Title: Lyons v. Walker Regional Medical Center

State: alabama

Issuer: Alabama Supreme Court

Document:

868 So. 2d 1071 (2003)
Margaret LYONS, as the administratrix of the estate of Kenneth Cook, deceased
v.
WALKER REGIONAL MEDICAL CENTER, INC., and Laurie Hunter.
1011101.

Supreme Court of Alabama.
April 11, 2003.
Rehearing Denied June 13, 2003.
*1072 Stephen A. Strickland of Jaffe, Strickland & Drennan, P.C., Birmingham; and James C. King of King, Harrison & Bryan, Jasper, for appellant.
Jasper P. Juliano and Dorothy A. Powell of Parsons, Lee & Juliano, P.C., Birmingham, for appellees.
HARWOOD, Justice.
Margaret Lyons, as the administratrix of the estate of Kenneth Cook, deceased, appeals from a judgment in favor of the defendants, Walker Regional Medical Center, Inc., and Laurie Hunter, in the medical-malpractice action she brought against Walker Regional and Hunter (Walker Regional and Hunter are hereinafter referred to collectively as "the defendants"). Lyons had brought an earlier appeal in the case, following a summary judgment in favor of the defendants; this Court reversed the summary judgment and remanded the case. Lyons v. Walker Reg'l Med. Ctr., 791 So. 2d 937 (Ala.2000) (hereinafter "Lyons I"). In that opinion, this Court quoted the following details concerning the events underlying the litigation from the trial judge's "Memorandum Opinion and Order," entered when he had initially denied the defendants' motion for a summary judgment:
791 So. 2d  at 939-41 (emphasis in original).
Although certain of those facts were put in a different light by additional facts presented during the subsequent trial of this case, the recitation of those facts from Lyons I is important to provide the context in which this Court made its rulings in Lyons I, and as a reasonably reliable, albeit incomplete, summary of the underlying events.
On remand, a six-day jury trial was conducted, resulting in a verdict for Walker Regional and Hunter. Lyons filed a timely motion for a new trial or, in the alternative, for a judgment as a matter of law, which the trial judge denied on February 19, 2002. Lyons appealed.
Lyons presents the following five issues for appellate review:
We consider those issues in the order Lyons has presented them.
"The trial court erred in allowing the defendants to put in the same old evidence and then argue contributory negligence and assumption of risk. Moreover, the trial court erred in instructing the jury on these two affirmative defenses." and "The trial court erred in holding that contributory negligence can legally apply to this medical malpractice case."
In her argument directed to the first sentence of Issue I, Lyons asserts "[t]his Court's opinion [in Lyons I] and the evidence show that the defendants' affirmative defenses of contributory-negligence and assumption of risk are not applicable to this case." Consequently, she continues, "the defendants should have been precluded from arguing or mentioning contributory negligence and assumption of risk," and the trial court therefore "erred in instructing the jury on these two affirmative defenses." Lyons argues, in essence, that the doctrine of "law of the case" should have operated to preclude any further assertion of those defenses in the case, absent "new evidence."
In assessing Lyons's argument, it is important to remember that the question before the Court in Lyons I with regard to the defense of contributory negligence (the defense of assumption of risk was not separately acknowledged or discussed in that opinion) was whether each of the elements of that affirmative defense had been established by undisputed facts, or whether, to the contrary, a genuine issue of material fact existed with respect to one or more or those elements. The actual ruling of the Court in that regard was as follows:
791 So. 2d  at 944-45.
In coming to that conclusion, this Court considered the following:
791 So. 2d  at 944.
The only issue concerning contributory negligence in Lyons I was whether a genuine issue of material fact existed as to any of the essential elements of that defense. *1077 This Court concluded that it was "questionable" whether the blanket statement "you could die" would have been enough to make Cook appreciate the danger of his condition. 791 So. 2d  at 944. The only explanation of the content of that "blanket statement" in the opinion was in the trial court's recitation of the "undisputed facts": that Hunter told Cook "`that "after signing out AMA [`against medical advice'], you understand you could die or something else could happen to you," which is what she tells all her patients,'" and that "`no instructions whatsoever were given to Cook, his guard, or the Walker County Jail before or after they went back to the jail.'" 791 So. 2d  at 940-41.
