Shultz, F. & W. v. York Hospital

J-A09030-23

NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT OP 65.37

FRED L. AND ELLEN W. SHULTZ : IN THE SUPERIOR COURT OF
: PENNSYLVANIA
Appellants :
:
:
v. :
:
:
YORK HOSPITAL, WELLSPAN : No. 984 MDA 2022
MEDICAL GROUP, T/D/B/A :
WELLSPAN HOSPITALISTS :

Appeal from the Judgment Entered August 17, 2022
In the Court of Common Pleas of York County Civil Division at No(s):
2016-SU-001288-82

BEFORE: PANELLA, P.J., OLSON, J., and KUNSELMAN, J.

MEMORANDUM BY OLSON, J.: FILED: APRIL 16, 2024

Appellants, Fred L. and Ellen W. Shultz (husband and wife), filed an

action alleging corporate negligence against York Hospital, together with

claims for vicarious liability against York Hospital and Wellspan Medical Group,

t/d/b/a Wellspan Hospitalists (“Wellspan Hospitalists”) (collectively, the

“Appellees”) after Fred L. Shultz (“Shultz”) suffered a stroke in September

2014. At the close of Appellants’ case-in-chief, the trial court granted

Appellees’ motion for a compulsory non-suit. After the court denied

Appellants’ request to remove the non-suit, Appellants appealed following the

entry of an adverse judgment. We affirm, in part, reverse, in part, and

remand for a new trial.

The trial court summarized the relevant facts of this case as follows.

[Shultz], then 65[ years-old], was admitted to York Hospital on
September 25, 2014[,] after waking up early in the morning
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with a feeling of numbness and weakness in his left side. The
day before his admission, Shultz underwent an operation on his
right leg for varicose veins. [At] the time Shultz arrived at York
Hospital[,] it was unknown whether he was still within the time
[period during which an effective dose of tissue plasminogen
activator1 could be administered;] thus, it was not administered
to him. Dr. Craig Goldstein attended to Shultz while at York
Hospital. Dr. Goldstein identified trace right leg edema in
addition to the obvious stroke [Shultz suffered].

Dr. Goldstein formulated a treatment plan for Shultz, which
included [the administration of] a transthoracic echocardiogram
to determine whether Shultz[‘s] heart contained a patent
foramen ovale [(“PFO”)2]. Dr. Goldstein’s treatment plan did
not include either a transesophageal echocardiogram or a right
leg ultrasound to confirm or rule out the presence of a deep
vein thrombosis [(“DVT”)] in Shultz’[s] leg at the area of the
varicose vein surgery. After the transthoracic echocardiogram,
further testing was recommended on an outpatient basis as []
some abnormalities [] were noted. York Hospital’s physicians
and nursing staff performed additional tests to confirm it was
safe to discharge Shultz, and he was in fact discharged on
September 26, 2014.

Notably, prior to [Shultz’s] discharge on September 26, 2014[,
a] York Hospital nurse[,] Kimberly Pope[,] identified research
connecting varicose vein surgery in the presence of a [PFO] with
subsequent stroke. Even with this connection, [] Pope noted
[that,] even if further testing confirmed the presence of a
[PFO], this discovery “would not change [the hospital’s]
management at this point.” Another York Hospital doctor, Dr.
Kathy McGill, relied upon [] Pope’s statement in not ordering a
transesophageal echocardiogram before Shultz[‘s] discharge.

____________________________________________

1 Introduced to the body through intravenous means, tissue plasminogen
activator is a medical treatment that dissolves blood clots that block blood
flow to the brain. HTTS://www.ninds.nih.gov (last visited 8/8/23).

2 A patent foramen ovale or PFO is a small opening between the two upper

chambers of the heart, the right and left atrium. A PFO can allow blood clots
to travel from the right atrium to the left atrium and out to blood vessels of
the body. HTTS://www.hopkinsmedicine.org (last visited 8/14/23).

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Shultz returned to York Hospital on September 27, 2014 at
11:55 p.m. with stroke symptoms. This second stroke was
described as “a large territory right middle cerebral artery
infarction.” While hospitalized for this stroke, Shultz underwent
a transesophageal echocardiogram on September 29, 2014.
The next day, September 30, [2014,] Shultz underwent a right
calf endovenous ultrasound which confirmed the presence of
[DVT] at the site of Shultz[‘s] varicose vein surgery. Almost
immediately upon confirmation of both the [PFO] and [DVT],
Shultz was started on an anticoagulant, specifically[,]
[C]oumadin.

Trial Court Opinion, 8/12/22, at 1-3 (footnotes added).

On May 11, 2016, Appellants filed a complaint against Appellees, which

they amended on June 22, 2016. In their amended complaint, Appellants set

forth a claim of corporate negligence against York Hospital. In addition,

Appellants set forth claims alleging vicarious liability against Wellspan

Hospitalists and York Hospital. In support of their vicarious liability claims,

Appellants averred that physicians, nurses, and other hospital personnel,

acting as Wellspan Hospitalists’ agents and as York Hospital’s ostensible

agents, failed to provide reasonable care under the circumstances and that

this failure caused Shultz’s subsequent stroke.

On May 28, 2021, Appellants moved for summary judgment, arguing

that, pursuant to Thompson v. Nason Hospital, 591 A.2d 703 (Pa. 1991),

York Hospital owed a duty to “ensure [Shultz’s] safety and well[-]being” while

admitted as a patient in the hospital. Appellants’ Brief in Support of Motion

for Summary Judgment, 5/28/21, at 30. Appellants claimed that York Hospital

breached this duty by discharging Shultz without proper medications and

without conducting all appropriate tests to accurately assess his medical

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condition after his first stroke. Id. at 37-41. Appellants also alleged that

these failures caused Shultz’s second stroke. Id. at 37-41. Within their

motion, Appellants alleged that no disputed material facts existed, and they

were entitled to judgment as a matter of law with respect to their corporate

negligence claim against York Hospital and their vicarious liability claims

against Appellees, collectively. Id. at 47-48.

On June 1, 2021, Appellees moved for partial summary judgment,

asserting that Appellants’ claims of corporate negligence against York Hospital

were subject to summary dismissal. In particular, Appellees argued that

Appellants misrepresented and incorrectly sought to expand the standard of

care set forth in Thompson by claiming York Hospital owed a duty to “’ensure

the safety and well[-]being’ of its patients” through development and

enforcement of procedures intended to ensure “point of care” supervision.

Appellees’ Brief in Support of Partial Summary Judgment, 6/1/21, at 9

(citations omitted). Appellees also claimed that, in a recent case, this Court

“explained [that] the doctrine of corporate negligence [did] not require a

hospital to direct or override its providers’ clinical judgment.” Id. at 10, citing

Ruff v. York Hospital, 257 A.3d 43 (Pa. Super. 2021). Accordingly,

Appellees argued they were entitled to an order granting partial summary

judgment and dismissing Appellants’ corporate negligence claim against York

Hospital. On September 10, 2021, the trial court denied both sides’ requests

for summary judgment, concluding that genuine issues of fact remained, and

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summary judgment was therefore inappropriate. Trial Court Opinion,

9/10/21, at *7 (unpaginated).

On April 6, 2022, Appellees filed an omnibus motion in limine, seeking,

inter alia, to preclude Appellants’ expert, Kevin Brady, M.D., from “reading []

or citing [to] the Patient Safety Advisory of 2010” (hereinafter, the “Advisory”)

during his testimony.3 Appellees’ Omnibus Motion in Limine, 4/6/22, at 8-9,

¶¶ 31-33. Appellees argued that this Court in Ruff ostensibly treated the

Advisory as a learned treatise, which is inadmissible under the Pennsylvania

Rules of Evidence. As such, Appellees maintained that the trial court was

required to prohibit Dr. Brady from making extensive references to the

Advisory during his expert testimony. See Appellees’ Memorandum of Law in

Support of Omnibus Motions in Limine, 4/13/22, at 10; see also Ruff, 257

A.3d at 59.

On April 13, 2022, Appellants filed their own motions in limine.

Appellants’ Consolidated Pre-Trial Motions, 4/13/22, 1-3. The trial court

issued an omnibus order of court on May 11, 2022, which, in relevant part,

denied most of Appellants’ motions in limine and generally granted Appellees’

motions. Trial Court’s Omnibus Order, 5/11/22, at 1-7. Importantly, the trial

court granted Appellees’ motion seeking to limit Dr. Brady’s expert testimony

insofar as it concerned the Advisory. In particular, the trial court allowed Dr.

____________________________________________

3 We describe Dr. Brady’s role as Appellants’ expert, as well as the nature and

substance of the Advisory, in greater detail below.

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Brady to “make reference to the Advisory,” but prohibited him from “read[ing

it at length.” Id. at 4.

On June 13, 2022, the matter proceeded to a jury trial. During trial, the

court dismissed Appellants’ expert, Dr. Brady, as a witness because he “read

directly from the Advisory in direct violation of the [trial court’s May 11, 2022

omnibus order].” Trial Court Opinion, 8/12/22, at 8. At the conclusion of

Appellants’ case-in-chief, Appellees moved for compulsory non-suit.

Appellees argued that, without Dr. Brady’s expert testimony, Appellants could

not sustain a claim of corporate negligence against York Hospital. Appellees’

Motion for Non-suit, 6/17/22, at 2-3. Moreover, Appellees claimed Appellants’

other experts, Irfan Altafullah, M.D. and Brian T. Larkin, M.D., presented

“irrevocably conflicting testimony on a number of points critical to

[Appellants’] prima facie case” concerning the negligence of the clinical care

providers, rendering non-suit appropriate as to Appellants’ vicarious liability

claims against Appellees. Id. at 9, ¶ 29. Ultimately, the trial court granted

Appellees’ motion. Trial Court Order, 6/17/22, at 1. Appellants filed a motion

for post-trial relief on June 23, 2022, asking the trial court to remove the

non-suit. The trial court denied Appellants’ motion on July 5, 2022. Trial

Court Order, 7/5/22, at 1. Appellants brought this appeal following the entry

of an adverse final judgment.4

____________________________________________

4 Originally, Appellants filed a notice
of appeal from the July 5, 2022 order
that denied their post-trial motion for relief. Because no final, appealable
(Footnote Continued Next Page)

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Appellants raise the following issues on appeal:5

1. Did the trial court err in failing to grant [Appellants’] motion
for summary judgment, as a matter of law?

2. Did the trial court abuse its discretion by granting
[Appellees’] pre-trial motion[s] in limine and refusing
[Appellants’] motions in limine?

