Case Title: Cox, et al. v. St. Joseph's Hospital, et al.

Citation: 

Docket Number: SC09-1771

State: florida

Court: Florida Supreme Court

Date: 2011-07-07T00:00:00Z

Document:
Supreme Court of Florida 
 
 
____________ 
 
No. SC09-1771 
____________ 
 
WILLIAM COX, et al.,  
Petitioners, 
 
vs. 
 
ST. JOSEPHS HOSPITAL, et al.,  
Respondents. 
 
[July 7, 2011] 
 
PARIENTE, J. 
 
In this medical malpractice case, the key issue is whether the Second District 
Court of Appeal impermissibly reweighed the testimony presented by the 
plaintiffs’ expert witness as to whether the conduct of the hospital and emergency 
room doctor (the defendants) caused William Cox to suffer devastating damages as 
a result of a stroke.  We conclude that by reweighing the evidence, the Second 
District’s decision in St. Joseph’s Hospital v. Cox, 14 So. 3d 1124 (Fla. 2d DCA 
2009), expressly and directly conflicts with this Court’s decisions in Wale v. 
Barnes, 278 So. 2d 601 (Fla. 1973), and Gooding v. University Hospital Building, 
 
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Inc., 445 So. 2d 1015 (Fla. 1984).  We have jurisdiction.  See art. V, § 3(b)(3), Fla. 
Const. 
FACTS 
At the age of sixty-nine, William Cox suffered a stroke with devastating 
consequences, leaving him with permanent paralysis and aphasia.  Following a jury 
trial on his claim of medical malpractice, he received a jury verdict that awarded 
substantial damages to him and his wife.  The key issue in this medical malpractice 
case was the legal sufficiency of the plaintiffs’ expert testimony regarding 
causation; that is, whether more likely than not, the administration of a tissue 
plasminogen activator (tPA), a drug that dissolves blood clots, would have 
prevented or mitigated the devastating consequences of the stroke.  
The facts presented to the jury established that on the morning of January 
19, 2001, Mr. Cox was at a friend’s car dealership.  Mr. Cox initially appeared 
normal and was able to speak to a visitor.  However, approximately fifteen to 
twenty minutes later, the same visitor found Mr. Cox incapacitated and unable to 
speak or walk, and he immediately called 911.  Emergency personnel quickly 
arrived on scene to transport Mr. Cox to St. Joseph’s Hospital.  The visitor 
informed the responding paramedics that Mr. Cox’s loss of ability occurred at 
some point during the fifteen- or twenty-minute period before he had called 911.   
 
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Based on the information provided at the scene, the paramedics knew the 
approximate time of the onset of Mr. Cox’s stroke, but for unknown reasons, the 
emergency room staff at St. Joseph’s Hospital did not obtain this vital information 
and never attempted to acquire it.  The failure of the defendants to obtain 
information regarding the time of onset of the stroke was the crux of the medical 
malpractice case because knowing the time of onset was critical to being able to 
treat Mr. Cox with tPA.   
Specifically, Mr. Cox suffered an ischemic stroke, which is caused by a 
blood clot.  An ischemic stroke can be treated with the use of tPA, which dissolves 
blood clots.  However, doctors have a short window of opportunity in which to 
administer this drug: no more than three hours after the onset of the stroke if 
administered intravenously and no more than six hours after onset if administered 
intra-arterially.  Therefore, in order to consider using tPA, the treating doctor must 
know the time of onset of the stroke.  Here, although Mr. Cox arrived at the 
hospital within the window for administering tPA and had undergone several tests, 
including a cranial computed tomography (CT scan), which was normal at the time 
of the admission to the hospital, the emergency room doctor never considered the 
use of tPA because he did not know the time of onset of the stroke.  
Mr. Cox and his wife filed a medical malpractice action against St. Joseph’s 
Hospital, the emergency room doctor, and the doctor’s medical practice.  Because 
 
