Title: H. Ray Harrison and Julie Anderson v. D. Lee Binnion, M.D. and St. Alphonsus RMC Negligent credentialing

State: idaho

Issuer: Idaho Supreme Court (civil)

Document:

IN THE SUPREME COURT OF THE STATE OF IDAHO 
 
Docket No. 34731 
 
H. RAY HARRISON, 
 
Plaintiff-Appellant, 
 
and 
 
JULIE ANDERSON, 
 
Plaintiff, 
 
v. 
 
D. LEE BINNION, M.D. and SAINT 
ALPHONSUS REGIONAL MEDICAL 
CENTER, INC., an Idaho non-profit 
corporation, 
 
Defendants-Respondents, 
 
and 
 
JEFFREY HARTFORD, M.D., 
 
Defendant. 
 
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Boise, February 2009 Term 
 
2009 Opinion No.  90 
 
Filed: July 7, 2009 
 
Stephen W. Kenyon, Clerk 
 
 
 
Appeal from the District Court of the Fourth Judicial District of the State of 
Idaho, in and for Ada County.  The Hon. Cheri C. Copsey, District Judge. 
 
The judgment of the district court is affirmed in part and vacated in part. 
 
Rossman Law Group, PLLC, Boise, for appellant.  Eric S. Rossman argued. 
 
Moffatt, Thomas, Barrett, Rock & Fields, Chartered, Boise for respondent 
Binnion.  Patricia M. Olsson argued. 
 
Gjording & Fouser, Boise, for respondent Saint Alphonsus Regional Medical 
Center, Inc.  Jack S. Gjording argued. 
 
 
 
EISMANN, Chief Justice. 
 
2 
 
This is an appeal from:  (a) an order denying a motion to amend the complaint to assert a 
claim of negligent credentialing against a hospital; (b) an order refusing to order discovery of 
certain medical records provided by a physician to the board of medicine; and (c) the granting of 
summary judgment in favor of an emergency room physician.  We reverse the order of the 
district court holding that Idaho Code § 39-1392c grants immunity from a claim for negligent 
credentialing.  We decline to decide the issue of whether certain medical records provided to the 
board of medicine were privileged because the appellant did not name the physician claiming 
that privilege as a respondent to this appeal.  We affirm the grant of summary judgment in favor 
of the emergency room physician.  Finally, we decline to award the emergency room physician 
attorney fees on appeal. 
  
I.  FACTS AND PROCEDURAL HISTORY 
 
On November 14, 2003, at about 11:35 p.m., H. Ray Harrison arrived at the emergency 
room (ER) of Saint Alphonsus Regional Medical Center (Hospital).  His symptoms included 
nausea, vomiting, diarrhea, imbalance, and speech impediment.  According to his family, 
Harrison‟s condition had been deteriorating over the preceding seven weeks, with episodes of 
vomiting and diarrhea occurring three or four times a day.  Julie Anderson, his significant other 
whom he later married, reported that for the prior three days he had not consumed anything other 
than alcoholic beverages.  A nurse drew blood from Harrison for necessary chemistry panels, 
including a basic metabolic panel of blood tests called a Chem 7. 
 
Dr. Binnion was working in the ER that night.  At about 1:00 a.m. she began her 
assessment of Harrison.  About forty minutes later, she received lab results from the Chem 7 
showing that Harrison‟s blood sodium level was 96 milliequivalents per liter (mEq/L), a low 
level of sodium that was life-threatening.  The lab results also showed that Harrison‟s blood 
alcohol content was 0.13.  Dr. Binnion ordered that Harrison be given an intravenous (IV) saline 
solution at the rate of 200 cc‟s per hour.  The saline IV was started at 1:50 a.m. and was replaced 
at 2:20 a.m. 
 
Dr. Binnion could not admit Harrison into the hospital.  At about 2:25 a.m. she 
telephoned Dr. Hartford, who was the on-call physician for Harrison‟s treating physician.  Dr. 
Hartford agreed to admit Harrison into the hospital.  Dr. Binnion suggested that Harrison be 
admitted to the telemetry unit, but Dr. Hartford thought that it would be too stimulating in light 
 
3 
of Harrison‟s alcohol abuse and that he should be admitted to the medical floor.  Dr. Binnion 
wrote the admission orders for Dr. Hartford.  Those orders included that Harrison be given IV 
sodium at 200 cc‟s per hour and that Harrison have blood draws every six hours for a Chem 7 
test.  Apparently because of the lack of available beds in the medical unit, Harrison was admitted 
to the orthopedic unit at 3:26 a.m.  At that point, Dr. Binnion was no longer responsible for 
Harrison‟s care. 
 
Dr. Hartford first saw Harrison at 11:17 a.m. on November 15, 2003.  By that time, 
results of the second Chem 7 test done at 6:00 a.m. showed a sodium level of 105 mEq/L.  After 
reviewing the medical records and examining Harrison, Dr. Hartford wrote his treatment plan.  It 
included IV sodium at 200 cc‟s per hour and a Chem 7 test done every six hours. 
 
Dr. Hartford continued the saline IV until 10:00 a.m. on November 17, 2003.  During that 
period, Harrison‟s sodium levels continued to increase to 110 mEq/L at 12:27 p.m. on November 
15, 2003; to 114 mEq/L at 5:58 p.m. on November 15, 2003; to 124 mEq/L at 3:57 a.m. on 
November 16, 2003; and to 126 mEq/L at 10:10 a.m. on November 16, 2003. 
 
Harrison‟s condition continued to deteriorate under Dr. Hartford‟s care.  On November 
22, 2003, another physician diagnosed Harrison as suffering from central pontine myelinolysis 
(CPM), a condition in which the myelin sheath covering brainstem nerve cells is destroyed 
which prevents nerve signals being transmitted properly.  CPM is caused by a too rapid change 
in sodium levels in the body.  Harrison contends that his CPM was caused by his sodium level 
rising too rapidly. 
 
On April 28, 2004, Harrison and Anderson (Plaintiffs) filed this action against Drs. 
Hartford and Binnion and the Hospital alleging that they were negligent in their treatment of 
Harrison and that they also committed the torts of negligent and intentional infliction of 
emotional distress.  On November 15, 2005, Plaintiffs filed a motion to amend their complaint to 
allege that the Hospital was negligent in credentialing Dr. Hartford.  After the motion was 
briefed and argued, the district court denied the motion to amend.  It held that there was no cause 
of action in Idaho for negligent credentialing because Idaho Code § 39-1392c granted the 
Hospital immunity from such a claim. 
 
During the litigation, the Plaintiffs served interrogatories and requests for production 
upon Dr. Hartford seeking information regarding any substance abuse treatment he had received 
and whether he had been disciplined by the Idaho Board of Medicine.  Dr. Hartford objected to 
 
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this discovery, and on May 26, 2005, the Plaintiffs filed a motion to compel discovery.  The 
district court held that under Idaho Rule of Evidence 503, Dr. Hartford had a privilege to refuse 
to disclose communications made for the purpose of diagnosis or treatment of alcohol or drug 
addiction and that Dr. Hartford had not waived that privilege by disclosing the information to the 
Idaho Board of Medicine.  The court also held that the under Idaho Code § 39-308, the fact of 
whether Dr. Hartford had obtained treatment through a certified substance abuse treatment 
program was also privileged.  The court therefore denied the motion to compel to the extent that 
it sought discovery of such privileged information. 
 