"It is well established that on remand the issues decided by an appellate court become the `law of the case,' and that the trial court must comply with the appellate court's mandate." Gray v. Reynolds, 553 So. 2d 79, 81 (Ala.1989). If, however, an observation by the appellate court concerning an issue is premised on a particular set of facts, and the nature of the remand is such that it is permissible and appropriate to consider additional facts relevant to the issue, the law-of-the-case doctrine is inapplicable. Quimby v. Memorial Parks, Inc., 835 So. 2d 134 (Ala. 2002); United States Fid. & Guar. Co. v. Baldwin County Home Builders Ass'n, 823 So. 2d 637 (Ala.2001); Blumberg v. Touche Ross & Co., 514 So. 2d 922 (Ala. 1987); Gonzalez v. Blue Cross & Blue Shield of Alabama, 760 So. 2d 878 (Ala.Civ. App.2000).
The certificate of judgment sent by this Court to the trial court advising of the reversal of its judgment in Lyons I explained that the case was being "remanded to the court below for further proceedings therein." Pursuant to that mandate, the trial now under review took place.
The considerations that should attend a trial judge's determination of whether contributory negligence has been established as a matter of law so as to entitle a defendant to a summary judgment and the considerations a jury should be instructed to apply in determining whether contributory negligence has been proven at trial are different, as discussed in Hannah v. Gregg, Bland & Berry, Inc., 840 So. 2d 839 (Ala.2002). However, the parties do not discuss that distinction in their briefs, and properly so, given that the trial court's charge to the jury to the contrary concerning the elements of contributory negligence and assumption of the risk was never objected to by either side on the basis of any such distinction.
It is well established that neither the trial court nor this Court may undertake credibility assessments in reviewing testimonial evidence submitted in favor of, and in opposition to, a motion for a summary judgment, whereas making such credibility assessments is one of the key functions of the trial jury. See, e.g., Scott v. Farnell, 775 So. 2d 789, 793 (Ala.2000), and Camp v. Yeager, 601 So. 2d 924, 929 (Ala.1992). Consequently, during the trial following remand, the jury was authorized to assess the credibility of the testimony of the various witnesses who appeared "live" before it, and accord such weight to their respective testimony as it deemed to be warranted, under a jury instruction the trial judge gave to that effect. Accordingly, when this Court made its observation in Lyons I that it was "questionable" whether the blanket statement "you could die" would have caused Cook to appreciate the danger of his condition, the Court was speaking in the context of a summary-judgment record. Based on that record, the Court concluded only that, given that Cook's appreciation of his danger was "questionable" and that he had been "released" *1078 from the hospital for allegedly "refusing treatment" only because he had complained of pain when "a nurse was trying to stick tubes in his nose," a genuine issue of material fact existed as to some of the elements of the defense of contributory negligence. At trial, however, Walker Regional and Hunter were entitled to adduce additional, "new" evidence with regard to the defenses of contributory negligence and assumption of the risk in an attempt to show that other relevant information and warnings were given to Cook before he signed out against medical advice, as opposed to only the blanket statement that he "could die or something else could happen to [him]." 791 So. 2d  at 940.
Accordingly, we first review the trial record to determine if, as Lyons asserts, the "same old evidence" summarized in Lyons I was presented to the jury, or whether additional relevant evidence was introduced. Because the timing, content, and emphasis of what Hunter told Cook is so important in this regard, we elect not to try to paraphrase or simply summarize it, but rather set out verbatim the testimony of the various witnesses in the order they testified as follows:
Testimony of Debbie ("Deb") Evans (a registered nurse working in Walker Regional's emergency department):
Testimony of Rochelle Harris (the data terminal operator on duty starting at 6:00 p.m. on the day Kenneth Cook was treated):
*1082 The against-medical-advice form, which Hunter indisputably read to Cook verbatim, stated:
(Emphasis in original.)
