Title: Anna Breland, a minor, by and through her mother and next friend, Julie Breland v. Leonard Rich, M.D., and Vision Partners, LLC

State: alabama

Issuer: Alabama Supreme Court

Document:

Rel:03/11/2011
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-
0649), 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, 2010-2011
____________________
1091425
____________________
Anna Breland, a minor, by and through her mother and next
friend, Julie Breland
v.
Leonard Rich, M.D., and Vision Partners, LLC
Appeal from Mobile Circuit Court
(CV-07-2425)
BOLIN, Justice.
Anna Breland, a minor, by and through her mother and next
friend, Julie Breland, appeals from a summary judgment entered
1091425
2
in favor of defendants Dr. Leonard Rich and Vision Partners,
LLC, a professional corporation of which Dr. Rich is a member.
Facts and Procedural History
Anna was born on April 9, 2003, at the University of
South Alabama Children's and Women's Hospital (hereinafter
"USA") in Mobile. Anna was born prematurely at 23 weeks
gestation, and she weighed 12.87 ounces at birth.  Because she
was premature, Anna was admitted to USA's Neonatal Intensive
Care Unit (hereinafter "the NICU") for treatment and care.
Dr. Fabian Eyal was the medical director of the NICU.
Anna's prematurity placed her at risk of developing
several serious medical conditions, including retinopathy of
prematurity (hereinafter "ROP"), a condition that affects the
normal growth of retinal blood vessels and can cause blindness
in premature infants.  ROP typically presents some time after
birth. Because early diagnosis is critical for treatment to be
successful, premature infants should be screened early and
regularly for ROP.  Anna was placed on the list of premature
infants at risk for ROP by pediatric ophthalmologist Dr. Rich,
the board-certified ophthalmologist consulted by the NICU.
1091425
3
Dr. Rich would typically retrieve the NICU's eye-exam
book (a bound book containing the list of premature infants to
be examined on a particular date) and would take the eye-exam
book with him to each patient's bedside.  Dr. Rich would
perform the ROP exam and would note his findings on an eye
form, which would be left at the patient's bedside for
inclusion in the patient's chart.  Renée Rogers, nurse manager
of the NICU, testified that the eye forms would sometimes be
found in a stack on an unused desk in the NICU or that
sometimes Dr. Rich would place the eye form in the chart.  She
also stated that several eye forms might be found at one
patient's bedside and that, on one occasion, an eye form was
found in a restroom in the NICU.  Dr. Rich would keep a copy
of the eye form for his own office records.  One section of
the eye form contains a drawing of the different zones of the
eyes where the various stages of ROP might be located during
an eye examination along with separate sections to note other
examination findings and information.  
After completing the eye form for a particular patient,
Dr. Rich would transpose the diagnosis and follow-up-treatment
information from each patient's eye form into the bound eye-
1091425
4
exam book.  The eye-exam book contains dates, a list of the
names of the patients in the NICU needing ROP exams, and an
indication as to whether further examination is necessary.
Dr. Rich used symbols to indicate whether further treatment
was necessary on both the eye form and in the eye-exam book.
One of those symbols was two dashes with circles around them
to indicate that there was no ROP and that no follow-up ROP
exam was necessary.  After completing all the scheduled ROP
exams each day, Dr. Rich would return the eye-exam book to the
ward clerk's desk.  Dr. Rich stated that he was the only
person to write diagnosis and treatment information in the
eye-exam book and that he used the eye-exam book to make sure
that he did not miss any appointments on a given day.  Dr.
Rich stated that since 1981 he had been writing notations on
the eye form and then simultaneously taking that information
regarding the diagnosis and any follow-up treatment and
writing it in the eye-exam book.  Thereafter, the ward clerk
would open the eye-exam book to Dr. Rich's entries and would
schedule patients for follow-up ROP examinations as indicated.
On May 21, 2003, Dr. Rich performed an ROP examination on
Anna.  He noted on the eye form that Anna should be examined
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5
again in two weeks.  Dr. Rich then entered the same
information in the eye-exam book beside Anna's name.  Using
the eye-exam book, the ward clerk scheduled Anna for another
ROP examination.  On June 2, 2003, Dr. Rich examined Anna and
entered his findings on the eye form.  He indicated that Anna
should be examined again in two weeks.  Dr. Rich then recorded
that information in the eye-exam book.  The ward clerk, using
the eye-exam book, placed Anna on the list of patients to be
examined in two weeks.  On June 16, 2003, Dr. Rich again
examined Anna.  Dr. Rich noted on his eye form "tube, 2wk,"
indicating that Anna was on a ventilator and that she should
be examined again in two weeks.  However, Dr. Rich wrote in
the eye-exam book next to Anna's name that Anna was negative
for ROP and that no further examinations were needed.  Based
on the notations in the eye-exam book, Anna was not placed on
the list of patients to be examined in two weeks.   
On July 4, July 6, and July 9, 2003, nurse practitioners
in the NICU observing Anna made notes that a follow-up ROP
examination 
was 
due. 
 
This 
is 
because 
it 
had 
been
approximately two weeks since Anna had had her last exam, and,
because Dr. Rich did not always have appointments scheduled
1091425
6
for exactly two weeks from the prior appointment, the NICU
nurse practitioners would note that a follow-up exam was due.
Dr. Eyal testified that, at that point, he would have checked
the eye-exam book to see if another exam was necessary.
Because Dr. Rich had indicated in the eye-exam book following
his examination of Anna on June 16, 2003, that no further exam
was necessary, Anna was not reexamined.
Dr. Eyal testified that the progress notes made by the
NICU nurse practitioners do not "trigger" exams; instead, the
eye-exam book is the trigger for scheduling ROP examinations.
He stated that the progress notes are often copied from one
day to the next.  Dr. Eyal testified that the NICU has relied
upon the eye-exam book for 15 years because the eye-exam book
stays in the NICU and cannot be misplaced, whereas the eye
forms do not immediately appear in the patient's chart and
because charts are "thinned out" on a regular basis, possibly
removing the eye form from the patient's chart and placing the
culled reports in a different place in the NICU.  Dr. Eyal
testified that Dr. Rich is the only person to write in the
eye-exam book, which prevented a ward clerk from possibly
1091425
Section 6-5-482(a), Ala. Code 1975, of the AMLA provides,
1
in pertinent part:
7
misinterpreting Dr. Rich's handwriting in transferring the
notes from the eye form to the eye-exam book.  
On August 12, 2003, a NICU nurse practitioner discovered
the conflict in the notations in Dr. Rich's eye form and his
notations in the eye-exam book.  The conflicting notes were
shown to Dr. Eyal, and he asked that Anna be reexamined for
ROP.  That same evening, Dr. Rich was in the NICU and he was
notified that Anna needed another exam.  After examining Anna,
Dr. Rich discovered that Anna had stage III to stage IV ROP in
both her eyes since her last exam on June 16, 2003.  After
being diagnosed with ROP, Anna went to a children's hospital
where she underwent several procedures and surgeries, but the
ROP had progressed to such an extent that Anna's retina in her
right eye was completely detached and her retina in her left
eye was only 10% attached.  As a result, Anna was permanently
blind.
On December 3, 2007, Julie Breland, Anna's mother, sued
Dr. Rich, Vision Partners, Dr. Eyal, USA, and USA Health
Services Foundation pursuant to the Alabama Medical Liability
Act ("AMLA").   USA moved for and was granted a summary
1
1091425
"(a) All actions against physicians, surgeons,
dentists, medical institutions, or other health care
providers for liability, error, mistake, or failure
to cure, whether based on contract or tort, must be
commenced within two years next after the act, or
omission, or failure giving rise to the claim, and
not afterwards; provided, that if the cause of
action is not discovered and could not reasonably
have been discovered within such period, then the
action may be commenced within six months from the
date of such discovery or the date of discovery of
facts which would reasonably lead to such discovery,
whichever is earlier; provided further, that in no
event may the action be commenced more than four
years after such act ...."
The issue of the statute of limitations has not been raised or
addressed on appeal. 
8
judgment on the ground of sovereign immunity. Dr. Rich  and
Vision Partners filed a motion for a partial summary judgment.
They based their motion upon the pleadings; Dr. Rich's
affidavit and excerpts from his deposition; excerpts from Dr.
Eyal's deposition; excerpts from nurse Rogers's deposition;
excerpts from ward clerk Shirley Mauldin's deposition; USA's
eye-examination 
protocol 
for 
premature 
infants, 
dated 
December
1998 and revised May 2000; the June 16, 2003, eye form
completed by Dr. Rich; and the nurse-practitioner notes
contained in Anna's medical record regarding her fourth ROP
examination.  Julie filed a response in opposition to the
1091425
9
motion.  In support of her opposition, she filed excerpts from
certain 
depositions, 
Anna's 
medical 
records, 
the 
eye-exam-book
pages, and the affidavit of Dr. Richard Saunders, a pediatric
ophthalmologist.  Dr. Saunders's affidavit provided, in
pertinent part, as follows:
"3. 
I 
have 
reviewed 
the 
medical 
records
pertaining to Anna Breland. Prior to my execution of
this Affidavit, I reviewed the following records and
things relevant to the treatment of Anna Breland
during the times made the basis of this case:
University of South Alabama Children's & Women's
Hospital's Neonatal Intensive Care Unit ('USA NICU')
Admission 
and 
Discharge summaries; USA NICU's
Neonatal Nurse Practitioner Progress Notes; Dr.
