Judith Willis v. Royal Caribbean Cruises, LTD.

[PUBLISH]
In the
United States Court of Appeals
For the Eleventh Circuit
____________________
No. 22-11569
____________________
JUDITH WILLIS,
Plaintiff-Appellant,
versus
ROYAL CARIBBEAN CRUISES, LTD.,
Defendant-Appellee.
____________________
Appeal from the United States District Court
for the Southern District of Florida
D.C. Docket No. 1:20-cv-21192-KMM
____________________
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 1 of 16

-- 1 of 16 --

2 Opinion of the Court 22-11569
Before R OSENBAUM , BRANCH, and BRASHER , Circuit Judges.
B RANCH, Circuit Judge:
Judith Willis brought a three-count maritime negligence
action against Royal Caribbean Cruises, Ltd. (“Royal Caribbean”)
after she fell aboard one of its cruise ships. She alleged that during
the ship’s muster drill,1 a Royal Caribbean employee rushed her
down a set of stairs—causing her to fall and severely injure her
neck.
The district court granted summary judgment in favor of
Royal Caribbean. First, on Count I (general negligence) and Count
II (negligent failure to warn), the district court found that Willis
failed to show that Royal Caribbean had notice of the dangerous
conditions that allegedly caused her fall. Second, on Count III
(general negligence against Royal Caribbean for its employee’s
conduct under a theory of vicarious liability), the district court
determined that Willis put forth insufficient evidence of medical
causation.2
On appeal, Willis argues that these conclusions were
erroneous and asks us to reverse. After careful review, and with
the benefit of oral argument, we conclude that Willis failed to
adduce sufficient medical evidence to satisfy proximate cause. And
because proximate cause must be satisfied for each of her three
1 Muster drills are safety exercises that cruise lines are required to conduct.
2 The district court noted that the lack of evidence on medical causation was
an additional reason to grant summary judgment on Counts I and II.
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 2 of 16

-- 2 of 16 --

22-11569 Opinion of the Court 3
negligence-based claims to prevail, we affirm the district court’s
grant of summary judgment to Royal Caribbean.
I. Background
A. Factual Background
On May 4, 2019, Willis was a passenger aboard the Anthem
of the Seas, a Royal Caribbean cruise ship. Shortly after the ship
departed, Willis—like all passengers—was required to participate
in a muster drill. As part of the drill, Willis was directed to the
ship’s Royal Theater. According to Willis, once she reached the
theater, a Royal Caribbean employee, Valeriya Artyushenko,
rushed Willis through the seat-finding process which caused her to
fall down a set of steps:
[Royal Caribbean Counsel]: What happened when
you arrived at the theater?
[Willis]: Well, they swiped us in . . . . So we went in
and [Artyushenko] comes up to me and says, You’re
late. Hurry up. Get a seat.
So I felt, you know, she was attacking me. So I said
all right. And I went to the edge of the steps, and I
looked around. I said, where are the seats? There
were tons of people there.
So she said, follow me. She really had an attitude. So
I held on, and I went down. And she said go in there.
She points to a place. I went over there, and there
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 3 of 16

-- 3 of 16 --

4 Opinion of the Court 22-11569
was a pole. And then there was like 6 inches room,
and then there was the next banister, the hand.
I said, I can’t fit in there. She said—I’m fat, you know.
I can’t. So she said go in there. I said I can’t go in
there. I can’t climb. I’m old. I’m fat. So she says, oh,
come on, follow me. So I held on again, and I stepped
down and I went down. I don’t know what
happened. I went down. She was rushing me.
In her amended complaint and throughout her deposition
testimony, Willis emphasized that she fell because she was rushed
by Artyushenko even though Artyushenko knew that Willis’s age
and weight limited her physical abilities. In fact, Willis specifically
disclaimed other potential causes; she noted that her view of the
steps was not blocked, the lighting was sufficient for her to see, she
did not slip on any liquid or foreign substance, and the steps did not
surprise her (i.e., she knew she was about to go down steps—she
just fell once she started descending them).
According to Willis, the fall “injured her neck, lower back,
both arms and hips.” The medical evidence she provided at the
district court level, however, focused primarily on her neck injury.3
That evidence included her deposition testimony that she hurt her
neck, an MRI of her neck from June 2019 (roughly one month after
3 On appeal, Willis focuses exclusively on her neck injury.
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 4 of 16