The affidavit testimony of Cook's cellmate considered important in Lyons I was not presented to the jury. Rather, Lyons expressly elected to forgo calling the cellmate to the stand even though he was available, because "the jailer put into the record that he was aware of the fact that Cook wanted to return [to the hospital] and that he claimed that he was sick and they didn't let him." The jailer, Deputy Sheriff Hayron Bridges, who had escorted Cook to and from the hospital, could not recall anything at trial about the cellmate's conversation referenced in Lyons I, but acknowledged that if in his deposition he had said that a trusty, Timothy Smith, had told him after Cook had returned from the hospital that Cook was sick and that he needed to go to the doctor, he was sure that that was correct. He went on to explain, however:
The omission from the evidence at trial of the rest of the cellmate's testimony specifically cited in Lyons I would represent a different state of the record.
We conclude that, whatever weight the trial court might have accorded the aforementioned comments in Lyons I, there was in fact new evidence presented at trial relevant to the issues of contributory negligence and assumption of risk that went well beyond that relied on in Lyons I. Lyons argues that "none of this is new evidence and it is extremely doubtful based on other witnesses' testimony that Hunter told Kenneth Cook anything other than a blanket statement that you could die." (Lyons's brief, p. 39.) However, as noted, it was the province of the jury to make credibility assessments and otherwise to weigh conflicting testimony, and Lyons does not explain what "other witnesses' testimony" she has in mind. As noted, when we compare the facts mentioned in Lyons I with the portions of the trial record excerpted above, we respectfully disagree that no "new evidence" was presented.
The proposition asserted by the second sentence of Issue Ithat the trial court erred in instructing the jury on contributory negligence and assumption of the risk can appropriately be considered in combination with the proposition in Issue II that "[t]he trial court erred in holding that *1083 contributory negligence can legally apply to this medical malpractice case."
The trial judge instructed the jury as follows concerning contributory negligence and assumption of the risk:
At the close of all of the evidence, Lyons moved for a "directed verdict" (a judgment as a matter of law) on the issues of contributory negligence and assumption of the risk, on the ground that the opinion in Lyons I had eliminated those defenses from the case. The trial judge denied the motion, noting that the Lyons I opinion "was based on the record before [the Supreme Court], and we have a new record here today" and that "contributory negligence is almost always a matter for the jury to decide." In the course of those discussions, counsel for both sides agreed that the pattern charge number 30.05, Alabama Pattern Jury Instructions: Civil (2d ed.1993),[2] which the definition of contributory negligence in Lyons I parallels, correctly listed the elements of both contributory negligence and assumption of risk. Counsel for Lyons stated that APJI 30.05 was a "combined charge." After the judge gave that charge, Lyons objected, again stating that, after Lyons I, the defenses of contributory negligence and assumption of the risk were not "appropriate in this case," and also stating that, because contributory negligence has to be "in response to an underlying charge of negligence," it could have no field of reference in a medical-malpractice *1084 case, because such a case involved only the concept of "deviation from the standard of care." She later elaborated on that argument:
When the jury subsequently sent out a note requesting that the trial judge "[r]estate the contributory negligence factors," he recharged them in essentially the same language he had used initially. Counsel for Lyons objected to the reprised charge, stating as grounds "the same ones" previously asserted.
Pertinent to Lyons's argument that she never alleged negligence in the case because "we can't make such an allegation" in a medical-malpractice case, we note that she alleged in both her original complaint and her amended complaint, on which she went to trial, that Walker Regional and Hunter's failure to provide Cook with proper care and treatment "constituted negligence and wantonness." She went on to assert that Walker Regional and Hunter "were negligent and/or wanton" in seven specified ways. She also sought punitive damages "because of the defendants' wanton conduct." Furthermore, at Lyons's request the trial court gave APJI 33.01, which reads:
In arguing this issue on appeal, Lyons states that she "agrees that assumption of risk can apply to a medical malpractice, if there are facts to support such a defense [but that] contributory negligence cannot apply to a medical malpractice because it is designed to only apply to negligence causes of action." She cites no cases in support of her position, implied in her argument, that a medical-malpractice claim cannot be predicated on negligence, and, in fact, acknowledges that "[t]his Court has previously held that contributory negligence can apply to a medical malpractice. See Cackowski v. Wal-Mart Stores, Inc., 767 So. 2d 319, 330 (Ala.2000)." Lyons's sole authority in support of Issue II is Dennis v. American Honda Motor Co., 585 So. 2d 1336 (Ala.1991). In Dennis, this Court held that, in an action brought under *1085 the Alabama Extended Manufacturer's Liability Doctrine ("AEMLD") against the manufacturer of a motorcycle helmet the plaintiff was wearing at the time of a motorcycle accident, "[t]he defense of contributory negligence in an AEMLD action should be limited to assumption of risk and misuse of the product. The plaintiff's negligence relating to accident causation should not bar recovery." 585 So. 2d  at 1339. Lyons argues that, by analogy, to allow the defendants in this case to argue "contributory negligence as it relates to the causation in this case" is contrary to the public policy of protecting patients from medical malpractice. We fail to see the parallel, believing that a closer analogy would be if a defendant in a medical-malpractice action was charged with failure to diagnose a disease and attempted to defend on the basis that the patient had been contributorily negligent in contracting the disease.