3. Did the trial court, under the facts of this case, err by ruling
that[,] under the corporate negligence theory of liability
outlined in [Thompson], York Hospital:

a) Had no standard of care (conduct) duty to ensure the
safety and well-being of [Shultz];

b) Had no legal duty to act for the protection of [Shultz] from
a discharge from the hospital without a diagnosis of the
cause of his first stroke and the proper medication needed
to prevent his second disabling stroke?

4. Did the trial court err and abuse its discretion in disqualifying
[Dr. Brady] and prohibiting him from testifying about York
Hospital’s corporate negligence?

5. Did the trial court err in granting [Appellees’] motion for
non[-]suit of [Appellants’] corporate liability claim[?]

____________________________________________

judgment appeared on the trial court’s docket, this Court issued an order on
August 16, 2022, directing Appellants to praecipe the trial court prothonotary
to enter an adverse judgment. See International Ass’n of Theatrical
Stage Employees, Local Union No. 3 v. Mid-Atlantic Promotions, Inc.,
856 A.2d 102 (Pa. Super. 2004) (reiterating that denial of post-trial motion to
remove non-suit is interlocutory and generally not immediately appealable; it
is the subsequent entry of judgment that is appealable). Appellants filed a
certified copy of the trial court docket on August 16, 2022 showing that
judgment was properly entered on the non-suit on August 17, 2022. Based
upon the foregoing, we deem Appellants’ appeal timely filed. See Pa.R.A.P.
905(a)(5) (“A notice of appeal filed after the announcement of a determination
but before the entry of an appealable order shall be treated as filed after such
entry and on the day thereof.”).

5 We have reordered Appellants’ issues for ease of discussion and disposition.

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6. Did the trial court err in granting [Appellees’] motion for
non[-]suit of [Appellants’] vicarious liability claim[?]

Appellants’ Brief at 8-9 (superfluous capitalization omitted).

In their first three appellate issues, Appellants challenge the trial court’s

denial of their motion for summary judgment, as well as the trial court’s

disposition of the parties’ opposing motions in limine. In large part,

Appellants’ claims center upon the trial court’s interpretation and application

of the doctrine of corporate negligence as outlined in Thompson, wherein our

Supreme Court delineated the duties of care owed by a hospital organization.

See Appellants’ Brief at 37-47, 66-68, and 71. In particular, Appellants argue

that the trial court erred in holding that Thompson did not impose a general

duty to ensure Shultz’s “safety and well-being” while he was a patient at York

Hospital. Id. at 46. In addition, Appellants claim that the trial court erred in

declining to engage in a pre-trial analysis, either in the context of summary

judgment litigation or other pre-trial stages, to consider whether, pursuant to

Section 328B of the Restatement (Second) of Torts6 or Althaus v. Cohen,

____________________________________________

6 Section 328B of the Restatement (Second) of Torts outlines the functions

of the trial court in an action for negligence. It states that, in an action for
negligence, a trial court determines the following:

(a) whether the evidence as to the facts makes an issue upon
which the jury may reasonably find the existence or
non-existence of such facts;
(b) whether such facts give rise to any legal duty on the part of
the defendant;
(c) the standard of conduct required of the defendant by his
legal duty;
(Footnote Continued Next Page)

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756 A.2d 1166 (Pa. 2000),7 York Hospital owed “Shultz an affirmative duty to

protect him from the foreseeable risk of a second stroke.” Appellants’ Brief at

67; see also Appellant’s Brief at 41-47 and 71. These issues “present pure

questions of law,” and, as such, “our standard of review is de novo and our

scope of review is plenary.” In re Vencil, 152 A.3d 235, 241 (Pa. 2017).

Inasmuch as Appellants’ initial claims focus upon Thompson, we begin

our analysis with an overview of that case and then turn to the trial court’s

application of the corporate negligence doctrine to the pre-trial motions filed

herein. In Thompson, our Supreme Court “first adopted the theory that a

corporation, specifically a hospital, can be held directly liable for corporate

negligence.” Welsh v. Bulger, 698 A.2d 581, 585 (Pa. 1997). At the outset,
____________________________________________

(d) whether the defendant has conformed to that standard, in
any case in which the jury may not reasonably come to a
different conclusion;
(e) the applicability of any rules of law determining whether the
defendant's conduct is a legal cause of harm to the plaintiff; and
(f) whether the harm claimed to be suffered by the plaintiff is
legally compensable.
Id.

7 In Althaus, supra, our Supreme Court explained that, in order to determine

“whether a duty exists in a particular case,” a court must weigh the following
factors:

(1) the relationship between the parties; (2) the social utility of
the actor's conduct; (3) the nature of the risk imposed and
foreseeability of the harm incurred; (4) the consequences of
imposing a duty upon the actor; and (5) the overall public
interest in the proposed solution.

Id. at 1169.

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the Thompson Court explained the doctrine of corporate negligence as

follows:

Corporate negligence is a doctrine under which the hospital is
liable if it fails to uphold the proper standard of care owed the
patient, which is to ensure the patient's safety and well-being
while at the hospital. This theory of liability creates a
nondelegable duty which the hospital owes directly to a patient.
Therefore, an injured party does not have to rely on and
establish the negligence of a third party.

Thompson, 591 A.2d at 707. In defining the contours of this theory, the

Supreme Court channeled a hospital’s duties into the following “four general

areas:”

(1) a duty to use reasonable care in the maintenance of safe
and adequate facilities and equipment; (2) a duty to select and
retain only competent physicians; (3) a duty to oversee all
persons who practice medicine within its walls as to patient
care; and (4) a duty to formulate, adopt and enforce adequate
rules and policies to ensure quality care for the patients.

Id. (citations omitted).

Having delineated, in Thompson, a hospital organization’s corporate

duties within the context of patient care and safety, the Supreme Court in

Welsh explained that a plaintiff must plead and prove the following to present

a prima facie case of corporate negligence:

1. [the hospital] acted in deviation from the standard of care;

2. [the hospital] had actual or constructive notice of the defects
or procedures which created the harm; and

3. [] the conduct was a substantial factor in bringing about the
harm.

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Whittington v. Episcopal Hosp., 768 A.2d 1144, 1149 (Pa. Super. 2001),

citing Welsh, 698 A.2d at 585. In addition, the Court stated that, “unless the

hospital’s negligence is obvious, an expert witness is required to establish two

of the three prongs: that the hospital deviated from the standard of care and

that such deviation was a substantial factor in bringing about the harm.”

Whittington, 768 A.2d at 1149, citing Welsh, 698 A.2d at 585.

Within the context of the parties’ motions for summary judgment and

their motions in limine, the trial court recognized that it was “called upon” to

analyze the Supreme Court’s decision in Thompson, including the limits of

the theory, about which “the[] parties [were] truly conflicted.” Trial Court

Opinion, 9/10/21, at *4. The trial court explained that Thompson initially

stated that “the responsibility for a hospital under the theory of corporate

negligence is described as, ‘to ensure the patient’s safety and well-being while

at the hospital.’” Id. at *4, quoting Thompson, 591 A.2d at 707. The trial

court, however, recognized that Thompson refined the descriptive label of

“patient safety and well-being” by limiting a hospital’s responsibility to “four

specified duties.” Trial Court Opinion, 9/10/21, at *4. In conclusion, the trial

court stated:

this [c]ourt is confident in continuing to uphold Thompson’s
four duties as the primary expressions of access to relief under
a corporate negligence case against a hospital. The
requirement to ensure safety and well-being, while itself
general, is certainly meaningfully restricted to the four duties
laid out in Thompson; those duties are not mere “areas” of
example as to what the responsibility requires, but are specific
duties and theories of negligence under which a party can
plainly bring suit.

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Id. at *6-*7 (unpaginated).

Upon review, we conclude that the trial court correctly interpreted and

applied our Supreme Court’s decision in Thompson. Indeed, the trial court

recognized that, at the outset of the opinion, the Thompson Court, for the

first time, held that a hospital had a responsibility to “ensure [a] patient’s

safety and well-being while at a hospital.” Thompson, 591 A.2d at 707. The

trial court, however, correctly observed that Thompson did not impose upon

a hospital an overarching and general duty to ensure a patient’s safety and

well-being. Instead, the Thompson Court, in explaining the scope of a

hospital’s general responsibility, “outlin[ed] the boundaries of the

doctrine” by imposing liability upon a hospital if it “fail[ed] to uphold any one

of the . . . four [expressly enumerated] duties.” Whittington, 768 A.2d

at 1149 (emphasis added). Hence, the trial court astutely directed Appellants

to channel their corporate negligence claims against York Hospital into one (or

more) of the duties outlined in Thompson. This is consistent with subsequent

case law interpreting Thompson. See Welsh, 698 A.3d at 586 (Pa. 1997)

(associating the appellant’s claims of negligence with the second, third and

fourth duties outlined in Thompson); Ruff, 257 A.3d at 49 (“Under a

corporate negligence theory, four general, non-delegable duties are imposed

on the hospital[.]”); Sokolsky v. Eidelman, 93 A.3d 858, 869 (Pa. Super.