-- 4 of 16 --

22-11569 Opinion of the Court 5
her fall),4 and a one-paragraph letter from her treating physician
that read:
[Willis] has been a patient in this medical practice
since 2012. She has been seen on a regular basis
because of a number of comorbid medical illnesses.
During that period of time there had been no
complaint of neck pain until her visit on June 19, 2019.
During that visit she did describe a fall that occurred
while being on a cruise and related having been seen
by an orthopedic surgeon who had requested an MRI
of the cervical spine because of pain which she had
been suffering from since her fall. The MRI did
indeed show multi-level disc disease of the cervical
spine. There had never been any prior radiologic
study of the spine to my knowledge to which any
comparison could be made. I hope this information
has been helpful.
B. Procedural History
Willis initially sued Royal Caribbean in March 2020, but then
moved to stay the case pending completion of her medical
treatment. The district court granted Willis’s motion and stayed
the case. In September 2021, the district court granted Willis’s
motion to reopen the case, and she filed an amended complaint,
which became the operative complaint in this case.
4 The MRI indicated that Willis had some disc herniations (C4-C5; C5-C6) and
some bulging discs (C6-C7; C7-T1) in her spinal column.
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 5 of 16

-- 5 of 16 --

6 Opinion of the Court 22-11569
The operative complaint asserted claims for general
negligence, negligent failure to warn, and negligence for
Artyushenko’s conduct under a theory of vicarious liability. After
answering and asserting affirmative defenses, Royal Caribbean
filed (1) an omnibus motion in limine that sought to exclude
evidence of three prior incidents that Willis sought to introduce to
prove that Royal Caribbean was on notice that injuries like hers
could occur aboard its ships, and (2) a motion for summary
judgment. The district court granted the motion in limine in part,
determining that the three prior incidents that Willis pointed to
were not “substantially similar” to Willis’s fall such that they were
inadmissible. Then, the district court granted summary judgment
in favor of Royal Caribbean, focusing—in pertinent part—on the
fact that Willis lacked medical expert testimony which the district
court understood to be required when a plaintiff’s complained-of
injury is not readily observable.5
5 More specifically, as to proximate cause, Willis pointed to (1) her deposition
testimony that she hurt her neck, (2) an MRI of her neck from June 2019, and
(3) the one-paragraph letter from her treating physician. Royal Caribbean
responded that her physician’s letter did not “actually opine on whether
[Willis’s] fall on the cruise caused the injury to her neck” and that expert
testimony is required to establish medical causation for conditions that are
“not readily observable” under Eleventh Circuit precedent. The district court
found that Willis’s physician’s letter did not adequately address causation
because it simply stated that Willis had neck pain and noted that there had not
been previous studies of her neck. In other words, the district court
understood the evidence to show that Willis had a neck injury, but not show
when that injury began or whether that injury was caused by her fall on the
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 6 of 16

-- 6 of 16 --

22-11569 Opinion of the Court 7
Willis appeals.
II. Standard of Review
“We review de novo a district court’s grant of summary
judgment, applying the same legal standards as the district court.”
Chapman v. AI Transport, 229 F.3d 1012, 1023 (11th Cir. 2000) (en
banc). This familiar standard dictates that “[t]he court shall grant
summary judgment if the movant shows that there is no genuine
dispute as to any material fact and the movant is entitled to
judgment as a matter of law.” Fed. R. Civ. P. 56(a).
III. Discussion
Willis puts forth three arguments. First, she argues that the
district court erred in excluding the prior incident evidence she
sought to introduce. Second, on the issue of medical causation, she
argues that the district court erred procedurally—by prematurely
shifting the summary judgment burden from Royal Caribbean to
her—and substantively—by wrongfully determining that she did
not present sufficient evidence. Third, she argues that the district
court erred in determining that she did not present sufficient
evidence in support of her vicarious liability claim.
We start our analysis by jumping straight to Willis’s second
argument (medical causation) because causation is an element
required by each of her three negligence-based claims. We
conclude that Willis fails to provide sufficient evidence to create a
ship. As such, the district court determined that Willis had not “borne her
burden of bringing forth medical expert evidence opining on . . . causation.”
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 7 of 16

