In the case of Teresa Lynn Stanfield v. John Neblett, Jr., M.D., et al., the Court of Appeals of Tennessee affirmed the Circuit Court's judgment in a medical malpractice suit. The jury found that while Dr. Neblett deviated from the standard of care regarding the treatment of Teresa Lynn Stanfield’s daughter, Trista Jane Greene, this deviation was not the legal cause of her death. Appellant Stanfield challenged several aspects of the trial court's decisions, including the denial of her motion for a directed verdict, the handling of expert witness objections, the language on the verdict form, and the allowance of a PowerPoint presentation during trial. The court, however, identified no errors in these rulings and upheld the verdict. The case stemmed from an ATV accident on August 29, 2005, leading to Greene's admission to Jackson Madison County Hospital, where her condition deteriorated, resulting in her death on August 31, 2005. Stanfield alleged negligence against Dr. Neblett for failing to adequately assess and treat Greene and for the hospital staff's failure to recognize her deteriorating condition, which Dr. Neblett denied, attributing fault to the hospital. The jury trial commenced on February 23, 2009, concluding with a verdict in favor of Dr. Neblett on March 3, 2009, and a formal judgment issued on March 24, 2009.
On April 22, 2009, Ms. Stanfield filed a Motion for New Trial, citing ten issues justifying her request. The trial court denied this motion on September 4, 2009. Ms. Stanfield later voluntarily dismissed her claims against Jackson Madison County General Hospital District. Dr. Neblett claimed comparative fault from Ms. Greene or others involved in the ATV accident, which the trial court struck at Ms. Stanfield's request, a non-appealable issue. Ms. Stanfield filed a notice of appeal on September 11, 2009, raising seven issues for review, all previously included in her Motion for New Trial, according to Tenn. R. App. P. 3(e). These issues include claims of trial court errors related to the jury's exposure to trial transcript excerpts, the denial of her directed verdict motion regarding Dr. Neblett's comparative fault claims, the admissibility of expert testimonies, and the appropriateness of a PowerPoint presentation by Dr. Neblett's counsel during opening arguments.
The court addressed the directed verdict motion, stating that such decisions are legal questions assessed without weighing evidence or witness credibility. The court must only grant the motion if reasonable minds cannot differ on the conclusions drawn from the evidence. Dr. Neblett's defense included claims of comparative fault against the hospital and nursing staff, and he bore the burden of proof. The court found sufficient evidence, including Dr. Neblett's testimony on the nursing staff's failure to timely inform him of Ms. Greene's condition, to justify the jury's potential finding of fault against them. Consequently, the trial court did not err in denying Ms. Stanfield’s motion for a directed verdict.
Dr. Marvin Rozear, an expert for Ms. Stanfield, criticized the accuracy of the Glasgow Coma score and nurse's notes regarding Ms. Greene’s condition on August 30, 2005, asserting that a timely notification to Dr. Neblett could have altered the outcome. Dr. Isabelle Richmond echoed these concerns, noting inconsistencies in the nurse's documentation and the failure to inform Dr. Neblett of significant patient changes, which she believed would have led to Ms. Greene's survival had he been notified. Dr. Arthur Daus supported the expectation that nurses should contact the doctor upon status changes. Conversely, Dr. Owen Samuels, representing Dr. Neblett, emphasized that the nurses breached their duty by not communicating changes at 7:00 p.m. on the same day. The nurse on duty acknowledged the standard requirement to contact the doctor but hesitated due to uncertainty about the patient's condition and instead consulted fellow nurses. The trial court's denial of Ms. Stanfield’s motion for a directed verdict was affirmed based on the evidence presented.
The document also outlines the standard for reviewing trial court decisions on evidence admissibility, which is based on whether the court acted within its discretion, assessed the evidentiary foundation, and applied the correct legal principles without reaching an unreasonable conclusion. Additionally, Ms. Stanfield contested the admissibility of Dr. Neblett’s experts' testimony, arguing that their opinions were not disclosed as required by Rule 26 of the Tennessee Rules of Civil Procedure, which could justify exclusion if it led to unfair surprise or trial ambush.
