IN THE COURT OF APPEALS OF NORTH CAROLINA

No. COA 20-27

Filed: 16 June 2020

Wake County, No. 18 CVS 3250

ROBERT E. MONROE, as Administrator of the Estate of NAKA HAMILTON, 

Plaintiff,

v.

REX HOSPITAL, INC. d/b/a REX HOSPITAL, REX HEALTHCARE, UNC REX 

HOSPITAL, UNC REX HEALTHCARE, UNC REX HEMATOLOGY ONCOLOGY 

ASSOCIATES and HENRY CROMARTIE, III, M.D., Defendants.

Appeal by defendant from order entered 24 July 2019 by Judge A. Graham 

Shirley II in Wake County Superior Court. Heard in the Court of Appeals 26 May 

2020.

Charles G. Monnett III & Associates, by Charles G. Monnett III, and 

Spangenberg Shibley & Liber LLP, by Jeremy A. Tor and Stuart E. Scott, for 

plaintiff-appellant.

Young Moore and Henderson, P.A., by Madeleine M. Pfefferle and Elizabeth P. 

McCullough, for defendant-appellee.

YOUNG, Judge.

This appeal arises out of a medical malpractice claim. Plaintiff failed to show

causation, and there was no genuine issue of material fact exists. Therefore, the trial 

court properly granted summary judgment. Accordingly, we affirm.

I. Factual and Procedural History
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On 27 April 2016, Naka Hamilton (“Ms. Hamilton”) went to the Rex Hospital 

Emergency Department (“Rex ED”). John Lilley, M.D., (“Dr. Lilley”) was the doctor 

present at Rex ED when Ms. Hamilton arrived. Dr. Lilley called Henry Cromartie, 

III., M.D., (“Dr. Cromartie”). Ms. Hamilton was admitted to Rex and received a 

diagnosis of Thrombotic thrombocytopenic purpura (“TTP”). TTP can rapidly 

progress and the treatment for it is plasma exchange therapy (“PLEX”). If TTP is left 

untreated, multi-organ failure and death can occur. Without PLEX, the mortality 

rate is 90%. If PLEX is timely administered, the mortality rate is 10%.

Upon Ms. Hamilton’s TTP diagnosis, Dr. Cromartie recommended a bridge 

therapy treatment be administered to correct her anemia prior to the initiation of 

further treatment. Dr. Cromartie recommended that Dr. Lilley order Ms. Hamilton 

further laboratory tests and believed Ms. Hamilton should receive packed blood cells 

(“PRBC”) and fresh frozen plasma (“FFP”) as her first line of treatment. Dr. 

Cromartie claims he was not the on-call hematologist on 27 or 28 April 2016, but that 

he agreed to consult on the patient and did not tell Dr. Lilley that he was not on-call.

After Dr. Cromartie’s conversation with Dr. Lilley, Ms. Hamilton was admitted 

to the Intensive Care Unit (“ICU”) by Rex Hospitalist Ahmed Khan, M.D. (“Dr. 

Khan”). Dr. Cromartie spoke with Dr. Khan at approximately 1:30 a.m. on 28 April 

2016 and provided his recommendations. Dr. Cromartie was not consulted further 

and did not have any further involvement in Ms. Hamilton’s care. Dr. Cromartie 
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expected transfusions of PRBC and FFP would be completed within five to seven 

hours, which would approximately coincide with shift changes when the morning 

physicians would arrive at the hospital. 

The orders were not entered until 4:40 a.m. on 28 April 2016, the first FFP 

transfusion was not administered until around 9:00 a.m., and the first PRBC was not 

administered until 11:08 a.m. Ms. Hamilton remained at the hospital for more than 

eleven hours after Dr. Cromartie’s conversation with Dr. Khan. She was treated by 

numerous health care providers until she passed on 28 April 2016 at approximately 

2:28 p.m. without receiving PLEX. 

Ms. Hamilton was survived by a one-year-old daughter. A complaint for 

wrongful death, medical malpractice was filed by Ms. Hamilton’s estate. The 

complaint named Dr. Cromartie and several other defendants. All defendants except 

Dr. Cromartie have been voluntarily dismissed from the case. Plaintiff called John 

Feigert, M.D. (“Dr. Feigert”) as the only causation expert. 

On 31 May 2019, Dr. Cromartie filed a motion for summary judgment, a motion 

to strike, and a motion to dismiss. The trial court entered an order granting summary 

judgment and dismissed the case based on the defense of superseding negligence. 

Plaintiff filed timely written notice of appeal. 

II. Standard of Review
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“On appeal, the appellate court reviews summary judgments to determine if 

there was a genuine issue as to any material fact and whether the movant is entitled 

to judgment as a matter of law. The standard of review for summary judgment is de 

novo.” Howse v. Bank of Am., N.A., 255 N.C. App 22, 26, 804 S.E.2d 552, 555 (2017); 

see also Robinson v. Duke Univ. Health Sys., Inc., Inc., 229 N.C. App. 215, 219, 747 

S.E.2d 321, 326 (2013); N.C. Gen. Stat. § 1A-1, Rule 56 (c)(2019).

