Court Opinion

ID: 9958564
Source: CourtListenerOpinion
Date Created: 2024-04-09 16:12:12.87706+00
Date Added: 2024-06-11T08:18:29.151759
License: Public Domain

J-A03032-24

                             2024 PA Super 68

 LESLIE NIGON, INDIVIDALLY AND AS :         IN THE SUPERIOR COURT OF
 ADMINISTRATRIX OF THE ESTATE OF :               PENNSYLVANIA
 THOMAS A. NIGON, DECEASED        :
                                  :
                 Appellant        :
                                  :
            v.                    :
                                  :
                                  :         No. 671 WDA 2023
 BRIAN F. JEWELL, M.D.; TRI-STATE :
 ORTHOPAEDICS AND SPORTS          :
 MEDICINE, INC; UPMC PASSAVANT;   :
 UPMC; THOMAS J. MALVAR, M.D.,    :
 INDIVIDUALLY AND AS GENERAL      :
 PARTNER/MEMBER OF THE MEDICAL :
 PRACTICE GENERALLY KNOWN AS      :
 AND D/B/A MALVAR AND             :
 ASSOCIATES A/K/A MALVAR          :
 ASSOCIATES A/K/A DOCTOR MALVER :
 AND ASSOCIATE; MARITONI          :
 MALVAR, M.D., INDIVIDUALLY AND   :
 AS A GENERAL PARTNER/MEMBER OF :
 THE GENERALLY KNOWN AS AND       :
 D/B/A MALVAR AND ASSOCIATE       :
 A/K/A MALVAR ASSOCIATES A/K/A    :
 DOCTOR MALVAR AND ASSOCIATE;     :
 MALVAR & ASSOCIATES A/K/A        :
 DOCTOR MALVAR AND ASSOCIATE      :
                                  :

                 Appeal from the Order Entered June 7, 2023
              In the Court of Common Pleas of Lawrence County
                       Civil Division at No. 2019-30009

BEFORE: BOWES, J., KUNSELMAN, J., and MURRAY, J.

OPINION BY MURRAY, J.:                      FILED: April 9, 2024

     Leslie Nigon, individually and as administratrix of the Estate of Thomas

A. Nigon, deceased (the estate), appeals from the entry of summary judgment
J-A03032-24

in favor of Thomas J. Malvar, M.D., individually and as a general partner of

Malvar & Associates;1 Maritoni Malvar, M.D., individually and as a general

partner of Malvar & Associates; and Malvar & Associates (sometimes referred

to as the practice) (collectively, the Malvar Defendants), which effectively

dismissed all claims against the Malvar Defendants in this medical malpractice

action.2 We reverse and remand.

       The trial court explained:

              Thomas A. Nigon was first seen by Dr. Thomas J. Malvar[,
       his primary care physician,] relative to a blood clotting issue on or
       about September 13, 2017, at which time Dr. [Thomas] Malvar
       prescribed Eliquis, a blood thinner and anticoagulant.

             On January 25, 2018, Mr. Nigon underwent an ultrasound
       of his right [leg] which showed the prior [deep vein thrombosis
       (DVT)] had resolved with medication, and as a result, Dr. Malvar
       ordered a discontinuance of the Eliquis prescription.

            From January 25, 2018[,] until April 26, 2019, Mr. Nigon
       had no medical issues and sought no medical treatment.

              On April 26, 2019, Mr. Nigon, age 54, fell down the steps at
       his home and suffered a leg injury. After the fall, Mr. Nigon
       presented himself to the emergency room at UPMC Jameson
       relative to complaints of the left leg injury and concerns about a
       DVT. Mr. Nigon was told by the medical staff at UPMC Jameson
       that he did not have a DVT, and he was instructed to follow[ ]up
       with an orthopedic surgeon of his choice for his left leg injury.
____________________________________________

1 Malvar & Associates is also known as Malvar Associates and Dr. Malvar and

Associates.

2 This order was made final by the trial court’s June 7, 2023, order approving

a joint tort settlement with respect to the remaining named defendants.
Loftus v. Decker, 289 A.3d 1093, 1097 (Pa. Super. 2023) (“A final order is
any order that disposes of all claims and of all parties.”) (citing Pa.R.A.P.
341(b)(1) (brackets omitted)).

                                           -2-
J-A03032-24

              Mr. Nigon scheduled an appointment with [] Brian F. Jewell,
       M.D., an orthopedic surgeon with [] Tri-State Orthopaedics &
       Sports Medicine, Inc. [(Tri-State)], for his left leg injury on May
       1, 2019, at which time he was evaluated by [] Dr. Jewell, and his
       physician’s assistant …, diagnosed with a high-grade tear of the
       left quadriceps, and was advised that he needed surgery.

             At the May 1, 2019[,] office visit with [] Dr. Jewell, Mr. Nigon
       advised [] Dr. Jewell[] of his history of blood clots.

             Mr. Nigon was instructed to seek standard pre-operative
       clearance from … Dr. Thomas Malvar. Mr. Nigon met with Dr.
       Thomas Malvar on May 6, 2019, at which time, despite [] Dr.
       Thomas Malvar being aware of Mr. Nigon’s history of DVT, no
       mention was made of his need for thromboprophylactic
       medication, and there was no discussion with Mr. Nigon relative
       to his increased risk of deadly blood clots affiliated with the
       pending surgery. [] Dr. Thomas Malvar[] cleared Mr. Nigon for
       surgery, without mentioning the blood clotting issue.

             On May 9, 2019, Mr. Nigon was admitted to UPMC Passavant
       Hospital, at which time he underwent a surgical left quadricep
       tendon repair, performed by Dr. Jewell. [] UPMC Passavant’s
       chart from Mr. Nigon’s surgery states that Mr. Nigon required
       “Xarelto post-opt”[3] [sic] which was also acknowledged by Dr.
       Jewell as part of the documentation at Tri-State….

            After the surgery, Mrs. Nigon was provided with patient
       education per [Dr.] Jewell’s request, which alleged[ly] excluded
       any reference to risk of clots and made no mention of
       thromboprophyla[xis].

