Court Opinion

ID: 6353510
Source: CourtListenerOpinion
Date Created: 2022-06-24 15:02:29.275405+00
Date Added: 2024-06-11T09:14:32.485706
License: Public Domain

2022 IL 127942

                                          IN THE
                                 SUPREME COURT
                                              OF
                            THE STATE OF ILLINOIS

                             (Docket Nos. 127942, 127944 cons.)

     WILLIAM “WES” JOHNSON, Appellee, v. LUCAS ARMSTRONG et al., Appellants.

                                  Opinion filed June 24, 2022.

          JUSTICE GARMAN delivered the judgment of the court, with opinion.

          Chief Justice Anne M. Burke and Justices Theis, Neville, Michael J. Burke,
       Overstreet, and Carter concurred in the judgment and opinion.

                                          OPINION

¶1         Plaintiff suffers from severe and permanent nerve damage in his leg, which he
       alleges was caused by a negligently performed hip replacement surgery. He brought
       a claim of negligence against his surgeon expressed in two separate counts: one
       based on specific negligence and one based on the doctrine of res ipsa loquitur. He
       also brought a claim of negligence based on res ipsa loquitur against a surgical
       technician who participated in the surgery. Plaintiff provided only one expert
       witness, also a surgeon, to establish the elements of res ipsa loquitur. The McLean
     County circuit court granted summary judgment to the surgical technician because
     (1) plaintiff had failed to present an expert witness to establish the standard of care
     for a surgical technician, (2) the control element of res ipsa loquitur was not met,
     and (3) there was no evidence of negligence on the surgical technician’s part. As a
     result, the surgical technician was completely dismissed from the case. The circuit
     court subsequently granted summary judgment in favor of the surgeon on the res
     ipsa loquitur count, leaving the count of specific negligence against the surgeon
     remaining in the circuit court. The appellate court reversed both judgments.

¶2       In this case, we review whether the elements of res ipsa loquitur have been met
     and whether any additional expert testimony was required for the doctrine to apply
     under these facts. Initially, however, we review a jurisdictional issue related to
     whether a Rule 304(a) interlocutory appeal of a count of negligence based on res
     ipsa loquitur is proper where there remains a pending count of specific negligence
     against the same defendant in the circuit court. Ill. S. Ct. R. 304(a) (eff. Mar. 8,
     2016).

¶3                                     BACKGROUND

¶4       Dr. Lucas Armstrong, with assistance from two surgical technicians, Sarah
     Harden and Pamela Rolf, performed a left, total hip arthroplasty, commonly known
     as a hip replacement, on plaintiff, William “Wes” Johnson. After the surgery,
     plaintiff suffered from femoral nerve palsy. Electromyography (EMG) readings
     demonstrated a severe left femoral neuropathy “specific to the branches to vastus
     lateralis and rectus femoris muscles.”

¶5       Plaintiff brought a professional medical negligence suit in four counts. Count I
     alleged specific negligence against Dr. Armstrong in that he (1) failed to identify,
     preserve, and protect plaintiff’s femoral nerve; (2) improperly retracted plaintiff’s
     femoral nerve or improperly directed the placement of the retractors; or (3) directly
     traumatized plaintiff’s femoral nerve. Count II alleged that McLean County
     Orthopedics, Ltd. (McLean County Orthopedics), was vicariously liable for this
     negligence as Dr. Armstrong’s employer under the doctrine of respondeat superior.

¶6       Count III alleged negligence against Dr. Armstrong, Harden, and Rolf based on
     the doctrine of res ipsa loquitur in that (1) the injury to his femoral nerve occurred

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     “while the retractors, scalpel, electrocautery device and other surgical instruments
     were under the control of ARMSTRONG, HARDEN and ROLF” and (2) that, in
     the ordinary course of events, plaintiff’s injury “would not have occurred if
     ARMSTRONG, HARDEN, and ROLF had used a reasonable standard of
     professional care while the retractors, scalpel, electrocautery device and other
     surgical instruments were under their control.” Count IV alleged that Advocate
     Health and Hospitals Corporation, doing business as Advocate BroMenn Medical
     Center (Advocate BroMenn), was vicariously liable for this negligence as the
     employer of Harden and Rolf under the doctrine of respondeat superior.

¶7        Dr. Armstrong, Harden, and Rolf were all deposed and generally testified to the
     following. 2021 IL App (4th) 210038, ¶¶ 12-21. Dr. Armstrong was the only one
     authorized to position and move any instrument in contact with plaintiff’s body,
     and Dr. Armstrong was the only one to have done so. As the “first scrub,” Rolf’s
     primary function was to hand surgical instruments and material to Dr. Armstrong.
     As the “second scrub,” Harden’s function was to do whatever Dr. Armstrong told
     her to do. That included holding certain instruments, such as a retractor, while the
     instrument was in contract with the plaintiff’s body. As she said, “I don’t use
     anything—I hold things,” and, “I hold what I’m told to hold—whatever the doctor
     tells me to do, I do.” Rolf also indicated that the second scrub might handle other
     instruments apart from a retractor, such as a Kocher clamp, and would be
     responsible for suction. In light of the above, Rolf was voluntarily dismissed
     without prejudice.