The trial court's discretion under Rule 37.03 to exclude expert testimony is upheld unless there is an abuse of that discretion. Ms. Stanfield contends the court erred in permitting Dr. Neblett’s experts to testify about the nurses' actions, particularly their failure to notify Dr. Neblett, as these opinions had not been disclosed prior to trial. She also objects to Dr. Owen Samuels testifying about a new opinion on Ms. Greene’s transfer summary. Ms. Stanfield had previously filed a motion in limine to restrict testimonies to those disclosed under Rule 26, which the court granted, stating experts could not offer new opinions but could respond to criticisms from Ms. Stanfield’s experts.
Upon review, the court found that the expert testimony regarding the nursing staff's actions was adequately disclosed, as Dr. Samuels had noted the nurses' obligation to notify Dr. Neblett of a significant change in Ms. Greene’s condition. Other experts also criticized the nurses’ failure to notify Dr. Neblett, making their testimony within the scope of Rule 26 disclosures. Additionally, the court determined that Dr. Neblett’s experts were responding to critiques from Ms. Stanfield’s experts, which included questioning the nurses' duty to contact Dr. Neblett upon changes in patient status and the adequacy of the transfer summary. The court emphasized that the purpose of discovery rules is to prevent “trial by ambush,” and since Ms. Stanfield’s examination of her experts indicated awareness of these issues, the trial court did not abuse its discretion in allowing the testimonies.
Numerous objections were raised regarding the qualifications of the expert witnesses in the trial. Ms. Stanfield argued that Dr. Neblett’s experts were inadequately qualified to testify. The trial court has the discretion to determine the admissibility and qualifications of expert testimony, reviewed under an abuse of discretion standard. Ms. Stanfield specifically contended that Dr. Manuel Weiss, Dr. Richard Miller, and Dr. Owen Samuels did not meet the locality requirement set forth in Tennessee Code Annotated §29-26-115(b), which mandates that an expert must be licensed and actively practicing in Tennessee or a contiguous state in the year preceding the alleged injury. The Court determined that all of Dr. Neblett’s experts satisfied this requirement: Dr. Samuels practiced in Georgia, Dr. Miller was a trauma director in Tennessee, and Dr. Weiss was a licensed neurosurgeon in Tennessee.
Ms. Stanfield appeared to conflate the locality requirement with the standard of care requirement, which are distinct. The latter demands that an expert be familiar with the standard of care pertinent to the defendant's specialty in the relevant community, as per Tennessee Code Annotated §29-26-115(a). The expert must substantiate their familiarity with the standard of care with factual basis rather than mere assertions. The burden of proof lies with the party presenting the expert testimony. The Court has rejected both a national and statewide standard of care, asserting that an expert does not need to know all medical statistics of a community but must have sufficient knowledge of the community's medical resources to appropriately understand the standard of care required.
The trial court's decision regarding the expert's familiarity with the standard of care in the defendant's community is reviewed under the abuse of discretion standard. The court will not overturn this decision simply because alternative conclusions are possible. The Tennessee Supreme Court has consistently examined whether experts possess adequate knowledge of local standards, affirming trial court decisions that support expert testimony when the expert clearly establishes their familiarity with the local standard rather than relying on a national standard. In *Stovall v. Clarke*, the court upheld an expert's qualifications, noting their comprehensive review of Tennessee-specific medical practices despite lacking direct local practice experience. Conversely, in *Robinson v. Le Corps*, the court rejected an expert's testimony because it was based solely on assumptions about similarity to national standards without substantial evidence. Additionally, in *Ayers v. Rutherford Hosp. Inc.*, the expert was excluded for failing to demonstrate any knowledge about the local community, and similar findings occurred in *Mabon* and *Kenyon*, where experts lacked essential local context. Ultimately, the review of Dr. Neblett’s experts' testimonies supports the trial court's determination that they possessed sufficient knowledge of the standard of care relevant to Dr. Neblett's community.
