Court Opinion

ID: 7806420
Source: CourtListenerOpinion
Date Created: 2022-09-06 09:11:23.679185+00
Date Added: 2024-06-11T16:30:12.984920
License: Public Domain

TEXAS COURT OF APPEALS, THIRD DISTRICT, AT AUSTIN

                                     NO. 03-21-00296-CV

           Robin Dunnick, Individually, and as Next Friend to Raynee Dunnick,
                            and Dana Dunnick, Appellants

                                                v.

                                Kristy Marsillo, D.O., Appellee

              FROM THE 201ST DISTRICT COURT OF TRAVIS COUNTY
   NO. D-1-GN-19-007132, THE HONORABLE DUSTIN M. HOWELL, JUDGE PRESIDING

                                         OPINION

               Robin Dunnick, individually and as next friend to Raynee Dunnick, and Dana

Dunnick (collectively, the Dunnicks) appeal the trial court’s order granting summary judgment

and dismissing their healthcare liability claim against Kristy Marsillo, D.O.1        Because we

conclude there is more than a scintilla of probative evidence to show that Dr. Marsillo acted with

“willful and wanton negligence” and that her acts or omissions proximately caused injury, we

will reverse the trial court’s summary judgment and remand for further proceedings.

                                       BACKGROUND

               The Dunnicks filed suit after their thirteen-year-old daughter, Raynee, was treated

at Seton Medical Center Hays (“Seton Hays”) on September 26, 2018, for a rattlesnake bite.

       1
           Because several of the parties share the same last name, for clarity, we will refer to
these parties by their first names when referring to them individually.
Raynee was bitten by the rattlesnake on her left foot while in her family’s yard and was

transported by EMS to the emergency room at Seton Hays. The EMS records show that the

snakebite occurred at approximately 8:20 p.m., and Raynee arrived at Seton Hays at 9:14 p.m.

Within a few minutes, Raynee was triaged and assessed by nursing staff and then seen by the

attending physician, Dr. Marsillo.

               At approximately 9:22 p.m., Dr. Marsillo issued initial orders that included

administering an EKG, starting two IVs, and obtaining a urinalysis. In addition, she also issued

orders for lab work and blood-coagulation studies and for the nursing staff to measure and mark

any progression of the bite site (for signs of pain and swelling) every thirty minutes. At

approximately 11:50 p.m., Dr. Marsillo ordered six vials of CroFab (antivenom) for Raynee. At

12:29 a.m., a little more than four hours after Raynee was bitten and three hours after she arrived

at the emergency room, the antivenom began infusing. During this time, Dr. Marsillo secured a

transfer and overnight admission for Raynee at Dell Children’s Medical Center.

               Raynee was discharged from Seton Hays at 1:02 a.m. on September 27 and

transferred to Dell Children’s Medical Center, where she received additional vials of antivenom.

In total, Raynee received 37 vials of antivenom during the course of her treatment. She was

discharged on September 28, with instructions for at-home physical therapy exercises and orders

to keep her leg elevated until the swelling subsided.

               In their petition, the Dunnicks alleged that Dr. Marsillo failed to exercise the

appropriate standard of care for treating Raynee’s snakebite injury.2 In addition, the Dunnicks

alleged that Dr. Marsillo’s negligence, including the three-hour delay of the administration of

       2
          The Dunnicks also filed suit against Seton Hays but later settled their claims against the
hospital. As a result, Seton Hays is not a party to this appeal.

                                                 2
antivenom upon Raynee’s arrival to the emergency room, caused further complications, such as

permanent impairment, disfigurement, and ongoing pain and suffering.

              Dr. Marsillo filed a no-evidence motion for summary judgment on the ground that

there was no probative evidence that she acted with willful and wanton negligence in treating

Raynee or that Raynee’s injuries were proximately caused by Dr. Marsillo’s negligence. See

Tex. R. Civ. P. 166a(i). Following a nonevidentiary hearing, the trial court granted summary

judgment in favor of Dr. Marsillo. This appeal followed.

