Court Opinion

ID: 4570507
Source: CourtListenerOpinion
Date Created: 2020-09-28 23:12:43.296894+00
Date Added: 2024-06-11T09:28:00.058220
License: Public Domain

09/28/2020
                IN THE COURT OF APPEALS OF TENNESSEE
                           AT KNOXVILLE
                                 August 19, 2020 Session

                  TRAVIS KANIPE v. PRAGNESH PATEL MD

                  Appeal from the Circuit Court for Hamblen County
                     No. 14-CV-061     Thomas J. Wright, Judge

                              No. E2019-01211-COA-R3-CV

This appeal arises from a health care liability lawsuit. In 2013, Sandra Kanipe (“Ms.
Kanipe”) died from an undiagnosed aortic dissection while in the care of Dr. Pragnesh
Patel, M.D. (“Dr. Patel”). Travis Kanipe (“Mr. Kanipe”), Ms. Kanipe’s son, sued Dr. Patel
in the Circuit Court for Hamblen County (“the Trial Court”). After a trial, the jury found
in favor of Dr. Patel. The Trial Court granted Mr. Kanipe’s motion for a new trial on
grounds that Dr. Patel had, through his testimony, shifted blame to a non-party despite
having never pled comparative fault. After a second trial, the jury found in favor of Mr.
Kanipe. Dr. Patel appeals, arguing among other things that he never shifted blame. From
our review of the record, we conclude that Dr. Patel did, in fact, shift blame to a non-party
when he testified in the first trial that the nurses never notified him of Ms. Kanipe’s ongoing
chest pain. In view of our Supreme Court’s holding in George v. Alexander, 931 S.W.2d
517 (Tenn. 1996), the Trial Court did not abuse its discretion in ordering a retrial. We
affirm the judgment of the Trial Court.

  Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Circuit Court Affirmed;
                                  Case Remanded

D. MICHAEL SWINEY, C.J., delivered the opinion of the court, in which JOHN W.
MCCLARTY and KRISTI M. DAVIS, JJ., joined.

Raymond G. Lewallen, Jr., Knoxville, Tennessee, for the appellant, Pragnesh Patel, M.D.

Leslie A. Muse and Grant E. Mitchell, Knoxville, Tennessee, and Tasha C. Blakney,
Knoxville, Tennessee, for the appellee, Travis Kanipe, as Administrator of the Estate of
Sandra Kanipe, deceased.
                                              OPINION

                                             Background

        Early on December 31, 2012, Ms. Kanipe, a 66-year old Hamblen County resident,
was taken by EMS to the Emergency Department at Morristown-Hamblen Hospital. There,
she complained of chest pains that radiated to her neck and jaw. Emergency Department
physician Dr. Jackie Livesay attended to Ms. Kanipe. Dr. Livesay then consulted with Dr.
Patel, the cardiologist on call. Ms. Kanipe thereafter was Dr. Patel’s patient. At 10:00
a.m., Dr. Patel examined Ms. Kanipe. Dr. Patel’s admitting diagnosis for Ms. Kanipe was
unstable angina, or acute coronary syndrome. Nitroglycerin was administered to Ms.
Kanipe, which helped initially. Dr. Patel decided that he would wait until the next day to
determine what sort of testing Ms. Kanipe should undergo moving forward. Orders were
issued that Dr. Patel be called for questions, orders, or changes in Ms. Kanipe’s condition.
Dr. Patel went home. At 12:07 p.m., Ms. Kanipe was transferred from the Emergency
Department to the monitored telemetry floor of the hospital. Ms. Kanipe reported her pain
as 6 out of 10 at that time.

       At 3:30 p.m., Nurse Amy Crespo (“Nurse Crespo”)1 phoned Dr. Patel. This call
was to prove one of the most contested parts of the case. Dr. Patel would testify later that
he never was notified of Ms. Kanipe’s ongoing pain, and that the call from Nurse Crespo
was just to see if he had any more orders for medication in case Ms. Kanipe needed it.
Nurse Crespo would testify, on the other hand, that she told Dr. Patel in no uncertain terms
that Ms. Kanipe was continuing to experience chest pain. In either event, Dr. Patel put in
an order for Ultram and Zofran, medications for pain and nausea. Dr. Patel never re-
evaluated Ms. Kanipe. At 1:47 a.m. the following morning, Ms. Kanipe was pronounced
dead. An autopsy revealed that Ms. Kanipe died from an aortic dissection.

       In April 2014, Mr. Kanipe filed a health care liability lawsuit against Dr. Patel in
the Trial Court alleging negligence in the medical treatment provided to Ms. Kanipe.2 Dr.
Patel did not plead the comparative fault of any nurse in his answer, a fact that was to prove
significant later. The matter was tried before a jury beginning April 3, 2017 through April
11, 2017. Among the witnesses to testify for Mr. Kanipe was Dr. Bryan Barksdale (“Dr.
Barksdale”), a cardiologist from the University of Michigan. Dr. Barksdale was asked how
aortic dissections are diagnosed and whether Dr. Patel’s care for Ms. Kanipe met the
applicable standard of care:

1
  Amy Crespo later married and became Amy Cochran. We refer to her by the Crespo surname since that
is what she went by at the times relevant to this case.
2
  Mr. Kanipe sued certain other parties, as well. Dr. Patel is the sole remaining defendant in this appeal.
                                                   -2-
Q. Now, doctor, as a result of your review of medical records, do you have
an opinion within a reasonable degree of medical certainty as to whether or
not the care provided by Dr. Patel complies or does not comply with the
standard of care as it applied in Morristown in 2012?
A. I do. I do not think it complies, no. The thing that worries me the most,
you’ve got a patient that’s continuing to have chest pain. They give her
repeated doses of nitroglycerin. No one ever calls the doctor. There’s no
order in the chart that says “If she continues to have chest pain, call me.” She
required several doses of nitroglycerin. The pain never went away. She’s
got normal EKGs, normal troponins. Something else is going on. Either take
her to the cath lab or get a CT. Don’t wait around until the next day….

