated that Mr. Poteet was showing early signs of interrupted blood flow to the brain as early as November 11, 2004, evidenced by unequal pupils, which required urgent action to facilitate treatment.
Dr. Salzman believed that had Mr. Poteet been transferred by 7 a.m. on November 13, his neurological outcomes would likely have been less severe, potentially avoiding a locked-in syndrome, despite still experiencing some deficits. No cardiac abnormalities were found in Mr. Poteet’s EKG that could have led to a clot. During cross-examination, Dr. Salzman acknowledged his lack of specialization in neurology or stroke treatment.
He attributed the clot's formation to a potential dissection of the left vertebral artery, possibly stemming from neck twisting during a seizure or intubation. Notably, no imaging or reports indicated dissection of the arteries involved. Dr. Salzman rejected the idea that the stroke was caused by an embolic clot from elsewhere, asserting instead that it was a thrombus originating within the brain. He explained that the observed changes in pupillary response were due to a partial occlusion on November 11, which later normalized as blood flow improved.
On November 11, 2004, Dr. Jaggers observed the patient’s pupils to be equally round and reactive to light, indicating no signs of stroke at that time. Despite a prior mention of possible anisocoria, Dr. Jaggers found no abnormalities during his examination and determined that further imaging or transfer was unnecessary. By the morning of November 12, while noting sluggish pupil reaction, he did not identify any neurological status changes or stroke symptoms. Dr. Jaggers confirmed that the patient was moving all four extremities, which is inconsistent with motor stroke. He explained that pupil size variations can occur in sedated patients and do not necessarily indicate a developing stroke. Dr. Farber, a neurologist, also found no evidence of stroke and supported a diagnosis of seizures due to alcohol withdrawal, stating that while CT scans are typically ordered for acute neurological conditions, MRIs are not always necessary.
The excerpt outlines the complexities and risks associated with transporting ICU patients for MRI scans, particularly when they are on ventilators and multiple IVs. It emphasizes that such procedures are often unnecessary unless there's clear evidence of a stroke or tumor. Dr. Devlin noted that Mr. Poteet showed no signs of a stroke when assessed on November 12, and the subsequent CAT scan at Cleveland Community Hospital revealed brainstem changes, indicating that the stroke likely occurred more than three hours prior. Dr. Devlin expressed high confidence (over 95%) that the stroke was not recent based on these findings. He highlighted the challenges in diagnosing vertebral basilar issues, noting that a significant percentage of patients go undiagnosed in the early hours following onset. Dr. Devlin also stated that Mr. Poteet's first signs of a stroke appeared around 1:00 PM on November 13. Dr. Alfred Callahan confirmed that Mr. Poteet suffered a massive stroke and was not a candidate for IV tPA treatment. He clarified that while seizures can occur with strokes, they do not necessarily indicate a stroke affecting the brain's cortex.
Mr. Poteet experienced generalized seizures likely due to alcohol withdrawal rather than a brain stem stroke during his episode at the jail and subsequent emergency department visit. A medical expert confirmed that there was no clinical evidence suggesting a stroke at that time; instead, it appeared to be seizures from withdrawal. He opined with reasonable medical certainty that Mr. Poteet suffered a cerebral embolus—a traveling clot—on November 13, 2004, although the exact time of occurrence was uncertain. The clot likely originated from the arterial side of circulation and completely occluded the top portion of the basilar artery without signs of dissection or plaque.
Regarding the care provided at Cleveland Community Hospital, the expert concluded that neither Dr. Fall nor the nursing staff could have taken different actions to prevent the embolus or its consequences, including death or significant neurological damage. Dr. Uskovitch, a neurologist, corroborated that there was no evidence of vertebral dissection and affirmed that the healthcare providers' actions did not contribute to the seizure activity or the stroke's occurrence. He noted that mild pupillary changes are common in ICU patients due to their medical conditions and treatments. Overall, he attributed the stroke to an acute embolism occurring around midday on November 13.
The patient experienced an acute change in neurological function due to a clot in the basilar artery, leading to progressive motor function loss and total occlusion of the basilar artery, which is critical for brain blood supply. There was no evidence of arterial dissection, lesions, or atherosclerosis in the vertebral or basilar arteries that could explain the stroke; imaging studies did not support these theories. Dr. Uskovitch indicated that prior to the diagnosis of stroke on November 13, there were no signs of stroke, attributing earlier neurological deficits to status epilepticus linked to alcohol withdrawal. Dr. Fall, upon examining the patient, confirmed that he showed no signs of stroke at that time and suggested that movement during seizures indicated the absence of a stroke. He acknowledged that a stroke occurred on November 13 but did not consider ischemia or interrupted blood flow on November 11, based on the patient's symptoms. The clinical evaluation focused on the implications of seizures and their relationship to the observed neurological condition.
