J-S10033-18
NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT I.O.P. 65.37
DENISE R. BRADLEY, : IN THE SUPERIOR COURT OF
ADMINISTRATOR OF THE ESTATE OF : PENNSYLVANIA
WALTER BRADLEY, DECEASED :
:
Appellant :
:
:
v. :
: No. 2915 EDA 2017
:
THOMAS JEFFERSON HEALTH SYSTEM :
AND HCR MANOR CARE HEALTH :
SERVICES :
Appeal from the Orders Entered August 4, 2017
In the Court of Common Pleas of Philadelphia County Civil Division at
No(s): 04435 August Term 2015
BEFORE: BOWES, J., OLSON, J., and NICHOLS, J.
MEMORANDUM BY NICHOLS, J.: FILED JULY 17, 2018
Appellant Denise R. Bradley, administrator of the estate of Walter
Bradley, deceased (Decedent), appeals from the orders granting summary
judgment in favor of Appellees Thomas Jefferson Health System (TJHS) and
Manor Care Health Services (MCHS). Appellant claims the trial court erred in
concluding that there was insufficient evidence of causation and that the
statute of limitations barred Appellant’s claims.1 We affirm in part, reverse in
part, and remand for further proceedings consistent with this memorandum.
According to Appellant’s amended complaint, Decedent suffered a stroke
on March 17, 2013, and was admitted as an inpatient to “Jefferson,” a health
____________________________________________
1 We have reordered Appellant’s arguments for the purpose of this appeal.
J-S10033-18
care facility owned and operated by TJHS. At that time, Decedent suffered
from an ulcer on his right foot and a general lack of skin integrity. According
to Appellant, Jefferson failed to treat Decedent’s skin conditions properly,
which resulted in the deterioration of the ulcer on his foot and the formation
of at least two additional bedsores. Decedent was discharged from Jefferson
on April 10, 2013.
That same day, Decedent was transferred from Jefferson to a facility
owned, operated, and maintained by MCHS. Appellant averred that at the
MCHS facility, Decedent failed to receive necessary care, which resulted in a
deterioration of his bedsores.
On April 15, 2013, Decedent was transferred from the MCHS facility to
Fitzgerald Mercy Hospital (Fitzgerald) for surgery on the ulcer. At that point,
Decedent was suffering from stage four bedsores that affected his bone tissue.
On April 24, 2013, Decedent was discharged from Fitzgerald and
readmitted to the MCHS facility. On May 23, 2013, Decedent was transferred
back to Fitzgerald due to suspected pneumonia and an infected sacral
decubitus ulcer.
Decedent was subsequently discharged from Fitzgerald to his home.2
Fitzgerald reported that Decedent was clinically stable at the time of this
discharge and that his sacral ulcer needed no further intervention.
____________________________________________
2 Appellant did not specify when Decedent was discharged from Fitzgerald to
his home.
-2-
J-S10033-18
Decedent passed away on September 3, 2013. A death certificate
indicated that the cause of death was “cerebral vascular accident” and
“hypertension.” MCHS’s Mot. Summ. J., 5/1/17, Ex. C. Appellant was granted
letters of administration on December 13, 2013.
On September 2, 2015, Appellant commenced the instant action by writ
of summons. Appellant filed a complaint on October 15, 2015. On October
27, 2015, Appellant discontinued her action against Fitzgerald. On November
30, 2015, Appellant filed an amended complaint against TJHS and MCHS.
Appellant asserted claims of corporate negligence against each defendant
(counts 1 and 2), as well as a wrongful death action (count 3), and a survival
action (count 4).3
____________________________________________
3 In her amended complaint, Appellant alleged:
17. The negligent defendant [TJHS] directly and proximately
caused [Decedent] to suffer the following injuries and damages:
a. delay in diagnosis of ulcer formation risk factors;
b. formation of additional ulcers and bedsores;
c. severe pain, suffering and discomfort;
d. change in mental status;
e. fear and anxiety;
f. economic damages.