This Court has frequently discussed medical-malpractice claims as involving negligence. See, e.g., McAfee v. Baptist Med. Ctr., 641 So. 2d 265, 267 (Ala.1994), and University of Alabama Health Servs. Found., P.C. v. Bush, 638 So. 2d 794, 802 (Ala.1994).
We find that the trial court did not err in charging the jury on contributory negligence and assumption of the risk over Lyons's objection.
Under the court's "combined" charge on contributory negligence and assumption of risk, the jury was to determine whether Cook knew of and had an appreciation for the dangerous condition, yet put himself in the way of it. As already noted, Hunter told Cook that he did not have to have the NG tube inserted and implored him: "Just stay here and let us treat you.... Maybe there's something else we can do for you." She explained to him that she did not know what was wrong with him and warned that if he left he could bleed to death or suffer a heart attack or a stroke. She emphasized that the medical personnel did not know what was wrong with him and that he could die from his condition if he left the hospital. According to Deb Evans, Hunter was "trying to talk him into staying ... trying to, you know, telling him to stay and let us finish evaluating you." According to Evans, Cook "refused all treatment. At that point in time he refused any and all treatment. He didn't want anything else done." He rejected all treatment despite being read the against-medical-advice form, which advised him that in refusing treatment he did so with the understanding "that a medical screening is necessary in order for the hospital and physician to determine if I have a medical emergency." Cook belligerently and sometimes profanely insisted that he knew what was wrong with him and that it was his appendix; that he knew his rights and the hospital did not have the right to hold him against his will just because he was an inmate; that the hospital could not keep him there; that he did not "have to do anything"; that the hospital staff "didn't know what the `F' [they] were doing" and that the hospital was "a piece of `S'"; that he could go back to jail and, indeed, he stated: "I want to go back to jail, you mother `F's,'" and "Take me back to the jail. I want to go back to the jail. I don't want any treatment." According to Evans, Cook said that he did not want any more treatment. He told the officer to "let him loose." Despite Cook's intransigence and verbal abuse, Hunter continued to try to impress upon Cook the need to stay for a full evaluation. She also explained to him that even after he left, he could change his mind and come back, and similarly told the deputy, "if he changes his mind or gets worse, bring him back."
*1086 There was ample opinion testimony before the jury, without objection, that Cook would have known from the duration and significance of his symptoms that he was sick and that his condition could be serious. Even Deb Calhoun, the nursing expert called by Lyons, testified as follows:
The following exchange also took place between defense counsel and Calhoun:
Also placed before the jury was the following testimony of Joy Morris, the defendants' nursing expert:
When Calhoun was asked if anything stronger could be said to a patient than if he did not allow medical personnel to care for him "you may die," she agreed, "No, sir, there isn't anything stronger that you could say." She also agreed that she could not have done any more than Hunter did, stating, "No, sir. There's no greater risk than death." Dr. Marshall Boone likewise agreed that if Hunter had told Cook that if he left before medical personnel had finished evaluating and treating him, "You could die," there was nothing more strong or more clear that could have been said to him at the time. He testified further that "I don't know anything more explicit that, you know, `We don't know what's wrong with you. If you leave here, you could die,' that's pretty explicit." He opined that "everybody understands the significance of hemorrhaging" and that Cook left knowing that Boone was "trying to rule out internal bleeding." Boone stated and explained:
Dr. Boone was of the opinion that Cook "voted with his feet" by walking out of the hospital, because "we can't keep people that want to leave." Finally, Dr. Boone testified as follows:
The jury, in applying the court's charge on contributory negligence and assumption of risk to all of the testimony, could have concluded that Cook, with knowledge of the seriousness of his sickness and with the appreciation that it posed significant danger, including death, failed to exercise care for his own safety, by putting himself in the way of the danger about which he was warned, including death. Under the charge, the jury was not required to focus exclusively on the specific danger posed by the specific condition of diabetic ketoacidosis.
