Title: Johnson v. Armstrong

State: illinois

Issuer: Illinois Supreme Court

Document:

2022 IL 127942 
IN THE 
SUPREME COURT 
OF 
THE STATE OF ILLINOIS 
(Docket Nos. 127942, 127944 cons.) 
WILLIAM “WES” JOHNSON, Appellee, v. LUCAS ARMSTRONG et al., Appellants. 
Opinion filed June 24, 2022. 
JUSTICE GARMAN delivered the judgment of the court, with opinion. 
Chief Justice Anne M. Burke and Justices Theis, Neville, Michael J. Burke, 
Overstreet, and Carter concurred in the judgment and opinion. 
OPINION 
¶ 1 
Plaintiff suffers from severe and permanent nerve damage in his leg, which he 
alleges was caused by a negligently performed hip replacement surgery. He brought 
a claim of negligence against his surgeon expressed in two separate counts: one 
based on specific negligence and one based on the doctrine of res ipsa loquitur. He 
also brought a claim of negligence based on res ipsa loquitur against a surgical 
technician who participated in the surgery. Plaintiff provided only one expert 
witness, also a surgeon, to establish the elements of res ipsa loquitur. The McLean 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
County circuit court granted summary judgment to the surgical technician because 
(1) plaintiff had failed to present an expert witness to establish the standard of care 
for a surgical technician, (2) the control element of res ipsa loquitur was not met, 
and (3) there was no evidence of negligence on the surgical technician’s part. As a 
result, the surgical technician was completely dismissed from the case. The circuit 
court subsequently granted summary judgment in favor of the surgeon on the res 
ipsa loquitur count, leaving the count of specific negligence against the surgeon 
remaining in the circuit court. The appellate court reversed both judgments. 
¶ 2 
In this case, we review whether the elements of res ipsa loquitur have been met 
and whether any additional expert testimony was required for the doctrine to apply 
under these facts. Initially, however, we review a jurisdictional issue related to 
whether a Rule 304(a) interlocutory appeal of a count of negligence based on res 
ipsa loquitur is proper where there remains a pending count of specific negligence 
against the same defendant in the circuit court. Ill. S. Ct. R. 304(a) (eff. Mar. 8, 
2016). 
¶ 3 
BACKGROUND 
¶ 4 
Dr. Lucas Armstrong, with assistance from two surgical technicians, Sarah 
Harden and Pamela Rolf, performed a left, total hip arthroplasty, commonly known 
as a hip replacement, on plaintiff, William “Wes” Johnson. After the surgery, 
plaintiff suffered from femoral nerve palsy. Electromyography (EMG) readings 
demonstrated a severe left femoral neuropathy “specific to the branches to vastus 
lateralis and rectus femoris muscles.” 
¶ 5 
Plaintiff brought a professional medical negligence suit in four counts. Count I 
alleged specific negligence against Dr. Armstrong in that he (1) failed to identify, 
preserve, and protect plaintiff’s femoral nerve; (2) improperly retracted plaintiff’s 
femoral nerve or improperly directed the placement of the retractors; or (3) directly 
traumatized plaintiff’s femoral nerve. Count II alleged that McLean County 
Orthopedics, Ltd. (McLean County Orthopedics), was vicariously liable for this 
negligence as Dr. Armstrong’s employer under the doctrine of respondeat superior. 
¶ 6 
Count III alleged negligence against Dr. Armstrong, Harden, and Rolf based on 
the doctrine of res ipsa loquitur in that (1) the injury to his femoral nerve occurred 
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“while the retractors, scalpel, electrocautery device and other surgical instruments 
were under the control of ARMSTRONG, HARDEN and ROLF” and (2) that, in 
the ordinary course of events, plaintiff’s injury “would not have occurred if 
ARMSTRONG, HARDEN, and ROLF had used a reasonable standard of 
professional care while the retractors, scalpel, electrocautery device and other 
surgical instruments were under their control.” Count IV alleged that Advocate 
Health and Hospitals Corporation, doing business as Advocate BroMenn Medical 
Center (Advocate BroMenn), was vicariously liable for this negligence as the 
employer of Harden and Rolf under the doctrine of respondeat superior. 
¶ 7 
Dr. Armstrong, Harden, and Rolf were all deposed and generally testified to the 
following. 2021 IL App (4th) 210038, ¶¶ 12-21. Dr. Armstrong was the only one 
authorized to position and move any instrument in contact with plaintiff’s body, 
and Dr. Armstrong was the only one to have done so. As the “first scrub,” Rolf’s 
primary function was to hand surgical instruments and material to Dr. Armstrong. 
As the “second scrub,” Harden’s function was to do whatever Dr. Armstrong told 
her to do. That included holding certain instruments, such as a retractor, while the 
instrument was in contract with the plaintiff’s body. As she said, “I don’t use 
anything—I hold things,” and, “I hold what I’m told to hold—whatever the doctor 
tells me to do, I do.” Rolf also indicated that the second scrub might handle other 
instruments apart from a retractor, such as a Kocher clamp, and would be 
responsible for suction. In light of the above, Rolf was voluntarily dismissed 
without prejudice. 