Leonard Rich's ROP eye examination forms ('Eye
Forms') dated May 21, 2003, June 1, 2003, June 16,
2003 and August 12, 2003; USA NlCU's ROP Eye
Examination Protocol dated 12/98 and revised 05/00;
select records from the office chart of Dr. Leonard
Rich; 
correspondence 
from 
Dr. 
Baker 
Hubbard
regarding his treatment of Anna Breland; USA NICU's
ROP log book ('Eye book') entries for Anna Breland
on May 21, 2003, June 2, 2003 and June 16, 2003;
portions of the deposition of Dr. Fabian Eyal; and
the deposition of Dr. Leonard Rich. 
"4. At all times relevant to the medical care
that Dr. Leonard Rich provided to Anna Breland, and
the time of the acts and/or omissions detailed
herein, I was actively engaged in the practice of
medicine as a specialist in pediatric ophthalmology
and strabismus[;] I continue to be actively engaged
in the practice of medicine as a specialist in
pediatric ophthalmology and strabismus.  I am
familiar with the prevailing standards of care
applicable to the national community of board-
certified 
ophthalmologists 
performing 
ROP 
eye
1091425
10
examinations and follow-up care and treatment for
premature infants and/or patients in a NICU.  My
qualifications are set forth in more detail in my
curriculum vitae, a copy of which is attached to
this statement. 
"5. After reviewing all of the above-stated
material relevant to Dr. Leonard Rich's treatment of
Anna Breland, it is my opinion, within a reasonable
degree of medical certainty, that Dr. Rich's care
violated the applicable standards of care for a
board-certified ophthalmologist performing ROP eye
examinations and follow-up care of premature infants
and/or infants in a neonatal care unit in the 2003
time frame. 
"6. First, Dr. Rich violated the applicable
standards of care by failing to properly convey his
request for a follow-up examination of Anna Breland
after his June 16, 2003, eye examination was
concluded.  The applicable standard of care for a
board-certified ophthalmologist performing ROP eye
examinations in a NICU requires that information
provided to physicians and staff regarding follow-up
examinations 
(if 
required) 
be 
reliably 
and
accurately conveyed in such a manner as to minimize
the likelihood of misinterpretation or scheduling
errors. The NICU had an eye examination protocol in
place, but it was not followed. To that end, Dr.
Rich typically wrote his clinical findings in the
ROP Eye Book and knew that he was the person who was
transcribing his findings into the Eye Book. The
NICU staff and Dr. Eyal relied upon Dr. Rich's
notations in the Eye Book to schedule follow-up ROP
eye examinations.  On June 16, 2003, following
Anna's third ROP eye examination.  Dr. Rich wrote
conflicting information in the Eye Form, which is
placed in the child's medical record, and the Eye
Book, which is reviewed by the Ward Clerk and, if
necessary, by the neonatologist. Dr. Rich fell below
the standard of care because he incorrectly and
improperly recorded in the USA NICU Eye Book that
1091425
11
Anna Breland required no follow-up eye examinations,
although she remained at extremely high risk for
developing blinding ROP. It is my opinion, within a
reasonable degree of medical certainty, that Dr.
Rich's failure to properly convey his request for a
follow-up ROP eye examination on June 16, 2003 was
the proximate cause of a six (6) week lapse in the
follow-up examinations and proper care of Anna
Breland's eyes, during which time she developed
severe ROP in both eyes. 
"7. Second, Dr. Rich violated the applicable
standards of care by failing to implement practices
and procedures to safeguard against lapses in care
of patients such as Anna Breland. The applicable
standard 
of 
care 
for 
a 
board-certified
ophthalmologist performing ROP eye examinations in
a busy level 3 NICU requires that the pediatric
ophthalmologist 
work 
closely 
with 
neonatology
services to establish criteria for ROP examinations,
which should be clear, unambiguous, and minimize the
risk of scheduling and other errors. In the present
matter, there was an ROP Eye Exam Protocol in place
during the time frame in question; however, that
protocol was deficient as it failed to provide
adequate safeguard against lapses in the follow-up
examinations of infants within the NICU. The
existence of a protocol does not abrogate the
ophthalmologist of responsibility if reasonable
board-certified ophthalmologists in the national
medical community who perform ROP examinations would
find the protocol deficient.  Here, the protocol
contained inadequate safeguards against patients
'falling through the cracks' since the Eye Book was
relied upon to schedule follow-up examinations and
there were no alternative safeguards or triggers to
ensure follow-up eye examinations of children who
needed them. Dr. Rich states that he relied upon the
ward clerk -- an individual with no medical training
or experience -- to interpret his medical record
findings 
in 
order 
to 
schedule 
follow-up
examinations. There were no other procedures or
1091425
12
protocols employed by Dr. Rich in order to ensure
that his requests for follow-up examinations were
properly conveyed or carried out. Moreover, Dr. Rich
failed to work with and consult neonatology services
at USA NICU to formulate a protocol that included
such necessary safeguards so as to prevent lapses in
ROP examinations of patients within the NICU. It is
my opinion, within a reasonable degree of medical
certainty, that Dr. Rich's failure to implement
practices and procedures to safeguard against lapses
in the care of patients such as Anna Breland
proximately caused a six (6) week lapse in the
follow-up examination and care of Anna Breland's
eyes, during which time she developed severe ROP in
both eyes. 
"8.  Third, Dr. Rich violated the applicable
standards of care by failing to follow and provide
follow-up care for his patient, Anna Breland.
Treatment of ROP is most likely to be effective if
applied during a relatively narrow treatment window
which typically lasts 1 to 3 weeks as the disease is
becoming severe, but prior to the development of a
large amount of abnormal vascular tissue or the
onset of retinal detachment.  For this reason, it is
essential that screening examinations be performed
on all high risk infants and repeated as necessary
based on ocular findings until the risk for
developing severe disease has passed. The applicable
standard 
of 
care 
for 
a 
board-certified
ophthalmologist performing ROP eye examinations in
a NICU requires that needed follow-up examinations
were scheduled and actually performed. In the
present case, Dr. Rich had an ongoing patient-
physician relationship with Anna Breland beginning
with his first examination on May 21, 2003. Despite
that ongoing relationship, Dr. Rich failed to assure
that follow-up examinations of Anna Breland would
occur as requested and, when she failed to re-appear
on the examination list, he further failed to
conduct any investigation as to why she was no
longer on the list. It is my opinion, within a
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13
reasonable degree of medical certainty, that Dr.
Rich's failure to follow and provide follow-up care
and treatment to Anna Breland following her June 16,
2003, eye exam proximately caused the lapse in her
care and her development of severe ROP in both eyes.
"9. Finally, Dr. Rich violated the applicable
standards of care by failing to properly document
his eye exam findings on Anna Breland's medical
records.  The applicable standard of care for a
board-certified ophthalmologist performing ROP eye
examinations 
in 
a 
NICU 
requires 
that 
the
ophthalmologist identify and record the location and
sequential retinal changes on the medical record
using 
the 
International 
Classification 
of
Retinopathy 
of 
Prematurity. 
 
Dr. 
Rich's 
eye
examination records were generally inadequate in
that they contained minimal information and provided
no indication as to why this information was lacking
on the June 2nd and June 16th examinations.
Specifically, Dr. Rich failed to make any drawings,
notations, or clear documentation regarding presence
or absence of ROP or the zone of retinal vascular
maturity, 
which 
is 
exceeding 
important 
in
determining 
risk and an appropriate follow-up
interval.  The terminology used in the Eye Form that
'Blank = normal' is inadequate.  It is my opinion
within a reasonable degree of medical certainty that
Dr. Rich's failure to properly document the results
of his ROP eye examination on the eye exam record
fell below the applicable standard of care for a
board-certified ophthalmologist performing ROP eye
examinations on premature infants. 
"10. As set forth herein, it is my opinion,
following a review of the aforementioned medical
records, documentation, and other items pertinent to
the treatment and care of Anna Breland, that Dr.
Rich failed to exercise such reasonable care, skill
and diligence as other similarly-situated healthcare
providers in the same general line of practice
ordinarily exercise in a similar case. It is further
1091425
14
my opinion that the various deviations from the
applicable standards of care by Dr. Rich in this
case proximately caused Anna Breland's injuries and
damages."
On July 28, 2009, the trial court denied Dr. Rich and
Visions Partners' motion for a partial summary judgment.
Subsequently, Dr. Rich deposed Dr. Saunders.  At his
deposition, Dr. Saunders testified, in pertinent part, as
follows:
"Q. [Counsel for Dr. Eyal and USA Health
Services Foundation:] Dr. Rich should have assessed
Anna's eyes for ROP every two weeks until he saw
full vascularization of the retinas regardless of
what he wrote on any medical form, correct? 
"A.  Not necessarily two weeks, but, again,
there should have been recurrent examinations at
appropriate intervals. 
"Q. Let me ask this: Dr. Rich should have
assessed Anna's eyes for ROP on a recurrent basis
until he saw full vascularization of her retinas
regardless of what he wrote on any medical form,
correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A. Or until the child was out of risk for
retinal detachment.
 
"Q.  And any failure on the part of Dr. Rich to
assess Anna's eyes for ROP on a recurrent basis
until such time constituted a deviation from the
standard 
of 
care 
applicable 
to 
a 
pediatric
ophthalmologist, correct?
1091425
15
 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A.  Only to the extent that he remained her eye
doctor and the care was not transferred to another
appropriately qualified individual, yes.
 
"Q. And it's your opinion in this case that Dr.
Rich 
remained 
Anna 
Breland's 
pediatric
ophthalmologist throughout her hospitalization from
May, June, July and August 2003 at Children's &
Women's Hospital, correct? 