Mr. Poteet exhibited movement in all extremities during his emergency room visit and subsequent ICU care, leading Dr. Fall to conclude that he had not suffered a stroke or ischemia until the 13th of November 2004. Dr. Fall opined that if Mr. Poteet had been sent to the Erlanger Stroke Center, the doctors would have found no reason to intervene on November 11th or 12th. The standard of care in Bradley County, Tennessee, required doctors to evaluate, treat, and monitor patients, adjusting care as necessary. Dr. Mark Williams testified that the standard of care for Mr. Poteet's condition involved managing seizures and monitoring him, which he believed Dr. Fall adhered to, providing high-quality care.
At trial, the jury found that while the nurses breached the standard of care, this breach did not cause Mr. Poteet’s injury. They also concluded that Dr. Fall was not negligent. A question regarding insufficient neurology coverage was not answered by the jury due to their findings on negligence. The jury's verdict included affirmations that the nurses deviated from the standard of care but did not cause injury, and that Dr. Fall did not deviate from the standard. The judgment was entered on May 14, 2009, and subsequently, the Hospital filed a motion regarding the neurology coverage issue, while the Plaintiffs sought a new trial on multiple grounds, which are under appeal.
On September 10, 2009, the trial court denied the Plaintiffs’ motion for a new trial and granted the Hospital’s motion for a directed verdict, as well as the Defendants’ motions for discretionary costs. The Plaintiffs subsequently filed a notice of appeal.
Key issues raised by the Plaintiffs include:
1. Alleged error in granting the Hospital’s partial summary judgment regarding a bonus incentive plan offered to Dr. Fall, including the exclusion of evidence related to the plan.
2. The applicability of Tenn. Code Ann. § 29-26-115 (a) and (b) in limiting the testimony of the Plaintiffs’ neurology expert, Dr. Lyden.
3. Potential confusion and inconsistency in the jury verdict form concerning the Hospital’s liability related to neurology coverage.
4. Alleged error in granting a directed verdict for the Hospital on claims of negligence regarding adequate neurology coverage.
5. Material evidence supporting the jury’s findings about the Hospital’s nurses.
6. Material evidence supporting the jury’s findings regarding Dr. Fall.
7. The trial court's role as thirteenth juror in denying the motion for a new trial.
8. Alleged error in awarding discretionary costs to the Hospital and Dr. Fall.
The Plaintiffs argue that the trial court misapplied the summary judgment standard by concluding there was insufficient evidence for the bonus incentive plan, which led to the exclusion of relevant proof at trial. Under Tennessee law, summary judgment is appropriate only when there is no genuine issue of material fact and the moving party is entitled to judgment as a matter of law. The Tennessee Supreme Court has clarified that the moving party must affirmatively negate an essential element of the nonmoving party’s claim or demonstrate the nonmoving party cannot prove an essential element at trial, thereby shifting the burden to the nonmoving party to establish disputed material facts.
The nonmoving party in a legal case must provide evidence, such as affidavits or other discovery materials, to demonstrate a genuine issue for trial; failure to do so may result in summary judgment against them under Tenn. R. Civ. P. 56.06. Summary judgments are reviewed without a presumption of correctness on appeal, requiring the court to view evidence favorably towards the non-movant and resolve factual inferences in their favor. However, if undisputed facts lead to one conclusion, the moving party is entitled to judgment as a matter of law.
In assessing evidence admissibility, the appellate standard is "abuse of discretion," granting trial courts significant leeway. A trial court's decision is only deemed an abuse of discretion if it applies an incorrect legal standard or reaches an illogical decision that results in injustice. Moreover, the moving party has the initial burden to negate an essential element of the nonmoving party's claim or demonstrate that the nonmoving party cannot prove that element at trial.
In this case, the essential element was whether a proposed bonus incentive plan had been implemented. The Hospital provided an affidavit indicating the plan was never instituted, which could satisfy its burden. However, the trial court's conclusion that this evidence was unrebutted was incorrect, as the Plaintiffs presented circumstantial evidence suggesting the plan was indeed implemented, including the presence of the bonus document in Dr. Fall’s personnel file and its provision under his employment agreement.