¶ 8 
Plaintiff presented a single expert witness, Dr. Sonny Bal. Dr. Bal testified that 
he had performed hundreds of hip replacement surgeries using the same method 
that Dr. Armstrong had used. Dr. Bal testified that nerve palsies are a recognized 
complication of hip replacement surgery and that the fact of a femoral nerve injury 
does not indicate, per se, a breach in the standard of care. Dr. Bal specifically 
testified, however, that this plaintiff’s injury is of a type that does not normally 
occur in the absence of negligence. Dr. Bal believed that the injury was most likely 
caused by the improper use of a retractor. Despite this belief, he testified that, 
according to the surgical records, Dr. Armstrong did not deviate from the standard 
of care in making the incision and management of the retractor. Dr. Bal did not 
purport to offer any standard of care for Harden. He did, however, testify that, from 
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all the surgical records, it appeared that Harden did only as instructed by Dr. 
Armstrong throughout the procedure. 
¶ 9 
Harden and Advocate BroMenn moved for summary judgment on the res ipsa 
loquitur and respondeat superior counts. The circuit court granted the motion at a 
hearing on October 30, 2020, on the grounds that (1) no qualified expert had 
established the standard of care for Harden, (2) there was no evidence of negligence 
on the part of Harden, and (3) Harden did not control the retractor for purposes of 
res ipsa loquitur. After the court orally rendered this judgment, defense counsel 
requested permission to submit a written order to reflect the court’s ruling. The 
court agreed. The record sheet reflects the following: “Defendant Advocate and 
Harden’s Motion for Summary Judgment argued and granted. Request for Rule 
304(a) finding granted. [Defense counsel] to submit written order.” 
¶ 10 
On December 15, 2020, the circuit court granted Dr. Armstrong’s oral motion 
for summary judgment on the res ipsa loquitur count. No record of this proceeding 
appears in the record. The record sheet reflects the following: 
“Defendant Armstrong’s oral Motion for Summary Judgment as to Count III 
(res ipsa loquitur) granted over objection. Pursuant to Supreme Court Rule 
304(a), the court finds there is no just reason for delaying appeal as to the res 
ipsa loquitur counts. Remaining counts of negligence against Defendant 
Armstrong and McLean County Orthopedics stayed, pending appeal of the res 
ipsa loquitur and discovery issues. Counsel to submit written orders.” 
¶ 11 
On December 22, 2020, the circuit court filed a written order entering summary 
judgment in Dr. Armstrong’s favor and found no just reason for delaying 
enforcement or appeal of that order pursuant to Rule 304(a). The court stayed any 
pending litigation on the remaining counts against Armstrong and McLean County 
Orthopedics (counts I and II) “pending resolution of the issues going up on appeal.” 
The record sheet reflects: “Order re: Defendant Armstrong[’s] Motion for Summary 
Judgment entered. See Order.” 
¶ 12 
On January 5, 2021, the circuit court filed a written order granting summary 
judgment in favor of Harden and Advocate BroMenn finding no just reason for 
delaying the appeal of its order pursuant to Rule 304(a). The record sheet reflects: 
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“Order re: Advocate and Harden’s Motion for Summary Judgment entered. See 
Order.” 
¶ 13 
Plaintiff filed a notice of appeal on January 6, 2021, pursuant to Rule 304(a), 
seeking to appeal both the December 22, 2020, order and the January 5, 2021, order 
entering summary judgment for defendants on the res ipsa loquitur counts. 
¶ 14 
The appellate court reversed, holding that res ipsa loquitur applied against both 
Dr. Armstrong and Harden. In doing so, the court held that Harden had control over 
the retractor. The court further held that no additional expert testimony was needed 
to establish Harden’s standard of care, saying: “In essence, the control element of 
the res ipsa doctrine is sufficient to establish a duty of care.” (Emphasis in original.) 
2021 IL App (4th) 210038, ¶ 68. In so holding, the court declined to follow its own 
decision in Taylor v. City of Beardstown, 142 Ill. App. 3d 584 (1986). 2021 IL App 
(4th) 210038, ¶ 69. 
¶ 15 
Harden, Advocate BroMenn, and Dr. Armstrong appealed to this court pursuant 
to Rule 315 in two separate cases raising distinct yet related issues. Those petitions 
were allowed and consolidated by this court. Ill. S. Ct. R. 315 (eff. Oct. 1, 2021). 
We also allowed the Illinois Trial Lawyers Association to file an amicus curiae 
brief. Ill. S. Ct. R. 345 (eff. Sept. 20, 2010). 
¶ 16 
ANALYSIS 
¶ 17 
Jurisdiction 
¶ 18 
Before proceeding to the merits, this court has an independent duty to ensure 
that jurisdiction is proper, regardless of whether the parties have raised any 
jurisdictional challenge. Vasquez Gonzalez v. Union Health Service, Inc., 2018 IL 
123025, ¶ 8 (citing Clemons v. Mechanical Devices Co., 202 Ill. 2d 344, 349 
(2002)). 
¶ 19 
Article VI, section 6, of the Illinois Constitution of 1970 confers upon the 
appellate court jurisdiction to hear appeals from final judgments entered in the 
circuit court. Ill. Const. 1970, art. VI, § 6. It also grants this court the power to 
“provide by rule for appeals to the Appellate Court from other than final judgments 
of Circuit Courts.” Id. “ ‘Accordingly, absent a supreme court rule, the appellate 
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court is without jurisdiction to review judgments, orders, or decrees that are not 
final.’ ” Armstead v. National Freight, Inc., 2021 IL 126730, ¶ 20 (quoting 
Blumenthal v. Brewer, 2016 IL 118781, ¶ 22). 