"A. Yes.  
"Q. You see nowhere in the record where Dr. Rich
transferred the pediatric ophthalmology care of Anna
Breland to another ophthalmologist, correct? 
"A. Correct.  
"Q. By deviating from the standard of care
applicable to pediatric ophthalmologists in failing
to assess Anna's eyes on a recurrent basis until
there was full vascularization, Dr. Rich caused Anna
to 
develop 
severe 
ROP 
which 
was 
essentially
untreatable by the time the disease was finally
detected, correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A. There was more than one cause, I think, but
that was certainly one of the causes. 
"Q. If Anna Breland is blind today, then Dr.
Rich's deviation from the standard of care in
failing to assess her eyes for ROP on a recurrent
basis until she had full vascularization of her
retinas was a cause of Anna Breland's blindness,
correct? 
1091425
16
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A. Without -- Recurrent eye examinations
prompted by any method, more likely than not, would
have prevented the child from going blind. 
"Q. I don't understand. Let me ask my question
again and see if you can incorporate that and
explain it to me a little better. If Anna Breland is
blind today, then Dr. Rich's deviation from the
standard of care in failing to assess her eyes on a
recurrent basis until full vascularization of her
retinas caused Anna Breland's blindness; isn't that
right? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A.  Well, one of the number of causes, but
ultimately the failure to examine the child was the
cause of the blindness since an examination would
have prompted treatment, more likely than not, which
would have resulted in salvaged vision.
"....
"Q. If the eye-exam book, Dr. Saunders, is the
appointment book, then when Dr. Rich wrote a symbol
meaning no further follow-up examination for Anna
Breland on June 17 [sic], 2003, then Dr. Rich took
Anna Breland out of the eye reexamination schedule,
correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A. He indicated that he did not -– presumably
in error –- he did not want a follow-up.
 
"Q. Okay. And my question is, assuming that the
ward clerk prepares a follow-up examination schedule
1091425
17
based on what Dr. Rich writes in the eye book, then
by writing no further follow-up or a symbol for
that, Dr. Rich took Anna out of the follow-up
scheduling from the ward clerk, correct?
 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A. He did not request a follow-up, and unless
it was picked up, the error was picked up by some
other methodology, the child likely would not have
been followed up.
 
"Q. But, as I understand your testimony, even
though Dr. Rich incorrectly wrote no follow-up
necessary in the eye appointment book on June 17
[sic], 2003 resulting in Anna not getting a
scheduled 
follow-up, 
Dr. 
Rich 
should 
have,
nonetheless, seen Anna on June 30th, 2003 for a ROP
examination, correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form of the question. 
"A. The child should have been examined. It was
his responsibility to make sure that happened, not
his 
exclusive 
responsibility, 
but 
his
responsibility. 
"Q. Now, if you look again at the protocol,
Doctor, don't you agree that it would have been
superfluous for the ward clerk to rewrite data from
the eye form in the eye book because Dr. Rich had
already done it in this case, correct? 
"A. Yes. Actually, that would have been a very
difficult system because the ward clerk would then
have to be interpreting medical records. 
"Q. And it's my understanding that it's your
opinion that it was a better practice for Dr. Rich
to personally transfer data regarding the patient's
1091425
18
eye care from the eye form into the eye book because
a ward clerk would not have to interpret his notes
in the eye form, correct? 
"A. Yes.
 
"Q. Now, by personally writing in the eye-exam
book writing about his finding and recommendations
for follow-up of a patient for eye care, Dr. Rich
failed to follow the eye exam protocol, if you
assume that the word 'note' in [section] G means to
write, correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form of the question. 
"A.  Yes. I think that's true as well.
 
"Q. I mean. If Dr. Rich would not have written
in the eye-exam book and just let the ward clerk go
to the eye form and get the information, then she
probably would have done it correctly, right, and
not made the mistake he did, correct? 
"A. If it were left blank rather than incorrect
information being logged, it would be more likely
than not that the need for follow-up examination
would have been identified. 
"Q. She probably would not have made the same
mistake that Dr. Rich made, correct? 
"A.  That's correct. In this one -– as a single
instance, because it wouldn't have been likely they
both would have made an error. 
"Q. I think you've already agreed with this, but
let me ask again.  Dr. Rich's note in the eye-exam
book 
on 
June 
17 
[sic], 
2003, 
'No 
follow-up
examination,' made certain that Anna would not be
regularly scheduled for an eye appointment on or
about June 30th, 2003, correct?
1091425
19
 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"[Other 
counsel 
for 
Dr. 
Rich 
and 
Vision
Partners]: Object to the form. 
"Q. Isn't that correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A.  Well, it wasn't written that way but a
symbol indicating no follow-up.  It didn't make it
certain, but it made it unlikely, unless the error
was detected, that the child would receive the
follow-up, given the system that was actually being
used. 
"Q. In your opinion, did Dr. Rich deviate from
the standard of care applicable to a pediatric
ophthalmologist on June 16 or 17, 2003 by writing in
the eye-exam book that no follow-up care or
assessment of Anna's eyes were necessary? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A.  Yes. 
"Q. And that deviation of the standard of care
on the part of Dr. Rich caused her blindness,
correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A. Without that -– Let's rephrase that. Had it
been noted correctly, the child would have been
followed up appropriately, more likely than not.
1091425
Dr. Rich also challenged the amount of time Dr. Saunders
2
spent reviewing the documentary evidence before him upon which
he based his expert opinion, and Dr. Rich challenged Dr.
Saunders's understanding of proximate cause as defined by
Alabama law.  Those challenges would go toward the weight of
Dr. Saunders's testimony if the case went to trial before a
jury.  See Charles W. Gamble and Robert J. Goodwin, McElroy's
Alabama Evidence § 127.02(8)(6th ed. 2009) ("An expert
opinion, or expert testimony in some other form, is admitted
to assist the trier of fact.  What weight, if any, is given
such testimony is for the trier of fact." (footnotes
omitted)).  See also Ala. R. Evid., Rule 104(e), Advisory
Committee's Notes ("Evidence of facts sufficient to qualify a
20
"Q. And barring something, some unforeseeable,
unreasonable event, then Anna Breland would not have
developed 
severe 
stage 
III 
ROP 
and 
possible
blindness, correct? 
"[Counsel for Dr. Rich and Vision Partners]:
Object to the form. 
"A.  She would have had about an 80 percent
chance of salvage with timely treatment." 
On January 27, 2010, Dr. Rich and Vision Partners filed
another summary-judgment motion, arguing that Dr. Saunders
failed to establish that Dr. Rich's negligence proximately and
probably caused the lapse in Anna's ROP examinations and
treatment.  Dr. Rich argued that, in examining the facts
regarding the scheduling of ROP examinations, Dr. Saunders
identified numerous possible causes of the missed ROP exam,
but that none of these causes were opined by him to have been
the probable or proximate cause.   Julie filed a response in
2
1091425
witness as an expert in no way precludes the jury from
deciding what weight, if any, to give that witness's
testimony.").   
21
opposition to the motion.  On March 8, 2010, the trial court
granted the motion.  On March 12, 2010, Julie reached a
settlement with Dr. Eyal and USA Health Services Foundation.
On April 30, 2010, the trial court approved the settlement.
Julie filed a timely Rule 59(e), Ala. R. Civ. P., motion
to alter, amend, or vacate the summary judgment in favor of
Dr. Rich and Vision Partners.  Attached to the motion was a
supplemental affidavit from Dr. Saunders, which provided, in
pertinent part:
"2. In my previous Affidavit and subsequent
deposition testimony, I indicated that there were a
number of breaches of the standards of care by Dr.
Rich that contributed to Anna Breland's blindness.
However, my deposition testimony from November 16,
2009 wherein I state there were multiple 'causes' of
Anna's blindness (p. 186, lines 2-6) was in response
to a question posed by defense counsel as to whether
'Dr. Rich caused Anna to develop severe ROP.' (p.
185, lines 1-2). Clearly Dr. Rich did not cause
Anna's eye disease, which is produced by severe
prematurity as well as numerous other medical
factors (i.e., 'causes').  However, the proximate
cause of the child's blindness is another matter,
and I stated unambiguously: 'ultimately, the failure
to examine the child was the cause of the blindness,
since an examination would have prompted treatment,
more likely than not, which would have resulted in
salvaged vision.' (p. 816, lines 3-6).  Simply
stated, Dr. Rich failed to re-examine Anna's eyes
1091425
22
when she was still at risk for developing blinding
retinopathy 
of 
prematurity. 
 
This 
lapse 
in
examination would not have occurred except that Dr.
Rich improperly recorded his examination findings
and need for follow-up in the 'Eye Book' on June 16,
2003. The Eye Book was the tracking method relied on
by Dr. Rich, Dr. Eyal, and the nursery staff to
schedule follow-up examinations for ROP.  This
acknowledged error by Dr. Rich directly resulted in
Anna Breland's eyes not being examined two weeks
later, as was required by the standard of care at
that time.  Since no examination was performed,
there was no method of detecting her advancing ROP,
which would have been detected had this examination,
and subsequent required eye examinations, been
performed. Even though the ROP became severe enough
to warrant laser treatment, no treatment was offered
when the disease was curable, and the opportunity to
save her vision was permanently lost. 
"3. It is my opinion, within a reasonable degree
of medical certainty, that timely laser treatment
prior to August 1, 2003, would most likely have been
effective in preventing retinal detachment in both
of Anna Breland's eyes. In the absence of this
treatment, both eyes developed inoperable retinal
detachment. These retinal detachments have rendered
the child permanently and incurably blind. 