"The trial court erred in refusing to instruct the jury that wantonness and/or willfulness by the defendants negate the defendants' contributory negligence and assumption of risk defenses."
Although Lyons pleaded wantonness, she never requested the trial judge to charge the jury on it, and she never objected to the trial judge's failure to so instruct the jury. Her only citations to the record in connection with this issue are to pages where, at one point, she said concerning the jury instruction the court had given, "One other thing and I failed to mention it ... I meant to also adopt the previous arguments made at the charging conference wherein I said that if the court does give contributory negligence, then we believe it must give the charge that says that contributory negligence would not be a defense to any willful or intentional conduct ...." (Emphasis supplied.) Unfortunately, there is no record of the charging conference this statement references, or even confirmation that one was conducted. "The charge" referenced in the statement is nowhere identified. Throughout the portions of the record Lyons cites to in her brief on this issue she argued only with respect to the propositions of "willful or intentional conduct" (stated one time), "a willful act" (stated three times), and "willful and intentional conduct" (stated two times). She never used the term "wantonness" or any variation of it in those discussions with the trial court she cites. When, at a point in the record to which Lyons does not direct our attention, the trial judge recharged the jury on contributory negligence and assumption of risk, Lyons objected by stating only: "Your honor, the same ones that we've asserted with regard to the issues that we addressed previously, I would like to make a record with regard to the Court not further giving the charge having to do with intentional or willful conduct." After the jury had rendered its verdict and had been released, Lyons elaborated upon her objection, again referencing "willful and *1089 intentional" and "willful, intentional conduct," but for the first time alternatively referencing, without taking any special note of the change in wording, "willful and wanton or intentional conduct" and in one instance, "intentional, willful or wanton conduct." Her counsel explained at that time that when the judge had recharged the jury and then asked if counsel had any objections, counsel was hampered in making a full objection because of the presence of the jury. The trial judge responded that counsel could have asked that the jury be excused and that the judge would have excused the jury, but acknowledged that Lyons's desire to expand on her objection "was brought to our attention immediately after leaving the room," and it was agreed that "it would be done as soon as we come back."
This Court has explained the difference between wantonness, on the one hand, and "willful or intentional," on the other hand. See, e.g., English v. Jacobs, 263 Ala. 376, 82 So. 2d 542 (1955), and Dickey v. Russell, 268 Ala. 267, 105 So. 2d 649 (1958). Lyons acknowledges the distinction in her brief to this Court, citing to Sellers v. Sexton, 576 So. 2d 172, 175 (Ala.1991). The two are different and distinct concepts, and willful and/or intentional conduct was nowhere pleaded by Lyons. As noted in Dickey, supra, "a count alleging `willful and wanton' conduct requires proof of willfulness or design or purpose." 268 Ala. at 270, 105 So. 2d  at 651.
Lyons cites Sims v. Crates, 789 So. 2d 220 (Ala.2000), as being "[a] case directly on point." In Sims, this Court reversed a judgment as to one defendant on account of the trial court's failure to explain in its jury charge on contributory negligence that contributory negligence was not a legal defense to a claim based on willful or wanton acts. We held that such a qualifying instruction should have been given "because whether [the defendant's] conduct was willful or wanton was an issue submitted to the jury." 789 So. 2d  at 226. In contrast, whether the defendants' conduct in this case was wanton (or willful) was not an issue submitted to the jury. Therefore, such a qualifying charge would have had no field of operation in this case, and Sims is thus clearly distinguishable. Whether the issue of wantonness (or willfulness, although not pleaded) should have been submitted to the jury is not an issue directly raised by Lyons. She does argue at points in her briefs to this Court that the defendants' conduct was such that they were guilty of wantonness (and "willfulness," and "willfulness and wantonness," and conduct "criminal and reprehensible to our society") but, as noted, she never requested the trial judge to charge the jury on any of those concepts and never objected to his failure to do so. Accordingly, we find no error on the part of the trial court as to Issue III.