¶ 20 
Here, both orders for summary judgment were brought to the appellate court 
pursuant to Illinois Supreme Court Rule 304(a) (eff. Mar. 8, 2016). Rule 304(a) 
provides that “an appeal may be taken from a final judgment as to one or more but 
fewer than all of the parties or claims only if the trial court has made an express 
written finding that there is no just reason for delaying either enforcement or appeal 
or both.” Id. “By its terms, Rule 304(a) applies only to final judgments or orders.” 
Blumenthal, 2016 IL 118781, ¶ 24. “The special finding contemplated by the rule 
will make a final order appealable, but it can have no effect on a nonfinal order.” 
Id. “If the order is in fact not final, inclusion of the special finding in the trial court’s 
order cannot confer appellate jurisdiction.” Id. Both orders included the Rule 304(a) 
finding language; thus, the question becomes whether each order constitutes a final 
judgment. 
¶ 21 
“[T]o be considered final and appealable for purposes of Rule 304(a), a 
judgment or order must terminate the litigation between the parties on the merits of 
the cause, so that, if affirmed, the trial court only has to proceed with execution of 
the judgment.” Id. ¶ 25. Although the order need not dispose of all claims presented 
by the pleadings, “it must be final in the sense that it disposes of the rights of the 
parties, either upon the entire controversy or upon some definite and separate part 
thereof.” Id. “Where an order disposes only of certain issues relating to the same 
basic claim, such a ruling is not subject to review under Rule 304(a).” Armstead, 
2021 IL 126730, ¶ 24 (citing In re Marriage of Leopando, 96 Ill. 2d 114, 119-20 
(1983)). 
¶ 22 
In Armstead, we reiterated the distinction between orders that dispose of 
separate, unrelated claims—which are appealable pursuant to Rule 304(a)—and 
orders that dispose only of separate issues relating to the same claim—which are 
not. Id. ¶ 25. In that case, we determined that the order appealed from disposed only 
of an issue: whether plaintiff was precluded from asserting certain injuries as part 
of his negligence case. Because that order only resolved one issue related to the 
surviving negligence claim, that order was not appealable under Rule 304(a). Id. 
¶¶ 27-29. 
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¶ 23 
Here, the order granting summary judgment to Harden and Advocate BroMenn 
is final as to them because it terminates the litigation as to them. The order granting 
summary judgment to Dr. Armstrong, however, is not a final judgment because res 
ipsa loquitur is not a claim in and of itself; rather, it is an evidentiary doctrine that 
allows a plaintiff to prove negligence under a unique set of proofs. Heastie v. 
Roberts, 226 Ill. 2d 515, 531 (2007); Imig v. Beck, 115 Ill. 2d 18, 26-27 (1986). 
Although plaintiff expressed his negligence claim against Dr. Armstrong in two 
counts, these are but alternative theories for proving Dr. Armstrong’s liability for 
negligence. The fact that plaintiffs in Illinois are required to specifically plead res 
ipsa loquitur does not itself transform this evidentiary doctrine into a stand-alone 
claim. Our appellate court has dismissed appeals on these very grounds. Russell v. 
Good Shepherd Hospital, 222 Ill. App. 3d 140, 144-45 (1991) (“where a party states 
one claim alternatively in several counts, the dismissal of fewer than all such counts 
is not a final judgment as to fewer than all of the party’s claims as required by 
Supreme Court Rule 304(a)” (emphasis in original), and res ipsa loquitur is “ ‘a 
rule of evidence and not a separate theory of recovery’ ” (quoting Prado, 72 Ill. 
App. 3d at 625)). 
¶ 24 
Thus, the operative effect of the summary judgment in favor of Dr. Armstrong 
is to preclude plaintiff from proving that Dr. Armstrong was negligent under the 
unique proofs of res ipsa loquitur, but plaintiff’s claim for negligence against Dr. 
Armstrong remains outstanding. Consequently, the order granting summary 
judgment to Dr. Armstrong was not a final judgment, and the appellate court lacked 
jurisdiction under Rule 304(a) to review that order. The appeal of that order is 
dismissed, and those portions of the appellate opinion addressing that order are 
vacated. 
¶ 25 
Effect of Dismissal of Dr. Armstrong 
¶ 26 
We observe that the dismissal of Dr. Armstrong leaves this case in a curious 
position. Although summary judgment in favor of Harden was orally pronounced 
in October 2020, the order granting that summary judgment was filed, and therefore 
became final, in January 2021. See Ill. S. Ct. R. 272 (eff. Jan. 1, 2018) (“If at the 
time of announcing final judgment the judge requires the submission of a form of 
written judgment to be signed by the judge ***, the clerk shall make a notation to 
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that effect and the judgment becomes final only when the signed judgment is 
filed.”); Williams v. BNSF Ry. Co., 2015 IL 117444, ¶ 37 (explaining the conditions 
under which a circuit court’s oral ruling may constitute an entry of judgment). 
However, Dr. Armstrong was dismissed from the res ipsa loquitur count in 
December 2020. 
¶ 27 
What we are left with, then, is a negligence claim based on res ipsa loquitur 
against Harden alone. The question arises, can the unique proofs of res ipsa 
loquitur, which generally require exclusive control on the part of those against 
whom the proofs are being applied, be applied solely to Harden in a situation such 
as this where she was exercising joint control? Drewick v. Interstate Terminals, 
Inc., 42 Ill. 2d 345, 348 (1969) (“The purpose of [the control element] is, of course, 
to limit the application of the doctrine to those cases where the negligence, if any, 
must reasonably have been that of the defendant.”); Prosser and Keeton on the Law 
of Torts § 39, at 248 (W. Page Keeton et al. eds., 5th ed. 1984) (“The injury must 
either be traced to a specific instrumentality or cause for which the defendant was 
responsible, or it must be shown that the plaintiff was responsible for all reasonably 
probable causes to which the accident could be attributed.”); Restatement (Second) 
of Torts § 328D cmt. g (1965) (by establishing exclusive control by defendant, “the 
responsibility of the defendant is proved by eliminating that of any other person”). 