¶8       Plaintiff presented a single expert witness, Dr. Sonny Bal. Dr. Bal testified that
     he had performed hundreds of hip replacement surgeries using the same method
     that Dr. Armstrong had used. Dr. Bal testified that nerve palsies are a recognized
     complication of hip replacement surgery and that the fact of a femoral nerve injury
     does not indicate, per se, a breach in the standard of care. Dr. Bal specifically
     testified, however, that this plaintiff’s injury is of a type that does not normally
     occur in the absence of negligence. Dr. Bal believed that the injury was most likely
     caused by the improper use of a retractor. Despite this belief, he testified that,
     according to the surgical records, Dr. Armstrong did not deviate from the standard
     of care in making the incision and management of the retractor. Dr. Bal did not
     purport to offer any standard of care for Harden. He did, however, testify that, from

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       all the surgical records, it appeared that Harden did only as instructed by Dr.
       Armstrong throughout the procedure.

¶9         Harden and Advocate BroMenn moved for summary judgment on the res ipsa
       loquitur and respondeat superior counts. The circuit court granted the motion at a
       hearing on October 30, 2020, on the grounds that (1) no qualified expert had
       established the standard of care for Harden, (2) there was no evidence of negligence
       on the part of Harden, and (3) Harden did not control the retractor for purposes of
       res ipsa loquitur. After the court orally rendered this judgment, defense counsel
       requested permission to submit a written order to reflect the court’s ruling. The
       court agreed. The record sheet reflects the following: “Defendant Advocate and
       Harden’s Motion for Summary Judgment argued and granted. Request for Rule
       304(a) finding granted. [Defense counsel] to submit written order.”

¶ 10       On December 15, 2020, the circuit court granted Dr. Armstrong’s oral motion
       for summary judgment on the res ipsa loquitur count. No record of this proceeding
       appears in the record. The record sheet reflects the following:

          “Defendant Armstrong’s oral Motion for Summary Judgment as to Count III
          (res ipsa loquitur) granted over objection. Pursuant to Supreme Court Rule
          304(a), the court finds there is no just reason for delaying appeal as to the res
          ipsa loquitur counts. Remaining counts of negligence against Defendant
          Armstrong and McLean County Orthopedics stayed, pending appeal of the res
          ipsa loquitur and discovery issues. Counsel to submit written orders.”

¶ 11      On December 22, 2020, the circuit court filed a written order entering summary
       judgment in Dr. Armstrong’s favor and found no just reason for delaying
       enforcement or appeal of that order pursuant to Rule 304(a). The court stayed any
       pending litigation on the remaining counts against Armstrong and McLean County
       Orthopedics (counts I and II) “pending resolution of the issues going up on appeal.”
       The record sheet reflects: “Order re: Defendant Armstrong[’s] Motion for Summary
       Judgment entered. See Order.”

¶ 12       On January 5, 2021, the circuit court filed a written order granting summary
       judgment in favor of Harden and Advocate BroMenn finding no just reason for
       delaying the appeal of its order pursuant to Rule 304(a). The record sheet reflects:

                                              -4-
       “Order re: Advocate and Harden’s Motion for Summary Judgment entered. See
       Order.”

¶ 13       Plaintiff filed a notice of appeal on January 6, 2021, pursuant to Rule 304(a),
       seeking to appeal both the December 22, 2020, order and the January 5, 2021, order
       entering summary judgment for defendants on the res ipsa loquitur counts.

¶ 14       The appellate court reversed, holding that res ipsa loquitur applied against both
       Dr. Armstrong and Harden. In doing so, the court held that Harden had control over
       the retractor. The court further held that no additional expert testimony was needed
       to establish Harden’s standard of care, saying: “In essence, the control element of
       the res ipsa doctrine is sufficient to establish a duty of care.” (Emphasis in original.)
       2021 IL App (4th) 210038, ¶ 68. In so holding, the court declined to follow its own
       decision in Taylor v. City of Beardstown, 142 Ill. App. 3d 584 (1986). 2021 IL App
       (4th) 210038, ¶ 69.

¶ 15       Harden, Advocate BroMenn, and Dr. Armstrong appealed to this court pursuant
       to Rule 315 in two separate cases raising distinct yet related issues. Those petitions
       were allowed and consolidated by this court. Ill. S. Ct. R. 315 (eff. Oct. 1, 2021).
       We also allowed the Illinois Trial Lawyers Association to file an amicus curiae
       brief. Ill. S. Ct. R. 345 (eff. Sept. 20, 2010).

¶ 16                                        ANALYSIS

¶ 17                                         Jurisdiction

¶ 18       Before proceeding to the merits, this court has an independent duty to ensure
       that jurisdiction is proper, regardless of whether the parties have raised any
       jurisdictional challenge. Vasquez Gonzalez v. Union Health Service, Inc., 2018 IL
       123025, ¶ 8 (citing Clemons v. Mechanical Devices Co., 202 Ill. 2d 344, 349
       (2002)).

¶ 19       Article VI, section 6, of the Illinois Constitution of 1970 confers upon the
       appellate court jurisdiction to hear appeals from final judgments entered in the
       circuit court. Ill. Const. 1970, art. VI, § 6. It also grants this court the power to
       “provide by rule for appeals to the Appellate Court from other than final judgments
       of Circuit Courts.” Id. “ ‘Accordingly, absent a supreme court rule, the appellate

                                                 -5-
       court is without jurisdiction to review judgments, orders, or decrees that are not
       final.’ ” Armstead v. National Freight, Inc., 2021 IL 126730, ¶ 20 (quoting
       Blumenthal v. Brewer, 2016 IL 118781, ¶ 22).