                                      ***

Q. Do you have an opinion within a reasonable degree of medical certainty
as to what a CT more likely than not would have shown if one had been
performed?
A. She had absolutely a dissection. That’s easy to say in hindsight. I know
what she had. But there’s no question in my mind, a CT at 1:00, 2:00, 6:00
in the morning, they would have diagnosed the dissection and gotten her to
appropriate care.
Q. That was my next question, doctor. If they had diagnosed an aortic
dissection, what would have been the appropriate care or what would have
been required according to the standard of care?
A. To get her to a cardiovascular surgeon for urgent, emergent surgery.
Q. If a heart catheterization would have been performed that day, do you
have an opinion as to what it would have likely shown?
A. It would have shown a dissection.
Q. And is that within a reasonable degree of medical certainty?
A. Yes.
Q. And would the treatment have been the same regardless of how it was
diagnosed?
A. Yes, regardless. The beauty of the CT scan, as I mentioned, it’s a lot
quicker. You lay them out, 15 minutes for a heart cath. You have to get
them down, get them prepped, get them ready. It’s an hour procedure. A CT
scan takes 15 minutes, max.
Q. Doctor, do you have an opinion whether, with treatment, Ms. Kanipe
would more likely have survived this illness?
A. I think the earlier they would have gotten her to surgery, the better. It’s
like I said, it’s a 1- to 2-percent increase in mortality every hour you wait. In
her favor, she didn’t smoke, she had good kidney function, she didn’t have
                                       -3-
       hypertension. She wasn’t a diabetic. So in this event, she’s about the lowest
       risk. I can quote from this international study I referred to, and the last update
       was in 2009. In the best of circumstances, the mortality is 5 percent if you
       can get them to surgery. I would say, on average in the United States, it’s
       about 20 percent. In other words, even if you get them to surgery, they will
       die. But 20 percent beats the heck out of an 80-percent chance of dying.
       Q. That was my next question. If the mortality for her would have been at
       the 20-percent range, does that mean it’s an 80-percent chance that she more
       likely -- she would have survived?
       A. Survived the surgery. A few percent have complications and don’t get
       out of the hospital. But like I said, she was about as low a risk. Just to do a
       straightforward bypass, we think a risk of 2 percent is pretty high. We like
       to say it’s 1 to 1 and-a-half percent. So 20 percent is a high risk, don’t get
       me wrong. But we don’t have any choice. There’s no other options to save
       the patient.
       Q. And do you believe that the negligence of Dr. Patel was a substantial
       factor in the death of Ms. Kanipe?
       A. Yes.

      On cross-examination, Dr. Patel’s attorney pursued the issue of whether Dr. Patel
was notified of Ms. Kanipe’s ongoing pain following his initial examination of her. Mr.
Kanipe’s attorney objected:

       Q. All right. And you certainly read the admitting orders that say, No. 20,
       quote: “Call admitting M.D.” -- that’s Dr. Patel -- “for questions, orders, or
       changes in patient condition.” That order was in this chart, correct?
       A. Correct.
       Q. And as you told us, no one ever called Dr. Patel, correct?
       MS. MUSE: Your Honor, I object. There was no comparative fault
       allegation here. They’re not a party. This is inappropriate.
       MR. O’KANE: I’m just picking up on what he said.
       THE COURT: Overruled. Continue.

      Dr. Barksdale testified critically regarding the language used in Dr. Patel’s order in
Ms. Kanipe’s chart:

              He clearly -- I don’t think his order was real forcible, “Call me if
       there’s” -- I would put danged-gum well, “If there’s any pain, if the patient
       changes and had to have more nitroglycerin, you call me immediately.”

                                              -4-
              I don’t think his order was very forcible. I don’t want to get into that.
      Even when she died, he didn’t come into the hospital. Maybe the nurses are
      afraid to call him. I don’t know what the problem was.

       Dr. Patel took the stand and testified regarding what he knew about Ms. Kanipe’s
condition and when. On cross-examination, Dr. Patel stated as follows, in relevant part:

      Q. So anywhere in this does it say aortic dissection is a medical emergency,
      but you should consider it and then wait 24 hours to either confirm or not
      confirm the diagnosis? That would be silly, wouldn’t it?
      A. Well, that would be silly. But again, what I was trying to get at is that if
      you have a diagnosis or symptoms fit the picture then it is okay to wait,
      because you don’t consider -- I did not consider aortic dissection in Ms.
      Kanipe. Her presentation was -- 90 percent of the people present with severe
      chest pain with aortic dissection. The likelihood of three out of -- if you take
      even the statistics of Ms. Kanipe having an aortic dissection based on all the
      studies that you have shown, 3 out of 100,000 people have aortic stenosis --
      or aortic dissection, I’m sorry. Of that, if you take away 50 percent of people
      who don’t present with classic ripping pain, that makes it 1.5 out of 100. And
      90 percent of those will at least have severe or the worst pain ever. That
      makes it just 10 percent who present without the -- with the diagnosis who
      you’re going to miss, which is .15 out of 100,000.
      Q. Okay. So at 12:07, when she was taken from the emergency room to the
      floor, her pain spiked. And if you need to look at it, it is at Page 15 of the
      medical record but it’s also on the screen behind you, sir.
      A. Yes.
      Q. All right. So at 12:07, when she was taken to the floor and her pain was
      documented as a 6 out of 10, did that confirm an alternate diagnosis for you?
      A. I was not notified of any of that.