Plaintiff himself essentially argued in the circuit and appellate courts that res ipsa 
loquitur could only be applied here if both Harden and Dr. Armstrong were 
included within its proofs. Consequently, the point in time at which we analyze the 
summary judgment in favor of Harden—whether as the case stood in October 2020 
or January 2021—will affect the outcome. 
¶ 28 
After due consideration, we believe that the use of our supervisory authority is 
warranted in this case to review summary judgment as the case stood in October 
2020. “Our supervisory authority extends to ‘the adjudication and application of 
law and the procedural administration of the courts.’ ” City of Urbana v. Andrew 
N.B., 211 Ill. 2d 456, 470 (2004) (quoting Kunkel v. Walton, 179 Ill. 2d 519, 528 
(1997)). “Even when a circuit court’s ruling does not satisfy the normal finality 
requirements, this court may elect to exercise its supervisory authority to 
intercede.” Vasquez Gonzalez, 2018 IL 123025, ¶ 16 (citing People v. Heddins, 66 
Ill. 2d 404, 406-07 (1977) (dismissing the appeal but entering a supervisory order 
to direct the circuit court to vacate a clearly erroneous interlocutory order)). 
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¶ 29 
Per the normal appellate process, we would review whether summary judgment 
in favor of Harden was proper at a time when Dr. Armstrong had been dismissed 
from the res ipsa loquitur proofs. In doing so, we would have to determine whether 
res ipsa loquitur can be applied to Harden in the absence of Dr. Armstrong. This is 
an issue that has not been raised, briefed, or argued before this court, and although 
plaintiff raised arguments related to this issue below, neither of the courts below 
appear to have squarely addressed this question. Were we to find that res ipsa 
loquitur could not be applied to Harden without including Dr. Armstrong, plaintiff 
would be precluded from obtaining meaningful relief. Furthermore, the only reason 
this conundrum is presented is because the written order for summary judgment in 
favor of Harden was delayed for months after its oral pronouncement, while the 
written order in Dr. Armstrong’s favor was filed days after its oral pronouncement. 
Accordingly, in the exercise of our supervisory authority we will review the 
summary judgment in favor of Harden as of the date it was pronounced. 
¶ 30 
Summary Judgment 
¶ 31 
We now turn to the order granting summary judgment to Harden and Advocate 
BroMenn. Summary judgment is appropriate when “the pleadings, depositions, and 
admissions on file, together with the affidavits, if any, show that there is no genuine 
issue as to any material fact and that the moving party is entitled to a judgment as 
a matter of law.” 735 ILCS 5/2-1005(c) (West 2018). “A genuine issue of material 
fact precluding summary judgment exists where the material facts are disputed, or, 
if the material facts are undisputed, reasonable persons might draw different 
inferences from the undisputed facts.” (Internal quotation marks omitted.) Monson 
v. City of Danville, 2018 IL 122486, ¶ 12. When examining whether a genuine issue 
of material fact exists, a court construes the evidence in the light most favorable to 
the nonmoving party and strictly against the moving party. Beaman v. Freesmeyer, 
2019 IL 122654, ¶ 22. Summary judgment is a drastic means of disposing of 
litigation and “should be allowed only when the right of the moving party is clear 
and free from doubt.” (Internal quotation marks omitted.) Id. A circuit court’s entry 
of summary judgment is reviewed de novo. Id. 
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¶ 32 
Res Ipsa Loquitur 
¶ 33 
We described the nature and purpose of res ipsa loquitur, “the thing speaks for 
itself,” in Metz v. Central Illinois Electric & Gas Co., 32 Ill. 2d 446, 448-49 (1965): 
“When a thing which caused the injury is shown to be under the control or 
management of the party charged with negligence and the occurrence is such as 
in the ordinary course of things would not have happened if the person so 
charged had used proper care, the accident itself affords reasonable evidence, 
in the absence of an explanation by the party charged, that it arose from want 
of proper care. [Citations.] This in essence is the doctrine of res ipsa loquitur, 
and its purpose is to allow proof of negligence by circumstantial evidence when 
the direct evidence concerning cause of injury is primarily within the 
knowledge and control of the defendant.” 
¶ 34 
If res ipsa loquitur applies, the factfinder is permitted to infer negligence from 
a set of facts that “speaks for itself.” Imig, 115 Ill. 2d at 26-27. The defendant may 
then offer evidence tending to disprove negligence, but the inference of negligence 
does not simply vanish or disappear when contrary evidence appears. Id. at 26-28. 
Rather, the inference arising from res ipsa loquitur, along with the evidence 
provided by the defendant, is weighed by the factfinder. Id. at 27. “The inference 
may be strong, requiring substantial proof to overcome it, or it may be weak, 
requiring little or no evidence to refute it.” Id. In the end, the trier of fact is free to 
accept or reject the inference. 