Dr. Samuels, a Georgia-licensed physician and board-certified neurologist, serves as the director of neurological care at Emory University School of Medicine. He acknowledged that he does not treat patients in Tennessee but has spoken at Vanderbilt Medical School. He described the hospital in Jackson as large, with approximately six hundred beds, multiple sub-specialties, an active neurosurgery service, and a significant catchment area of five hundred thousand people, similar to Emory. Dr. Samuels detailed that the Jackson hospital has comprehensive trauma services, including a neurological intensive care unit, operating rooms, and extensive radiological services, enabling it to treat cases like that of Ms. Greene effectively.
He affirmed his familiarity with the nursing flow sheets and monitoring methods used at the Jackson hospital, which he found comparable to Emory's practices. Despite acknowledging differences between the communities of Jackson and Atlanta, he maintained that the medical communities are similar. Dr. Samuels demonstrated sufficient knowledge of the Jackson medical community's standards of care through his thorough understanding of local hospitals and resources.
While Ms. Stanfield did not have the opportunity to voir dire Dr. Samuels, she fully cross-examined him, focusing mainly on the community comparison. The court emphasized that it cannot assume facts not present in the record and concluded that the trial court did not abuse its discretion in accepting Dr. Samuels' testimony as sufficient to establish his familiarity with the standard of care in a comparable medical community.
Dr. Miller, the medical director of the trauma unit at Vanderbilt University Medical Center, testified about his qualifications and familiarity with the standard of care for trauma patients like Ms. Greene in Jackson, where he had treated referred patients and engaged with local physicians. He highlighted that the City of Jackson has a population of approximately 60,000, with two hospitals, one having around 600 beds, a neurological intensive care unit, and a step-down unit. Dr. Miller asserted that the standard of care in Jackson was similar to that at Vanderbilt and provided evidence supporting his familiarity with Jackson's medical standards, including his involvement in the state's trauma system and teaching the ATLS course in the region. The absence of cross-examination on this point strengthened the trial court's decision to accept his expertise.
Dr. Weiss, a neurosurgeon practicing in Nashville, also testified regarding his knowledge of the standard of care in Jackson, detailing the hospital's capacity, resources, and treatment practices. He confirmed familiarity with the community's medical landscape, noting Jackson's population and the presence of multiple hospitals. Dr. Weiss corroborated his assertion of familiarity by mentioning his experience treating patients referred from Jackson and providing specific insights into the hospital's operations and standards of care relevant to neurosurgical practices in 2005. Both experts successfully demonstrated their knowledge of Jackson's medical standards, supporting the trial court's finding that they were adequately familiar with the standard of care applicable in that jurisdiction.
Dr. Weiss demonstrated comprehensive knowledge of the healthcare resources and standard of care in Jackson, which was not contested by Ms. Stanfield during cross-examination. The trial court found that Dr. Weiss provided adequate support for his familiarity with the standard of care. Ms. Stanfield challenged the qualifications of Dr. Miller and Dr. Samuels to testify regarding the neurosurgical standard of care, referencing Tennessee Code Annotated §29-26-115(b). However, it was established that Dr. Samuels, a board-certified neurologist and director of neurological care at Emory University, trains neurosurgeons and oversees neurocritical care, making his testimony relevant. Dr. Miller, the medical director of the trauma unit at Vanderbilt and board-certified in general surgery and surgical critical care, also has relevant experience in treating critical patients and interpreting CT scans. Their testimonies were pertinent to allegations against Dr. Neblett regarding the care of Ms. Greene.
Even if any errors occurred in admitting the experts' testimonies, the appellate court deemed these errors harmless based on jury findings. The jury determined that while Dr. Neblett deviated from the standard of care, this deviation was not the legal cause of Ms. Greene's death. The evidence indicated that the nursing staff failed to contact Dr. Neblett promptly, a violation of their duty, and expert testimony supported that timely communication could have altered the outcome.
Dr. Isabelle Richmond, an expert for Ms. Stanfield, testified that the nursing staff made errors in documenting Ms. Greene's medical records and failed to contact Dr. Neblett in a timely manner, which, if corrected, could have resulted in Ms. Greene's survival. The nurse on duty admitted she was aware of the standard of care requiring her to contact Dr. Neblett but did not do so. Based on this testimony, the jury concluded that while Dr. Neblett deviated from the standard of care, this deviation was not the legal cause of Ms. Greene's death, as supported by Ms. Stanfield’s experts and the treating nurse. Consequently, any potential error in allowing Dr. Neblett's experts to testify was deemed harmless.