            Mr. Nigon was discharged from UPMC Passavant the same
       day as his surgery. The discharge was handled by [a registered
       nurse], at which time[, the estate] alleges [,Mr. Nigon] was
       without a prescription for any thromboprophylactic[] medication.
____________________________________________

3 Xarelto is a prescription medication used, in part, to treat and reduce the

risk of blood clots. See XARELTO, https://www.xarelto-us.com (last visited
Feb. 1, 2024); see also Dr. Jewell’s Brief in Support of Motion for Summary
Judgment, 8/23/21, Exhibit D (Deposition of Dr. Jewell), at 63-64 (discussing
the use of Xarelto as an anticoagulant in this case).

                                           -3-
J-A03032-24

             [The estate’s] complaint alleges that Mr. Nigon’s discharge
       instructions included the pack of information which [] Dr. Jewell[]
       told Mrs. Nigon would include “everything needed”, but did not
       include a prescription for Xarelto, and made no reference to
       thromboprophyla[xis] or the risk of clots.

              On May 14, 2019, Mr. Nigon was at home alone, recovering
       from the surgery. Mrs. Nigon was at work, where she received a
       call from her husband at approximately 9:00 a.m. informing her
       that her husband was in trouble. Mrs. Nigon rushed home and
       called an ambulance … Unfortunately, Mr. Nigon passed away
       from a massive bi-lateral pulmonary emboli[sm] cause[d] by
       [DVT] of his left lower extremity before the medical technicians
       could get Mr. Nigon to the local hospital.

Trial Court Opinion and Order, 11/3/21, at 7-9 (footnote added).

       On August 28, 2019, the estate filed a complaint against the Malvar

Defendants.4 Concerning Dr. Thomas Malvar, the estate asserted causes of

action in medical negligence (survival and wrongful death) and lack of

informed consent (survival and wrongful death). Against Dr. Maritoni Malvar,

a general partner of the practice,5 the estate alleged survival and wrongful

____________________________________________

4 The complaint also named as defendants Dr. Jewell, Tri-State, UPMC
Passavant, UPMC, and Enclave Cryotherapy, LLC. Enclave Cryotherapy, LLC,
was removed from the action after the trial court sustained its preliminary
objections in the nature of a demurrer. The remaining defendants are not
parties to the instant appeal. For simplicity, we limit our recitation of the
procedural history to the Malvar Defendants.

5 Dr. Maritoni Malvar’s status as a general partner in Malvar & Associates is

not in dispute. See Plaintiff’s Response in Opposition to Dr. Maritoni Malvar’s
Motion for Summary Judgment, 10/14/21, Exhibit A (Dr. Malvar’s Responses
to Plaintiff’s First Request for Admission), Exhibit B (Partnership Agreement),
Exhibit C (Deposition of Dr. Thomas Malvar). We further note that although
the estate named Dr. Maritoni Malvar as a defendant both individually and in
(Footnote Continued Next Page)

                                           -4-
J-A03032-24

death causes of action based on a theory of vicarious liability. As to Malvar &

Associates, the estate asserted survival and wrongful death claims based on

vicarious liability. Further, the estate asserted a claim for negligent infliction

of emotional distress (NIED) against all named defendants. The estate sought

both compensatory and punitive damages.

       The Malvar Defendants filed preliminary objections in the nature of a

demurrer.6 Dr. Maritoni Malvar also filed an affidavit of non-involvement and

a related motion to dismiss, arguing she had neither provided medical care to

Mr. Nigon nor acted in a supervisory capacity to a treating physician. 7 In a

____________________________________________

her capacity as general partner, the causes of action in the complaint advance
only a theory of vicarious liability.

6 In part, Dr. Thomas Malvar argued he was not required to obtain Mr. Nigon’s

informed consent for pre-operative clearance, as it is not a “procedure” under
Section 504 of the Medical Care Availability and Reduction of Error (MCARE)
Act. Preliminary Objections, 8/13/19, ¶¶ 17-30 (citing 40 P.S. § 1303.504
(concerning informed consent)). The estate did not contest Dr. Thomas
Malvar’s preliminary objection to the informed consent counts. Response,
9/26/19, ¶¶ 17-30. In its March 5, 2020, order, the trial court sustained all
uncontested preliminary objections. Order, 3/5/20, at 3.

7 Section 506 of the MCARE Act provides:

       (a) General provisions.--Any health care provider named as a
       defendant in a medical professional liability action may cause the
       action against that provider to be dismissed upon the filing of an
       affidavit of noninvolvement with the court. The affidavit of
       noninvolvement shall set forth with particularity the facts which
       demonstrate that the provider was misidentified or otherwise not
       involved, individually or through its servant or employees, in the
       care and treatment of the claimant and was not obligated, either
(Footnote Continued Next Page)

                                           -5-
J-A03032-24

March 5, 2020, order, the trial court overruled Dr. Maritoni Malvar’s

preliminary objections and denied her motion to dismiss, citing her potential

vicarious liability as a general partner in the practice. The Malvar Defendants

filed an answer and new matter.

       On April 27, 2021, the estate filed a second amended complaint. As to

its survival action against Dr. Thomas Malvar, the estate alleged:

       100. The injuries and damages set forth above were caused by
       the negligent, careless, and reckless acts of [Dr.] Thomas Malvar,
       including, but not limited to, the following:

          a. Failing to adequately evaluate [Mr. Nigon’s] condition
          and/or problem;

          b. Failing to recognize that [Mr. Nigon] was at an increased risk
          of DVT and PE;

          c. Failing to prophylactically recommend or prescribe any
          medication, treatment, therapy, devices, remedies, and/or any
          monitoring to prevent thrombosis;

          d. Unreasonably clearing [Mr. Nigon] for a surgery with a
          known risk of DVT and PE, while knowing [Mr. Nigon] had an
          increased risk of DVT and PE, without taking any precautionary
          measures;

          e. Failing to thoroughly review [Mr. Nigon’s] medical history to
          appreciate his recent history of DVT and PE;

          f. Improperly discontinuing [Mr. Nigon’s] usage of Eliquis;

          g. Failing to diagnose the cause of [Mr. Nigon’s] original DVT
          and PE;
____________________________________________

       individually or through its servants or employees, to provide for
       the care and treatment of the claimant.

40 P.S. § 1303.506(a).

                                           -6-
J-A03032-24

        h. Failing to take a proper, thorough, and accurate history
        relating to [Mr. Nigon];

        i. Failing to review his own medical records which outline [Mr.
        Nigon’s] recent history of DVT and PE;

        j. Failing to properly prevent DVT and PE;

        k. Failing to conduct a thorough examination of [Mr. Nigon]
        prior to clearing him for surgery; and

        l. Failing to exercise reasonable care and diligence in the
        application of knowledge and skill to [Mr. Nigon].