¶ 35 
For res ipsa loquitur to apply, the plaintiff must plead and prove that he was 
injured (1) in an occurrence that ordinarily does not happen in the absence of 
negligence (the probability element) (2) by an agency or instrumentality within the 
defendant’s exclusive control (the control element). Heastie, 226 Ill. 2d at 531-32; 
Gatlin v. Ruder, 137 Ill. 2d 284, 296-97 (1990). Whether res ipsa loquitur applies 
is a question of law to be decided in the first instance by the trial court. Imig, 115 
Ill. 2d at 27; 735 ILCS 5/2-1113 (West 2020). “In making that determination, the 
court shall rely upon either the common knowledge of laymen, if it determines that 
to be adequate, or upon expert medical testimony, that the medical result 
complained of would not have ordinarily occurred in the absence of negligence on 
the part of the defendant.” 735 ILCS 5/2-1113 (West 2020). “Proof of an unusual, 
unexpected or untoward medical result which ordinarily does not occur in the 
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absence of negligence will suffice in the application of the doctrine.” Id. 
¶ 36 
Res Ipsa Loquitur—Probability 
¶ 37 
We first examine whether plaintiff has presented sufficient evidence to survive 
a motion for summary judgment on the first element: that the severe and permanent 
nerve damage suffered here is an injury that ordinarily does not happen in the 
absence of negligence. 
¶ 38 
Given that severe femoral neuropathy specific to the branches of vastus lateralis 
and rectus femoris muscles, presenting after a total hip arthroplasty, is of a type that 
is outside the common knowledge of laymen, expert testimony was required to 
determine whether such an injury would ordinarily occur absent negligence. 
Unequivocal testimony to this effect will directly establish plaintiff’s initial burden 
on the probability component of res ipsa loquitur, although it will not constitute 
proof that the injury would never happen without negligence. Spidle v. Steward, 79 
Ill. 2d 1, 8-9 (1980) (directed verdict against res ipsa loquitur counts improper 
where expert gave equivocal testimony in response to question on probability 
because that testimony, when considered with the entire record, established the 
probability element). 
¶ 39 
Here, plaintiff presented sufficient evidence to satisfy the probability element. 
Plaintiff presented Dr. Bal, a retired orthopedic surgeon, who testified that he had 
performed between 100 and 200 total hip arthroplasty procedures per year on 
average. Dr. Bal confirmed that he most commonly used the anterior approach, 
which was the same approach used by Dr. Armstrong here. Dr. Bal testified that, 
as a general proposition, nerve palsies are a recognized complication of hip 
replacement surgery. He also testified that the mere fact of a nerve injury does not 
establish a breach in the standard of care. In fact, Dr. Bal had two patients, in the 
entirety of his career, who developed femoral nerve palsies after a hip replacement 
surgery. One was caused by bleeding, which put pressure on the nerve, and the 
other had an unknown cause. He agreed that the cause of femoral nerve palsies is 
often unknown. However, he specifically distinguished between different forms of 
femoral nerve neuropathies: 
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“There are two distinct types of femoral nerve neuropathies, and I want to 
make sure we’re clear on the distinction. 
Transient femoral neuropathy injury, neuropraxia palsy, as referred to in 
this paper *** occurs in the absence of negligence. It is transient; it has a good 
prognosis; strength returns, and the patient goes on with a temporary time 
period during which there is a deficit that improves rapidly, and those are what 
I’ve encountered in my practice. That palsy can occur and does occur in the 
absence of negligence from a variety of factors. 
My testimony here is a complete injury to the femoral nerve, as occurred 
here, verified by repeat EMG and subsequent treatment by a nerve specialist 
like Dr. Tung, does not occur absent negligence.” 
¶ 40 
Dr. Bal supported this unequivocal testimony with repeated reference to his 
experience, his review of the literature, and the postoperative EMG readings. From 
all this, plaintiff established that nerve damage like the kind he suffered does not 
ordinarily occur after a hip replacement surgery absent negligence. Consequently, 
the first element of res ipsa loquitur was satisfied for purposes of summary 
judgment. 
¶ 41 
Res Ipsa Loquitur—Control 
¶ 42 
The second element of res ipsa loquitur is that the plaintiff was injured by an 
agency or instrumentality within the defendant’s exclusive control. As we said in 
Heastie, “some authorities speak of ‘management and control’ rather than 
‘exclusive control,’ but the terms have come to be viewed as interchangeable.” 
Heastie, 226 Ill. 2d at 532. Regardless, “the requisite control is not a rigid standard, 
but a flexible one in which the key question is whether the probable cause of the 
plaintiff’s injury was one which the defendant was under a duty to the plaintiff to 
anticipate or guard against.” Id. Indeed, the word “control” may itself be 
misleading, as the fact of a defendant’s literal control over the occurrence may be 
nonexistent, yet the defendant may nevertheless be responsible for the occurrence. 
Restatement (Second) of Torts § 328D cmt. g (1965) (“The essential question 
becomes one of whether the probable cause is one which the defendant was under 
a duty to the plaintiff to anticipate or guard against.”); Prosser and Keeton on the 
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Law of Torts § 39, at 250-51 (W. Page Keeton et al. eds., 5th ed. 1984) (suggesting 
that it “would be far better, and much confusion would be avoided, if the rigid 
‘control’ test were discarded altogether, and we were to require instead that the 
apparent negligent cause of the accident be such that the defendant would more 
likely than not be responsible for it”). 
¶ 43 
Generally speaking, the plaintiff must identify the instrumentality of his injury, 
as well as everyone who was in control of that instrumentality. However, 
“while reliance on the res ipsa doctrine may normally require that the injury 
can be traced to a specific cause for which the defendant is responsible, Illinois 
law also authorizes use of the doctrine where it can be shown that the defendant 
was responsible for all reasonable causes to which the accident could be 
attributed.” Heastie, 226 Ill. 2d at 538 (citing Napoli v. Hinsdale Hospital, 213 
Ill. App. 3d 382, 388 (1991), and Prosser and Keeton on the Law of Torts § 39, 
at 248 (W. Page Keeton et al. eds., 5th ed. 1984)). 