Ms. Stanfield argued that the trial court erred in permitting Dr. Neblett’s counsel to impeach her experts using certain medical treatises, specifically claiming that Dr. Richmond should not have been questioned about the eighth edition of the ATLS Guidelines, which was not in effect at the time of Ms. Greene's death. However, Tennessee Rule of Evidence 618 allows for the impeachment of expert witnesses using published treatises if established as reliable. Dr. Richmond acknowledged the reliability of the ATLS guidelines and testified that the differences between the seventh and eighth editions were negligible. Thus, the court found no error in allowing questioning regarding the eighth edition, and any potential error was considered harmless.
The questioning surrounding the ATLS Guidelines focused on whether a Glasgow Coma Score of 13 indicated a minor or moderate head injury. Dr. Richmond acknowledged that even if it indicated a moderate head injury, there was a 90% chance of recovery. Since the jury found that Dr. Neblett’s deviation from the standard of care was not the legal cause of Ms. Greene’s death, any error from the trial court in allowing this questioning was deemed harmless under Tenn. R. App. P. 36(b).
Additionally, Ms. Stanfield argued that the trial court improperly permitted Dr. Rozear to be questioned about medical literature not verified as reliable. During cross-examination, counsel for Dr. Neblett asked Dr. Rozear about literature regarding the use of Mannitol and steroids, without specifying any documents. Dr. Rozear acknowledged the existence of opposing literature. The court emphasized that expert witnesses can be rigorously cross-examined to challenge the weight of their opinions, allowing broad latitude for opposing counsel to question the factual basis of an expert’s opinion, including literature the expert did not consider.
Furthermore, Ms. Stanfield claimed error in allowing counsel to question another expert, Dr. Arthur Daus, about the ATLS Guidelines while displaying a page from these guidelines on a projection screen. Dr. Daus confirmed the reliability of the ATLS Guidelines. However, the specific page displayed was not included in the court record for review. The transcript indicates it was from the eighth edition of the guidelines, and no abuse of discretion was found in this line of questioning.
Questioning based on the eighth edition was deemed appropriate, and the trial court did not abuse its discretion by displaying a page to the jury, which was not read or admitted as evidence but served as an aid during Dr. Daus's questioning. No authority was found to suggest the display was improper. Regarding the Verdict Form, Ms. Stanfield argued that the term "legal cause" misled the jury into believing Dr. Neblett had to be the sole cause of Ms. Greene’s death, contrary to her request for the phrase “cause or contributed to.” Under Tennessee Rules of Civil Procedure, the trial court has broad discretion in the use of special verdict forms. The Court reviews such forms and jury instructions de novo, ensuring that the legal issues are clearly defined and not misleading. The trial court instructed the jury that negligence and causation are required to establish fault, with causation comprising both factual and legal components. To determine legal cause, two criteria must be satisfied: the conduct must significantly contribute to the harm, and the harm must be reasonably foreseeable. Inconsistencies between the verdict form and the jury instructions may create confusion.
A legal cause of an injury does not need to be the sole cause, the last act, or the nearest cause, as long as it is a substantial factor in producing the injury or damage. Multiple negligent acts or omissions from different individuals or entities can contribute to a single injury. The plaintiff bears the burden of proving Dr. Neblett's fault, while Dr. Neblett must prove the fault of Jackson-Madison County General Hospital. If multiple parties are found at fault, the jury must assign a percentage of fault to each. The trial court's instructions and verdict form clearly defined legal cause, allowing for multiple causes without requiring Dr. Neblett to be the sole cause.
Additionally, the trial court did not err in permitting Dr. Neblett’s counsel to use a PowerPoint presentation during opening and closing statements, despite Ms. Stanfield's claims of prejudice. Opening statements are meant to broadly inform the jury of the case, and trial courts have significant discretion in managing counsel's arguments. The trial court's decision is reviewed for abuse of discretion, and there was no prior ruling prohibiting PowerPoint use during opening arguments. The transcript from the pretrial conference does not support Ms. Stanfield's argument that such use was previously restricted.
