Court Opinion

ID: 2803635
Source: CourtListenerOpinion
Date Created: 2015-05-27 15:10:41.522972+00
Date Added: 2024-06-11T12:14:35.471850
License: Public Domain

May 27 2015, 8:51 am

APPELLANT PRO SE                                          ATTORNEYS FOR APPELLEES
Kathy L. Siner                                            KINDRED HOSPITALS, DENNIS
Indianapolis, Indiana                                     NICELY, AND DAVID UHRIN
                                                          Melinda R. Shapiro
                                                          Libby Y. Goodknight
                                                          Lauren C. Sorrell
                                                          Krieg DeVault LLP
                                                          Indianapolis, Indiana
                                                          ATTORNEYS FOR APPELLEE
                                                          MOHAMMED MAJID
                                                          Michael Roth
                                                          Brett T. Clayton
                                                          Eichhorn & Eichhorn, LLP
                                                          Indianapolis, Indiana

                                            IN THE
    COURT OF APPEALS OF INDIANA

Kathy L. Siner, Personal                                  May 27, 2015
Representative of the Estate of                           Court of Appeals Case No.
Geraldine A. Siner, Deceased,                             49A05-1404-CT-165
and John T. Siner, prior                                  Appeal from the Marion Superior
Enduring Power of Attorney and                            Court
Medical Representative of the                             The Honorable Heather Welch,
Deceased                                                  Judge
                                                          Cause No. 49D12-1305-CT-20123
Appellants-Plaintiffs,

        v.

Kindred Hospital Limited
Partnership d/b/a Kindred
Hospital of Indianapolis, et al.,

Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015                    Page 1 of 19
      Mohammed A. Majid, M.D.,
      Dennis Nicely, David Uhrin,
      RN.
      Appellees-Defendants.

      Bradford, Judge.

                                           Case Summary
[1]   In 2013, Appellants-Plaintiffs Kathy and John Siner (collectively “the Siners”)

      brought a medical malpractice suit against Appellee-Defendant Kindred

      Hospital and its employees Appellees-Defendants Dennis Nicely and David

      Uhrin (collectively “Kindred”) as well as Appellee-Defendant Dr. Mohammed

      Majid. The Siners alleged that Kindred and Dr. Majid (collectively the

      “Defendants”) were negligent in their medical treatment of the Siners’ mother,

      Geraldine Siner, resulting in her injury. The Siners filed their complaint after a

      medical review panel determined, in 2012, that the Defendants were negligent

      and that their negligence may have caused injury to Geraldine. The trial court

      granted separate motions for summary judgment in favor of Dr. Majid and

      Kindred, finding that the Siners had failed to designate evidence which created

      an issue of material fact with regards to whether Defendants’ allegedly negligent

      conduct proximately caused injury to Geraldine. We affirm the trial court’s

      grant of summary judgment with regards to Dr. Majid and reverse with regards

      to Kindred.

      Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015   Page 2 of 19
                             Facts and Procedural History
[2]   October 26, 2007, eighty-six-year old Geraldine Siner became a patient at

      Kindred Hospital. Geraldine suffered from advanced dementia caused by

      Alzheimer’s disease and as a result could no longer care for herself. Geraldine’s

      son, John Siner, was designated as her health care representative and had

      power of attorney. Upon Geraldine’s admission to Kindred, and several times

      thereafter, John informed Dr. Mohammad Majid, Geraldine’s attending

      physician, that Geraldine was to be a ‘full code’ patient. On November 16,

      2007, Kindred’s Ethics Committee decided to make Geraldine a No Code/Do

      Not Resuscitate (“DNR”) patient, meaning that Kindred staff would not

      attempt to resuscitate her in the event that she went into respiratory or cardiac

      arrest (otherwise known as “coding”). The Ethics Committee did not receive

      approval from John or any other family member to change Geraldine’s status in

      this manner. Geraldine’s health continued to decline over the following two

      weeks and Kindred declined to keep Geraldine on ‘full code’ status despite her

      family’s protests.

[3]   As a result of their dissatisfaction with Kindred, the family had Geraldine

      moved from Kindred to Methodist Hospital on December 8, 2007. Geraldine

      required immediate treatment for a collapsed lung, “over-whelming infection,

      and septic shock at the time of intake.” Appellant’s App. p. 190. Geraldine

      died on December 28, 2007 while at Methodist Hospital.

      Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015   Page 3 of 19
[4]   On November 10, 2009, Kathy Siner, Geraldine’s daughter and personal

      representative of her estate, filed a medical malpractice claim against

      Defendants with the Indiana Department of Insurance. On December 17,

      2012, a medical review panel determined, by unanimous opinion, “that the

      evidence supports the conclusion that the defendants failed to comply with the

      appropriate standard of care, and that their conduct may have been a factor of

      some resultant damages, but not the death of the patient.” Appellee’s App. p.

      15.

[5]   On May 6, 2013, the Siners filed a complaint against Defendants in Marion

      Superior Court. On September 12, 2013, one of the medical review panel

      members, Dr. James Krueger, provided an affidavit to clarify the reasoning

      behind his panel decision. In his affidavit, Dr. Krueger states that the only

      negligent care provided by Defendants was the prolonged use of a CPAP mask. 1

      Dr. Krueger went on to state that upon further review, after the panel had

      rendered its decision, he learned that IU Pulmonary and Critical Care (“IU

      Pulmonary”) directed Geraldine’s pulmonary care during her hospitalization at

      Kindred and that “it was reasonable for Kindred to defer to the judgment of the

      Pulmonology Service as it related to Ms. Siner’s pulmonary care. Therefore, it

      is my opinion that Kindred met the standard of care by consulting the

      1
       CPAP, or continuous positive airway pressure, is a treatment that uses air pressure to keep the respiratory
      airways open and is typically used by patients having difficulty breathing. What is CPAP?, US Dep’t of
      Health and Human Services. Nat’l Heart, Lung, and Blood Institute. (December 13, 2011).
      http://www.nhlbi.nih.gov/health/health-topics/topics/cpap (last visited March 27, 2015).

      Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015                            Page 4 of 19
      Pulmonology Service….” Appellee’s App. p. 22. Dr. Krueger did not speak as

      to the opinion of the other two panel members.

[6]   On September 3, 2013, Dr. Majid filed a motion for summary judgment arguing

      that there was no disputed material fact regarding causation and he designated

      the panel opinion and affidavit from Dr. Krueger as evidence. The Siners

      timely filed a response on November 1, 2013, but did not designate any expert

      witness evidence beyond the panel opinion. On November 19, 2013, the date

      of the hearing on Dr. Majid’s motion, the Siners filed their belated designation

      of evidence. Because the evidence was designated belatedly, the trial court did

      not consider it pursuant to Indiana Trial Rule 56. On November 26, 2013, the

      trial court granted Dr. Majid’s motion for summary judgment.

[7]   On December 6, 2013, Kindred filed a motion for summary judgment which

      similarly argued that there was no genuine issue of material fact as to causation.

      The Siners filed a response and designated the affidavits of Drs. Timothy

      Pohlman and Lawrence Reed. Pohlman opined that the Defendants breached

      their duty of care in multiple respects and that Geraldine’s injuries likely

      resulted from those breaches. On March 13, 2014, the trial court granted

      Kindred’s motion for summary judgment reasoning that “neither [Pohlman nor

      Reed’s] affidavit addresses the issue of causation of Geraldine Siner’s injuries or

      death.” Appellee’s App. p. 107. The Siners now appeal both orders granting

      summary judgment.

                                 Discussion and Decision
      Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015    Page 5 of 19
                                      I. Standard of Review
[8]           On appeal, our standard of review is the same as that of the trial court:
              summary judgment is appropriate only where the evidence shows
              there is no genuine issue of material fact and the moving party is
              entitled to judgment as a matter of law. We construe all facts and
              reasonable inferences drawn from those facts in favor of the non-
              moving party. On appeal, the trial court’s order granting or denying a
              motion for summary judgment is cloaked with a presumption of
              validity. A party appealing from an order granting summary judgment
              has the burden of persuading the appellate tribunal that the decision
              was erroneous.
      Roberts v. Sankey, 813 N.E.2d 1195, 1197 (Ind. Ct. App. 2004) (citations

      omitted).

