The opinion
IN THE COURT OF APPEALS OF TENNESSEE
WESTERN SECTION AT NASHVILLE
LISA J. PRINCE and husband, )
RICKY PRINCE, )
)
Plaintiffs/Appellants, ) Coffee Circuit No. 24,504
)
VS. ) Appeal No. 01A01-9508-CV-00342
)
COFFEE COUNTY, TENNESSEE
d/b/a COFFEE MEDICAL CENTER,
)
)
)
FILED
Defendant/Appellee. )
May 3, 1996
APPEAL FROM THE CIRCUIT COURT OF COFFEE COUNTYCecil W. Crowson
AT MANCHESTER, TENNESSEE Appellate Court Clerk
THE HONORABLE GERALD L. EWELL, SR., JUDGE
RICK L. MOORE
RUSSELL D. HEDGES
J. BROOKS FOX
MOORE & HEDGES
Tullahoma, Tennessee
Attorneys for Appellants
ROBERT L. TRENTHAM
MARK TYLER SEITZ
TRABUE, STURDIVANT & DEWITT
Nashville, Tennessee
Attorneys for Appellee
REVERSED AND REMANDED
ALAN E. HIGHERS, J.
CONCUR:
W. FRANK CRAWFORD, P.J., W.S.
HEWITT P. TOMLIN, JR., SR. J.
This is a medical malpractice case. Plaintiffs, Lisa and Ricky Prince, are husband
and wife. Lisa Prince ("Plaintiff") was injured during out-patient surgery, allegedly as a
result of improperly administered anesthetic. Initially, the suit was brought against Coffee
Medical Center, Dr. Ramprasand (the surgeon), and Michael Cruz (the nurse anesthetist).
Dr. Ramprasand and Cruz settled with Plaintiffs and were dismissed prior to this action.
Plaintiff alleges on appeal that Coffee Medical Center ("CMC") was negligent in failing to
establish adequate anesthetic policies and procedures and in failing to enforce its own
anesthesia policies and procedures. The trial court granted summary judgment in favor
of CMC and Plaintiff has appealed. For the reasons stated below, we reverse.
Dr. Ramprasand, Plaintiff's physician, admitted her to CMC on June 19, 1989, to
undergo same-day surgery for release of carpal tunnel syndrome. Dr. Ramprasand was
to perform the surgery and Michael Cruz, a certified registered nurse anesthetist, was to
administer the regional anesthetic. Cruz was employed by Warren Anesthesia Associates,
an organization with which the CMC had a contract obligating Warren to provide anesthetic
services to CMC patients.
The procedure for administering the regional anesthetic entails placing a double
tourniquet in the area of the elbow while injecting the anesthetic agent (.5% Xylocaine)
intravenously into the patient's arm. The hospital pharmacy was closed at the time of
Plaintiff's surgery, and the standard anesthetic, a .5% single dose vial of Xylocaine, was
not stocked in the operating room. Consequently, Cruz compounded his own solution of
.5% Xylocaine.
After two attempts to establish a tourniquet cuff on Plaintiff, Cruz injected the
anesthetic solution that he had prepared into Plaintiff's arm. Following surgery, the
tourniquet was removed. Soon thereafter, multiple blue patches appeared on Plaintiff's
arm and no pulse registered below her elbow. Plaintiff was taken by ambulance to St.
Thomas Hospital for corrective surgery.
Plaintiff was diagnosed at St. Thomas Hospital as having sustained a compartment
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syndrome and peripheral nerve injury. At St. Thomas Hospital she underwent a
fasciotomy, where a surgical incision is made in the arm to relieve pressure in the fascial
compartments. The fasciotomy left an open wound in Plaintiff's arm that required skin
grafting to correct. Plaintiff subsequently underwent several skin grafts, extensive physical
therapy, and other surgical procedures. Plaintiff has incurred approximately $140,000 in
medical expenses.