"The trial court erred in refusing to instruct the jury on subsequent negligence as part of [Lyons's] response to the defendants' defenses."
Lyons asserts in her reply brief that she requested that the jury be instructed that subsequent negligence by the defendants "negates the defendants' contributory negligence and assumption of risk defenses." Her citations to the record in support of this contention reveal only that, after the court had initially charged the jury and asked Lyons for her objections to the charge, she stated, among other things:
Lyons then stated, "and if the court were to address any issues at all, there was one point ....," going on to discuss a separate issue. The court agreed that the issue specified was deserving of a supplemental instruction to the jury and subsequently gave one satisfactory to Lyons. No supplemental charge relating to "subsequent Alabama Medical Liability Action Responsibility" was submitted or requested by Lyons, and no ruling by the trial judge was otherwise invoked or made. For all that appears in the record, Lyons had not previously alerted the trial judge that subsequent negligence might be an issue in the case. Under all of these circumstances, we cannot find that the trial judge erred in failing to attempt to fashion, on its own, some supplemental charge articulating a proposition of "subsequent violation of the Alabama Medical Liability Act."
"The trial court erred in refusing to grant [Lyons's] `Motion for a Directed Verdict' and her `Motion for New Trial, or in the Alternative, Judgment Notwithstanding the Verdict' as to the defendants' liability."[3]
Lyons provides no citation to the record in either of her briefs to the trial court's refusal to grant her motion for a directed verdict. We do find in the record "Plaintiff's Motion for a Directed Verdict on the Defendants' Affirmative Defenses and Motion for a Directed Verdict as to the Defendants' Liability" (emphasis added). As to the "affirmative defenses," the motion asserted the ground already addressed in this opinionthat Lyons I had eliminated the defenses of contributory negligence and assumption of risk. She also asserted that "the defendants have presented no evidence on their statute of limitations defense because there is none." That defense is nowhere mentioned in this appeal. As to the "liability" contention, the motion stated:
At the conclusion of the evidentiary stage of the case, Lyons argued only that aspect of the motion relating to the affirmative *1091 defenses; she did not argue or otherwise specifically call the trial judge's attention to the "liability" aspect. Nonetheless, considering the "liability" ground properly before the trial court because it was contained in the written motion, we find no error in the denial of that aspect of the motion. The ground is premised on the proposition that the evidence showed "that the hospital did not follow its procedures when the results of the electrolytes tests were not recorded on the front of Kenneth Cook's chart." That same position is reiterated in Lyons's brief to this Court, where she again asserts only that the defendants "did not follow their procedures when the results of the electrolytes tests were not recorded on the front of Kenneth Cook's chart." That was indeed the understanding of the trial judge when he composed the memorandum opinion quoted at length in Lyons I, 791 So. 2d  at 941. Testimony at trial, however, contradicted the idea that Walker Regional had failed to follow its procedures when it failed to record Cook's electrolytes test results on the front of his chart. As noted in the trial judge's memorandum opinion, "Cook's electrolyte results were reported at 6:07 p.m. over the computer." 791 So. 2d  at 941. Rochelle Harris testified that lab results came into the emergency department over a computer "sitting right next to me." It was her responsibility as data terminal operator to copy the lab results from the computer printout onto the face sheet of the chart "in a timely manner." She did not know how to read or interpret the lab results; she just knew how to log them in on the chart. She denied that she had ever received Cook's electrolytes lab results or that she had seen them on the night in question. She had been scheduled to work from 7:00 p.m. on May 7, 1994, until 7:00 a.m. the following morning, but had come in a little before 6:00 p.m. because she had been called to come in early to fill in for the data terminal operator who had the shift before her, but who had called in sick. She does not know what time she might have finally gotten to her desk, located approximately 100 yards from where she clocked in. Hunter, for her part, testified that she did not see the results of the electrolytes tests when they came in over the computer because she had been with Cook in his room, and he had signed the against-medical-advice form at 6:05 p.m. She thereafter "came back to the desk, got the chart, made a note on it, and put it in the completed bin," "in another pile for Rochelle to do with it what she does with it, and I went on treating other people who were there who were needing my attention." The note she made on the chart, entered at 6:10 p.m., stated that Cook "signed out AMA (with form read to him)." The lab values were never reported to her.