Am. Compl., 11/30/15, ¶17. Additionally, with respect to her survival action
Appellant asserted the following:
-3-
J-S10033-18
Appellees filed preliminary objections to Appellant’s amended complaint,
which the trial court overruled. Appellees filed separate answers and new
matter raising various affirmative defenses. At the close of pleadings and
discovery, Appellees filed motions for summary judgment seeking dismissal
of all claims against them with prejudice.
Of relevance to this appeal, Appellees asserted that Appellant’s claims
were barred by the two-year statute of limitations pursuant to 42 Pa.C.S. §
5524. TJHS’s Mot. for Summ. J., 4/26/17, ¶ 43; MCHS’s Mot. for Summ. J. ¶
49, 58. Appellees also argued that the report of Appellant’s sole expert, John
N. Cardello, R.N., Esq., failed to establish that their conduct caused Decedent’s
____________________________________________
39. As a direct and proximate result of the aforesaid acts of
negligence, [Decedent] suffered and defendants are liable for the
following damages:
a. [D]ecedent’s pain and suffering between the time of his
injuries and the time of his death;
b. [D]ecedent’s total estimated future earning power less his
estimated cost of personal maintenance;
c. [D]ecedent’s loss of retirement and Social Security income;
d. [D]ecedent’s other financial losses suffered as a result of his
death;
e. [D]ecedent’s loss of enjoyment of life.
Id. ¶ 39.
-4-
J-S10033-18
death or increased the risk of harm or death.4 TJHS’s Mot. for Summ. J. ¶¶
75-76.; MCHS’s Mot. for Summ. J. ¶¶ 29-32. MCHS attached to its motion for
summary judgment a copy of Decedent’s death certificate that listed the cause
of death as cerebral vascular accident and hypertension.
In response to TJHS’s summary judgment motion, Appellant asserted
that Cardello’s expert report contained sufficient opinions to create a factual
issue that the negligence with respect to the creation and exacerbation of the
bedsores caused death. Appellant claimed that portions of Cardello’s report
implicated an increased risk of harm while Decedent was receiving care at
Jefferson. Appellant did not address TJHS’s statute of limitations claim.
In response to MCHS’s summary judgment motion, Appellant also
asserted that Cardello’s causation opinion was adequate for a factfinder to
determine the negligence with respect to bedsores as the cause death, and
cited Klein v. Aronchick, 85 A.3d 487 (Pa. Super. 2014).5 Appellant further
____________________________________________
4 Both Appellees raised additional defenses in their motions for summary
judgment. For example, TJHS asserted that (1) it did not provide any
treatment to Decedent and was not a proper defendant, and (2) Cardello failed
to state his opinion to a reasonable degree of medical certainty and relied on
speculation. MCHS also claimed that (1) it was an improperly named
defendant, (2) service was improper, and (3) Cardello failed to state his
opinions to the requisite degree of certainty. As discussed below, the trial
court did not rule on these alternative grounds for summary judgment.
5 Appellant did not seek to strike the death certificate attached to MCHS’s
motion or respond to the allegation that bedsores were not a listed cause of
death.
-5-
J-S10033-18
claimed that she was entitled to file her claims within two years of Decedent’s
death based on section 5524(2), as well as 40 P.S. § 1303.513, the “statute
of repose” contained in the Medical Care Availability and Reduction of Error
Act (MCARE).6
The trial court entered orders granting Appellees’ motions for summary
judgment on July 24, 2017, which the court amended on August 7, 2017. The
court concluded Appellant failed to proffer adequate evidence that Appellees’
negligence caused Decedent’s death. The court further concluded that
Appellant’s claims were barred because Appellant failed to file her action
within two years of the bedsores. The court did not consider any other basis
for granting summary judgment in favor of Appellees.
Appellant timely appealed on August 21, 2017. The trial court did not
order a Pa.R.A.P. 1925(b) statement, but filed an opinion suggesting that it
properly granted summary judgment in favor of Appellees based on the issues
of causation and the applicable statute of limitations.
Appellant presents the following questions for review, which we have
reordered as follows:
Whether the [trial c]ourt erred in granting summary judgment to
the Appellees where [Appellant’s] medical expert provided a
report that explained the causal relationship between the
negligence of each of the Appellees and [D]ecedent’s death?
