FI L ED U.S. COURT OF APPEAL S EL EVENTHCI RCUI T MARCH 22, 2011 J OHN L EY CL ERK [DO NOT PUBLISH] IN THE U

NITED STATE S COURT OF APPEALS FOR THE ELE VENTH CIRCUIT

__ __ __ __ __ __ __ __ __ __ __ __ No. 1 0- 12 92 7

__ __ __ __ __ __ __ __ __ __ __ __ D.C. Dock etNo. 2 :0 7- cv -0 03 49 -J EO ELLIS M. HAMMONDS, in di vi du al ly andby andth ro ug h h is Nex t Leg al Fri en d, No rm anE. Ham m on ds , ll ll ll ll ll ll ll ll ll ll l Pl ai nt iff - App el la nt , vers us UNITED STAT ES OF AMERIC A, th ro ug h i ts ag en ts , serva nt s an d e m pl oyees orag en ts , serva nt s, an d e m pl oyees o f it s ag en cy , ll ll ll ll ll ll ll ll ll ll l Defen da nt- App el le e.

__ __ __ __ __ __ __ __ __ __ __ __ App eal fro m

th e Uni te d S ta te s Di st ric t Co urt forth e North ern Dis tri ctof Al ab am a

__ __ __ __ __ __ __ __ __ __ __ __ (Ma rch 22 , 20 11 )Befo re CARNES a ndPRYOR, Ci rcu itJu dg es , andSEITZ, Dis tri ctJu dg e. * PER CURI AM: W e m us t d et erm in e in th is cas e whe th er the re i s l iabi li ty on am ed ic al
ne gl ig en ce cl ai m

when th e ri skgi vi ng ris e to a du ty of care di d n otcau se th e h arm bu t the ha rm

m ig hthave be enser en di pi to us ly avo id edif t he st an dardof c are h ad
no t b een bre ach ed . To res ol ve th is is su e we ap pl y Alab am a la w, whi ch for

bo th th e dut y an d p ro xi m at e cau se ele m en ts of ane gl ig en ce cl ai m requi res th e ri skof ha rm to be for es eeab le . Fore se eab il ity is in co ns is te ntwith s eren di pi ty. I. InDecem be r 20 03 Ell is Ham

m on ds , who is a ve te ran , hadbi la te ral hi p rep la cem en ts . On Oct ob er 4 , 20 05 , Ham m on ds wentto th e Vet eran s Adm in is tra ti on Med ic al Cen te r inBirm in gh am , Alab am a to see a de nt is t. Dr. Den ni s R affe rty didanora l ex am in at io n a ndpre sc rib edan ti bi ot ic s t o Hamm on ds be fo re cl ean in g h is tee th . Ant ib io ti cs were n eces sa ry be cau se of t he ris k t ha t Ham m on ds m ig htde ve lo p an i nf ect io n i n h is art ifi ci al hi p jo in ts as ares ul t o f th e te eth c le an in g.

Honora ble Patricia A . Seitz , United States District Judg e for the Southern District of * Florida , sitti ngby

designation. 2On No ve m be r 3, 2 00 5, Hamm on ds was s ch edul edto ha ve whathe de sc rib es as “ a se da ti ve -in du cedde nt al pro cedur e.” Bef or e th e sc he du le d d at e fo r th e pr oc edur e, Dr. Cas hi on , a st aff d en ti stat t he VA Med ic al Cen te r, pr es cri be d
an ti bi ot ic s fo r Hamm on ds
. A li tt le ov er a wee k b efo re Hamm on ds ’ Nov em be r 3 ap po in tm en t, Dr. Rex Adam s i ns tru ct edhi m to tak e fo uran ti bi ot ic cap su le s o ne ho urbe fo re the de nt al pro cedur e. Dr. Adam s, wh o was Ham m on ds ’ tre at in g d en ti stforth e Nov em be r 3 pr oc edur e, la te r te st ifi edin hi s d ep os it io n t ha t fo r a p at ie ntwho ha d u nd erg on e a hi p re pl acement t he st an da rdof c are r equi redpro ph y la ct ic an ti bi ot ic th erap y , sp eci fic al ly two g ram s o f am ox ic il li n o ne ho urbe fo re the de nt al ap po in tm en t. If th e p at ie ntsai d h e h adno t t ak enth e an ti bi ot ic , th e dru g wo ul d b e ad m in is te red , an d t he de nt al pro cedur e wou ldbe de la y edforanho ur . Ham m on ds tes ti fie d i n h is de po si ti on th ataft er h is m ou th ha d b een “ nu m be d” an d t he pro cedur e was un de rway , he r em em