¶ 20       Here, both orders for summary judgment were brought to the appellate court
       pursuant to Illinois Supreme Court Rule 304(a) (eff. Mar. 8, 2016). Rule 304(a)
       provides that “an appeal may be taken from a final judgment as to one or more but
       fewer than all of the parties or claims only if the trial court has made an express
       written finding that there is no just reason for delaying either enforcement or appeal
       or both.” Id. “By its terms, Rule 304(a) applies only to final judgments or orders.”
       Blumenthal, 2016 IL 118781, ¶ 24. “The special finding contemplated by the rule
       will make a final order appealable, but it can have no effect on a nonfinal order.”
       Id. “If the order is in fact not final, inclusion of the special finding in the trial court’s
       order cannot confer appellate jurisdiction.” Id. Both orders included the Rule 304(a)
       finding language; thus, the question becomes whether each order constitutes a final
       judgment.

¶ 21       “[T]o be considered final and appealable for purposes of Rule 304(a), a
       judgment or order must terminate the litigation between the parties on the merits of
       the cause, so that, if affirmed, the trial court only has to proceed with execution of
       the judgment.” Id. ¶ 25. Although the order need not dispose of all claims presented
       by the pleadings, “it must be final in the sense that it disposes of the rights of the
       parties, either upon the entire controversy or upon some definite and separate part
       thereof.” Id. “Where an order disposes only of certain issues relating to the same
       basic claim, such a ruling is not subject to review under Rule 304(a).” Armstead,
       2021 IL 126730, ¶ 24 (citing In re Marriage of Leopando, 96 Ill. 2d 114, 119-20
       (1983)).

¶ 22       In Armstead, we reiterated the distinction between orders that dispose of
       separate, unrelated claims—which are appealable pursuant to Rule 304(a)—and
       orders that dispose only of separate issues relating to the same claim—which are
       not. Id. ¶ 25. In that case, we determined that the order appealed from disposed only
       of an issue: whether plaintiff was precluded from asserting certain injuries as part
       of his negligence case. Because that order only resolved one issue related to the
       surviving negligence claim, that order was not appealable under Rule 304(a). Id.
       ¶¶ 27-29.

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¶ 23        Here, the order granting summary judgment to Harden and Advocate BroMenn
       is final as to them because it terminates the litigation as to them. The order granting
       summary judgment to Dr. Armstrong, however, is not a final judgment because res
       ipsa loquitur is not a claim in and of itself; rather, it is an evidentiary doctrine that
       allows a plaintiff to prove negligence under a unique set of proofs. Heastie v.
       Roberts, 226 Ill. 2d 515, 531 (2007); Imig v. Beck, 115 Ill. 2d 18, 26-27 (1986).
       Although plaintiff expressed his negligence claim against Dr. Armstrong in two
       counts, these are but alternative theories for proving Dr. Armstrong’s liability for
       negligence. The fact that plaintiffs in Illinois are required to specifically plead res
       ipsa loquitur does not itself transform this evidentiary doctrine into a stand-alone
       claim. Our appellate court has dismissed appeals on these very grounds. Russell v.
       Good Shepherd Hospital, 222 Ill. App. 3d 140, 144-45 (1991) (“where a party states
       one claim alternatively in several counts, the dismissal of fewer than all such counts
       is not a final judgment as to fewer than all of the party’s claims as required by
       Supreme Court Rule 304(a)” (emphasis in original), and res ipsa loquitur is “ ‘a
       rule of evidence and not a separate theory of recovery’ ” (quoting Prado, 72 Ill.
       App. 3d at 625)).

¶ 24       Thus, the operative effect of the summary judgment in favor of Dr. Armstrong
       is to preclude plaintiff from proving that Dr. Armstrong was negligent under the
       unique proofs of res ipsa loquitur, but plaintiff’s claim for negligence against Dr.
       Armstrong remains outstanding. Consequently, the order granting summary
       judgment to Dr. Armstrong was not a final judgment, and the appellate court lacked
       jurisdiction under Rule 304(a) to review that order. The appeal of that order is
       dismissed, and those portions of the appellate opinion addressing that order are
       vacated.

¶ 25                           Effect of Dismissal of Dr. Armstrong

¶ 26       We observe that the dismissal of Dr. Armstrong leaves this case in a curious
       position. Although summary judgment in favor of Harden was orally pronounced
       in October 2020, the order granting that summary judgment was filed, and therefore
       became final, in January 2021. See Ill. S. Ct. R. 272 (eff. Jan. 1, 2018) (“If at the
       time of announcing final judgment the judge requires the submission of a form of
       written judgment to be signed by the judge ***, the clerk shall make a notation to

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       that effect and the judgment becomes final only when the signed judgment is
       filed.”); Williams v. BNSF Ry. Co., 2015 IL 117444, ¶ 37 (explaining the conditions
       under which a circuit court’s oral ruling may constitute an entry of judgment).
       However, Dr. Armstrong was dismissed from the res ipsa loquitur count in
       December 2020.