Dr. Ramprasand and Cruz entered into a settlement with Plaintiff, which resulted in
their dismissal from the suit. CMC filed a Motion for Summary Judgment based on the
fact that any potential liability against CMC was extinguished by the dismissal of Cruz and
Dr. Ramprasand from the case. CMC reasoned that any claims against it would be based
upon the conduct of either Dr. Ramprasand or Cruz and that, therefore, the common law
rule providing that when a servant is released from liability, the master is also released,
absolved CMC of any liability. CMC also argued that it was entitled to summary judgment
because the Plaintiff failed to allege specific acts of negligence in the original complaint.
Conversely, Plaintiff alleged that Cruz and Dr. Ramprasand were independent
contractors and that the claims against CMC rested solely upon independent grounds,
rather than upon derivative liability stemming from the acts of Cruz and Dr. Ramprasand.
Specifically, Plaintiff alleged that CMC was negligent in failing to enforce its own anesthetic
policies and procedures and in failing to establish anesthetic procedures that "would have
insured that those with limited staff privileges could not have exceeded their authority to
administer anesthetics to the Plaintiff, Lisa J. Prince."
In her original complaint dated June 18, 1990, Plaintiff alleged that CMC was
negligent in the following respects:
(a) In failing to provide competent medical personnel, including
doctors and nurses for the examination and treatment of its
patient, Plaintiff, Lisa J. Prince, following the completion of her
surgery;
(b) In failing to provide properly functioning equipment and
gauges necessary for the performance of a Bier Block and
application of a tourniquet.
(c) In failing to provide an anesthesiologist to administer the
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anesthesia and tourniquet to Plaintiff while she underwent
surgery;
(d) By otherwise failing to exercise that degree of care to
which the Defendant hospital was bound.
After filing her complaint, Plaintiff moved to amend the complaint to add Dr.
Ramprasand as a defendant. The trial court granted the motion. Thereafter, on May 19,
1994, Plaintiff again moved to amend her complaint in order to add specific acts of
negligence on the part of CMC, which are as follows:
(e) The Coffee Medical Center breached its duty of care to its
patient, Lisa Prince, by failing to provide a physician
anesthesiologist to the patient; and in the absence of a
physician anesthesiologist, the Coffee Medical Center failed to
assure that the operating surgeon, Dr. Mittur Ramprasand, was
qualified and aware of his obligation to supervise the nurse
anesthetist, Mr. Michael Cruz.
(f) The Coffee Medical center breached its duty of care to its
patient, Lisa Prince, by allowing a Certified Registered Nurse
Anesthetist to practice anesthesiology in its hospital in an
unsupervised capacity.
(g) The Coffee Medical Center breached its duty to its patient,
Lisa Prince, by failing to stock the appropriate anesthetic at the
time of her surgery; and by allowing a registered nurse to
independently prepare, compound and dispense drugs.
(h) The Coffee Medical Center breached its duty to its patient,
Lisa Prince, by negligently failing to assure that Mrs. Prince's
anesthesia care was supervised by an appropriate physician
with special knowledge of anesthesia.
Initially, the trial court granted Plaintiff's's motion to amend, but later vacated its
decision and denied the motion. In its memorandum opinion, the trial court reviewed the
extensive discovery and pleadings that had occurred in the case and held that justice did
not mandate the granting of the amendment. The trial court stated:
If, as counsel for the plaintiffs states on oral argument, the
amendment does not change the cause or causes of action
against the defendant, Coffee County Hospital, it is
unnecessary. If it does change or add the cause of action, it
triggers additional discovery and proof, and while the Court is
aware that amendments are to be freely granted, it is, in this
case, the opinion of the Court that justice does not mandate
that the amendment should be granted.
Rule 15.01 Tenn. R. Civ. P. provides, "A party may amend his pleadings once as
a matter of course at any time before a responsive pleading is served...[o]therwise a party
may amend his pleadings only by written consent of the adverse party or by leave of
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court..." Although the rule provides that permission to amend may be liberally granted, the
decision to amend lies within the sound discretion of the trial court, and will not be reversed
absent a showing of abuse of discretion. Welch v. Thuan, 882 S.W. 2d 792, 793 (Tenn.
