Court Opinion

ID: 9963853
Source: CourtListenerOpinion
Date Created: 2024-04-26 14:05:33.763061+00
Date Added: 2024-06-11T08:25:02.306816
License: Public Domain

RENDERED: APRIL 19, 2024; 10:00 A.M.
                    TO BE PUBLISHED

           Commonwealth of Kentucky
                  Court of Appeals
                     NO. 2023-CA-0748-MR

DEBORAH LLOYD                                       APPELLANT

           APPEAL FROM JEFFERSON CIRCUIT COURT
v.           HONORABLE TRACY E. DAVIS, JUDGE
                   ACTION NO. 20-CI-005331

NORTON HOSPITALS, INC. D/B/A
NORTON’S WOMEN’S AND
CHILDREN’S HOSPITAL;
CHRISTOPHER DALE HENLEY,
M.D.; DARREN CAIN, M.D.;
DIAGNOSTIC X-RAY PHYSICIANS,
PSC (DXP); AND SHEILA SLONE
KCSA                                                APPELLEES

                         OPINION
                    AFFIRMING IN PART
                  AND REVERSING IN PART

                        ** ** ** ** **

BEFORE: CETRULO, GOODWINE, AND JONES, JUDGES.
CETRULO, JUDGE: This is an appeal from summary judgments granted in favor

of three defendants in a medical malpractice action. We affirm one of those

judgments and reverse the other two.

                                       FACTS

             Deborah Lloyd (“Lloyd”) underwent a total knee replacement surgery

on December 20, 2019 at Appellee Norton Hospitals, Inc. d/b/a Norton’s Women’s

and Children’s Hospital (“Norton”). Dr. Sean Griffin (“Dr. Griffin”) performed

the surgery. Appellee Sheila Slone (“Slone”), a surgical assistant who worked

independent of the hospital and for various physicians on a per-patient basis, used

a suture needle to close the outermost layer of skin on Lloyd’s knee. While doing

so, the needle became separated from the needle holder; therefore, when the nurses

conducted an instrument count, the needle count was off. The nurses in the

operating room and Dr. Griffin conducted a search for the needle but did not locate

it. Dr. Griffin ordered an x-ray to determine whether the needle was in Lloyd’s

body. Dr. Griffin and two radiologists, Appellees Dr. Christopher Henley and Dr.

Darren Cain (“the Radiologists”), each reviewed the x-rays and did not see the

needle. Dr. Griffin then concluded that the needle was likely lost, and the wound

should not be reopened to search for the needle.

             A few weeks later, in a follow-up visit with Dr. Griffin, additional

x-rays were conducted, and the needle was observed in Lloyd’s knee. Lloyd’s

                                         -2-
medical records from that visit recorded that x-rays demonstrated the presence of a

thin metal filament of unclear origin, but which could be from metallic

instrumentation used during surgery. Two weeks later, Lloyd presented again with

right knee pain. The record at that visit noted that “there is an associated foreign

body on x-ray that is not visible at this time. I am going to recommend surgical

treatment [in] order to prevent further complications including prosthetic

infection.” On February 7, 2020, Lloyd underwent a right knee wound revision

and removal of the foreign body which, it was noted, appeared to be a suture

needle.

              In September 2020, Lloyd filed a complaint against Dr. Griffin, Slone,

and Norton.1 Lloyd subsequently amended the complaint to add the Radiologists.

Lloyd settled her claims against Dr. Griffin, and he was dismissed as a party as the

matter proceeded. A scheduling order required Lloyd to identify experts and

provide disclosures by April 2022. Defendants were to provide disclosures by

June 2022. For her expert witnesses, Lloyd identified Dr. Morrison, an infectious

disease expert and Dr. Dysart, an orthopedic surgeon. The disclosures, required by

Kentucky Rule of Civil Procedure (“CR”) 26, stated in part, that Dr. Dysart would

testify as follows:

1
  All parties refer to a circulating nurse or nursing staff in the operating room as the only
employee(s) of Norton referenced in this matter. For ease throughout, we simply refer to those
claims as against Norton.

                                              -3-
             Dr. Griffin failed to locate, remove, and document a suture
             needle, which had been confirmed by an incorrect
             instrument count. Retained foreign bodies are known to
             cause great risk to patients, including but not limited to
             infection and/or sepsis, possible re-operation,
             readmissions and prolonged hospital stays, sever[e] pain,
             and even death.

