Case Title: Mobile Infirmary Association v. Fagerstrom

Citation: 

Docket Number: SC-2023-0355

State: alabama

Court: Alabama Supreme Court

Date: 2023-11-17T00:00:00Z

Document:
Rel: November 17, 2023 
 
 
 
 
 
 
 
Notice: This opinion is subject to formal revision before publication in the advance sheets of Southern 
Reporter.  Readers are requested to notify the Reporter of Decisions, Alabama Appellate Courts, 
300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334) 229-0650), of any typographical or other 
errors, in order that corrections may be made before the opinion is printed in Southern Reporter. 
 
 
SUPREME COURT OF ALABAMA 
 
OCTOBER TERM, 2023-2024 
 
_________________________ 
 
SC-2023-0355 
_________________________ 
 
Mobile Infirmary Association d/b/a Mobile Infirmary Medical 
Center and Gulf Health Hospitals, Inc., d/b/a Thomas Hospital 
 
v. 
 
Wayne Fagerstrom, individually and as administrator of the 
Estate of Sylvia Fagerstrom, deceased 
 
 
 
Appeal from Baldwin  Circuit Court 
(CV-20-900001) 
 
SELLERS, Justice. 
 
 
SC-2023-0355 
2 
 
 
In this medical-malpractice/wrongful-death case, the Baldwin 
Circuit Court entered a judgment on a jury verdict in favor of the plaintiff 
Wayne Fagerstrom, individually and as the administrator of the estate 
of Sylvia Fagerstrom, deceased.  The defendants are Mobile Infirmary 
Association d/b/a Mobile Infirmary Medical Center ("MIMC") and Gulf 
Health Hospitals, Inc., d/b/a Thomas Hospital.  The defendants argue on 
appeal that the trial court erred in denying their renewed motion for a 
judgment as a matter of law at the close of all the evidence, in which they 
asserted that the plaintiff had failed to offer sufficient evidence 
demonstrating that the proximate cause of Sylvia's death was sepsis 
resulting from an infected pressure ulcer allegedly caused by the 
defendants' breaches of the standard of care.  We agree with the 
defendants and reverse the trial court's judgment. 
 
 Sylvia was 85 years old when doctors discovered a tumor on her 
brain.  In October 2018, a surgeon at MIMC extracted the tumor, but 
Sylvia did not recover as hoped.  Instead, she became malnourished and 
lethargic, had trouble speaking, and developed high blood pressure and 
a blood clot.  She also suffered from chest pain, nausea, swelling in her 
SC-2023-0355 
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lower extremities, toxic metabolic encephalopathy, and a recurring 
urinary-tract infection that was particularly resistant to antibiotics. 
 
As is relevant to the plaintiff's theory of liability, Sylvia also 
developed a pressure injury on her sacrum while at MIMC.  Sylvia's 
injury began as a small "tear" but later progressed to a Stage 3 pressure 
ulcer during Sylvia's stay at MIMC.  The plaintiff asserts that nurses at 
MIMC breached the applicable standard of care and caused her pressure 
injury by not turning her frequently enough in her hospital bed.  In 
November 2018, Sylvia was transferred to a nursing home, where her 
ulcer apparently began to heal.  Thereafter, however, she was admitted 
to Thomas Hospital and her injury progressed to a Stage 4 pressure ulcer.  
The plaintiff asserts that Sylvia's injury worsened at Thomas Hospital 
because the nurses there, like the nurses at MIMC, allegedly failed to 
turn her frequently enough. 
After her stay at Thomas Hospital, Sylvia was transferred to a 
second nursing home, where, according to the plaintiff's expert witness, 
her ulcer became infected.  Sylvia was then transferred back to Thomas 
Hospital and, after further treatment, returned to the second nursing 
SC-2023-0355 
4 
 
home.  She died at that nursing home approximately three and one-half 
months after her brain surgery at MIMC. 
 