"4. Thus, as stated in my previous Affidavit to
this Court and as I testified in my deposition in
this case, it is my opinion within a reasonable
degree of medical certainty that Dr. Rich's failure
to examine and monitor Anna Breland's eyes, as
required by the standard of care, was the probable
and proximate cause of the child's blindness."
The trial court denied the motion, and Julie timely
appealed.   
Standard of Review
1091425
23
Our standard of review of a summary judgment is well
settled:
"'The standard of review applicable to a summary
judgment is the same as the standard for granting
the motion....' McClendon v. Mountain Top Indoor
Flea Market, Inc., 601 So. 2d 957, 958 (Ala. 1992).
"'A summary judgment is proper when
there is no genuine issue of material fact
and the moving party is entitled to a
judgment as a matter of law. Rule 56(c)(3),
Ala. R. Civ. P. The burden is on the moving
party to make a prima facie showing that
there is no genuine issue of material fact
and that it is entitled to a judgment as a
matter of law. In determining whether the
movant has carried that burden, the court
is to view the evidence in a light most
favorable to the nonmoving party and to
draw all reasonable inferences in favor of
that party. To defeat a properly supported
summary judgment motion, the nonmoving
party must present "substantial evidence"
creating a genuine issue of material fact--
"evidence of such weight and quality that
fair-minded persons in the exercise of
impartial judgment can reasonably infer the
existence of the fact sought to be proved."
Ala. Code 1975, § 12-21-12; West v.
Founders Life Assurance Co. of Florida, 547
So. 2d 870, 871 (Ala. 1989).'
"Capital Alliance Ins. Co. v. Thorough-Clean, Inc.,
639 So. 2d 1349, 1350 (Ala. 1994).  Questions of law
are reviewed de novo. Alabama Republican Party v.
McGinley, 893 So. 2d 337, 342 (Ala. 2004)."
Pritchett v. ICN Med. Alliance, Inc.,  938 So. 2d 933, 935
(Ala. 2006).
1091425
24
Issues Presented
Julie argues that she demonstrated a genuine issue of
material fact by presenting substantial evidence that Dr.
Rich's negligence proximately caused Anna's blindness because
Dr. Saunders's testimony, viewed as a whole, stated that the
lapse between the June 16, 2003, examination and the ultimate
treatment resulted in Anna's blindness and that Dr. Rich
caused that delay by failing to properly request a follow-up
ROP examination on June 16, 2003, instead indicating that no
follow-up examination was necessary.  Julie argues that Dr.
Rich and Vision Partners, in seeking a summary judgment,
raised the issue of combined and concurring negligence and
attempted to avoid responsibility by asserting that other
parties were at fault and that those parties proximately
caused Anna's blindness.  Dr. Rich and Vision Partners argue
that Julie's expert, Dr. Saunders, testified that Dr. Rich's
negligence was one of a number of causes resulting in Anna's
eye examination being delayed and that none of the causes was
identified by Dr. Saunders as the probable or most likely
cause of Anna's injury.  They further argue that because no
cause has been identified, Dr. Rich's alleged negligence does
1091425
25
not constitute a cause that can be combined and concurred with
any other cause alleged by Julie, and that, even if the
concept of combined and concurring negligence were applicable,
it has fallen into desuetude in medical-malpractice actions.
Accordingly, the issues presented in this appeal are whether
Julie presented substantial evidence that Dr. Rich breached
the applicable standard of care, which breach proximately
caused Anna's injury, and, if so, whether evidence of combined
and concurring negligence of more than one defendant for a
single injury diminishes Dr. Rich's liability.
Discussion
The AMLA, at § 6-5-548(a), Ala. Code 1975, provides, in
relevant part:
"In any action for injury ... against a health care
provider for breach of the standard of care, the
plaintiff shall have the burden of proving by
substantial evidence that the health care provider
failed to exercise such reasonable care, skill, and
diligence as other similarly situated health care
providers in the same general line of practice
ordinarily have and exercise in a like case."
"To prevail on a medical-malpractice claim, a plaintiff
must prove '"1) the appropriate standard of care, 2) the
doctor's deviation from that standard, and 3) a proximate
causal connection between the doctor's act or omission
1091425
26
constituting the breach and the injury sustained by the
plaintiff."' Pruitt [v. Zeiger], 590 So. 2d [236,] 238 [(Ala.
1991)] (quoting Bradford v. McGee, 534 So. 2d 1076, 1079 (Ala.
1988))."  Giles v. Brookwood Health Servs., Inc., 5 So. 3d
533, 549 (Ala. 2008).
"A plaintiff in a medical-malpractice action
must ... present expert testimony establishing a
causal connection between the defendant's act or
omission constituting the alleged breach and the
injury suffered by the plaintiff. Pruitt v. Zeiger,
590 So. 2d 236, 238 (Ala. 1991). See also Bradley v.
Miller, 878 So. 2d 262, 266 (Ala. 2003); University
of Alabama Health Servs. Found., P.C. v. Bush, 638
So. 2d 794, 802 (Ala. 1994); and Bradford v. McGee,
534 So. 2d 1076, 1079 (Ala. 1988). To prove
causation 
in 
a 
medical-malpractice 
case, 
the
plaintiff 
must 
demonstrate '"that the alleged
negligence 
probably 
caused, 
rather 
than 
only
possibly caused, the plaintiff's injury."'  Bradley,
878 So. 2d at 266 (quoting University of Alabama
Health Servs., 638 So. 2d at 802)."
Sorrell v. King, 946 So. 2d 854, 862 (Ala. 2006).
Out the outset, with regard to proximate cause, we note
that Dr. Rich and Vision Partners argue that Dr. Saunders
failed to identify the proximate cause of the lapse in
examinations after June 16, 2003. Julie argues that they are
improperly characterizing the delay in examining Anna's eyes
as Anna's injury and that, instead, Anna's compensable injury
is the blindness she suffered as a result of untreated ROP
1091425
27
caused by the delay in her eye examination.  This Court has
discussed proximate cause in cases where a delay in diagnosis
and/or treatment was an issue.  
In Parker v. Collins, 605 So. 2d 824 (Ala. 1992), Joyce
Parker discovered a lump in her breast and underwent a
mammogram.  Dr. Collins, a radiologist, interpreted the test
results as negative for cancer.  Subsequent surgery resulted
in the removal of her breast and several mammary glands, which
were found to be cancerous.  Parker underwent chemotherapy and
radiation to destroy any cancer cells that might have spread
into her lymph nodes.  Parker and her husband sued Dr.
Collins, alleging that he negligently performed a mammogram
and that he negligently interpreted those test results.  The
Parkers further argued that had Mrs. Parker's cancer been
detected 
earlier, 
she 
could 
have 
avoided 
undergoing
chemotherapy and radiation treatments and that her chance of
long-term survival would have been much better.  At trial, the
Parkers submitted the expert testimony of several radiologists
who stated that the X-ray film Dr. Collins had used to make
his diagnosis was "grossly inadequate" and that Dr. Collins
violated the standard of care by basing his diagnosis on the
1091425
Rule 50(a), Ala. R. Civ. P., effective October 1, 1995,
3
renamed a "motion for a directed verdict" a "motion for a
judgment as a matter of law."
28
film.  The Parkers presented testimony from a cancer
specialist who stated that, based on the size of the lump in
January 1988 (when Dr. Collins performed the mammogram) and
the medical evidence of the subsequent growth of the lump, "he
was 80% certain that the cancer had not spread into Mrs.
Parker's lymph nodes as of January [1988]."  605 So. 2d at
826.  Mrs. Parker's surgeon testified that her "mastectomy and
the course of chemotherapy and radiation treatments that
followed were necessary, because the cancer had spread into
her lymph nodes" and that "breast cancer has a higher rate of
reccurrence once it has spread into the lymph glands."  Id.
At the close of the Parkers' evidence, the trial court granted
Dr. Collins's motion for a directed verdict  on the ground
3
that the Parkers had failed to establish the element of
proximate causation because they presented no evidence
indicating that Dr. Collins's incorrect interpretation of the
substandard mammogram caused Mrs. Parker to undergo a course
of treatment she would not have had to endure in January 1988
had the proper diagnosis been made.
1091425
29
On appeal, this Court reversed the judgment of the trial
court, holding that the Parkers had provided sufficient
evidence  to create a jury question as to the proximate cause
of Mrs. Parker's injuries.  At the outset of this Court's
discussion, we cited  the established principle that "the
issue of causation in a malpractice case may properly be
submitted to the jury where there is evidence that prompt
diagnosis and treatment would have placed the patient in a
better position than she was in as a result of the inferior
medical care."  605 So. 2d at 827 (citing Waddell v. Jordan,
302 So. 2d 74 (Ala. 1974); Murdoch v. Thomas, 404 So. 2d 580
(Ala. 1981)).  "It is not necessary to establish that prompt
care would have prevented the injury or death of the patient;
rather, the plaintiff must produce evidence to show that her
condition was adversely affected by the alleged negligence."
Id.   This Court then held:
"While the facts do not establish that Mrs.
Parker's cancer could have been prevented altogether
if Dr. Collins had rendered a prompt diagnosis based
on a clearer X-ray, medical testimony suggests that
Mrs. Parker's condition worsened as a direct result
of a diagnosis based upon a substandard X-ray. That
evidence was sufficient to create a jury question as
to proximate cause in this case; accordingly, we
reverse that portion of the judgment based on the
directed verdict for Dr. Collins."  