The Plaintiffs then sought to obtain from the Idaho Board of Medicine documents that 
had been entered as exhibits during an administrative disciplinary hearing regarding Dr. 
Hartford.  On April 3, 2006, Dr. Hartford filed a motion for a protective order seeking to prevent 
disclosure of those documents to the extent that they consist of records relating to substance 
abuse treatment.  He also sought redaction of any references to substance abuse treatment in 
letters from his former attorney to the Board of Medicine.  The district court granted that motion. 
 
The Plaintiffs ultimately settled their claims against Dr. Hartford.  Pursuant to stipulation, 
on August 29, 2006, the district court entered an order dismissing with prejudice the Plaintiffs‟ 
claims against Dr. Hartford. 
 
On April 27, 2007, Dr. Binnion moved for summary judgment on the grounds that the 
Plaintiffs‟ expert did not show that he was familiar with the applicable standard of care and there 
was no evidence that any alleged negligence by Dr. Binnion was a proximate cause of any harm 
to Harrison.  After briefing and argument, the district court granted the motion on the ground that 
there was no evidence of causation with respect to the alleged negligence of Dr. Binnion.  The 
district court also held that the Plaintiffs‟ expert had not familiarized himself with the applicable 
standard of care.  On Plaintiffs‟ motion for rehearing, the court modified its order granting 
summary judgment by reserving until trial any ruling on whether Plaintiffs‟ expert had 
adequately familiarized himself with the applicable standard of care. 
 
Pursuant to stipulation, on September 18, 2007, the district court entered an order 
dismissing Plaintiffs‟ remaining claims against the Hospital.  Harrison then timely appealed. 
 
 
 
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II.  ISSUES ON APPEAL 
1. Did the district court err in holding that Idaho Code § 39-1392c granted the Hospital 
immunity from a claim of negligent credentialing? 
2. Did the district court err in holding that Dr. Hartford did not waive any privilege when he 
presented documents regarding his substance abuse treatment to the Idaho Board of 
Medicine in connection with a disciplinary hearing? 
3. Did the district court err in granting Dr. Binnion‟s motion for summary judgment on the 
issue of causation? 
4. Is Dr. Binnion entitled to an award of attorney fees on appeal pursuant to Idaho Code § 
12-121? 
 
III.  ANALYSIS 
A.  Did the District Court Err in Holding that Idaho Code § 39-1392c Granted the Hospital 
Immunity from a Claim of Negligent Credentialing? 
 
The Plaintiffs sought to amend their complaint to add a claim against the Hospital for 
negligent credentialing in granting hospital privileges to Dr. Hartford.  The district court held 
that such claim was barred by Idaho Code § 39-1392c.1  The applicable portion of that statute 
provides, “The furnishing of information or provision of opinions to any health care organization 
or the receiving and use of such information and opinions shall not subject any health care 
organization or other person to any liability or action for money damages or other legal or 
equitable relief.”  The information furnished and opinions provided are to be used by the health 
care organization “in conducting peer review,” id., which includes “[c]redentialing, privileging 
or affiliating of health care providers as members of, or providers for, a health care 
organization,” I.C. § 39-1392a(11)(a).  The district court reasoned that if a health care 
                                                 
1 The statute states as follows: 
The furnishing of information or provision of opinions to any health care organization or 
the receiving and use of such information and opinions shall not subject any health care 
organization or other person to any liability or action for money damages or other legal or 
equitable relief.  Custodians of such records and persons becoming aware of such data and 
opinions shall not disclose the same except as authorized by rules adopted by the board of 
medicine or as otherwise authorized by law.  Any health care organization may receive such 
disclosures, subject to an obligation to preserve the confidential privileged character thereof and 
subject further to the requirement that such requests shall be made and such use shall be limited to 
aid the health care organization in conducting peer review. 
 
 
6 
organization has immunity for using information and opinions when making a credentialing 
decision, then it must also have immunity for the credentialing decision ultimately made.  In so 
holding, the district court erred. 
 
“The interpretation of a statute is a question of law over which we exercise free review.”  
State v. Thompson, 140 Idaho 796, 798, 102 P.3d 1115, 1117 (2004).  “It must begin with the 
literal words of the statute; those words must be given their plain, usual, and ordinary meaning; 
and the statute must be construed as a whole.  If the statute is not ambiguous, this Court does not 
construe it, but simply follows the law as written.”   McLean v. Maverik Country Stores, Inc., 
142 Idaho 810, 813, 135 P.3d 756, 759 (2006). (Citations omitted.) 
 
There is nothing in the wording of the statute that purports to grant immunity to a health 
care organization for making a credentialing decision.  The statute grants immunity for “[t]he 
furnishing of information or provision of opinions to any health care organization” and for “the 
receiving and use of such information and opinions.”  The obvious purpose of the statute is to 
encourage the free exchange of information and opinions regarding peer review activities, which 
includes credentialing.  A person who provides such information or opinions need not fear a 
subsequent lawsuit alleging claims such as slander, defamation, tortious interference with 
contract or prospective economic advantage, or intentional infliction of emotional distress.  The 
statute grants immunity from “liability or action for money damages or other legal or equitable 
relief.”  I.C. § 39-1392c. (Emphasis added.)  The broad grant of immunity may also form a basis 
for the recovery of attorney fees under Idaho Code § 12-121 and/or Idaho Rule of Civil 
Procedure 11(a)(1).  The health care organization that receives or relies upon such information or 
opinions is likewise immune from any claim or action for damages or other legal or equitable 
relief for doing so. 
 
The district court held that immunity for using the information or opinions must also 
include immunity for the decision ultimately made.  Had the legislature so intended, it would 
have drafted the statute to provide for such immunity.  Although the gathering and consideration 
of information are preliminary steps in making a decision, they are separate from the making of 
the decision.  This is illustrated by the fact that it is common for experts to arrive at conflicting 
opinions after considering the same information.  Holding that Idaho Code § 39-1392c grants 
immunity for credentialing decisions would be an expansion of that statute beyond its wording.  
The district court therefore erred in holding that the statute granted such immunity. 
 
7 
 
B.  Did the district court err in holding that Dr. Hartford did not waive any privilege when 
he presented documents regarding his substance abuse treatment to the Idaho Board of 
Medicine in connection with a disciplinary hearing? 
 
Dr. Hartford objected to the disclosure of records relating to his substance abuse 
treatment that he provided to the Idaho Board of Medicine.  He claimed that such records were 
privileged pursuant to Idaho Rule of Evidence 503(b)(1).  That Rule provides: 
A patient has a privilege in a civil action to refuse to disclose and to 
prevent any other person from disclosing confidential communications made for 
the purpose of diagnosis or treatment of the patient‟s physical, mental or 
emotional condition, including alcohol or drug addiction, among the patient, the 
patient‟s physician or psychotherapist, and persons who are participating in the 
diagnosis or treatment under the direction of the physician or psychotherapist, 
including members of the patient‟s family. 
 