             He is further expected to testify that [the Radiologists] had
             a duty to review, identify, and document the intra-
             operative and post-operative x-rays, showing the retained
             suture needle, and failed to do so. Failing to locate,
             identify, and remove the retained suture needle caused a
             delay in treatment and significant harm to [Lloyd],
             including but not limited to an infection which required
             two subsequent surgeries on February 7, 2020 and
             February 28, 2020, as well as long-term antibiotic use and
             chronic suppressive therapy which caused further health
             complications and harm to [Lloyd].

             Thereafter, in August 2022, Dr. Dysart was deposed. During that

deposition, he provided further criticism of Norton, the Radiologists, and Slone.

He admitted that those criticisms were not contained within the disclosures or his

prior written report. In October 2022, Dr. Morrison’s deposition was taken.

Lloyd’s prior disclosures as to Dr. Morrison revealed that he would testify relative

only to the care of the surgeon, Dr. Griffin. Early in his deposition, however, he

elaborated that he would also provide testimony that the Radiologists and “agents

of Norton” violated the standard of care in failing to follow hospital policy or their

own protocol. Dr. Morrison’s deposition was adjourned in progress with all

                                         -4-
counsel agreeing that they would take this issue – whether Dr. Morrison could

testify regarding the Radiologists and Norton – up with the trial court.

              Norton filed a motion to strike various testimony and opinions of

Lloyd’s experts as to its staff. Lloyd then filed a motion for leave to amend the

CR 26.02 disclosures to include some of Dr. Morrison’s additional opinions. The

trial court denied the motion to amend and granted Norton’s motion to strike

certain portions of Dr. Dysart’s testimony from his deposition. At least two

motions to reconsider those rulings were heard and denied.

              Thereafter, Norton moved for summary judgment arguing that,

without the testimony of Dr. Dysart against its nurse (which was stricken from his

deposition), the case against Norton could not proceed. Similarly, Slone moved for

summary judgment, followed by the Radiologists. In February 2023, the trial

court2 granted summary judgment for all three appellees, stating, in relevant part

that

              [b]ecause of the court’s prior rulings on November 23 and
              December 22, 2022, the court finds it will be impossible
              for [Lloyd] to now present evidence at the trial warranting
              a judgment in her favor. While the court believes its
              predecessor the Hon. Judge Mary Shaw, may have been
              overly harsh in these rulings, Judge Shaw was presented
              with the opportunity to revisit the issue and had the benefit
              of the parties’ arguments concerning the same.

2
  Judge Mary Shaw presided over Division 5 of the Jefferson Circuit Court throughout most of
these proceedings. Judge Tracy Davis took office in January 2023 and authored the opinion and
order granting summary judgment in February 2023.

                                             -5-
             On appeal, Lloyd argues that the trial court erred in striking portions

of Dr. Dysart’s testimony and in granting the Radiologists’ motion for summary

judgment. As to Slone and Norton, Lloyd admits there was no specific expert

critical of them after the trial court limited certain testimony and denied her motion

to amend the disclosures. However, Lloyd argues that the doctrine of res ipsa

loquitor should have been applied to allow those claims to proceed to a jury, with

an inference drawn from the mere occurrence of the needle being left in the

patient’s body.

                            STANDARD OF REVIEW

             The standard of review on appeal when the lower court has granted a

motion for summary judgment is whether the record, when viewed in a light most

favorable to the non-moving party, shows no genuine issue of material fact so that

the moving party is entitled to judgment as a matter of law. Phoenix Am. Adm’rs,

LLC v. Lee, 670 S.W.3d 832, 838 (Ky. 2023) (citation omitted). As this is a legal

question involving no factual findings, we review the grant of summary judgment

de novo. Brown v. Griffin, 505 S.W.3d 777, 781 (Ky. App. 2016) (citation

omitted). “[W]e generally review the grant of summary judgment without

deference to either the trial court’s assessment of the record or its legal

conclusions.” Cantrell v. Conley, 679 S.W.3d 1, 3 (Ky. App. 2023).

                                          -6-
             However, as to a trial court’s evidentiary rulings, we review for an

abuse of discretion. Goodyear Tire & Rubber Co. v. Thompson, 11 S.W.3d 575,

577 (Ky. 2000) (citations omitted). A trial court abuses its discretion only if its

“decision was arbitrary, unreasonable, unfair, or unsupported by sound legal

principles.” Miller v. Eldridge, 146 S.W.3d 909, 914 (Ky. 2004) (citation

omitted).

