Court Opinion

ID: 9539234
Source: CourtListenerOpinion
Date Created: 2023-08-07 15:01:00.796121+00
Date Added: 2024-06-11T14:58:38.424507
License: Public Domain

USCA11 Case: 22-13645   Document: 28-1    Date Filed: 08/07/2023   Page: 1 of 15

                                                 [DO NOT PUBLISH]
                                 In the
                 United States Court of Appeals
                        For the Eleventh Circuit

                         ____________________

                               No. 22-13645
                         Non-Argument Calendar
                         ____________________

        GLORIA SMITH,
                                                    Plaintiﬀ-Appellant,
        versus
        UNITED STATES OF AMERICA,

                                                  Defendant-Appellee,

        DR. KENNEDY OKERE,

                                                           Defendant.

                         ____________________
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        2                      Opinion of the Court                22-13645

                   Appeal from the United States District Court
                      for the Southern District of Georgia
                    D.C. Docket No. 4:20-cv-00286-RSB-CLR
                            ____________________

        Before JORDAN, JILL PRYOR, and BRANCH, Circuit Judges.
        PER CURIAM:
               Appellant Gloria Smith brought a lawsuit against the United
        States under the Federal Tort Claims Act, alleging that Dr. Ken-
        nedy Okere, a doctor at the Curtis V. Cooper Primary Health Cen-
        ter (“CVC”), a federally-supported health center, committed med-
        ical malpractice. According to Smith, Okere prescribed a medica-
        tion that caused her to have a severe allergic reaction and be hos-
        pitalized. To support her claim, Smith introduced testimony from
        an expert who opined that the medication Okere prescribed caused
        Smith’s allergic reaction. But the district court excluded the ex-
        pert’s opinion under Daubert v. Merrill Dow Pharmaceuticals, Inc.,
        509 U.S. 579 (1993), and then granted summary judgment to the
        United States. On appeal, Smith challenges the district court’s deci-
        sions to exclude her expert’s opinion and to grant summary judg-
        ment to the government. After careful consideration, we affirm.
                                         I.
               Smith, who suffers from high blood pressure, received med-
        ical care at CVC. In 2016, Smith was prescribed an ACE inhibitor,
        a type of medication used to treat high blood pressure. After taking
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        22-13645                Opinion of the Court                           3

        the medication, Smith had an allergic reaction and needed to go to
        the hospital.
               In December 2018, Smith was seen by Okere at CVC. At that
        appointment, he prescribed the drug lisinopril, an ACE inhibitor,
        to treat her high blood pressure. Inexplicably, Okere selected this
        medication, despite multiple warnings in Smith’s medical records
        stating that she was allergic to ACE inhibitors. For a four-month
        period, Smith dutifully took lisinopril every day.
               In the afternoon of April 8, 2019, Smith experienced a severe
        allergic reaction. She felt her tongue swelling inside her mouth and
        her throat closing. She immediately went to the hospital.
                At the hospital, Smith was diagnosed with angioedema. An-
        gioedema is a condition that involves the swelling of tissue in the
        lips, tongue, face, hands, or feet. In rare cases, this swelling can lead
        to airway obstruction and potentially death.
               At the hospital, Smith’s condition initially improved. But she
        quickly took a turn for the worse. She was admitted to the intensive
        care unit and ended up in a medically induced coma. After approx-
        imately two weeks, Smith’s condition improved, and she was re-
        leased from the hospital. Medical records from the hospital show
        that Smith reported taking several medications at home on the day
        she experienced the allergic reaction, including lisinopril and aspi-
        rin.
              Smith sued the United States, bringing a claim for medical
        malpractice under the Federal Tort Claims Act, 28 U.S.C. §§ 1346,
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        4                           Opinion of the Court                         22-13645

        2671 et seq. 1 She alleged that Okere committed medical malpractice
        by prescribing her lisinopril, which caused her allergic reaction.
                During the litigation, Smith identified Dr. James Cornwell,
        Jr., an experienced primary care physician, as an expert whose opin-
        ions she would be relying on in the case. In his expert report, Corn-
        well opined that Okere and CVC deviated from the applicable
        standard of care. He explained that it was a “breach of the standard
        of care to prescribe a medication to which the patient has a known
        allergy or adverse reaction.” Doc. 33 at 8. 2
               In addition to providing an opinion on the standard of care,
        Cornwell also opined about causation. In his expert report, his en-
        tire opinion on causation consisted of one sentence, which stated
        that “[w]ithin a reasonable degree of medical certainty, the afore-
        mentioned negligent acts and omissions of CVC and . . . Okere
        caused . . . Smith to suffer a severe, life-threatening adverse