The plaintiff's expert witness, Dr. David Seignious, testified that 
the defendants' alleged breaches of the standard of care caused Sylvia to 
develop the ulcer, which became infected and led to a bone infection, 
which caused sepsis that resulted in Sylvia's death.  The defendants, 
however, challenge Dr. Seignious's opinion that Sylvia died from sepsis 
caused by the infected ulcer.  Accordingly, they assert that the plaintiff 
failed to present sufficient evidence of proximate cause and that his claim 
therefore should not have been submitted to the jury. 
Section 6-5-549, Ala. Code 1975, provides, in pertinent part:  
"In any action for injury or damages or wrongful death, 
whether in contract or in tort, against a health care provider 
based on a breach of the standard of care, the minimum 
standard of proof required to test the sufficiency of the 
evidence to support any issue of fact shall be proof by 
substantial evidence." 
 
See also Hrynkiw v. Trammell, 96 So. 3d 794, 797 (Ala. 2012) (indicating 
that, to avoid the entry of a judgment as a matter of law in favor of the 
defendants, the plaintiffs in a medical-malpractice action bore the burden 
of presenting substantial evidence in support of all the elements of their 
claims).  "[S]ubstantial evidence is evidence of such weight and quality 
SC-2023-0355 
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that fair-minded persons in the exercise of impartial judgment can 
reasonably infer the existence of the fact sought to be proved."  West v. 
Founders Life Assurance Co. of Florida, 547 So. 2d 870, 871 (Ala. 1989).  
To establish proximate cause, the plaintiff was required to demonstrate 
with expert medical testimony that Sylvia probably died from sepsis 
caused by her infected ulcer.  See University of Alabama Health Servs. 
Found., P.C. v. Bush, 638 So. 2d 794, 802 (Ala. 1994) ("To prove causation 
in a medical malpractice case, the plaintiff must prove, through expert 
medical testimony, that the alleged negligence probably caused, rather 
than only possibly caused, the plaintiff's injury.").  The trial court's denial 
of the defendants' renewed motion for a judgment as a matter of law is 
subject to de novo review, but we must view the evidence in a light most 
favorable to the plaintiff.  See Thompson v. Patton, 6 So. 3d 1129, 1133 
(Ala. 2008). 
The defendants assert that Dr. Seignious's opinion that Sylvia died 
from sepsis caused by her ulcer was based on mere speculation instead of 
"objective data" obtained from medical testing, such as measurements of 
Sylvia's pulse, respiration, blood pressure, and body temperature.  Dr. 
Seignious agreed that it is important to consider that sort of medical data 
SC-2023-0355 
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when diagnosing or ruling out sepsis.  He also agreed when asked if it is 
particularly important to study a patient's vital signs "toward the end of 
life" in order to diagnose sepsis because it is possible that a patient could 
have sepsis at some earlier point, but not at death.   
Dr. Seignious's testimony suggests, however, that some of this 
important objective data had been omitted from Sylvia's medical records 
and that he was therefore unable to review it.  Although Dr. Seignious 
testified that he "believe[d] there were some vitals done around the 10th 
or 12th of February," which was within two days of Sylvia's death, it is 
not clear from the parties' briefs exactly what those vital signs showed.  
In his brief to this Court, the plaintiff references those vital signs, but he 
does not clearly explain what they indicated or how they suggested that 
Sylvia died from sepsis caused by her infected ulcer.  The only express 
reference to sepsis in Sylvia's medical records that Dr. Seignious testified 
to during the trial was a statement made by a surgeon approximately 
three weeks before Sylvia died indicating that the surgeon had discussed 
with Sylvia's family the potential risks of removing dead tissue 
surrounding her ulcer, which included the potential for "bleeding, 
SC-2023-0355 
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infection, the need for further [removal of tissue], sepsis, and other 
cardiopulmonary complications." 
According to Dr. Seignious, in the absence of objective data, experts 
must rely on their "medical judgment" and "what the projected course or 
the normal course of the condition is."  In other words, he based his 
opinion that Sylvia died from sepsis resulting from her infected ulcer on 
what he claimed was the typical progression and end result of the sort of 
infection Sylvia had.  But, as the defendants point out, results from 
several medical tests performed on Sylvia at the second nursing home 
and in hospice care multiple times every day during the 10 days before 
she died did indeed reveal a significant number of objective vital signs for 
each of those days, including Sylvia's pulse, respiration, blood pressure, 
and body temperature.  Dr. Seignious, however, apparently was unaware 
of those records before the trial.1 
 