              A defendant is entitled to judgment as a matter of law when he shows
              that the undisputed material facts negate at least one element of the
              plaintiff’s claim for relief. A court must grant summary judgment,
              after adequate time for discovery and upon motion, against a party
              who fails to make a showing sufficient to establish the existence of an
              element essential to that party’s case, and on which that party will bear
              the burden of proof at trial.
      Briggs v. Finley, 631 N.E.2d 959, 963 (Ind. Ct. App. 1994) (citations omitted).

[9]   “In a medical negligence claim, the plaintiff must prove by expert testimony not

      only that the defendant was negligent, but also that the defendant’s negligence

      proximately caused the plaintiff’s injury.” Clarian Health Partners, Inc. v. Wagler,

      925 N.E.2d 388, 392 (Ind. Ct. App. 2010) (citing Schaffer v. Roberts, 650 N.E.2d

      341, 342 (Ind. Ct. App. 1995)). The only issue facing this court is whether there

      is a genuine issue of material fact on the subject of causation. Defendants do

      not dispute that there is a factual issue regarding whether they breached their

      duty of care.

      Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015          Page 6 of 19
           II. Standard for Reliance on Expert Medical Testimony
[10]   In Noblesville Casting Division of TRW, Inc. v. Prince, 438 N.E.2d 722 (Ind. 1982),

       the Indiana Supreme Court addressed the standard for admissibility of expert

       witness evidence and the degree of certainty with which that evidence must be

       offered by the expert in order to support a verdict. 2 In Noblesville Casting, the

       plaintiff, Prince, aggravated a preexisting degenerative spinal condition while

       lifting heavy objects at work. Id. at 724. The sole expert testimony in the case

       had come from Prince’s surgeon who testified that it was “possible” that the

       incident at work had aggravated his preexisting condition. Id. at 725.

                [W]e reiterate that no threshold level of certainty or conclusiveness is
                required in an expert’s opinion as a prerequisite to its admissibility.
                Assuming the subject matter is one which is appropriate for expert
                testimony and that a proper foundation has been laid, the expert’s
                opinion or conclusion that, in the context of the facts before the
                witness, a particular proposition is “possible,” “could have been,”
                “probable,” or “reasonably certain” all serve to assist the finder of fact
                in intelligently resolving the material factual questions. The degree of
                certainty in which an opinion or conclusion is expressed concerns the
                weight to be accorded the testimony, which is a matter for the jury to
                resolve.
                Notwithstanding the probative value and admissibility of an expert’s
                opinion which falls short of “reasonable scientific or medical
                certainty,” we also reiterate that standing alone, an opinion which
                lacks reasonable certainty or probability is not sufficient evidence by
                itself to support a verdict.

       2
         Both the majority and concurring opinions in Noblesville Casting received two votes, with one Justice not
       participating. Although the two opinions disagreed on the standard of admissibility for expert opinions, both
       agreed on the requisite level of certainty necessary for an expert opinion to support a verdict. As only the
       latter issue is relevant to this case, it is of no importance that there was no majority or plurality opinion.

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015                            Page 7 of 19
                                                    ***
               Of course, an expert’s opinion that something is “possible” or “could
               have been” may be sufficient to sustain a verdict or award when it has
               been rendered in conjunction with other evidence concerning the
               material factual question to be proved. No hard and fast rule can be
               stated; the matter is a factual one to be resolved on a case-by-case
               basis, depending upon the particular standards of proof or review
               which are applicable, as well as the evidence presented, including the
               expertise of the witness and the data and analytical methods upon
               which the opinion is based.
       Id. at 731 (citations omitted). See also Malooley v. McIntyre, 597 N.E.2d 314, 318

       (Ind. Ct. App. 1992) (plaintiff in a medical malpractice case must provide

       “evidence which tends to support the…allegation that there was a causative

       nexus between conduct and [injury].”).

[11]   The Court in Noblesville Casting instructed that courts should be careful not to

       elevate form over substance, or as the court phrased it, “elevate[] the law’s

       demand for certainty in language over the state of the particular art and the

       value of the advances made” by the expert. 438 N.E.2d at 727.