        1 The parties agree that the Federal Tort Claims Act provides the exclusive
        remedy for Smith’s malpractice claim. Because Okere was a physician working
        as a contractor for CVC and the facility was a federally-supported health cen-
        ter, Okere is “deemed to be an employee of the Public Health Service.” See
        42 U.S.C. § 233(g)(1)(A). Federal law specifies that the Federal Tort Claims Act
        provides the “exclusive” remedy “for damage for personal injury . . . resulting
        from the performance of medical . . . functions . . . by any . . . employee of the
        Public Health Service.” Id. § 233(a), (g)(1)(A); see Allen v. Christenberry, 327 F.3d
        1290, 1294 (11th Cir. 2003) (describing statutory scheme).
        2 “Doc.” numbers refer to the district court’s docket entries.
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        22-13645               Opinion of the Court                         5

        reaction, including angioedema, for which she required emergency
        medical care and hospitalization.” Id.
               The government moved to exclude Cornwell’s opinion
        about causation under Daubert. First, it argued that Cornwell was
        not qualified because he did not have any experience in determin-
        ing the causes of angioedema. Second, it asserted that Cornwell’s
        opinion about causation was not based on a reliable methodology.
        According to the government, Cornwell’s “report display[ed] no
        methodology on causation” because his entire discussion of causa-
        tion consisted of a single sentence and was entirely “devoid of fac-
        tual or analytical support.” Doc. 35 at 10 (internal quotation marks
        omitted). The government pointed out that Cornwell did not
        “note or rule out other possible causes for [Smith’s] illness.” Id. at
        11.
                The government argued that if Cornwell’s opinion on cau-
        sation was excluded, the court should grant summary judgment. It
        explained under the Federal Tort Claims Act, Georgia law gov-
        erned because the allegedly negligent act—prescribing lisinopril—
        occurred in Georgia. See 28 U.S.C. § 1346(b)(1). And under Georgia
        law, to prove proximate causation for a medical malpractice claim,
        a plaintiff must present expert testimony. If Cornwell’s opinion on
        causation was excluded, the government reasoned, it would be en-
        titled to summary judgment because Smith would have no expert
        testimony regarding causation.
               Smith opposed the government’s motions to exclude Corn-
        well’s causation opinion and for summary judgment. With her
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        6                     Opinion of the Court                22-13645

        opposition, she filed a supplemental affidavit from Cornwell. In the
        affidavit, he provided more information about his qualifications,
        including that he previously had treated between 20 and 30 patients
        suffering from angioedema.
               He also provided more details about the relationship be-
        tween ACE inhibitors and angioedema. He explained that it was
        “well accepted and documented in the medical community that lis-
        inopril can cause angioedema” and that “0.1-0.7% [of] patients pre-
        scribed ACE inhibitors experience angioedema.” Doc. 38-1 at 2. He
        also noted that “angioedema is the second most common adverse
        reaction to ACE inhibitors, behind dry cough.” Id. at 2–3. And he
        observed that “patients who take ACE inhibitors can experience
        the adverse effect of angioedema several months or even up to a
        year after being prescribed the medication.” Id. at 3.
               Cornwell attached to his affidavit several medical publica-
        tions on which he had relied. These publications stated that other
        medications, including nonsteroidal anti-inflammatory drugs such
        as aspirin, could cause angioedema. Despite relying on these pub-
        lications that recognized other medications could cause angi-
        oedema, there was nothing in Cornwell’s affidavit showing that he
        had considered whether another medication could have caused
        Smith’s angioedema.
                 After reviewing Cornwell’s affidavit, the government again
        argued that his causation opinion should be excluded under Daub-
        ert. It continued to assert that he was not qualified to opine about
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        22-13645                Opinion of the Court                          7