                                     ANALYSIS

      A.     Summary Judgment in favor of the Radiologists

             Lloyd argues that the summary judgment in favor of the Radiologists

should be overturned because: 1) portions of her expert’s testimony were

improperly excluded and 2) the expert, although not a radiologist, was still

qualified to provide opinions as to the Radiologists.

             Thus, we begin our analysis with consideration of the evidentiary

ruling that struck expert testimony presented by Lloyd. As noted, all parties were

given reasonable deadlines on disclosures of experts. Lloyd’s experts were

disclosed by April 1, 2022. The various defendants disclosed experts by June

2022. This began the process of scheduling expert depositions for a trial date set

for February 2023.

             In her Rule 26 disclosures, Lloyd did indicate that Dr. Dysart would

provide opinions critical of Dr. Griffin, as well as the Radiologists. In August,

                                          -7-
when Dr. Dysart was deposed, he also provided opinions that were critical of

Norton and Slone.3 Norton moved to strike the late-disclosed opinions, and Lloyd

moved to amend her disclosures. The trial court held a lengthy hearing on these

motions on November 23, 2022, and then signed an order prepared by counsel for

Norton, striking those late-disclosed opinions and denying the motion by Lloyd to

amend. Lloyd moved the trial court to reconsider, which was denied in December

2022. In the order, the trial court specifically stated that the “late-disclosed

opinions of Dr. Dysart contained in his deposition from page 169 to the conclusion

of his deposition on page 235 are hereby stricken from the record.” Norton

submitted this order, which was aimed at preventing the testimony regarding

Norton’s nurse. Specifically, the order stated that:

               [Lloyd’s] experts are expressly prohibited from proffering
               testimony, either at deposition or trial, of any criticism
               they may have of [Norton] because [Lloyd] failed to
               timely disclose any such criticism in her expert disclosure
               filed on April 1, 2022.

               We have found no indication throughout the very large record below

that the Radiologists moved to strike Dysart’s testimony or argued surprise or non-

disclosed criticisms. Indeed, the disclosures, written report, and other non-stricken

3
  Dr. Morrison also provided opinions that were critical of several parties and purportedly not
previously disclosed. Lloyd sought to amend her disclosures as to Dr. Morrison, which the trial
court denied. However, the disclosures as to Morrison did indicate his opinions included that the
suture needle was the causative source of plaintiff’s subsequent infection. All parties agree that
it is only the testimony of Dr. Dysart that is in issue on this claim.

                                               -8-
testimony of Dr. Dysart included criticisms of the Radiologists for failure to

observe the suture needle in the x-ray image, if nothing else.

             However, armed with these rulings limiting testimony of Lloyd’s

experts, the Radiologists joined others in moving for summary judgment. The

basis for their summary judgment motion was that expert witness Dr. Dysart was

not an expert in the field of radiology, and that he could not testify that the

Radiologists failed to act as “reasonable radiologists under the same or similar

circumstances.” The trial court’s summary judgment as to the Radiologists

concluded that Lloyd’s failure to have an expert qualified in the field of radiology

testify as to the standard of care was fatal to her case.

             On review, we are limited to the record before us, but the record

indicates Dr. Dysart was critical of the Radiologists for their failure to observe the

needle on x-rays conducted on the day of surgery. When asked about the images

he reviewed, he indicated that he was qualified to describe them and interpret

them. While he testified that he was not a radiologist, he stated “from an

orthopedic opinion, [the Radioligist] missed it – which is a disaster.” While some

of his specific criticisms were set forth in more detail in the pages stricken by the

trial court’s subsequent order, these criticisms remained in the record at the time of

the Radiologists’ motion for summary judgment.

                                           -9-
             Secondly, Lloyd’s initial disclosures revealed that Dr. Dysart would

be critical of the Radiologists’ failure to diagnose or observe the needle. The

written report of Dr. Dysart was similarly critical of the Radiologists’ failure to

recognize the presence of a foreign object (the needle) on x-ray. Dr. Dysart was

cross-examined on the fact that he is an orthopedic physician, and not a radiologist.

