Court Opinion

ID: 4158164
Source: CourtListenerOpinion
Date Created: 2017-04-05 15:09:02.523808+00
Date Added: 2024-06-11T14:28:22.457682
License: Public Domain

MEMORANDUM DECISION

Pursuant to Ind. Appellate Rule 65(D),
this Memorandum Decision shall not be                                   FILED
regarded as precedent or cited before any                          Apr 05 2017, 5:29 am

court except for the purpose of establishing                            CLERK
the defense of res judicata, collateral                             Indiana Supreme Court
                                                                       Court of Appeals
                                                                         and Tax Court
estoppel, or the law of the case.

ATTORNEY FOR APPELLANT                                    ATTORNEYS FOR APPELLEE
Cynthia S. Rose                                           Robert G. Zeigler
Arthur R. Baxter, Jr.                                     Marilyn A. Young
Baxter James & Rose LLP                                   Erin E. Bowles
Indianapolis, Indiana                                     Zeigler Cohen & Koch
                                                          Indianapolis, Indiana

                                           IN THE
    COURT OF APPEALS OF INDIANA

Debra K. Ford, Personal                                   April 5, 2017
Representative of the Estate of                           Court of Appeals Case No.
Darlene M. Welsh,                                         49A04-1606-CT-1334
Appellant-Plaintiff,                                      Appeal from the Marion Superior
                                                          Court
        v.                                                The Honorable James B. Osborn,
                                                          Judge
Indiana Heart Hospital,                                   Trial Court Cause No.
Appellee-Defendant                                        49D14-1510-CT-037696

Mathias, Judge.

Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017        Page 1 of 19
[1]   Darlene M. Welsh (“Welsh”) died while recovering from open heart surgery at

      the Indiana Heart Hospital (“the Hospital”)1 in Indianapolis. Debra K. Ford

      (“Ford”), Welsh’s daughter and the personal representative of her estate, sued

      the Hospital for medical negligence. The trial court granted summary judgment

      in the Hospital’s favor. From that grant, Ford now appeals, claiming her

      designation created a fact issue as to the applicable standard of care and

      precluded judgment as a matter of law.

[2]   We reverse.

                                    Facts and Procedural Posture

[3]   Darlene Welsh was an eighty-two-year-old woman, described with medical

      objectivity as “quite functional for her age and very active.” Appellant’s App. p.

      59. On May 2, 2011, Welsh received previously scheduled open heart surgery at

      the Hospital to repair her mitral valve and to bypass a blocked coronary artery.

[4]   Once the repair and bypass were completed, the surgeon, Dr. John Storey

      (“Storey”), placed a single “pacing wire” in Welsh’s chest. Pacing wires

      connect the heart to an artificial pacemaker and may be placed temporarily in

      the chests of postoperative open heart surgery patients to help regulate (“pace”)

      heart rhythms and blood flow until the heart can function normally on its own.

      See id. p. 90. Storey anchored one end of the pacing wire in Welsh’s

      1
          The Hospital now operates under a different name.

      Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 2 of 19
      myocardium, the heart muscle, and ran the other end through the sternotomy

      incision in the left side of Welsh’s chest.

[5]   By all accounts, the surgery went well. On May 3, 2011, the first day after

      surgery, Storey noted, “[Welsh]’s doing fine. Cardiac function is fine. Labs

      okay . . . . We will discontinue her tubes lines and wires . . . .” Id. p. 29 (sic).

      Storey could not later say what “wires” referred to here. Id. p. 84. In any event,

      Welsh’s pacing wire was not removed on that day. Storey’s outlook on May 4,

      2011, was similarly optimistic, and Welsh had “no complaints.” Id. p. 30. On

      and after May 5, 2011, Storey was on vacation in New York City, and a new

      doctor supervised Welsh’s care in his absence. “[N]o new issues” were reported

      that day by the new doctor. Id. p. 31.