                                 STANDARD OF REVIEW

              After adequate time for discovery, a party may move for summary judgment on

the ground that there is no evidence of one or more essential elements of a claim or defense on

which the nonmovant would have the burden of proof at trial. AEP Tex. Cent. Co. v. Arredondo,

612 S.W.3d 289, 295 (Tex. 2020); see Tex. R. Civ. P. 166a(i). Once the motion is filed, the

burden shifts to the nonmovant to produce summary-judgment evidence raising a genuine

issue of material fact on the challenged element. B.C. v. Steak N Shake Operations, Inc.,

598 S.W.3d 256, 259 (Tex. 2020).       A trial court properly grants a no-evidence summary

judgment if the nonmovant produces no more than a scintilla of probative evidence—that is, if

the nonmovant’s evidence does not rise to a level that would enable reasonable and fair-minded

people to differ in their conclusions. Dallas Morning News, Inc. v. Tatum, 554 S.W.3d 614,

625 (Tex. 2018).

              We review a trial court’s ruling on summary judgment de novo. Traveler’s Ins. v.

Joachim, 315 S.W.3d 860, 862 (Tex. 2010). In conducting that review, we examine the entire

record in the light most favorable to the nonmovant, crediting evidence a reasonable juror could

                                               3
credit and disregarding contrary evidence unless a reasonable juror could not. Merriam v. XTO

Energy, Inc., 407 S.W.3d 244, 248 (Tex. 2013). When, as here, the trial court does not specify

the grounds for its summary-judgment ruling, we must affirm if any ground on which summary

judgment was sought has merit Id.

                                            ANALYSIS

               To prevail on a claim for medical negligence, a plaintiff is required to prove

“(1) a duty by the healthcare provider to act according to a certain standard, (2) a breach of

the applicable standard of care, (3) an injury, and (4) a sufficient causal connection between

the breach of care and the injury.” Miller v. Mullen, 531 S.W.3d 771, 778-79 (Tex. App.—

Texarkana 2016, no pet.); Sage v. Howard, 465 S.W.3d 398, 407 (Tex. App.—El Paso 2015, no

pet.). In addition, in certain suits involving healthcare liability claims arising out of the provision

of emergency medical care, the legislature has heightened the standard of proof. Tex. Civ.

Prac. & Rem. Code § 74.153; Jones v. Baylor Scott & White Health, No. 07-19-00387-CV,

2020 Tex. App. LEXIS 9150, at *6 (Tex. App.—Amarillo Nov. 20, 2020, no pet.) (mem. op.).

Section 74.153 of the Texas Civil Practice and Remedies Code, in relevant part, states:

       In a suit involving a health care liability claim against a physician or health
       care provider for injury to or death of a patient arising out of the provision of
       emergency medical care in a hospital emergency department, . . . the claimant
       bringing the suit may prove that the treatment or lack of treatment by the
       physician or health care provider departed from accepted standards of medical
       care or health care only if the claimant shows by a preponderance of the evidence
       that the physician or health care provider, with willful and wanton negligence,
       deviated from the degree of care and skill that is reasonably expected of an
       ordinarily prudent physician or health care provider in the same or similar
       circumstances.

Tex. Civ. Prac. & Rem. Code § 74.153 (emphasis added).

                                                  4
              Here, there is no dispute that the Dunnicks’s suit against Dr. Marsillo involves a

healthcare liability claim arising out of the provision of emergency medical care and that their

suit is governed by Section 74.153. Consequently, Dr. Marsillo moved for summary judgment

on the grounds that there is no probative evidence to show that (1) she acted with willful and

wanton negligence in providing treatment to Raynee, or (2) a causal connection exists between

the breach of the standard of care and any of Raynee’s injuries. On appeal, the Dunnicks assert

that the trial court erred to the extent it granted summary judgment in favor of Dr. Marsillo

on either of these grounds. On review, we will first consider whether there is any probative

evidence of willful and wanton negligence.

Evidence of Willful and Wanton Negligence

              Although the statute does not define “willful and wanton negligence,” the Dallas

court of appeals has interpreted the phrase to mean “gross negligence.” Turner v. Franklin,

325 S.W.3d 771, 780–81 (Tex. App.—Dallas 2010, pet. denied) (“We conclude the legislature

intended ‘wilful and wanton negligence,’ as used in [section 74.153], to mean ‘gross

negligence.’”). In reaching this conclusion, our sister court reviewed the statute’s legislative

history as well as cases construing the phrase “willful and wanton” in the context of other

statutes. Id. Because we agree with the court’s analysis in Turner, we join those courts of

appeals that have followed Turner and conclude that the legislature intended the phrase “willful

and wanton negligence,” as used in Section 74.153, to mean “gross negligence.” Martinez-

Gonzalez v. EC Lewisville, LLC, No. 02-17-00122-CV, 2018 Tex. App. LEXIS 1800, at *15

(Tex. App.—Fort Worth Mar. 8, 2018, pet. denied) (mem. op.) (following Turner); Ho v.