He acknowledged that he has a different specialty; however, he also testified that

he was very familiar with reviewing films, particularly in orthopedic

circumstances:

             So, in my experience dealing with multiple radiologists,
             we can often read a film better than they can about a
             specific issue; and the reason is we see many, many more
             of the same thing.

             As such, regarding the Radiologists, the issue before the trial court

was whether it would be impossible for Lloyd to proceed against the Radiologists

without expert testimony from a physician in the same specialty. The trial court

held that it would and granted summary judgment on that basis.

             The Radiologists assert that plaintiffs in a medical malpractice case

are required to present expert testimony establishing the standard of care expected

of the “class of physicians or specialists to which he belongs.” However, our

caselaw indicates that once the trial court determines the expert is properly

qualified, the jury is responsible for weighing the expert’s testimony. See

Washington v. Goodman, 830 S.W.2d 398, 400 (Ky. App. 1992) (citations omitted)

                                         -10-
(stating factors like qualifications, experience, and training go to the weight of the

testimony, not admissibility). See also Lee v. Butler, 605 S.W.2d 20 (Ky. App.

1979), and Ingersoll-Rand Co. v. Rice, 775 S.W.2d 924 (Ky. App. 1989),

abrogated on other grounds as recognized in Cont’l Marine, Inc. v. Bayliner

Marine Corp., 929 S.W.2d 206 (Ky. App. 1996). Likewise, this Court has

recognized that “[t]here are numerous reported cases where a physician has been

held qualified to express an opinion on medical matters outside his area of

expertise.” Owensboro Mercy Health Sys. v. Payne, 24 S.W.3d 675, 677-78 (Ky.

App. 1999) (citations omitted). See also Tapp v. Owensboro Med. Health Sys.,

Inc., 282 S.W.3d 336, 339 (Ky. App. 2009).

             In Tapp, this Court explained that an “expert witness assessment turns

on whether the proposed witness’s special knowledge, skill, experience, training,

or education will assist the jury.” Id. at 341 (citing Kentucky Rule of Evidence

(“KRE”) 702 and Stringer v. Commonwealth, 956 S.W.2d 883, 891 (Ky. 1997)).

“[A] physician or other medical provider is not automatically disqualified from

testifying against a defendant who specializes in a different area of medicine or

who is licensed or practices in a different medical discipline.” Id. (citing Payne, 24

S.W.3d at 677-78). Indeed, in Tapp, a physician testified as to the care rendered

by a nurse, stating that he was “familiar with the standard of care expected of

hospitals and their nurses under the circumstances faced by the nurses” in that

                                         -11-
case. Id. at 339. This Court found that such qualifications have been deemed

sufficient to render a physician qualified to provide expert testimony. Id. (citation

omitted).

             To be clear, we do not find the trial court abused its discretion in

striking portions of Dr. Dysart’s testimony because “[a] trial court has broad

discretion in addressing a violation of its [discovery order.]” Turner v. Andrew,

413 S.W.3d 272, 279 (Ky. 2013) (internal quotation marks and citation omitted).

However, the trial court did abuse its discretion in determining that there was

insufficient evidence in Dr. Dysart’s remaining testimony to submit to a jury on

Lloyd’s claims that the Radiologists failed to diagnose or locate the suture needle.

As discussed, testimony from a medical provider who specializes in a different

area of medicine or who is licensed or practices in a different medical discipline

may not carry as much weight with a jury. Payne, 24 S.W.3d at 677-78.

             Here, the trial court based its summary judgment in favor of the

Radiologists on a determination that it would be impossible for Lloyd to proceed to

trial without an expert qualified in the field of radiology. However, Dr. Dysart was

qualified to testify regarding the Radiologists; therefore, there was a genuine issue

of material fact for the jury to review. See Goodman, 830 S.W.2d at 400. Thus, as

to the Radiologists, we reverse the summary judgment in their favor.

                                         -12-
      B.     Summary Judgment in Favor of Slone

             We also reverse the summary judgment in favor of Slone. The trial

court entered judgment on different grounds for each defendant in its consolidated

opinion and award. Lloyd admits that there was no specific expert disclosed in her

CR 26 compliance to criticize Slone. Likewise, the trial court largely excluded the

criticisms regarding Slone from the experts’ depositions and then concluded that

the case against her could not proceed without expert testimony. However, Lloyd

counters that expert testimony is not required in a res ipsa loquitur case where the

jury can reasonably infer both negligence and causation from the mere occurrence

of the event. Thus, as to Slone, the issue is the applicability of the res ipsa loquitur

doctrine.