     101. [Dr. Thomas Malvar] undertook and assumed a duty to [Mr.
     Nigon] to render prompt, proper, adequate, and appropriate
     medical care. [Dr. Thomas Malvar] also undertook and assumed
     a duty to [Mr. Nigon] to take appropriate measures to improve his
     condition and to avoid harm, which was breached as referred to
     above.

     102. [Dr.] Thomas Malvar’s careless, negligent, and reckless
     breaches of the standard of care were the direct and proximate
     cause of [Mr. Nigon’s] DVT, PE, and subsequent death.

Second Amended Complaint, 4/27/21, ¶¶ 100-02 (some capitalization

modified). The estate incorporated the above allegations by reference in its

wrongful death action against Dr. Thomas Malvar. Id., ¶ 105. The Malvar

Defendants filed an answer and new matter to the second amended complaint.

     The parties engaged in extensive discovery, which included requests for

admissions, depositions, and submission of expert reports. Relevant to this

appeal, the estate submitted expert reports prepared by Eric Coris, M.D. (a

family medicine expert), and John Ludgin, M.D., Esquire (an expert in root

cause analysis). Dr. Coris explained that although Dr. Thomas Malvar ordered

                                   -7-
J-A03032-24

some testing following Mr. Nigon’s DVT in 2017, he did not order certain other

“standard” tests.    Estate’s Motion for Summary Judgment on Comparative

Fault, 8/24/21, Exhibit D (Expert Report by Dr. Coris), at 2. Dr. Coris indicated

that discovery of Mr. Nigon’s prothrombin gene mutation “would have

warranted lifetime coagulation to protect from future blood clots.” Id. at 3.

Dr. Coris opined that Dr. Thomas Malvar deviated from the standard care in

his treatment of Mr. Nigon’s 2017 DVT and in relation to the 2019 surgical

clearance visit. See id. at 3-4 (detailing specific failures to show deviation

from the standard of care).        Importantly, Dr. Coris opined that these

deviations from the standard of care “directly caused Mr. Nigon’s death.” Id.

at 5.    Dr. Coris also stated that he rendered his opinions to a reasonable

degree of medical certainty. Id.

        Dr. Ludgin attributed “the multitude of system failures that led to [Mr.]

Nigon’s discharge … without anticoagulation therapy”, causing him to die five

days later, “to each of the defendants and the defendants as a whole.” Id.,

Exhibit B (Expert Report of Dr. Ludgin), at 11. Dr. Ludgin opined that Dr.

Thomas Malvar deviated from the standard of care by failing to adequately

communicate Mr. Nigon’s history of DVT and emphasize the need for post-

operative anticoagulation therapy. Id. at 10. Dr. Ludgin offered his opinions

“to a reasonable degree of medical-administrative certainty….” Id. at 9.

        On August 17, 2021, the Malvar Defendants, both individually and

collectively, filed motions for summary judgment. Dr. Thomas Malvar sought

                                       -8-
J-A03032-24

partial summary judgment on the issue of punitive damages. Dr. Thomas

Malvar also filed a separate motion for summary judgment concerning the

medical negligence claims. He argued there was no causal link between his

conduct and Mr. Nigon’s death, and that Dr. Jewell was aware of Mr. Nigon’s

need for anticoagulants following surgery.       Dr. Thomas Malvar attached a

portion of Dr. Jewell’s deposition transcript:

      [Malvar Defendants’ Counsel]: Okay. You testified earlier that you
      performed your own [history and physical (H&P)] on Mr. Nigon
      prior to the surgery, correct?

      [Dr. Jewell]: We performed an H&P and placed it on the UPMC
      chart, yes.

      Q: Okay. And you testified that you were aware of Mr. Nigon’s
      history of clotting issues or DVTs prior to the surgery, correct?

      A: I agree.

      Q: And because you were aware of that, you prescribed him the
      Xarelto, correct, as a postoperative course?

      A: I agree.

      Q: So, isn’t it true, then, that regardless of whether Dr. [Thomas]
      Malvar would have identified a DVT as a risk on that medical
      clearance form, you were already aware of that because you
      performed the H&P prior to the surgery?

      A: I do not think that the information on his note or lack thereof
      affected my care in any way directly.

                                      -9-
J-A03032-24

Dr. Thomas Malvar’s Brief in Support of Summary Judgment, 8/17/21, Exhibit

E (Deposition of Dr. Jewell), at 113-14.8

       Additionally, Dr. Maritoni Malvar filed a motion for summary judgment,

citing her original affidavit of noninvolvement. The Malvar Defendants filed a

motion for partial summary judgment as to the NIED claim and request for

punitive damages. The estate filed responses.

       The trial court heard argument on the motions for summary judgment

and partial summary judgment in October 2021. On November 3, 2021, the

trial court issued an order addressing all motions for summary judgment.

Pertaining to the Malvar Defendants, the trial court 1) granted the Malvar

Defendants’ motion for partial summary judgment as to the NIED and punitive

damage claims; 2) granted Dr. Thomas Malvar’s and the Malvar Defendants’

motions for summary judgment concerning medical negligence; and 3)

granted Dr. Maritoni Malvar’s motion for summary judgment based on her

affidavit of noninvolvement and dismissed her as an individual defendant.9

____________________________________________

8 Dr. Thomas Malvar attached only a portion of Dr. Jewell’s deposition to his

brief in support of summary judgment. The complete transcript is attached
to Dr. Jewell’s brief in support of summary judgment as Exhibit D.

9 The trial court noted its prior denial of Dr. Maritoni Malvar’s motion to dismiss

at the preliminary objections stage, pending discovery. In its order granting
summary judgment, the trial court explained that discovery had been
completed, and the estate did not depose Dr. Maritoni Malvar. Trial Court
Opinion and Order, 11/3/21, at 31.

                                          - 10 -
J-A03032-24

See Trial Court Opinion and Order, 11/3/21, at 38-39. In sum, the trial court

dismissed all claims against the Malvar Defendants.