¶ 27        What we are left with, then, is a negligence claim based on res ipsa loquitur
       against Harden alone. The question arises, can the unique proofs of res ipsa
       loquitur, which generally require exclusive control on the part of those against
       whom the proofs are being applied, be applied solely to Harden in a situation such
       as this where she was exercising joint control? Drewick v. Interstate Terminals,
       Inc., 42 Ill. 2d 345, 348 (1969) (“The purpose of [the control element] is, of course,
       to limit the application of the doctrine to those cases where the negligence, if any,
       must reasonably have been that of the defendant.”); Prosser and Keeton on the Law
       of Torts § 39, at 248 (W. Page Keeton et al. eds., 5th ed. 1984) (“The injury must
       either be traced to a specific instrumentality or cause for which the defendant was
       responsible, or it must be shown that the plaintiff was responsible for all reasonably
       probable causes to which the accident could be attributed.”); Restatement (Second)
       of Torts § 328D cmt. g (1965) (by establishing exclusive control by defendant, “the
       responsibility of the defendant is proved by eliminating that of any other person”).
       Plaintiff himself essentially argued in the circuit and appellate courts that res ipsa
       loquitur could only be applied here if both Harden and Dr. Armstrong were
       included within its proofs. Consequently, the point in time at which we analyze the
       summary judgment in favor of Harden—whether as the case stood in October 2020
       or January 2021—will affect the outcome.

¶ 28        After due consideration, we believe that the use of our supervisory authority is
       warranted in this case to review summary judgment as the case stood in October
       2020. “Our supervisory authority extends to ‘the adjudication and application of
       law and the procedural administration of the courts.’ ” City of Urbana v. Andrew
       N.B., 211 Ill. 2d 456, 470 (2004) (quoting Kunkel v. Walton, 179 Ill. 2d 519, 528
       (1997)). “Even when a circuit court’s ruling does not satisfy the normal finality
       requirements, this court may elect to exercise its supervisory authority to
       intercede.” Vasquez Gonzalez, 2018 IL 123025, ¶ 16 (citing People v. Heddins, 66
       Ill. 2d 404, 406-07 (1977) (dismissing the appeal but entering a supervisory order
       to direct the circuit court to vacate a clearly erroneous interlocutory order)).

                                               -8-
¶ 29       Per the normal appellate process, we would review whether summary judgment
       in favor of Harden was proper at a time when Dr. Armstrong had been dismissed
       from the res ipsa loquitur proofs. In doing so, we would have to determine whether
       res ipsa loquitur can be applied to Harden in the absence of Dr. Armstrong. This is
       an issue that has not been raised, briefed, or argued before this court, and although
       plaintiff raised arguments related to this issue below, neither of the courts below
       appear to have squarely addressed this question. Were we to find that res ipsa
       loquitur could not be applied to Harden without including Dr. Armstrong, plaintiff
       would be precluded from obtaining meaningful relief. Furthermore, the only reason
       this conundrum is presented is because the written order for summary judgment in
       favor of Harden was delayed for months after its oral pronouncement, while the
       written order in Dr. Armstrong’s favor was filed days after its oral pronouncement.
       Accordingly, in the exercise of our supervisory authority we will review the
       summary judgment in favor of Harden as of the date it was pronounced.

¶ 30                                   Summary Judgment

¶ 31        We now turn to the order granting summary judgment to Harden and Advocate
       BroMenn. Summary judgment is appropriate when “the pleadings, depositions, and
       admissions on file, together with the affidavits, if any, show that there is no genuine
       issue as to any material fact and that the moving party is entitled to a judgment as
       a matter of law.” 735 ILCS 5/2-1005(c) (West 2018). “A genuine issue of material
       fact precluding summary judgment exists where the material facts are disputed, or,
       if the material facts are undisputed, reasonable persons might draw different
       inferences from the undisputed facts.” (Internal quotation marks omitted.) Monson
       v. City of Danville, 2018 IL 122486, ¶ 12. When examining whether a genuine issue
       of material fact exists, a court construes the evidence in the light most favorable to
       the nonmoving party and strictly against the moving party. Beaman v. Freesmeyer,
       2019 IL 122654, ¶ 22. Summary judgment is a drastic means of disposing of
       litigation and “should be allowed only when the right of the moving party is clear
       and free from doubt.” (Internal quotation marks omitted.) Id. A circuit court’s entry
       of summary judgment is reviewed de novo. Id.

                                                -9-
¶ 32                                      Res Ipsa Loquitur

¶ 33       We described the nature and purpose of res ipsa loquitur, “the thing speaks for
       itself,” in Metz v. Central Illinois Electric & Gas Co., 32 Ill. 2d 446, 448-49 (1965):

               “When a thing which caused the injury is shown to be under the control or
           management of the party charged with negligence and the occurrence is such as
           in the ordinary course of things would not have happened if the person so
           charged had used proper care, the accident itself affords reasonable evidence,
           in the absence of an explanation by the party charged, that it arose from want
           of proper care. [Citations.] This in essence is the doctrine of res ipsa loquitur,
           and its purpose is to allow proof of negligence by circumstantial evidence when
           the direct evidence concerning cause of injury is primarily within the
           knowledge and control of the defendant.”

¶ 34       If res ipsa loquitur applies, the factfinder is permitted to infer negligence from
       a set of facts that “speaks for itself.” Imig, 115 Ill. 2d at 26-27. The defendant may
       then offer evidence tending to disprove negligence, but the inference of negligence
       does not simply vanish or disappear when contrary evidence appears. Id. at 26-28.
       Rather, the inference arising from res ipsa loquitur, along with the evidence
       provided by the defendant, is weighed by the factfinder. Id. at 27. “The inference
       may be strong, requiring substantial proof to overcome it, or it may be weak,
       requiring little or no evidence to refute it.” Id. In the end, the trier of fact is free to
       accept or reject the inference.