____________________________________________
6 The Medical Care Availability and Reduction of Error Act, 40 P.S. §§
1303.101-1303.910.
-6-
J-S10033-18
Whether the [trial c]ourt erred in granting summary judgment to
the Appellees where the litigation against each of them was
initiated within the applicable statute of repose of the MCARE Act?
Appellant’s Brief at 6.
The standards governing our review of a trial court’s grant of summary
judgment are well settled.
Summary judgment is appropriate, inter alia, where there is no
genuine issue of any material fact as to a necessary element of
the cause of action or defense that could be established by
additional discovery. See Pa.R.C.P. No. 1035.2(1). In considering
the merits of a motion for summary judgment, the record is
viewed in the light most favorable to the non-moving party, and
doubts as to the presence of a genuine issue of material fact are
resolved against the moving party. The appellate review is for
errors of law or abuse of discretion.
Wilson v. El-Daief, 964 A.2d 354, 359 (Pa. 2009). “Summary judgment
should be granted when the ‘party who will bear the burden of proof at trial
has failed to produce evidence of facts essential to the cause of action or
defense which in a jury trial would require the issues to be submitted to a
jury.’” Vazquez v. CHS Prof’l Practice, P.C., 39 A.3d 395, 397 (Pa. Super.
2012) (citation omitted).
With respect to claims of medical malpractice,
a plaintiff must demonstrate the elements of negligence: a duty
owed by the physician to the patient, a breach of that duty by the
physician, that the breach was the proximate cause of the harm
suffered, and the damages suffered 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.
-7-
J-S10033-18
Stimmler v. Chestnut Hill Hosp., 981 A.2d 145, 154-55 (Pa. 2009) (citation
omitted).
To establish the causation element in a professional negligence
action, the plaintiff is not required to show that the defendant’s
negligence was the actual “but for” cause of the plaintiff’s harm.
Rather, under the “increased-risk-of-harm” standard, the plaintiff
must introduce sufficient evidence that the defendant’s conduct
increased the risk of the plaintiff’s harm.
Winschel v. Jain, 925 A.2d 782, 788 (Pa. Super. 2007) (citation omitted)
(emphasis in original).
Evidence regarding the increased risk of harm standard involves two
prongs. Klein, 85 A.3d at 492 (Pa. Super. 2014). First, the plaintiff’s expert
must be able testify to a reasonable degree of medical certainty that the
negligence could have caused the type of harm suffered. Id. Second, the
negligence must have been able to cause the actual harm. Id. In cases of
death, the increased risk of harm standard permits a case to proceed where
there was “any substantial possibility of survival and the defendant has
destroyed it.” Hamil v. Bashline, 392 A.2d 1280, 1288 (Pa. 1978).
It is also helpful to provide a brief overview of the distinctions between
wrongful death and survival actions.
A survival claim and a wrongful death claim are separate and
distinct even though they originate from the same wrongful act.
[U]nder the Pennsylvania wrongful death statute, recovery passes
to the limited group of beneficiaries defined in 42 Pa.C.S. §
8301(b), “the spouse, children or parents of the deceased.”
An action for wrongful death may be brought by the
personal representative of those persons entitled to receive
damages for wrongful death under the statute. . . .
-8-
J-S10033-18
Wrongful death damages are established for the purpose of
compensating the spouse, children, or parents of a
deceased for pecuniary loss they have sustained as a result
of the death of the decedent. . . .
A survival action, on the other hand, is brought by the
administrator of the decedent’s estate in order to recover
the loss to the estate of the decedent resulting from the tort.
...
These two actions are designed to compensate two different
categories of claimants[,] the spouse and/or members of
the decedent’s family for wrongful death of the decedent,
and the decedent herself through the legal person of her
estate.