                                            ***

      Q. Doctor, today it’s your testimony that you would have expected to have
      been notified of this 6 out of 10, correct?
      A. Probably so.
      Q. That’s because this is a clinically significant finding, isn’t it? This is
      important in evaluating Ms. Kanipe’s status, isn’t it?
      A. Well, what I can always say is that the order set pathway says to notify a
      physician of any change of condition. If there is a change in pain, worsening
      of pain, probably so.

                                             -5-
Q. So now, when this case was brought against you, you have an opportunity
through the legal process to blame other people, don’t you?
A. I’m not going to blame anybody.

                                     ***

Q. If you’d been aware of this, the standard of care would have required you
to do something different, wouldn’t it?
A. The standard of care would not have required me to do something
different. The standard of care would be that if I was notified, depending on
what was conveyed to me, I would have gone back in and reevaluated Ms.
Kanipe.

                                     ***

Q. So let’s move on and let’s look at her pain down here throughout the day.
Next slide, it’s Page 76 in the medical records. It documents 2, 2, and 7. So
we know that she did continue to have pain throughout the day, correct?
A. From the documentation, yes.
Q. And that was clinically significant, wasn’t it?
A. Probably so.
Q. Okay. And if you had known all of these things -- that she had a pain
spike, that she had a normal troponin, and that she continued to have pain --
the standard of care would have required you to do something different,
wouldn’t it?
A. The standard of care would have been, again, that I go in -- I’ve been
notified of the pain, I go and evaluate the patient and then make whatever
decision I need to make.
Q. Okay. Doctor, you were notified of the pain, weren’t you?
A. No, I was not.

                                     ***

Q. A conversation is a two-part endeavor, isn’t it? They can ask you stuff
and you can tell them stuff, can’t you?
A. It can be. But if it wasn’t significant -- they didn’t notify me that she’s
having more chest pain.
Q. Okay. But --
A. Since they didn’t notify me and I knew she was pain-free, I didn’t ask if
she was having chest pain.

                                     -6-
      Q. You didn’t ask if she was having chest pain? Okay. Did you ask them
      what the results of the second troponin were?
      A. No, I did not.
      Q. Okay.
      A. I assumed it was negative because they did not notify me. The standard
      of care at Morristown was that they would notify you immediately if there
      were -- if the tests showed any abnormalities.

       Mr. Kanipe called Nurse Crespo to testify on rebuttal. According to Nurse Crespo,
during her 3:30 p.m. phone call to Dr. Patel, she informed him of Ms. Kanipe’s ongoing
pain. Nurse Crespo testified, in pertinent part:

      Q. Can you tell us why it is that you reached out and called Dr. Patel that
      afternoon?
      A. The reason that I had called Dr. Patel was I had given some nitro
      sublingual per my standing orders for the chest pain.
      Q. How many times had you given that sublingual nitro per the standing
      order?
      A. I gave it twice, and I don’t exactly know why a third dose wasn’t given.
      It could have been that she had become so hypotensive that I couldn’t give it
      again, because I know that we were checking the blood pressure in between
      --
      Q. Okay.
      A. -- her standing orders. And the whole reason for the call was to let him
      know that this had not worked. The chest pain continued, along with some
      nausea. You know, it was more to raise the red flag to him that I didn’t have
      anything else to do for her for the chest pain, and it did continue.
      Q. Do you recall whether you specifically told him that the nitroglycerin that
      you were giving her for pain was not working anymore?
      A. Yes.
      Q. All right.
      A. That’s a thing for the nurses. If the nitro doesn’t work, you have to call
      the physician.
      Q. Do you recall specifically making him aware that the patient at that time
      was experiencing pain, actively experiencing pain at that time?
      A. Yes, that the chest pain had not subsided. Actually, never did it go to a 0
      with me on shift.
      Q. All right. To the extent that there has been some perhaps guess or
      speculation that perhaps the reason that you called Dr. Patel is because you
      were -- it was getting later in the day or it was getting close to the end of your

                                             -7-
       shift and you just wanted clarification about this particular patient or this
       case, what is your response to that testimony?
       A. No, I was just calling to let him know what was going on, to see if there
       was anything else we needed to be doing, other tests, anything else, you
       know. Not just a bandaid for the symptoms, per se.
       Q. Did you specifically tell Dr. Patel that you were developing concerns
       yourself as you followed her from a nursing standpoint about this particular
       patient?
       A. I said I was concerned because she continued to hold her chest and she
       said something wasn’t right. You know, she knew something wasn’t right.
       And that’s all that I said.
       Q. And you told him that?
       A. Yes.
       Q. Did you call him for the specific purpose of getting prescriptions?
       A. No. I actually wasn’t expecting a med order, honestly.
       Q. What were you expecting?
       A. Possibly an order for another test or him to come up there and see her,
       because the nitro didn’t work. I didn’t know he was going to give me that;
       but because he did, I have to write it down as the order.