             The Kentucky Supreme Court has explained

             [m]ost medical malpractice claims involve issues of
             science or professional skill outside the ordinary
             experiences and range of knowledge of typical jurors and
             judges. For that reason, most, but certainly not all,
             medical malpractice claims cannot be proven without
             expert opinion testimony to establish that the conduct in
             question departed from the applicable standard of care and
             was a proximate cause of the damages claimed.

Adams v. Sietsema, 533 S.W.3d 172, 179 (Ky. 2017).

             Thus, typically, “the plaintiff in a medical negligence case is required

to present expert testimony” establishing both “the standard of skill expected of a

reasonably competent . . . practitioner” and the proximate cause of the injury.

                                         -13-
Andrew v. Begley, 203 S.W.3d 165, 170 (Ky. App. 2006) (citations omitted).

There are two very limited exceptions to that requirement outlined in our

jurisprudence. Id. (citation omitted). First, expert testimony is not required when

“the common knowledge or experience of laymen is extensive enough to . . . infer

negligence from the facts.” Jarboe v. Harting, 397 S.W.2d 775, 778 (Ky. 1965)

(citation omitted).

             The first exception applies only when “any layman is competent to

pass judgment and conclude from common experience that such things do not

happen if there has been proper skill and care[.]” Perkins v. Hausladen, 828

S.W.2d 652, 655 (Ky. 1992) (citation omitted). If the doctrine applies, negligence

can be inferred, even in the absence of expert testimony. See id. at 654-55.

             Lloyd argues that the doctrine is particularly applicable in a retained

foreign object case and that this case falls within the first exception. Indeed, our

Supreme Court has stated cases in which a foreign object had been left in the

patient’s body during an operation illustrated the “common knowledge” exception.

Id. at 655 (citation omitted). Our Supreme Court recently reaffirmed that the first

exception is best “illustrated by cases where the surgeon leaves a foreign object in

the body or removes or injures an inappropriate part of the anatomy.” St. Elizabeth

Med. Ctr., Inc. v. Arnsperger, ___ S.W.3d ___, 2024 WL 316434, at *4 (finality

                                         -14-
entered by Kentucky Supreme Court on Feb. 8, 2024) (citing Hausladen, 828

S.W.2d at 655).

             Second, expert testimony is also not required where other medical

testimony provides an adequate “foundation for res ipsa loquitur on more complex

matters.” Hausladen, 828 S.W.2d at 655 (citation omitted). Citing Nazar v.

Branham, 291 S.W.3d 599, 604 (Ky. 2009), Lloyd further quotes our Supreme

Court holding that “juries should generally be permitted to determine a healthcare

professional’s liability in a retained foreign object case.” This is the classic case,

Lloyd argues, to permit a jury to infer negligence from the mere fact of the retained

foreign object, while also giving them the latitude to analyze other facts and

evidence relevant to liability and responsibility for the fact that an item was left in

a patient’s body. We agree that based upon our precedent, the res ipsa loquitur

doctrine applies and based upon these facts, both exceptions to the requirement of

expert testimony apply.

             Kentucky has adopted the majority view that “the res ipsa loquitur

doctrine is an evidentiary doctrine which allows a jury to infer negligence on the

part of the defendant.” Baxter v. AHS Samaritan Hosp., LLC, 328 S.W.3d 687,

692 (Ky. App. 2010) (citing Sadr v. Hager Beauty Sch., Inc., 723 S.W.2d 886, 887

(Ky. App. 1987)). Therefore, if the doctrine of res ipsa loquitur is applicable, it

                                          -15-
creates a question of fact for the jury and may enable a plaintiff to survive a

summary judgment motion. Id. at 691.

               The highest Court in Kentucky has found res ipsa loquitur to apply in

numerous situations:

               Jewish Hospital Association of Louisville, Ky. v. Lewis,
               Ky., 442 S.W.2d 299 (1969), holding res ipsa loquitur
               applied where there was extensive bleeding following a
               catheterization procedure; Neal v. Wilmoth, Ky., 342
               S.W.2d 701 (1961), holding res ipsa loquitur applied
               where the dentist’s drill slipped off the tooth; Meiman v.
               Rehabilitation Center, Ky., 444 S.W.2d 78 (1969),
               holding res ipsa loquitur applied where a bone was broken
               during therapy treatment; and Laws v. Harter, Ky., 534
               S.W.2d 449 (1976), holding that res ipsa loquitur applied
               where a sponge was left in the patient during a surgical
               procedure. In all of these cases an inference of negligence
               was sufficiently supplied by medical testimony of record
               even though the plaintiff had no expert witness to opine
               that the conduct fell below the standard of acceptable
               professional care.