be redth e an ti bi ot ic pre sc rip ti on an d t ol d Dr. Ad am s t ha t h e ha d n ottak enit . He was g iv enth e an ti bi ot ic , bu t the pro cedur e was in pro gr es s an d t he re was no on e h ou r de la y . 1

In Hammonds’ medica l rec ords Dr. A dams noted that he a sked Hammonds whether he 1 had take n the medication, and Hammonds responde d that he had. I n our re view of the decision to gr ant summary

judgme nt to the defe ndant, howeve r, “a ll facts ar e viewe d, and all fa ctual disputes are resolved, in the light most favorable to the plaintiff.” Johnson v. Univ. Health Servs., Inc., 161 F .3d 1334, 1337 n.5 (11th Cir. 1998). 3A few week s af te r th e Nov em

be r 3 d en ta l p ro cedur e Hamm on ds , who ha d
no hi st ory

of h eartpro bl em s, was di ag no se d wi th in fect iv e en do card it is , whi ch is
anin fla m m at io n o f th e in ne r la y er o f th e h eart . Ham m on ds di d n otde ve lo p a ny co m pl ic at io ns rel at edto hi s h ip rep la cem en ts . II. Ham m on ds fil eda la wsu itag ai ns t the Uni te d S ta te s u nd er the Fed eral Tort Cl ai m s Act , 28 U.S.C. § 2 67 1 e t s eq ., all eg in g d en ta l n eg li ge nc e. Afte r th e di sc ov ery pe rio d h adclo se d, t he Uni te d S ta te s fi le d am ot io n fo r su m m ary jud gm en t. Inrul in g o n t ha t m ot io n t he di st ric t co urt co rrec tl y ob se rv edas a n in it ia l m at te r th atAlab am a subs ta nt iv e la w app li es to Ham m on ds ’ FTCA cl ai m . See Och ran v. Un it edSta te s, 2 73 F.3d13 15 , 13 17 (11 th Cir . 20 01 ) (ex pl ai ni ng th at“ th e [FTCA’s] refere nc e to th e ‘law of th e p la ce’ m ean s l aw of

th e St at e—t he
so ur ce o f subs ta nt iv e li ab il it y un de r th e FTCA.”). If t he re i s n o s ta te law l iabi li ty, th ere i s n o F TCA li ab il it y . Id. The di stric t co urt n ot edth atHam m on ds ha d p res en te d e vi de nc e o f th e ap pl ic ab le st an da rdof c are t hr ou gh Dr. Adam s’ tes ti m on y . The co urt ex pl ai ne d: [Dr. Ada m s] st at edin hi s d ep os it io n tha t the st an da rdof c are i n Nov em be r 20 05 with re sp ectto pro ph y la ct ic an ti bi ot ic th erap y for pa ti en ts who ha d u nd erg on e h ip rep la cem en t s ur ge ry li ke th e p la in ti ff was two gra m s o f am ox ic il li n o ne ho urpri orto th e d en ta l ap po in tm en t. Ad di ti on al ly, Dr. Adam s s ta te d t ha t i f a p at ie ntha d n ot 4ta ke n the an ti bi ot ic on e h ou r pr io r to th e p ro cedur e, th e an ti bi ot ic