       The estate filed timely a motion for reconsideration, arguing the trial

court failed to mention the estate’s expert reports or to consider all reports in

a light most favorable to the estate.              See Motion for Reconsideration,

11/16/21. The estate further averred it had established Dr. Maritoni Malvar’s

vicarious liability for Dr. Thomas Malvar’s negligence by virtue of her general

partner status.     The trial court initially granted reconsideration and heard

argument. After argument, the trial court denied reconsideration. See Order,

3/18/22.

       After the remaining defendants reached a settlement,10 which rendered

the summary judgment order final, the estate timely appealed.            Both the

estate and the trial court have complied with Pa.R.A.P. 1925.

       The estate raises two issues for review:

       I. Did the trial court abuse its discretion or err as a matter of law
       in concluding at summary judgment that Dr. Thomas J. Malvar’s
       negligent medical care was not a factual cause of Thomas A.
       Nigon’s death?

       II. Did the trial court err as a matter of law by holding that agency
       law does not apply to physicians who are general partners in a
       general partnership?

Estate’s Brief at 8 (some capitalization modified).

____________________________________________

10 Dr. Jewell, Tri-State, and UPMC Passavant settled the wrongful death and

survival claims. See Order Approving Joint Tort Settlement, 6/7/23.

                                          - 11 -
J-A03032-24

      Our standard of review is well-settled:

      A trial court should grant summary judgment only in cases where
      the record contains no genuine issue of material fact and the
      moving party is entitled to judgment as a matter of law. The
      moving party has the burden to demonstrate the absence of any
      issue of material fact, and the trial court must evaluate all the
      facts and make reasonable inferences in a light most favorable to
      the non-moving party. The trial court is further required to
      resolve any doubts as to the existence of a genuine issue of
      material fact against the moving party and may grant summary
      judgment only where the right to such a judgment is clear and
      free from doubt. … [T]he summary judgment standard that a trial
      court must view the facts, and all reasonable inferences, in a light
      most favorable to the non-moving party clearly includes all expert
      testimony and reports submitted by the non-moving party or
      provided during discovery; and, so long as the conclusions
      contained within those reports are sufficiently supported, the trial
      judge cannot sua sponte assail them in an order and opinion
      granting summary judgment. An appellate court may reverse a
      grant of summary judgment only if the trial court erred in its
      application of the law or abused its discretion.

Bourgeois v. Snow Time, Inc., 242 A.3d 637, 649-50 (Pa. 2020) (internal

citations and quotation marks omitted). “[T]he issue as to whether there are

no genuine issues as to any material fact presents a question of law, and

therefore, on that question our standard of review is de novo.” Summers v.

Certainteed Corp., 997 A.2d 1152, 1159 (Pa. 2010) (citation omitted); see

also Wright v. Misty Mountain Farm, LLC, 125 A.3d 814, 818 (Pa. Super.

2015) (stating “we apply the same standard as the trial court, reviewing all

the evidence of record to determine whether there exists a genuine issue of

material fact.”).

      In its first issue, the estate argues the trial court erred by concluding

that Dr. Thomas Malvar’s conduct was not a factual cause of Mr. Nigon’s death.

                                     - 12 -
J-A03032-24

Estate’s Brief at 23. According to the estate, “[Dr. Thomas] Malvar does not

get a pass simply because Dr. Jewell also failed Mr. Nigon.” Id. at 25. The

estate contends the trial court failed to review its expert reports in the light

most favorable to the estate. See id. at 27-32. The estate claims the experts’

opinions     (i.e.,     that   Dr.    Thomas       Malvar’s   failures   to   provide

thromboprophylaxis and to provide adequate patient education caused Mr.

Nigon’s death) are supported by the factual record. See id. at 32-37.

       Additionally, the estate asserts that Dr. Thomas Malvar provided

negligent care during the initial onset of Mr. Nigon’s DVT in 2017. Id. at 37.

The estate again points to Dr. Coris’s expert opinion that Dr. Thomas Malvar

negligently failed to evaluate Mr. Nigon for hereditary thrombophilia and

prescribe a lifetime anticoagulant medication.11 See id. at 38-41. The estate

claims the trial court failed to consider its expert reports or this theory of

liability. Id. at 41.

       Further, the estate contends that in evaluating Dr. Thomas Malvar’s

summary judgment motion, the trial court ignored a critical fact: Dr. Thomas

Malvar altered Mr. Nigon’s medical chart in the early morning hours on the

day after Mr. Nigon died. Id. at 41. According to the estate, the trial court

usurped a jury function by declining to consider the post-mortem alteration of

____________________________________________

11 The estate does not argue that a life-long prescription for anticoagulation

medication would have prevented the post-operative embolism.

                                          - 13 -
J-A03032-24

medical records. Id. at 43 (citing Pa. SSJI (Civil) § 14.40 (2020) (Alteration

or Destruction of Medical Records)).12

       The Malvar Defendants counter, “Dr. Jewell and his entire staff admitted

full   knowledge     of   Mr.   Nigon’s        medical   history   and   the   need   for

anticoagulation.”     Appellees’ Brief at 7.        The Malvar Defendants claim Dr.

Jewell’s admissions severed any potential causal connection between Dr.

Thomas Malvar’s care and Mr. Nigon’s death. Id. at 7, 9. Further, the Malvar

Defendants assert the estate’s expert opinions directly contradict the

established facts. Id. at 11.

       “Medical malpractice can be broadly defined as the unwarranted

departure from generally accepted standards of medical practice resulting in

injury to a patient….” Toogood v. Owen J. Rogal, D.D.S., P.C., 824 A.2d

1140, 1145 (Pa. 2003). To establish a prima facie case of medical negligence,

a plaintiff must demonstrate

       a duty owed by the physician, that the breach was the proximate
       cause of the harm suffered, and the damages were a direct result
       of harm. With all but the most self-evident medical malpractice
       actions[,] there is also the added requirement that the plaintiff
       must provide a medical expert who will testify as to the elements
       of duty, breach, and causation.

Vazquez v. CHS Prof’l Practice, P.C., 39 A.3d 395, 397-98 (Pa. Super.

2012) (citations and quotation marks omitted); see also Krishack v. Milton

____________________________________________

12 The estate does not identify the alterations Dr. Thomas Malvar purportedly

made to Mr. Nigon’s medical chart.