[6]   On May 6, 2011, the fourth day after surgery, Welsh was scheduled to go home

      from the Hospital. Lindsay Cool (“Cool”), a nurse practitioner, had been asked

      by the new doctor to remove (“pull”) the pacing wire from Welsh’s chest. The

      doctor had apparently planned to pull the wire himself but forgot to do so on

      his rounds earlier that morning. Id. p. 73. “There were a few of the nurse

      practitioners that worked for the cardiologists that were comfortable removing

      pacemaker wires, but they did not routinely do that. It was up to [surgical nurse

      practitioners like Cool] on [their] rounds to do that” if a physician was not

      available. Id. p. 74. Cool testified that, when she pulled Welsh’s pacing wire,

      she was not following a written policy, procedure, or protocol, because the

      Hospital did not have one, nor did the physician group within the Hospital for

      which Cool worked. Id. p. 72.

      Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 3 of 19
[7]   Welsh was sitting comfortably in a reclining chair in her hospital room as Cool

      pulled the wire. Cool felt no resistance “whatsoever” as she pulled the wire out

      from Welsh’s myocardium through her chest; if Cool had felt any, she would

      have stopped. Id. p. 73. “That wasn’t bad,” Welsh said when Cool was finished.

      Id.

[8]   About ten minutes later, around 8:35 a.m., Welsh was sitting in bed getting

      ready to eat breakfast. She suddenly felt unwell and lost consciousness. A

      “Code Blue” was called and “extensive” emergency resuscitation was

      attempted by responding Hospital staff — to no avail. Id. p. 37. An

      echocardiogram indicated a “large” pericardial effusion. Id. Cardiac

      tamponade, a potentially fatal compression of the heart by the pressure of the

      accumulating blood and other fluid around it, see id. p. 89, was suspected. This

      could have been treated surgically, but Welsh was judged “really far too

      unstable” for immediate surgery. Id. p. 37. Over one liter of blood and other

      fluid was drawn from her chest by aspiration, “but this did not result in any

      improvement in [Welsh’s] clinical status.” Id. After about fifty minutes, further

      resuscitative efforts were deemed futile. Welsh was pronounced dead at 9:21

      a.m.

[9]   Ford, Welsh’s daughter and the personal representative of her estate, brought

      suit, alleging medical negligence. On April 5, 2013, as required by Indiana’s

      Medical Malpractice Act, Ind. Code art. 34-18, Ford first filed her proposed

      complaint with a medical review panel, id. § 8-4, naming the Hospital, Storey,

      and Cool as proposed defendants. Appellant’s App. p. 14. On August 11, 2015,

      Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 4 of 19
       the panel issued its opinion, here in full: “The evidence does not support the

       conclusion that the [proposed] Defendants failed to meet the applicable

       standard of care as charged in the [proposed] complaint.” Id. p. 17. On October

       30, 2015, the panel’s opinion notwithstanding, Ford filed her complaint in

       Marion Superior Court, naming only the Hospital as defendant.

[10]   On January 8, 2016, the Hospital moved for summary judgment, designating in

       support the panel’s opinion finding no breach of the standard of care. The

       Hospital argued that the opinion “demonstrate[d] the absence of a genuine

       issue of material fact on the elements of breach of the standard of care and

       proximate causation.” Id. p. 22. In response, Ford designated excerpts of

       Welsh’s medical records, excerpts of Storey’s and Cool’s deposition testimony,

       and the affidavit of Amanda Dillow (“Dillow”), a registered nurse and certified

       nurse legal consultant (“the Dillow affidavit”).

[11]   The Dillow affidavit set out Dillow’s relevant training and experience. Id. p. 77

       ¶¶ 2-6. Dillow affirmed that her experience included “developing and educating

       nursing staff in the care of patients with temporary . . . pacemakers [and] pre-

       op[erative] and post-op[erative] care according to policies and procedures . . . .”

       Id. ¶ 4. Dillow affirmed further that she was “familiar with the standard of care

       for . . . removing temporary pacing wires in post-op[erative] open heart

       [surgery] patients,” id. ¶ 6, and that she had reviewed Ford’s and the Hospital’s

       submissions. Id. ¶ 7. Dillow concluded the Hospital “did not meet the standard

       of care” in Welsh’s case. Id. ¶ 8. Particularly:

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 5 of 19
               [a]mong other issues, Ms. Cool stated in her deposition that she
               did not follow a hospital policy and procedure when she removed
               the pacing wires.