        At the conclusion of trial, the jury found in favor of all defendants, including Dr.
Patel. The Trial Court approved the verdict as thirteenth juror. Mr. Kanipe subsequently
filed a motion for a new trial. Upon hearing the motion, the Trial Court initially reaffirmed
its earlier approval of the verdict. However, the Trial Court went on to enter an order
granting Mr. Kanipe’s motion and ordering a new trial on grounds that Dr. Patel had,
through his testimony, shifted blame to a non-party despite never having pled comparative
fault. In its oral ruling attached to its order, the Trial Court stated, in relevant part:

              At the end of the day, though, I just really feel that Dr. Patel pointed
       the finger at the nurses and said “I’m not at fault because they didn’t tell me.”
       And he says on Page 131 -- and other places, but specifically there, that “I
       was never notified that she was having chest pains, so there was no reason to
       go for a second imaging study.”

                                             ***

              And, you know, for the record, for the Court of Appeals whenever this
       gets there at some point in time, seriously -- you know, I guess I see witnesses
       and try to evaluate them for a living. And seriously, the plaintiff’s counsel
       was surprised at trial, and I let them put on their rebuttal witness, the nurse,
       because I believed that they were surprised at trial.
                                              -8-
        Having reviewed the transcript, I don’t think they should have been
surprised at trial about the denial of getting the information. I understand
why it was overlooked, because you’ve got a medical record and you had
nursing testimony that indicated that he had been notified.
        And specifically, the record is not definitive as to the conversation,
obviously, or Dr. Patel wouldn’t be able to testify one way and the nurse
another one on what the nature of the conversation was. And what actually
happened, who knows?
        But I believe that counsel for plaintiff was surprised at trial. But I also
say it doesn’t matter, based on this George [v. Alexander] case, which
basically says in this case, to me, if being notified of continued pain had made
a different result potential -- nothing’s for sure, obviously, in these cases --
for Ms. Kanipe, then you’re shifting the blame by continuing to assert that
“The nurses didn’t tell me. They didn’t tell me.”
        And let’s give Mr. -- Dr. Patel the benefit of the doubt. They didn’t
tell him. Well, it’s the danged nurses’ fault, then. But unfortunately that ship
has sailed, I believe.
        So obviously, the plaintiffs don’t think that’s correct, and there’s at
least one nurse that says it’s not.
        I guess it’s frustrating for everybody. I certainly understand how
frustrating it is to Dr. Patel’s attorneys, when you’ve got his deposition
transcript where he says “I was never notified of any increase in pain
throughout the whole hospitalization.”
        So -- but he still can’t throw off on them. And maybe he didn’t
anticipate that it was going to be a throw-off on the nurses before the trial;
but essentially, that’s the way it strikes me, is that he did.
        So pointing the finger back at the nurses and saying, “If they had
notified me, things would have been different. I had an order in the file that
said ‘Notify me of changes in pain.’” She had changes in pain, we all know
that. The first one was at 12:07. We know the nurses dropped the ball on
that, apparently. So it was 6 out of 10 when they moved her to the floor.
Why didn’t they call him then? It may be that the nurses are 100-percent
liable in the case, and they’ve been let off.
        Here’s the deal. I can’t try your case for you, so I’m saying that we
had an allegation of comparative fault in here that wasn’t pled, so that’s not
a fair trial.
        But I can’t make you allege the comparative fault of the nurses, and I
don’t see how you can go back through the trial without doing that, if Dr.
Patel’s testimony is not going to change. And obviously, you don’t anticipate
that happening.

                                       -9-
       Dr. Patel sought an interlocutory appeal at this stage, which the Trial Court allowed.
However, Dr. Patel’s application was denied by the Court of Appeals of Tennessee and the
Tennessee Supreme Court. Thus, a second trial was conducted in January of 2019. Before
the retrial, the parties contested certain evidentiary matters. Dr. Patel filed a motion in
limine seeking a ruling allowing him to testify to what he knew about Ms. Kanipe’s
condition merely as a factual matter, not as a way of shifting blame. The Trial Court ruled
that Dr. Patel and Nurse Crespo could testify about the 3:30 phone call, but it would instruct
the jury that there was no other party to potentially blame besides Dr. Patel.

        Dr. Patel also sought, on the basis of peer review privilege, to exclude any evidence
reflecting that since the underlying events of the case he had voluntarily relinquished his
privileges to practice at Morristown-Hamblen Hospital. The Trial Court entered an order
denying Dr. Patel’s request, stating in pertinent part:

               Plaintiff correctly points out that the Court’s previous exclusion of
       this information allowed Dr. Patel to testify in a way that likely create[d] the
       false impression that he maintained privileges at the hospital and was
       continuing to care for patients there. In evaluating the discrepancy between
       the testimony of Dr. Patel and the nurse who called him on the afternoon
       before Mrs. Kanipe’s death, the jury should be allowed to consider the fact
       that Dr. Patel no longer sees patients at that hospital and that Dr. Patel
       voluntarily gave up that right in lieu of going through a disciplinary
       proceeding at the hospital.
               Furthermore, it seems clear to the undersigned that surrendering
       medical privileges at a hospital in lieu of going through a disciplinary
       proceeding is a factor to be considered in assessing the competence and
       qualifications of an expert witness. The Tennessee Legislature clearly found
       that such actions by health care providers can be an important consideration
       for the health care consumer when deciding whether to commit “their health
       care to such provider.” Tenn. Code Ann. §63-3-102(a). The Health Care
       Consumer Right to Know Act of 1998 requires a surrender of hospital
       privileges, such as the surrender by Dr. Patel at issue in this case, to be
       publicly disclosed. Tenn. Code Ann. §63-32-105(a)(4). Such information
       may also be of importance to a jury in weighing the differing opinions of
       expert witnesses in a medical negligence case.
               Dr. Patel’s surrender of privileges in lieu of investigation is not a
       record of a QIC and it is a fact required to be publicly disclosed by the Health
       Care Consumer Right to Know Act of 1998. Plaintiff’s have obtained this
       document and information through that public disclosure and not from any
       QIC member or record. This information is, as plaintiffs correctly point out,
       “available from [an] original source...;” and, therefore not immune from
                                            -10-
       discovery or use in a judicial proceeding. Tenn. Code Ann. § 63-1-150
       (d)(2).
               Assuming the defendant testifies regarding the standard of care, and
       his compliance therewith, the jury is entitled to consider all relevant
       information regarding his qualifications and the introduction of the disputed
       evidence will not be restricted. However, the undersigned will provide the
       jurors with a limiting instruction in which they will be admonished not to
       consider this evidence in determining whether Dr. Patel was at fault in this
       case, but only in evaluating his testimony as an expert and that it may be
       considered in resolving any discrepancies between the testimony of Dr. Patel
       and current or former staff of the hospital. The attorneys are invited to file
       requested versions of this limiting instruction.

        The second trial proceeded, with much the same evidence introduced as in the first
trial. This time, however, Nurse Crespo testified in Mr. Kanipe’s case-in-chief, rather than
in rebuttal. Also, this time, evidence of Dr. Patel’s voluntary surrender of his privileges to
practice at Morristown-Hamblen Hospital was admitted, subject to the following limiting
instruction:

              There’s been evidence, obviously, presented to you about the
       surrender of hospital privileges by Dr. Patel at the Morristown Hamblen
       Hospital and that’s been admitted only for some limited purposes.
              What you may not consider this in connection with is whether or not
       Dr. Patel was at fault in this case, and this is not this case. This information
       has been admitted into evidence and you may consider it in evaluating Dr.
       Patel’s qualifications as an expert witness and you may consider the evidence
       in resolving any discrepancies between the testimony of Dr. Patel and the
       former hospital employee Nurse Crespo or Nurse Cochran, and those are the
       limited purposes for which you may consider this.

       Dr. Patel took the stand in the second trial and testified succinctly to the impact that
the jury believing he had been notified of Ms. Kanipe’s pain would have on the case:

       Q. Doctor, as you previously admitted, if you had been aware of Ms. Kanipe
       having chest pain, the standard of care was for you to go back in and
       reevaluate her. Correct?
       A. Correct.
       Q. So if the jury believes Nurse [Crespo], you did not comply with the
       standard of care. Isn’t that right?
       A. Yes.

                                             -11-
       Q. If you’re aware of the pain spike, the normal troponin, and that she
       continued to have pain, the standard of care, again, was for you to go in and
       reevaluate her?
       A. Correct.
       Q. And if Nurse [Crespo] was honest in her testimony here and the jury
       credits that, then by your own admission, you violated the standard of care.
       Correct?
       A. Correct.

      Following the second trial, the jury found in favor of Mr. Kanipe. The jury awarded
$10,000 for Ms. Kanipe’s pain and suffering; $9,300 for Ms. Kanipe’s funeral expenses;
and $300,000 for the pecuniary value of Ms. Kanipe’s life. Dr. Patel filed a motion for a
new trial, which the Trial Court denied in its June 2019 final order. Dr. Patel timely
appealed to this Court.

                                         Discussion

        Although not stated exactly as such, Dr. Patel raises the following issues on appeal:
1) whether the Trial Court erred in granting Mr. Kanipe’s motion for a new trial in the first
trial; 2) whether the Trial Court erred in admitting evidence of Dr. Patel’s voluntary
surrender of his privileges to practice medicine at Morristown-Hamblen Hospital in the
second trial; and, 3) whether the Trial Court failed to independently exercise its role as
thirteenth juror.

       We first address whether the Trial Court erred in granting Mr. Kanipe’s motion for
a new trial in the first trial. We have explained previously our standard of review of a trial
court’s decision on a motion for a new trial:

               A trial court is given wide latitude in granting a motion for new trial,
       and a reviewing court will not overturn such a decision unless there has been
       an abuse of discretion. Mize v. Skeen, 63 Tenn. App. 37, 42-43, 468 S.W.2d
733, 736 (1971); see also Tennessee Asphalt Co. v. Purcell Enter., 631
S.W.2d 439, 442 (Tenn. App. 1982). As the thirteenth juror, the trial judge
       is required to approve or disapprove the verdict, to independently weigh the
       evidence, and to determine whether the evidence preponderates in favor of
       or against the jury verdict. Mize, 63 Tenn. App. at 42, 468 S.W.2d at 736. If
       the trial judge is dissatisfied with the verdict, he should set it aside and grant
       a new trial. Hatcher v. Dickman, 700 S.W.2d 898, 899 (Tenn. App. 1985)
       (quoting Cumberland Tel. & Tel. Co. v. Smithwick, 112 Tenn. 463, 469, 79
S.W. 803, 804 (1904)).