¶ 35        For res ipsa loquitur to apply, the plaintiff must plead and prove that he was
       injured (1) in an occurrence that ordinarily does not happen in the absence of
       negligence (the probability element) (2) by an agency or instrumentality within the
       defendant’s exclusive control (the control element). Heastie, 226 Ill. 2d at 531-32;
       Gatlin v. Ruder, 137 Ill. 2d 284, 296-97 (1990). Whether res ipsa loquitur applies
       is a question of law to be decided in the first instance by the trial court. Imig, 115
       Ill. 2d at 27; 735 ILCS 5/2-1113 (West 2020). “In making that determination, the
       court shall rely upon either the common knowledge of laymen, if it determines that
       to be adequate, or upon expert medical testimony, that the medical result
       complained of would not have ordinarily occurred in the absence of negligence on
       the part of the defendant.” 735 ILCS 5/2-1113 (West 2020). “Proof of an unusual,
       unexpected or untoward medical result which ordinarily does not occur in the

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       absence of negligence will suffice in the application of the doctrine.” Id.

¶ 36                              Res Ipsa Loquitur—Probability

¶ 37      We first examine whether plaintiff has presented sufficient evidence to survive
       a motion for summary judgment on the first element: that the severe and permanent
       nerve damage suffered here is an injury that ordinarily does not happen in the
       absence of negligence.

¶ 38        Given that severe femoral neuropathy specific to the branches of vastus lateralis
       and rectus femoris muscles, presenting after a total hip arthroplasty, is of a type that
       is outside the common knowledge of laymen, expert testimony was required to
       determine whether such an injury would ordinarily occur absent negligence.
       Unequivocal testimony to this effect will directly establish plaintiff’s initial burden
       on the probability component of res ipsa loquitur, although it will not constitute
       proof that the injury would never happen without negligence. Spidle v. Steward, 79
       Ill. 2d 1, 8-9 (1980) (directed verdict against res ipsa loquitur counts improper
       where expert gave equivocal testimony in response to question on probability
       because that testimony, when considered with the entire record, established the
       probability element).

¶ 39       Here, plaintiff presented sufficient evidence to satisfy the probability element.
       Plaintiff presented Dr. Bal, a retired orthopedic surgeon, who testified that he had
       performed between 100 and 200 total hip arthroplasty procedures per year on
       average. Dr. Bal confirmed that he most commonly used the anterior approach,
       which was the same approach used by Dr. Armstrong here. Dr. Bal testified that,
       as a general proposition, nerve palsies are a recognized complication of hip
       replacement surgery. He also testified that the mere fact of a nerve injury does not
       establish a breach in the standard of care. In fact, Dr. Bal had two patients, in the
       entirety of his career, who developed femoral nerve palsies after a hip replacement
       surgery. One was caused by bleeding, which put pressure on the nerve, and the
       other had an unknown cause. He agreed that the cause of femoral nerve palsies is
       often unknown. However, he specifically distinguished between different forms of
       femoral nerve neuropathies:

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             “There are two distinct types of femoral nerve neuropathies, and I want to
          make sure we’re clear on the distinction.

              Transient femoral neuropathy injury, neuropraxia palsy, as referred to in
          this paper *** occurs in the absence of negligence. It is transient; it has a good
          prognosis; strength returns, and the patient goes on with a temporary time
          period during which there is a deficit that improves rapidly, and those are what
          I’ve encountered in my practice. That palsy can occur and does occur in the
          absence of negligence from a variety of factors.

              My testimony here is a complete injury to the femoral nerve, as occurred
          here, verified by repeat EMG and subsequent treatment by a nerve specialist
          like Dr. Tung, does not occur absent negligence.”

¶ 40        Dr. Bal supported this unequivocal testimony with repeated reference to his
       experience, his review of the literature, and the postoperative EMG readings. From
       all this, plaintiff established that nerve damage like the kind he suffered does not
       ordinarily occur after a hip replacement surgery absent negligence. Consequently,
       the first element of res ipsa loquitur was satisfied for purposes of summary
       judgment.

¶ 41                                Res Ipsa Loquitur—Control

¶ 42       The second element of res ipsa loquitur is that the plaintiff was injured by an
       agency or instrumentality within the defendant’s exclusive control. As we said in
       Heastie, “some authorities speak of ‘management and control’ rather than
       ‘exclusive control,’ but the terms have come to be viewed as interchangeable.”
       Heastie, 226 Ill. 2d at 532. Regardless, “the requisite control is not a rigid standard,
       but a flexible one in which the key question is whether the probable cause of the
       plaintiff’s injury was one which the defendant was under a duty to the plaintiff to
       anticipate or guard against.” Id. Indeed, the word “control” may itself be
       misleading, as the fact of a defendant’s literal control over the occurrence may be
       nonexistent, yet the defendant may nevertheless be responsible for the occurrence.
       Restatement (Second) of Torts § 328D cmt. g (1965) (“The essential question
       becomes one of whether the probable cause is one which the defendant was under
       a duty to the plaintiff to anticipate or guard against.”); Prosser and Keeton on the

                                                - 12 -
       Law of Torts § 39, at 250-51 (W. Page Keeton et al. eds., 5th ed. 1984) (suggesting
       that it “would be far better, and much confusion would be avoided, if the rigid
       ‘control’ test were discarded altogether, and we were to require instead that the
       apparent negligent cause of the accident be such that the defendant would more
       likely than not be responsible for it”).