 
   The district court held that such records were privileged under Rule 503(b)(1) and that 
Dr. Hartford had not waived that privilege by disclosing the information to the Idaho Board of 
Medicine.  Relying upon Idaho Rule of Evidence 510,2 Harrison contends that the district court 
erred in holding that Dr. Hartford had not waived the physician privilege provided by Rule 
503(b)(1). 
 
Harrison did not name Dr. Hartford as a respondent in the notice of appeal.  The notice of 
appeal was directed to:  “THE ABOVE NAMED RESPONDENTS, D. LEE BINNION, M.D. 
AND SAINT ALPHONSUS REGOINAL MEDICAL CENTER, INC.”  We long ago held, 
“Where a notice of appeal is addressed to certain parties, naming them, its legal effect is limited 
to such parties only.”  Williams v. Sherman, 34 Idaho 63, 66, 199 P. 646, 647 (1921).  During 
oral argument, counsel for Harrison stated that a copy of the notice of appeal was mailed to Dr. 
Hartford‟s counsel.  The certificate of service on the notice of appeal does not so indicate.  Even 
                                                 
2 Idaho Rule of Evidence 510 provides: 
A person upon whom these rules confer a privilege against disclosure of the confidential 
matter or communication waives the privilege if the person or the person‟s predecessor while 
holder of the privilege voluntarily discloses or consents to disclosure of any significant part of the 
matter or communication.  This rule does not apply if the disclosure is itself a privileged 
communication. 
 
 
 
 
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if a copy of the notice of appeal was mailed to Dr. Hartford‟s counsel, we held in Mahaffey v. 
Pattee, 46 Idaho 16, 18, 266 P. 430, 431 (1928), “Where a notice of appeal is directed to one 
party alone, its service upon another party would not have the effect of bringing such other party 
before the court.” 
 
Dr. Hartford is the one who would have a privilege to prevent the disclosure of 
confidential communications in his medical records.  Because Harrison did not name Dr. 
Hartford as a respondent, he is not a party to the appeal.  This Court cannot decide his rights 
without him having an opportunity to be heard.  Therefore, Harrison has failed to perfect an 
appeal regarding the issue of whether the district court was correct in holding that Dr. Hartford 
had not waived his physician privilege.  We will not consider that issue. 
 
C.  Did the District Court Err in Granting Dr. Binnion’s Motion for Summary Judgment 
on the Issue of Causation? 
In an appeal from an order of summary judgment, this Court‟s standard of review is the 
same as the standard used by the trial court in ruling on a motion for summary judgment.  
Infanger v. City of Salmon, 137 Idaho 45, 44 P.3d 1100 (2002).  All disputed facts are to be 
construed liberally in favor of the non-moving party, and all reasonable inferences that can be 
drawn from the record are to be drawn in favor of the non-moving party.  Id.  Summary 
judgment is appropriate if 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.  Id.  If the evidence reveals no disputed issues 
of material fact, then only a question of law remains, over which this Court exercises free 
review.  Id. 
In this case, expert testimony of causation is required.  In Swallow v. Emergency 
Medicine of Idaho, P.A. 138 Idaho 589, 597-98, 67 P.3d 68, 76-77 (2003), we held that expert 
testimony is required unless it is a matter within the usual and ordinary experience of a lay 
person.  We stated as follows: 
We have previously held that a lay person was not qualified to give an 
opinion about the cause of a medical condition or disease. Bloching v. 
Albertson‟s, Inc., 129 Idaho 844, 934 P.2d 17 (1997) (lay person was not qualified 
to testify that the seizure he suffered immediately after using a blend of pork and 
beef insulin was caused by the insulin); Evans v. Twin Falls County, 118 Idaho 
210, 796 P.2d 87 (1990) (husband was not qualified to testify that conduct by 
 
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sheriff‟s deputies on April 15, 1987, in grabbing and shaking his wife was a cause 
of her cardiac arrest and death over eleven months later); Flowerdew v. Warner, 
90 Idaho 164, 409 P.2d 110 (1965) (patient was not qualified to testify that his 
injury was caused by physician‟s treatment). In support of the holding in Evans v. 
Twin Falls County, we quoted from 31A Am. Jur. 2d, Expert & Opinion Evidence 
§ 207 as follows: 
Where the subject matter regarding the cause of disease, injury, or 
death of a person is wholly scientific or so far removed from the 
usual and ordinary experience of the average person that expert 
knowledge is essential to the formation of an intelligent opinion, 
only an expert can competently give opinion evidence as to the 
cause of death, disease or physical condition. 
118 Idaho at 214, 796 P.2d at 91. 
Whether a rise in sodium levels in a specified amount over a specified period of time 
would cause CPM in Harrison is not a matter within the usual and ordinary experience of lay 
people.  Likewise, whether the conduct of Dr. Binnion could be a cause of Harrison‟s CPM is 
likewise not a matter within the usual and ordinary experience of lay people.  Therefore, 
Harrison was required to produce expert testimony that Dr. Binnion‟s conduct was a proximate 
cause of Harrison‟s CPM. 
Dr. Binnion was Harrison‟s treating physician from 1:00 a.m. to 3:26 a.m. on November 
15, 2003, while he was in the emergency room.  During that time, she ordered that he be given 
an IV saline solution to raise his sodium level.  She also called Dr. Hartford to arrange for 
Harrison to be admitted into the Hospital and wrote the physician‟s orders for Dr. Hartford so 
that he would not have to come to the Hospital that night. 
The only expert testimony that Dr. Binnion‟s conduct was a cause of any harm to 
Harrison came from his expert witness Dr. Navar.  He testified that Dr. Binnion‟s alleged 
malpractice was:  (1) her failure to communicate to Dr. Hartford the seriousness of Harrison‟s 
condition; (2) her failure to include in her orders appropriate instructions to the nurses that they 
immediately tell the treating physician, Dr. Hartford, all of Harrison‟s laboratory sodium values; 
and (3) her failure to admit Harrison to ICU.3  He also testified that in his opinion each of these 
instances of negligence was a cause of Harrison‟s CPM. 
                                                 
3 Dr. Navar testified during his deposition as follows: 
Q  
It says: “Mr. Rossman, I‟m comfortable with the following statements.  Please 
contact me if you have any questions.” 
 