        the cause of Smith’s angioedema and that his causation opinion
        was not based on a reliable methodology.
               After the motions were fully briefed, a magistrate judge is-
        sued an order and report and recommendation. The magistrate
        judge granted the government’s motion to exclude Cornwell’s cau-
        sation opinion under Daubert, concluding that Cornwell was “not
        qualified to offer the causation opinion and that the opinion [was]
        not reliable.” Doc. 50 at 12.
                Regarding qualifications, the magistrate judge found that
        Cornwell was not qualified to opine on the cause of Smith’s angi-
        oedema. The magistrate judge accepted that based on his experi-
        ence Cornwell was qualified to opine on whether Smith’s allergic
        reaction qualified as angioedema. But the magistrate judge ex-
        plained that “expertise in the diagnosis and treatment of a condi-
        tion does not render a physician qualified to opine, in a scientifically
        reliable manner, about the causes of those medical conditions.” Id.
        at 14 (internal quotation marks omitted). Because there was no in-
        dication that Cornwell had experience in determining the cause of
        a patient’s angioedema, the magistrate judge concluded that Smith
        failed to carry her burden of establishing that Cornwell was quali-
        fied to opine on causation.
               The magistrate judge also concluded that Cornwell’s meth-
        odology was not reliable. The magistrate judge explained that
        Cornwell had not explained how he arrived at his conclusion about
        causation. Although there was a temporal relationship between
        Smith taking lisinopril and experiencing angioedema, the
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        8                     Opinion of the Court                22-13645

        magistrate judge explained that Cornwell could not conclude that
        lisinopril caused Smith’s angioedema simply because she experi-
        enced the allergic reaction after taking the medication. The magis-
        trate judge also pointed out that the medical publications Cornwell
        had relied on showed that a number of medications could cause
        angioedema. Because Cornwell failed “to even consider other fac-
        tors that could have been cause the cause of [Smith’s] angi-
        oedema,” the magistrate judge found his methodology unreliable.
        Id. at 21 (emphasis in original).
               After excluding Cornwell’s causation opinion, the magis-
        trate judge turned to the government’s summary judgment mo-
        tion. The magistrate judge explained that Georgia law applied to
        Smith’s Federal Tort Claims Act claim and that, under Georgia law,
        to survive summary judgment Smith had to “present expert testi-
        mony to establish that the breach of the applicable standard of care
        was the proximate cause of” her injury. Id. at 27. Because Corn-
        well’s opinion on causation had been excluded, the magistrate
        judge recommended that the district court grant summary judg-
        ment.
               Smith objected to the magistrate judge’s order and recom-
        mendation. On the Daubert motion, she argued the magistrate
        judge erred in determining that Cornwell was not qualified to ren-
        der a causation opinion and that his opinion was unreliable. She
        also argued that because Cornwell’s causation opinion should not
        be excluded, the district court should deny the government’s sum-
        mary judgment motion.
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        22-13645               Opinion of the Court                        9

              The district court overruled Smith’s objections. The court
        began by reviewing the magistrate judge’s order granting the Daub-
        ert motion. The court explained that it reviewed the magistrate
        judge’s order under a deferential standard of review—asking
        whether the decision was clearly erroneous or contrary to law—
        because the Daubert motion was not a dispositive motion.
               The district court then affirmed the magistrate judge’s deci-
        sion to exclude Cornwell’s causation opinion for two independent
        reasons: (1) he was not qualified to opine on the cause of Smith’s
        angioedema, and (2) his methodology was not reliable. The court
        explained that Cornwell’s methodology was unreliable because
        there was “nothing to indicate that [] Cornwell considered any al-
        ternative cause of [Smith’s] angioedema.” Doc. 58 at 7 (emphasis
        in original). Although the district court reached this conclusion af-
        ter applying a clearly erroneous standard, the court also stated that
        it would have reached the same conclusion under a de novo stand-
        ard of review.
              After affirming the magistrate judge’s decision on the Daub-
        ert motion, the district court adopted the recommendation to grant
        the government’s summary judgment motion. This is Smith’s ap-
        peal.
                                         II.
               “We review de novo the district court’s grant of summary
        judgment, construing the facts and drawing all reasonable infer-
        ences in favor of the nonmoving party.” Smelter v. S. Home Care
        Servs., Inc., 904 F.3d 1276, 1284 (11th Cir. 2018). Summary
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        10                      Opinion of the Court                   22-13645