III. Causation

Summary judgment is proper when the plaintiff fails to produce sufficient 

evidence of an essential element of a medical malpractice action: applicable standard 

of care, breach of the standard of care, causation, and damages. Weatherford v. 

Glassman, 129 N.C. App. 618, 621-22, 500 S.E.2d 466, 468-69 (1998). North Carolina 

courts “rely on medical experts to show medical causation because ‘the exact nature 

and probable genesis of a particular type of injury involves complicated medical 

questions so far removed from the ordinary experience and knowledge of laymen[.]’” 

Day v. Brant, 218 N.C. App. 1, 11, 721 S.E.2d 238, 246 (2012) (quoting Azar v. 

Presbyterian Hosp., 191 N.C. App. 367, 371, 663 S.E.2d 450, 453 (2008)). To hold a 

defendant responsible for injuries, expert medical testimony is necessary to establish 

that defendant’s negligence was a substantial factor, that is, a proximate cause of the 

particular injuries for which plaintiff seeks recovery. See Lee v. Stevens, 251 N.C. 

429, 433-34, 111 S.E.2d 623, 626-27 (1959).
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In North Carolina, the legal definition of proximate cause is:

a cause which in natural and continuous sequence, 

unbroken by any new and independent cause, produced the 

plaintiff’s injuries, and without which the injuries, would 

not have occurred, and one from which a person of ordinary 

prudence could have reasonably foreseen that such a 

result, or consequences of a generally injurious nature, was 

probable under all the facts as they existed.

Adam v. Mills, 312 N.C. 181, 192-93, 322 S.E.2d 164, 172 (1984) (quoting Hairston v. 

Alexander Tank & Equipment Co., 310 N.C. 227, 233, 311 S.E.2d 559, 565 (1984)).

The natural and continuous sequence of causation may be interrupted or 

broken by the negligence of a second actor. Muse v. Charter Hosp., 117 N.C. App. 

468, 452 S.E.2d 589 (1995); see also N.C.P.I. Civil 102.65 (2016). In analyzing when 

a subsequent negligent act insulates a defendant’s negligence, the North Carolina 

Supreme Court reasoned, “[s]upposing that if it had not been for the intervention of 

a responsible third party the defendant’s negligence would have produced no damage 

to the plaintiff, is the defendant liable to the plaintiff? This question must be 

answered in the negative, for the general reason that no causal connection between 

negligence and damage is broken by interposition of independent responsible human 

action.” Butner v. Spease, 217 N.C. 82, 87, 6 S.E.2d 808, 811 (1940).

If a second actor’s conduct creates a “new cause, which intervenes between the 

original negligent act and the injury ultimately suffered” and “breaks the chain of 

causation set in motion by the original wrongdoer”, the second actor becomes “solely 
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responsible for the injury.” Muse, 117 N.C. App. at 476, 452 S.E.2d at 595. “The 

doctrine of insulating negligence is an elaboration of a phase of proximate cause.” 

Hampton v. Hearn, __ N.C. App. __, __, 838 S.E.2d 650, 655 (2020) (internal quotes 

omitted) (citing Clarke v. Mikhail, 243 N.C. App. 677, 686, 779 S.E.2d 150, 158 (2015) 

(holding intervening and superseding cause is an extension of proximate cause, which 

the plaintiff bears the burden of establishing). The burden of proof remains on the 

plaintiff to prove the defendant’s conduct was a proximate cause of his injuries and 

the burden is not shifted to the defendant to prove that his negligence, if any, was 

insulated by the negligence of another. Hampton, __N.C. App. at __, 838 S.E.2d at 

655.

IV. Intervening and Superseding Cause

For an intervening cause to insulate an original negligent actor of liability the 

“cause must be an independent force which turns aside the natural sequence of events 

set in motion by the original wrongdoer and produces a result which would not 

otherwise have followed, and which could not have been reasonably anticipated.” 

Muse, 117 N.C. App. at 476, 452 S.E.2d at 595. “The test by which the negligent 

conduct of one is to be insulated as a matter of law by the independent negligent act 

of another, is reasonable unforeseeability on the part of the original actor of the 

subsequent intervening act and resultant injury.” Adams v. Mills, 312 N.C. 181, 194, 

322 S.E.2d 164, 173 (1984). Therefore, “in order for the conduct of the intervening 
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agent to break the sequence of events and stay the operative force of the negligence 

of the original wrongdoer, the intervening conduct must be of such nature and kind 

that the original wrongdoer had no reasonable grounds to anticipate it.” Id. North 

Carolina rejects the rule that “subsequent medical treatment is foreseeable as a 

matter of law.” Barber v. Constien, 130 N.C. App. 380, 384, 502 S.E.2d 912, 915 

(1998).