2014) (explaining Thompson “’embraced’ four established duties” hospitals

owe to patients) (citation omitted); Edwards v. Brandywine Hosp., 652

A.2d 1382, 1386 (Pa. Super. 1995) (explaining that the “enumerated duties

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[in Thompson] . . . appear broad and somewhat nebulas” but a court must

“discern their outlines”). Importantly, we note that the trial court’s decision

did not “destroy” Appellants ability to pursue an action for corporate

negligence against York Hospital. Appellants’ Brief at 46. In fact, the trial

court expressly rejected Appellees’ contention that Appellants’ allegations,

i.e., that York Hospital was liable for failing to supervise the diagnostic process

performed during Shultz’s stay or adopt certain procedures to ensure such

supervision, fell completely outside the scope of the duties outlined in

Thompson. Instead, the trial court simply directed Appellants to avoid

alleging that Thompson imposed a fifth, general duty. As stated above, the

trial court was correct in this determination.

Moreover, we disagree with Appellants’ contention that the trial court

erred by declining to analyze Appellants’ various claims and determine

“whether [] York Hospital owed . . . Shultz an affirmative duty to protect him

from the foreseeable risk of a second stroke” during the summary judgment

or other pre-trial stages pursuant to Section 328 of the Restatement (Second)

of Torts or Althaus, supra. Appellants’ Brief at 66-67; see also id. at 41-47

and 71; Appellants’ Brief in Support of Motion for Summary Judgment,

5/28/21, at 36-37; and Appellant’s Brief in Support of Consolidated Pre-Trial

Motions, 4/13/22, at 34-35. In asserting a need to undertake such an

analysis, Appellants appear to rely upon Scampone v. Highland Park Care

Ctr. LLC, 57 A.3d 582, 606 (Pa. 2012) (explaining that, in order to determine

whether a nursing home owed a duty of care to its patient, the trial court must

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apply “Section 323 of the Restatement [(describing in general terms the duty

of one to aid another as to whom one has undertaken to provide services,

gratuitously or for consideration)] or . . . the Althaus factors”); see

Appellants’ Brief at 75 (noting that, in Scampone, 57 A.3d at 606, our

“Supreme Court explained when an inquiry does not capture the appropriate

standard by which to decide whether a duty of care exists under Thompson[,]

employing the incorrect test generally effects how evidentiary proffers are

received and their relevant weight accorded to the relevant evidence”).

Appellants, however, overlook our Supreme Court’s determination that

an Althaus analysis is unnecessary in situations involving the application or

vindication of established duties (such as those established in Thompson) in

novel contexts. Specifically, in Alderwoods (Pennsylvania), Inc. v.

Duquesne Light Co., 106 A.3d 27 (Pa. 2014), our Supreme Court stated:

As to the aspects of this litigation centered on the Althaus
factors, we find these to be more relevant to the creation of
new duties than to the vindication of existing ones. It is not
necessary to conduct a full-blown public policy assessment in
every instance in which a longstanding duty imposed on
members of the public at large arises in a novel factual scenario.
Common-law duties stated in general terms are framed in such
fashion for the very reason that they have broad-scale
application.

Id. at 40–41. Hence, as a hospital’s duty to its patients was specifically

articulated in Thompson, a full-scale public policy analysis under the

Restatement (Second) of Torts or Althaus is superfluous in the present

context. See Scampone v. Grane Healthcare Company, 169 A.3d 600,

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617 (Pa. Super. 2017) (“Thus, Alderwoods indicates that if a common law

duty exists under the Restatement (Second) of Torts, the Althaus analysis is

not necessary.”); see also Shannon v. McNulty, 718 A.2d 828, 836 (Pa.

Super. 1998) (“The Welsh case involved a suit against a hospital and thus

Thompson was clearly applicable”). Accordingly, the trial court correctly

determined that, because Thompson specifically outlined York Hospital’s four

potential duties of care, any analysis pursuant to Althaus or the Restatement

(Second) of Torts was utterly unnecessary.

We have concluded that the trial court correctly determined that

Thompson did not impose a general duty of care and, instead, specifically

outlined four distinct duties of care upon which a claim of corporate negligence

may be grounded. For this reason, we also conclude that the trial court did

not need to resort to an analysis pursuant to Althaus or the Restatement

(Second) of Torts. Accordingly, to the extent Appellants attack the trial court’s

resolution of the parties’ opposing pre-trial motions based upon an errant

reading of Thompson, we conclude those claims are devoid of merit.8 We
____________________________________________

8 For similar reasons, we largely reject the contentions that Appellants raise

in their third issue. In the initial subpart of this claim, Appellants allege that
the trial court erred in concluding that, under Thompson, York Hospital owed
no duty to ensure Shultz’s safety and well-being. See supra at 7. This claim
runs counter to a proper reading of Thompson, as the trial court correctly
determined and as we have discussed above. In the second subpart of their
third issue, Appellants contend that York Hospital owed two distinct “duties.”
First, Appellants claim that the hospital owed a duty to protect Shultz from a
discharge without a diagnosis of the cause of his first stroke. Second,
Appellants claim that the hospital owed a duty to protect Shultz from a
(Footnote Continued Next Page)

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now turn to Appellants’ remaining challenges with respect to the trial court’s

rulings on their motion for summary judgment and the parties’ motions in

limine.

In their first issue, Appellants challenge the trial court’s order denying

their motion for summary judgment. See Appellants’ Brief at 66-67. Our

standard of review is well-settled:

We view the record in the light most favorable to the
non-moving party, and all doubts as to the existence of a
genuine issue of material fact must be resolved against the
moving party. Only where there is no genuine issue as to any
material fact and it is clear that the moving party is entitled to
a judgment as a matter of law will summary judgment be
entered. Our scope of review of a trial court's order granting or
denying summary judgment is plenary, and our standard of
review is clear: the trial court's order will be reversed only
where it is established that the court committed an error of law
or abused its discretion.

Daley v. A.W. Chesterton, Inc., 37 A.3d 1175, 1179 (Pa. 2012) (citation

omitted).

Herein, Appellants filed their motion for summary judgment asserting

that, pursuant to Thompson, York Hospital breached its duty of care as a

matter of law by failing to “supervise[] the diagnostic process that was being

____________________________________________

discharge without the proper medication needed to prevent his second stroke.
Here again, Appellants misread Thompson. York Hospital may be liable to
Appellants if, and only if, Appellants prove that a departure from one (or more)
of the duties enumerated in Thompson caused Shultz to be discharged
without a diagnosis of the cause of his first stroke or caused Shultz to be
discharged without the proper medication and York Hospital had actual or
constructive notice of the defects or procedures which led to Shultz’s harm.
See Whittington, 768 A.2d at 1149.

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performed in the care of . . . Shultz.” Appellants’ Motion for Summary

Judgment, 5/28/21, at 14; see also id. at 15. In essence, Appellants

contended that York Hospital was liable under a corporate negligence theory

because it failed to ensure or enact a policy to make “certain that patients

[were] not discharged without a careful review of the [care] provided to them

and verifying that all diagnostic tests were performed and acted upon and that

all risks of discharge have been evaluated and ruled out or minimized by

appropriate planning[.]” Id. at 23. To support this claim, Appellants cited

various aspects of their expert reports, which they claimed were

uncontradicted, as well as certain alleged discovery admissions, and argued

that, in light of the foregoing evidence, summary judgment on their claims

against York Hospital was appropriate. Id. at 18-23. In addition, Appellants

sought summary judgment on their vicarious liability claims, similarly arguing

that no issues of material fact existed and that, based upon the negligence of

Wellspan Hospitalists’ agents and York Hospital’s ostensible agents, as

detailed throughout the motion, they were entitled to judgment as a matter

of law.9 Id. at 26.

On June 25, 2021, Appellees responded to Appellants’ motion for

summary judgment. In their response, Appellees explained that, considering

the conflicting expert reports, there existed outstanding issues of fact
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9 In developing their claims before this Court, Appellants refer only to York
Hospital. Nonetheless, as Appellants moved for complete summary judgment,
not partial summary judgment, we will construe Appellants claims as if set
forth against both York Hospital and Wellspan Hospitalists.

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regarding the care provided to Shultz. See Appellees’ Brief in Support of

Appellees’ Response in Opposition to Appellants’ Motion for Summary

Judgment, 6/28/21, at 8-10. In addition, Appellees argued that Appellants

included only “[s]elf-serving testimony” and, thus, Appellants’ brief

“materially misrepresented” the discovery deposition testimony offered by

both fact and expert witnesses. Id. at 11-12. Appellees therefore claimed

that no “discovery admissions” occurred. Id. Finally, Appellees argued that

Appellants and “their experts incorrectly interpret[ed] the accepted standard

of care under corporate negligence” because they essentially sought to hold

York Hospital liable

for failing to supervise its medical providers by directing or
overriding their clinical judgment and to have policies or
procedures in place to ensure this level of . . . ‘point of care’
supervision over treating providers, regardless of their clinical
judgment based upon the objective findings from radiology,
labs, and physical examinations.

Id. at 13. Appellees claimed this Court recently “explained [in Ruff that] the

doctrine of corporate negligence does not require a hospital to direct or

override its’ providers clinical judgment.” Id. at 14; see also Ruff, 257 A.3d

at 53-54. Because Appellants’ counsel also served as counsel for the plaintiff

in Ruff, Appellees argued the failure to disclose this binding precedent

warranted the issuance of sanctions. On September 10, 2021, the trial court

denied Appellants’ motion for summary judgment, stating that issues of fact

remained, rendering summary judgment inappropriate.

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J-A09030-23

We conclude that the trial court correctly denied Appellants’ motion for

summary judgment. While Appellants asserted that their expert opinions were

uncontradicted, upon review, the parties’ experts clearly disputed the cause

of Shultz’s medical issues and whether Appellees did, in fact, provide deficient

care. See Appellees’ Brief in Support of Appellees’ Response in Opposition to

Appellants’ Motion for Summary Judgment, 6/28/21, at 8-10. Because issues

of fact existed, Appellants were not entitled to judgment as a matter of law.

In Appellants’ second issue, they challenge the trial court’s May 11, 2022

omnibus order, ruling on the parties’ various motions in limine. Appellants’

Brief at 67-71. “When ruling on a trial court's decision to grant or deny a

motion in limine, we apply an evidentiary abuse of discretion standard of

review.” Commonwealth v. Ivy, 146 A.3d 241, 250 (Pa. Super. 2016)

(citation omitted). An error of law constitutes an abuse of discretion. Nat'l

Cas. Co. v. Kinney, 90 A.3d 747, 753 (Pa. Super. 2013) (citation omitted).