¶ 43       Generally speaking, the plaintiff must identify the instrumentality of his injury,
       as well as everyone who was in control of that instrumentality. However,

          “while reliance on the res ipsa doctrine may normally require that the injury
          can be traced to a specific cause for which the defendant is responsible, Illinois
          law also authorizes use of the doctrine where it can be shown that the defendant
          was responsible for all reasonable causes to which the accident could be
          attributed.” Heastie, 226 Ill. 2d at 538 (citing Napoli v. Hinsdale Hospital, 213
          Ill. App. 3d 382, 388 (1991), and Prosser and Keeton on the Law of Torts § 39,
          at 248 (W. Page Keeton et al. eds., 5th ed. 1984)).

       “Similarly, Illinois law does not require a plaintiff to show the actual force which
       initiated the motion or set the instrumentality in operation in order to rely on the
       res ipsa doctrine.” Id. at 539. “To the contrary, if the specific and actual force which
       initiated the motion or set the instrumentality in operation were known
       unequivocally, leaving no reason for inference that some other unknown negligent
       act or force was responsible, the res ipsa doctrine could not even be invoked.” Id.

¶ 44        As for identifying the defendant or defendants, “plaintiff is not required to show
       that his injuries were more likely caused by any particular one of the defendants in
       order to proceed with his res ipsa claim, nor must he eliminate all causes of his
       injuries other than the negligence of one or more of the defendants.” Id. at 534
       (citing Collins v. Superior Air-Ground Ambulance Service, Inc., 338 Ill. App. 3d
       812, 822-23 (2003)). However, in a multiple-defendant situation, the plaintiff must
       ensure that all defendants who could have been at fault are included. See Smith v.
       Eli Lilly & Co., 137 Ill. 2d 222, 257 (1990) (“In res ipsa loquitur and alternative
       liability situations, all parties who could have been the cause of the plaintiff’s
       injuries are joined as defendants.”).

¶ 45      Here, plaintiff was committed to the care of, and subjected to surgery by, Dr.
       Armstrong and Harden. Consequently, plaintiff is not required to identify the

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       precise instrumentality that caused his nerve damage—the fact that he was under
       defendants’ care during surgery sufficiently establishes, for purposes of res ipsa
       loquitur, that whatever caused plaintiff’s nerve damage during the surgery was
       under defendants’ control. Kolakowski v. Voris, 83 Ill. 2d 388, 396 (1980) (“a
       plaintiff’s only recourse is to rely on the doctrine of res ipsa loquitur” where he is
       placed in the care and custody of defendants during surgery); id. (“ ‘The control, at
       one time or another, of one or more of the various agencies or instrumentalities
       which might have harmed the plaintiff was in the hands of every defendant or of
       his employees or temporary servants. This, we think, places upon them the burden
       of initial explanation.’ ” (quoting Ybarra v. Spangard, 154 P.2d 687, 689-90 (Cal.
       1944))). Likewise, plaintiff is not required under these circumstances to identify
       precisely who caused his nerve damage. What plaintiff must establish here is that
       all parties who were responsible for all reasonable causes of plaintiff’s nerve
       damage are identified. Plaintiff has done so, and consequently, the control element
       is met.

¶ 46       Harden (joined in her arguments by Advocate BroMenn) argues that the control
       element has not been met as to her. She specifically identifies the instrumentality
       of injury in this case to be the retractor, and she argues that she did not control the
       retractor because her only function was to hold it in place. She points to Dr. Bal,
       who confirmed that Dr. Armstrong was the only one authorized to place or move
       the retractor during surgery and that the surgical technician’s only retractor-related
       job is to hold it in place.

¶ 47       There are two problems with this argument. First, this argument is predicated
       upon the mistaken belief that plaintiff must identify the instrumentality of his injury
       in order to raise res ipsa loquitur. As we have already explained, while this is
       generally true, it is not true where, as here, plaintiff can show that defendants were
       responsible for all reasonable causes to which the injury could be attributed. It also
       rests on the mistaken belief that plaintiff has expressly identified the retractor as the
       instrumentality of his injury. On the contrary, plaintiff’s argument, supported by
       the evidence, is that he underwent surgery and suffered a severe and permanent
       injury. The instrumentality of his injury remains unknown and unidentified in his
       res ipsa loquitur count. In that count, plaintiff alleged that his injuries occurred
       “while the retractors, scalpel, electrocautery device and other surgical instruments
       were under the control of ARMSTRONG, HARDEN, and ROLF.” Indeed, there is

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       evidence supporting the allegation that other instruments, apart from the retractor,
       were handled by Harden during the procedure.

¶ 48       The second problem with this argument is more basic. The control element is a
       “flexible one in which the key question is whether the probable cause of the
       plaintiff’s injury was one which the defendant was under a duty to the plaintiff to
       anticipate or guard against.” Heastie, 226 Ill. 2d at 532. Assuming that the retractor
       was, in fact, the instrumentality of the injury, Harden was literally holding it while
       it was inside plaintiff’s body. Control, whether joint or individual, by Harden over
       the retractor could not be any clearer. It is of no consequence that Harden had no
       independent authority to place or move the retractor because she had independent
       capability of doing so. If she did move or mismanage the retractor while she was
       only supposed to be holding it still, then she would or could have been the negligent
       party at fault.

¶ 49                                     Standard of Care

¶ 50       Harden argues that, because plaintiff here did not present competent testimony
       as to the standard of care for a surgical technician, summary judgment in her favor
       was proper. Harden relies on Taylor, 142 Ill. App. 3d 584, for the proposition that
       a standard of care is required in addition to, or in order to satisfy, the elements of
       res ipsa loquitur in a medical professional negligence case; and she relies on
       Sullivan v. Edward Hospital, 209 Ill. 2d 100 (2004), for the proposition that a
       surgeon is not competent to testify as to the standard of care for a surgical
       technician. Plaintiff takes the opposite position.