                                          - 14 -
J-A03032-24

Hershey School, 145 A.3d 762, 765 (Pa. Super. 2016) (“Even with proof of

both breach of duty as prescribed under statute and the occurrence of injury,

… plaintiffs are still obligated to show the two were linked by causation.”

(citation omitted)).13

       “To show causation, the plaintiff must show that the defendant

physician’s failure to exercise the proper standard of care caused the plaintiff’s

injury.” Mazzie v. Lehigh Valley Hosp. – Muhlenberg, 257 A.3d 80, 87

(Pa. Super. 2021) (citation, quotation marks, and brackets omitted).

Generally, a plaintiff in a medical negligence action must present expert

testimony to establish the physician’s deviation from the standard of care

“proximately caused the plaintiff’s injury.” Grossman v. Barke, 868 A.2d

561, 566-67 (Pa. Super. 2005) (citation omitted).

       Further,

       [a] plaintiff cannot survive summary judgment when mere
       speculation would be required for the jury to find in plaintiff’s
       favor. A jury is not permitted to find that it was a defendant’s
       negligence that caused the plaintiff’s injury based solely upon
       speculation and conjecture; there must be evidence upon which
       logically its conclusion must be based. In fact, the trial court has
       a duty to prevent questions from going to the jury which would
       require it to reach a verdict based on conjecture, surmise, guess
       or speculation. Additionally, a party is not entitled to an inference
       of fact that amounts merely to a guess or conjecture.

Krishack, 145 A.3d at 766 (citation omitted).

____________________________________________

13 The estate does not set forth the elements of a medical negligence cause of

action in its brief. However, it is clear from the estate’s argument that it
challenges the causation requirement.

                                          - 15 -
J-A03032-24

       Instantly, the trial court determined the factual record provided no

evidence supporting the estate’s allegation of a causal connection between Dr.

Thomas Malvar’s conduct (i.e., failing to 1) educate Mr. Nigon and his wife

concerning DVT-PE;14 2) prescribe thromboprophylactic medication; and 3)

treat DVT-PE as a genetic disorder) and Mr. Nigon’s death.           Trial Court

Opinion, 3/18/22, at 3 (unnumbered). The trial court relied on Dr. Jewell’s

deposition testimony that he was aware of Mr. Nigon’s DVT-PE history and the

need for post-operative thromboprophylactic medication:

             As to the alleged failure to educate [Mr. Nigon] and his wife,
       the record in this case clearly establishes that Dr. Jewell and his
       staff met with [Mr. Nigon] and his wife prior to surgery, clearly
       discussed the need for anti-coagulation medication at the time of
       the surgery, and that such medication was in fact prescribed by
       Dr. Jewell following completion of the surgery[.] … [Mr. Nigon]
       was discharged following surgery with the prescriptions for not
       only [] pain medicine, but also the anti-coagulation medicine,
       which somehow, due to a failure and breakdown in some portion
       of the system, was apparently not provided to [Mr. Nigon].

       ….

             [The estate] has not produced any evidence whatsoever
       that there was any direct, unsevered relationship by and between
       any conduct of [Dr. Thomas Malvar] and the death of [Mr. Nigon].
       To the contrary, the uncontroverted evidence clearly is that Dr.
       Jewell was aware of [Mr. Nigon’s] past history of medication for
       the DVT-PE, and the need for anti-coagulation medicine following
       conclusion of the surgery.

____________________________________________

14 The term “DVT-PE” encompasses both deep vein thrombosis and pulmonary

embolism.

                                          - 16 -
J-A03032-24

Id. at 3-4 (unnumbered).15

       In its Rule 1925(a) opinion, the trial court reiterated its determination

that there was no causal connection between the Malvar Defendants’ conduct

and the DVT resulting in Mr. Nigon’s death after surgery.          Rule 1925(a)

Opinion, 7/25/23, at 3 (unnumbered).

             The record in this case is clear that [Mr. Nigon] and his wife
       met with Dr. Jewell and his staff prior to surgery, clearly
       discussing the need for anti-coagulate medication following
       surgery, and that such medication was in fact prescribed by Dr.
       Jewell following completion of the surgery. It was a tragic
       breakdown in the entry of that information upon the medical
       records system of … UPMC Passavant, which caused the death of
       Mr. Nigon.

              The contact of Dr. Thomas Malvar with [Mr. Nigon] was that
       of a [primary] care physician clearing [Mr. Nigon] for surgery. Dr.
       [Thomas] Malvar had no further contact whatsoever with [Mr.
       Nigon], nor did Dr. [Thomas] Malvar have any authority
       whatsoever to intervene in the performance of the surgery … by
       Dr. Jewell at the UPMC Passavant Hospital.

Id. (unnumbered). The trial court determined that regardless of any action

or inaction by Dr. Thomas Malvar, Dr. Jewell was aware of Mr. Nigon’s health

history and need for post-operative anticoagulation medication; hence, any

negligence by Dr. Thomas Malvar was completely severed by Dr. Jewell’s

involvement.

____________________________________________

15 Regarding Dr. Thomas Malvar’s failure to treat DVT-PE as a genetic disorder

requiring lifelong medication, the trial court stated, “the record is clear that
prior to surgery, [Mr. Nigon] was in good health for a [] period of time, and
was not in need of the anti-coagulation medication.” Trial Court Opinion,
3/18/22, at 3 (unnumbered).

                                          - 17 -
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      After careful review, and mindful of our standard of review, we disagree

with the trial court’s assessment that Dr. Thomas Malvar was entitled to

judgment as a matter of law. Instead, we conclude the estate raised a genuine

issue of material fact concerning Dr. Thomas Malvar’s liability.

      The estate submitted two expert reports in support of its medical

negligence claim against Dr. Thomas Malvar. Dr. Coris, the estate’s family

medicine expert, explained that Dr. Thomas Malvar had been Mr. Nigon’s

primary care provider since at least 2016.       Estate’s Motion for Summary

Judgment on Comparative Fault, 8/24/21, Exhibit D (Expert Report of Dr.

Coris), at 1. Dr. Coris stated that Dr. Thomas Malvar had ordered some blood

testing when Mr. Nigon presented with the DVT in September 2017. Id. at 2.