“Similarly, Illinois law does not require a plaintiff to show the actual force which 
initiated the motion or set the instrumentality in operation in order to rely on the 
res ipsa doctrine.” Id. at 539. “To the contrary, if the specific and actual force which 
initiated the motion or set the instrumentality in operation were known 
unequivocally, leaving no reason for inference that some other unknown negligent 
act or force was responsible, the res ipsa doctrine could not even be invoked.” Id. 
¶ 44 
As for identifying the defendant or defendants, “plaintiff is not required to show 
that his injuries were more likely caused by any particular one of the defendants in 
order to proceed with his res ipsa claim, nor must he eliminate all causes of his 
injuries other than the negligence of one or more of the defendants.” Id. at 534 
(citing Collins v. Superior Air-Ground Ambulance Service, Inc., 338 Ill. App. 3d 
812, 822-23 (2003)). However, in a multiple-defendant situation, the plaintiff must 
ensure that all defendants who could have been at fault are included. See Smith v. 
Eli Lilly & Co., 137 Ill. 2d 222, 257 (1990) (“In res ipsa loquitur and alternative 
liability situations, all parties who could have been the cause of the plaintiff’s 
injuries are joined as defendants.”). 
¶ 45 
Here, plaintiff was committed to the care of, and subjected to surgery by, Dr. 
Armstrong and Harden. Consequently, plaintiff is not required to identify the 
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precise instrumentality that caused his nerve damage—the fact that he was under 
defendants’ care during surgery sufficiently establishes, for purposes of res ipsa 
loquitur, that whatever caused plaintiff’s nerve damage during the surgery was 
under defendants’ control. Kolakowski v. Voris, 83 Ill. 2d 388, 396 (1980) (“a 
plaintiff’s only recourse is to rely on the doctrine of res ipsa loquitur” where he is 
placed in the care and custody of defendants during surgery); id. (“ ‘The control, at 
one time or another, of one or more of the various agencies or instrumentalities 
which might have harmed the plaintiff was in the hands of every defendant or of 
his employees or temporary servants. This, we think, places upon them the burden 
of initial explanation.’ ” (quoting Ybarra v. Spangard, 154 P.2d 687, 689-90 (Cal. 
1944))). Likewise, plaintiff is not required under these circumstances to identify 
precisely who caused his nerve damage. What plaintiff must establish here is that 
all parties who were responsible for all reasonable causes of plaintiff’s nerve 
damage are identified. Plaintiff has done so, and consequently, the control element 
is met. 
¶ 46 
Harden (joined in her arguments by Advocate BroMenn) argues that the control 
element has not been met as to her. She specifically identifies the instrumentality 
of injury in this case to be the retractor, and she argues that she did not control the 
retractor because her only function was to hold it in place. She points to Dr. Bal, 
who confirmed that Dr. Armstrong was the only one authorized to place or move 
the retractor during surgery and that the surgical technician’s only retractor-related 
job is to hold it in place. 
¶ 47 
There are two problems with this argument. First, this argument is predicated 
upon the mistaken belief that plaintiff must identify the instrumentality of his injury 
in order to raise res ipsa loquitur. As we have already explained, while this is 
generally true, it is not true where, as here, plaintiff can show that defendants were 
responsible for all reasonable causes to which the injury could be attributed. It also 
rests on the mistaken belief that plaintiff has expressly identified the retractor as the 
instrumentality of his injury. On the contrary, plaintiff’s argument, supported by 
the evidence, is that he underwent surgery and suffered a severe and permanent 
injury. The instrumentality of his injury remains unknown and unidentified in his 
res ipsa loquitur count. In that count, plaintiff alleged that his injuries occurred 
“while the retractors, scalpel, electrocautery device and other surgical instruments 
were under the control of ARMSTRONG, HARDEN, and ROLF.” Indeed, there is 
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evidence supporting the allegation that other instruments, apart from the retractor, 
were handled by Harden during the procedure. 
¶ 48 
The second problem with this argument is more basic. The control element is a 
“flexible one in which the key question is whether the probable cause of the 
plaintiff’s injury was one which the defendant was under a duty to the plaintiff to 
anticipate or guard against.” Heastie, 226 Ill. 2d at 532. Assuming that the retractor 
was, in fact, the instrumentality of the injury, Harden was literally holding it while 
it was inside plaintiff’s body. Control, whether joint or individual, by Harden over 
the retractor could not be any clearer. It is of no consequence that Harden had no 
independent authority to place or move the retractor because she had independent 
capability of doing so. If she did move or mismanage the retractor while she was 
only supposed to be holding it still, then she would or could have been the negligent 
party at fault. 
¶ 49 
Standard of Care 
¶ 50 
Harden argues that, because plaintiff here did not present competent testimony 
as to the standard of care for a surgical technician, summary judgment in her favor 
was proper. Harden relies on Taylor, 142 Ill. App. 3d 584, for the proposition that 
a standard of care is required in addition to, or in order to satisfy, the elements of 
res ipsa loquitur in a medical professional negligence case; and she relies on 
Sullivan v. Edward Hospital, 209 Ill. 2d 100 (2004), for the proposition that a 
surgeon is not competent to testify as to the standard of care for a surgical 
technician. Plaintiff takes the opposite position. 