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the claim was against the emergency room doctor, pursuant to section 
768.13(2)(b)(1), Florida Statutes (2000), the plaintiffs were required to show that 
the defendants acted with “reckless disregard” of Mr. Cox’s health in failing to 
obtain the information regarding the onset time of the stroke.  That issue of 
whether the plaintiffs met that burden of proving medical malpractice is not before 
us; rather, the focus is on whether the defendants’ actions caused damages to be 
suffered by Cox.  
During the trial, in order to prove causation, the plaintiffs presented the 
expert opinion testimony of Dr. Nancy Futrell.  Dr. Futrell is a specialist in strokes 
who has founded several stroke centers around the country.  Her background is 
extensive: she is certified in neurocineology (ultrasounds of the blood vessels in 
the neck and brain), MRI and CT reading, and she is board certified in vascular 
neurology.  In fact, in terms of CT scans, she had previously worked as a CT scan 
images analysis contracts investigator, where she reviewed CT scans, digitized 
them, and determined the exact size of a stroke.  In that job, she reviewed between 
900 and 1100 CT scans.  She has been treating stroke patients for over twelve 
years and has given tPA to patients approximately forty to fifty times during her 
practice.  
Dr. Futrell testified that “to a high degree of medical probability” she 
believed that if Mr. Cox had received tPA, he “would have had a very good 
 
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recovery and have minimal or no neurologic deficit.”  St. Joseph’s Hosp., 14 
So. 3d at 1126.  Dr. Futrell asserted that she based her opinion on what she knew 
about Mr. Cox’s case, her own clinical experience, and the pertinent medical 
literature.  During her testimony, Dr. Futrell explained why she believed that Mr. 
Cox was a good candidate for the use of tPA.  First, based on his CT scan, his brain 
appeared to be much younger than his stated age and had normal fluid spaces.  
Normally when one ages, the brain shrinks, and the fluid spaces get larger, but in 
his case, the fluid spaces were not enlarged at all; there was no evidence of 
shrinking and therefore his brain “looks much younger than this man’s stated age.”  
She saw no evidence of prior bleeding and no evidence that he had a prior stroke.  
Specifically she stated that “[i]f he had a bleed into his brain in the past, that bleed, 
if it had healed would leave a dark spot and I see no dark spots in here to suggest 
that he’s had any kind of a stroke or any kind of a bleed into his brain whatsoever.”  
She also saw no evidence of lesions or a subdural hematoma.  She opined that 
because his brain was not shrinking yet, he was “not at high risk for another 
subdural hematoma.”  Further, in response to the defense position that a prior 
subdural hematoma would have prevented the administration of tPA, she testified 
that even assuming he had a prior subdural hematoma, it was not significant 
enough to leave any shrinkage on the surface of the brain.  Thus, if she had been 
 
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the treating neurologist, she explained that she would not have been prevented 
from suggesting the use of tPA.   
Second, in her opinion, the CT scan showed that Mr. Cox was an excellent 
candidate for tPA because irreversible damage had not yet started to occur at that 
point.  Dr. Futrell recognized that a prior intracranial bleed is a contraindication to 
the use of tPA, but asserted that this does not mean that a doctor absolutely cannot 
give tPA to a patient based on this prior condition.  She asserted that there are 
indications and contraindications, so doctors must balance those to obtain a risk-
benefit profile, which requires good clinical judgment on the part of the doctor.   
On cross-examination of Dr. Futrell, the defendants attempted to attack Dr. 
Futrell’s opinion based on their general contention that a 1995 clinical study of 
tPA, known as the “NINDS” study,1 did not establish that there was a “more likely 
than not” chance of improvement from the effects of the stroke.  In addition, the 
defendants contended that administration of the drug was contraindicated because 
of their claim that Cox had suffered a previous subdural hematoma.   
Dr. Futrell disagreed with the defendants’ characterization of the NINDS 
study.  She further questioned the accuracy of the reports indicating that Mr. Cox 
                                         
1.  The “NINDS” study refers to the National Institute of Neurological 
Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study 
Group, the conclusions of which were reported in the December 14, 1995, issue of 
the New England Journal of Medicine.  The study itself was not introduced into 
evidence. 
 
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previously had suffered a subdural hematoma because Mr. Cox’s current brain CT 
scan was normal and she did not see any signs of prior significant hemorrhages.   
The defendants moved for a directed verdict on the issue of causation, which 
the trial court denied.  The jury subsequently found in favor of the plaintiffs and 
awarded substantial damages.  The defendants appealed to the Second District, 
which reversed the trial court on the basis that the plaintiffs failed to meet their 
burden of proving causation.  St. Joseph’s Hosp., 14 So. 3d at 1125.  The district 
court reviewed the evidence before the trial court and held that the plaintiffs failed 
to meet this burden because the testimony of the expert witnesses was based only 
on speculation.  In rejecting the plaintiffs’ argument that causation was sufficiently 
proven by the expert testimony in this case, the Second District held the cases 
relied upon by the plaintiffs were distinguishable because in those cases, the expert 
testimony was not constrained by statistical evidence revealing a success rate of 
less than fifty percent.  Id. at 1128.  The plaintiffs appealed, asserting that the 
decision of the Second District is in express and direct conflict with this Court’s 
decisions in Wale and Gooding. 
ANALYSIS 
The issue before this Court is whether the district court reweighed legally 
sufficient evidence of causation from the plaintiffs’ expert witness that the 
administration of tPA, more likely than not, would have mitigated the devastating 
 