        judgment is appropriate if the record gives rise to “no genuine dis-
        pute as to any material fact,” such that “the movant is entitled to
        judgment as a matter of law.” Fed. R. Civ. P. 56(a). A genuine dis-
        pute of material fact exists when “the evidence is such that a rea-
        sonable jury could return a verdict for the nonmoving party.” An-
        derson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986).
               We review for abuse of discretion a district court’s decision
        to exclude an expert’s testimony. See St. Louis Condo. Ass’n, Inc. v.
        Rockhill Ins. Co., 5 F.4th 1235, 1242 (11th Cir. 2021). “The abuse of
        discretion standard allows a range of choice for the district court,
        so long as that choice does not constitute a clear error of judg-
        ment.” Carrizosa v. Chiquita Brands Int’l, Inc., 47 F.4th 1278, 1296
        (11th Cir. 2022) (alteration adopted) (internal quotation marks
        omitted). “A district court necessarily abuses its discretion if it bases
        a ruling on an erroneous view of the law or on a clearly erroneous
        assessment of the evidence.” Id. (alteration adopted) (internal quo-
        tation marks omitted).
                                          IV.
               Smith argues on appeal that the district court erred in ex-
        cluding Cornwell’s opinion on causation and in granting the gov-
        ernment’s motion for summary judgment. We address each issue
        in turn.
                                           A.
              We begin with Smith’s challenge to the district court’s deci-
        sion to grant the government’s Daubert motion and exclude
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        22-13645                Opinion of the Court                           11

        Cornwell’s expert testimony on causation. We cannot say that the
        district court abused its discretion.
                “The admission of expert evidence is governed by Federal
        Rule of Evidence 702, as explained by Daubert and its progeny.”
        Rink v. Cheminova, Inc., 400 F.3d 1286, 1291 (11th Cir. 2005) (foot-
        note omitted). Under Rule 702 and Daubert, in deciding whether to
        admit expert testimony, a district court acts act as a “gatekeep[er].”
        Id. (internal quotation marks omitted). To fulfill its obligation, a
        district court must engage in a “rigorous inquiry” and determine
        whether: (1) “the expert is qualified to testify competently regard-
        ing the matters he intends to address”; (2) “the methodology by
        which the expert reaches his conclusions is sufficiently reliable as
        determined by the sort of inquiry mandated in Daubert”; and (3) the
        expert’s testimony “assists the trier of fact, through the application
        of scientific, technical, or specialized expertise, to understand the
        evidence or to determine a fact in issue.” Id. at 1291–92 (internal
        quotation marks omitted).
                Regarding reliability, we have recognized that a district
        court “may exclude expert testimony that is imprecise and unspe-
        cific or whose factual basis is not adequate explained.” Cook ex rel.
        Est. of Tessier v. Sheriff of Monroe Cnty., 402 F.3d 1092, 1111 (11th Cir.
        2005) (internal quotation marks omitted). “Because the task of eval-
        uating the reliability of expert testimony is uniquely entrusted to
        the district court under Daubert, we give the district court consid-
        erable leeway in the execution of its duty.” Rink, 400 F.3d at 1291
        (internal quotation marks and citation omitted); see United States v.
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        12                        Opinion of the Court                      22-13645

        Pon, 963 F.3d 1207, 1219 (11th Cir. 2020) (explaining that the “def-
        erence we show trial courts on evidentiary rulings is especially pro-
        nounced in the Daubert context, where the abuse of discretion
        standard places a heavy thumb . . . on the district court’s side of the
        scale” (internal quotation marks omitted)). Of course, granting this
        “leeway is not the same thing as abdicating appellate responsibil-
        ity.” Pon, 963 F.3d at 1219–20 (internal quotation marks omitted).
                Here, in excluding Cornwell’s causation opinion, the district
        court found that his methodology was unreliable because he did
        not consider any alternative cause of Smith’s angioedema. Smith
        does not dispute that to provide a reliable opinion on causation, an
        expert sometimes must expressly address and rule out other poten-
        tial causes of the plaintiff’s injury. But Smith says that Cornwell was
        not required to rule out alternative causes of Smith’s angioedema
        in this case because there was “no evidence in this case of any cause
        of . . . Smith’s angioedema[] other than the admittedly mis-pre-
        scribed lisinopril.” Appellant’s Br. at 37–38 (emphasis added). We
        disagree.
               The district court did not abuse its discretion when it ex-
        cluded Cornwell’s opinion as unreliable based on his failure to con-
        sider alternative possible causes of Smith’s angioedema.3 Certainly,