Hausladen, 828 S.W.2d at 655.

               Here, as in Hausladen, the medical evidence of record established that

this type of injury was not an ordinary risk of the surgery; that the method by

which it occurred was within the exclusive control of Slone; and that the injury

was not due to any voluntary action or contribution on the part of Lloyd.4 Here,

4
  We recognize the argument that Slone lacked the authority to reopen without the doctor’s
direction, and this may be an argument for subsequent motions, but the trial court did find as a
factual finding that the instrumentality was within the exclusive control of Slone.

                                               -16-
the fact that a surgical instrument was left in Lloyd’s body was not an ordinary risk

of surgery and we have been directed to no testimony that otherwise questioned

causation.

              This case is unlike Green v. Owensboro Medical Health System, Inc.,

231 S.W.3d 781, 784 (Ky. App. 2007), where this Court upheld a summary

judgment in the absence of medical testimony even though a patient went into

surgery for her hand and woke up with four loose bloody teeth. There, the Court

stated that

              [w]hile it seems unusual for a patient to enter an operating
              room for hand surgery with teeth intact and emerge with
              loose, misaligned, and bloody teeth, we do not believe a
              layman, without medical expert testimony identifying the
              required standard of care and the breach thereof, could
              competently determine an anesthesiologist, surgeon,
              and/or health care facility did something wrong before,
              during, and/or after Green’s surgery so as to cause damage
              to her teeth. Such medical negligence would have been
              even less obvious to the average juror in the present case
              because Green admitted in her deposition that she suffers
              from multiple sclerosis and periodontal disease, thereby
              possibly making her more prone to dental injury.

Green, 231 S.W.3d at 784.

              Here, in contrast, there was a suture needle inside the knee on which

Lloyd had surgery. Lloyd went into surgery without a needle in her knee and left

with one. The trial court specifically found that the only defendant who had

control of that instrumentality was Slone. Further, the record indicated that the

                                         -17-
needle was the cause of Lloyd’s subsequent revision surgery. Still, the trial court

stated that the res ipsa loquitur presumption was rebutted by the fact that Lloyd’s

expert witness did not specifically testify as to negligence on the part of Slone.

Indeed, Lloyd’s expert agreed that a suture needle could become detached without

any negligence on the part of Slone. However, that alone does not rebut the

reasonable inference that a needle should not remain in the body of a patient.

             In fact, Dr. Griffin testified that they “looked for the needle and didn’t

find it and therefore determined that the object was very unlikely to be left in her

body and that it was most likely lost.” Obviously, that conclusion was incorrect.

Subsequently, Dr. Griffin testified that at the second surgery, when this needle was

retrieved, it was confirmed to be the suture needle from the first surgery. Slone

testified that the needle became separated from the holder and was missing, and the

trial court found it was within her exclusive control. The fact that the needle was

left and that it caused injury to Lloyd is certainly something that the jury could

infer through common knowledge as something that should not have happened. It

is a matter of common understanding to any layperson that a needle does not

remain in a patient’s body after surgery “if there has been proper skill and care.”

See Hausladen, 828 S.W.2d at 655 (citation omitted).

             On appeal, Slone acknowledges that Lloyd was seeking to hold her

liable for two discrete events: 1) allowing the needle to become separated from the

                                         -18-
needle holder and land within the surgical field and 2) failing to find the needle and

remove it before the surgery was concluded. Slone argued successfully below that

neither of those theories could be presented to the jury in the absence of expert

proof. However, we do not read our caselaw that restrictively. The doctrine of res

ipsa loquitur recognizes that as a matter of common knowledge and experience the

very nature of an occurrence may justify an inference of negligence on the part of

the person who controls the instrumentality causing the injury. See id.