However, Dr. Thomas Malvar “did not obtain labs for: Prothrombin gene

mutation, anti-thrombin III, MHTFR mutation, or homocysteine. All of these

are standard tests that must be ordered with new onset of [venous

thromboembolism (VTE)].” Id. (emphasis added). Regarding Dr. Thomas

Malvar’s failure to order this subset of tests, Dr. Coris stated:

      Mr. Nigon’s children have been tested and are positive for the
      prothrombin gene mutation. Prothrombin gene mutations are the
      third leading cause of thrombophilia … and are present in
      approximately 2-4% of Caucasians. Mrs. Nigon was also tested
      for prothrombin gene mutations and her test results were
      negative. This indicates that Mr. Nigon would have passed on
      the mutation to his children and was positive for a prothrombin
      gene mutation. Inexcusably, a prothrombin gene mutation was
      not tested for during Mr. Nigon’s evaluation for his DVT and PE. A
      mutation of the prothrombin gene, if properly tested for and
      identified, would have warranted lifetime anticoagulation to
      protect from future blood clots.

                                     - 18 -
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Id. at 3 (emphasis added). Dr. Coris opined that Dr. Thomas Malvar deviated

from the standard of care during his initial treatment of Mr. Nigon’s 2017 DVT-

PE by:

      •     Failing to conduct a thorough history, failing to appropriately
            follow up, failing to conduct a full physical exam, and failing to
            document the cause of Mr. Nigon’s new onset VTE;

      •     Failing to conduct a thorough and appropriate hematologic
            evaluation for thrombophilia when faced with Mr. Nigon’s new
            onset, unprovoked VTE;

      •     If Dr. [Thomas] Malvar was uncomfortable handling and caring
            for Mr. Nigon’s new onset VTE, he deviated from the
            appropriate standard of care by failing to consult with or refer
            Mr. Nigon to a hematology specialist;

      •     Failing to test Mr. Nigon for known and common hereditary
            thrombophilia diseases, including, but not limited to, a
            mutation of the prothrombin gene, which Mr. Nigon had—as
            evidenced by his family’s blood results;

      •     Improperly conducting the limited coagulopathies that Mr.
            Nigon did undergo, as they were conducted during acute VTE
            and done while Mr. Nigon was on anticoagulation medication;

      •     Failing to provide and/or document any follow up care for Mr.
            Nigon’s VTE after January of 2018; and

      •     Failure to provide appropriate patient education on VTE, a life-
            threatening condition. Dr. [Thomas] Malvar at no time had a
            discussion of future risk of VTE with initial evaluation and
            treatment, and at no time discussed the future settings of
            increased risk (i.e. surgery) that Mr. Nigon faced.

Id. at 4.

      Dr. Coris also evaluated Dr. Thomas Malvar’s treatment of Mr. Nigon

during his pre-operative visit. Dr. Thomas Malvar noted “no medical issues”

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surrounding Mr. Nigon’s surgery, and he did not discuss with Mr. Nigon the

risk of DVT-PE following orthopedic surgery with subsequent immobilization.

Id. at 2.     Dr. Coris opined that Dr. Thomas Malvar deviated from the

acceptable standard of care by:

      •   Conducting a pre-operative evaluation that was severely
          devoid of content;

      •   Failing to do any risk assessment for VTE prior to clearing a
          patient for an orthopedic surgery with a known increased risk
          of VTE;

      •   Ignoring and not taking into account [Mr. Nigon’s] previous
          medical history and risks affiliated with medical history;

      •   Failing to mention prior VTE while clearing [Mr. Nigon] for an
          orthopedic surgery with an increased risk of VTE;

      •   Failing to appreciate the increased risk of VTE affiliated with
          Mr. Nigon’s orthopedic surgery;

      •   Failing to appreciate the increased risk of VTE Mr. Nigon faced
          because of his history of VTE;

      •   Inaccurately stating “There are no medical concerns” in
          clearance for orthopedic surgery;

      •   No discussion of peri-operative anticoagulation or increased
          risk of VTE with [Mr. or Mrs. Nigon];

      •   Failed to appropriately review Mr. Nigon’s medical records and
          medical history—which show a history of DVT and PE—prior to
          clearing him for surgery; and

      •   Failure to coordinate with orthopedic surgeon to ensure Mr.
          Nigon, who clearly needed anticoagulation in conjunction with
          his pending orthopedic surgery, received the needed
          anticoagulants.

Id. at 4-5.

                                    - 20 -
J-A03032-24

      In sum, Dr. Coris offered the following opinion to a reasonable degree

of medical certainty:

      [I]t is my opinion that the deviations in the standard of
      care by Dr. [Thomas] Malvar … directly caused Mr. Nigon’s
      death. Moreover, the failures of Mr. Nigon’s entire medical team
      in conjunction with his May 9, 2019 orthopedic surgery … directly
      caused Mr. Nigon’s death.       VTE post operatively is largely
      preventable with appropriate thromboprophylactic care and risk
      assessment. Mr. Nigon was not provided any thromboprophylaxis
      and was not provided any patient education on the subject. The
      failure to provide Mr. Nigon the appropriate thromboprophylaxis
      and patient education directly caused his death, and pain and
      suffering he endured prior to his death, on May 14, 2019.
      Additionally, had Dr. [Thomas] Malvar provided Mr. Nigon with a
      proper work up for hereditary thrombophilia upon the initial onset
      of VTE in 2017, Mr. Nigon would have been prescribed lifetime
      anticoagulation, which would have prevented his untimely death.

Id. at 5 (emphasis added).

      Additionally, the estate submitted an expert report authored by Dr.

Ludgin, a root cause analysis expert. According to Dr. Ludgin, “[n]umerous

system failures” led to Mr. Nigon’s discharge following surgery without a

prescription for anticoagulation medication. See Estate’s Motion for Summary

Judgment on Comparative Fault, 8/24/21, Exhibit T (Expert Report by Dr.