               In addition and among other issues, Ms. Cool stated that there
               was no policy and procedure at the . . . Hospital for the removal
               of temporary pacing wires in May, 2011.

               There are other ways in which the . . . Hospital, through the acts
               of its employees did not meet the standard of care in these
               circumstances.

       Id. ¶¶ 9-11 (sic passim) (internal citations and subdivisions omitted).

[12]   The trial court heard argument on the Hospital’s motion on May 9, 2016, and

       took it under advisement. On May 11, 2016, the court granted the motion

       without entering its findings or conclusions.

[13]   Ford timely filed notice of appeal on June 9, 2016. The parties join issue on

       whether the Dillow affidavit was sufficient to create a genuine issue of material

       fact preclusive of summary judgment. We hold that it was.

                                          Standard of Review

[14]   As a purely legal question, we review de novo the trial court’s grant of

       judgment as a matter of law. Hughley v. State, 15 N.E.3d 1000, 1003 (Ind. 2014).

       We will not affirm unless the designated evidence shows there is no genuine

       issue as to any material fact. Id. “A fact is material if its resolution would affect

       the outcome of the case, and an issue is genuine if a trier of fact is required to

       resolve the parties’ differing accounts of the truth, or if the undisputed material

       facts support conflicting reasonable inferences.” Id. (internal quotation and
       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 6 of 19
       citation omitted). We draw all reasonable inferences in the non-movant’s favor.

       Id. “[A]lthough the [non-movant] has the burden on appeal of persuading us

       that the grant of summary judgment was erroneous, we carefully assess the trial

       court’s decision to ensure that she was not improperly denied her day in court.”

       Id. (internal quotation and citation omitted).

[15]   In contrast to federal practice, an Indiana summary judgment movant may not

       rely on a non-movant’s failure to designate evidence in support of each element

       of her claim. Id. Rather, Indiana practice places the burden on the movant

       affirmatively to negate — that is, to designate evidence disproving — an

       element of the non-movant’s claim. Id. If carried, the burden then shifts to the

       non-movant to come forward with contrary evidence requiring resolution by a

       trier of fact. Id. Such evidence precludes judgment as a matter of law. This rule

       reflects our policy of “consciously err[ing] on the side of letting marginal cases

       proceed to trial on the merits, rather than risk short-circuiting meritorious

       claims.” Id. at 1004.

[16]   The elements of a medical malpractice claim are three: that defendant

       healthcare provider owed plaintiff patient a duty; that defendant breached that

       duty; and that plaintiff’s injuries were proximately caused by that breach. Siner

       v. Kindred Hosp. Ltd. P’ship, 51 N.E.3d 1184, 1187 (Ind. 2016). The unanimous

       opinion of a medical review panel designated by a movant ordinarily suffices to

       shift the burden to the non-movant on the elements to which the opinion

       speaks, requiring the non-movant to rebut the opinion with her own expert

       medical testimony on those elements. Id. at 1187-88. If the non-movant’s expert

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 7 of 19
       designation contradicts the panel’s opinion, her case is “by definition

       inappropriate for summary judgment, because weighing evidence is a matter for

       trial . . . .” Id. at 1088 (internal citation and quotation omitted).

                                         Discussion and Decision

[17]   Ford argues that the Dillow affidavit was legally and factually sufficient under

       the applicable standard to create a genuine fact issue as to the existence and

       breach of the standard of care. The Hospital raises several arguments in support

       of the judgment below, but only one is properly presented for our review: that

       the Dillow affidavit was legally and factually insufficient to create a genuine

       fact issue. The rest are challenges to the admissibility of the affidavit which the