sh ou ldbe adm in is te redan d t he pro cedur e d el ay edfor on e h ou r. The co urt d et erm in edth atDr. Adam s’ “ fai lu re t o fo ll ow t he tes ti fie d- to pro to co l whe n d eal in g wi th cert ai n h ip rep la cem en t p at ie nt s ex po se d t he pl ai nt iff to a ri sk of ha rm fro m in fect io n i n h is hi p jo in ts .” Even so , th e co urt re jecte d Hamm on ds ’ effo rts to “ tra ns fer t ha t ri skof h arm to th e ri skof d ev el op in g a‘ ba ct eri al -rel at ed [in fect io n] tri gg eredby the de nt al pro cedur e.’” It co nc lu de d t ha t “ itwou ldbe in ap pr op ria te un de r th e ci rcu m st an ces to im po se su ch a ge ne ral du ty.” T he co urt he ldth at“ th ere was no leg al du ty to g iv e th e p la in ti ff an an ti bi ot ic reg im e[n ] pr eced in g t he
. . . de nt al pro cedur e b ey on d the ris k a ss oc ia te d wi thth e h ip rep la cem en t.” Ham m on ds lat er fi le d aRu le 59 m ot io n t o a lt er o r am en d the jud gm en t, whi chth e d is tri ctco urt d en ie d. Th e co urt re it erat edth atth ere was a qu es ti on of factab ou t wh ethe r Dr. Ada m s h adbre ach edth e st an da rdof c are wh enhe fai le d t o gi ve Ham m on ds two gra m s o f am ox ic il li n o ne ho urbe fo re h is de nt al pro cedur e in
or de r to pre ve ntin fect io n i n h is art ifi ci al hi p jo in ts . The co urt co nc lu de d, ho wev er, tha t “ th is was n ota qu es ti on of m at eri al fact , bec au se ev enif Dr. Ad am s fai le d t o fo ll ow t he st an da rd , th e in jury Plai nt iff

su ffer ed , bac te ria l en do card it is , was no t fo res eeab le at t he ti m e o f th e p ro cedur e.” The reas on in g was th at

5Ham

m on ds ha d n o h is to ry

of h eartdi se as e, so th e in jury thatoc curredwas un fo res eeab le , andun de r Alaba m a la w Dr. Adam s h adno du ty to p rev en t an un fo res eeab le in

jury. The co urt wen t o n t o s ta te th at“ Dr. Adam s’ du ty w as to pr ev en t o nl y

th e in jury thatwas fo res eeab le to hi m at t he ti m e o f th e d en ta l pr oc edur e, i.e., i nf

ect io n t o P la in ti ff’s h ip rep la cem en t jo in t.” Fu rth erm or e, “ were itno t fo r Pl ai nt iff’s ris k o f de ve lo pi ng in fect io n t o h is hi p re pl acement jo in t, Dr. Ada m s wo ul d n othave adm in is te redth e an ti bi ot ic in th e fi rs t p la ce.” III.

“ W e rev ie w de n ov o t he di st ric t co urt’s g ran t o f a m ot io n fo r su m m ary jud gm en t, co ns id eri ng all of t he ev id en ce an d t he in fere nc es itm ay y ie ldin th e li gh t m os t fa vo rab le to th e n on m ov in g p arty .” Ell is v. En gl an d, 4 32 F.3d13 21 , 13 25 (11 th Cir . 20 05 ). Ham m on ds co nt en ds th atth e fo res eeab le ris k o f ha rm fro m th e fai lure t o p ro pe rly adm in is te r th e am ox ic il li n was th e d ev el op m en t o f an in fect io n, re ga rd le ss of i ts lo cat io n i n the bo dy. He as se rts th atDr. Adam s’ du ty was to pre ve ntall for es eeab le in fect io ns , no t ju sta si ng le on e, an d t ha t an un in te nd edbe ne fitof p ro pe rly adm in is te redan ti bi ot ic s wo ul d h av e b een th e pr ev en ti on of i nf