10 
Proximate cause contains two components:  actual cause, which is a factual question of 
whether a person‟s conduct produced a particular harm, and legal cause, which is a legal 
question of whether legal liability attaches to the conduct.  Newberry v. Martens, 142 Idaho 284, 
288, 127 P.3d 187, 191 (2005).  Where an expert testifies regarding the factual basis for his or 
her opinion regarding causation, we will examine those facts to see if they support the opinion.  
Each of Dr. Navar‟s allegations of negligence by Dr. Binnion will be discussed separately. 
1.  Dr. Binnion’s alleged failure to communicate to Dr. Hartford the seriousness of 
Harrison’s condition.  Dr. Binnion first saw Harrison at about 1:00 a.m. on November 15, 2003.  
At about 2:25 a.m., she telephoned Dr. Hartford, who was the on-call physician for Harrison‟s 
treating physician.  Dr. Hartford agreed to admit Harrison into the hospital, but Dr. Hartford did 
not come into the hospital to see Harrison until about 11:00 a.m.  Dr. Navar thought that if Dr. 
Binnion had given Dr. Hartford more information when they talked on the telephone, then Dr. 
Hartford would have seen Harrison sooner than 11:00 a.m.4  For Dr. Binnion to be liable for this 
                                                                                                                                                             
“Number one, Mr. Harrison visited the ER department with, among other diagnoses, a 
condition of profound chronic hyponatremia. 
“Number two, Dr. Binnion breached the local standard of care by failing to fully and 
completely communicate Mr. Harrison‟s history, physical exam, symptoms and test results to Dr. 
Hartford prior to the admission of Mr. Harrison to the orthopedic floor of the hospital. 
“Number three, Dr. Binnion breached the local standard of care by failing to 
communicate within her physician‟s orders at the time they were written, her concerns about rapid 
elevation of sodium, and that all laboratory sodium values be immediately communicated to the 
attending physician upon receipt by attending nursing staff. 
"Number four, Dr. Binnion breached the prevailing local standard of care by admitting 
Mr. Harrison to the orthopedic floor of the hospital rather than the ICU. 
“Number 5, Dr. Binnion‟s breach of the prevailing local standard of care as identified 
above was a substantial factor in causing the condition of Central Pontine Myelinolysis in Mr. 
Harrison.” 
MS. OLSSON:  You can read it from the exhibit. 
MR. ROSSMAN:  Central Pontine Myelinolysis. 
BY MS. OLSSON: 
Q 
Are those your opinions, Doctor? 
A 
They are. 
Q 
Do you have any other opinions in this case? 
A 
No. 
 
4 Dr. Navar testified in his deposition: 
THE WITNESS:  One of my criticisms is that it‟s my opinion that Dr. Binnion 
did not give a full – did not reveal the acuity of the situation in her deposition.  I couldn‟t find that 
she actually gave Dr. Hartford the actual sodium results. 
She did mention he had hyponatremia, and my concern would be that Dr. Hartford, you 
know, not being present to see Mr. Harrison, may not have been aware of the acuity of the 
situation and the necessity for him to report to the hospital for Mr. Harrison‟s evaluation right 
away. 
 
11 
alleged negligence, there must be expert testimony supporting a conclusion that Dr. Hartford‟s 
failure to see Harrison prior to 11:00 a.m. was a cause of Harrison‟s CPM. 
Dr. Binnion was responsible for Harrison‟s care from 1:00 a.m. to 3:26 a.m. on 
November 15, 2003.  During that period, she ordered that Harrison be given IV sodium at the 
rate of 200 cc‟s per hour, which was started at 1:50 a.m.  She also wrote the physician orders for 
Dr. Hartford that were in effect from 3:26 a.m. until 11:00 a.m. when Dr. Hartford saw Harrison 
in the Hospital.5  Those physician orders also directed that Harrison be given IV sodium at the 
rate of 200 cc‟s per hour. 
Harrison‟s first lab results on November 15, 2003, showed a sodium level of 96 mEq/L at 
12:49 a.m., a life threateningly low level of sodium.  After reviewing those lab results at 1:00 
a.m., Dr. Binnion began sodium replacement by ordering that Harrison have a saline IV at the 
rate of 200 cc‟s per hour.  The second lab results at 6:00 a.m. showed that Harrison‟s sodium 
level had increased to 105 mEq/L.  According to Dr. Navar, at that point the rate of sodium 
replacement should have been slowed significantly or stopped.  Dr. Hartford did not become 
aware of the 6:00 a.m. lab results until he examined Harrison at 11:00 a.m.  Thus, there was 
evidence supporting Dr. Binnion‟s liability if that five-hour delay in Dr. Hartford learning of the 
6:00 a.m. lab results was a cause of any harm to Harrison.  There was no factual basis for 
concluding that it was. 
First, after Dr. Hartford examined Harrison and reviewed the medical records showing 
the 9 mEq/L increase in Harrison‟s sodium levels from 12:49 a.m. to 6:00 a.m., Dr. Hartford 
decided to give Harrison IV saline at 200 cc‟s per hour.  He testified that in his opinion he could 
not slow the rate of sodium replacement because of Harrison‟s vomiting, dehydration, and 
hypokalemia.  In fact, Dr. Hartford did not alter the rate of sodium replacement until 10:00 a.m. 
on November 16, 2003, when he stopped the saline IV.  There is no evidence that Dr. Hartford 
would have done anything different had he come into the hospital and seen Harrison earlier. 
Second, assuming that Dr. Hartford would have altered the rate of sodium replacement 
had he been at the hospital at 6:00 a.m. rather than at 11:00 a.m., there was no evidence that the 
failure to alter the rate of sodium replacement between 6:00 a.m. and 11:00 a.m. was a cause of 
                                                 
5 The record does not reflect whether Dr. Hartford dictated what Dr. Binnion was to write for his physician orders or 
whether she used her own discretion.  We therefore assume she used her own discretion in writing the orders for Dr. 
Hartford. 
 
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any harm to Harrison.  During the period from 12:49 a.m. to 12:27 p.m., Harrison‟s sodium level 
increased from 96 mEq/L to 110 mEq/L, an increase of 14 mEq/L during a twelve-hour period.  
Although that rate of increase would support a finding of negligence, in order for Dr. Binnion to 
be liable there must also be evidence that her negligence was a proximate cause of harm to 
Harrison.  He did not produce any expert testimony supporting a finding that it was. 
Dr. Navar testified that he did not know whether the 14 mEq/L increase in Harrison‟s 
sodium level during that initial 12-hour period was a cause of harm to Harrison.  Dr. Navar‟s 
deposition testimony on this issue was as follows: 
A  
I don‟t know whether that initial increase from 96 to 110 over a 
12-hour period would have been enough to result in the insult just by itself. 
Q  
And that was 14 milliequivalents in approximately a 12-hour 
period of time? 
A  
Right. 
Q  
Okay.  How about the 9 milliequivalent increase in the 
approximate six-hour period of time from 0049 to 6 a.m., would that in and of 
itself have been enough to cause CPM in Mr. Harrison? 
A  
I don‟t know. 
 