       Hospital did not raise below and therefore waived.2 Paramo v. Edwards, 563

       2
         The Hospital argues that Dillow was incompetent to give expert testimony as to the existence or breach of
       the standard of care by the Hospital or Cool, and that the medical records designated with the affidavit were
       not certified as required by Indiana Trial Rule 56(E). These challenges to admissibility were not raised in the
       trial court. Waiver notwithstanding, we note the following.
       As to the first argument, it presents precisely the sort of question that cannot be intelligently decided without
       the record developed by contemporaneous objection. While it is true that, under Indiana Evidence Rule 702,
       we have held that nurses are generally incompetent to give expert testimony on the standard of care for
       physicians or on medical causation, Long v. Methodist Hosp. of Ind., Inc., 699 N.E.2d 1164, 1168-69 (Ind. Ct.
       App. 1998), we have also expressly declined to propound “a blanket rule that nurses cannot qualify as expert
       witnesses” with respect to duty and breach by any and every nonphysician health care provider, Curts v.
       Miller’s Health Systems, Inc., 972 N.E.2d 966, 971 (Ind. Ct. App. 2012), such as nursing homes, id., hospitals,
       or nurse practitioners. Indeed, it seems reasonable to expect that a nurse would be qualified to give expert
       testimony on whether nurses, whether registered nurses like Dillow or nurse practitioners like Cool, should
       be governed by written protocols when extracting metal wires from beating hearts. We could not say whether
       a ruling to this effect, or its contrary, would constitute abuse of the trial court’s “broad discretion,” Ford v.
       Jawaid, 52 N.E.3d 874, 877 (Ind. Ct. App. 2016), in the absence of an objection, and thus a record, below.
       As to the second argument, even if the medical records had been objected to and struck, as the Hospital itself
       concedes, the Dillow affidavit “did not refer to any specific facts found in [them] . . . .” Appellee’s Br. p. 13.
       Dillow referred to them only to say she had reviewed them, as required of medical expert affiants in this
       context, Jordan v. Deery, 609 N.E.2d 1104, 1110 (Ind. 1993), and Ford apparently designated them only in an
       attempt to comply with T.R. 56(E), requiring “[s]worn or certified copies . . . of all papers . . . referred to in
       an affidavit . . . .” In other words, the records were and are not part of Ford’s substantive argument on

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017                  Page 8 of 19
N.E.2d 595, 600 (Ind. 1990) (“A complaining party has a duty to direct the trial

       court’s attention to a defective affidavit, and failure to raise an objection

       constitutes waiver. We decline to excuse the lack of timely objection despite the

       defendants’ argument that a reviewing court is bound to affirm a trial court’s

       grant of summary judgment if sustainable on any theory or basis found in the

       record.” (original emphasis, internal citations omitted)); Dunaway v. Allstate Ins.

       Co., 813 N.E.2d 376, 387 (Ind. Ct. App. 2004) (“Issues not raised before the

       trial court on summary judgment cannot be argued for the first time on appeal

       and are waived.”); Long v. Methodist Hosp. of Ind., Inc., 699 N.E.2d 1164, 1166

       (Ind. Ct. App. 1998) (“[A]ny objection raised to an affidavit after a ruling on

       summary judgment is . . . waived as untimely.”); Bankmark of Fla., Inc. v. Star

       Fin. Card Servs., Inc., 679 N.E.2d 973, 980 (Ind. Ct. App. 1997) (“[A] party

       complaining that an affidavit is defective has a duty to direct this complaint to

       the trial court, and the failure to do so constitutes waiver.”). We therefore

       confine our review to the question of the Dillow affidavit’s sufficiency.

[18]   In medical malpractice cases, the otherwise admissible affidavit of a medical

       expert designated by a non-movant, controverting the movant’s position as to

       whether the applicable standard of care has been satisfied, is ordinarily

       sufficient to preclude summary judgment in the movant’s favor. Siner v. Kindred

       Hosp. Ltd. P’ship, 51 N.E.3d 1184, 1190 (Ind. 2016) (reversing grant of summary

       summary judgment. See Mills v. Berrios, 851 N.E.2d 1066, 1072 (Ind. Ct. App. 2006) (“[W]e conclude that
       [plaintiff’s expert’s] affidavit [relying on plaintiff’s medical records] is not legally insufficient merely because
       [plaintiff’s] medical records were not attached or designated.”).