Appellants’ first challenge revolves around the trial court’s disposition of

Appellees’ motion in limine in which Appellees argued that, in addition to Dr.

Brady, Appellants’ other experts, namely, Stephen H. Broomes, M.D., Dr.

Larkin, and Dr. Altafullah, claimed that York Hospital “breached the standard

of care and [is] liable for corporate negligence.” Appellees Omnibus Motion in

Limine, 4/6/22, at 10. Appellees, therefore, claimed that Drs. Broomes, Larkin

and Altafullah’s proposed expert testimony was “cumulative” and must be

limited as such. Id. On appeal, Appellants claim that the trial court erred in

granting Appellees’ motion, arguing that it inappropriately “blocked and

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J-A09030-23

prohibited . . . [their] expert witnesses and their testimony” supporting

Appellants’ claim of corporate negligence against York Hospital. Appellants’

Brief at 70.

The trial court, however, did not grant Appellees’ motion in limine on

this basis. In its omnibus order, the trial court stated:

[Appellees’] fifth motion is styled as seeking to bar cumulative
testimony as to corporate negligence. We disagree with [the
styling of Appellees’ motion] in that form but find the
nature of the objection to be proper and consistent with the
remaining parts of this [o]rder. Drs. Larkin, Broomes, and
Altafullah are precluded from testifying as to any type of
corporate negligence which is not specifically based on one of
the enumerated duties set forth in [Thompson, supra,] and
within the fair scope of their respective report[s.]

Trial Court’s Omnibus Order, 5/11/22, at 5 (emphasis added). Contrary to

Appellants’ claim, the trial court permitted Drs. Larkin, Broomes, and

Altafullah to offer their expert opinions regarding York Hospital’s alleged

corporate negligence. The court simply required them to confine their

testimony to the four distinct duties outlined in Thompson and their

respective expert reports. Further, as will be discussed in greater detail below,

we consider whether Drs. Larkin and Altafullah’s expert testimony sufficiently

supported Appellants’ corporate negligence claim against York Hospital.10

Thus, Appellants claim is not only meritless, but also belied by the record.

____________________________________________

10 Ultimately, Dr. Broomes was not called as a witness during Appellants’
case-in-chief.

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J-A09030-23

In addition, Appellants argue that the trial court erred in granting

Appellees’ motion in limine which precluded Dr. Brady from “reading [] or

citing” the Advisory during his testimony. Appellants’ Brief at 68; see also

Ruff, 257 A.3d at 59 (explaining that the Advisory is a publication issued by

the Pennsylvania Patient Safety Authority, which was created under the

Medical Care and Reduction of Error Act, 40 P.S. § 1303.301. et. seq., and

“related to the reduction of medical errors for the purpose of ensuring patient

safety”). In particular, Appellants claim the trial court’s ruling was error

because the Advisory was independently admissible, either to prove notice or

because the Advisory constituted a public record which is an exception to the

hearsay rule. Appellant’s Brief at 69.

Hearsay, as defined by Pa.R.E. 801(a)-(c), is a declarant’s out-of-court

statement or assertion offered into evidence to prove the truth of the matter

asserted. Id. If a statement is hearsay, it is generally inadmissible. Pa.R.E.

802. If, however, a statement or assertion is offered “for a purpose other

than to prove the truth of the matter asserted,” such as notice or warning, it

is not hearsay and, as such, is admissible. Pa.R.E. 801, comment. In addition,

there are numerous exceptions to the prohibition against hearsay, as outlined

in Pa.R.E. 803.

This Court previously addressed an expert’s ability to testify about

reports or opinions that would otherwise be barred as hearsay. We stated:

Pennsylvania Rule of Evidence 703 provides the following:

Rule 703. Bases of opinion testimony by experts

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J-A09030-23

The facts or data in the particular case upon which an
expert bases an opinion or inference may be those
perceived by or made known to the expert at or before the
hearing. If of a type reasonably relied upon by experts in
the particular field in forming opinions or inferences upon
the subject, the facts or data need not be admissible in
evidence.

Pa.R.E. 703 ([emphasis omitted]).

While it is true that “an expert may not act as a ‘mere conduit
or transmitter of the content of an extrajudicial source[,]’”
Woodard v. Chatterjee, 827 A.2d 433, 444 (Pa. Super.
2003), there is a well-settled exception to the hearsay rule in
which an expert may express an opinion based, in part, upon
reports or the opinions of other experts provided such reports
or opinions are of a type customarily relied upon by experts in
the field. Primavera v. Celotex Corp., 608 A.2d 515, 521
(Pa. Super. 1992). In sum:

An “expert” should not be permitted simply to repeat
another's opinion or data without bringing to bear on it his
own expertise and judgment. Obviously in such a
situation, the non-testifying expert is not on the witness
stand and truly is unavailable for cross-examination. The
applicability of the rule permitting experts to express
opinions relying on extrajudicial data depends on the
circumstances of the particular case and demands the
exercise, like the admission of all expert testimony, of the
sound discretion of the trial court. Where . . . the expert
uses several sources to arrive at his or her opinion, and
has noted the reasonable and ordinary reliance on similar
sources by experts in the field, and has coupled this
reliance with personal observation, knowledge and
experience, . . . the expert's testimony should be
permitted.

Id. (footnote omitted).

Nazarak v. Waite, 216 A.3d 1093, 1108 (Pa. Super. 2019) (parallel citations

omitted).

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J-A09030-23

In their motion in limine, Appellees requested the trial court to “preclude

Dr. Brady from reading [] or citing the [Advisory].” Appellees Omnibus Motion

in Limine, 4/6/22, at 8. Appellees claimed that, in Ruff, this Court affirmed

the trial court order granting a similar defense motion and prevented Dr. Brady

from “introducing the [Advisory] into the record in its entirety” during his

testimony. Id. at 9. Based upon the foregoing, Appellees requested the trial

court in the instant matter to similarly limit Dr. Brady’s testimony, i.e., allow

Dr. Brady to “testify that he relied on the [Advisory] in reaching his opinion,

but [preclude] the document [from being] introduced [into evidence] in its

entirety.” Id.

In response to Appellees’ motion, Appellants stated:

It is submitted that the contents of the [Advisory] provide[]
important information concerning the danger of delayed or
missed diagnostic errors which is an important part of
[Appellants’] corporate negligence claims in this case.

The information contained in the Advisory is specifically relevant
to the concept of giving notice to York Hospital concerning the
dangers involving not complying with the duty to promulgate
appropriate policies and rules.

***

[Dr. Brady’s] use of the [Advisory] should permit him not only
to indicate that he relied on this publication in forming an
opinion, but also [to point] out how this publication has special
significance as notice to the hospital of what is required to
comply with the corporate standard of care to ensure the safety
and wellbeing of patients while in hospitals and how to perform
the third and fourth duties set forth in [Thompson.]

Appellants’ Brief in Opposition to Appellees’ Omnibus Motion in Limine,

4/18/22, at 31-33. Hence, Appellants asked that Dr. Brady be permitted to

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J-A09030-23

testify, in detail, regarding the contents of the Advisory to enable them to

establish their claims of corporate negligence against York Hospital namely,

the requisite standard of care and notice.

Ultimately, the trial court issued the following order regarding Dr.

Brady’s use of the Advisory:

[Appellees’] second, third and fourth motions seek to preclude
[Dr.] Brady[,] a proffered expert witness, from . . . introducing
the [Advisory.] … [W]hile an[] expert can rely upon materials
such as the [Advisory], they cannot be a conduit for the
introduction of the work which would otherwise be barred by
the hearsay rule. Thus, Dr. Brady can certainly make reference
to the Advisory through the course of his testimony, but he may
not read from it at length, nor will it be introduced as
independent evidence in this matter.

Trial Court’s Omnibus Order, 5/11/22, at 4. In issuing this ruling, the trial

court clearly considered the Advisory to be inadmissible hearsay. Specifically,

the court considered the Advisory to be a learned treatise, which is

inadmissible in Pennsylvania. See N.T. Trial, 6/13/22-6/17/22, at 649 (the

court stating: “We [are] not going to get into the nature of the document

again because I believe I [have] made it clear that for purposes of examining

the witness, it is to be treated as a learned treatise[.]”); see also Pa.R.E. 803

(18), cmt. (“Pennsylvania has not adopted F.R.E. 803(18). Pennsylvania does

not recognize an exception to the hearsay rule for learned treatises.”). Hence,

the trial court held that Dr. Brady was permitted to reference the Advisory as

a basis for his opinion, but he was not permitted to “act as a ‘mere conduit or

transmitter of [its content].’” Woodard, 827 A.2d at 444; see also Aldridge

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J-A09030-23

v. Edmunds, 750 A.2d 292, 298 (Pa. 2000) (explaining that, while “judicious

use of learned treatises may be made on direct examination of an expert

witness in appropriate circumstances for the limited purpose of explaining the

basis for the opinion,” a trial court must “impose appropriate constraints”).

Accordingly, because the trial court considered the Advisory to be a learned

treatise, it allowed Dr. Brady to reference the Advisory during his testimony

but prohibited him from reading it “at length.” Trial Court’s Omnibus Order,

5/11/22, at 4.

Herein, we initially conclude that Appellants’ present claim of error,

which alleges that the Advisory is independently admissible as a public record,

is waived. Upon review, it is apparent that Appellants never raised this issue

in a pre-trial motion in limine or in their opposition to Appellees’ omnibus

motions in limine. Instead, the first time Appellants referenced the

independent admissibility of the Advisory as a public record was briefly during

trial when Appellants responded to Appellees’ counsel’s objection to the

introduction of its contents during Dr. Brady’s testimony. See N.T. Trial.