             Whether a jury would assess liability or whether the case would

survive a directed verdict remains to be seen. Slone’s disclosures indicated that

her expert witness would testify that she acted appropriately in response to this

event, and that she did not have the authority to reopen without the express order

from Dr. Griffin. Slone’s argument on appeal is that, as a surgical assistant, she

was limited to what she could do upon discovery of the missing needle. While

those may be valid defenses before a jury, the inference is not defeated by those

facts as a matter of law.

             The final requirement for res ipsa loquitur to apply is causation, i.e.,

that “[t]he plaintiff’s injury must have resulted from the accident.” Cox v. Wilson,

267 S.W.2d 83, 84 (Ky. 1954). That, too, is present here. Although the doctrine is

inapplicable “where more than one inference can be drawn from the evidence as to

the cause of the injury,” we find no alternative causes here. See Schroerlucke v.

                                         -19-
McDaniel Funeral Home, Inc., 291 S.W.2d 6, 8 (Ky. 1956) (citation omitted).

Here, the record does not indicate any cause for Lloyd’s complications or

subsequent revision surgery other than the suture needle remaining in her knee.

             In Arnsperger, 2024 WL 316434, at *2, a patient being wheeled

through a medical facility by hospital staff was purportedly knocked against a

registration desk. This “collision” allegedly displaced surgical hardware and

required further surgery on the patient’s ankle, which had recently been operated

on. Id. There was no expert testimony to the effect that this “collision” caused the

displacement of the hardware. Id. Because the trial court determined testimony on

causation was required and the patient failed to provide any, it granted summary

judgment. Id. at *3. This Court reversed the trial court based on the belief that the

patient’s injuries did “not require a medical expert to relay to a layperson the

cause-and-effect relationship between the hospital staffer employee’s conduct and

[the patient’s] injury. Id. However, our Supreme Court reinstated the summary

judgment, finding that “[t]he instrumentality which caused the injury [was]

disputed, thus, that the injury was caused by the desk collision [was] disputed.” Id.

at *5. There, the Supreme Court noted that the patient had a complex medical

history involving the injured ankle and had complications during his most recent

surgery; therefore, the issue was whether the act of pushing the patient into the

desk caused his claimed injuries. Id. at *2. The Supreme Court found that the

                                         -20-
causation of the injury under such circumstances was “beyond the common

knowledge of the jury.” Id. at *5. Further, the patient had undergone a surgery on

the same ankle only days before the “collision,” and the successful outcome of that

surgery was still in question at that time. Id.

             In contrast, here, there was no dispute that the needle was left in

Lloyd’s body during her knee replacement surgery. Additionally, there was no

dispute that her subsequent medical treatment was caused by the retained foreign

object. As such, the record indicates that Lloyd’s injury – and subsequent

surgery – resulted from the “accident,” i.e., the needle being left in her knee. See

Cox, 267 S.W.2d at 84.

             We also distinguish Ashland Hospital Corporation v. Lewis, 581

S.W.3d 572, 578-79 (Ky. 2019), where our Supreme Court held that res ipsa

loquitur could not be used to establish causation against a radiologist who had

failed to diagnose a stroke following a cerebral angiogram. There, the patient

argued the doctrine applied because the necessity of prompt treatment for strokes

was a matter of common knowledge. Id. at 578. The Supreme Court disagreed,

concluding that “increased public awareness and knowledge about stroke

symptoms and timely intervention . . . cannot provide the medical expertise

necessary to evaluate this particular claim of medical malpractice.” Id. at 578-79.

Moreover, there were issues as to whether the failure to timely diagnose a stroke

                                         -21-
caused an injury other than that which would have resulted from the stroke itself.

Id. at 575.

              In contrast, here there was no dispute as to causation, and improperly

leaving a surgical instrument in the body, as was done here, is a matter of common

knowledge appropriate for res ipsa loquitur application. As our Supreme Court

held in Nazar, “[u]nder this standard, juries may – but are not required to – infer

negligence from the fact that a surgical item was left in a patient’s body.” Nazar,

291 S.W.3d at 603. Namely, there is a genuine issue of material fact.

              As these recent Supreme Court cases illustrate, the Court has warned

against efforts to expand the res ipsa loquitor exception and to virtually eliminate

the need for expert opinion evidence in medical malpractice actions. See Ashland

Hospital, 581 S.W.3d at 579 (citation omitted) (acknowledging “Kentucky’s long-

standing practice of requiring expert opinion evidence in medical malpractice

actions to assist the finder-of-fact”; see also Arnsperger, 2024 WL 316434, at *4

(citation omitted) (“[I]t is not the first time in recent history this Court has felt the

need to check an unwarranted expansion of res ipsa loquitur for questions of

causation in the medical context.”)).