Dr. Binnion started Harrison‟s sodium replacement when he was in the ER.  Once 
Harrison was admitted into the Hospital, Dr. Binnion no longer had any responsibility for his 
care.  Dr. Hartford became Harrison‟s treating physician.  It was his obligation to monitor the 
change in Harrison‟s sodium levels and to adjust the rate of sodium replacement accordingly.  
This is not a situation in which Dr. Binnion began a negligent course of treatment that continued 
because Dr. Hartford negligently failed to detect it.  Dr. Navar twice testified that he had no 
criticism of Dr. Binnion for ordering the saline IV‟s that Harrison received in the ER. 
Dr. Binnion also wrote the initial physician‟s orders for Dr. Hartford, and those orders 
remained in effect until he wrote his own after examining Harrison at 11:00 a.m.  In those initial 
physician‟s orders, Dr. Binnion wrote that Harrison was to be given IV sodium at the rate of 200 
cc‟s per hour.  There was no testimony, however, that she was negligent for doing so. 
There was one statement by Dr. Navar that could be interpreted as being critical of Dr. 
Binnion‟s treatment while Harrison was in the ER.  After testifying that he was not critical of Dr. 
Binnion for ordering the IV saline in the ER to begin sodium replacement, Dr. Navar stated that 
                                                                                                                                                             
 
 
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Dr. Binnion should have slowed the rate of administration significantly after receiving the lab 
test results showing a sodium level of 96 mEq/L.  His testimony was as follows: 
A  
But at the time that the sodium value became available 
again, at that point, I would think that the sodium level or the rate of 
administration of fluid would need to be closely monitored from that 
standpoint.  It probably should have been slowed down significantly from 
the time that it was -- and I guess that‟s not listed in this opinion. 
Q  
When did you form that opinion, that the rate of 
administration should have been slowed down? 
A  
I‟ve had that opinion from the beginning. 
Q  
When should the administration of normal saline have been 
slowed down? 
A  
When Dr. Binnion got the lab report back that the sodium 
level was 96.  
 
 
It is obvious that Dr. Navar misspoke when stating that Dr. Binnion should have slowed 
the rate of sodium replacement after receiving the lab results showing a sodium level of 96 
mEq/L.  Dr. Navar began by saying that “at the time that the sodium value became available 
again.”  (Emphasis added.)  The use of the word “again” indicates that he thought there had been 
a prior lab test showing an earlier sodium level.  There had not been.  The 96 mEq/L sodium 
level was from the first lab test.  It was the results of the second lab that showed an increase in 
Harrison‟s sodium level.  Dr. Navar also stated that when the lab report showing the 96 mEq/L 
sodium level was received, the rate of administration of fluid should have been “slowed down 
significantly.”  (Emphasis added.)  At the time Dr. Binnion saw the lab results showing a sodium 
level of 96 mEq/L, the saline infusion had not even been started.  She did not order the saline IV 
until after receiving those lab results.  It is apparent that Dr. Navar misspoke and was referring to 
the second lab results that showed an increase in Harrison‟s sodium level to 105 mEq/L.  Both 
before and after making the statement quoted above, Dr. Navar testified that he was not critical 
of Dr. Binnion for the saline IV‟s she ordered while Harrison was in the ER.6 
                                                 
6 Before testifying that the rate of administration of fluid should have been slowed down significantly when the lab 
results were again available showing a sodium level of 96 mEq/L, Dr. Navar testified as follows: 
 
Q  
Okay.  Do you have criticism, Doctor, of Dr. Binnion‟s treatment, actual 
treatment of the sodium replacement for Mr. Harrison while he was in the emergency department 
at St. Alphonsus Hospital? 
A  
No, I don‟t specifically.  I – Dr. Binnion was not aware of the sodium level until 
sometime in the latter portion of his visit, so I don‟t have a specific criticism regarding the fact 
that he was given some fluid boluses in the emergency department. 
 
14 
 
Even accepting Dr. Navar‟s testimony at face value that Dr. Binnion should have slowed 
the rate of saline replacement that she had not yet begun after what were the first lab results were 
again available, there was no testimony that her failure to do so was a cause of any harm to 
Harrison.  As pointed out above, Harrison did not produce any expert testimony stating that the 
rate of sodium replacement during the first twelve hours was a cause of any harm to him.  He 
also did not produce any expert testimony stating that the increase in Harrison‟s sodium level 
during the first twelve hour period combined with the subsequent increases while under Dr. 
Hartford‟s care caused Harrison‟s CPM. 
There is no evidence supporting Dr. Navar‟s opinion that Dr. Binnion‟s alleged 
negligence in failing to give Dr. Hartford more details so he would come to the hospital sooner 
than he did was a cause of any harm to Harrison.  The district court did not err in dismissing this 
claim of alleged negligence.  
2.  Dr. Binnion’s failure to include in her orders appropriate instructions to the 
nurses that they immediately tell Dr. Hartford all of Harrison’s laboratory sodium values.  
Dr. Navar also testified that in his opinion Dr. Binnion was negligent for failing to include in the 
physician‟s orders a direction to the nurses to immediately tell Dr. Hartford of Harrison‟s 
laboratory sodium values and that such negligence was a cause of Harrison‟s CPM.  The 
physician‟s orders written by Dr. Binnion were in effect from 3:26 a.m. until 11:00 a.m., when 
Dr. Hartford examined Harrison and wrote his own physician‟s orders.  The only lab results 
received during that period of time were those obtained at 6:00 a.m.  Had Dr. Binnion done as 
Dr. Navar suggests, Dr. Hartford would have learned of those lab results at around 6:00 a.m. 
rather than at 11:00 a.m.  For the reasons stated above regarding the alleged negligence in not 
                                                                                                                                                             
 
After testifying that the rate of saline replacement should have been slowed after receipt of the lab results showing a 
sodium level of 96 mEq/L, Dr. Navar testified as follows: 
 
Q  
Okay.  So you have no criticism of the normal saline boluses; right? 
A  
No. 
 
A “bolus” is “a: a dose of a substance (as a drug) given intravenously b: a large dose of a substance given by 
injection for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream.”  Merriam-
Webster Online Dictionary (visited March 23, 2009)  
 
 
 
 
15 
making Dr. Hartford aware of the need to come into the hospital as soon as possible to see 
Harrison, there is no evidence that Dr. Hartford‟s failure to learn of the 6:00 a.m. lab results 
earlier was a cause of any harm to Harrison.  Thus, there is no evidence supporting Dr. Navar‟s 
opinion that the Dr. Binnion‟s failure to order the nurses to immediately advise Dr. Hartford of 
the lab results was a cause of any harm to Harrison.  The district court did not err in dismissing 
this claim of alleged negligence. 
3.  Dr. Binnion’s failure to admit Harrison to the ICU.  Dr. Navar testified that Dr. 
Binnion was negligent for not admitting Harrison to the ICU, where he would have had blood 
draws more frequently than every six hours to more closely monitor his sodium levels.  It is 
uncontradicted that Dr. Binnion did not have authority either to admit Harrison to the Hospital or 
to decide whether he would be admitted to ICU rather than to some other part of the Hospital.  
Where Dr. Binnion did not have any authority to admit Harrison to the Hospital, her alleged 
failure to admit him to the ICU in the Hospital cannot legally be a proximate cause of his CPM.  
She cannot be held liable for failing to do something she had no authority to do.  The district 
court did not err in dismissing this claim of alleged negligence. 
 