1091425
30
605 So. 2d at 827.
McAfee v. Baptist Medical Center, 641 So. 2d 265 (Ala.
1994), involved the consolidated appeals of two medical-
malpractice plaintiffs.  One plaintiff was Martin McAfee, an
infant who "developed bacterial meningitis and suffered
permanent brain damage and vision impairment" as a result of
the alleged malpractice of his neonatalogist. 641 So. 2d at
266. The other plaintiff was Brenda Roberts, who developed
breast cancer, which she alleged her radiologists failed to
discover. Id. McAfee alleged that Baptist Medical Center and
others (collectively referred to as "Baptist Medical") "failed
to recognize, appreciate, and treat [his] bacterial infection
in a timely manner, ... [resulting] in a worsening of [his]
condition."  Id. Similarly, Roberts alleged that Life
Diagnostic Radiology and others "fail[ed] to properly evaluate
[a] lump ... found in [her] right breast ... [resulting] in a
one-year delay of treatment and ... an unnecessary worsening
of her condition."  Id.  In each case, the trial court granted
the defendants' summary-judgment motions. This Court affirmed
both  summary judgments, explaining:
"We have carefully studied the record in each of
the cases before us and in both cases we conclude
1091425
31
that the defendants made a prima facie showing that
they were entitled to a judgment as a matter of law
on the issue of causation by producing evidence that
their actions did not cause the patient's condition
to worsen. In neither case did the plaintiffs submit
substantial evidence that the patient's condition
worsened as a direct result of the actions of the
defendant physicians.
"In the first case, the baby, Martin McAfee,
contracted meningitis from bacteria.  He was treated
by Dr. Rodney Dorand. Dr. Dorand, a board certified
neonatologist, submitted an affidavit stating that
he was familiar with the degree of care, skill, and
diligence 
normally 
exercised 
by 
physicians
practicing neonatology in 1990, and that, in his
opinion, nothing he did or did not do in his care
and treatment of Martin McAfee probably caused or
contributed to cause any injury. The affidavit of
the plaintiffs' expert, Dr. O. Carter Snead III,
offered a conjectural observation that, generally,
the sooner the onset of treatment, the better the
expected result.  There is no evidence that the
actions of Dr. Dorand or those of Dr. Gillis Payne,
who first saw the baby, probably caused the poor
outcome.  In the second case, the plaintiffs
submitted affidavits stating, generally, that 'time
is of the essence' in treating breast cancer, and
that patients who receive earlier treatment obtain
a better result.  There was no expert testimony to
rebut the testimony submitted by the defendants
indicating that the metastasis to the lymph nodes
probably occurred in the early stages before the
cancer could be diagnosed.  The affidavits of the
plaintiffs' experts did not rise to the level of
substantial evidence that the actions of the
defendants 
probably 
caused 
Brenda 
Roberts's
injuries."
641 So. 2d at 267-68.  In other words, the general statements
proffered by McAfee and Roberts –- that "time [was] of the
1091425
32
essence" and that "the sooner the onset of treatment, the
better the expected result" –- did not constitute substantial
evidence that any of the physicians charged in McAfee with
medical malpractice probably caused the plaintiffs' injuries.
In Shanes v. Kiser, 729 So. 2d 319, 320 (Ala. 1999), the
plaintiff alleged that an emergency-room physician failed to
diagnose and treat her mother's "heart-related problem" while
her mother was in the emergency room.  The mother was released
and was later found dead in her home.  No autopsy was
performed, and both the emergency-room physician and the
plaintiff's expert identified other possible causes for the
mother's death.  The plaintiff's expert expressed the opinion
that the mother had died of a heart attack based on
statistical data "suggesting that more people die each year of
heart-related problems than any other cause" and on the fact
that the mother had exhibited symptoms in the emergency room
that might suggest a heart-related problem.  729 So. 2d at
322. This Court wrote:
"More specifically, [the plaintiff] based her
theory of the case –- and, consequently, her expert
testimony –- solely on the assumption that [her
mother] died of heart failure, which fact was never
established. All of [the plaintiff's expert]'s
testimony as to the breach of the standard of care
1091425
33
related to what might have been done to prevent, or
reduce the effects of a heart attack. Significantly,
if, in fact [the mother] died of one of the other
three possible causes discussed, then the record
provides no evidence as to the standard of care
allegedly breached, that is, as to what [the
emergency-room doctor] should have done under those
circumstances to prevent [the mother]'s death or to
reduce the effects of the malady. If [the mother]
died of a condition not heart-related, then [the
plaintiff] presented no evidence as to how [the
emergency-room doctor] breached the standard of care
relevant to that condition."
729 So. 2d at 323-24 (emphasis omitted).
DCH Healthcare Authority v. Duckworth, 883 So. 2d 1214
(Ala. 2003), also involved a delay in diagnosis and treatment.
In Duckworth, Dee Duckworth was injured on October 9, 1999,
when he fell on an escalator at a medical center.   He was
taken to the emergency room of the medical center at 11:00
a.m.  Dr. Malcolm Nelson, the emergency-room physician,
examined Mr. Duckworth and ordered an X-ray examination, which
began at 12:36 p.m.  For approximately 45 minutes preceding
the X-ray examination, Mr. Duckworth waited in the hallway of
the radiology department. While he was waiting, he developed
a headache and nausea.  He vomited during and after the X-ray
examination.  At 1:17 p.m., Dr. Nelson ordered a computerized
tomography scan ("CT scan"), which was performed at 1:54 p.m.
1091425
34
At 2:00 p.m., the radiology department notified emergency-room
personnel that Mr. Duckworth had a subdural hematoma.  At
approximately 2:15 p.m., Mr. Duckworth was relocated to the
critical-care unit and neurosurgeon Dr. Moses Jones was called
to relieve the hemorrhage.  Dr. Jones arrived at the medical
center at approximately 3:15 p.m. Surgery began at 4:40 p.m.
and was completed at 6:00 p.m.  Mr. Duckworth remained
hospitalized until October 22, 1999, when he died as a result
of the injuries he sustained in the fall.  
Mary Duckworth, his wife, sued the medical center.  Her
theory of the case was that the medical center's diagnosis of
her husband's condition and its treatment were dilatory. More
specifically, she complained that the failure of emergency-
room personnel to respond timely and appropriately to her
husband's visibly deteriorating condition over a three-hour
period was inferior care and adversely affected his condition,
namely, the subdural hematoma, from which he subsequently
died.  During the trial of the case, the medical center moved
for a judgment as a matter of law ("JML") at the close of Mrs.
Duckworth's evidence and again at the close of all the
evidence.  As a ground for the motions, the medical center
1091425
35
asserted that Mrs. Duckworth failed to present substantial
evidence of causation by expert testimony. The trial court
denied the motions, and a jury awarded Mrs. Duckworth
$350,000.  The medical center filed a postverdict motion for
a JML.  That motion was overruled by operation of law, and the
medical center appealed.  On appeal, this Court reversed the
judgment of the trial court, stating:
"As to causation in a dilatory-diagnosis-and-
treatment case such as this one, 'an action "may
properly be submitted to the jury where there is
evidence that prompt diagnosis and treatment would
have placed the patient in a better position than
she was in as a result of inferior medical care."'
Shanes v. Kiser, 729 So. 2d 319, 320-21 (Ala.
1999)(quoting Parker[v. Collins], 605 So. 2d [824]
at 827 [(Ala. 1992)])(emphasis added). 'It is not
necessary to establish that prompt care could have
prevented the injury or death of the patient;
rather, the plaintiff must produce evidence to show
that her condition was adversely affected by the
alleged negligence.'  Parker, 605 So. 2d at 827
(emphasis added). Unless 'the cause and effect
relationship between the breach of the standard of
care and the subsequent complication or injury is so
readily understood that a layperson can reliably
determine the issue of causation,' causation in a
medical-malpractice case must be established through
expert testimony.  Cain v. Howorth, 877 So. 2d 566,
576 (Ala. 2003); see also Bradley v. Miller, 878 So.
2d 262 (Ala. 2003); Rivard v. University of Alabama
Health Servs. Found., P.C., 835 So. 2d 987 (Ala.
2002)."
883 So. 2d at 1217-18.
1091425
36
In Duckworth, Dr. Jones, who performed the surgery on Mr.
Duckworth, testified, in pertinent part, as follows:
"'Q. [Counsel for the medical center:]
In your opinion, in your medical opinion,
doctor, 
to 
a 
reasonable 
degree 
of
certainty, would Mr. Duckworth's outcome
have been what it was?
"'A. Certainly. I see nothing about
this course of events that tells me we
could have corrected anything here by a
time factor.  You can always go back and
say, well, is there some other management
approach you could have taken, and it's a
second guess. But, then, every time you try
one of these other things, you can find
other complications that could have or
might have ar[isen].  So, sure, I don't see
anything different to change.'
"....
"'Q. [Mrs. Duckworth's counsel:] The
timing within which a surgeon can evacuate
a hematoma like Mr. Duckworth had has some
effect on the likelihood of a good outcome,
doesn't it?
"'A. [Dr. Jones:] Certainly.
"'Q. You want to get to it as soon as
possible?
"'A. That's always the ideal, yes.
"'Q. Regardless of whether it's an
elderly patient or an adolescent?
"'A. That's correct.
1091425
37
"'Q. 
When 
you 
say 
that 
subdural
hematomas like Mr. Duckworth suffered from
are known to have an 80% mortality rate,
timing 
of 
surgical 
intervention 
and
relieving the pressure has an effect on
improving the likelihood of a better
outcome?