¶ 51 
A brief comparison of negligence and res ipsa loquitur principles is warranted. 
“The elements of a negligence cause of action are a duty owed by the defendant to 
the plaintiff, a breach of that duty, and an injury proximately caused by the breach.” 
Jones v. Chicago HMO Ltd. of Illinois, 191 Ill. 2d 278, 294 (2000) (citing Cunis v. 
Brennan, 56 Ill. 2d 372, 374 (1974)). “The standard of care, also known as the 
standard of conduct, falls within the duty element.” Id.; Prosser and Keeton on the 
Law of Torts § 30, at 164 (W. Page Keeton et al. eds., 5th ed. 1984) (describing the 
duty element as: “A duty, or obligation, recognized by the law, requiring the person 
to conform to a certain standard of conduct, for the protection of others against 
- 15 ­
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
unreasonable risks.”). Thus, in every cause of action for negligence, the plaintiff 
must establish that a duty exists and must also identify what the duty is. 
¶ 52 
The standard of care in a medical professional negligence case is to act as would 
an “ ‘ “ordinarily careful professional.” ’ ” Jones, 191 Ill. 2d at 295 (quoting 
Advincula v. United Blood Services, 176 Ill. 2d 1, 23 (1996), quoting Cunis, 56 Ill. 
2d at 376). We have consistently held that the burden of establishing the standard 
of care—that is, what an ordinarily careful professional would do—in a medical 
professional negligence case is on the plaintiff. Sullivan, 209 Ill. 2d at 112 (citing 
Purtill v. Hess, 111 Ill. 2d 229, 241-42 (1986)). Generally speaking, expert 
testimony is required to establish what an ordinarily careful professional would do 
in a given situation “because jurors are not skilled in the practice of medicine and 
would find it difficult without the help of medical evidence to determine any lack 
of necessary scientific skill on the part of the physician.” Walski v. Tiesenga, 72 Ill. 
2d 249, 256 (1978). However, where defendant’s conduct is so grossly negligent or 
the treatment so common that a layman could readily appraise it, no expert 
testimony is necessary. Id. 
¶ 53 
Once the standard of care is established in a negligence cause of action, the 
plaintiff “must then prove that, judged in the light of these standards, the doctor 
was unskillful or negligent and that his want of skill or care caused the injury to the 
plaintiff.” Id. Again, expert testimony is generally required to establish that the 
defendant physician deviated from the standard of care unless the common 
understanding exception applies. Jones, 191 Ill. 2d at 295. In other words, the 
plaintiff must show, usually with expert testimony, a breach of the defendant’s duty. 
Finally, the plaintiff must prove that he was injured and that the injury was 
proximately caused by the defendant’s breach of duty. 
¶ 54 
At this point, it is important to note that the word “negligence” is often used 
interchangeably throughout the law to mean either (1) the cause of action/theory of 
liability comprising all of the elements above or (2) the breach of a duty. E.g., Jahn 
v. Troy Fire Protection District, 163 Ill. 2d 275, 280 (1994) (“Negligence is defined 
as the failure to use such care as a reasonably prudent and careful person would use 
under similar circumstances. Black’s Law Dictionary 1032 (6th ed. 1990).”); 
Restatement (Second) of Torts § 282 (1965) (“negligence is conduct which falls 
below the standard established by law for the protection of others against 
- 16 -
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
unreasonable risk of harm”); Restatement (Second) of Torts § 282 cmt. b (1965) 
(“negligent conduct subjects the actor to liability only if the [elements of a 
negligence cause of action] exist”). 
¶ 55 
Res ipsa loquitur (“the thing speaks for itself”), on the other hand, is not an 
alternate theory of liability in Illinois—the theory of liability remains “negligence” 
in the first sense of the word—rather, it is a species of circumstantial evidence that 
allows the trier of fact to draw an inference of “negligence” in the second sense of 
the word. Heastie, 226 Ill. 2d at 542; Imig, 115 Ill. 2d at 25-26. This is evident 
because the two elements of res ipsa loquitur (probability and control) are not 
sufficient in and of themselves to prove a negligence cause of action. For instance, 
the existence of a duty must be proved apart from the two elements of res ipsa 
loquitur. Spidle, 79 Ill. 2d at 7 (res ipsa loquitur “will not apply unless a duty of 
care is owed by the defendant to the plaintiff”). Likewise, the causation element 
must still be proven apart from the res ipsa loquitur elements. Edgar County Bank 
& Trust Co. v. Paris Hospital, Inc., 57 Ill. 2d 298, 304 (1974), overruled on other 
grounds by Gilbert v. Sycamore Municipal Hospital, 156 Ill. 2d 511 (1993). We 
have explained that “the application of the doctrine of res ipsa loquitur does not 
affect the necessity or manner of proof of proximate cause and that it is relevant 
only to the nature of the proof from which the trier of fact may draw an inference 
of negligence.” Id. 
¶ 56 
Thus, by saying that res ipsa loquitur “is relevant only to the nature of the proof 
from which the trier of fact may draw an inference of negligence,” we mean that 
the application of res ipsa loquitur relates to the nature of proof required to show a 
breach of duty. Restatement (Second) of Torts § 328D (1965) (under res ipsa 
loquitur, “[i]t may be inferred that harm suffered by the plaintiff is caused by 
negligence,” where negligence is defined in section 282 (id. § 282) as “conduct 
which falls below the standard established by law for the protection of others 
against unreasonable risk of harm”). The issue in this case may therefore be 
reframed as whether the standard of care portion of the duty element of negligence 
has been satisfied where the two elements of res ipsa loquitur have been satisfied. 