App. 1994); Wilson v. Ricciardi, 778 S.W. 2d 450, 453 (Tenn. App. 1989); Merriman v.
Smith, 599 S.W. 2d 548, 559 (Tenn. App. 1979).
The Tennessee Supreme Court has established several pertinent factors that a trial
court should consider in deciding whether to grant or deny a motion to amend. These
factors include "[u]ndue delay in filing; lack of notice to the opposing party; bad faith by the
moving party, repeated failure to cure deficiencies by previous amendments, undue
prejudice to the opposing party, and futility of amendment." Merriman, 599 S.W. 2d at 559.
After an extensive review of the record, we do not find any indication that the trial
court abused its discretion in denying the motion to amend. Examining this case in the
light of the above delineated factors, we find ample justification for the action of the trial
court in denying such motion.
With respect to Plaintiff's allegations that CMC was negligent in failing to implement
proper anesthetic standards and procedures, we hold that the original allegation, which
stated that CMC was negligent "by otherwise failing to exercise that degree of care to
which the Defendant hospital was bound," was sufficient to put CMC on notice of Plaintiff's
claim. Tennessee's notice pleading requires a complaint to contain only minimum general
facts that would support potential cause of action under Tennessee substantive law. A
complaint is generally sufficient if it states facts supporting any theory of relief, even if the
theory is different from that upon which the plaintiff intended to rely. LAW RENCE A. PIVNICK,
TENNESSEE CIRC UIT COURT PRACTICE § 7-2, at 244-45 (3rd ed. 1991). Consequently, to
permit Plaintiff to amend her complaint in order to allege that CMC was negligent in failing
to establish adequate anesthetic policies and procedures would be a futile effort because
it is unnecessary.
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To the extent that Plaintiff attempts to amend her complaint in order to state
a negligent credentialing claim against CMC, we agree with the trial court that granting the
amendment would result in substantial prejudice to CMC. Plaintiff's motion to amend was
filed more than four years after her original complaint was filed. It is our opinion that the
general allegation of failure to exercise due care did not serve to place CMC on notice of
Plaintiff's intent to pursue a negligent credentialing claim. A claim for negligent
credentialing is distinct from a malpractice action and requires separate elements of proof.
The trial court did not abuse its discretion in prohibiting Plaintiff from pursuing a new
avenue of liability in litigation that has been pending for over four years in light of the fact
that Plaintiff was previously allowed to amend her complaint and voluminous discovery,
motions, and pleadings have been filed.
The next issue for review is whether the trial court erred in granting CMC's motion
for summary judgment.
Summary judgment is to be rendered by a trial court only when it is shown that there
is no genuine issue as to any material fact and the moving party is entitled to a judgment
as a matter of law. Tenn. R. Civ. P. 56.03. When a motion for summary judgment is used
defensively, the plaintiff must present evidence sufficient to establish the essential
elements of the claim on which he will bear the burden of proof at trial. Blair v. Allied
Maintenance Corp., 756 S.W. 2d 267, 269-270 (Tenn. App. 1988) In ruling on a motion
for summary judgment, the trial court and the Court of Appeals must consider the matter
in the same manner as a motion for a directed verdict made at the close of the plaintiff's
proof. All of the evidence must be viewed in the light most favorable to the opponent of the
motion and all legitimate conclusions of fact must be drawn in favor of the opponent. It is
only when there is no disputed issue of material fact that a summary judgment should be
granted by the trial court and sustained by the Court of Appeals. Byrd v. Hall, 847 S.W.
2d 208, 211 (Tenn. 1993). If the court entertains any doubt as to whether a genuine issue
of material fact exists, it is the court's duty to overrule the motion. Id. This court may not
weigh the evidence when evaluating a motion for summary judgment. Id. When it is
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necessary that the evidence be weighed, a trial should ensue because such issues are not
properly capable of resolution on the basis of affidavits alone. Id. at 216.