"'A. That's correct.  Certainly, if
you operate on it next week as opposed to
today, that makes a big, big difference.
"'Q. Well, and hours can make a
difference, can't it.
"'A. All the studies show -- well, I
shouldn't say all the studies, but the
standard of -- by head-injury studies, put
it that way, have shown that you basically
have a major change in mortality based on
an eight-hour window after discovery of the
subdural. Now that's not necessarily after
the injury.
"'....
"'A. Because you don't have a precise
time when the bleeding started....
"'....
"'Q. Doctor, with this patient, taking
in 
consideration 
specifically 
with 
a
history of this fall and injury to his head
on the escalator and his resulting course,
can you tell us, in your opinion, when his
hematoma began to form in the subdural
region?
"'A. I have no clue. I can't –- I can
only tell you where it was at the time when
we did the CT [scan].
1091425
38
"'Q. 
Would 
you 
expect 
that 
the
subdural hematoma that you encountered and
which you described as being large would
have been smaller or less involved with
bleeding two hours earlier?
"'A. I would expect so, but I have no
way of knowing that.
"'Q. I mean, scientifically, as a
neurosurgeon, 
you 
would 
expect 
that
probability?
"'A. I think that's a reasonable
expectation, yeah. I think that you could
possibly say that it was smaller two hours
earlier than it was at the time I saw him.
"'....
"'Q. But if I'm understanding your
specialty and your practice correctly,
physicians like yourself, who are trained
to deal with these intracranial bleeds,
want to evacuate the bleed at the earliest
time to reduce the harm?
"'A. Right. And we have to have a
window of opportunity to do that and that's
why I said that the usual considered window
of 
opportunity, 
and 
this 
is 
not 
an
absolute. Obviously, you don't sit around
and wait for eight hours to occur. But if
you can get a subdural hematoma evacuated
within that basically eight-hour window,
the statistics show that those people
survive better.
"'Q. [Dr. Nelson] had told us [in] his
deposition when he was asked, generally,
with a subdural bleed like Mr. Duckworth
had, any delay in diagnosis can adversely
1091425
39
affect a person's condition, and he said:
"Yes, sir."  Would you agree with that in
general?
"'A. Yes. I think we've already said
that.'"
883 So. 2d at 1218-20 (emphasis omitted).  The Duckworth Court
stated:
"Conspicuously 
absent 
from 
this 
testimony 
is 
any
opinion as to how -- or whether -- the two- or
three-hour diagnostic, or preoperative, period of
which Mrs. Duckworth complains probably affected the
outcome of this case. On the contrary, Dr. Jones
testified that there was an optimum period of eight
hours between diagnosis and surgery. The hematoma
was discovered at 2:00 p.m. and removed by 6:00 p.m.
Even computing the time from 10:24 a.m., when
Duckworth arrived at the emergency room, until the
hematoma was evacuated, only 7 1/2 hours occurred
before the surgery -- within the optimum treatment
period Dr. Jones described. Although Dr. Jones
conceded that the hematoma 'could possibly [have
been] smaller two hours earlier,' he did not explain
how an increase in size would have adversely
affected Mr. Duckworth's ultimate condition. He
agreed with the general proposition that a 'delay in
diagnosis 
[could] 
adversely affect a person's
condition,' not that it did so in this case.
"....
"... Dr. Jones's opinion does not constitute
substantial evidence that the two- or three-hour
delay of which Mrs. Duckworth complains probably
adversely affected Mr. Duckworth's response to
treatment.  
"The expert testimony presented in the cases
cited by Mrs. Duckworth is clearly distinguishable.
1091425
40
Travis v. Scott, 667 So. 2d 674, 678 (Ala. 1995)
(plaintiff's expert testified that if surgery had
been performed on the decedent two days after she
was admitted to the hospital, rather than eight days
after 
admission, 
she 
'probably 
would 
have
survived'); University of Alabama Health Servs.
Found., P.C. v. Bush, 638 So. 2d 794, 803 (Ala.
1994) 
(plaintiff's 
expert 
testified 
that 
the
challenged 
delay 
in 
treating 
the 
plaintiff's
meningitis infection 'caus[ed]' or 'contributed to
the neurological damage that occurred'); Parker v.
Collins, 605 So. 2d [824] at 826 [(Ala. 1992)]
(breast-cancer patient's experts were '80% certain'
that cancer invaded the lymph nodes, necessitating
a 'mastectomy and [a] course of chemotherapy and
radiation treatments,' because of the defendant-
doctor's failure timely to diagnose a lump in the
plaintiff's breast)."
883 So. 2d at 1220-21 (emphasis omitted).
More recently, in Crutcher v. Williams, 12 So. 3d 631
(Ala. 2008), this Court reversed a judgment entered on a jury
verdict for a plaintiff in a medical-malpractice case.  The
plaintiff, Iola Williams, sued an emergency-room physician,
alleging that his failure to treat her dangerous brain
condition or to arrange for her to transfer to another medical
facility by emergency vehicle caused a delay in treatment and
a lack of emergency care when it was needed.  In our analysis,
this Court set out the relevant and longstanding standard of
care in medical-malpractice cases based on a delay in
treatment:   
1091425
41
"This is a medical-malpractice action governed
by the Alabama Medical Liability Act, § 6-5-480 et
seq. and § 6-5-541 et seq., Ala. Code 1975 ('the
AMLA'). See Mock v. Allen, 783 So. 2d 828, 832 (Ala.
2000)('The AMLA applies "[i]n any action for injury
or damages or wrongful death, whether in contract or
in tort, against a health care provider for breach
of the standard of care."' (quoting § 6-5-548(a),
Ala. Code 1975)). 'To prevail on a medical-
malpractice claim, a plaintiff must prove "'1) the
appropriate standard of care, 2) the doctor's
deviation from that standard, and 3) a proximate
causal connection between the doctor's act or
omission constituting the breach and the injury
sustained by the plaintiff.'"'  Giles v. Brookwood
Health Servs., Inc., 5 So. 3d 533, 549 (Ala. 2008)
(quoting Pruitt v. Zeiger, 590 So. 2d 236, 238 (Ala.
1991), quoting in turn Bradford v. McGee, 534 So. 2d
1076, 1079 (Ala. 1988)).  Although a delay in
medical treatment may, in an appropriate case,
constitute a breach of the standard of care as a
matter of law, it does not, in and of itself,
constitute an injury. See McAfee ex rel. McAfee v.
Family 
Med., 
P.C., 
641 
So. 
2d 
265 
(Ala.
1994)(holding that, absent proof of actual injury
caused by alleged delay in the diagnosis and
treatment of disease, plaintiffs could not recover
on 
their 
AMLA 
claims 
against 
medical-service
providers).  Rather, to prevail on a medical-
malpractice claim based on a delay in providing
medical treatment, the plaintiff must prove that a
breach of the standard of care, i.e., the delay in
treatment, proximately and probably caused actual
injury to the plaintiff. See McAfee, 641 So. 2d at
267 ('In medical malpractice cases, the plaintiff
must prove that the alleged negligence "probably
caused the injury."  Parrish v. Russell, 569 So. 2d
328, 330 (Ala. 1990), citing Williams v. Bhoopathi,
474 So. 2d 690, 691 (Ala. 1985).  This has been the
standard in Alabama for decades.').
"....
1091425
42
"Our careful examination of the record reveals
no evidence indicating that, once Williams arrived
at UAB hospital, Williams's treatment, or the
outcome of her treatment, was in any way affected by
any action Dr. Crutcher took or failed to take.
Conjecture by an expert witness that Williams might
have received treatment for her hydrocephalus sooner
had Dr. Crutcher treated Williams for that condition
at Hill Hospital and arranged for her transport to
UAB hospital is not sufficient to establish that she
probably 
would 
have 
received 
treatment 
for
hydrocephalus sooner.  It is undisputed that
Williams would not have been relieved of her pain
before the ventricular shunt was installed.  Dr.
Hadley's testimony that he would have or might have
admitted Williams to the hospital for monitoring
early on Saturday, June 27, 1998, if he had seen a
copy of the MRI report at that time, does not,
without more, indicate a probability that Dr. Hadley
would have performed the surgery to install the
ventricular shunt any earlier than Tuesday, June 30.
See McAfee, 641 So. 2d at 267 ('"The proof must go
further than merely show that an injury could have
occurred in an alleged way -- it must warrant the
reasonable inference and conclusion that it did so
occur as alleged ...."'(quoting McKinnon v. Polk,
219 Ala. 167, 168, 121 So. 539, 540 (1929))).
Because the record does not contain substantial
evidence indicating that Dr. Crutcher proximately
and probably injured Williams by causing a delay in
her medical treatment upon her arrival at UAB
hospital, we conclude that the evidence was not
sufficient to warrant a jury determination on
Williams's claim for damages resulting from delayed
treatment at UAB hospital."
12 So. 3d at 647-49.  
Our cases addressing a delay in diagnosis and/or
treatment provide that with regard to the issue of causation,
1091425
43
the question is whether the breach of the standard of care,
i.e., the delay in diagnosis and/or treatment, proximately and
probably caused actual injury to the plaintiff.  To resolve
the issue of causation, we must determine whether the
plaintiff presented evidence indicating  that the delay
proximately and probably caused the plaintiff an actual
injury.  