D.  Is Dr. Binnion Entitled to an Award of Attorney Fees on Appeal Pursuant to Idaho 
Code § 12-121?   
 
Dr. Binnion seeks an award of attorney fees under Idaho Code § 12-121.  That statute 
authorizes an award of attorney fees on appeal to Dr. Binnion, as the prevailing party, if Harrison 
brought or pursued the appeal frivolously, unreasonably, or without foundation.  Nampa & 
Meridian Irr. Dist. v. Mussell, 139 Idaho 28, 37, 72 P.3d 868, 877 (2003).  We do not find that 
Harrison brought or pursued the appeal against Dr. Binnion frivolously, unreasonably, or without 
foundation.  We therefore decline to award attorney fees under Idaho Code § 12-121. 
  
IV.  CONCLUSION 
 
We vacate the judgment dismissing this action as to the Saint Alphonsus Regional 
Medical Center, Inc., (Hospital) and remand this case for further proceedings against it consistent 
with this opinion.  We award Harrison costs on appeal against the Hospital.  We affirm the 
judgment dismissing this action against Dr. Binnion and award her costs on appeal against 
Harrison. 
 
16 
 
Justices BURDICK and J. JONES CONCUR. 
 
W. JONES, Justice,  
 
I respectfully dissent as to part III C of the majority opinion.  I agree with the majority in 
so much as Harrison was required to produce expert testimony on the issue of whether Dr. 
Binnion was the proximate cause of Harrison‟s resulting CPM.  However, I would hold that 
Harrison effectively met his burden at the summary judgment phase; therefore, I would reverse 
the district court‟s decision and remand this case for further proceedings.  For purposes of 
summary judgment Harrison was only required to show that a genuine issue of material fact 
existed as to whether Dr. Binnion‟s alleged negligence was a substantial factor in causing 
Harrison‟s resulting CPM.  I take issue with the majority requiring a higher standard of proof 
than what our current case law dictates. 
Proximate cause consists of actual cause and true proximate cause.  Newberry v. Martens, 
142 Idaho 284, 288, 127 P.3d 187, 191 (2005).  Actual cause determines whether the actor‟s 
conduct produced the harm and true proximate cause, or legal cause, determines whether liability 
for that conduct should attach.  Id.  “Actual cause is the factual question of whether a particular 
event produced a particular consequence.”  Id.  “If reasonable people might reach a different 
conclusion from conflicting inferences based on the evidence then the [summary judgment] 
motion must be denied.”  Cramer v. Slater, 146 Idaho 868, ___, 204 P.3d 508, 513 (2009).  In 
Idaho, the standard for applying proximate cause in medical malpractice actions containing 
multiple causes is the “substantial factor” test.  Fussell v. St. Clair, 120 Idaho 591, 602, 818 P.2d 
295, 306 (1991).  “By making the „substantial factor‟ test the standard for all proximate cause 
instructions [in multiple cause medical malpractice actions] [and] by removing the „but for‟ test 
we will have simplified proximate cause by eliminating the unnecessary search for single or 
multiple causes[.]” Id.  The Restatement (Second) of Torts § 431 (1965)7 states that an “actor‟s 
negligent conduct is a legal cause of harm to another if [] his conduct is a substantial factor in 
bringing about the harm[.]” 
                                                 
7 Impliedly adopted by this Court in Fussell, 120 Idaho at 602, 818 P.2d at 306.  See also Challis 
Irr. Co. v. State, 107 Idaho 338, 689, P.2d 230 (Ct. App. 1984); Crosby v. Rowand Machinery 
Co., 111 Idaho 939, 729 P.2d 414 (Ct. App. 1986); Edmark Motors v. Twin Cities Toyota, Inc., 
111 Idaho 846, 727 P.2d 1274 (Ct. App. 1987). 
 
17 
The following considerations are in themselves or in combination with one 
another important in determining whether the actor‟s conduct is a substantial 
factor in bringing about harm to another: 
(a) the number of other factors which contribute in producing the harm 
and the extent of the effect which they have in producing it; 
(b) whether the actor‟s conduct has created a force or series of forces 
which are in continuous and active operation up to the time of the harm, 
or has created a situation harmless unless acted upon by other forces for 
which the actor is not responsible; 
(c) lapse of time. 
 
Restatement (Second) of Torts § 433 (1965) (emphasis added).  As to subsection (b) of § 433 the 
comments reference the following: 
If the effects of the actor‟s negligent conduct actively and continuously operate to 
bring about harm to another, the fact that the active and substantially 
simultaneous operation of the effects of a third person‟s . . .  tortious . . . act is 
also a substantial factor in bringing about the harm does not protect the actor from 
liability. 
 
Restatement (Second) of Torts § 439 (1965) (emphasis added);8 see also Restatement (Second) 
of Torts § 433 cmt. e. 
Where the negligent conduct of the actor creates or increases the risk of a 
particular harm and is a substantial factor in causing that harm, the fact that the 
harm is brought about through the intervention of another force does not relieve 
                                                 
8  
Although in the great majority of cases to which the rule stated in this Section is 
applicable, the effects of the conduct of both the actor and the third person are in 
simultaneous active operation, it is not necessary that their operations shall be absolutely 
simultaneous.  It is enough that the two are in substantially simultaneous operation, as 
when the effect of the conduct of one or the other has ceased its active operation 
immediately before the other‟s conduct takes active effect in harm to the other. 
Restatement (Second) of Torts § 439 cmt a. 
 
18 
the actor of liability, except where the harm is intentionally caused by a third 
person and is not within the scope of the risk created by the actor‟s conduct. 
 
Restatement (Second) of Torts § 442B (1965) (emphasis added). 
In the present case, regardless whether it was alleged that Dr. Hartford committed greater 
acts of negligence than Dr. Binnion, Dr. Binnion‟s actions must be evaluated solely on whether 
her negligence was sufficient, when paired with any foreseeable subsequent negligence, to 
substantially contribute to the final outcome.  Therefore, Dr. Binnion‟s alleged negligence must 
be evaluated in light of Harrison‟s ultimate injury and not solely with respect to any subsequent 
actions on the part of Dr. Hartford.  Other jurisdictions have looked at multiple causation injuries 
and evaluated whether the “actor‟s negligent conduct actively and continuously operate to bring 
about harm to another[.]”  See Restatement (Second) of Torts § 439; Osborn v. Irwin Mem’l 
Blood Bank, 7 Cal. Rptr. 2d 101 (Cal. Dist. Ct. App. 1992) (finding that § 439 is applicable 
because “[a] „continuous‟ chain of cause and effect is manifest [where] [a boy] received blood 
from [the blood bank‟s] donor pool because [the blood bank] misrepresented that directed 
donations were not available; and [the boy] contracted AIDS because [the] blood was 
contaminated, just as his parents feared it would be”); Schnebly v. St. Joseph Mercy Hosp. of 
Dubuque, 217 N.W.2d 708, 730-31 (Iowa 1974) (overruled on other grounds) (finding the 
laboratory‟s negligence in reporting blood results set the stage for the subsequent negligence of 
the Doctor‟s reliance on those results despite other conflicting results and therefore, the Doctor‟s 
negligence was not a superseding cause to the laboratory‟s liability);  Rudeck v. Wright, 709 P.2d 
621, 627 (Mont. 1985) (holding that a doctor is not relieved from liability for his negligent act of 
leaving a lap mat in patient following surgery because his negligence “actively and continuously 
act[ed] to cause harm to his patient” along with the “active and substantially simultaneous 
negligent act of the nurses” in failing to account for the lap mat); Wilson v. Brister, 982 S.W.2d 
42, 45 (Tex. App. 1998) (finding summary judgment inappropriate where evidence supported the 
contention that physician was a concurring cause of patient‟s suicide despite the negligence of 
the friend that gave patient the gun and bullets). 
In the present case, for the purposes of summary judgment only, it was assumed that Dr. 
Binnion breached the local standard of care in the following areas: 
 