Dr. Boone, Hunter, and Morris each testified that the hospital's policies and procedures relative to the reporting and charting of lab values, and "Panic Values" in particular, applied only for so long as the hospital-patient relationship continued and, as to a regularly discharged patient, with respect to any lab results reported after the discharge. Dr. Boone and Morris stated that when a patient leaves against medical advice, that departure is not considered a "discharge." Dr. Boone explained that when a patient leaves against medical advice, "the normal reporting process breaks down." He compared a patient's status to that of the engine on a train pulling cars; once the patient leaves against medical advice, "the engine jumps the track" and "the whole process breaks down, just like the engine leaving the track." Dr. Boone testified that once Cook left the hospital against medical advice he became a nonpatient, and Walker Regional's policies did not apply to him. Morris testified that hospitals and nurses have no ongoing duty of follow-up care, including reporting laboratory *1092 test results that were pending but not reported, once a patient signs out against medical advice. She agreed with Lyons's counsel on cross-examination that "the fundamental crux" of her testimony was that once a patient signs out against medical advice, Walker Regional and its staff have no further responsibility to that patient. Given this body of testimony, although there was testimony to the contrary from other witnesses, we cannot hold that the trial judge erred in refusing Lyons's motion for a judgment as a matter of law predicated on the ground that "the hospital did not follow its procedures when the results of the electrolytes tests were not recorded on the front of Kenneth Cook's chart."
Vaughan v. Oliver, 822 So. 2d 1163, 1168 (Ala.2001).
With respect to the separate error on the part of the trial court alleged in Issue Vthe court's refusing to grant Lyons's "Motion for New Trial, or in the Alternative, Judgment Notwithstanding the Verdict"Lyons offers in her brief no argument or citation to the record. She does cite in the statement of the case in her brief those pages of the record where the motion is found. Consulting the motion, we conclude that all grounds asserted in it pertinent to the issues raised by Lyons in this appeal have already been addressed. The motion was denied by order dated February 19, 2002. If there was an actual hearing on the motion, no confirmation of that fact, or record of the hearing, appears in the record. We find no error in the denial of the motion.
In reviewing the record of the tragic circumstances of Kenneth Cook's death, we do not sit as a superseding jury, free to decide the case de novo. Our role is limited to considering only the specific errors Lyons asserts on the part of the trial court. Any alleged error is eligible for our consideration only where an adverse ruling was made by the trial court and the error attending it was otherwise properly preserved at the trial court level and subsequently properly identified and argued to this Court. See, e.g., Rule 28(a)(3), (4), and (5), Ala. R.App. P. In accordance with these cardinal principles of appellate review, we have determined the scope of each issue presented on appeal by Lyons; have considered her citations to the record and to caselaw; have in the course of our review read the entire record and researched relevant caselaw; and have determined the nature of each ruling Lyons claims was error. We simply do not find error as to any of those rulings, as Lyons has stated her issues. We affirm.
AFFIRMED.
MOORE, C.J., and SEE, BROWN, and STUART, JJ., concur.
[1]  Rule 50, Ala. R. Civ. P., has renamed the "motion for a directed verdict" as a "motion for a judgment as a matter of law," and has renamed the "motion for a judgment notwithstanding the verdict" as a "renewed motion for a judgment as a matter of law."
[2]  Alabama Pattern Jury Instructions: Civil 30.05 reads as follows:

"ASSUMPTION OF RISKELEMENTS
"The three elements essential to assumption of risk (or contributory negligence) in cases of this kind are that the party charged with assumption of risk (or contributory negligence) (1) had knowledge of the existence of the dangerous condition and (2) with appreciation of such danger (3) failed to exercise care for his (her) own safety by putting himself (herself) in the way of such known danger."
[3]  The proper terminology is a "motion for a judgment as a matter of law" and a "renewed motion for a judgment as a matter of law." Rule 50(a) and (b), Ala. R. Civ. P. See note 1.