Johnson, No. 09-15-00077-CV, 2016 Tex. App. LEXIS 1668, at *33−34 (Tex. App.—Beaumont

                                               5
Feb. 18, 2016, pet. denied) (mem. op.) (same); Sage, 465 S.W.3d at 407 (same); see also Miller,

531 S.W.3d at 779 n.7 (“For purposes of analyzing this summary judgment, we assume the

Turner definition of the willful and wanton standard, as urged by both parties.”).

               Gross negligence is comprised of two elements—one subjective and one

objective. U-Haul Int’l, Inc. v. Waldrip, 380 S.W.3d 118, 137 (Tex. 2012); Turner, 325 S.W.3d

at 781. For the objective element, we consider whether the defendant’s acts or omissions

departed from the standard of care “to such an extent that it creates an extreme degree of

risk of harming others, considering the probability and magnitude of the potential harm to

others.” Turner, 325 S.W.3d at 781 (citing Columbia Med. Ctr. of Las Colinas, Inc. v. Hogue,

271 S.W.3d 238, 248 (Tex. 2008)). “Extreme risk” does not mean a remote possibility of injury

or even a high probability of minor harm, but rather the likelihood of serious injury to the

plaintiff. Sage, 465 S.W.3d at 407. In examining the subjective component, we focus on the

defendant’s state of mind, examining whether she knew about the peril caused by her conduct

and continued to act in a way that demonstrated she did not care about the consequences.

Diamond Shamrock Ref. Co., L.P. v. Hall, 168 S.W.3d 164, 173 (Tex. 2005) (“What separates

ordinary negligence from gross negligence is the defendant’s state of mind; in other words, the

plaintiff must show that the defendant knew about the peril, but his acts or omissions

demonstrate that he did not care.”); Martinez-Gonzalez, 2018 Tex. App. LEXIS 1800, at *17

(“[W]e look for evidence of the defendant’s subjective mental state rather than the defendant’s

exercise of care.” (citing Turner, 325 S.W.3d at 784)); Sage, 465 S.W.3d at 407. A plaintiff

may establish the defendant’s state of mind by circumstantial evidence. Martinez-Gonzalez,

2018 Tex. App. LEXIS 1800, at *17. To raise a fact issue regarding willful and wanton

negligence, there must be legally sufficient evidence that the defendant had actual, subjective

                                                6
awareness that the conditions constituted an extreme degree of harm but the defendant

nevertheless was consciously indifferent to the rights, safety, or welfare of others. Ho, 2016

Tex. App. LEXIS 1668, at * 7.

               In their response to Dr. Marsillo’s motion for summary judgment, the Dunnicks

asserted that there is a genuine issue of material fact as to whether Dr. Marsillo was grossly

negligent in failing to order the administration of antivenom to Raynee when she was admitted to

the Seton Hays emergency room because when she presented, she was showing obvious signs of

envenomation, such as swelling, pain, and bruising. In support of this contention, the Dunnicks

attached the affidavit of Robin Dunnick, Raynee’s mother. In her affidavit, Robin explains that

Raynee presented at Seton Hays emergency room after being bitten by a rattlesnake and that “the

dead rattlesnake was brought into the emergency room to substantiate that it was, in fact, a

venomous snake that bit her.” Robin also states that Raynee’s leg was swelling and bruising and

that she “begged and pleaded for Raynee to be provided antivenom,” but “Dr. Marsillo did not

order any antivenom until Raynee was being transferred,” hours later. While in the Seton Hays

emergency room, Robin “took pictures with her cell phone of [Raynee’s] symptoms getting

worse.” Approximately one hour after Raynee’s admission, Robin took the following photo,

marking the swelling and bruising as it progressed up Raynee’s foot, ankle, and leg:

                                                7
Approximately three hours after admission, Robin took the following photo:

              The Dunnicks also attached the affidavit of Dr. Benjamin Abo, a physician who is

an expert in the field of emergency medicine and toxinology, “the practice and study devoted to

                                              8
toxins from living things, such as fauna and flora.” In his affidavit, Dr. Abo states that snake

envenomation is a time-sensitive emergency and that only the administration of antivenom can

stop the progression and toxic effects of venom, which can include not only mortality but also

permanent pain, disability, and disfigurement. “The object is to, as soon as possible gain control

of a bite as defined by no progression of local findings (pain, tenderness, skin changes), lab

abnormalities trending toward normal, and complete resolution of any systemic signs.” Thus,

according to Dr. Abo, the standard of care in this case required “Dr. Marsillo to have evaluated

and examined Raynee for life threats, systematic signs of envenomation, abnormal vital signs

signaling envenomation, both locally or systematically, and for any progression of local findings,

including ecchymosis, swelling, oozing, pain, or tenderness.” Although Dr. Marsillo’s initial

exam noted “obvious signs of envenomation,” she did not order or administer antivenom. In

addition, “progression from the bite site indicating local findings spreading/progressing up more

and more proximally was evidenced by Robin Dunnick’s photographs.”

               According to Dr. Abo’s affidavit testimony, “[i]mmediate administration of

antivenom was necessary for Raynee once she exhibited signs of envenomation.                To not

immediately administer antivenom is negligent and falls below the standard of care for an

emergency medicine physician.” In addition, Dr. Abo opines, “Dr. Marsillo had the subjective

awareness that [Raynee] had been envenomated by the rattlesnake and acted consciously

indifferent to administering antivenom. . . . A reasonable ER physician would eliminate the

extreme risk of harm that venom causes the body by immediately administering antivenom to

Raynee upon her admission.”

               In response, Dr. Marsillo contends that the Dunnicks’s summary-judgment

evidence fails to create a fact issue as to whether, objectively, there was an extreme risk posed by

                                                 9
her failure to immediately administer antivenom and whether, subjectively, she was aware of a

risk of injury and deliberately chose to ignore it. Dr. Marsillo asserts that, to the contrary, the

undisputed medical record, which she attached in support of her motion for summary judgment,

shows that she “immediately evaluated, re-evaluated, and treated [Raynee’s] snakebite, and

decided when to give antiven[om] in accordance with the snakebite treatment guidelines that was

the standing protocol at Seton [Hays] for the treatment of snakebites.” These snakebite treatment

guidelines, recorded in the medical records as “ED Snakebite,” utilize a system that evaluates

and scores six categories pertaining to the patient’s state of health following the snakebite

(including pulmonary symptoms, cardiovascular system, local wound, gastrointestinal system,

hematologic symptoms, and central nervous system). Each of these categories are evaluated,

scored for their current severity, and totaled to obtain the patient’s “severity score.” Under this

algorithm, if the patient’s coagulopathy labs are normal and the severity score is three or less,

antivenom is not administered. In that case, the patient would be observed and reassessed to

determine if there are any changes to labs or symptoms that would require an adjustment

to the score.

                Dr. Marsillo points out that, according to the medical record, the hospital staff’s

initial assessment of Raynee revealed normal neurologic, respiratory, coagulation studies, and

cardiovascular systems. In light of this assessment, Dr. Marsillo recorded Raynee’s severity

score as a two, which meant that the criteria for the administration of antivenom as per the

snakebite treatment guidelines were not met. Thereafter, the nursing staff continued to monitor

Raynee, take additional vitals, and measure the swelling of her foot and leg every 15 to 30

minutes as ordered by Dr. Marsillo. At 10:38 p.m., Raynee began feeling a burning sensation in

her toe, and Dr. Marsillo arrived to reevaluate her condition at 11:20 p.m. Dr. Marsillo increased

                                                10
Dunnick’s total severity score to a three, which is still below the criteria for the administration of

antivenom. In addition, Dr. Marsillo ordered repeat coagulation labs. The lab results came back

at 11:39 p.m., showing a drop in platelets and a decrease in Raynee’s Fibrinogen level (a protein

that helps to form blood clots). As a result, Dr. Marsillo added two points to Raynee’s severity

score, increasing the total score from three to five and, based on that score, ordered that Raynee

receive antivenom treatment. Dr. Marsillo asserts that the undisputed medical record shows

that she followed the hospital’s snakebite treatment guidelines in treating Raynee, including

the timing of her decision to order antivenom, and that “[f]ollowing a hospital’s policy for an

emergent condition is no evidence of a conscious indifference to that very same condition.”