                                             -12-
Loeffler v. Kjellgren, 884 S.W.2d 463, 468-69 (Tenn. Ct. App. 1994). Appellate courts
ordinarily permit discretionary decisions to stand when reasonable judicial minds can differ
concerning their soundness. Overstreet v. Shoney’s, Inc., 4 S.W.3d 694, 709 (Tenn. Ct.
App. 1999).

       In granting Mr. Kanipe’s motion for a new trial, the Trial Court relied on our
Supreme Court’s holding in George v. Alexander. In George v. Alexander, our Supreme
Court ruled that the defendants, having failed to plead comparative fault, contravened
Tenn. R. Civ. P. 8.033 by shifting blame to another party at trial. The George Court stated,
in relevant part:

               The plaintiff argues that because the deposition of Dr. Allen was
        offered for the sole purpose of shifting the blame for the injuries away from
        the defendants and onto Dr. Daniell—the surgeon primarily responsible for
        positioning the patient—Rule 8.03 required the defendants to affirmatively
        plead Daniell’s fault as a defense….

                                                     ***

               In response, the defendants argue that Rule 8.03 is triggered only
        when the defendant seeks to show that another person was legally at fault for
        the plaintiff’s injuries….

                                                     ***

               While the defendants’ position seems plausible at first blush, its
        assumption that proof of proximate cause is necessary to “shift the blame” to
        another is unfounded. Since proximate cause is actually just a policy
        decision of the judiciary to “deny liability for otherwise actionable causes of
        harm,” see Kilpatrick v. Bryant, 868 S.W.2d 594, 598 (Tenn. 1993); Joseph
        H. King, Jr., Causation, Valuation and Chance in Personal Injury Torts
        Involving Preexisting Conditions and Future Consequences, 90 Yale L.J.
        1353, 1355, n. 7 (1981), the defendants’ position ignores the fact that “blame-

3
  Rule 8.03 provides: “In pleading to a preceding pleading, a party shall set forth affirmatively facts in short
and plain terms relied upon to constitute accord and satisfaction, arbitration and award, express assumption
of risk, comparative fault (including the identity or description of any other alleged tortfeasors), discharge
in bankruptcy, duress, estoppel, failure of consideration, fraud, illegality, laches, license, payment, release,
res judicata, statute of frauds, statute of limitations, statute of repose, waiver, workers’ compensation
immunity, and any other matter constituting an affirmative defense. When a party has mistakenly
designated a defense as a counterclaim or a counterclaim as a defense, the court, if justice so requires, shall
treat the pleading as if there had been a proper designation.”
                                                     -13-
       shifting” in a negligence context actually has to do with the element of
       causation in fact. Once the defendant introduces evidence that another
       person’s conduct fits this element, it has effectively shifted the blame to that
       person. Therefore, if the defendants’ position were to be accepted, any
       defendant wishing to transfer blame to another person at trial could always
       maintain that it is not trying to show that the other’s conduct satisfies the
       legal definition of negligence, but that it is merely trying to establish that the
       other person’s conduct actually caused the injury. In the latter situation,
       however, the defendant has fully accomplished what Rule 8.03 was intended
       to prevent: it has effectively shifted the blame to another person without
       giving the plaintiff notice of its intent to do so. Therefore, the purpose of
       Rule 8.03 would be undermined to a substantial degree if the defendants’
       overly technical argument were to prevail.

George v. Alexander, 931 S.W.2d 517, 520-21 (Tenn. 1996) (footnote omitted, emphases
in original). This Court later observed that “the Supreme Court clearly established that
‘Rule 8.03 is a prophylactic rule of procedure that must be strictly adhered to if it is to
achieve its purposes.’” Dickson v. Kriger, 374 S.W.3d 405, 412-13 (Tenn. Ct. App. 2012)
(quoting George, 931 S.W.2d at 522).

       In his brief, Dr. Patel acknowledges George but argues it is inapplicable here. Dr.
Patel denies he blamed the nurses. He states that no expert testimony regarding the nursing
standard of care, or deviation from that standard of care, was presented on his behalf. Dr.
Patel argues that he did not flout George simply by answering a factual question on cross-
examination. At oral argument, Dr. Patel’s attorney argued that even if Dr. Patel had been
notified of Ms. Kanipe’s ongoing chest pain and went in to re-evaluate her, he would have
stuck to his original plan of waiting until the next day to decide on further tests. Per this
argument, the phone call was of no causative effect.

       In response, Mr. Kanipe argues that Dr. Patel’s testimony tended to show that the
nursing staff’s failure to notify him of Ms. Kanipe’s chest pain was the cause in fact of her
death. However, Dr. Patel never pled the comparative fault of any nurse. Thus, argues Mr.
Kanipe, Dr. Patel’s attempt to shift blame to the nurses at trial ran afoul of George and
warranted a new trial. Mr. Kanipe asserts there is no support for a distinction to be drawn
between “factual” testimony and “accusatory” testimony.