When the evidence is reviewed in a light most favorable
to Julie, as the nonmovant, and all reasonable inferences from
the evidence drawn in her favor, as we are required to do when
reviewing a summary judgment, the evidence presented indicates
that premature infants are at risk for ROP, which affects the
blood vessels on the retina in a premature infant's eyes.  ROP
is diagnosed during an eye examination, and premature infants
should have their eyes examined at regular intervals until the
infant has reached full vascularization or until the risk of
developing ROP has passed.  A delay in the frequency of
examinations of the infant's eyes  can allow ROP to develop
and to progress to such a stage as to render treatment
ineffective and result in blindness.     
1091425
Dr. Rich began consulting as a pediatric ophthalmologist
4
with the NICU in 2001.  Before that time, Dr. Rich was a
professor of ophthalmology at USA's medical school.
44
Dr. Saunders testified that generally a pediatric
ophthalmologist is responsible for scheduling and performing
necessary ROP follow-up examinations.  He stated that Dr. Rich
was responsible for the follow-up examination and treatment of
Anna's eyes if he was the only person who could assess the
severity of ROP (if it was present), make recommendations for
its treatment, determine the intervals of Anna's eye
examinations, and, assuming an ongoing physician-patient
relationship, continue to render follow-up examinations and
treatment until Anna reached full vascularization or until the
risk of retinal detachment had passed.  Dr. Saunders testified
that all of those factors applied to Dr. Rich as the pediatric
ophthalmologist treating infants in the NICU.   
4
Dr. Saunders testified that Anna's failure to appear on
the list in the eye-exam book as a patient scheduled for an
ROP reexamination on June 30, 2003, should have triggered some
sort of investigation by Dr. Rich as to why Anna was not in
the book.  Dr. Rich testified that he was expecting to see
Anna on June 30, 2003, for her follow-up examination.  Dr.
1091425
In Mobile Infirmary Association v. Tyler, 981 So. 2d
5
1077 (Ala. 2007), a medical-malpractice and wrongful-death
action arising out of death of a hospital patient from
intestinal infection, evidence supported a finding that the
hospital nurse negligently failed to adequately and accurately
communicate the nature and severity of patient's abdominal
pain.  The patient's son testified that the patient was
screaming in pain and that the nurse was present with the
patient when the son entered the patient's room, and other
relatives corroborated his testimony.  The nurse's notes of
45
Saunders went on to opine that recurrent ROP eye examinations
more likely than not would have prevented Anna from going
blind and that ultimately the failure to examine Anna's eyes
was the cause of her blindness because an examination would
have prompted treatment, which, more likely than not, would
have resulted in an 80% chance of salvaged vision.  Dr.
Saunders testified that Dr. Rich deviated from the applicable
standard of care by writing in the eye-exam book that Anna's
eyes did not need further examination.  
With regard to ROP eye examinations in the NICU, it is
undisputed that Dr. Rich was the only person to write in the
eye-exam book as to whether follow-up examinations were needed
and that he wrote down the incorrect information in the eye-
exam book regarding Anna's need for a follow-up ROP
examination.  Transposing the information incorrectly was an
act of negligence in and of itself.   Nevertheless, Dr. Rich
5
1091425
her treatment of the patient stated that the patient reported
experiencing the worst abdominal pain she had ever had.   The
nurse did not communicate that the patient was experiencing
serious abdominal pain, and a similarly situated health care
provider testified that the nurse's action in failing to
communicate that the patient described her pain as the worst
she had ever experienced fell below the applicable standard of
care. "There was sufficient evidence to show that an accurate
communication [from the nurse to the triage nurse] would have
ultimately resulted in a surgeon performing an embolectomy,
which [the patient] probably would have survived."  981 So. 2d
at 1101.
46
essentially argues that it was not his error in transposing
the information from the eye form to the eye-exam book that
caused the delay in Anna's treatment but the error of the NICU
in using the eye-exam book instead of the eye form to
determine whether an infant needed to be reexamined for ROP.
However, Julie has presented substantial evidence of the
existence of a genuine issue of material fact as to whether
the eye-exam book was the proper source for scheduling ROP
examinations.  Dr. Eyal testified that the NICU has used the
eye-exam book as the source for scheduling ROP examination for
at least 15 years because the eye form is not always
available.  The eye-exam book stays in the NICU and cannot be
misplaced, whereas the eye forms do not immediately appear in
a patient's chart and charts are "thinned out" on a regular
basis, possibly removing the eye form from the patient's chart
1091425
47
and placing the culled reports in a different place in the
NICU.  Dr. Eyal testified that Dr. Rich is the only person to
write in the eye-exam book, which prevented a ward clerk from
possibly misinterpreting Dr. Rich's handwriting on the eye
form and transposing incorrect data into the eye-exam book.
We recognize that Dr. Rich testified that the NICU had
violated its own written policy by not having the ward clerk
responsible for using the eye form to write in the eye-exam
book who needed a follow-up ROP examination and to then
schedule the necessary exams with his office.   Dr. Saunders
testified that Dr. Rich appears to have modified the protocol
himself by writing the results of his eye exams in the eye-
exam book as noted on the eye form.  Dr. Saunders also
testified that generally the eye-exam book was more reliable
than the eye form so a deviation from the NICU's written
protocol would have been appropriate.  Dr. Saunders testified
that the information in the eye-exam book was a directive on
care of the child and it was part of the medical records for
multiple children.  Dr. Saunders testified that, if Dr. Rich
believed that the protocol and procedure for ROP examinations
at the NICU was deficient, he had a responsibility to advise
1091425
48
USA of that belief.  Additionally, Dr. Saunders testified that
Dr. Rich's completion of Anna's eye forms was deficient.
Moreover, there is a reasonable inference that Dr. Rich knew
that the eye-exam book was used to schedule follow-up eye
examinations because he was the only person writing such
information in the eye-exam book.  Dr. Rich characterized the
eye-exam book as a "spent" page used to make sure he did not
miss any patients during his visit.  However, he placed
information regarding follow-up visits in the eye-exam book.
Dr. Rich and Vision Partners argue that because there
were two sources for  identifying whether an infant needed a
follow-up ROP examination (the eye form and the eye-exam
book), then there should have been testimony to the effect
that Dr. Rich knew or should have known that one of these
"safeguards" would fail.  In support of his argument, Dr. Rich
cites a special writing in Thompson v. Patton, 6 So. 3d 1129
(Ala. 2008), involving the death of a psychiatric patient. 
This Court had previously addressed the issue of proximate
cause in Thompson v. Patton, 958 So. 2d 303 (Ala. 2006).  A
psychiatrist's patient had been treated for psychiatric
illness for approximately 30 years when she was admitted to a
1091425
49
hospital after she had attempted suicide.  She had been
admitted three times in the previous year following suicide
attempts, and the psychiatrist had been her physician during
those hospital admissions.  The patient was placed on a
suicide watch during her stay.  She was discharged after 11
days, although the day before her discharge she stated that
she hoped she would not hurt herself and that she was scared
and worried, showing signs of paranoia.  The psychiatrist had
implemented a discharge plan for the patient that included: 1)
a follow-up appointment with her therapist from the mental-
health center; (2) arrangements for daily visits by a home-
health psychiatric nurse; and (3) help from a relative in
monitoring her medication compliance.  The patient kept her
appointment at the mental-health center, but the therapist
noted that the patient had been unable to fill her
prescription for a drug used to treat schizophrenia, that she
was obsessed with psychotic thoughts, that she was frightened,
and that she had an "inappropriate and blunted affect."  958
So. 2d at 305.  The patient was found dead in her apartment
two days later.  The patient's family sued the psychiatrist
under the AMLA, alleging that the psychiatrist breached the
1091425
50
standard of care by prematurely discharging the patient from
the hospital, by failing to formulate an appropriate
outpatient-treatment plan, by failing to readmit her to a
psychiatric unit, and by failing to implement proper suicide
precautions.  The trial court denied the psychiatrist's
summary-judgment motion, concluding that evidence regarding
the foreseeability of the patient's suicide was sufficient to
create a genuine issue of material fact as to whether the
psychiatrist's alleged negligence caused the patient's death.
On appeal, this Court stated that "a medical-malpractice
action based on a patient's suicide is different from a
general medical-malpractice action," 958 So. 2d at 312,
because  the foreseeability of the plaintiff's suicide is an
essential element of proof in a medical-malpractice action
arising out of a suicide.  The question whether the
psychiatrist knew or should have known that the patient might
harm herself must be addressed to determine whether a duty to
prevent her suicide existed.  The psychiatrist knew that the
patient had suicidal tendencies and that she had manifested
suicidal proclivities during her most recent hospital stay;
therefore, the psychiatrist had a duty to take reasonable
1091425
51
precautions to prevent the patient's suicide.  However,
evidence of foreseeability was not sufficient to show that the
breach of the psychiatrist's duty caused the patient's
suicide.  The patient's family needed to present substantial
evidence of the applicable standard of care, that the
psychiatrist breached that standard of care, and that the
breach was a proximate cause of the patient's suicide.  This
Court remanded the case for the trial court to determine
whether the patient's family had established those elements as
well.  
On the second appeal, this Court concluded that the
patient's family failed to present substantial evidence of
proximate cause.  Thompson v. Patton, 6 So. 3d 1129 (Ala.
2008).  The patient's family presented substantial evidence
that when the patient was discharged from the hospital, it was
reasonably foreseeable to the psychiatrist that there was a
probability that the patient would attempt suicide or self
harm, and that evidence, along with the expert's testimony
that the psychiatrist breached the standard of care, created
a question of fact as to whether the psychiatrist breached the
standard of care.  However, that evidence showed only that
1091425
52
there was an unquantative probability that the patient might
possibly attempt suicide or self harm, and evidence showing
only a probability of a possibility is insufficient to
establish proximate causation in a negligence action alleging
medical malpractice.  The foreseeability evidence went to the
question of the psychiatrist's duty to the patient and was not
enough by itself to establish that the psychiatrist's breach
caused the patient to commit suicide.  