              However, our ruling here does not expand the doctrine, but rather

recognizes that this is the very type of case upon which the doctrine’s foundational

principles are based. The res ipsa loquitur inference applies and as such, Lloyd

                                           -22-
was entitled to proceed beyond summary judgment without expert testimony

critical of Slone.

             C. Summary Judgment in Favor of Norton

             The same cannot be said, however, as to the judgment in favor of

Norton. All agree that the only relevant employee of Norton in issue was the

circulating nurse. Norton’s nurse charted the incorrect instrument count and the

search efforts for the needle. She also recorded that Dr. Griffin ordered, read, and

cleared an x-ray. The disclosures by Lloyd required by April 1, 2022 did not list

any nursing experts who would provide testimony or indicate any criticism as to

Norton’s staff. For their disclosures, Norton indicated that their experts would

testify that the staff appropriately performed their duties, including documenting

the incorrect count during the skin closure, performing an appropriate search for

the needle, obtaining imaging per physician’s order, and relaying information

about the missing needle.

             Further, there was no evidence that Norton’s nurse was in control of

the suture needle that remained lodged within Lloyd’s knee. If there was any

failure on the part of Norton, Lloyd did not allege that Norton staff created or

contributed to the presence of the retained object or the subsequent complications.

Neither control of the instrumentality nor causation was ever established as to

Norton. Also, other evidence of record did not provide even circumstantial

                                         -23-
evidence by which a jury could infer negligence. Hausladen, 828 S.W.2d at 656

(citation omitted). Thus, to proceed beyond summary judgment, against Norton,

expert testimony was required. Lloyd’s counsel has admitted they failed to timely

disclose any expert critical of Norton.

             Lloyd argues though that Norton produced evidence regarding its

protocol or internal policies on handling of an improper needle count. Then, in the

deposition of Dr. Dysart, he relied upon those policies to criticize Norton. The trial

court excluded that portion of his testimony because the Rule 26 disclosures had

not indicated that any expert would be critical of Norton or its nurse. We have

already addressed the trial court’s evidentiary ruling and found that there was no

abuse of discretion.

             Moreover, Lloyd cannot simply rely upon the hospital’s policy

without expert testimony, to establish the standard of care. Our Supreme Court has

“previously held that a hospital’s internal policies and procedures, in and of

themselves, do not establish the standard of care.” Ky. Guardianship Adm’r, LLC

v. Baptist Healthcare Sys., Inc., 635 S.W.3d 14, 37 (Ky. 2021) (citing Lake

Cumberland Reg’l Hosp., LLC v. Adams, 536 S.W.3d 683, 696 (Ky. 2017)).

Without admissible testimony establishing a breach of the standard of care and

causation, and without applicability of res ipsa loquitur, Lloyd failed to prove her

theory that Norton, by some unknown action of its nurse, violated its duty to her.

                                          -24-
Therefore, there is no genuine issue of material fact regarding Norton, and the trial

court properly granted summary judgment.

              For the foregoing reasons, the summary judgments in favor of Slone

and in favor of the Radiologists are REVERSED AND REMANDED for further

proceedings consistent with this Opinion; and the judgment in favor of Norton is

AFFIRMED.

             ALL CONCUR.

                                        -25-
BRIEFS FOR APPELLANT:     BRIEF FOR APPELLEE
                          DIAGNOSTIC X-RAY
Richard P. Schiller       PHYSICIANS, P.S.C.,
Louisville, Kentucky      CHRISTOPHER DALE HENLEY,
                          M.D., AND DARREN L. CAIN,
                          M.D.:

                          Craig L. Johnson
                          Robert L. Whitmer
                          Louisville, Kentucky

                          BRIEF FOR APPELLEE
                          SHEILA SLONE:

                          Edward H. Stopher
                          Charles H. Stopher
                          Louisville, Kentucky

                          BRIEF FOR APPELLEE
                          NORTON HOSPITALS, INC. D/B/A
                          NORTON’S WOMEN’S AND
                          CHILDREN’S HOSPITAL:

                          Karen L. Keith
                          Virginia Leigh Schell
                          Louisville, Kentucky

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