               To the extent Dr. Marsillo suggests that adherence to a hospital’s treatment

protocols or guidelines necessarily negates a physician’s subjective awareness of risk in every

case, we disagree. See Turner, 325 S.W.3d at 784 (“Evidence of ‘some care’ will not disprove

gross negligence as a matter of law.”). A hospital is an institution licensed to provide health

care, but only a licensed doctor can provide medical care. Doctors Hosp. at Renaissance, Ltd. v.

Andrade, 493 S.W.3d 545, 548 (Tex. 2016); see Reed v. Granbury Hosp. Corp., 117 S.W.3d

404, 413 (Tex. App—Fort Worth 2003, no pet.) (explaining that in Texas, “medical decisions are

to be made by attending physicians” and that “[a] hospital cannot practice medicine and therefore

cannot be held directly liable for any acts or omissions that constitute medical functions”).

Therefore, although Dr. Marsillo’s adherence to Seton Hays’s snakebite treatment guidelines

may explain why she decided to wait three hours after Raynee’s admission to order antivenom

treatment in this case, it does not negate the possibility that, objectively, her adherence to the

guidelines posed an extreme risk of harm to Raynee or that, subjectively, she was aware of

that risk. As previously discussed, Dr. Abo opines in his affidavit that snake envenomation is

                                                 11
a time-sensitive emergency, that only the administration of antivenom can stop the progression

and effects of the venom, and that the failure to do so can cause permanent injury to the

patient. Similarly, in her deposition testimony, which the Dunnicks also attached to their

summary-judgment response, Dr. Marsillo acknowledged that Raynee was exhibiting signs of

envenomation upon her admission to the emergency room, including bruising, swelling, and

pain; that rattlesnake envenomation is a time-sensitive emergency; and that while antivenom is

not a “cure,” it is the only treatment available to prevent envenomation from spreading. Nothing

in the evidence suggests, and Dr. Marsillo does not contend, that the decision to delay

administering antivenom for three hours was necessary in light of some countervailing risk. See

Miller, 531 S.W.3d at 780−81 (concluding that although physician was aware of risk created by

administering aspirin to patient who could be experiencing hematoma, he was not consciously

indifferent to that risk because patient was exhibiting symptoms of heart attack, and aspirin is

part of standard heart-attack-prevention protocol).

               Viewing the summary-judgment evidence in the light most favorable to the

Dunnicks, including Dr. Abo’s affidavit, Robin Dunnick’s affidavit, and Dr. Marsillo’s

deposition testimony, we conclude that there is a genuine issue of material fact as to whether

adherence to the Seton Hays snakebite treatment guidelines poses an extreme risk of harm to

patients who, like Raynee, exhibit signs of envenomation hours before their severity score under

the guidelines reaches the minimum threshold necessary for the administration of antivenom.

In addition, there is more than a scintilla of probative evidence suggesting that Dr. Marsillo

was aware of that risk but nevertheless adhered to the guidelines and, consequently, failed to

promptly order antivenom for Raynee. To the extent the trial court granted summary judgment

                                                12
in favor of Dr. Marsillo on the ground that there was no evidence of “willful and wanton

negligence,” we conclude that the trial court erred.

Evidence of Causation

               Next, we consider whether the trial court erred in granting summary judgment on

the ground that there is no probative evidence as to whether Dr. Marsillo’s negligence caused

Raynee’s complained-of injury. Proximate cause is an essential element of a medical-negligence

claim and consists of (1) cause in fact, and (2) foreseeability. Windrum v. Kareh, 581 S.W.3d

761, 777 (Tex. 2019) (citing Bustamonte v. Ponte, 529 S.W.3d 447, 456 (Tex. 2017)).

Foreseeability requires only that the defendant should have anticipated that his negligent act or

omission would create danger or harm for others; it does not require the defendant to have

actually anticipated the precise manner in which the injury would have occurred. Travis v. City

of Mesquite, 830 S.W.2d 94, 98 (Tex. 1992). To establish cause in fact, the plaintiff must show

by a preponderance of the evidence that the defendant’s negligent conduct “was a substantial

factor in bringing about the injuries, and without it, the harm would not have occurred.”