Thus, in a wrongful death suit, claims are brought for and on
behalf of the statutory beneficiaries to obtain compensation for
their loss resulting from the deceased’s death. A wrongful death
claim belongs exclusively to the decedent’s beneficiaries and is
meant to cover pecuniary and emotional loss suffered by those
beneficiaries as a result of the death. By contrast, a survival claim
is simply the action the decedent could have brought for the
injuries he suffered prior to his death and is generally for the
benefit of the estate.
Rickard v. Am. Nat’l Prop. & Cas. Co., 173 A.3d 299, 305-06 (Pa. Super.
2017) (en banc) (citations omitted).
Mindful of the foregoing principles, we proceed to consider Appellant’s
arguments that the trial court erred in granting summary judgment in favor
of Appellees.
Appellant first claims that Cardello’s report provided sufficient bases for
a factfinder to find an increased risk of harm of death. Appellant emphasizes
that Cardello opined that “negligence was at root of [Decedent’s] downward
spiral.” Appellant’s Brief at 22. Additionally, Appellant contends that Cardello
-9-
J-S10033-18
attached to his report literature indicating that pressure sores “present a
‘serious problem’ that can ‘lead to sepsis or death.’” Id. at 22-23.
Following our review of the record, we agree with the trial court that
Cardello’s passing reference to a “downward spiral” failed to raise a genuine
issue of fact for the jury to decide. The causal connection from bedsores to
sepsis to death is not so self-evident that expert testimony was not required.
See Stimmler, 981 A.2d at 154–55. Similarly, Appellant cannot simply rely
on the literature indicating bedsores could result in sepsis and lead to death
as a substitute for a proper expert opinion that the negligent treatment of the
bedsores alleged herein increased the risk of sepsis and death. Thus, even
reviewing the record in a light most favorable to Appellant as the non-moving
party, we discern no abuse of discretion or error of law in the trial court’s
ruling.
Because Appellant failed to adduce adequate allegations that the alleged
negligence caused death, we affirm the trial court’s ruling dismissing
Appellant’s wrongful death action set forth in Appellant’s amended complaint.
For the same reasons, we agree with the trial court that Appellant cannot
maintain a survival action based on the claims that Appellees caused or
increased the likelihood of Decedent’s death.
Nevertheless, a survival action may include injuries Decedent suffered
short of death, for example, the bedsores themselves.7 See 42 Pa.C.S. §
____________________________________________
7See supra note 3 (indicating Appellant sought damages including pain and
suffering prior to death in her survival action).
- 10 -
J-S10033-18
8302 (prescribing that “[a]ll causes of action . . . real or personal” survive the
death of the plaintiff); cf. Rickard, 173 A.3d at 306 (“a survival claim is
simply the action the decedent could have brought for the injuries he suffered
prior to his death and is generally for the benefit of the estate”). Therefore,
we must consider the trial court’s ruling that the statute of limitations barred
Appellant’s action.
Appellant claims the MCARE Act created a separate statute of limitation
in section 1303.513(d) that preempts the general statute of limitations in
section 5524. Appellant’s Brief at 16-17. Appellant thus suggests that section
1303.513 permitted her to commence her action within two years of
Decedent’s death. Id. at 18.
Appellant’s claim raises a question of statutory interpretation. Our
review, therefore, is de novo and plenary. See Bulebosh v. Flannery, 91
A.3d 1241, 1243 (Pa. Super. 2014).
Section 5524(2) provides that “[a]n action to recover damages for
injuries to the person or for the death of an individual caused by the wrongful
act or neglect or unlawful violence or negligence of another” must be
commenced within two years. 42 Pa.C.S. § 5524(2). “The time within which
a matter must be commenced” is generally computed “from the time the cause
of action accrued.” 42 Pa.C.S. § 5502(a). A cause of action generally accrues
when an injury is inflicted. Wilson, 964 A.2d at 361.
Section 1303.513 states:
- 11 -
J-S10033-18
(a) General rule.--Except as provided in subsection (b) or (c),
no cause of action asserting a medical professional liability claim
may be commenced after seven years from the date of the alleged
tort or breach of contract.
(b) Injuries caused by foreign object.--If the injury is or was
caused by a foreign object unintentionally left in the individual’s
body, the limitation in subsection (a) shall not apply.