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017                    Page 9 of 19
       judgment). “[E]xpert opinions which conflict on ultimate issues necessarily

       defeat summary judgment.” Id. A different result is required only in the

       exceptional case, not presented here, where a party-physician affiant,

       unsupported by other evidence, attempts to bootstrap his naked litigation

       position into admissible evidence. Scripture v. Roberts, 51 N.E.3d 248 (Ind. Ct.

       App. 2016) (affirming grant of summary judgment).3

[19]   In Chi Yun Ho v. Frye, 880 N.E.2d 1192 (Ind. 2008) (affirming denial of

       summary judgment), our supreme court considered “whether conflicting

       opinions [in medical malpractice cases] regarding whether a physician met the

       applicable standard of care, in the absence of facts supporting such opinions, operate

       to create a genuine issue of material fact precluding summary judgment.” Id. at

       1201 (emphasis added). It was held that such conflicting opinions preclude

       summary judgment. Id. There, defendant physician resisted plaintiff patient’s

       motion for summary judgment by designating one affidavit, his own, and parts

       of the deposition testimony of a second physician, not a party to the suit, who

       treated the plaintiff after the defendant. Id. at 1200. The designation was

       “extremely sparse in factual content,” id., did not set out in terms what the

       3
         The Hospital relies heavily on Scripture. There, we expressly reserved the question “whether a defendant
       doctor’s own affidavit standing alone is sufficient to defeat summary judgment.” Id. at 251 n.2. We did not
       discuss Chi Yun Ho v. Frye, 880 N.E.2d 1192 (Ind. 2008), discussed here infra. Rather, in Scripture, we held
       that defendant physicians’ unsupported and conclusory affidavits did not defeat summary judgment in the
       plaintiffs’ favor, because the affidavits “cited no facts that would support that they met the standard of care or
       that their conduct did not cause the [plaintiffs’] damages.” Id. at 254. To the extent that Scripture and Chi Yun
       Ho conflict, of course the former must yield to the latter. However, we do not think they do conflict, if
       Scripture is understood to stand for the proposition recited here and contemplated (though reserved) there.

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017                Page 10 of 19
       applicable standard of care was, see id., but affirmed that the defendant had met

       it. Id.

[20]   In Chi Yun Ho, our supreme court held that, together, the affidavit and

       deposition extract sufficed to preclude summary judgment in the plaintiff’s

       favor because they created a genuine issue of material fact. Id. at 1201.

       “Medical negligence is . . . not generally a conclusion that may be reached by a

       jury without . . . an expert opinion [as to the applicable standard of care] among

       the evidence presented. Such expert opinion takes on the character of an

       evidentiary fact in medical malpractice cases.” Id. In such cases, therefore, “an

       opinion on the ultimate fact of whether a defendant physician’s conduct fell

       below the applicable standard of care may be seen as qualitatively different,”

       id., from cases where mere “speculation, not evidence” is designated by a

       defendant in an attempt to furnish nonnegligent explanations for his conduct.

       Cox v. Paul, 828 N.E.2d 907, 913 (Ind. 2005).

[21]   “Of course, [such conclusory] opinions would be greatly enhanced by detailing

       the factual circumstances upon which they were based. Numerous cases,

       however, have treated such detailing as affecting the weight and credibility to be

       given to the opinion [by the trier of fact] rather than its admissibility” and

       sufficiency to defeat a motion for summary judgment. Jordan v. Deery, 609
N.E.2d 1104, 1111 (Ind. 1993) (“reluctantly” reversing summary judgment)

       (quoting Kopec v. Memorial Hosp. of South Bend, 557 N.E.2d 1367 (Ind. Ct. App.

       1990), trans. denied). Our supreme court has emphasized that the question on

       summary judgment is not whether the evidence would support a verdict in favor

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 11 of 19
       of the non-moving party, but whether “a conflict of evidence may exist” on a

       material issue. Siner, 51 N.E.3d at 1189 (original emphasis) (quoting Purcell v.

       Old Nat’l Bank, 972 N.E.2d 835, 841 (Ind. 2012)).