Dr. Fall's employment contract included provisions for "Incentive Compensation" linked to goals outlined in a separate document, which specified a 10% bonus based on certain criteria. He had received bonuses from the hospital, and the only relevant written documentation was the bonus incentive plan, clearly marked and free of revisions or amendments. The Hospital did not present evidence indicating any changes to this plan. A genuine dispute remained regarding the implementation of the bonus incentive plan, permitting the case to survive partial summary judgment.
The Plaintiffs contended there was a factual issue about whether the incentive program influenced Dr. Fall's treatment decisions, warranting a jury's consideration. The Hospital's primary defense was a self-serving affidavit from Dr. Fall, claiming the bonus plan did not affect his decision-making. The court noted that summary judgment is rarely appropriate in cases where a party's state of mind is critical. Despite the Hospital's arguments, the Plaintiffs provided sufficient evidence to suggest that the incentive plan may have influenced Dr. Fall’s care decisions.
However, the court ultimately upheld the partial summary judgment for the Hospital. It concluded that the bonus incentive could not be considered an independent cause of Mr. Poteet’s injury, especially in light of the jury's prior finding of non-negligence against Dr. Fall. Thus, the Plaintiffs failed to prove a necessary element of their claim, allowing the Hospital to secure judgment as a matter of law.
No genuine issue of material fact exists for a jury regarding Dr. Fall’s negligence in not ordering an MRI for Mr. Poteet, as the jury has already determined that Dr. Fall met the applicable standard of care. Even if the Hospital's bonus incentive plan influenced Dr. Fall’s decision-making, it cannot establish independent negligence since Dr. Fall was exonerated. The connection between the bonus plan and Mr. Poteet's injury is broken, as liability can only arise from negligent treatment, which was not found in this case. Thus, holding the Hospital liable for the bonus incentive plan without a corresponding finding of negligence against Dr. Fall would be illogical. The trial court's partial summary judgment for the Hospital on this issue is affirmed.
Additionally, the plaintiffs argue for a new trial due to the exclusion of evidence regarding the bonus incentive plan, which the trial court ruled as irrelevant in the context of Dr. Fall’s malpractice claim. Although the incentive plan may relate to the Hospital's liability, its relevance to Dr. Fall’s clinical decisions is questionable. Even if there were disagreement about the evidence's relevance, the standard of review for such evidentiary rulings is limited to assessing whether there was an abuse of discretion by the trial court.
The abuse of discretion standard limits appellate courts from substituting their judgment for that of trial courts, upholding the trial court's decision as long as reasonable minds could disagree on its propriety. Mere disagreement does not justify overturning a trial court's exclusion of evidence. The trial court operates under a presumption of correctness, and the Plaintiffs failed to demonstrate that the court abused its discretion in excluding evidence related to a bonus incentive proposal.
The Plaintiffs contended that the trial court erred by excluding parts of neurology expert Dr. Lyden's testimony. Dr. Lyden, not licensed in Tennessee, was allowed to testify on limited issues regarding strokes as an educational witness. However, his testimony was curtailed when it strayed beyond the permitted scope, with the trial court sustaining the Defendants' objections.
Appellate review of evidentiary rulings focuses on whether the trial court's decision was factually supported, legally sound, and within acceptable alternatives. If the improper admission or exclusion of evidence affects the trial outcome, a new trial may be warranted. The qualifications for a medical expert in malpractice cases are governed by Tenn. Code Ann. § 29-26-115, which requires proof of the standard of care in the relevant community, deviation from that standard, and resultant injury due to negligence.
A health care professional must be licensed in Tennessee or a contiguous state and have practiced there within the year preceding an alleged injury to provide expert testimony in court regarding causation in malpractice actions. The statute, Tenn. Code Ann. 29-26-115, mandates that such testimony must establish the facts outlined in subsection (a), which includes proving that the plaintiff's injuries were a proximate result of the defendant's negligence. The court's interpretation in Farley indicates that while familiarity with the local standard of care is not required for causation experts, they must still meet the licensure and practice requirements specified in subsection (b). In the case of Dr. Lyden, he did not meet these criteria as he had never been licensed or practiced medicine in Tennessee or a bordering state, making his testimony inadmissible.