(c) Injuries of minors.--No cause of action asserting a medical
professional liability claim may be commenced by or on behalf of
a minor after seven years from the date of the alleged tort or
breach of contract or after the minor attains the age of 20 years,
whichever is later.
(d) Death or survival actions.--If the claim is brought under
42 Pa.C.S. § 8301 (relating to death action) or 8302
(relating to survival action), the action must be
commenced within two years after the death in the absence
of affirmative misrepresentation or fraudulent concealment of the
cause of death.
(e) Applicability.--No cause of action barred prior to the
effective date of this section shall be revived by reason of the
enactment of this section.
(f) Definition.--For purposes of this section, a “minor” is an
individual who has not yet attained the age of 18 years.
40 P.S. § 1303.513 (emphasis added). The MCARE Act defines a “medical
professional liability claim” as “[a]ny claim seeking the recovery of damages
or loss from a health care provider arising out of any tort or breach of contract
causing injury or death resulting from the furnishing of health care services
which were or should have been provided.” 40 P.S. § 1303.103.
The Pennsylvania Supreme Court recently discussed the interaction
between section 5524(2) and section 1303.513 in Dubose v. Quinlan, 173
- 12 -
J-S10033-18
A.3d 634 (Pa. 2017).8 The decedent in Dubose suffered from bedsores that
deteriorated during a 2005 stay at a nursing home. She developed additional
bedsores after her admission to a hospital. One of the sores became infected
in July of 2007. The infection resulted in sepsis, and the decedent was
readmitted to the hospital in September 2007. One month later, the decedent
died from septic shock caused by multiple bedsores and dehydration.
The administrator of the decedent’s estate in Dubose commenced an
action against the nursing home and the hospital in August of 2009 and
asserted claims of negligence and wrongful death. The administrator then
filed a second action against the nursing home and hospital administrators
asserting wrongful death and survival actions. The administrator of the estate
prevailed at trial.
The appellants in Dubose—the nursing home and the hospital—
appealed, arguing, in relevant part, that the action was barred by the two-
year statute of limitations pursuant to section 5524(2). The appellants
asserted that the trial court erred in relying on section 1303.513(d) to “revive
causes of action that the statute of limitations barred.” Dubose, 173 A.3d at
637-38. This Court affirmed the trial court’s ruling on the statute of
limitations. Id. at 639 (discussing Dubose v. Quinlan, 125 A.3d 1231 (Pa.
Super. 2015)). The Pennsylvania Supreme Court granted allowance of appeal.
____________________________________________
8The Pennsylvania Supreme Court decided Dubose on November 22, 2017,
one month after the trial court authored its Rule 1925(a) opinion.
- 13 -
J-S10033-18
In Dubose, the Pennsylvania Supreme Court recognized that
traditionally, “a statute of limitations creates ‘a time limit for suing in a civil
case, based on the date when the claim accrued.’ Measured by this standard,
a claim accrues in a personal-injury or property-damage action ‘when the
injury occurred or was discovered.’” Id. at 643-44 (citations omitted). With
respect to survival actions, the Court noted the traditional view that:
[t]he statute [of limitations] will, of course, begin to run prior to
death with respect to injuries that the afflicted individual should
reasonably have “discovered” while alive, and, for this reason, it
was held in [Anthony v. Koppers Co., 436 A.2d 181, 185 (Pa.
1981)] that the survival statute begins to run, “at the latest,” at
death. The explanation for this lies in the nature of the survival
cause of action, for, as stated in Anthony, “the survival statutes
do not create a new cause of action; they simply permit a personal
representative to enforce a cause of action which has already
accrued to the deceased before his death.” . . . [T]he “accrual”
concept was expressly recognized in Anthony; hence, the statute
of limitations was regarded as running, at the latest, from the time
of death, unless it had earlier “accrued” through the fact that the
victim knew, or should reasonably have known, of his injury.
***
In the context of survival actions, which, as heretofore discussed,
merely permit a personal representative to pursue a cause of
action that had already accrued to a victim prior to death, the
Pocono[ International Raceway v. Pocono Produce, Inc., . .