[22]   Chi Yun Ho is to be further distinguished from cases in which an affiant

       physician affirmed merely that “he would have treated [the patient] differently,

       not that [defendant physician]’s treatment fell below the applicable standard [of

       care].” Oelling v. Rao, 593 N.E.2d 189, 190–91 (Ind. 1992) (original emphasis).

       Such a designation is insufficient as a matter of law to preclude summary

       judgment because it does not address the applicable legal standard: whether the

       patient’s treatment fell below the applicable standard of care. Thus, “[t]o refute

       the defendants’ evidence, the affidavit needed to set out the applicable standard

       of care and a statement that the treatment in question fell below that standard.”

       Id. at 190.

[23]   Under this approach, for example, Indiana appellate courts have deemed the

       following sufficient to preclude summary judgment: a medical review panel

       opinion that defendants’ “conduct may have been a factor of some resultant

       damages,” Siner, 51 N.E.3d at 1189; a defendant’s affidavit that he “took all the

       necessary and reasonable steps, in accordance with the standard of care, to

       remove all sponges from [the plaintiff’s] abdomen,”4 Chi Yun Ho, 880 N.E.2d at

       4
         “The fact that the nursing staff made and recorded sponge counts showing all sponges accounted for and
       reported that fact to [defendant physician] does not preclude [his] liability [because] a surgeon may not
       escape his responsibility to remove sponges used during the surgery simply by delegating responsibility for
       tracking surgical sponges to attending nurses.” Chi Yun Ho, 880 N.E.2d at 1200. That fact, averred in the

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017             Page 12 of 19
       1200; a plaintiff’s expert’s affidavit that “set forth her conclusion that the

       defendants violated the standard of care in their treatment of the child and that

       such treatment caused the complained-of injuries” without being “informative

       in any way as to the nature of the deviation,” Deery, 609 N.E.2d at 1111; and a

       plaintiff’s expert’s affidavit that “he is familiar with the standard of care of

       physicians engaged in abdominal surgery in [the county], he reviewed the

       relevant medical records of [the plaintiff] and the depositions, and he was of the

       opinion that the care rendered to [the plaintiff] by all Defendants was below the

       applicable standard of care and was causative in [the plaintiff’s] death.”

       Randolph Cnty. Hosp. v. Livingston, 650 N.E.2d 1215, 1219 (Ind. Ct. App. 1995).

[24]   Here, resolving, as we must, all reasonable inferences and all ambiguities in

       Ford’s favor, we conclude that a fair reading of the Dillow affidavit reveals that

       Dillow first stated her experience included “developing and educating nursing

       staff in the care of patients with temporary . . . pacemakers [and] pre-op[erative]

       and post-op[erative] care according to policies and procedures,” Appellant’s

       App. p. 77 ¶ 4, and that she was “familiar with the standard of care for this

       procedure of removing temporary pacing wires in post-op[erative] open heart

       patients.” Id. ¶ 6. She then stated the Hospital fell short of the standard of care

       in Welsh’s case. Id. ¶ 8. “Among other issues,” she then identified two

       particular ways in which the Hospital did so: by allowing Cool to pull Welsh’s

       defendant’s affidavit, therefore was judged irrelevant to the question of whether the affidavit operated to
       create a genuine fact issue as to duty and breach. Compare this with Appellee’s Brief p. 14 (asserting that
       defendant in Chi Yun Ho “did provide facts and indeed established the standard of care . . . .”).

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017              Page 13 of 19
       pacing wire unregulated by a “hospital policy and procedure,” id. ¶ 9, and by

       failing to establish such a “policy and procedure” with respect to “removal of

       temporary pacing wires” to begin with. Id. ¶ 10.

[25]   In sum, Dillow affirmed that, given her training and experience as a registered

       nurse who educates other nurses in the care of postoperative open heart surgery

       patients according to protocol, and given her familiarity with the standards for

       pacing wire removal, the Hospital fell short of the standard of care when it

       allowed a nurse practitioner to remove a pacing wire unregulated by written

       protocols, and when the Hospital failed to establish such protocols at all. While

       the affidavit expressly stated only the minor premise and the conclusion of the

       argument, the implied major premise, that the standard of care requires

       regulation by written protocols of pacing wire removal by nurse practitioners, is

       only one reasonable inferential step away. We believe this was sufficient to

       create a genuine fact issue requiring resolution by the trier of fact.