               “Medicine, for instance, is not yet an exact science; to demand
               reasonable certainty in medical opinions places a sometimes
               insurmountable barrier in the face of the candid and straightforward
               medical expert. New York’s highest court explained:
                        Of course, one can pick out the words ‘assumed’ and
                        ‘possibly’. But this careful physician was saying all that
                        an opinion expert could honestly say, that is that
                        although there could not be certainty in such a case his
                        professional judgment was that causality should and
                        could be assumed and acted upon although in the nature
                        of things it could never be scientifically proven or
                        disproven.

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015           Page 8 of 19
                         “Our function is not to reject opinion evidence because
                         nonlawyer witnesses fail to use the words preferred by
                         lawyers and Judges but to determine whether the whole
                         record exhibits, as it does here, substantial evidence of
                         aggravation ....” Ernst v. Boggs Lake Estates, (1963) 12
                         N.Y.2d 414, 416, 240 N.Y.S.2d 153, 154, 190 N.E.2d
                         528, 529.
                                                      ***
                What must be “reasonably certain,” it has been recognized, is that the
                witness is in fact an expert and that the analytical and scientific
                methods employed are generally accepted in the particular community
                of expertise; in other words, “reasonable certainty” is primarily a
                formulation designed to guarantee the trustworthiness or reliability of
                the opinion offered, rather than the fact to be proved. Boose v. Digate,
                (1969) 107 Ill. App. 418, 246 N.E.2d 50; State v. Wind, (1973) 60
                Wis.2d 267, 208 N.W.2d 357.
       Id. at 727, 729.

[12]   Ultimately, the Court held that the expert’s testimony, despite being couched in

       speculative terms, was sufficient to support a verdict for Prince because it was

       supported by additional anecdotal evidence suggesting causation. Id. at 732. In

       a concurring opinion, Justice Pivarnik also found that the expert’s testimony

       was sufficient to support the verdict. However, Justice Pivarnik reasoned that

       despite the expert’s use of the speculative phrases “it is possible” and “it could

       be,” his overall analysis connoted a higher level of certainty which was

       sufficient to support a verdict on its own. Id. at 738. 3

       3
         We note that the Defendants have cited to the cases Colaw v. Nicholson, 450 N.E.2d 1023, 1030 (Ind. Ct.
       App. 1983) and Topp v. Leffers, 838 N.E.2d 1027, 1033-1034 (Ind. Ct. App. 2005). These cases reiterate the
       standard provided in Noblesville Casting. However, the court in Colaw misquotes Noblesville Casting, and that
       misquotation is subsequently repeated in Topp and cited in Kindred’s appellate brief.

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015                             Page 9 of 19
[13]   “Under Indiana law, the evidentiary standard required to establish the fact of

       causation in this matter is by a preponderance of the evidence.” Hardiman v.

       Davita Inc., 2007 WL 1395568, at *13 (N.D. Ind. May 10, 2007) (citing City of

       Indianapolis v. Parker, 427 N.E.2d 456 (Ind. Ct. App. 1981)). The rule outlined

       in Noblesville Casting “is simply a counterpart to the standard and burden of

       proof.” 438 N.E.2d at 731. Accordingly, an expert opinion must serve to

       overcome this standard in order to support a verdict. Expert opinions offered

       with reasonable medical certainty (in terms of their scientific/methodological

       reliability) which opine that a given injury was “probable” or “more likely than

       not” caused by defendant’s actions, fulfill the plaintiff’s burden to meet the

       preponderance standard, and may support a verdict standing alone. Id.; See also

       Hardiman, 2007 WL 1395568, at *15 (“Thus, admissible medical expert

       testimony must only be more conclusive than “possibility” when it stands alone

       as proof of proximate causation.” (quotation omitted)). Expert opinions that

       are, overall, speculative in nature are generally not sufficient to support a

                Noblesville Casting held that expert medical opinion couched in terms less than that of a
                reasonable degree of medical certainty; such as “possible,” “probable,” or “reasonably
                certain,” are admissible and do have probative value. However, such medical testimony
                standing alone, unsupported by other evidence, is not sufficient to support a verdict....
       Colaw, 450 N.E.2d at 1030; Topp, 838 N.E.2d at 1033-34. This is not the standard enunciated in Noblesville
       Casting. It is correct that medical opinions using speculative terms such as “possible” will generally be
       insufficient, absent additional evidence, to support a verdict. However, the terms “probable” and
       “reasonably certain” were specifically referenced in Noblesville Casting as being sufficient to support a verdict
       standing alone. See Id. at 731. (“we also reiterate that standing alone, an opinion which lacks reasonable
       certainty or probability is not sufficient evidence by itself to support a verdict.”)