Bustamante, 529 S.W.3d at 456 (citation omitted). Consequently, the plaintiff must “adduce

evidence of a ‘reasonable medical probability’ or ‘reasonable probability’” that the defendant’s

negligence caused the plaintiff’s injury—that is, it must be “‘more likely than not’ that the

ultimate harm or conditions resulted from such negligence.” Id. (quoting Jelinek v. Casas,

328 S.W.3d 526. 532-33 (Tex. 2010)).

               Expert testimony is necessary to establish causation as to medical conditions

outside the common knowledge and experience of jurors.          JLG Trucking, LLC v. Garza,

466 S.W.3d 157, 162 (Tex. 2015). “A conclusory statement of causation is inadequate; instead,

                                                13
the expert must explain the basis of his statements and link conclusions to specific facts.”

Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 224 (Tex. 2018). In addition, “when the

facts support several possible conclusions, only some of which establish that the defendant’s

negligence caused the plaintiff’s injury, the expert must explain to the fact finder why those

conclusions are superior based on verifiable medical evidence, not simply the expert’s opinion.”

Jelinek, 328 S.W.3d at 536.

               The Dunnicks assert that there is a genuine issue of material fact as to whether

Dr. Marsillo’s negligence in failing to administer the antivenom when Raynee was first admitted

at Seton Hays emergency room proximately caused her to suffer long-term pain and impairment.

In support of this contention, the Dunnicks rely on Dr. Abo’s affidavit. As previously discussed,

Dr. Abo stated that by not immediately administering antivenom when envenomation was first

observed in Raynee, Dr. Marsillo’s treatment fell below the applicable standard of care. As to

causation, Dr. Abo explained, in relevant part:

       The only cure for envenomation is antivenom, which can only stop the ongoing
       effects of the venom and not reverse local progressive issues. The point of
       providing antivenom when appropriate is not only to fight mortality, but also to
       fight significant morbidity including permanent pain, permanent disability,
       permanent disfigurement. Outcomes are best when definitive management occurs
       as soon as possible, especially with rattlesnakes.

       ...

       The significant delay of care led to a significantly increased amount of antivenom
       needed to regain control of Raynee’s medical condition. Raynee not only had a
       further protracted hospital stay and requirement for larger repeat doses of
       antivenom to gain control, but she also has irreversible pain, skin, and nerve
       damage . . . which would not have been incurred but for the delay in the
       administration of antivenom.

       ...

                                                  14
       Based upon my review of the above-mentioned medical records and bills, as well
       as my training, knowledge, and experience in the field of Emergency Medicine,
       EMS, toxinology, and wilderness/austere medicine, my personal interview of
       Raynee’s mother, Robin Dunnick, as well as documented in these citations for
       information on the standards of care [citations omitted], with a reasonable degree
       of medical probability, it is my expert opinion that Raynee’s permanent damages
       to her leg and financial burden . . . [were] directly attributable to the delay in
       Raynee receiving antivenom immediately upon admission to Seton Hays Hospital.

              Viewed in the light most favorable to the Dunnicks, Dr. Abo’s affidavit

establishes that the risk of permanent physical injury increases the longer envenomation is

allowed to proceed and that, therefore, the failure to receive antivenom for three hours after

her arrival at Seton Hays more likely than not caused Raynee’s injury or, at least, caused her

injury to be worse than it would have been had she received antivenom when her envenomation

symptoms were first noted. We conclude that the summary-judgment record contains more than

a scintilla of probative evidence to show that Raynee’s complained-of injuries were a foreseeable

consequence of Dr. Marsillo’s failure to promptly administer antivenom. Consequently, the trial

court erred in granting summary judgment on the ground that there was legally insufficient

evidence to support the element of proximate cause.

                                        CONCLUSION

              Because we conclude that the trial court erred in granting summary judgment in

favor of Dr. Marsillo on any of the grounds raised in her motion for no-evidence summary

judgment, we reverse the judgment of the trial court and remand the case for further proceedings.

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                                           __________________________________________
                                           Chari L. Kelly, Justice

Before Chief Justice Byrne, Justices Kelly and Smith

Reversed and Remanded

Filed: August 31, 2022

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