Ludgin), at 6-7. Concerning the estate’s claim against Dr. Thomas Malvar,

Dr. Ludgin explained that Dr. Thomas Malvar was aware of Mr. Nigon’s history

of DVT-PE, and knew or should have known Mr. Nigon would need

anticoagulation medication following surgery.    See id. at 7.    Dr. Ludgin

rendered the following opinion, to a reasonable degree of medical certainty:

      3. Dr. [Thomas] Malvar, as the physician with direct knowledge
      and experience from Mr. Nigon’s 2017 episode of DVT/PE, fell

                                    - 21 -
J-A03032-24

       below the accepted standard of care in his own office by
       possessing all the information and yet failing to incorporate the
       context of Mr. Nigon’s health history in his pre-op clearance … and
       the completion and transmission of those documents[,] together
       with the material facts (DVT/PE and the need for post-op
       anticoagulation) needed to ensure safe care for Mr. Nigon. Dr.
       [Thomas] Malvar also failed to highlight the need for post-op
       anticoagulation. The communication from Dr. [Thomas] Malvar
       and his office of the information in its files was a miserable failure.

          a. As a direct and proximate result, communication and further
          emphasis of Mr. Nigon’s 2017 pulmonary embolus and the need
          for post-op anticoagulation from the physician who [k]new (or
          should have known him best) was lost entirely. In addition,
          Dr. [Thomas] Malvar failed to communicate with Tri-State on
          Mr. Nigon’s post-op medical needs and failed to determine
          which office and which physician would take responsib[ility] for
          managing Mr. Nigon’s non-surgical problem (clotting disorder).
          Further, the necessary post-op care (anticoagulation) for Mr.
          Nigon was lost in a series of incomplete and unsafe practices …
          that resulted in Mr. Nigon not being discharged on Xarelto.

          b. As the clinical experts will testify, this resulted in the
          formation of [a] clot that traveled to Mr. Nigon’s lung, blocking
          blood flow to both his right and left lung, the direct
          consequence of which was his untimely death.

Id. at 10.16      Ultimately, Dr. Ludgin concluded “the multitude of system

failures” leading to Mr. Nigon’s death “are attributable to each of the

defendants and to the defendants as a whole.” Id. (emphasis added);

____________________________________________

16 Dr. Ludgin also references the alleged alteration to Mr. Nigon’s medical
record made by Dr. Thomas Malvar following Mr. Nigon’s death. See Estate’s
Motion for Summary Judgment on Comparative Fault, 8/24/21, Exhibit D
(Expert Report by Dr. Coris), at 11. Dr. Ludgin describes these changes as “a
poorly executed but definite attempt at a ‘cover-up’ to mislead and
obfuscate…. It likewise smacks as a conscious admission that Dr. [Thomas]
Malvar provided sub-standard pre-op clearance services.” Id. But see id.
(Dr. Ludgin noting he “did not review the audit trail [or] chronic[le] the
entirety of [the] changes that were made….”).

                                          - 22 -
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see also id. (stating each defendant is responsible for the circumstances

leading to Mr. Nigon’s death).

      After careful review, we conclude the record, viewed in the light most

favorable to the estate, does not support the grant of summary judgment in

Dr. Thomas Malvar’s favor.    See Bourgeois, 242 A.3d at 650. We reiterate

that this standard applies to expert reports, where the expert’s conclusions

are supported by the record. See id. Moreover, “while conclusions recorded

by experts may be disputed, the credibility and weight attributed to those

conclusions are not proper considerations at summary judgment; rather, such

determinations reside in the sole province of the trier of fact….” Summers,

997 A.2d at 1161.

      In their respective reports, the experts set forth the materials of record

they reviewed in reaching their conclusions. See Estate’s Motion for Summary

Judgment on Comparative Fault, 8/24/21, Exhibit D (Expert Report of Dr.

Coris), at 1 (identifying all written discovery, including Mr. Nigon’s medical

records; deposition transcripts; other expert reports; and blood test results

from Mr. Nigon’s family members); Exhibit T (Expert Report of Dr. Ludgin), at

2-3 (listing all materials reviewed).     Thus, contrary to the trial court’s

summary conclusion, it is clear Dr. Coris and Dr. Ludgin reviewed the facts of

record before rendering their expert opinions.

      Read in their entirety, the estate’s expert reports raised a genuine issue

of material fact by attributing Mr. Nigon’s DVT/PE and resulting death either

                                    - 23 -
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in whole or in part to Dr. Thomas Malvar.     Whether Dr. Thomas Malvar’s

alleged breach of the standard of care was a proximate cause of Mr. Nigon’s

death was a disputed issue that should have been reserved for a jury. See

Summers, 997 A.2d at 1161-62 (where exposure to asbestos was not

disputed and medical records established pleural thickening, holding the

question of whether pleural thickening proximately caused the appellants’

symptoms should have gone to the jury). Therefore, the trial court erred by

granting summary judgment.

     In its second issue, the estate argues the trial court erred by

disregarding agency law and dismissing Dr. Maritoni Malvar from the case.

Estate’s Brief at 44. The estate avers Dr. Maritoni Malvar and Dr. Thomas

Malvar are jointly and severally liable as general partners of Malvar &

Associates. Id. at 46. The estate additionally voices its concerns regarding

the trial court’s “unexplainable reversal in its application of long-standing

partnership law on summary judgment.” Id.

     The Malvar Defendants counter the record is devoid of any allegation

that Dr. Maritoni Malvar supervised Dr. Thomas Malvar or was in any way

involved with Mr. Nigon’s treatment. Appellees’ Brief at 12-13.

     We begin with a brief review of the trial court’s consideration of Dr.

Maritoni Malvar’s affidavits of non-involvement and motions to dismiss at the

preliminary objection and summary judgment stages of this litigation.

Following argument on the parties’ preliminary objections, the trial court

                                   - 24 -
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overruled Dr. Maritoni Malvar’s preliminary objection in the nature of a

demurrer and denied her related motion to dismiss. See Trial Court Opinion,

3/5/20, at 11-14. In doing so, the trial court relied on various sections of

Pennsylvania’s Uniform Partnership Act,17 and stated as follows:

       Simply put, though the lines between a general partnership and
       its members may be blurred at times …, they are clear for
       purposes of vicarious liability in Pennsylvania: the entities are one
       and the same, and an action proceeding on this legal theory
       against a general partnership may and should be done in
       conjunction with an identical cause of action against each member
       thereof.

Id. at 13. The trial court concluded that Dr. Thomas Malvar acted within the

scope of the partnership; therefore, the estate properly joined Malvar &

Associates and Dr. Maritoni Malvar, as a general partner, in the action. Id. at

13-14.