        In keeping with George, our inquiry is with respect to causation in fact. Therefore,
whether the nurses adhered to the nursing standard of care is not before us. The issue is
whether Dr. Patel cast blame on non-party nurses for causing Ms. Kanipe’s death. Dr.
Patel testified that he was not trying to blame anybody. However, if a defendant states that

                                             -14-
he is not trying to blame anybody, but then proceeds to blame somebody, the disclaimer
that he is not trying to blame anybody rings hollow.

       Dr. Barksdale’s testimony from the first trial reflects that, with an aortic dissection,
time is of the essence, and that either a CT scan or heart catheterization likely would have
revealed it in Ms. Kanipe. Dr. Patel’s own testimony highlights how impactful it would
have been had he known about Ms. Kanipe’s ongoing chest pain. Dr. Patel testified such
pain is a clinically significant finding. Dr. Patel testified that his being notified of such
pain would have led him to re-evaluate Ms. Kanipe, which he never did.

       Dr. Patel’s argument notwithstanding, we are unpersuaded that the matter of
whether he ever was notified about Ms. Kanipe’s ongoing chest pain somehow was
immaterial to a determination of the cause in fact of her death. The jury in the first trial
could well have concluded that non-party nurses were to blame for Ms. Kanipe’s death
rather than Dr. Patel. Under George, it was incumbent upon Dr. Patel to plead the
comparative fault of the nurses in his answer if he intended to assert that they never notified
him of Ms. Kanipe’s ongoing pain, but he failed to do so.

        Dr. Patel argues, nevertheless, that Mr. Kanipe opened the door to the issue of
notification and should not have been granted a retrial on account of a subject he
introduced. Dr. Patel points to the direct examination testimony of Dr. Barksdale, who
testified critically about the language used in the order in Ms. Kanipe’s chart. Dr. Patel
asserts that, in contrast, his own factual testimony regarding notification was elicited only
during his cross-examination, and that Mr. Kanipe failed to object or move to strike.

       We note first that when Dr. Patel’s attorney pursued on Dr. Barksdale’s cross-
examination the issue of whether Dr. Patel was notified, Mr. Kanipe’s attorney timely
objected on grounds that comparative fault had not been pled. The objection was
overruled; she did not have to object continually to preserve her objection. With respect
to Dr. Barksdale’s testimony about notification, this did not tend to blame the nurses for
Ms. Kanipe’s death. If anything, Dr. Barksdale faulted Dr. Patel for not ensuring there was
stronger language in the order about calling him if Ms. Kanipe continued to experience
chest pain. Mr. Kanipe did not introduce the issue of the nurses’ potential fault. Dr. Patel
did when he testified point-blank that he never was notified of Ms. Kanipe’s pain and would
have re-evaluated her had he known of it. In keeping with our Supreme Court’s holding in
George v. Alexander, we discern no abuse of discretion in the Trial Court’s decision to
grant Mr. Kanipe’s motion for a new trial.

       We next address whether the Trial Court erred in admitting evidence of Dr. Patel’s
voluntary surrender of his privileges to practice medicine at Morristown-Hamblen Hospital
in the second trial. Dr. Patel argues that admission of this evidence violated peer review
                                             -15-
privilege and lacked any probative value. In response, Mr. Kanipe argues, among other
things, that the information falls under the “original source exception.”

       Regarding evidentiary decisions, “trial courts are accorded a wide degree of latitude
in their determination of whether to admit or exclude evidence, even if such evidence
would be relevant.” Dickey v. McCord, 63 S.W.3d 714, 723 (Tenn. Ct. App. 2001). This
Court has discussed the original source exception as follows:

              To further protect those who participate in a QIC [quality
       improvement committee] or provide information or testimony to a QIC, the
       General Assembly mandated that all records of a QIC, including testimony
       or statements by persons relating to activities of the QIC, are not only
       confidential and privileged, they are protected from discovery or admission
       into evidence. Tenn. Code Ann. § 68-11-272(c)(1)….

                                            ***

               Nevertheless, the HCQIA provides an exception to the above, known
       as the “original source” exception. See Tenn. Code Ann. § 68-11-272(c)(2).
       Pursuant to this exception, any information, documents or records that were
       not produced for use by a QIC, or which were not produced by persons acting
       on behalf of a QIC, and are available from original sources, are not immune
       from discovery or admission into evidence even if the information was
       presented during a QIC proceeding. Tenn. Code Ann. § 68-11-272(c)(2).
       Furthermore, persons who provided testimony or information to or as part of
       a QIC are not exempt from discovery and are not prohibited from testifying
       as to their knowledge of facts or their opinions. Id.; see Powell v. Community
       Health Systems, Inc., 312 S.W.3d 496, 510 (Tenn. 2010); see also Stratienko
       v. Chattanooga-Hamilton County Hosp. Auth., 226 S.W.3d 280, 287 (Tenn.
       2007) (Holding that, under the TPRL, information that had been furnished to
       a peer review committee by original sources “outside the committee” could
       be obtained directly from the original sources, unless otherwise privileged).