[26]   The Hospital cites our decision in Payne v. Marion General Hospital, 549 N.E.2d
1043 (Ind. Ct. App. 1990), trans. denied, for the proposition that a plaintiff

       alleging a hospital’s negligent failure to establish a written policy must produce

       evidence of “policies used by [another] hospital” or evidence that “other

       hospitals use written policies” to rebut a medical review panel’s conclusion of

       no breach and survive summary judgment. Id. at 1051. However, Payne

       established no such rule. There, defendant physician entered a do-not-

       resuscitate order without any attempt to obtain plaintiff patient’s informed

       consent. We excused the plaintiff from the ordinary requirement to present

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 14 of 19
       expert evidence as to defendant physician’s alleged breach of the standard of

       care because the plaintiff’s situation was “within the realm of the ordinary

       laym[a]n’s comprehension.” Id. at 1050. No expert testimony was needed to

       help a jury decide whether the plaintiff would have been physically and

       mentally competent to give his consent had defendant physician sought it. Id.

[27]   However, in Payne, we also declined to excuse the plaintiff’s complete lack of

       expert testimony as to his claim against defendant hospital for failure to have a

       written policy regulating a physician’s entry of do-not-resuscitate orders. In

       other words, we held only that the plaintiff’s claim against the hospital was

       subject to the ordinary requirements of proof in medical negligence cases. Id. at

       1051 (“Although we have determined that [plaintiff’s] claim against [defendant

       physicians] qualifies for exceptional treatment, we cannot come to a similar

       conclusion concerning [plaintiff’s] claim against the Hospital.”). Here, in

       contrast, we have concluded that the Dillow affidavit satisfied those

       requirements.

[28]   It is, of course, irrelevant to the questions of duty and breach whether a

       Hospital policy regulating the removal of pacing wires by nurse practitioners

       would have caused Cool to proceed differently in pulling Welsh’s wire, and

       whether that different procedure would have prevented Welsh’s death. Those

       questions go to causation, as to which the Hospital designated no evidence

       below. It was therefore never Ford’s burden to designate evidence on causation

       in rebuttal. Bunch v. Tiwari, 711 N.E.2d 844, 850-51 (Ind. Ct. App. 1999)

       (“When the movant on summary judgment relies only upon the opinion of the

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 15 of 19
       medical review panel which found no breach of the standard of care but was

       silent as to the other elements . . . , the plaintiff non-movant is only obligated to

       present expert testimony on the standard of care element . . . .”) (quoting

       Randolph Cnty. Hosp., 650 N.E.2d at 1219).

[29]   Judge Baker’s dissent on this point rests on the assumption that, as a matter of

       law, there is no factual situation in which Hospital policy could have prevented

       Welsh’s death, so long as Cool otherwise (that is, other than in failing to follow

       Hospital policy) met the nurse practitioner’s standard of care for pulling pacing

       wires. This inference is a reasonable one, and may in fact be true. However, it is

       also an inference drawn in the movant’s favor, and the movant has not shown it

       to be true and did not argue the point in these terms. It cannot, therefore, afford

       the Hospital a basis for relief at the summary judgment stage.

                                                 Conclusion

[30]   Because the Dillow affidavit sufficiently stated that the Hospital breached the

       standard of care in Welsh’s case, it created a genuine issue of material fact as to

       duty and breach, and the trial court’s grant of summary judgment was

       inappropriate. We therefore reverse that grant and remand for further

       proceedings.

[31]   Reversed.

       Pyle, J., concurs.

       Baker, J., dissents with separate opinion.

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 16 of 19
                                                  IN THE
           COURT OF APPEALS OF INDIANA

       Debra K. Ford, Personal                                   Court of Appeals Case No.
       Representative of the Estate of                           49A04-1606-CT-1334
       Darlene M. Welsh,
       Appellant-Plaintiff,

               v.