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015                               Page 10 of 19
       verdict absent additional supporting evidence. Topp, 838 N.E.2d at 1035;

       Noblesville Casting, 438 N.E.2d at 731.

                                                III. Analysis
                                        A. Kindred Defendants
[14]   Kindred argues that the Siners failed to designate any evidence which indicates

       that its purportedly negligent acts caused Geraldine’s injuries or death. The

       trial court adopted this conclusion in its order granting summary judgment.

               The Plaintiff designated the Affidavits of Dr. Timothy H. Pohlman
               and Lawrence Reed. Both of these physicians do opine that the
               Defendants found that there was practice below the standard of care.
               However, neither affidavit addresses the issue of causation of
               Geraldine Siner’s injuries or death.
       Appellee’s App. p. 107.

[15]   However, it appears that Dr. Pohlman’s affidavit did in fact opine that the

       Defendants’ allegedly negligent standard of care caused injury to Geraldine.

                      3. On December 8, 2007, Geraldine A. Siner was transferred
               from Kindred Hospital to Methodist Hospital’s ICU…. The patient
               required intubation and immediate bronchoscopy for left atelectasis
               (collapsed lung) which I found on initial imaging studies. I recall
               Gerri Siner’s family expressed shock when informed of her collapsed
               lung, saying that Kindred Hospital had not informed them of this.
               According to patient records obtained from Kindred Hospital, the left
               lung atelectasis was known on December 5, 2007. In my opinion that
               the lack of timely resolution of the lung collapse on December 5, 2007
               represents a deviation from the Standard of Care.
                      4. I recall that Gerri Siner had wounds on her cheeks indicating
               the prolonged use of a BiPAP mask, which were documented by our
               ‘wound team. In my opinion, the prolonged use of BiPAP and CPAP

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015         Page 11 of 19
        to the point of facial wounds, constitutes a breach in the accepted
        Standard of Care. Adverse effects of non-invasive ventilation such as
        pressure necrosis on the face…. The development of pressure necrosis
        is one factor that can limit the tolerance and duration of noninvasive
        ventilation, and requires continuous readjustment of the mask. There
        is no clinical record that this occurred at Kindred Hospital for this
        patient.
                5. Moreover, continuing CPAP was recommended because
        alternative treatments “such as tracheotomy and intubation were not
        appropriate in a terminal patient.” [emphasis in original] However, the
        designation of ‘terminal patient’ is typically made by a patient’s
        attending physician, and not by a division such as ‘Pulmonary
        Services.’ Further, Kindred’s Ethics Committee recommended over-
        riding the wishes of the family and instructions of the patient’s medical
        representative for full treatment, and instituted Do Not Resuscitate
        (DNR) order, which ruled out such alternative treatments.
                6. Methodist records document that Gerri Siner was also
        suffering from over-whelming infection, and septic shock at the time of
        intake. There is no documentation produced for me that indicate
        SCCM Surviving Sepsis Guidelines, even from 2004, were followed
        (Crit Care Med, 2004;32:858-73). These guidelines were not followed
        apparently because the patient was under a DNR order. This is an
        additional breach in the Standard of Care.
                 7. Full damages and suffering that more likely than not resulted from
        re-prioritization of treatment modalities for Gerri Siner based on her existing
        ‘DNR’ order that was left in place without full agreement and consent
        of her Surrogate decision makers would warrant reassessment of her
        care at Kindred Hospital. [emphasis added]
Appellant’s App. pp. 189-91. In sum, Dr. Pohlman opined that Geraldine

suffered facial wounds as a result of a breach in the accepted standard of care.

He goes on to state that Kindred’s DNR order likely led to additional damages

and suffering caused by failure to properly treat Geraldine’s collapsed lung,

infection, and sepsis.

Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015               Page 12 of 19
[16]   In contrast to the trial court’s order, Dr. Pohlman’s affidavit does address the

       issue of causation. Furthermore, in light of Dr. Pohlman’s analysis on the

       whole, and by his statement that the negligent DNR order “more likely than

       not” resulted in damages and suffering, we think the affidavit meets the

       standard outlined in Noblesville Casting for sufficiency to support a verdict.

       Therefore, the affidavit did create a material issue of fact and so the trial court

       erred in granting Kindred’s motion for summary judgment.

[17]   Kindred briefly points to the fact that IU Pulmonary directed Geraldine’s

       pulmonary care during her hospitalization at Kindred and that Dr. Krueger

       found that it was reasonable for Kindred to rely on IU Pulmonary for decisions

       regarding Geraldine’s pulmonary treatment. However, this argument only goes

       to Kindred’s alleged negligent use of the CPAP mask and does not change the

       fact that there is a factual dispute regarding Kindred’s decision to impose a

       DNR order for Geraldine, a decision which was unrelated to her pulmonary

       care.

[18]   Furthermore, we find Dr. Krueger’s affidavit to be considerably suspect. After

       hearing evidence presented by both parties, Dr. Krueger, along with two other

       members of the medical review panel, unanimously determined that the

       Defendants breached their respective standards of care and may have caused

       injury to Geraldine. Seven months later, Dr. Krueger offered an affidavit which

       opined that Defendants had not breached their duties of care. This affidavit was

       based on Dr. Krueger’s further review of unspecified medical records. Dr.

       Krueger provided no insight as to what prompted his subsequent review of the

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015     Page 13 of 19
       case, what medical records were reviewed, or why those records led him to a

       different conclusion than during his initial review as part of the medical review

       panel. Nevertheless, the medical panel’s decision was inconclusive regarding

       causation, so the burden was on the Siners to offer evidence sufficient to create

       a material issue of fact on causation. As such, the Defendants were under no

       duty to offer such evidence and the existence of Dr. Krueger’s affidavit, valid or

       not, is irrelevant to our decision. See Clarian Health Partners, Inc. v. Wagler, 925

       N.E.2d 388, 393 (Ind. Ct. App. 2010) (A medical review panel’s opinion stating

       that it cannot determine from the evidence whether a defendant’s conduct

       caused the injury to patient affirmatively negates the causation element and

       shifts to the patient the burden of demonstrating the existence of a genuine issue

       of material fact as to causation).

                                                 B. Dr. Majid
[19]   The Siners did not obtain or designate Dr. Pohlman’s affidavit as evidence with

       regards to Dr. Majid’s motion for summary judgment. The only expert witness

       evidence designated by the Siners was the medical review panel’s opinion

       which stated that the Defendants’ conduct “may have been a factor of some

       resultant damages, but not the death of the patient.” Appellee’s App. p. 15.

       Dr. Majid claims that such an opinion, standing alone, is insufficient to gain a

       verdict for medical malpractice. We agree.

[20]   The medical review panel’s determination that “[Defendants’] conduct may

       have been a factor of some resultant damages” is a clear example of a

       speculative expert opinion which does not establish causation with reasonable
       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015     Page 14 of 19
       certainty or probability. The three-sentence panel opinion lacks any context

       with which a higher degree of certainty might be gleaned and the Siners did not

       designate any additional supporting evidence. As such, the medical panel

       opinion is not sufficient to support a verdict under the Noblesville Casting

       standard. “A court must grant summary judgment…against a party who fails

       to make a showing sufficient to establish the existence of an element essential to

       that party’s case, and on which that party will bear the burden of proof at trial.”

       Briggs, 631 N.E.2d at 963. Therefore, the medical panel opinion did not create

       an issue of material fact regarding causation sufficient to preclude Dr. Majid’s

       motion for summary judgment.

[21]   The judgment of the trial court is affirmed in part and reversed in part.

       Vaidik, C.J., concurs.
       Kirsch, J., concurs in part and dissents in part with opinion.

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015    Page 15 of 19
                                            IN THE
    COURT OF APPEALS OF INDIANA

Kathy L. Siner, Personal                                  Court of Appeals Case No.
                                                          49A05-1404-CT-165
Representative of the Estate of
Geraldine A. Siner, Deceased,
and John T. Siner, prior
Enduring Power of Attorney and
Medical Representative of the
Deceased
Appellants-Plaintiffs,

        v.