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damages of Mr. Cox’s stroke.  In this case, the Second District recognized that in 
Florida, a plaintiff seeking to establish a negligence action must demonstrate that 
the negligence “probably caused” the plaintiffs’ injury and that Dr. Futrell testified 
that “Mr. Cox probably would have had a good recovery from the stroke if he had 
received tPA therapy.”  St. Joseph’s Hosp., 14 So. 3d at 1127.  However, after 
scrutinizing her testimony, the district court stated that it could “glean no facts that 
support her assertion that Mr. Cox would have had a fifty-one percent or greater 
chance of benefitting from tPA treatment.”  Id.   
In order to decide the matter before us, it is helpful to first review how this 
Court has addressed this issue in the two conflict cases.  In Wale v. Barnes, 278 
So. 2d 601, 603 (Fla. 1973), one of the conflict cases, the plaintiffs brought a 
medical malpractice case against two doctors, asserting that the doctors negligently 
used certain forceps during the delivery of a child that caused serious injuries to 
the child, who was later treated for bilateral subdural hematomas.  During the trial, 
conflicting evidence showed that the injuries could have been caused by the type of 
forceps that the doctor chose or the nonnegligent act of the infant moving down the 
birth canal.  Id. at 604.  The district court in Wale misapplied prior decisions that 
held a defendant may be entitled to a directed verdict where the plaintiff did not 
eliminate possible nonnegligent causes because, in those cases, the plaintiff failed 
to introduce direct proof that the injury resulted from a definite negligent act.  Id.  
 
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This Court reversed, relying on the fact that the plaintiffs in Wale presented an 
expert who stated that the specific forceps that the defendant used were not the 
standard in this situation and opined that “within reasonable medical probability, 
the cause of the chronic subdural hematomas was the traumatic or injurious forceps 
delivery of this child in which the head was injured.”  Id. at 605.  Based on that 
testimony, this Court held the plaintiffs made a prima facie case as to causation.  
Id.  Although there was conflicting evidence as to the cause of the injury, the Court 
held that this issue was a matter for the jury to resolve. 
In contrast, in Gooding v. University Hospital Building, Inc., 445 So. 2d 
1015, 1017 (Fla. 1984), the plaintiff brought a medical malpractice action, 
asserting that the hospital was negligent in failing to take adequate steps to 
diagnose and treat Mr. Gooding’s abdominal aneurysm before he bled out and 
went into cardiac arrest.  In that case, while the plaintiffs’ expert witness testified 
that the inaction of the emergency room staff violated accepted medical standards, 
the expert did not testify that immediate diagnosis and surgery would have, more 
likely than not, enabled Mr. Gooding to survive.  Id.  After discussing Wale and 
the general standards that apply in negligence actions, this Court held that the 
defendant was entitled to a directed verdict because “the testimony established a no 
better than even chance for Mr. Gooding to survive, even had there been an 
immediate diagnosis of the aneurysm and emergency surgery.”  Id. at 1018. 
 
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In turning to this case, the Second District correctly recognized that, in order 
to establish a negligence action, Florida follows the “more likely than not” 
standard in proving causation, i.e., that the negligence “probably caused” the 
plaintiff’s injury.  St. Joseph’s Hosp., 14 So. 3d at 1127.  Further, a plaintiff cannot 
sustain this burden of proof by relying on pure speculation—a rule that also applies 
to medical experts.  Id.  In applying the standard to this case, however, the court 
held that even though Dr. Futrell testified that the negligence probably caused the 
injury, her testimony was pure speculation.  Id.  The Second District held that her 
testimony was legally insufficient to meet causation because during cross-
examination, defense counsel discussed some opposing medical literature, 
including the NINDS study, which first established the efficacy of tPA therapy, 
and Dr. Futrell failed to respond to this cross-examination by comparing Mr. Cox 
to the patients in the NINDS study or testifying that she had enjoyed a greater 
success rate with tPA than how defense counsel had characterized the study.  Id. at 
1126-27.  Specifically, the district court found Dr. Futrell’s testimony to be 
speculative based on the following reasoning: 
Even assuming that Mr. Cox was an ideal candidate for the 
treatment—thus indulging for these purposes Dr. Futrell’s doubts that 
the treatment was contraindicated in Mr. Cox’s case because he 
previously suffered a subdural hematoma—we find nothing in Dr. 
Futrell’s testimony or anywhere else in the evidence to suggest that 
Mr. Cox’s chances of benefiting from tPA therapy exceeded those of 
other patients.  Dr. Futrell herself never testified that she had enjoyed 
a greater success rate with tPA than that documented in the NINDS 
 