The trial court can declare whether an act was the proximate cause of an injury 

when there is such little evidence as to warrant an inference of proximate cause. Lee, 

251 N.C. 433-43, 111 S.E.2d at 627 (“We may say with certainty that evidence which 

merely shows it possible for the fact in issue to be as alleged, or which raises a mere 

conjecture that it was so, is an insufficient foundation for a verdict, and should not be 

left to the jury”).

V. Analysis

In this case, there is no evidence that the subsequent negligence was directly 

related to or dependent upon Dr. Cromartie’s alleged negligence. Plaintiff’s only

causation expert, Dr. Feigert, testified that the negligent delay in administering the 

blood products redirected the natural sequence of events set in motion by Dr. 

Cromartie’s recommendation and produced a result that would not have otherwise 

occurred. 
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Furthermore, there is no evidence that the negligent delay in the 

administration of blood products was related to or dependent upon Dr. Cromartie’s 

alleged negligent failure to immediately order PLEX or to more adequately convey a 

sense of urgency to Dr. Khan. Dr. Cromartie was entitled to presume and act upon 

the presumption that Ms. Hamilton’s subsequent health care providers would comply 

with their duty to treat her according to the applicable standard of care. See Weavil

v. Myers, 243 N.C.386, 391, 90 S.E.2d 733, 737 (1956); Barber, 130 N.C. App. at 384, 

502 S.E.2d at 915.

Dr. Cromartie does not dispute that he did not order PLEX upon his initial 

consultation, but rather ordered PRBC and FFP to correct Ms. Hamilton’s anemia, 

nor does he dispute Dr. Feigert opined those actions were a breach of standard of 

care. Rather, Plaintiff is unable to prove that Dr. Cromartie’s alleged negligence 

proximately caused Ms. Hamilton’s death.

Dr. Feigert expected all orders for Ms. Hamilton to be “STAT” orders based on 

her admission to the ICU. Furthermore, Dr. Feigert’s expected time frame within 

which it would be reasonable for PRBC and FFP to be prepared and transfused is 

consistent with Dr. Cromartie’s expectation and the other Rex physicians. Dr. Feigert 

opined that it was a breach of the standard of care to order blood products as a bridge 

to PLEX, but if bridge therapy was the plan, then it was reasonable to anticipate the 
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blood products would have been administered within the time frame Dr. Cromartie 

expected. 

Therefore, the evidence shows that the delay in the administration of blood 

products was not reasonably foreseeable to Dr. Cromartie. Dr. Feigert also opined 

the result would have been different if the natural sequence of events had occurred 

according to Dr. Cromartie’s reasonable expectation and no delay in the 

administration of the blood products intervened. Plaintiff contends that Dr. 

Cromartie’s recommendation would not permit the team to begin to mobilize until 

8:00 a.m. and PLEX not to be initiated until 4 p.m., which is past the point of no 

return. However, this is contrary to the evidence in the record, most importantly the 

testimony of Plaintiff’s only expert witness designated to offer causation opinions. 

Dr. Feigert testified that not only would Ms. Hamilton more likely than not have 

survived if Dr. Cromartie’s expectation had come to fruition, but also that Ms. 

Hamilton more likely than not would have survived if the blood products had been 

administered in a timely fashion. 

Here, the hospital’s failure to administer the ordered blood products was an 

independent force, at least two steps removed from Dr. Cromartie, such that he could 

not have foreseen its occurrence. Plaintiff’s causation expert opined it was not 

foreseeable to Dr. Cromartie that the blood products ordered by Dr. Khan would not 

be provided and Ms. Hamilton’s death would result. 
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North Carolina law clearly establishes that Dr. Cromartie is “not bound to 

anticipate negligent acts or omissions on the part of others”, so he was entitled to 

presume and to act upon the presumption that the individuals caring for Ms. 

Hamilton would perform their duties. Weavil, 243 N.C. at 391, 90 S.E.2d at 737. As 

such, it was not reasonably foreseeable that the blood products would not be timely 

and efficiently administered, thereby delaying the initiation of PLEX past the point 

of no return. 

The delay in the administration of blood products redirected the natural 

sequence of events set in motion by Dr. Cromartie’s recommendation. Plaintiff did 

not dispute this. Plaintiff also did not address his own expert’s testimony that the 

delay redirected the sequence of events set into motion by Dr. Cromartie such that 

Ms. Hamilton died, a result that would not have followed.

Plaintiff failed to establish a prima facie case because he did not prove that Dr. 

Cromartie’s alleged negligence was a proximate cause of Ms. Hamilton’s death. The 

independent and unforeseeable negligent delay in the administration of the blood 

products redirected the natural sequence of events set in motion by Dr. Cromartie’s 

recommendation and caused Ms. Hamilton’s death, which would not have otherwise 

followed. Without proving proximate cause, Plaintiff cannot prove causation, and 

therefore, cannot prove medical malpractice. There is no genuine issue of material 
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fact. Accordingly, summary judgement was properly granted, and the trial court’s 

order is affirmed.

AFFIRMED.

Judges BRYANT and TYSON concur.