19 
1. Dr. Binnion failed to fully and completely communicate Harrison‟s history, physical 
exam, symptoms and test results to Dr. Hartford prior to Harrison‟s admission to the 
orthopedic floor. 
2. Dr. Binnion failed to communicate within her physician‟s orders at the time they were 
written[] her concerns about rapid elevation of sodium[] and that all laboratory values be 
immediately communicated to Dr. Hartford upon receipt. 
3. Dr. Binnion violated the local standard of care by “admitting” Harrison to the orthopedic 
floor rather than the Intensive Care Unit (even though he also testified she had no 
admitting privileges), and 
4. Dr. Binnion failed to slow the rate [at which] Harrison‟s sodium levels were corrected. 
 
Thus, the inquiry of this Court on review is whether there exists a genuine issue of material fact 
as to whether any of the presumed breaches was a substantial factor in bringing about Harrison‟s 
CPM.9 
 
In his deposition Dr. Navar states that in his opinion Dr. Binnion‟s breach of the local 
standard of care was a substantial factor in causing the condition of CPM in Harrison.  The 
district court‟s opinion states that plaintiff “failed to produce admissible expert testimony that, to 
a reasonable degree of medical certainty, Dr. Binnion caused Harrison‟s CPM by failing to slow 
the correction of his sodium levels before 3:25 a.m. when her care transferred to Dr. Hartford.”  
                                                 
9 The following are cases citing Restatement (Second) of Torts § 431 and discussing whether 
alleged negligence was the proximate cause of the injury pursuant to the substantial factor test.  
Daniels v. Hadley Mem’l Hosp., 566 F.ed 749, 760 (D.C. Cir. 1977) (finding that a hospital‟s 
failure to administer forced oxygen to patient in aniphilactic shock was a substantial factor 
leading to his death not because it decreased circulation and distribution of sus-phrine injection, 
but because patient‟s lack of respiration lead to cardiac arrest and neurological death); Duarte v. 
Zachariah, 28 Cal. Rprt.2d 88, 91 (Cal. Dist. Ct. App. 1994) (holding that injury to bone marrow 
allegedly caused by an over-prescription of medication is actionable regardless whether plaintiff 
can show that it caused reoccurrence of plaintiff‟s cancer); Kaiser Found. Health Plan v. Sharp, 
741 P.2d 714, 720 (Colo. 1987) (finding a triable issue of fact exists even if the doctor “could not 
say „in terms of probability‟ whether hospitalization would have stabilized [plaintiff‟s] 
condition” because “[t]he plaintiffs were not required to prove their case before the trial court on 
a motion for summary judgment”);  Kastler v. Iowa Methodist Hosp., 193 N.W. 2d 98, 103 (Iowa 
1971) (finding that the defendant hospital was a substantial factor in bringing about plaintiff 
patient‟s injury by allowing patient with known fainting spells to shower unsupervised); NKC 
Hosp., Inc. v. Anthony, 849 S.W.2d 564, 565-68 (Ky. Ct. App. 1993) (the hospital‟s negligence 
in prematurely discharging pregnant patient suffering from an undiagnosed perforated appendix 
was a substantial factor in causing her death and not excused by the treating physician‟s failure 
to timely diagnose and treat the condition). 
 
 
20 
The district court and the majority rely on the following testimony of Dr. Navar to support this 
contention: 
A:  I don‟t know whether the initial increase from 96 to 110 over a 12-hour period 
would have been enough to result in the insult just by itself. 
. . . 
Q:  Okay.  How about the 9 milliequivalent increase in the approximate six-hour 
period of time from 0049 to 6 a.m., would that in and of itself have been enough 
to cause CPM in Mr. Harrison? 
A:  I don‟t know. 
 
(emphasis added).  It is clear from the language “just by itself” and “in and of itself” that this 
portion of Dr. Navar‟s deposition addressed whether but-for Dr. Binnion‟s presumed negligence 
the injury to Harrison would not have occurred.  This inquiry misses the point.  The important 
question is: whether Dr. Binnion‟s presumed negligence was a substantial factor in contributing 
to Harrison‟s injury, not whether it was the sole cause.  Dr. Navar specifically addressed this 
question stating in his opinion that “Dr. Binnion‟s breach of the prevailing local standard of care 
as identified above was a substantial factor in causing the condition of [CPM] in Mr. Harrison.” 
The majority takes issue with the fact that Dr. Navar‟s testimony is not supported 
sufficiently with evidence in the record.  However, it was not sufficiently contested either.  The 
only testimony regarding the cause of Harrison‟s CPM addressed whether Dr. Binnion‟s actions 
were sufficient standing alone.  As previously stated, the evidence should have addressed 
whether Dr. Binnion‟s actions were a substantial factor in causing the injury rather than the sole 
cause. 
Further, Dr. Laureno stated that he would be able to provide the following opinions at 
trial and that these opinions were developed to a reasonable degree of medical certainty:10 
6.  The rapid elevation of sodium was a substantial factor in causing the condition 
of CPM, resulting in “Locked-in Syndrome” and neurological injury. 
7.  Had Mr. Harrison‟s sodium been raised at a reasonably conservative rate, more 
likely than not, Mr. Harrison would not have suffered from the condition of CPM. 
 
21 
8.  The rapid elevation of sodium, and resulting CPM, were substantial factors in 
requiring further hospitalization, care, treatment and medical expenses to Mr. 
Harrison. 
 