6/13/22-6/17/22 at 648. In particular, following Appellees’ objection,

Appellants’ counsel stated:

[Aldridge, supra, is inapplicable because it] was dealing with
learned treatises, individuals or a number of individuals who
write about medicine. This is something different. It [is] a
governmental publication.

Id. Thus, the only time Appellants claimed the Advisory was a public record

before the trial court was during trial, after the court already ruled on the

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J-A09030-23

parties’ motions in limine and, even then, only through a passing statement,

without an offer of proof. Appellants seemingly concede this fact on appeal

because, in their appellate brief, they claim they “clearly notified” the trial

court that the Advisory “was a governmental report” in their “1925(b) filing.”

Appellants’ Brief at 69; see also Pa.R.A.P. 1925(b). Because Appellants first

presented the Advisory as a public record in their 1925(b) statement and on

appeal, this claim is waived. See Pa.R.A.P. 302 (“Issues not raised in the

lower court are waived and cannot be raised for the first time on appeal.”).

We also conclude that the trial court did not abuse its discretion by

treating the Advisory as an inadmissible learned treatise or by limiting Dr.

Brady’s testimony on this basis. While Appellants argued that the Advisory

was admissible to prove “notice” and, ostensibly, that it was admissible for

non-hearsay purposes, Appellants response to Appellees’ omnibus motion in

limine belies this claim, as Appellants admit they contemplated a broader use

of the document in that they sought to introduce the Advisory to establish

their corporate negligence claim against York Hospital. Indeed, Appellants

requested the trial court to permit Dr. Brady to relay the contents of the

Advisory to the jury so they could establish “how to perform the third and

fourth duties set forth in [Thompson].” Appellants’ Brief in Opposition to

Appellees’ Omnibus Motion in Limine, 4/18/22, at 31-33. Hence, Appellants

undoubtedly sought to offer the Advisory into evidence, not merely as proof

of notice, but as substantive evidence supporting their claim that York Hospital

breached one or more of its duties under Thompson.

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J-A09030-23

Moreover, the trial court’s decision to treat the Advisory as a learned

treatise and, as such, inadmissible hearsay, is supported by this Court’s

decision in Ruff. In Ruff, this Court confronted this exact issue, with the

exact same Advisory, and the exact same expert witness, Dr. Brady. See

Ruff, 257 A.3d at 59 (stating that the appellant asked the Court to consider

whether the trial court erred in granting York Hospital’s “motion in limine []

request[ing] the court to preclude [the a]ppellant’s expert, Dr. Brady, from

referring to the [Advisory]” during his testimony). Ultimately, the Ruff Court

affirmed the trial court’s ruling which held that the Advisory constituted a

learned treatise, and then precluded Dr. Brady from reading the text of the

Advisory during his testimony at trial. See id. (“In accordance with Aldridge,

the trial court permitted [Dr.] Brady to testify that the [Advisory] was

authoritative and that he relied upon it when rendering his opinion against

York [Hospital].”). Thus, for all of these reasons, we hold that Appellant’s

claim of error fails.

In Appellants’ fourth issue, they argue that the trial court erred in

disqualifying their expert, Dr. Brady. Appellants’ Brief at 72-78. The trial

court dismissed Dr. Brady because he repeatedly read from portions of the

Advisory during his expert testimony in violation of the trial court’s May 11,

2022 omnibus order. Appellants’ claim is meritless.

As this Court previously explained:

The purpose of pretrial motions in limine is to “give[] the trial
judge the opportunity to weigh potentially prejudicial and

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J-A09030-23

harmful evidence before the trial occurs, thus preventing the
evidence from ever reaching the jury.”

***

[As such, t]he grant of a motion in limine is a court order
that must be observed. … Why would counsel ever bother
filing such a motion if opposing counsel were free to
blithely ignore it without the court's affording any relief to
the offended party by way of the grant of a mistrial upon
proper application?

Buttaccio v. Am. Premier Underwriters, Inc., 175 A.3d 311, 320–321 (Pa.

Super. 2017) (internal citations omitted).

Herein, Appellants do not dispute that Dr. Brady violated the trial court’s

order and read from the Advisory during his expert testimony. Instead,

Appellants, again, argue that the trial court erroneously granted Appellees’

motion in limine and, as such, erroneously prohibited Dr. Brady from reading

from the Advisory at trial. See Appellants’ Brief at 72-77. As indicated above,

however, the trial court correctly limited Dr. Brady’s testimony based upon

the record before it. Moreover, upon review, it is apparent that Dr. Brady was

repeatedly asked about, and detailed the contents of, the Advisory during his

testimony, in direct contravention to the trial court’s May 11, 2022 omnibus

order. See N.T. Trial, 6/13/22-6/17/22, at 637-650 and 652-655. In similar

circumstances, we have approved more drastic remedies such as orders

granting a mistrial. See Buttaccio, 175 A.3d at 320-321. Accordingly, we

conclude that the trial court did not err in granting Appellees’ request and

dismissing Dr. Brady as an expert, a “lesser remedy” than ordering a mistrial.

Factor v. Bicycle Technology, Inc., 707 A.2d 504, 506-507 (Pa. 1998).

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J-A09030-23

In Appellants’ fifth and sixth issues, they argue that the trial court

erroneously granted Appellees’ motion for compulsory non-suit. We review a

challenge to an order granting or denying a compulsory non-suit as follows:

A motion for compulsory non-suit allows a defendant to test the
sufficiency of a plaintiff's evidence and may be entered only in
cases where it is clear that the plaintiff has not established a
cause of action; in making this determination, the plaintiff must
be given the benefit of all reasonable inferences arising from
the evidence. When so viewed, a non-suit is properly entered
if the plaintiff has not introduced sufficient evidence to establish
the necessary elements to maintain a cause of action; it is the
duty of the trial court to make this determination prior to the
submission of the case to the jury.

A compulsory non-suit is proper only where the facts and
circumstances compel the conclusion that the defendants are
not liable upon the cause of action pleaded by the plaintiff.

Hoffa v. Bimes, 954 A.2d 1241, 1243 (Pa. Super. 2008) (internal citations,

quotations, and corrections omitted).

We first address Appellants’ challenge to the trial court’s decision to

grant compulsory non-suit regarding their corporate negligence claim. As

stated above, to sustain a cause of action for corporate negligence, a plaintiff

must plead and prove: (1) the hospital breached one of the four specifically

enumerated duties in Thompson; (2) the hospital had actual or constructive

notice of the defects creating the harm; and (3) causation. See Whittington,

768 A.2d at 1149. In Welsh, our Supreme Court explained that, in general,

expert testimony is necessary to sustain a corporate negligence action. It

stated:

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J-A09030-23

In a traditional medical malpractice action, where the
defendant's negligence is not obvious, a plaintiff must present
expert testimony to establish to a reasonable degree of medical
certainty that the defendant's acts deviated from an accepted
medical standard, and that such deviation was the proximate
cause of the harm suffered. Mitzelfelt v. Kamrin, 584 A.2d
888 (Pa. 1990); Hamil v. Bashline, 392 A.2d 1280 (Pa. 1978).
The Commonwealth Court has determined that this expert
testimony requirement is equally applicable to claims of
corporate negligence where the hospital's negligence is not
obvious. Walls v. Hazleton State Gen. Hosp., 629 A.2d 232
(Pa. Commw. 1993). We believe the Commonwealth Court's
determination is sound, and accordingly, we hold that, unless a
hospital's negligence is obvious, a plaintiff must produce expert
testimony to establish that the hospital deviated from an
accepted standard of care and that the deviation was a
substantial factor in causing the harm to the plaintiff. We do
not, however, require experts to use “magic words” when
expressing their opinions. Mitzelfelt, supra. Instead, we look
at the substance of their testimony. Id.

Welsh, 698 A.2d at 585-586.

At trial, Appellants sought to establish a prime facie case of corporate

negligence based upon a violation of the third and fourth duties outlined in

Thompson, 591 A.2d at 707 (explaining that a hospital owes patients “a duty

to oversee all persons who practice medicine within its walls as to patient care”

and “a duty to formulate, adopt and enforce adequate rules and policies to

ensure quality care for the patients.”). The trial court granted non-suit

because it determined Appellants failed to present expert testimony to support

their claim of corporate negligence under either theory. Specifically, in its

1925(a) opinion, the trial court stated:

As to direct corporate liability, [Appellants] attempted to call
only one expert witness to prove corporate liability. We must
say “attempted” to call the witness, as when Dr. Brady was

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J-A09030-23

called as a witness[,] he was not qualified as an expert in the
area of corporate liability. Accordingly, regardless of the other
issues regarding Dr. Brady’s testimony discussed above,
[Appellants] failed to provide any expert testimony opining
[that] York Hospital breached one of the necessary duties to
establish corporate liability.

In our May 11, 2022, [o]mnibus [o]rder[,] we opined that
[Appellants] would be required to provide expert testimony to
establish corporate negligence. … Here, the alleged corporate
negligence was not “obvious.” Thus, [Appellants were] required
to produce expert testimony to establish corporate negligence.
[They] failed to produce such an expert[] and[,] therefore,
there was no factual basis to send that claim to the jury.
Accordingly, we did not error in granting non[-]suit in favor of
York Hospital on [Appellants’] corporate liability claim.

Trial Court Opinion, 8/12/22, at 15-16 (footnote and internal citations

omitted).

We initially address Appellants’ claim that York Hospital violated the

fourth Thompson duty, i.e., that York hospital failed to create policies and

procedures to ensure patients’ quality care. See Thompson, 591 A.2d at

707. A review of the trial transcripts reveals that Appellants sought to offer

Dr. Brady’s expert testimony to support this claim. See N.T. Trial,

6/13/22-6/17/22, at 603 and 647-648. No other experts testified in support

of this claim. As outlined above, however, Dr. Brady was disqualified as an

expert witness and his testimony stricken from the trial court record.11

Without Dr. Brady’s expert testimony, we conclude that Appellants failed to

present sufficient evidence to sustain their claim that York Hospital violated
____________________________________________

11 We previously determined that the trial court acted within the bounds of its

discretion in dismissing Dr. Brady as an expert witness as a sanction for his
violation of the trial court’s pre-trial order May 11, 2022. See, infra.