The duty of a hospital is to exercise such reasonable care toward patients as the
patients' conditions require. Keeton v. Maury County Hospital, 713 S.W. 2d 314, 316
(Tenn. App. 1986). In order to recover, a plaintiff must show that the hospital violated that
standard of care. Id. at 317. The burden of proof is on the plaintiff to prove the standard
of care, violation of that standard, and causation. T.C.A. § 29-26-115. Unless the alleged
malpractice lies within the ordinary knowledge of a layman, there must be expert testimony
as to the standard of care, breach of that standard, and causation. Coyle v. Prieto, 822
S.W.2d 596, 598 (Tenn. App. 1991); Stokes v. Leung, 651 S.W.2d 704, 706 (Tenn. App.
1982).
CMC supported its motion for summary judgment with the affidavit of Jane Hamby,
R.N., who stated that CMC's nursing staff complied fully with the recognized standard of
acceptable practice for nurses and that the tourniquet functioned properly.
In opposition to CMC's motion for summary judgment, Plaintiff filed the affidavits and
deposition testimony of three experts. Dr. James A. Ramsey, an anesthesiologist who
treated Plaintiff while she was hospitalized at St. Thomas Hospital, is a board certified
anesthesiologist who practices in Nashville, Tennessee. He executed two affidavits, one
of which states in pertinent part as follows:
The Coffee Medical Center was negligent in failing to assure
that Michael Cruz, Certified Registered Nurse Anesthetist, was
supervised by an appropriate physician with special knowledge
of anesthesia.
Dr. Ramsey stated in another affidavit as follows:
In my opinion, the injury to Lisa Prince would not have
occurred if the Coffee Medical Center had not breached its
duty of care that it owed to its patient Lisa Prince, and assured
that the operating surgeon was qualified to supervise the nurse
anesthetist, and further, assured that the operating surgeon
realized his obligation to supervise the nurse anesthetist...
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Dr. William Bradley Worthington, another anesthesiologist who cared for Plaintiff
testified that in the present situation, the standard of care required the surgeon to be
responsible for supervising the CRNA.
James L. Massey, II, professor of hospital and health administration at Governors
State University in Illinois, was the third expert to testify for Plaintiff. Mr. Massey testified
that CMC was negligent in credentialing Dr. Ramprasand and Michael Cruz. Mr. Massey
also testified that CMC breached the standard of care for hospitals through failing to
review, update, and abide by the medical staff by-laws on credentialing, by failing to
establish rules and regulations for anesthesia services and surgeon supervision of CRNA's,
by failing to make certain that all surgeons were qualified sufficiently in anesthesia, by
failing to establish policies and procedures for anesthesia services, by failing to insure that
pre-surgical checks by nurses were made, and by failing to establish proper controls on the
use of equipment.
Because we have ruled that Plaintiff may not pursue her negligent credentialing
theory of recovery, Massey's testimony relating to a claim for negligent credentialing is
immaterial. However, Massey also stated in his affidavit that CMC deviated from the
standard of care through its "[f]ailure to specify that each surgeon has a responsibility to
supervise anesthesia," its "[f]ailure to have policies and procedures for anesthesia," and
its "[f]ailure to provide Lisa J. Prince with a preanesthesia evaluation." Massey's affidavit
provides:
Coffee Medical Center in this case failed to implement the
proper standards both internally and nationally...[I]t is my
opinion that those causal factors would have been avoided if
proper hospital procedures and credentialing had been in
place. As a direct result of Coffee Medical Center's breach of
the appropriate hospital standards Lisa Prince sustained injury.
It is inappropriate for this Court to weigh the evidence in evaluating a motion for
summary judgment. When the above evidence is viewed in a light most favorable to
Plaintiff and all countervailing evidence is discarded, a genuine issue of material fact exists
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in the present case.
Accordingly, we are of the opinion that the affidavits and testimony offered by
Plaintiff in opposition to CMC's motion for summary judgment establish that there exists
a genuine issue of material fact, thereby rendering summary judgment inappropriate. The
order granting CMC summary judgment is reversed and this case is remanded to the trial
court for such other and further proceedings as may be necessary. Costs on appeal are
assessed equally against the parties.
HIGHERS, J.
CONCUR:
CRAWFORD, P.J., W.S.
TOMLIN, Sr. J.
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