        3 The district court gave two separate reasons for excluding Cornwell’s causa-
        tion opinion: because (1) it was unreliable, and (2) Cornwell was not qualified
        to opine on causation. Because we conclude that the district court did not
        abuse its discretion in excluding Cornwell’s opinion as unreliable, we do not
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        22-13645                  Opinion of the Court                               13

        ACE inhibitors, like lisinopril, may cause angioedema. But the rec-
        ord shows that ACE inhibitors are not the only medications that
        cause angioedema. Indeed, the medical publications that Cornwell
        relied upon show that other drugs, including non-steroidal anti-in-
        flammatory drugs (like aspirin), may cause angioedema. And the
        record reflects that Smith took both lisinopril and aspirin at home
        on the day of her allergy attack in 2019. Although Smith apparently
        ingested multiple drugs that could cause angioedema, there is
        nothing in Cornwell’s initial expert report or his affidavit that indi-
        cates that he considered whether anything other than lisinopril
        caused Smith’s angioedema. In these circumstances, we cannot say
        that the district court made a clear error of judgment when it con-
        cluded that Cornwell’s causation opinion was unreliable. See Wil-
        liams v. Mosaic Fertilizer, LLC, 889 F.3d 1239, 1250 (11th Cir. 2018)
        (affirming district court decision to exclude expert opinion that
        “failed to meaningfully address other potential causes of [the plain-
        tiff’s] condition” because “[t]his fundamental methodological fail-
        ure undermined the soundness of [the expert’s] causation opin-
        ions”).4

        decide whether the district court abused its discretion in concluding that Corn-
        well was not qualified to opine on causation.
        4 On appeal, Smith also argues that the district court erred in granting the
        government’s Daubert motion because the court reviewed the magistrate
        judge’s decision to grant the motion under a clearly erroneous, instead of a de
        novo, standard. Even assuming that the district court was required to review
        the magistrate judge’s Daubert ruling under a de novo standard of review, there
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        14                        Opinion of the Court                     22-13645

                                             B.
               Having concluded that the district court did not abuse its
        discretion in excluding Cornwell’s opinion on causation, we also
        affirm the district court’s decision to grant summary judgment to
        the government.
               In this action, Smith brought a claim against the government
        under the Federal Tort Claims Act for medical malpractice. Liabil-
        ity under the Federal Tort Claims Act is “determined in accordance
        with the law of the place where the government’s act or omission
        occurred.” Stevens v. Battelle Mem’l Inst., 488 F.3d 896, 899 n.3 (11th
        Cir. 2007); see 28 U.S.C. § 1346(b)(1). Because Okere’s acts and
        omissions occurred in Georgia, Georgia law governs.
               Under Georgia law, to prevail on a medical malpractice
        claim, a plaintiff must show: “(1) the duty inherent in the health
        care provider-patient relationship; (2) breach of that duty by failing
        to exercise the requisite degree of skill and care; and (3) that this
        failure is the proximate cause of the injury sustained.” Knight v. W.
        Paces Ferry Hosp., Inc., 585 S.E.2d 104, 105 (Ga. Ct. App. 2003). Geor-
        gia law requires the plaintiff to present expert testimony establish-
        ing that the medical professional’s breach of the standard of care
        was the proximate cause of her injury. See Porter v. Guill, 681 S.E.2d
        230, 235 (Ga. Ct. App. 2009). Given the exclusion of Cornwell’s cau-
        sation opinion and Smith’s failure to present any other expert

        was no error here. In its order, the district court expressly stated that even
        under a de novo standard and considering the entire record, it would reach the
        same conclusion.
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        22-13645              Opinion of the Court                       15

        testimony on this issue, it follows that the government was entitled
        to summary judgment. See McDowell v. Brown, 392 F.3d 1283, 1302
        (11th Cir. 2004) (affirming grant of summary judgment on medical
        malpractice claim arising under Georgia law after opinions from
        plaintiffs’ experts were excluded under Daubert).
              AFFIRMED.