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J-A09030-23

the fourth Thompson duty and, in turn, caused Shultz’s injury. See Welsh,

698 A.2d at 585-586.

We now turn to Appellants’ contention that York Hospital violated the

third Thompson duty, i.e., the duty to “oversee all persons who practice

medicine within its walls as to patient care.” Thompson, 591 A.2d at 707.

At trial, Appellants sought to establish that, to uphold its duty of oversight,

York Hospital needed to implement point of care supervision. See Appellant’s

Brief at 31 (arguing that Thompson’s oversight duty required York Hospital

“to act [to protect Shultz] from a missed diagnosis of the cause of his stroke

[on September 25, 2014] and to [ensure that Shultz] receive[d] proper

treatment to avoid [his] second stroke.”). Indeed, Appellants claimed York

Hospital was required to ensure (1) that all appropriate tests were

administered (a right leg ultrasound and a transesophageal echocardiogram);

(2) that York Hospital’s providers discovered that Shultz had a DVT and a PFO;

and, finally, (3) that York Hospital administered Shultz a blood thinner before

discharge, as opposed to an aspirin. Appellants claim that implementation of

such supervisory measures would have prevented Shultz’s second stroke on

September 27, 2014.

As indicated previously, Appellants presented multiple expert witness

during their case-in-chief, in addition to Dr. Brady. We consider, therefore,

whether the testimony of Appellants’ experts, Drs. Altafullah and Larkin,

supported each of the essential elements of a corporate negligence claim, i.e.,

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J-A09030-23

whether Drs. Altafullah and Larkin offered expert testimony regarding the

standard of care and causation.12

First, Dr. Altafullah testified, in relevant part, as follows:

Q. Doctor, what was the standard of care for treatment in
2014?

A. Yes. Actually, that [is] a very easy answer. It was the same
standard in 2014 as it is now, vis-à-vis this situation. The
recommendation for anticoagulation in the setting of [DVT],
pulmonary embolism, and PFO in 2014, and this is part of the
guidelines of the American Heart and Stoke Association, in 2014
was to anticoagulate the patient.

By the way, this was a level 1A recommendation. Now, what
that means is there are various grades of recommendations.
Level 1A is the highest quality of recommended anticoagulation
for someone with a PFO and a [DVT], paradoxical embolism,
and stroke. That has not changed.

Q. Doctor, do you have an opinion based upon your review of
the records and based upon your experience whether or not the
stroke care providers in providing care to [] Shultz fell below
the appropriate standard of care in his diagnosis and treatment?

A. At the end, there were some errors of omission. As I said,
the doctors who saw him were right on target with their
hypothesis generation when he first came. If you read Dr.
Mingle’s note, he lays out all these possibilities. For some
reason, the plan was not executed appropriately.

Q. I [am] going to ask the question again. Did the physicians
treating [] Shultz on his first visit to [York H]ospital comply with
the standard of care and provide him with good and accepted
treatment practices in [accordance with their] diagnosis and
treatment of the stroke?

A. I would say they did not. As I said, there were omissions
that could have led to a very different course of action. And so
____________________________________________

12 Welsh expressly mandated expert testimony to establish only the first and

third prongs of a corporate negligence prima facie case. See Welsh, 698
A.2d at 585-586.

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J-A09030-23

while it pains me to say it about colleagues, I think there were
some omissions there that fell below the standard of care.

Q. Did the failure to provide a test to determine whether or not
there was DVT in his leg increase the risk of harm to this
patient?

A. Yes.

Q. And did it fall below the standard of care of good and
accepted practices not to perform a DVT test with an
ultrasound?

A. In the context of the recent sclerotherapy, the answer is
yes, that should have been done.

Q. And was it below the standard of care not to perform a
transesophageal echocardiogram on [] Shultz before
discharging him from the hospital?

A. Yes, it was.

Q. Did that—

A. As I said before, after the transthoracic had been done and
the ultrasound had been done and there were no answers as to
why he had had a stroke, that should have been done.

Q. And why is that?

A. Well, as I said, you know, there [is] a hierarchy of tests.
You do [not] do every test on everybody, but you [have] got to
go through. And so even with the reference to the [DVT] test,
compression venous ultrasound, you would [not] do it on
everybody, but you do it as somebody who had sclerotherapy
the day before who had a stroke. You [have] got to think this
through a little bit.

He just had a procedure in his leg injecting foam and doing
radiofrequency ablation. We know that can predispose to a
[DVT]. Okay? So if you are not finding an arterial source of
stroke, if you are not finding significant carotid disease, if you
are not finding significant small vessel disease on his MRI, why
did he have a stroke? You have to try and answer that question.
And it was [not] that difficult. It was a matter of doing an
ultrasound and another echo, which was ultimately done and
did give the answer a few days later.

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J-A09030-23

Q. And that would have indicated he should have been given
anticoagulant medication before he was discharged as part of
the discharge?

A. That is my opinion, correct.

Q. And is your opinion based upon reasonable medical
certainty?

A. Yes.

Q. I have to ask you another question concerning causation.
Do you have an opinion on whether or not the failure to provide
good and accepted care to these patients increased the risk of
harm of a second stroke?

A. Yes.

Q. Did that second stroke occur?

A. Yes.

Q. And it is your opinion that there was a second stroke; is that
correct?

A. Absolutely.

N.T. Trial. 6/13/22-6/17/22, at 246-250.

Thereafter, Dr. Larkin provided the following relevant testimony:

Q. Do you, based on your education, training, and experience,
have an opinion as to the cause of the stroke suffered by []
Shultz on September 25th and 27th?

A. I do.

Q. And what is that opinion?

A. His stroke was caused by blood clots that complicated his
vein procedure that embolized to the right heart. Some of them
went through the lungs, and some of them went through – or
one of them went through the PFO that caused his first stroke.
And then his second stroke was caused by the same mechanism
with a second blood clot that was much larger than the first.

Q. And is your opinion based upon reasonable medical
certainty?

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J-A09030-23

A. It is.

Q. Okay. I [am] going to ask the same question a different
way. Do you have an opinion concerning whether or not the
strokes that were diagnosed in [] Shultz’s hospitalization were
two separate events caused by the passage of emboli through
the PFO to the brain?

A. I do.

Q. And what is that opinion?

A. There were two separate events and two separate emboli
that passed through the PFO.

Q. Okay. I [am] going to repeat myself here because the basis
for that opinion you have already shown us, right, that there
was a wide open middle cerebral artery, and then there was a
--- the second time it was closed.

A. Right.

Q. Is that right?

A. That [is] right.

Q. Do you have opinions stated to a reasonable degree of
medical certainty concerning your review of the medical record
and whether the individual health care providers who were
providing stoke care to Fred Shultz acted in a manner that was
below the standard of care?

A. I do.

Q. And what is that? What deviations do you find?

A. Well, number one, despite knowing that the stroke could
have been due to the brain – to the vein procedures with a PFO,
they did [not] investigate that possibility. They did [not] do the
appropriate test, the transesophageal echo, which would have
diagnosed [] Shultz’s large PFO that he had at the time of the
vein procedure. That went undiagnosed before he was
discharged the first time. So that was below the standard of
care because the treatment would have been different.

Had they known there was a PFO and blood clots were being
thrown through the PFO, he would have been put on a blood
thinner, and it [is] highly likely the blood thinner would have

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prevented the second stroke. Sending him home on an aspirin
is woefully inadequate for this type of situation.

Q. That falls below the standard of care?

A. Yes.

Q. And does it increase the risk of a second stroke?

A. Yes.

Q. Based upon your training, education, and experience, is the
discharge of [] Shultz from this hospital without a diagnosis of
the cause of his stroke a departure from good and accepted
standards of practice?

A. Yes.

Q. And did that increase the risk of harm to him?

A. Yes.

Q. And did that harm occur?

A. Yes.

Q. How?

A. He had a second stroke because he was unprotected against
the second stroke because his diagnosis was [not] made before
they discharged him the first time.

Q. Was it below the standard of care not to provide
anticoagulant medication to him rather than an aspirin?

A. Yes.

Q. And did that increase the harm that did occur to him?

A. Yes.

Id. at 423-427.

The foregoing exchanges illustrate that the substance of Drs. Altafullah’s

and Larkin’s expert testimony pertained to Appellants’ claims that York

Hospital breached Thompson’s oversight duty in failing to ensure that (1) all

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appropriate tests were administered (a right leg ultrasound and a

transesophageal echocardiogram); (2) York Hospital providers discovered that

Shultz had a DVT and PFO; and (3) York Hospital providers prescribed

anticoagulants to Shultz upon discharge. We therefore conclude that

Appellants did, in fact, present expert testimony in support of their corporate

negligence claim against York Hospital. We must now determine whether, in

light of the aforementioned expert testimony, Appellants presented sufficient

evidence to establish a claim of corporate negligence based upon a violation

of the third Thompson duty; i.e. “a duty to oversee all persons who practice

medicine within its walls as to patient care.” See Thompson, 591 A.2d at

707.

Importantly, in a recent decision issued by this Court, we explained the

type of evidence a plaintiff must present to sustain a cause of action of

corporate negligence based upon an alleged violation of Thompson’s

oversight duty. See Corey v. Wilkes-Barre Hospital Company, LLC, 2023

WL 8535079 *1 (Pa. Super. Dec. 11, 2023) (en banc). We recognized that

recovery for corporate negligence is limited to instances in which a plaintiff

demonstrates “systemic negligence” on the part of a hospital. Id. at *8. In

other words, a claim for corporate negligence based upon an alleged breach

of a hospital’s oversight duty cannot be established by evidence of individual

decisions made by medical care providers with respect to the care and

treatment provided to a particular patient during a limited hospital visit. Id.