              We find it significant that the original source exception to the HCQIA
       privilege parallels the work product doctrine in many respects. See Tenn. R.
       Civ. P. 26.02(3); see also Robert Banks, Jr. & June F. Entman, Tennessee
       Civil Procedure § 8-1[i] at 8-25 (3d ed. 2009). Like the original source
       exception, the work product doctrine does not prevent the discovery of facts
       from the original source of the information. Id. § 8-1[i] at 8-26. Thus, while
       the work product doctrine prohibits a litigant from obtaining from the adverse
       party its work product, the litigant may obtain substantially the same
                                            -16-
       information directly from the original sources. See id. § 8-1[i] at 8-28.
       Although the HCQIA privilege is problematic, it does not prohibit Dr.
       Pinkard from obtaining evidence that goes to the heart of the case from the
       original sources.

Pinkard v. HCA Health Servs. of Tennessee, Inc., 545 S.W.3d 443, 452-53 (Tenn. Ct. App.
2017) (footnotes omitted).

       Dr. Patel points out correctly that the purpose of peer review privilege is to foster
the improvement of healthcare services by protecting the records of QICs from discovery
and thereby encouraging frankness in their deliberations. However, the fact of Dr. Patel’s
surrender of privileges in lieu of an investigation at Morristown-Hamblen Hospital is not,
in our judgment, the sort of material the disclosure of which would tend to chill the work
of QICs as envisioned by peer review privilege. Mr. Kanipe’s attorney found this
information on the Tennessee Department of Health website under Dr. Patel’s publicly
available Practitioner Profile. In addition, the Trial Court instructed the jury that it had to
confine its consideration of this evidence to questions of Dr. Patel’s competence as an
expert witness and his credibility in resolving the factual dispute over the content of the
3:30 p.m. phone call with Nurse Crespo. Evidence of Dr. Patel’s surrender of privileges
thus was relevant for impeachment purposes. Dr. Patel’s later surrender of his privileges
at Morristown-Hamblen Hospital was not offered for the purpose of showing that Dr. Patel
was negligent in his treatment of Ms. Kanipe. We do not presume without evidence that
the jury ignored the Trial Court’s limiting instruction. Given this narrowing of what the
jury could use the information for, and in view of the original source exception, we find no
abuse of discretion in the Trial Court’s admission into evidence of Dr. Patel’s voluntary
surrender of privileges at Morristown-Hamblen Hospital.

      The third and final issue we address is whether the Trial Court failed to
independently exercise its role as thirteenth juror. Dr. Patel points to a comment the Trial
Court made after the first trial: “And, you know, there was plenty of evidence on which to
make a finding on behalf of Dr. Patel in the case, so I’m not ruling that it was against the
weight of the evidence.” Dr. Patel argues:

       Upon consideration of the facts and evidence presented during these two
       trials, it is apparent that the trial court failed to properly exercise its role as
       thirteenth juror, when, upon hearing the same evidence presented on two
       separate occasions, determined that the verdict in favor of Dr. Patel after the
       first trial was supported by the evidence, and then the opposite verdict against
       Dr. Patel after the second trial, based upon the same evidence, was also
       supported by the weight of the evidence.

                                              -17-
       Regarding a trial court’s duty to independently exercise its role as thirteenth juror
and the consequences of a trial court’s failure to do so, this Court has discussed:

       When a party moving for a new trial asserts that the jury’s verdict was
       contrary to the weight of the evidence, it is the trial judge’s duty to
       independently weigh the evidence to determine whether it preponderates
       against the verdict and, if so, to grant a new trial. Jones v. Tenn. Farmers
       Mut. Ins. Co., 896 S.W.2d 553, 556 (Tenn. Ct. App. 1994). Like the jury,
       the trial judge is not bound to give any reasons for its decision to grant or
       deny a new trial based on the preponderance of the evidence. Cooper v.
       Tabb, 347 S.W.3d 207, 221 (Tenn. Ct. App. 2010). When the trial judge
       approves the verdict without comment, the appellate court will presume that
       the trial judge adequately performed his or her function as the thirteenth
       juror. Id. However, a statement indicating that the trial judge has
       misconceived his or her duty is grounds for reversal on appeal. Shivers v.
       Ramsey, 937 S.W.2d 945, 947 (Tenn. Ct. App. 1996).

In re Estate of Link, 542 S.W.3d 438, 467 (Tenn. Ct. App. 2017).

        With respect to the Trial Court’s comment cited by Dr. Patel, we disagree that it
reflects deference to the jury. Rather, it is the Trial Court’s assessment of the
preponderance of the evidence. Dr. Patel’s larger point appears to be that, because the Trial
Court heard evidence in two consecutive trials of the same matter with largely the same
evidence presented, yet reached different conclusions each time with both conclusions
aligning with the respective juries’ conclusions, the Trial Court ipso facto displayed a lack
of independence. We find no basis for this would-be rule. While the trials were similar,
they were not identical. For example, in the second trial, Nurse Crespo testified in Mr.
Kanipe’s case in chief instead of in rebuttal. It is just as conceivable that the Trial Court
found Mr. Kanipe’s case more compelling in the second trial than it did the first as it is that
the Trial Court improperly deferred to the jury. At no point did the Trial Court state, or
hint, that it deferred to the jury. We find no evidence that the Trial Court failed to
independently exercise its role as thirteenth juror. We affirm.

                                         Conclusion

      The judgment of the Trial Court is affirmed, and this cause is remanded to the Trial
Court for collection of the costs below. The costs on appeal are assessed against the
Appellant, Pragnesh Patel, M.D., and his surety, if any.

                                           ______________________________________
                                           D. MICHAEL SWINEY, CHIEF JUDGE
                                             -18-