1The plaintiff appears to suggest that there were other types of tests 
that were not performed on Sylvia in the days leading up to her death, 
including "blood count" tests and "kidney function" tests.  To the extent 
that the plaintiff suggests that, in the absence of those two types of tests, 
none of the available objective vital signs, such as pulse, blood pressure, 
or body temperature, should have been considered, the portion of the 
record he cites does not support that suggestion.  
SC-2023-0355 
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Other medical experts, including Dr. Donald Plummer, an 
infectious-disease specialist who personally treated Sylvia, testified that 
Sylvia's vital signs leading up to her death did not indicate that she had 
sepsis when she died.  To the contrary, Dr. Plummer testified, Sylvia did 
not have a fever, her blood pressure was stable, and her heart rate was 
not unusually high.  Dr. Jimmy Adkisson, who prepared Sylvia's death 
certificate, opined that Sylvia died from renal failure with contributions 
from deep-vein thrombosis, coronary artery disease, valvular heart 
disease, and malnutrition.  There is no mention on the death certificate 
of Sylvia's ulcer or sepsis, and Dr. Adkisson testified that, based on 
Sylvia's medical records, she was in fact not septic when she died.  A third 
expert called by the defendants, Dr. Aimee Garcia, who is a wound 
specialist with experience in pressure injuries and sepsis, agreed with 
Dr. Plummer and Dr. Adkisson that, based on Sylvia's objective vital 
signs leading up to her death, she was not septic when she died. 
In affirming a summary judgment in favor of a defendant in a 
medical-malpractice action, this Court has said: 
"'[T]he opinions of an expert may not rest on "mere 
speculation and conjecture." Townsend v. General Motors 
Corp., 642 So. 2d 411, 423 (Ala. 1994).' Dixon v. Board of 
Water & Sewer Comm'rs of Mobile, 865 So. 2d 1161, 1166 
SC-2023-0355 
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(Ala. 2003). '[A]s a theory of causation, a conjecture is simply 
an explanation consistent with known facts or conditions, but 
not deducible from them as a reasonable inference. See, e.g., 
Griffin Lumber Co. v. Harper, 247 Ala. 616, 25 So. 2d 505 
(1946).' Alabama Power Co. v. Robinson, 447 So. 2d 148, 153-
54 (Ala. 1983). An expert witness's opinion that is conclusory, 
speculative, and without a proper evidentiary foundation 
cannot create a genuine issue of material fact. Becton v. 
Rhone-Poulenc, Inc., 706 So. 2d 1134, 1141-42 (Ala. 1997)." 
 
Bradley v. Miller, 878 So. 2d 262, 266 (Ala. 2003).2  Evidence indicating 
that an injury could have occurred a certain way is not sufficient; the 
proof must support a reasonable inference that the injury did occur as 
alleged.  Shanes v. Kiser, 729 So. 2d 319, 321 (Ala. 1999). 
As the defendants note in their brief to this Court, "Dr. Seignious's 
testimony concerned what he thought potentially might happen in a so-
called 'projected,' 'normal course,' but it is undisputed that every other 
physician who reviewed what actually happened -- the 'objective data' in 
the vital signs -- unanimously and conclusively testified that [Sylvia] did 
not die of sepsis."  The defendants' brief at 48.  Thus, according to the 
 