See also Welsh, 698 A.2d at 585 (“A cause of action for corporate negligence

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J-A09030-23

arises from policies, actions or inaction of the institution itself rather than the

specific acts of individual hospital employees.”); Boring v. Conemaugh

Memorial Hosp., 760 A.2d 860, 861 (Pa. Super. 2000) (holding that the

plaintiff simply established “that the nurses failed to act appropriately in this

case” and failed to show “systemic negligence” on the part of the hospital and,

as such, the trial court correctly declined to charge the jury on corporate

negligence). Thus,

a plaintiff sets forth sufficient evidence to sustain a cause of
action of corporate negligence based upon a violation of
Thompson’s oversight duty if he or she demonstrates systemic
shortcomings in diagnostic or treatment practices, such as
where patient care and safety are negligently overlooked and/or
ignored despite repeated presentations over extended periods
of time until it is too late to act.

***

[In general,] this requires a showing of ‘numerous and repeated
deviations from the standard of care by hospital personnel
[because] . . . [s]uch conduct over a period of time would allow
health care providers, namely, nurses, sufficient time to
observe and ‘go to their supervisor[s] and inform [them of the]
problem[s] that [] developed’ and, in turn, an opportunity for
hospital supervisors to implement corrective action.
Whittington, 768 A.2d at 1150.

Corey at *18-*19 (Concurring Opinion, J. Olson).

When we consider the facts and contentions presented by Appellants in

light of the teachings of Corey, we are compelled to conclude that the trial

court correctly entered a non-suit on Appellants’ claims of negligent corporate

oversight. Appellants’ allegations of corporate negligence in this case are

based exclusively upon a single admission to York Hospital and the conduct of

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J-A09030-23

its medical personnel on one day: September 25, 2014. Indeed, Appellants

did not present evidence showing that, over the course of days, weeks, or

months, the health care providers at York Hospital engaged in continued and

repeated negligence with respect to Shultz’s care, including proof tending to

demonstrate that he was overlooked and/or ignored as a patient at York

Hospital. In other words, Appellants failed to prove that York Hospital had

corporate knowledge of recurring departures from the standard of care

sufficient to establish “systemic negligence”. We therefore conclude that

Appellants did not present sufficient evidence to submit a cause of action of

corporate negligence against York Hospital to the jury and affirm the trial

court’s decision to grant York Hospital’s motion for non-suit on this basis.13

Lastly, we address Appellants’ claim that the trial court erred in granting

Appellees’ request for a compulsory non-suit regarding their vicarious liability

claims. The trial court entered a compulsory non-suit because it determined

that Drs. Larkin and Altafullah “expressed conflicting opinions as to the

standard of care appropriate to Shultz that [were] absolute and in opposition

to each other.” Trial Court Opinion, 8/12/22, at 16. Upon careful review, we

conclude that Drs. Larkin and Altafullah did not provide conflicting expert

testimony. As such, the trial court erred in granting Appellees’ motion for

____________________________________________

13 It “is well settled that where the result is correct, an appellate court may

affirm a lower court’s decision on any ground without regard to the ground
relied upon by the lower court itself.” Commonwealth v. Lehman, 275 A.3d
513, 520 n.5 (Pa. Super. 2022) (quotation omitted).

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J-A09030-23

compulsory non-suit with respect to Appellants’ vicarious liability claims

against Appellees.

In Mudano v. Phila. Rapid Transit Co., 137 A. 104 (Pa. 1927), our

Supreme Court held that a plaintiff cannot sustain his or her burden of proof

upon the presentation of conflicting expert testimony. In particular, the

Mudano Court held that if expert testimony is

so conflicting regarding the proper inference to be drawn as to
render either one of two inconsistent inferences possible of
adoption, the adoption of the one or the other would be nothing
more than a guess, and, under such circumstances, [the]
plaintiff fails to sustain the burden of proof which the law casts
upon him [or her].

Id. at 106. In subsequent decisions, however, our Supreme Court recognized

that, since Mudano, it “has allowed juries to consider and resolve conflicts

among expert witnesses.” Brannan v. Lankenau Hosp., 417 A.2d 196, 200

(Pa. 1980) (citing cases). Thus, “relatively minor divergence[s] in only a part

of [an] expert’s testimony, when viewed against the testimony as a whole”

will “not justify removal of [a party’s negligence] from jury consideration:”

“conflicts in [expert] testimony are fatal only if absolute.” Id.; see also

Brodowski v. Ryave, 885 A.2d 1045, 1061 (Pa. Super. 2005) (holding that

the experts’ testimony “did not present an irreconcilable conflict such that the

Mudano rule would apply to neutralize their opinions”).

Herein, the trial court held that Drs. Altafullah and Larkin presented

conflicting testimony regarding the administration of a certain type of

anticoagulant, Coumadin. In particular, the trial court stated:

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J-A09030-23

Dr. Altafullah testified that York Hospital deviated from the
standard of care by . . . not administering a B-12 anticoagulant,
specifically [C]oumadin. … Dr. Larkin also believed York
Hospital should have administered an anticoagulant, but
specifically testified it should not have been [C]oumadin, but a
different anticoagulant. Dr. Larkin specifically opined to have
given [C]oumadin would have also been a deviation from the
standard of care.

Trial Court Opinion, 8/12/22, at 17. Based upon the foregoing, the trial court

concluded that “the jury had no basis . . . to determine whether York Hospital

was to have administered [C]oumadin or some other fast-acting

anticoagulant. The jury would have been left to simply speculate.” Id. at 18.

In contrast to the trial court’s conclusion, we find that the opinions set

forth by Drs. Altafullah and Larkin regarding the administration of Coumadin

or some other anticoagulating agent were not so contradictory to each other,

that they left the jury to speculate regarding the standard of care. Drs.

Altafullah and Larkin both testified that York Hospital’s failure to administer

an anticoagulant before Shultz was discharged on September 25, 2014 fell

below the standard of care and, if York Hospital administered an

anticoagulant, it would have prevented Shultz’s second stroke. See N.T. Trial,

6/13/22-6/17/22, at 246-247 (Dr. Altafullah testifying that, in 2014, the

American Heart and Stroke Association recommended to “anticoagulate [a]

patient” in “the setting of [DVT], pulmonary embolism, and PFO”); see id. at

256 (Dr. Altafullah testifying that, if Shultz were given an anticoagulant

following his first stroke, his second stroke would not have occurred); see

also id. at 425-426 (Dr. Larkin explaining that Appellees deviated from the

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J-A09030-23

standard of care by not anticoagulating Shultz prior to his discharge and that

this failure increased the risk of his second stroke); see id. at 405-406 (Dr.

Larkin testifying that if Shultz were “anticoagulated instead of just being put

on an aspirin” it was “highly likely that would have prevented the second

stroke”).

In addition, Drs. Altafullah and Larkin consistently testified regarding

the administration of Coumadin. The exchanges in question occurred during

the doctors’ respective cross-examinations. In particular, the relevant

portions of Dr. Altafullah’s testimony are as follows:

Q. If one were to determine as a provider that a patient has an
embolic stroke and determines that the source of that stroke is
from a DVT, a paradoxical stroke from a DVT in the setting of a
PFO, in that situation, the treatment, I do [not] like that term,
the medication regimen for prophylaxis against recurrent stroke
changes from an antiplatelet, like aspirin and a statin, to an
anticoagulant and a statin?

A. Yes, that is correct.

Q. All of this is pursuant to the American Stroke Association
guidelines, correct?

A. Well, like I said, the guidelines provide the umbrella
recommendations, yes. But we individualize treatment all the
time. So[,] it [is] not like you can [not] do anything else as
long as you can justify it.

Q. Sure. But you actually said that this was level 1A best
evidence, correct?

A. That is the recommendation for those set of circumstances,
correct.

Q. In that set of circumstances, the anticoagulant that would be
given, again, in a patient who's been determined to have a
paradoxical embolic stroke due to DVT in the setting of PFO is

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J-A09030-23

an oral anticoagulant, specifically an oral vitamin K antagonist
anticoagulant, correct?

A. Not necessarily. So let me tell you what happens. We do
one of two things. We usually use -- if there [is] a high risk,
we start off with intravenous Heparin and transition to
Coumadin using a bridging drug called Lovenox, or we
can start them on a second[-]generation oral
anticoagulant such as Eliquis. In this case, we do not use
Heparin or Lovenox bridging. So[,] there are many
different ways of doing this.

Q. Doctor, the guidelines actually say that in this setting, a
provider should use a vitamin K antagonist oral anticoagulant,
correct?

A. Correct.

Q. Like Coumadin, correct?

A. Say that again.

Q. Doctor, the ASA, American Stroke Association guidelines, as
you said, their level 1A best evidence recommendations for the
treatment of a patient who is found to have a paradoxical stroke
from a DVT in the setting of a PFO is an oral anticoagulant,
specifically a vitamin K antagonist like Coumadin, correct?

A. Correct.

Q. The guidelines do not recommend using Heparin, correct?

***

A. They do say that. They do [not] recommend not to use it
either.

Q. Okay, Doctor.

A. You have -- okay. You have to -- counsel, the decision the
other day -- let me finish this up. You have to make a treatment
decision based on the individual circumstances.

Q. Doctor, I just want to make sure I understand this. The
American Stroke Association puts out guidelines based upon
what you said is grade level 1A best evidence, and those
guidelines specifically say the anticoagulant that you would use
is an oral vitamin K antagonist like Coumadin, and you [are]

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J-A09030-23

now saying that because it's silent on whether you can
also use Heparin, that's a perfectly fine choice?

A. Yeah. Absolutely.

Q. My goodness. There is actually guidelines that suggest using
Heparin in the setting of a stroke would so increase the risk of
hemorrhagic conversion that the risk would far outweigh the
benefit, correct?

A. Counsel, you should go to a neurology residency for this.
This is a very complex issue, and do [not] try to reduce it to
two or three lines. Okay? The recommendation -- let me finish
now. The recommendation for Heparin – one indication for
Heparin is in thrombotic strokes or in large atrial fibrillation
caused strokes. Each case is different. We routinely
anticoagulate patients with dissections and strokes. We
routinely anticoagulated patients with small strokes and venous
emboli. So[,] I think if you are going to make those blanket
statements, you need to also qualify them. Heparin is not
contraindicated in every patient with stroke. It is not indicated
in the large body of thrombotic stroke you are talking about.
Heparin is not contraindicated stroke, blanket.