ect iv e en do card it is
. The Uni te d S ta te s co nt en ds th atbe cau se Ham m on ds ha d n o h is to ry

of h eart tro ub le hi s d ev el op m en t o f in fect iv e en do card it is was u nf or es eeab le , andth e VA 6Med ic al Cen te r owe d h im no du ty to t ak e p ro ph y la ct ic m eas ur es ag ai ns t the ris k o f th atin jury. Ham

m on ds ha s o ffer edno ev id en ce s ug ge st in g t ha t a r is k o f in fect io n in hi s h ip joi nt s i nd ic at es an y ris k o f de ve lo pi ng in fect iv e en do card it is
. The Uni te d S ta te s as se rts th atDr. Adam s h adno reas on to th in k t ha t the de nt al pr oc edur e wou ldsubjec t Hamm on ds to a wid e v ari ety of b od il y in fect io ns . Hip joi ntin fect io n was th e o nl y in fect io n t ha t p os eda ri sk , andth atparti cu la r ri skwas th e o nl y reas on a pr op hylact ic an ti bi ot ic was p res cri be d. Und er Al ab am a la w “ th e que st io n o f whe th er a l eg al du ty exi st s i s es se nt ia ll y

a qu es ti on of l aw fo r th e co urt, t o b e res ol ve d b y de te rm in in g wh ethe r th e in jury w as for es eeab le .” Keeb le r v. Win fie ldCarr away Hos p., 5 31 So . 2d84 1, 84 4 (Al a. 19 88 ) (ci ta ti onom it te d) . App lying th atrul e, th e Alaba m a Supr em e Co urt h as he ldth ata ph y si ci an ’s du ty to g ua rdag ai ns t h is pa ti en t’s co m m it ti ng su ic id e d ep en ds up onth e fo res eeab il it y of t he su ic id e. See i d. at84 5. Ch arl es Keeb le r ha d b een tre at edat aho sp it al for a po ss ib le ov erd os e o f va li um an d al co ho l an d t he n was rel eas edfro m th e h os pi ta l’s ca re. Id . at 8 45 . Keebl er was ta ke n t o jai l wh ere h e h an ge d h im se lf. Id . at 8 43 –4 4. Hi s wi fe fi le d alaws ui t ag ai ns t the ho sp it al as we ll as t he do ct oran d n ur se who tre at edKeeb le r, all eg in g 2
The plaintiff a lso brought claims ag ainst the City of Winfield and some city employees, 2 but those claims wer e settled be fore trial. I d. at 842. 7wro ng fu l d eat h b as edon m ed ic al m al pr act ic e. She ass ert edth atth e d efen da nt s 3 ha d adu ty to co nt in ue m ed ic al tre at m en t an d t o p ro hi bi t Kee bl er fro m lea vi ng th e ho sp it al . See i d. at84 4. Th e co urt o bs erv edth atKeeb le r ha d n otbe enadm it te d t o th e h os pi ta l as a res ul t o f a s ui ci de att em pt , hadno hi st ory

of s ui ci da l t en de nc ie s, an d h adno t d is pl ay edan y at t he ho sp it al . Id. at84 5. Be cau se Keeb le r’s su ic id e was no t fo res eeab le , th ere was no leg al du ty to p ro vi de co nt inue d m ed ic al care in
or de r to pre ve ntit , andth e tr ia l co urt co rrec tl y en te reda di rect edve rd ic t i n fa vo r of th e d efen da nt s. Id
. Ina la te r de ci si on , th e Alaba m a Supr em e Co urt cl ari fie d t he fun ct io n o f fo res eeab il it y

in an al y zi ng th e dut y

ele m en t o f a m ed ic al m al pr act ic e cl ai m . See Pat to n v . Tho m

ps on , 95 8 S o. 2 d 3 03 , 31 0– 11 (Ala . 20 06 ). The co urt ex pl ai ne d 4 Dental malpr actice claims are subject to the same a naly sis as other medica l malprac tice 3 claims bec ause, a s the Alabama Supreme Court ha s rec ognized, the Alabama Me dical L iability Act of 1987, A la. Code §§ 6-5- 540 through -552, “spe cifica lly includes dentists within the definition of ‘he alth car e provide rs’ c overe d under the AMLA.” Schuf fer t v. Morg an, 777 So. 2d 87, 88 n.1 (Ala. 2000)
. A re cent Ala