Counsel for Ms. Stanfield raised concerns regarding the use of PowerPoint presentations, referencing a prior trial judge's ruling that required all displayed materials to be admitted into evidence. The trial court agreed with this approach, stating that PowerPoint usage would require mutual consent or prior approval. Dr. Neblett's counsel indicated her intention to use PowerPoint during opening statements without presenting unapproved evidence. The court instructed both parties to exchange relevant materials and promised to address the matter if no agreement was reached.
Ms. Stanfield's counsel had prior knowledge of Dr. Neblett's PowerPoint plans and was granted a twenty-minute recess to review the slides before opening arguments, during which no objections were raised regarding the presentation content. Ms. Stanfield claimed prejudice due to the inclusion of unaudited documents in the PowerPoint, but this argument was deemed disingenuous. The record indicates that only Ms. Greene's medical records and possibly Dr. Neblett’s curriculum vitae were displayed during the opening. Ms. Stanfield's counsel had previously requested a stipulation regarding the medical records, which Dr. Neblett’s counsel accepted. Although the records were not formally admitted at the time, they had been stipulated to, and Ms. Stanfield’s counsel introduced them into evidence later without objection.
The admissibility of Dr. Neblett’s curriculum vitae was not challenged, and he testified about his qualifications. The trial court did not abuse its discretion in allowing the PowerPoint presentation, as it contained stipulated and admissible evidence. Additionally, Ms. Stanfield objected to the use of trial transcript excerpts during Dr. Neblett's closing arguments, but the transcripts had not been certified at that time.
Counsel for Ms. Stanfield objected to the use of the trial transcript during closing arguments, but the trial court overruled this objection, allowing Dr. Neblett's counsel to proceed. Closing arguments are critical in jury trials, providing an opportunity for counsel to present their case theories and highlight evidence strengths and weaknesses. Courts grant counsel wide latitude in closing arguments and allow trial courts discretion in regulating them, reviewed under an abuse of discretion standard.
Ms. Stanfield argued that unauthorized portions of the trial transcript should not be shown to the jury, claiming it violated the prohibition against using inadmissible evidence in closing arguments. However, the record did not indicate that Dr. Neblett's counsel used inadmissible testimony. While it is improper for juries to take transcripts into deliberations, it is acceptable for counsel to remind juries of witness testimonies during closing arguments. Dr. Neblett's counsel used the transcript to emphasize her case's strengths and Ms. Stanfield's weaknesses.
Ms. Stanfield's counsel also referenced testimony in his closing arguments but chose not to display the transcript. No authority was found to prohibit displaying transcript portions during closing arguments. Tennessee Code Annotated § 20-9-303 permits using visual aids, including transcripts, to illustrate arguments. Dr. Neblett's counsel acted within the statute's provisions, and the trial court did not err in permitting the display of transcript portions during closing arguments.
Ms. Stanfield contends that the accuracy of the transcript used during closing arguments cannot be verified as it was not authenticated or certified by the court reporter. The record lacks a copy of what was shown to the jury, containing only the transcript of the closing arguments. Upon reviewing the transcript, it is unclear what was displayed versus what was said by Dr. Neblett's counsel. Notably, both parties agree that the displayed content was sourced directly from the court reporter, and Ms. Stanfield's counsel did not object during the display or claim inaccuracies on the record.
Rule 6 of the Court of Appeals requires Ms. Stanfield to provide specific citations to the record regarding alleged prejudice, which she failed to do, preventing any finding of prejudice from the use of the transcript in closing arguments. Additionally, Ms. Stanfield's objection pertains to the context of the displayed testimony, but closing arguments are intended for summarizing the case, supporting evidence, and highlighting weaknesses in the opposing argument. Counsel is permitted to emphasize favorable testimony without necessarily presenting opposing evidence at that moment. Any claims of context misrepresentation could have been addressed during rebuttal. Consequently, the trial court did not abuse its discretion in permitting the display of transcript portions during closing arguments. The court affirms the trial court’s judgment, with costs of the appeal taxed to Ms. Stanfield and her surety.