2The judgment under review in Bradley was a summary judgment, 
not a ruling on a renewed motion for a judgment as a matter of law.  But 
the standard of review for a ruling on each sort of motion is "materially 
indistinguishable."  Hathcock v. Wood, 815 So. 2d 502, 506 (Ala. 2001).  
Specifically, the standard is whether the nonmoving party has submitted 
substantial evidence in support of his or her claims.   
SC-2023-0355 
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defendants, Dr. Seignious's opinion was not supported by a proper 
evidentiary foundation, was conclusory and speculative, and did not 
justify submitting the issue of causation to the jury.   
In Shanes v. Kiser, 729 So. 2d 319 (Ala. 1999), upon which the 
defendants rely, this Court affirmed a judgment as a matter of law in 
favor of a defendant medical provider based on the lack of sufficient 
evidence indicating that the decedent in that case had died from a heart 
attack the defendant medical provider allegedly failed to discover or 
anticipate.  The plaintiff's expert in Shanes opined that the cause of death 
was likely a heart attack because the symptoms the decedent exhibited 
were consistent with a heart problem and because "statistics suggest[ed] 
that more people die each year of heart-related problems than of any 
other cause."  729 So. 2d at 322.  This Court, however, concluded that 
that testimony simply demonstrated that the decedent could have 
suffered a heart attack, not that she actually did.  We agree with the 
defendants in this case that Dr. Seignious's testimony regarding "the 
projected course or the normal course of the condition" is analogous to the 
expert testimony in Shanes.  Although there is evidence indicating that 
Sylvia developed a pressure ulcer while at MIMC and that that ulcer 
SC-2023-0355 
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worsened to the point of infection while under the care of the defendants, 
the plaintiff did not submit substantial evidence indicating that, when 
she died, Sylvia was suffering from sepsis caused by the infected ulcer 
and that that specific condition caused her death. 
The plaintiff relies heavily on Hannon v. Duncan, 594 So. 2d 85 
(Ala. 1992), in which this Court determined that a trial court had not 
erred in denying a defendant physician's motion for a judgment as a 
matter of law.  The physician had performed surgery on the plaintiff's 
decedent, which allegedly resulted in her becoming paralyzed.  The 
decedent died six years later while suffering from pressure ulcers and 
kidney infection, which are common conditions in paraplegics.  On 
appeal, the physician argued that the plaintiff's expert testimony was not 
sufficient evidence indicating that the decedent's death was caused by 
the paralysis that allegedly led to ulcers and infections.  This Court 
disagreed.  The Court in Hannon, however, relied on the old "scintilla 
rule" of evidence, which justified the submission of a claim to a jury if 
there was so much as a mere gleam or glimmer of evidence to support 
that claim.  That outdated standard does not apply in the present case; 
the plaintiff in this case was required to present substantial evidence of 
SC-2023-0355 
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causation.  Moreover, as the defendants point out, nothing in Hannon 
suggests that the expert witness in that case failed to consider the 
relevant objective data or criteria necessary to reach an opinion on the 
cause of death. 
We do note that laboratory reports from blood tests that were 
performed a month before Sylvia's death and again three and a half 
weeks before her death showed that Sylvia had an increasing white-
blood-cell count, which indicated that she had an unspecified infection at 
those times.  Nothing demonstrates, however, that she had an elevated 
white-blood-cell count at the time of her death.  The defendants also 
acknowledge "a few references to 'sepsis' or 'urosepsis' … in [Sylvia's] 
medical records … two or more weeks before her … death."  The 
defendants' brief at 21 n.7.  According to Dr. Plummer, however, those 
references related to Sylvia's urinary-tract infection, not her pressure 
ulcer.  And, according to Dr. Adkisson, a single reference to "sepsis, 
unspecified organism" on an "Inpatient Coding Summary" created by 
Thomas Hospital two weeks before Sylvia died did not support a 
conclusion that Sylvia was septic when she died.  Moreover, Dr. Seignious 
SC-2023-0355 
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did not testify regarding the above-referenced mentions of "sepsis" in 
Sylvia's medical records.3 
We reverse the trial court's judgment and remand this matter for 
the entry of a judgment as a matter of law in favor of the defendants.  The 
Court pretermits discussion of the defendants' alternative argument that 
they are entitled to a new trial based on the trial court's alleged error in 
refusing to strike certain prospective jurors from the jury panel. 
 
REVERSED AND REMANDED. 
 
Shaw, Wise, Bryan, Stewart, Mitchell, and Cook, JJ., concur. 
 
Parker, C.J., and Mendheim, J., concur in the result. 
 
3The plaintiff does not offer a convincing response to the defendants' 
assertion that the passing references to sepsis in Sylvia's medical records 
do not constitute evidence of causation because causation must be proven 
by expert medical testimony.