¶ 51       A brief comparison of negligence and res ipsa loquitur principles is warranted.
       “The elements of a negligence cause of action are a duty owed by the defendant to
       the plaintiff, a breach of that duty, and an injury proximately caused by the breach.”
       Jones v. Chicago HMO Ltd. of Illinois, 191 Ill. 2d 278, 294 (2000) (citing Cunis v.
       Brennan, 56 Ill. 2d 372, 374 (1974)). “The standard of care, also known as the
       standard of conduct, falls within the duty element.” Id.; Prosser and Keeton on the
       Law of Torts § 30, at 164 (W. Page Keeton et al. eds., 5th ed. 1984) (describing the
       duty element as: “A duty, or obligation, recognized by the law, requiring the person
       to conform to a certain standard of conduct, for the protection of others against

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       unreasonable risks.”). Thus, in every cause of action for negligence, the plaintiff
       must establish that a duty exists and must also identify what the duty is.

¶ 52       The standard of care in a medical professional negligence case is to act as would
       an “ ‘ “ordinarily careful professional.” ’ ” Jones, 191 Ill. 2d at 295 (quoting
       Advincula v. United Blood Services, 176 Ill. 2d 1, 23 (1996), quoting Cunis, 56 Ill.
       2d at 376). We have consistently held that the burden of establishing the standard
       of care—that is, what an ordinarily careful professional would do—in a medical
       professional negligence case is on the plaintiff. Sullivan, 209 Ill. 2d at 112 (citing
       Purtill v. Hess, 111 Ill. 2d 229, 241-42 (1986)). Generally speaking, expert
       testimony is required to establish what an ordinarily careful professional would do
       in a given situation “because jurors are not skilled in the practice of medicine and
       would find it difficult without the help of medical evidence to determine any lack
       of necessary scientific skill on the part of the physician.” Walski v. Tiesenga, 72 Ill.
       2d 249, 256 (1978). However, where defendant’s conduct is so grossly negligent or
       the treatment so common that a layman could readily appraise it, no expert
       testimony is necessary. Id.

¶ 53       Once the standard of care is established in a negligence cause of action, the
       plaintiff “must then prove that, judged in the light of these standards, the doctor
       was unskillful or negligent and that his want of skill or care caused the injury to the
       plaintiff.” Id. Again, expert testimony is generally required to establish that the
       defendant physician deviated from the standard of care unless the common
       understanding exception applies. Jones, 191 Ill. 2d at 295. In other words, the
       plaintiff must show, usually with expert testimony, a breach of the defendant’s duty.
       Finally, the plaintiff must prove that he was injured and that the injury was
       proximately caused by the defendant’s breach of duty.

¶ 54       At this point, it is important to note that the word “negligence” is often used
       interchangeably throughout the law to mean either (1) the cause of action/theory of
       liability comprising all of the elements above or (2) the breach of a duty. E.g., Jahn
       v. Troy Fire Protection District, 163 Ill. 2d 275, 280 (1994) (“Negligence is defined
       as the failure to use such care as a reasonably prudent and careful person would use
       under similar circumstances. Black’s Law Dictionary 1032 (6th ed. 1990).”);
       Restatement (Second) of Torts § 282 (1965) (“negligence is conduct which falls
       below the standard established by law for the protection of others against

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       unreasonable risk of harm”); Restatement (Second) of Torts § 282 cmt. b (1965)
       (“negligent conduct subjects the actor to liability only if the [elements of a
       negligence cause of action] exist”).

¶ 55       Res ipsa loquitur (“the thing speaks for itself”), on the other hand, is not an
       alternate theory of liability in Illinois—the theory of liability remains “negligence”
       in the first sense of the word—rather, it is a species of circumstantial evidence that
       allows the trier of fact to draw an inference of “negligence” in the second sense of
       the word. Heastie, 226 Ill. 2d at 542; Imig, 115 Ill. 2d at 25-26. This is evident
       because the two elements of res ipsa loquitur (probability and control) are not
       sufficient in and of themselves to prove a negligence cause of action. For instance,
       the existence of a duty must be proved apart from the two elements of res ipsa
       loquitur. Spidle, 79 Ill. 2d at 7 (res ipsa loquitur “will not apply unless a duty of
       care is owed by the defendant to the plaintiff”). Likewise, the causation element
       must still be proven apart from the res ipsa loquitur elements. Edgar County Bank
       & Trust Co. v. Paris Hospital, Inc., 57 Ill. 2d 298, 304 (1974), overruled on other
       grounds by Gilbert v. Sycamore Municipal Hospital, 156 Ill. 2d 511 (1993). We
       have explained that “the application of the doctrine of res ipsa loquitur does not
       affect the necessity or manner of proof of proximate cause and that it is relevant
       only to the nature of the proof from which the trier of fact may draw an inference
       of negligence.” Id.

¶ 56       Thus, by saying that res ipsa loquitur “is relevant only to the nature of the proof
       from which the trier of fact may draw an inference of negligence,” we mean that
       the application of res ipsa loquitur relates to the nature of proof required to show a
       breach of duty. Restatement (Second) of Torts § 328D (1965) (under res ipsa
       loquitur, “[i]t may be inferred that harm suffered by the plaintiff is caused by
       negligence,” where negligence is defined in section 282 (id. § 282) as “conduct
       which falls below the standard established by law for the protection of others
       against unreasonable risk of harm”). The issue in this case may therefore be
       reframed as whether the standard of care portion of the duty element of negligence
       has been satisfied where the two elements of res ipsa loquitur have been satisfied.