Q. Doctor, generally speaking, a provider pursuant to the
American Stroke Association guidelines would not routinely
anticoagulate stroke patients in the hope of preventing
propagation of a stroke, correct?

A. Absolutely. We are not talking about routinely. We are not
talking about routine. We are specifically talking about an
individual. That [is] the whole point.

Q. And, Doctor, specific to this individual, in the setting of what
you have opined is a paradoxical stroke from a DVT in the
setting of a PFO, the guidelines specifically say the treatment is
a vitamin K antagonist oral anticoagulant like Coumadin,
correct?

A. Yes.

Q. Thank you. Can we agree that it takes several days for
Coumadin to become therapeutic?

A. Yes. And that's why we use bridging therapy.

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J-A09030-23

Q. Doctor, if you look at these guidelines, and trust me, I [have]
spent days studying and memorizing these guidelines, if you
look at these guidelines, there are other situations where the
American Stroke Association actually recommends bridging.
This is not one of those situations, correct?

A. I disagree with you. I completely disagree with you.
I am -- if this were my patient, and I [am] under oath, if
this were my patient and I were treating him and I found
that he had [DVT] and pulmonary emboli and a PFO and
a small stroke, I would anticoagulate him with a bridging
therapy or a second[-]generation oral anticoagulant.
Period. The guidelines do not prohibit individual decision
making based on individual patient characteristics. I [have]
said this all along. So[,] I [am] very consistent in my opinion
that the guidelines provide an umbrella. They do not dictate
every single case that you come across.

N.T. Trial, 6/13/22-6/17/22, at 289-294 (emphasis added).

The relevant portions of Dr. Larkin’s testimony are as follows:

Q. Can we agree that the treatment under the American Stroke
Association guidelines for a cryptogenic embolic stroke is the
same as a thrombotic stroke, being an antiplatelet like aspirin
or Plavix?

A. I [am] not that familiar with the guidelines to differentiate
the treatment differentiation between a cryptogenic stroke and
a thrombotic stroke. It [is] more of a neurology question. And
I [am] sure Dr. Altafullah has answered that.

Q. Let me ask this. If -- Coumadin is a vitamin K antagonist
anticoagulant, correct?

A. Correct.

Q. Coumadin, per the American Stroke Association guidelines,
would be the treatment for someone who has been diagnosed
with an ischemic stroke in the setting of a PFO and a DVT. Can
we agree to that?

A. That might be a guideline. But in – that [is] just a
guideline. And in certain cases, especially this case, you
[would] need to use something to anticoagulate him
sooner than five days like Heparin or Lovenox. Those are

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J-A09030-23

guidelines. That does [not] mean that [is] the way you have to
treat the patient. You treat the patient individually according
to their needs. A vitamin K agent waiting five days, not really
appropriate in [] Shultz's case in my opinion.

Q. Can we agree that if a provider followed the American Stroke
Association guidelines for the treatment of certain stroke
patients, that that would be within the standard of care?

A. Not necessarily.

Q. Doctor, are you suggesting that a provider cannot rely on
the American Stroke Association guidelines regarding the
recommendation for treatments of stroke patients?

A. Guidelines are just guidelines. You have to treat the
individual patient. So[,] you have to take -- each patient is
different. And guidelines are guidelines. They are something
to kind of get you started, but each patient is different.

Q. Dr. Altafullah yesterday told us that that recommendation
under the American Stroke Association guidelines is level 1A
best evidence recommendation. Do you disagree with that?

A. I did [not] hear Dr. Altafullah's testimony. I [have] not read
his testimony. So[,] I [am] not going to comment on his
testimony.

Q. I [am] going to ask you a hypothetical then, which I [am]
entitled to do of an expert. If Dr. Altafullah hypothetically
responded to one of my questions that way yesterday, would
you agree with him or disagree with him?

A. Responded in what way? That it was level 1A evidence?

Q. Yes. That the recommendation for a vitamin K antagonist as
the treatment plan for an ischemic stroke patient in the setting
of a PFO and DVT was . . . level 1A evidence -- best evidence.
Do you agree with that or disagree with that?

***

[A]. I [am] not really sure what you are asking. I [am] not
really comfortable answering it. Level 1A evidence is the
strongest evidence that we have in medicine. Medicine is
evidence based, and that's the strongest evidence. So[,] if Dr.
Altafullah said level 1A evidence says that something works,

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J-A09030-23

then I would say that's the strongest evidence that there is
available. That I can agree with.

***

Q. Let me ask it more generally then. Can we at least agree
that level 1A evidence is the best evidence that one can have in
formulating guidelines or care standards?

A. It is.

Q. Can we agree that Coumadin, as we [have] been discussing
here, takes several days to become therapeutic?

A. Coumadin does take several days, yes.

Q. In fact, in this particular case, when [] Shultz began taking
Coumadin, it took five days for it to become therapeutic,
correct?

A. I did [not] see that, how long it took. I did [not] see his
[international normalized ratio] after five days. I believe you
because that [is] how long it usually takes.

***

Q. I want to assume a hypothetical. I [am] going to assume as
part of this hypothetical that your opinion is correct that []
Shultz had two separate strokes. Those two separate strokes
happened within 48 hours, correct?

A. Correct.

Q. Even if [] Shultz, when he first arrived at York Hospital's
emergency department for the first stroke, even if -- although
it clearly would be inappropriate, if the first thing the providers
did was put a [five] milligram tablet of Coumadin in his mouth
and asked him to swallow it, and did the same thing the next
day on [September] 26[,] he still would not be anywhere close
to therapeutic on the Coumadin by the time he had, in your
opinion, the second stroke, correct?

A. I think we can agree that Coumadin by itself would not
be the appropriate treatment for Mr. Shultz after the first --

Q. Yes. Coumadin, even if it had been started the very second
he came in, would not have prevented what you believe to be
a second stroke, correct?

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J-A09030-23

A. Coumadin would not have, but there are other options
that would have prevented -- probably would have
prevented the second stroke. So[,] Coumadin by itself,
you are right, is not adequate to prevent the second
stroke in the first five days.

Q. And so, again, just to reorient ourselves, if the American
Stroke Association guidelines suggest that the treatment for an
ischemic stroke patient in the setting of a PFO and a DVT is
Coumadin, that standard, that guideline from the American
Stroke Association would not have prevented Mr. Shultz's
second stroke less than 48 hours later?

A. Coumadin would not have prevented his second
stroke. But, again, those are guidelines just to get
started. They do [not] take into account he just had a
vein procedure that causes blood clots. They do [not]
take into account he had pulmonary emboli in both lungs.
If those things are evident, then you put him on a blood
thinner that works immediately to prevent the second
stroke.

Id. at 470-479 (emphasis added).

It is clear that, during cross-examination of Appellants’ experts,

Appellees’ counsel attempted to pigeonhole them into agreeing that, in a

similar situation, i.e., in the setting of a PFO and a DVT, the American Stroke

Association called for the administration of Coumadin and that, because

Coumadin takes several days to become therapeutic, even if the doctors at

York Hospital administered it to Shultz, it would not have prevented his second

stroke. Importantly, Dr. Altafullah and Dr. Larkin both agreed that Coumadin,

alone, would not have prevented Shultz’s second stroke for this very reason.

In recognition of this fact, both experts called for the administration of an

anticoagulant like Heparin or Lovenox at the outset, as well as the

administration of Coumadin, and opined that, if York Hospital had taken this

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J-A09030-23

approach, it would likely have prevented Shultz’s second stroke.14

Accordingly, Appellants’ experts did not provide conflicting testimony and the

trial court erred in granting Appellees’ non-suit on this basis.

We reverse the trial court’s order granting Appellees’ motion for

compulsory non-suit on Appellants’ vicarious liability claim. We therefore

remand for a new trial. We, however, affirm the trial court’s orders in all other

respects, including its orders regarding the parties’ motions in limine,

Appellants’ motion for summary judgment and Appellees’ motion for

compulsory non-suit on Appellants’ corporate liability claims against York

Hospital.

____________________________________________

14 In their motion for compulsory non-suit, as well as on appeal, Appellees
argue that Appellants’ vicarious liability claims also failed because they could
not establish causation. In particular, Appellees point to the fact that
Appellants’ experts, specifically, Dr. Larkin, testified that “Coumadin by itself
. . . is not adequate to prevent the second stroke in the first five days.” N.T.
Trial, 6/13/22-6/17/22 at 478; see also Appellees’ Brief at 30. As indicated
above, Appellees’ claim regarding Dr. Larkin’s testimony is correct, but it also
fails to recognize that both Dr. Larkin and Dr. Altafullah consistently testified
that if Appellees administered Coumadin, in addition to another anticoagulant
like Heparin or Lovenox, Shultz would not have suffered his subsequent
stroke. See N.T. Trial, 6/13/22-6/17/22 at 289-294 and 470-479. Hence,
Appellants’ experts consistently testified that Appellees’ agents and ostensible
agents acted negligently by failing to administer Coumadin and another, fast
acting anticoagulant, and that this failure caused Shultz’s second stroke. If
Appellees’ counsel wishes to rely upon the guidelines of the American Stroke
Association as setting forth definitive parameters for patient care, he may do
so but, in the circumstances, it seems that any argument which emphasizes
deviations from the guidelines goes more to the weight of the expert’s
testimony and does not establish grounds for a non-suit based upon alleged
irreconcilability of the opinion evidence.

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J-A09030-23

Judgment affirmed, in part, reversed, in part. Case remanded for a new

trial. Jurisdiction relinquished.

Judge Kunselman files a Concurring Memorandum in which President

Judge Panella joins.

Judgment Entered.

Benjamin D. Kohler, Esq.
Prothonotary

Date: 04/16/2024

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