Under Tenn. Code Ann. § 29-26-115(b), an expert must be licensed in Tennessee or a contiguous state and have practiced there in the year preceding the alleged injury. Plaintiffs did not establish a need to waive this requirement. They sought a de novo review of the trial court's evidentiary rulings related to the medical malpractice statute, asserting that the court misinterpreted statutory standards. However, the court found that the Plaintiffs were contesting the trial court's discretion regarding causation-related testimony from Dr. Lyden, which is not subject to de novo review but rather an abuse of discretion standard. The court determined there was no abuse of discretion in the trial court's rulings.
Additionally, the Plaintiffs challenged the jury's special verdict form, which instructed jurors to disregard the Hospital's alleged negligence if Dr. Fall and the nurses were found not negligent. As the jury found Dr. Fall and the nurses not negligent, the Hospital's claim was not considered, leading the Plaintiffs to argue that this created a defective verdict. They cited Concrete Spaces, Inc. v. Sender, which requires a new trial if a verdict form prevents adequate jury responses to claims. However, after the jury's verdict was polled and confirmed, and no objections were raised by counsel at that time, the trial court found that the decision on the special verdict form was within its discretion. A new trial is only warranted if the form is confusing or inconsistent with the court's instructions.
Reversal of a verdict is warranted if an error in the verdict form likely influenced the judgment. The Plaintiffs appropriately raised the issue of the jury verdict form in their motion for a new trial, despite the Defendants' claims of waiver due to a lack of earlier objection. Tennessee Rules of Civil Procedure allow for objections to jury instructions to be preserved for appeal if raised in a motion for a new trial, as established in Rolen v. Wood Presbyterian Home, Inc. The court has historically ruled that failure to address a jury verdict issue prior to discharge does not constitute waiver. Although there may have been an error regarding the jury's failure to address the Hospital's liability for inadequate neurology coverage, a new trial is not warranted because jury instruction errors must affect trial results to justify reversal. The trial court's granting of the Hospital's directed verdict on the insufficient neurology coverage claim rendered any verdict form defects moot, as the Plaintiffs did not suffer prejudice. Furthermore, the trial court found the Plaintiffs lacked the necessary expert testimony to support their neurology coverage claim, as they did not establish the applicable standard of care or the Hospital's deviation from it.
A trial court should grant a motion for judgment based on a directed verdict under Rule 50.02 only when the evidence is insufficient to create a jury issue or when reasonable minds can only reach one conclusion. Even if facts are undisputed, a motion cannot be granted if conflicting conclusions can be drawn. In the case referenced, it was established that actions against health or medical entities are not automatically considered medical malpractice claims. However, if a claim alleges negligent conduct substantially related to medical treatment by a medical professional, the medical malpractice statute applies. The court emphasized that the availability of a neurologist at a hospital is indeed substantially related to medical treatment, particularly given the interconnected nature of Mr. Poteet’s treatment, which required consultations from multiple specialists.
The trial court found that the issue regarding neurological coverage was not a general negligence claim but one linked to medical treatment, thus falling under the medical malpractice statute. The Plaintiffs failed to provide expert testimony to demonstrate what level of neurology coverage was necessary at a community hospital or that the Hospital's level of coverage failed to meet the standard of care in 2004. Their evidence, largely anecdotal and vague, did not satisfy the statutory requirements, leading the court to agree with the trial court’s decision to grant the Hospital’s directed verdict motion.
Additionally, the Plaintiffs sought to overturn the jury’s verdict on the basis of inadequate evidence, specifically contesting the finding that the nurses' deviations from the standard of care did not cause Mr. Poteet's injury, despite the jury ruling in favor of the Plaintiffs on other alleged deviations.