       Indiana Heart Hospital,
       Appellee-Defendant

       Baker, Judge, dissenting.

[32]   Because I believe that the majority’s analysis is missing the forest for the trees, I

       respectfully dissent.

[33]   Ford is attempting to recover damages under two theories. Under the first

       theory, Ford alleges that the manner in which Nurse Cool pulled the pacing

       wire from Welsh’s chest fell below the standard of care, which resulted in

       Welsh’s death. Under the second theory, Ford alleges that the Hospital’s

       failure to have a policy and procedure for the removal of pacing wires fell below

       the standard of care. But in order to recover under the second theory, Ford will

       still need to show, ultimately, that the Hospital’s failure to have such a policy

       and procedure led to Cool pulling the pacing wire in a substandard way, which

       resulted in Welsh’s death. In other words, under either theory, Ford will need to

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 17 of 19
       prove that Cool pulled the pacing wire incorrectly. If Cool did everything she

       was supposed to do despite the absence of a policy, if she did not remove the

       pacing wire in a substandard manner, then the existence or absence of policies

       and procedures regarding pacing wires would be inconsequential and irrelevant.

[34]   The Hospital designated evidence—the unanimous opinion of the medical

       review panel—that Cool did not pull the wire in a substandard manner. The

       burden then shifted to Ford to rebut that opinion with her own expert

       testimony. Siner, 51 N.E.3d at 1187-88.

[35]   In rebuttal, Ford designated the affidavit of Registered Nurse Amanda Dillow.

       As the majority notes, Dillow has extensive experience in providing

       cardiovascular care, removing pacing wires, and educating nursing staff to do

       the same. After reviewing the relevant depositions, medical records, and

       documentation, Dillow did not testify that Cool pulled the wire in a substandard

       manner. Instead, Dillow testified only that the Hospital did not meet the

       standard of care because it did not have a “policy and procedure . . . for the

       removal of temporary pacing wires . . . .” Appellant’s App. p. 78. In short, the

       Hospital designated evidence disproving Ford’s allegation that the manner in

       which Cool removed the pacing wire fell below the standard of care, and Ford

       failed to rebut that evidence.

[36]   This clearly precludes Ford, as a matter of law, from recovering under her first

       theory. But the majority believes that Dillow’s affidavit saves Ford’s second

       theory from summary judgment. I cannot agree.

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 18 of 19
[37]   Dillow’s affidavit certainly creates a question of fact of whether the Hospital

       should have had a policy and procedure for pulling pacing wires. But the

       majority is wrong to write that “the Hospital designated no evidence below”

       regarding causation on this issue. Slip Op. at *15. Under the second theory,

       Ford will need to show that the Hospital’s lack of policy caused Cool to pull the

       wire incorrectly, or that the lack of policy otherwise led Cool or the Hospital to

       act in a manner that fell below the standard of care, leading to Welsh’s death.

       The Hospital’s designated evidence goes precisely to this issue: the unanimous,

       unrebutted opinion of the medical review panel is that Cool did not pull the

       wire incorrectly. More than an inference, this is evidence designated by the

       summary judgment movant that shows that there is no causal link between the

       lack of a policy, the care that was provided, and Welsh’s death.

[38]   Because the Hospital designated evidence showing that there is no causal link,

       the burden then shifted to Ford to designate evidence showing that there was a

       causal link. Again, Ford’s expert witness reviewed the entire case and declined

       to say that the lack of policy led to the provision of substandard care. Because

       the Hospital’s evidence was unrebutted, there is no genuinely disputed fact that

       the Hospital’s lack of a policy did not cause Welsh’s death. Without proof of

       causation, Ford cannot recover. Even under the second theory, the Hospital is

       entitled to judgment as a matter of law.

[39]   For the foregoing reasons, I would affirm the trial court’s grant of summary

       judgment. I respectfully dissent.

       Court of Appeals of Indiana | Memorandum Decision 49A04-1606-CT-1334 | April 5, 2017   Page 19 of 19