¶ 57       The reason that the standard of care is necessary in a regular professional
       negligence cause of action is because there must be a standard by which to judge
       the performance of the defendant physician. Purtill, 111 Ill. 2d at 241-42; Walski,

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       72 Ill. 2d at 255-56. Without a standard of care by which to judge the physician,
       there would be no way to determine whether any deviation or breach has occurred.
       Thus, in cases of specific negligence, where the plaintiff has alleged some specific
       course of conduct on the part of the defendant that breached the defendant’s duty,
       it must be shown what each defendant’s standard of care was in relation to that
       course of conduct.

¶ 58       In this case, however, the precise course of individual conduct that led to
       plaintiff’s injury is unknown. All plaintiff knows is that he was injured while under
       the care of multiple defendants. Plaintiff cannot establish an individual standard of
       care for either Dr. Armstrong or Harden that is independent of the injury itself
       because he does not know what individual standard Dr. Armstrong or Harden has
       deviated from. But by establishing that his injury is one that ordinarily does not
       occur absent negligence and that all of the instrumentalities that could have caused
       the injury were in the control of the defendant, plaintiff has provided the legally
       applicable standard of care from which negligence may be found: that under normal
       circumstances, a hip replacement does not result in severe and permanent nerve
       damage. Consequently, no additional testimony related to Harden’s standard of care
       was necessary here. We need not go further to determine which of the two res ipsa
       loquitur elements, taken alone, might satisfy the standard of care requirement
       because both elements are satisfied here.

¶ 59       In coming to this conclusion, we agree with the appellate court’s decision not
       to follow Taylor, 142 Ill. App. 3d 584. 2021 IL App (4th) 210038, ¶ 69. Although
       we agree with the judgment of Taylor, we do not approve of its reasoning. We also
       agree with the appellate court here that Taylor is an outlier in its explicit
       pronouncement regarding the requirement of establishing a standard of care. Id.
       Given this, we believe discussion of defendant’s argument based on Sullivan to be
       unnecessary.

¶ 60                                     Other Arguments

¶ 61       Harden makes two final arguments. First, she argues that, because plaintiff has
       suggested and/or provided evidence that the instrumentality of the injury was the
       retractor, plaintiff is barred from relying on res ipsa loquitur. She relies on the
       principle that, “if the specific and actual force which initiated the motion or set the

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       instrumentality in operation were known unequivocally, leaving no reason for
       inference that some other unknown negligent act or force was responsible, the res
       ipsa doctrine could not even be invoked.” Heastie, 226 Ill. 2d at 539.

¶ 62       As we explained in Kolakowski, 83 Ill. 2d at 397, this “would be accurate if the
       evidence introduced by plaintiff conclusively established the exact cause of his
       injuries.” But where plaintiff’s expert merely opines upon some cause of the injury,
       rather than conclusively establishes it, the opinion is “ ‘opinion only.’ ” Id. (quoting
       Clifford-Jacobs Forging Co. v. Industrial Comm’n, 19 Ill. 2d 236, 243 (1960)). We
       reaffirmed this principle from Kolakowski in Gatlin, 137 Ill. 2d at 298-99. Here,
       Dr. Bal’s testimony did not conclusively establish that the retractor caused
       plaintiff’s nerve damage. Rather, it was his “opinion only” as to what caused the
       nerve damage. Therefore, plaintiff is not barred from raising res ipsa loquitur
       merely because his expert has an opinion on the most likely cause of his injury.

¶ 63       Lastly, Harden argues that there is no evidence in this case that she deviated
       from any standard of care in any way. The evidence to which she refers is the
       testimony of each defendant, the defendants’ surgical records, and the testimony of
       Dr. Bal, all of which attest to the fact that Harden acted appropriately. Of course,
       the most important bit of evidence in a res ipsa loquitur case is the injury or
       occurrence itself. The fact of plaintiff’s severe and permanent nerve damage is itself
       evidence of negligence given that the elements of res ipsa loquitur are satisfied.
       The situation wherein there is no other evidence of negligence, apart from the
       injury, is precisely the type of situation for which res ipsa loquitur is designed.

¶ 64                                      CONCLUSION

¶ 65       The appellate court lacked jurisdiction under Rule 304(a) to hear the appeal
       from the December 22, 2020, order granting summary judgment to Dr. Armstrong
       because that order disposed of an issue rather than a claim. The appeal from that
       interlocutory order is therefore dismissed, and those portions of the appellate
       opinion addressing that order are vacated.

¶ 66      We exercise our supervisory authority to review the summary judgment in favor
       of Harden and Advocate BroMenn as it was pronounced in October 2020 and
       conclude that it was granted in error because the elements of res ipsa loquitur were

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       met at that time, and because no further expert testimony on the standard of care
       was required. We therefore affirm the appellate court’s judgment reversing the
       circuit court’s January 6, 2021, order, and we remand the case to the circuit court.
       Given that the summary judgment in favor of Dr. Armstrong was pronounced after
       Harden had been orally dismissed from the res ipsa loquitur count, we also direct
       the circuit court to reconsider the December 22, 2020, order granting summary
       judgment in light of this opinion.

¶ 67      No. 127944, Appeal dismissed.

¶ 68      No. 127942, Appellate court judgment affirmed in part and vacated in part.

¶ 69      Circuit court judgment reversed.

¶ 70      Remanded with directions.

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