       Later, following discovery, Dr. Maritoni Malvar filed a motion for

summary judgment, citing her affidavit of non-involvement, and arguing she

____________________________________________

17 Section 8435(a) provides:

       A partnership is liable for loss or injury caused to a person, or for
       a penalty incurred, as a result of a wrongful act or other actionable
       conduct, of a partner acting in the ordinary course of business of
       the partnership or with the actual or apparent authority of the
       partnership.

15 Pa.C.S.A. § 8435(a). Notwithstanding certain exceptions not relevant to
this case, “all partners are jointly and severally liable for all … liabilities of the
partnership….” Id. § 8436(a). Further, under Section 8437(b), “a partner
may be joined in an action against the partnership or named in a separate
action.” Id. § 8437(b).

                                          - 25 -
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could not be held liable for Dr. Thomas Malvar’s conduct, because she had no

supervisory authority over him.18 To support her position, Dr. Maritoni Malvar

relied on Strain v. Ferroni, 592 A.2d 698 (Pa. Super. 1991), which states

the following:

       Physicians and surgeons, like other persons, are subject to the law
       of agency and a physician may be at the same time the agent both
       of another physician and of a hospital even though the
       employment is not joint. … In determining whether a person is a
       servant of another[,] it is necessary that he not only be subject to
       the latter’s control or right of control with regard to the work to
       be done and the manner of performing it[,] but that this work is
       to be performed on the business of the master or for her benefit.
       … Actual control, of course, is not essential. It is the right to
       control which is determinative. On the other hand, the right to
       supervise, even as to the work and the manner of performance,
       is not sufficient; otherwise[,] a supervisory employee would be
       liable for the negligent act of another employee though he would
       not be the superior or master of that employee in the sense the
       law means it. …

Strain, 592 A.2d at 704 (citation omitted); see also Dr. Maritoni Malvar’s

Motion for Summary Judgment, 8/17/21, ¶ 14.

       Instantly, following argument on the motions for summary judgment,

the trial court changed course and “rejected the [estate’s] attempt to impose

general partnership law on the specific field of physicians and surgeons….”

Trial Court Opinion, 11/3/21, at 32. The court, evidently persuaded by Dr.

____________________________________________

18 In her motion for summary judgment, Dr. Maritoni Malvar conceded a claim

for vicarious liability could be raised against Malvar & Associates as the
partnership group. See Dr. Maritoni Malvar’s Motion for Summary Judgment,
8/17/21, ¶ 22.

                                          - 26 -
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Maritoni Malvar’s reliance on Strain, emphasized the right of control over

another’s actions must be the “absolute factor.” Id. at 32-33.

       After careful review, we conclude the trial court erred by dismissing Dr.

Maritoni Malvar from the action.     Preliminarily, any reliance on Strain is

misplaced.    In Strain, the plaintiffs (husband and wife) filed a medical

negligence claim against two physicians, Dr. Ferroni and Dr. Harrer, following

wife’s miscarriage. Dr. Ferroni was wife’s obstetrician-gynecologist. Strain,

592 A.2d at 352.     When wife was in her fourth month of pregnancy, she

suffered severe pain and cramping. Id. Because Dr. Ferroni was unavailable,

Dr. Harrer answered wife’s phone call and provided medical advice before wife

proceeded to the hospital for treatment.      Id. at 352-53.   Pertinent to the

instant case, plaintiffs argued Dr. Harrer was an agent of Dr. Ferroni and

sought to hold Dr. Ferroni liable for Dr. Harrer’s alleged negligence. Id. at

353.

       This Court evaluated the claim based on agency principles, as set forth

above. See id. at 704. This Court concluded “the nature of the professional

relationship shared by Drs. Ferroni and Harrer is not the type of arrangement

contemplated by cases which deal with principal-agency law.” Id. at 705; see

also id. at 704-05 (considering the extent of the physicians’ professional

relationship and whether Dr. Ferroni could be considered an “employer” or

“supervisor” of Dr. Harrer, or whether he otherwise exercised control over Dr.

Harrer).

                                     - 27 -
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      Our review reveals Strain is distinguishable from the instant case.

Significantly, the estate seeks to hold Dr. Maritoni Malvar liable as a general

partner of Malvar & Associates, rather than as a principal with liability for an

agent (as in Strain). Dr. Maritoni Malvar correctly states the estate did not

establish she employs, supervises, or exerts any control over Dr. Thomas

Malvar’s performance as a medical provider. However, because Drs. Maritoni

and Thomas Malvar are members of a partnership, the principal-agent

framework applied by the Strain Court is not at issue.

      This Court previously has addressed medical malpractice claims levied

against more than one physician, where each physician is named individually

and as a partner in a professional partnership. See Keech v. Mead Johnson

& Co., 580 A.2d 1374 (Pa. Super. 1990) (addressing physician’s dismissal

from medical malpractice suit in her individual capacity, though she remained

in litigation as a partner); see also Grubb v. Albert Einstein Med. Ctr., 387

A.2d 480 (Pa. Super. 1978) (en banc) (concluding physician could be held

liable for a tort committed by a partner physician acting within the ordinary

scope of their partnership).    Because the trial court declined to consider

partnership law in granting Dr. Maritoni Malvar’s motion for summary

judgment, we need not undertake a lengthy discussion of the facts of Keech

and Grubb. However, these cases illustrate that general partnership law can,

in fact, be applied to physicians. Thus, the trial court erred by concluding that

                                     - 28 -
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partnerships involving physicians must be categorically excluded from

application of partnership law.

       The estate averred that Malvar & Associates is a medical practice

operating as a partnership. Dr. Maritoni Malvar does not dispute her status

as a general partner in the practice.          Accordingly, the estate’s allegations,

viewed in a light most favorable to it as the non-moving party, were sufficient

to survive summary judgment.19            See generally Grubb, 387 A.2d at 488

(concluding there was sufficient evidence to allow a jury to assign liability

against both physicians in a partnership).           We therefore reverse the trial

court’s order in this regard as well.

       Order reversed. Case remanded for further proceedings. Jurisdiction

relinquished.

4/9/2024

____________________________________________

19 Importantly, we do not determine whether Dr. Maritoni Malvar is, in fact,

liable as a partner of Malvar & Associates. Rather, we conclude the trial court
erroneously dismissed Dr. Maritoni Malvar from litigation, thereby removing
the question of her liability from the jury. It is exclusively for the jury to
determine how liability, if any, should be apportioned among the various
defendants.

                                          - 29 -
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