¶ 57 
The reason that the standard of care is necessary in a regular professional 
negligence cause of action is because there must be a standard by which to judge 
the performance of the defendant physician. Purtill, 111 Ill. 2d at 241-42; Walski, 
- 17 -
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
72 Ill. 2d at 255-56. Without a standard of care by which to judge the physician, 
there would be no way to determine whether any deviation or breach has occurred. 
Thus, in cases of specific negligence, where the plaintiff has alleged some specific 
course of conduct on the part of the defendant that breached the defendant’s duty, 
it must be shown what each defendant’s standard of care was in relation to that 
course of conduct. 
¶ 58 
In this case, however, the precise course of individual conduct that led to 
plaintiff’s injury is unknown. All plaintiff knows is that he was injured while under 
the care of multiple defendants. Plaintiff cannot establish an individual standard of 
care for either Dr. Armstrong or Harden that is independent of the injury itself 
because he does not know what individual standard Dr. Armstrong or Harden has 
deviated from. But by establishing that his injury is one that ordinarily does not 
occur absent negligence and that all of the instrumentalities that could have caused 
the injury were in the control of the defendant, plaintiff has provided the legally 
applicable standard of care from which negligence may be found: that under normal 
circumstances, a hip replacement does not result in severe and permanent nerve 
damage. Consequently, no additional testimony related to Harden’s standard of care 
was necessary here. We need not go further to determine which of the two res ipsa 
loquitur elements, taken alone, might satisfy the standard of care requirement 
because both elements are satisfied here. 
¶ 59 
In coming to this conclusion, we agree with the appellate court’s decision not 
to follow Taylor, 142 Ill. App. 3d 584. 2021 IL App (4th) 210038, ¶ 69. Although 
we agree with the judgment of Taylor, we do not approve of its reasoning. We also 
agree with the appellate court here that Taylor is an outlier in its explicit 
pronouncement regarding the requirement of establishing a standard of care. Id. 
Given this, we believe discussion of defendant’s argument based on Sullivan to be 
unnecessary. 
¶ 60 
Other Arguments 
¶ 61 
Harden makes two final arguments. First, she argues that, because plaintiff has 
suggested and/or provided evidence that the instrumentality of the injury was the 
retractor, plaintiff is barred from relying on res ipsa loquitur. She relies on the 
principle that, “if the specific and actual force which initiated the motion or set the 
- 18 ­
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
instrumentality in operation were known unequivocally, leaving no reason for 
inference that some other unknown negligent act or force was responsible, the res 
ipsa doctrine could not even be invoked.” Heastie, 226 Ill. 2d at 539. 
¶ 62 
As we explained in Kolakowski, 83 Ill. 2d at 397, this “would be accurate if the 
evidence introduced by plaintiff conclusively established the exact cause of his 
injuries.” But where plaintiff’s expert merely opines upon some cause of the injury, 
rather than conclusively establishes it, the opinion is “ ‘opinion only.’ ” Id. (quoting 
Clifford-Jacobs Forging Co. v. Industrial Comm’n, 19 Ill. 2d 236, 243 (1960)). We 
reaffirmed this principle from Kolakowski in Gatlin, 137 Ill. 2d at 298-99. Here, 
Dr. Bal’s testimony did not conclusively establish that the retractor caused 
plaintiff’s nerve damage. Rather, it was his “opinion only” as to what caused the 
nerve damage. Therefore, plaintiff is not barred from raising res ipsa loquitur 
merely because his expert has an opinion on the most likely cause of his injury. 
¶ 63 
Lastly, Harden argues that there is no evidence in this case that she deviated 
from any standard of care in any way. The evidence to which she refers is the 
testimony of each defendant, the defendants’ surgical records, and the testimony of 
Dr. Bal, all of which attest to the fact that Harden acted appropriately. Of course, 
the most important bit of evidence in a res ipsa loquitur case is the injury or 
occurrence itself. The fact of plaintiff’s severe and permanent nerve damage is itself 
evidence of negligence given that the elements of res ipsa loquitur are satisfied. 
The situation wherein there is no other evidence of negligence, apart from the 
injury, is precisely the type of situation for which res ipsa loquitur is designed. 
¶ 64 
CONCLUSION 
¶ 65 
The appellate court lacked jurisdiction under Rule 304(a) to hear the appeal 
from the December 22, 2020, order granting summary judgment to Dr. Armstrong 
because that order disposed of an issue rather than a claim. The appeal from that 
interlocutory order is therefore dismissed, and those portions of the appellate 
opinion addressing that order are vacated. 
¶ 66 
We exercise our supervisory authority to review the summary judgment in favor 
of Harden and Advocate BroMenn as it was pronounced in October 2020 and 
conclude that it was granted in error because the elements of res ipsa loquitur were 
- 19 ­
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
met at that time, and because no further expert testimony on the standard of care 
was required. We therefore affirm the appellate court’s judgment reversing the 
circuit court’s January 6, 2021, order, and we remand the case to the circuit court. 
Given that the summary judgment in favor of Dr. Armstrong was pronounced after 
Harden had been orally dismissed from the res ipsa loquitur count, we also direct 
the circuit court to reconsider the December 22, 2020, order granting summary 
judgment in light of this opinion. 
¶ 67 
No. 127944, Appeal dismissed. 
¶ 68 
No. 127942, Appellate court judgment affirmed in part and vacated in part. 
¶ 69 
Circuit court judgment reversed. 
¶ 70 
Remanded with directions. 
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