bama Supre me Court decision discusses Patton and the issue of 4 fore seea bility in the medical malpr actice context. S ee B rela nd ex rel. Br eland v. Rich, — So. 3d —, 2011 WL835065, at *19–20 (Ala . Marc h 11, 2011). Even though the B rela nd opinion rec ognizes that suicide case s are differ ent from other medical malpr acticecase s, the dec ision does not overr

ule Alaba ma pre cede nt requiringfore seea bility as par t of the duty

and proximate cause elements of a

non-suicide medic al malpra ctice c laim. See id. at *20. The A labama Supreme Court explained: The pre sent ca se did not involve a suicide. The duty of hea lth-car e provide rs, when a patient may

attempt to harm himself, conte mplates the re asonably fore seea ble occ urre nce of

self har m, and such self

-destruc tive conduct involves 8th atin th e Keeb le r cas e: “ [T]he dut y th e em erg en cy -ro om

ph y si ci anowedto th e de ceas eddi d n otin cl ud e a s ta nd ardof c are t o p ro te ctag ai ns t o r to pre ve ntsu ic id e, be cau se th ere was anab se nc e o f fac to rs th atwou ldha ve m ad e th e p at ie nt ’s su ic id e fo res eeab le , th ereb y

tri gg eri ng su ch a du ty.” Id. at30 9. Fo r th e el em en t o f pr ox im at e cau se ina m ed ic al m al pr act ic e cl ai m , “ th e p la in ti ff m us t d em on strat e th atth e al le ge d n eg li ge nc e p ro babl y cau se d, ra th er tha n o nl y

po ss ib ly caus ed , th e pl ai nt iff’s in

jury.” Id. at 3 11 (qu ot at io n m ark s o m it te d) . The co urt al so reco gn iz edth at , whi le du ty is g en eral ly a qu es ti on of l aw, se e id . at 3 10 –1 1,

“pr ox im at e cau se is alm os t al way s a que st io n o f fac t.” Id . at 3 12 (qu ot at io n m ark s an d a lt erat io ns om it te d)
. Alt ho ug h t he ex is te nc e o f pr ox im at e cau se is “ al m os t al way s” a qu es ti on of fact , alm os t al way s i s n otalwa y s. Th e Alaba m a Supr em e Co urt h as affi rm ed
su m m ary jud gm en t fo r a d efen da nton a pl ai nt iff’s neg li ge nc e cl ai m s wh enth e the nec essity

of pre cautions or sa feguards to attempt to pre vent such ha rm. Her e, [the plaintiff] was not re quired to prove that Dr. Rich knew or should have known that it was fore seea

ble that the “sa feguard” of havingboth an eye for m and an eye-e x am book in the [neonatal intensive ca re unit] would fail. I d. The patient in that case w as at risk of de velopingretinopathy of pre maturity

(ROP), and he r treating pe diatric ophthalmolog ist, Dr. Rich, put her on the list of patients at risk for ROP. I d. at *1. It was for esee able that Dr . Rich’s failure to rec ord information corre ctly in the eye exam book might lea d to a fa ilure to provide, or at least a delay in providing, ne cessa

ry follow-up examinations t o detec t ROP, which then might lea d to the patient’s injury (blindness). In the prese nt case , by

contra st, there wa s no evidenc e that Dr . Adams’ f ailure to prope rly

administer a prophylactic a

ntibioti c might forese eably lead to Hammonds’ hear t infection bec ause H ammonds had no history

of hea rt trouble. 9pl ai nt iff

s’ in juri es were n otfor es eeab le an d fo r th atreas on no pro xi m at e cau se ex is te d. Se e Tho m