 
This Court recently adopted the Restatement (Second) of Torts § 457 (1965) which 
“generally applies to any subsequent medical negligence which is necessary to correct an 
original act of medical negligence, thereby making acts of subsequent medical negligence 
generally foreseeable.”  Cramer at ___, 204 P.3d at 514.  We also held that concurring acts of 
negligence would then be analyzed and weighted by the jury pursuant to Idaho‟s comparative 
fault statute.  Id.; See also I.C. § 6-801. 
In Manning, this Court held that a “substantial factor” instruction was properly given to 
the jury in a multiple cause medical malpractice action.11  Manning v. Twin Falls Clinic & Hosp., 
Inc., 122 Idaho 47, 51, 830 P.2d 1185, 1189 (1992).  On April 17, 1987, Daryl Manning was 
admitted for the final time to the Twin Falls Clinic & Hospital.  Id. at 49, 830 P.2d at 1187.  His 
chronic obstructive pulmonary disease (COPD) with marked hypoxemia and increased CO2 
retention had deteriorated to the point where “his death was imminent.”  Id.  On April 20, 
Daryl‟s physician informed the family that he had 24 hours to live; an arterial blood gas test was 
taken which confirmed that his “condition had deteriorated to a point nearly incompatible with 
the sustaining of life.”  Id. at 49-50, 830 P.2d at 1187-88.  Immediately following the arterial 
blood gas test, but prior to the results, the nursing staff temporarily disconnected Daryl‟s 
supplemental oxygen in order to move him to a private room.  Id. at 49, 830 P.2d at 1187.  Daryl 
had been moved less than fifteen feet from his bed when he suffered from extreme respiratory 
distress; he died shortly thereafter. Id. at 50, 830 P.2d at 1188.  Despite the imminence of his 
death, the jury concluded, and this Court affirmed, that the nurses who moved Daryl without the 
use of supplemental oxygen were a proximate cause of Daryl‟s death under the substantial factor 
test.  Id. at 51, 830 P.2d at 1189.  The Manning decision is similar to this case in that the question 
                                                                                                                                                             
10 Dr. Laureno testified at deposition that opinion nos. 6, 7, and 8 were accurate statements of his 
opinions. 
11 The instruction read: “[w]hen I use the expression „proximate cause,‟ I mean a cause which, in 
natural or probable sequence, produced the complained injury, loss or damage.  It need not be the 
only cause.  It is sufficient if it is a substantial factor in bringing about the injury, loss or 
damage.”  Manning, 122 Idaho at 51, 830 P.2d at 1189. 
 
22 
posed to the jury is not whether the removal of Daryl‟s oxygen was the sole cause of his death, 
but rather whether it substantially contributed to his death. 
Similarly, the question here should be posed as to whether Dr. Binnion‟s negligence 
substantially caused Harrison‟s resulting CPM, not whether Dr. Binnion was the sole cause.  It is 
then for the jury to apportion fault among all the allegedly negligent actors.  As in Cramer, the 
alleged negligence in this case of Dr. Binnion should be compared to the alleged negligence of 
Dr. Hartford pursuant to Idaho‟s comparative fault statute.  See I.C. § 6-801. 
 
There is no doubt that the evidence in the record is conflicting.  However, it is improper 
for this Court or the district court to weigh that conflicting evidence once the plaintiff 
sufficiently rebuts the defendant‟s contention that no genuine issue of material fact exists.  I find 
the expert testimony of Dr. Navar sufficient to create a genuine issue of material fact as to 
whether Dr. Binnion, the initiator in this unfortunate stream of events, was a substantial factor in 
causing Harrison‟s CPM.  It may well be that the evidence is weak compared to the competing 
evidence, but the weight of the evidence is not the issue at the summary judgment stage.  There 
is at least a triable issue of fact as to causation that should survive summary dismissal. 
 
HORTON, J., dissenting in part. 
 
I join in the Court‟s decision except for Part III(A), from which I respectfully dissent.  I 
am unable to conclude that the district court erred by denying Plaintiffs‟ motion to amend their 
complaint to add a claim against the Hospital for negligent credentialing by granting hospital 
privileges to Dr. Hartford. 
 
Setting aside the pivotal question whether I.C. § 39-1392c affords the Hospital immunity 
from a claim of negligent credentialing, it is evident that the district court applied the appropriate 
legal standards governing the motion to amend.  The district court correctly observed that the 
decision whether to grant Plaintiffs leave to amend their complaint was a matter committed to its 
discretion.  See e.g. Youngblood v. Higbee, 145 Idaho 665, 667, 182 P.3d 1199, 1201 (2008) 
(citing Hines v. Hines, 129 Idaho 847, 853, 934 P.2d 20, 26 (1997)).  The district court also 
correctly noted that I.R.C.P. 15(a) provides that such “leave shall be freely given when justice so 
requires.”  Finally, the district court properly recognized that in reaching its decision whether to 
grant leave to amend, it was appropriate to consider whether the amended pleading set forth a 
valid claim.  See e.g. Spur Products Corp. v. Stoel Rives LLP, 142 Idaho 41, 44, 122 P.3d 300, 
 
23 
303 (2005) (citing Black Canyon Racquetball Club, Inc. v. Idaho First Nat’l Bank, N.A., 119 
Idaho 171, 175, 804 P.2d 900, 904 (1991)).    
 
Turning to the question whether I.C. § 39-1392c provides immunity to the Hospital for its 
credentialing decision, the district court found the statute to be unambiguous.  The district court 
then summarized its analysis as follows: 
The Harrisons‟ logic would place this Court in the untenable position of granting 
St. Alphonsus immunity for reading the material but simultaneously holding St. 
Alphonsus liable for using the contents read by the committee in the material 
when granting or denying credentials.  As St. Alphonsus contends, the act of 
issuing the credential is the ultimate use of credentialing material. 
 
(emphasis original). 
 
I agree with the district court‟s conclusion.  The statute in question, I.C. § 39-1392c, 
provides as follows: 
 
The furnishing of information or provision of opinions to any health care 
organization or the receiving and use of such information and opinions shall not 
subject any health care organization or other person to any liability or action for 
money damages or other legal or equitable relief.  Custodians of such records and 
persons becoming aware of such data and opinions shall not disclose the same 
except as authorized by rules adopted by the board of medicine or as otherwise 
authorized by law.  Any health care organization may receive such disclosures, 
subject to an obligation to preserve the confidential privileged character thereof 
and subject further to the requirement that such requests shall be made and such 
use shall be limited to aid the health care organization in conducting peer review. 
  
The first sentence defines a broad grant of immunity for both “[t]he furnishing of information or 
provision of opinions to any health care organization” and “the receiving and use of such 
information and opinions.”  This begs the question:  What is the intended scope of conduct for 
which immunity is granted?  I believe that the final sentence of the statute answers this question:  
“Such use shall be limited to aid the health care organization in conducting peer review.”   
In my view, in addition to providing for the confidentiality of peer review materials, see 
I.C. § 39-1392b, by its adoption of I.C. § 39-1392c, the legislature expressly and unambiguously 
 
24 
provided a broad grant of immunity for peer review activities conducted by health care 
organizations.  This grant of immunity is extended beyond those who simply provide 
information; rather, the grant of immunity is extended to those who act on peer review 
information.  The statutory definition of “peer review” activities by a health care organization 
expressly includes credentialing decisions.  I.C. § 39-1392a(11)(a).   The Hospital clearly is a 
“health care organization” as defined by I.C. § 39-1392a(3).  As the legislature has 
unambiguously provided that a credentialing decision is a peer review activity, I would affirm 
the district court‟s decision denying Plaintiffs‟ motion to amend.