The nurses deviated from the sedation interruption protocol ordered by Dr. Fall by not interrupting Mr. Poteet’s sedation before it was turned off at 11:00 a.m. on November 13. Additionally, they failed to adequately communicate changes in Mr. Poteet’s pupil reactivity and size to Dr. Fall. However, the jury rejected the Plaintiffs’ claims that these failures caused Mr. Poteet’s locked-in condition, accepting evidence from the Hospital demonstrating that the injury would have occurred regardless of the nurses' actions. Under Rule 13(d) of the Tennessee Rule of Appellate Procedure, the jury's findings can only be set aside if there is no material evidence supporting the verdict. The appellate court must view the evidence favorably towards the verdict, assume the truth of supporting evidence, allow reasonable inferences, and disregard contrary evidence. Although the Plaintiffs provided competent evidence for their causation theory, the jury found the Hospital's expert testimony more credible. This testimony indicated that Mr. Poteet had not been having a stroke before 1 p.m. on November 13 and that his condition was caused by a “traveling clot,” not a dissection of the vertebral artery, which was unsupported by medical reports or angiograms. The jury accepted this expert evidence, satisfying the material evidence standard. Consequently, the court could not overturn the jury’s finding that the nurses’ inaction did not cause Mr. Poteet’s condition. The Plaintiffs also attempted to challenge the jury’s verdict regarding Dr. Fall’s adherence to the standard of care, presenting only one expert, Dr. Salzman, who lacked specialization in neurology or stroke treatment. Despite the Plaintiffs' claims, the court found ample evidence supporting the jury’s conclusion that Dr. Fall did not breach the applicable standard of care.
Defendants' expert witnesses affirmed that the standard of care for treating Mr. Poteet's seizures was to manage and monitor his condition, which Dr. Fall adhered to. They stated there was no indication of a stroke prior to Dr. Fall's diagnosis at 1:00 p.m. on November 13, making further diagnostics or transfer unnecessary at that time. Dr. Fall's initial diagnosis of Mr. Poteet's seizures due to alcohol withdrawal was deemed appropriate, corroborated by the neurologist who reached the same conclusion without ordering additional tests. The jury found the evidence compelling enough to support their verdict that Dr. Fall was not negligent and met the standard of care.
The Plaintiffs argued for a new trial, claiming the trial court misapplied its role as a thirteenth juror in assessing the evidence. A trial court has significant discretion in granting new trials, and appellate courts defer to these decisions unless there is an abuse of discretion. The trial court must independently evaluate the evidence and affirm the jury's verdict if satisfied. If the court's comments suggest a misunderstanding of its duties, the decision may be reversed. However, the trial court's approval of the jury's verdict without comment is presumed to indicate proper performance of its duties. The Plaintiffs did not provide evidence of any misinterpretation by the trial court regarding its evaluation responsibilities.
Plaintiffs have reiterated their arguments challenging the jury's verdict without providing new evidence. Even if the evidence were viewed more favorably for them, the court cannot overturn the jury's verdict or order a new trial, as this would exceed the permissible review scope of a trial court acting as a "thirteenth juror." The court's ability to reverse a trial court’s decision on a new trial motion is limited to instances of manifest abuse of discretion, which must be evident in the trial court's comments or rationale. If the trial court only states that it has conducted an independent review and found the jury's verdict supported by the evidence, it is assumed that proper discretion was exercised.
In this case, the trial court affirmed that it thoroughly reviewed the evidence and law, concluding that the evidence favored the jury's verdict, thus confirming no abuse of discretion occurred. The Plaintiffs also argued that the trial court abused its discretion by awarding discretionary costs to the Defendants, primarily based on the equities concerning Mr. Poteet’s medical and financial situation. When considering discretionary costs, a court must evaluate whether the requesting party is the prevailing party, whether costs are necessary and reasonable, and if the prevailing party's litigation conduct warrants denial of costs. The decision to award costs should not be punitive, should not depend on whether the prevailing party is a plaintiff or defendant, nor should it hinge on the credibility of particular witness testimony. The burden of proving entitlement to costs lies with the requesting party. Trial courts possess broad discretion in awarding these costs, which will not be disturbed unless there is clear evidence of an abuse of discretion. The trial court has the authority to allocate costs between litigants as equity demands.
A deferential standard is applied when reviewing a trial court's decision to grant or deny a motion under the relevant rule, reflecting broad discretion in such matters. Courts are generally reluctant to second-guess these decisions unless there is an abuse of discretion. On appeal, the appellant must demonstrate that the trial court abused its discretion regarding cost assessments. Mere inability to pay or indigency does not qualify as an extraordinary circumstance justifying a review of the trial court's discretionary cost awards. Despite recognizing the financial burdens faced by Mr. Poteet, the court concluded that the trial court's decision to impose costs did not constitute a manifest abuse of discretion. The plaintiffs failed to prove that there was no equitable basis for the trial court’s cost allocation or that the trial court clearly abused its discretion. Consequently, the judgment of the trial court is affirmed, with costs on appeal taxed to the appellants, Bennie Joe Poteet, II, and his conservator, Evelyn Poteet. The case is remanded for the collection of assessed costs.