ps on v. Gai er, 5 12 So . 2d77 5 (Al a. 19 87 ); a cco rdTho m ps on v. Pat to n, 6 So . 3d11 29 , 11 35 (Ala . 20 08 ) (aff irming jud gm en t as a m at te r of law gr an te d i n fa vo r of

th e d efen da ntan d e xp la in in g t ha t “ [u ]nde r Alaba m a la w, ev id en ce s ho win g o nl y

a pr ob ab il it y

of apo ss ib il it y

is no t s uf fic ie ntto est ab li sh pr ox im at e cau sa ti on in a ne gl ig en ce ac ti on all eg in g m ed ic al m al pr act ic e”). InTho m ps on a pi zza d el iv ery dr iv er ac ci de nt al ly dro ve hi s ca r on to th e Tho m ps on s’ pro pe rty, kno ck in g d own th ei r m ai lb ox an d n earl y hi tt in g o ne of t he Tho m ps on ch il dr en . 51 2 S o. 2 d a t 7 75 . The ch il d’s fa th er, wh o was reco ve rin g fro m ba ck su rg ery, tu rn edqu ic kl y

to see “ th e co m

m ot io n,” an d re -in

jure d h is ba ck
. Id . at 7 76 . The Th om

ps on s s ue d t he pi zza d el iv ery dr iv er an d h is em pl oyer for

“ ne gl ig en tl y

op erat in g am ot or

ve hi cl e an d n eg li ge nt ly m ai nt ai ni ng an d e nf or ci ng a p ol ic y of p iz za d el iv ery. ” Id . at 7 75 . The two Tho m

ps on ch il dr enwho were p res en t wh enth e acc id en t o ccu rred
co ul d n otcla im

in juri es be cau se “ inrep ly to anin te rro ga to ry co nc ern in g t he ir cl ai m edin

juri es , [th ey ] res po nd ed“N/A” o r no t ap pl ic ab le .” Id . As fo r th ei r fathe r, th e co urt h el d t ha t h is in juri es “ co ul d n otbe vi ewedas f or [e]see ab le an d a s a p ro xi m at e res ul t o f [the de fen da nt ’s] dri vi ng th e caron to th e p ro pe rty.” Id. at 77 6. Th e m ot he r’s in

juri es were n otfor es eeab le eit he r, be cau se sh e was no t

10pr es en t wh enth e acc id en t o ccu rred . Id. As ares ul t, the co urt af firm edsu m

m ary jud gm en t i n fa vo r of

th e d efen da nt s. Id . (“ [A]s th e p la in ti ffs ha ve ad du cedno ev id en ce t o s ho w th atth e d efen da nt s p ro xi m at el y cau se d t he ir i nju rie s, the tri al
co urt co rrec tl y

gra nt edth e su m

m ary jud gm en t an d tha t ju dg m en t i s due to be affi rm ed .”). Inth e p res en t ca se th e o nl y ha rm th atreas on ab ly cou ldha ve be enfor es een fro m Ham m on ds ’ fai lure t o t ak e th e p ro ph y la ct ic an ti bi ot ic as d ire ct edwas a n in fect io n i n h is art ifi ci al hi p jo in ts . There is no ev id en ce tha t h e sh owe d any sig ns of ris k o f an y

ot he r type o f in fect io n. Ev enif apro pe rly adm in is te redpro ph y la ct ic
an ti bi ot ic m ig htha ve pre ve nt edth e in fect iv e en do card it is , th atin jury w as on e th at co ul d n otha ve be enfor es een . Reg ard le ss of wh ethe r un fo res eeab il it y is vi ewedas a fai lu re t o e st ab li sh a ge nu in e is su e o f m at eri al factonth e dut y ele m en t o r on th e pr ox im at e cau se ele m en t, the res ul t i s t he same. The di st ric t co urt co rrec tl y gr an te d s umm ary jud gm en t i n fa vo r of th e Uni te d S ta te s. AFFIRMED.

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