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study, i.e., thirty-one percent.  She never compared any aspects of Mr. 
Cox’s physical condition to those of patients who had successful 
interventions in order to suggest that he, as opposed to sixty-nine 
percent of all patients, was predisposed to a positive outcome from 
tPA therapy.  In short, Dr. Futrell’s opinion on causation was purely 
speculative.  
Id. at 1127.   
 
A review of the district court’s opinion and the record demonstrates that the 
district court impermissibly reweighed the evidence and substituted its own 
evaluation of the evidence in place of the jury.  The district court’s opinion relied 
significantly upon the NINDS study and whether Dr. Futrell adequately addressed 
this conflicting evidence on cross-examination.       
The record shows that after Dr. Futrell recognized that the NINDS study was 
the first study to show that the use of tPA could be effective for this treatment, 
defense counsel questioned Dr. Futrell as follows: 
DEFENSE COUNSEL:  The NINDS study indicated, did it not, 
Doctor, with its data that for every patient that made almost a full 
recovery or the kind of recovery you described to this jury as being 
more likely than not this is the thing that’s going to happen to Mr. 
Cox, for every patient that made that kind of recovery, the NINDS 
study said one of eight patients you gave the medication would make 
that kind of recovery; right, one of every eight? 
DR. FUTRELL:  That’s not exactly what, that’s a distortion of the 
NINDS study. 
DEFENSE COUNSEL:  You said that’s a distortion but what’s not a 
distortion is the study said that 20 percent of the people made that 
kind of recovery without any medication and that when you gave tPA, 
that number went up to 31 percent.  That’s what it said, right? 
 
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DR. FUTRELL:  It said that, yes. 
DEFENSE COUNSEL:  And you know if you do the mathematical 
calculation that that means you got to give this medication to eight 
people to get one that makes the kind of recovery you say Mr. Cox is 
going to get, isn’t that true? 
DR. FUTRELL:  No, that’s not true. 
DEFENSE COUNSEL:  Why isn’t it? 
DR. FUTRELL:  Well, first of all, the categories that Mr. Cox would 
go to would be either of the two.  The NINDS study had one category 
that was for complete recovery and the [study] had the next category 
that was for very good recovery or minimal neurological deficit and 
then there were other categories of moderate deficit, severe deficit, 
and death, and there are various ways you can add those numbers 
together.  But the worst number in the NINDS that there was over a 
30 percent, it was like 36% improvement from other problems and 
that was including all the people in [the] trial that had bad prognostic 
factors so the data have, unfortunately, been excluded in subsequent 
papers.  What you’re quoting is a paper that later looked at the NINDS 
data and tried to say that tPA wasn’t that good.  That number didn’t 
come from the NINDS trial at all. 
(Emphasis added.)   
A review of this testimony illustrates that Dr. Futrell did not agree that 
defense counsel had correctly characterized the statistics from the NINDS study.  
She explained that there were numerous categories in the NINDS study and that 
counsel was not using numbers from the NINDS study but rather from another 
paper that disagreed with whether the NINDS study demonstrated that tPA was as 
effective as it claimed to be.  However, even though Dr. Futrell disagreed with this 
 
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characterization of the study, the Second District did not accept this portion of her 
testimony and reweighed the evidence. 
 
As our review of the caselaw illuminates, while a directed verdict is 
appropriate in cases where the plaintiff has failed to provide evidence that the 
negligent act more likely than not caused the injury, it is not appropriate in cases 
where there is conflicting evidence as to the causation or the likelihood of 
causation.  If the plaintiff has presented evidence that could support a finding that 
the defendant more likely than not caused the injury, a directed verdict is improper.  
Here, the jury was presented with conflicting testimony as to the significance of 
statistics from the NINDS study—which is a matter for the jury, not a matter for 
the appellate court to resolve as a matter of law. 
 