Kindred Hospital Limited
Partnership d/b/a Kindred
Hospital of Indianapolis, et al.,
Mohammed A. Majid, M.D.,
Dennis Nicely, David Uhrin,
RN.
Appellees-Defendants.

KIRSCH, Judge, concurring in part and dissenting in part.

Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015                Page 16 of 19
[22]   I fully concur in the decision to reverse the trial court’s grant of summary

       judgment with regard to the Kindred defendants, but I respectfully dissent form

       the decision to affirm the grant of summary judgment for Dr. Majid.

[23]   The basis of my dissent is two-fold:

[24]   First and foremost, I think that there are material questions of fact regarding

       whether Dr. Majid breached the applicable standard of care in his treatment of

       Geraldine Siner and whether such breach was a factor in the resultant damages.

       Second, I find it troubling that a single member of a Medical Review Panel can

       undermine the work of the panel of which he was a part by an ex parte and

       conclusory affidavit executed months after the fact without procedural

       safeguards.

[25]   The affidavit of James R. Krueger, M.D. was signed more than eight months

       after the Medical Review Panel convened and heard the evidence presented by

       the parties and their counsel and nearly seven months after it rendered its

       unanimous opinion. In his affidavit, Dr. Krueger states that “Since rendering

       my panel opinion, I have had the opportunity to review the medical records of

       Geraldine Siner in greater detail.” Dr. Krueger does not state which medical

       records he reviewed. Thus, we do not know whether he reviewed all of her

       records, all of the records introduced at the hearing and presented to the panel,

       or records which were not introduced at the hearing. We do not know the

       nature of such medical records, nor whether they met the relevancy and

       authentication standards for admission into evidence. Indeed, we have no

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015   Page 17 of 19
       knowledge about “the medical records” that Dr. Krueger reviewed “in greater

       detail.”

[26]   Similarly, we do not know the circumstances prompting Dr. Krueger’s further

       review. We do not know why, where or when it occurred, and we do not know

       who, if anyone, was present. We do not know how long Dr. Krueger spent

       reviewing the selected records “in greater detail.” We do not know whether Dr.

       Krueger drafted his affidavit or whether it was drafted by someone else.

[27]   All that we do know about Dr. Krueger’s opinion is that there is a contradiction

       between the opinion that Dr. Krueger rendered as a medical expert serving on

       the Medical Review Panel in this case and the one which he gave several

       months later. As a result, one of the three medical experts serving on the

       Medical Review Panel in this case had certain reservations about his opinion as

       a result of his later private review of certain of Ms. Siner’s medical records

       outside the purview of the Panel without the opportunity for authentication of

       the records or cross-examination.

[28]   From my perspective, one member of a Medical Review Panel cannot

       undermine the statutorily-prescribed Medical Review Panel process. At most,

       there is simply a question of material fact arising from the Medical Review

       Panel Opinion on one hand stating unanimously that “the evidence supports

       the conclusion that the defendants failed to comply with the appropriate

       standard of care, and that their conduct may have been a factor of some

       resultant damages, but not the death of the patient” and Dr. Krueger’s later

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015    Page 18 of 19
       opinion that “Dr. Majid met the standard of care and did not cause any injury

       to Geraldine Siner in connection with CPAP application.” Had Dr. Krueger

       held his later opinion at the time that the Medical Review process was

       conducted and voted accordingly, the panel vote would have been two to one.

       To me, the fact that Dr. Krueger issued a different opinion several months after

       the process is immaterial. The expert medical opinion arising from the Medical

       Review process remains that Dr. Majid “failed to comply with the appropriate

       standard of care, and that [his] conduct may have been a factor of some

       resultant damages, but not the death of the patient.”

[29]   The second basis from my dissent rises from the fact that the Medical Review

       process was created by our General Assembly. That process is mandated in

       nearly all legal proceedings alleging medical malpractice. The process includes

       a number of mandated procedural and evidentiary safeguards to protect the

       rights of all parties to the proceeding. That process should not be impeached or

       undermined months after it is concluded by an affidavit from a member of the

       panel issued without those procedural safeguards.

       Court of Appeals of Indiana | Opinion 49A05-1404-CT-165 | May 27, 2015   Page 19 of 19