. 468 A.2d 468 ( [Pa.] 1983),] rule causes the statute of
limitations to commence to run on the date when the victim
ascertained, or in the exercise of due diligence should have
ascertained, the fact of a cause of action. In no case, however,
can that date be later than the date of death; hence, the statute
runs, at the latest, from death. Because death is a definitely
ascertainable event, and survivors are put on notice that, if an
action is to be brought, the cause of action must be determined
through the extensive means available at the time of death, there
is no basis to extend application of the discovery rule to permit
- 14 -
J-S10033-18
the filing of survival actions, or wrongful death actions, at times
beyond the specified statutory period.
Id. at 645-46 (some citations and emphasis somitted).
The Dubose Court, however, determined that section 1303.513(d)
constituted a statute of limitation that modified the traditional accrual date for
survival actions. See id. at 643, 648. The Court first reasoned that the text
of section 1303.513(d) mirrored the traditional statute of limitation because
it focused “not on the defendant’s conduct but the time within which the
plaintiff must sue.” Id. at 647. Moreover, unlike statutes of repose that were
not subject to equitable tolling, section 1303.513(d) contained an equitable
tolling provision based on “‘affirmative misrepresentation or fraudulent
concealment of the cause of death.’” Id. (quoting 40 P.S. § 1303.513(d)).
The Dubose Court next determined that section 1303.513(d)
“prevail[ed] over the general statute of limitations for personal injuries actions
contained in [section 5524(2)].” Id. The Court noted that it was within the
General Assembly’s province to enact a “more specific statute of limitations
for medical professional liability that results in death.” Id. at 648.
If the General Assembly wanted to set a statute of repose of two
years from the date of decedent’s death, it could have provided,
similar to Section 513(a), “no cause of action for wrongful death
or survival may be commenced after two years from the death.”
It did not; instead, it created a statute of limitations for medical
professional liability cases resulting in death, which accrues at the
time of decedent's death.
Id.
The Court thus concluded that the intent of section 1303.513(d) was to
create a new statute of limitations for medical professional liability cases
- 15 -
J-S10033-18
resulting in death and thereby modify the traditional common law principle
that the survival action accrued at the time of the injury. Id. In the final
statement of its holding, the Dubose Court declared: “In conclusion, we hold
that [section 1303.513(d)] establishes a two-year statute of limitations for
medical professional liability cases in the form of wrongful death or survival
actions, which accrues at the time of the decedent’s death.” Id.
The remaining question in this appeal is whether the statute of limitation
in section 1303.513(d) is limited to cases resulting in death. Section
1303.513(d) does not distinguish between a survival action based on death or
an injury short of death. See 40 P.S. § 1303.513(d) (“[i]f the claim is brought
under . . . [section] 8302 (relating to survival action), the action must be
commenced within two years after the death”; see also 40 P.S. § 1303.103
(defining a medical professional liability claim as including claims for injury or
death). Therefore, although Dubose involved a survival claim resulting in
death, the plain language of section 1303.513(d) compels the conclusion that
the same statute of limitation be applied to all survival actions, including
actions involving injuries short of death. Accordingly, we are constrained to
conclude that Appellant had two years from the date of death to bring her
survival claims for injuries that did not result in death.
Thus, we reverse the trial court’s ruling to the extent that Appellant’s
claim for injuries short of death were barred because Appellant failed to
commence her action within two years of the injuries. Because the court did
not address Appellees’ remaining arguments in support of their motions for
- 16 -
J-S10033-18
summary judgment, we vacate the orders and remand for further
consideration of Appellees’ motions with respect to Appellant’s remaining
survival claim for damages based on the bedsores.9
Orders affirmed in part and reversed in part. Case remanded for further
proceedings consistent with this memorandum. Jurisdiction relinquished.
Judgment Entered.
Joseph D. Seletyn, Esq.
Prothonotary
Date: 7/17/18
____________________________________________
9 The trial court, following remand, may consider whether Appellant’s failure
to respond to TJHS’s motion for summary judgment constitutes waiver.
- 17 -