In reaching this holding, we agree that an expert cannot merely pronounce a 
conclusion that the negligent act more likely than not caused the injury.  In this 
case, however, Dr. Futrell did not simply provide a summary conclusion without a 
factual basis.  She conducted a full review of Mr. Cox’s medical records, provided 
a detailed analysis as to why she believed that Mr. Cox would have been an 
excellent candidate for tPA therapy, and based her testimony on her experience, 
the relevant medical literature, and her knowledge about the facts and records 
involved in this case, including an in-depth analysis of Mr. Cox’s CT scan.  
Defense counsel had the opportunity to cross-examine her as to the foundation of 
 
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her opinion, which he did.  However, during cross-examination, Dr. Futrell 
expounded on the factual foundation for her opinion regarding the NINDS study.  
In fact, Dr. Futrell explained during cross-examination that she disagreed with 
defense counsel’s characterization of the NINDS study and explained why she 
believed that defense counsel was inaccurate.  It was within the jury’s province to 
evaluate Dr. Futrell’s credibility and weigh her testimony.2  The Second District 
misapplied our precedent by reweighing the evidence and rejecting Dr. Futrell’s 
explanation. 
CONCLUSION 
For the reasons explained above, we quash the decision of the Second 
District and remand this case to the district court for further proceedings consistent 
with this opinion.  We do not address any of the remaining claims that were raised 
to the district court but were not a basis of its decision.3 
                                         
2.  We expressly do not rely on the opinion letter of Dr. Eddy Berges, a 
treating neurologist, in determining the sufficiency of the evidence on causation. 
Dr. Berges first supported the view of Dr. Futrell on causation and then later 
recanted his testimony.  See St. Joseph’s Hosp., 14 So. 3d at 1126.  However, as 
addressed above, the plaintiffs adequately supported the element of causation 
through Dr. Futrell’s testimony. 
 
3.  In their answer briefs submitted to this Court, the defendants collectively 
raise seven additional issues.  To the extent that these issues are not disposed of by 
our opinion but were properly raised on appeal before the Second District, the 
Second District may consider these additional issues on remand.  
 
 
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It is so ordered. 
LEWIS, QUINCE, POLSTON, LABARGA, and PERRY, JJ., concur. 
CANADY, C.J., dissents with an opinion. 
 
NOT FINAL UNTIL TIME EXPIRES TO FILE REHEARING MOTION, AND 
IF FILED, DETERMINED. 
 
 
 
CANADY, C.J., dissenting. 
 
I would discharge this case because the decision of the Second District in St. 
Joseph’s Hospital v. Cox, 14 So. 3d 1124 (Fla. 2d DCA 2009), does not expressly 
and directly conflict with either Wale v. Barnes, 278 So. 2d 601 (Fla. 1973), or 
Gooding v. University Hospital Building, Inc., 445 So. 2d 1015 (Fla. 1984).  
Neither Wale nor Gooding establishes a rule of law in conflict with the decision in 
St. Joseph’s Hospital, 14 So. 3d at 1127, that “purely speculative” expert opinion 
testimony—that is, opinion testimony offered with “no facts that support” the 
opinion—is not sufficient to establish causation in a medical negligence case.  See 
also § 90.705(2), Fla. Stat. (2010) (“If the party [against whom expert opinion 
testimony is offered] establishes prima facie evidence that the expert does not have 
a sufficient basis for the opinion, the opinions and inferences of the expert are 
inadmissible unless the party offering the testimony establishes the underlying 
facts or data.”). 
 
 
 
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Application for Review of the Decision of the District Court of Appeal - Direct 
Conflict of Decisions 
 
 
Second District - Case No. 2D07-1038 
 
 
(Hillsborough County) 
 
Joel D. Eaton of Podhurst Orseck, P.A., Miami, Florida, Alan F. Wagner of 
Wagner, Vaughan and McLaughlin, P.A., Tampa, Florida, and Weldon Earl 
Brennan of Brennan, Holden and Kavouklis, P.A., Tampa, Florida, 
 
 
for Petitioners 
 
Kimberly A. Ashby of Akerman Senterfitt, Orlando, Florida, and Roland J. Lamb 
of Morgan Lamb, et al., Tampa, Florida; Irene Porter, Mark Hicks, and Shannon 
Kain of Hicks, Porter, Ebenfeld and Stein, P.A., Miami, Florida; Richard B. 
Mangan, Jr., Edward M. Copeland, IV of Rissman, Barrett, Hurt, Donahue and 
McLain, P.A., Tampa, Florida, 
 
 
for Respondents