The present case did not involve a suicide.  The duty of
health-care providers, when a patient may attempt to harm
himself, 
contemplates 
the 
reasonably 
foreseeable 
occurrence 
of
self harm, and such self-destructive conduct involves the
necessity of precautions or safeguards to attempt to prevent
such harm.  Here, Julie was not required to prove that Dr.
Rich knew or should have known that it was foreseeable that
the "safeguard" of having both an eye form and an eye-exam
book in the NICU would fail.  
Dr. Rich and Vision Partners argue that because Dr.
Saunders identified other causes for the delay in Anna's
examination, Julie failed to present evidence indicating that
the actions or inactions of Dr. Rich proximately caused Anna's
1091425
Those causes included the NICU's removal of Dr. Rich's
6
eye form from Anna's chart; the failure of the ward clerk to
review the eye form; and the failure of the head nurse to
properly supervise the ward clerk.  
53
injury.  Dr. Rich identifies portions of Dr. Saunders's
testimony regarding the negligence of Dr. Eyal and USA.6
However, any negligence by NICU staff or Dr. Eyal does not
abrogate Dr. Rich and Vision Partners of liability for Dr.
Rich's alleged breach of the standard of care.  "[W]here
separate causes act contemporaneously to produce a given
result, the causes of injury are concurrent within the rule
making separate wrongdoers equally liable for the resultant
injury."  Davison v. Mobile Infirmary, 456 So. 2d 14, 26 (Ala.
1984).   In Looney v. Davis, 721 So. 2d 152 (Ala. 1998), the
plaintiff alleged that negligent health care by all three
defendants combined and concurred to cause the death of the
patient.  This Court stated:
"[W]e note that a particular defendant's negligence
need not be the sole cause of injury in order for an
action to lie against that defendant; it is
sufficient that the negligence concurred with other
causes to produce injury. Buchanan v. Merger
Enterprises, Inc., 463 So. 2d 121 (Ala. 1984).
However, it is still necessary that the plaintiff
prove that the defendant's negligence proximately
caused the injury.  Martin v. Arnold, 643 So. 2d 564
(Ala. 1994)."
1091425
54
721 So. 2d at 158. 
Dr. Rich and Vision Partners argue that if the doctrine
of combined and concurring negligence is applicable, Julie's
reliance on Davison v. Mobile Infirmary, supra, is misplaced
because that case was decided under the "scintilla rule," and
the 1996 amendments to the AMLA abandoned the scintilla rule
in favor of substantial evidence.  They argue that combined
and concurring negligence has since  fallen into desuetude in
medical-malpractice cases.  However, in Marsh v. Green, 782
So. 2d 223 (Ala. 2000), this Court held that the trial court
erred in failing to give a jury instruction on combined and
concurring negligence.  This Court references Davison in Marsh
for the proposition that combined and concurring negligence
can cause a single injury. In Marsh, the plaintiff sued her
physician, alleging that he committed medical malpractice by
failing to remove a cancerous mass from her breast.  The
plaintiff's physician, Dr. Green, asserted the negligence of
another doctor involved in treating the plaintiff.  This Court
stated:
"Marsh argues that the trial court erred in
refusing to charge the jury on the law of combining
and 
concurring 
negligence. 
Under 
the 
law 
of
combining and concurring negligence, Dr. Green can
1091425
55
be liable for his own negligence, notwithstanding
the fact that others, who are not his agents, could
be liable for their own negligence. See Davison v.
Mobile Infirmary, 456 So. 2d 14, 25 (Ala. 1984).
Marsh contends that she was entitled to instructions
on combining and concurring negligence because Dr.
Green had blamed Dr. Wenzel for Dr. Green's failure
to diagnose the cancer.  At trial, after Dr. Green
said he was not 'blaming Dr. Wenzel of anything,'
Marsh specifically asked Dr. Green, 'But you're
saying it's his fault that you didn't take the mass
out; aren't you?'  No objection was interposed on
the ground that Dr. Green was not qualified to
answer a question concerning the standard of care
owed by a pathologist. Dr. Green answered, 'There
was an error in his path report, yes.'  During
closing argument, Dr. Green stated, 'I understand
that Dr. Wenzel comes in here with some baggage.  I
understand about the mistake he made. I know that.
I understand that....' By characterizing the conduct
of Dr. Wenzel, Marsh contends that Dr. Green placed
the question of combining and concurring negligence
at issue.
"....
"The [Medical Liability Act] specifies the
plaintiff's burden of proof in a medical-malpractice
action.  Section 6-5-548(a), Ala. Code 1975, reads:
"'In any action for injury or damages
or wrongful death, whether in contract or
in tort, against a health care provider for
breach of the standard of care, the
plaintiff shall have the burden of proving
by substantial evidence that the health
care provider failed to exercise such
reasonable care, skill, and diligence as
other 
similarly 
situated 
health 
care
providers in the same general line of
practice ordinarily have and exercise in a
like case.'
1091425
56
"If a physician injects the fault of another health-
care provider not similarly situated to him, can
that physician avoid making combining and concurring
negligence an issue by pointing to the requirements
of § 6-5-548(a), requiring proof of the breach of
the standard of care by evidence from a similarly
situated health-care provider, and attacking the
evidence as lacking in this respect? We answer this
question in the negative.
"The [Medical Liability Act] was enacted to
protect the public from increased costs.  § 6-5-540.
The [Medical Liability Act] does so by imposing
strict standards on actions against health-care
providers. Clearly, it functions as a shield.  To
permit a health-care-provider defendant to inject
the alleged fault of another health-care provider
from a different specialty and then avoid any
instruction on combining and concurring negligence
by insisting upon the proof requirement of § 6-5-
548(a) would allow the defendant to use the statute
as a sword, not a shield.  We analogize this
circumstance to 'opening the door,' the situation
where allowing or offering inadmissible evidence
makes matters relevant that otherwise the factfinder
would not be able to consider. See Charles W.
Gamble, McElroy's Alabama Evidence, § 14.01 (5th ed.
1996).
"Because he presented evidence characterizing
Dr. Wenzel as at fault and injected an argument
about Dr. Wenzel's alleged mistake, notwithstanding
other testimony in which he disclaimed any attempt
to blame Dr. Wenzel, Dr. Green should be estopped to
insist on strict application of the § 6-5-548(a)
standard of proof as to Dr. Wenzel's conduct. Dr.
Green also argues that the requested instruction was
defective because it was not cast in terminology
consistent with the concept of medical malpractice
as described in the [Medical Liability Act], as
opposed to concepts of traditional negligence.
Having used terms such as 'fault' and 'mistake' to
1091425
57
describe Dr. Wenzel's conduct, however, Dr. Green
cannot 
now 
insist 
on 
the 
more 
sophisticated
terminology used in the [Medical Liability Act].
"If the trial court had charged the jury on
combining and concurring negligence, then the jury
would have been better equipped to deal with the
ignorance of Dr. Green that was caused by Dr.
Wenzel's negligence when combining with evidence of
negligence on the part of Dr. Green.  As previously
noted, Marsh also argues that the verdict is against
the great weight of the evidence because, she
argues, Dr. Green admitted that he gave medical
advice that caused her cancer to spread. While we
have declined to reverse the judgment for the trial
court's failure to grant a new trial as to this
issue, we refer to Marsh's contention at this
juncture to illustrate the existence of substantial
evidence in support of Marsh's claims against Dr.
Green. By failing to permit Marsh to argue and to
have a jury instruction on combining and concurring
negligence, the trial court allowed the jury to give
inappropriate weight to Dr. Green's defense based
upon his ignorance of the existence of cancer.
Because the trial court erred in refusing to give
the jury an instruction on combining and concurring
negligence, when such a charge was appropriate,
based on the testimony and argument of Dr. Green, we
must reverse and remand for a new trial."
782 So. 2d at 227-29.  The adoption of the substantial-
evidence rule in the 1996 Amendments to the AMLA changed an
evidentiary standard.  Combined and concurring negligence, in
contrast, is a doctrine of law applied to concurrent
tortfeasors.  Additionally, simply because this Court has not
addressed combined and concurring negligence in a medical-
1091425
58
malpractice case since it decided Marsh in 2000 does not mean
that the doctrine is no longer viable.
Conclusion
In conclusion, the trial court was charged with viewing
Julie's evidence in a light most favorable to her as the
nonmoving party, as well as drawing all reasonable inferences
from such evidence in her favor. Julie presented testimony by
a qualified expert with a proper evidentiary foundation that
Dr. Rich did not meet the standard of care in Anna's treatment
in several respects, including writing incorrect information
in the eye-exam book regarding Anna's need for follow-up
treatment.  She also presented substantial evidence indicating
that if Dr. Rich had not acted negligently, Anna probably
would have had a better outcome.  In fact, Dr. Saunders
testified that had Anna been timely examined and the resultant
proper treatment administered, she would have had an 80%
chance of salvaged vision.  Although persons other than Dr.
Rich may also have acted negligently, their negligence cannot
absolve Dr. Rich and Vision Partners of liability for Dr.
Rich's own breach of the standard of care.  Accordingly, the
1091425
59
summary judgment of the trial court is reversed and the cause
is remanded for proceedings consistent with this opinion.
REVERSED AND REMANDED.
Cobb, C.J., and Woodall, Murdock, and Main, JJ., concur.