-- 7 of 16 --

8 Opinion of the Court 22-11569
genuine dispute of material fact as to medical causation and,
therefore, we affirm the district court’s grant of summary
judgment to Royal Caribbean.6
A. Medical Causation
The district court found that Royal Caribbean was “entitled
to summary judgment on all claims . . . for which causation is an
essential element” (i.e., each of Willis’s claims) because Willis “has
not borne her burden of bringing forth medical expert evidence
opining on the issue of causation.” Willis argues that the district
court erred in making this determination because she put forth
three pieces of evidence that were sufficient to satisfy her burden
regarding medical causation: (1) her deposition testimony that she
hurt her neck when she fell, (2) the June 2019 MRI showing injuries
to her neck, and (3) the one-paragraph letter from her treating
physician that referenced her neck injury.7 We agree with the
district court and conclude that Willis’s evidence is insufficient.
As an initial matter, “[m]aritime law governs actions arising
from alleged torts committed aboard a ship sailing in navigable
6 In light of this conclusion, we need not analyze Willis’s first argument (prior
incident evidence). Even if she were to prove that the district court’s
“substantial similarity” analysis—which undergirded its decision to partially
grant Royal Caribbean’s motion in limine—constituted an abuse of discretion,
it would not change our ultimate conclusion in light of her failure to satisfy
the causation requirement.
7 Willis also argues that the district court prematurely shifted the summary
judgment burden from Royal Caribbean to her because Royal Caribbean had
not yet “negate[d]” an element of her claim. Willis misstates the fundamental
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 8 of 16

-- 8 of 16 --

22-11569 Opinion of the Court 9
waters.” Guevara v. NCL (Bahamas) Ltd., 920 F.3d 710, 720 (11th Cir.
2019). Along with our judicially created body of maritime law, we
“rely on general principles of negligence law” in analyzing a
maritime tort case. Id. (quotation omitted); Tesoriero v. Carnival
Corp., 965 F.3d 1170, 1178 (11th Cir. 2020) (“For maritime tort cases
in particular, we rely on general principles of negligence law.”
(quotation omitted)). Those general principles, of course, require
a plaintiff to show that “(1) the defendant had a duty to protect the
plaintiff from a particular injury; (2) the defendant breached that
duty; (3) the breach actually and proximately caused the plaintiff’s
injury; and (4) the plaintiff suffered actual harm.” Chaparro v.
Carnival Corp., 693 F.3d 1333, 1336 (11th Cir. 2012).
legal principle. The correct principle is simply that “[t]he moving party bears
the initial burden to show the district court, by reference to the materials on
file, that there are no genuine issues of material fact that should be decided at
trial.” Clark v. Coats & Clark, Inc., 929 F.2d 604, 608 (11th Cir. 1991). “Only
when that burden has been met does the burden shift to the non-moving party
to demonstrate that there is indeed a[n] . . . issue of [material] fact that
precludes summary judgment.” Id. But when the non-moving party bears the
burden of proof on an issue at trial, the moving party need not “support its
motion with affidavits or other similar material negating the opponent’s claim”
in order to discharge this initial responsibility. Celotex Corp. v. Catrett, 477 U.S.
317, 323 (1986) (emphasis in original). Instead, the moving party may simply
“point out to the district court that there is an absence of evidence to support
the nonmoving party’s case.” Rice-Lamar v. City of Ft. Lauderdale, 232 F.3d 836,
840 (11th Cir. 2000) (alterations adopted). Royal Caribbean satisfied this
requirement and met its initial burden—it showed the district court that Willis
could not prove the causation element because she lacked medical expert
testimony that opined on the cause of her neck injury. Willis’s argument that
Royal Caribbean had to do more is incorrect.
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 9 of 16

-- 9 of 16 --

10 Opinion of the Court 22-11569
The third element (causation) requires a plaintiff to show
that “the breach actually and proximately caused the plaintiff’s
injury.” Yusko v. NCL (Bahamas), Ltd., 4 F.4th 1164, 1167–68 (11th
Cir. 2021); see also Comcast Corp. v. Nat’l Ass’n of Afr. Am.-Owned
Media, 140 S. Ct. 1009, 1014 (2020) (“It is textbook tort law that a
plaintiff seeking redress for a defendant’s legal wrong typically
must prove but-for causation.” (quotation omitted)); Lexmark Int’l,
Inc. v. Static Control Components, Inc., 572 U.S. 118, 132 (2014) (“For
centuries, it has been a well established principle of [the common]
law, that in all cases of loss, we are to attribute it to proximate
cause, and not to any remote cause.” (quotation omitted)).
Our analysis of the causation question in this appeal boils
down to the following question: What does a plaintiff need to show
to prove causation in a maritime negligence claim involving non-
observable medical injuries?
The district court understood our law to require medical
expert testimony to prove causation for non-observable medical
injuries. That interpretation is understandable because we have
relied on such a rule in our unpublished case law. See, e.g., Rivera
v. Royal Caribbean Cruises Ltd., 711 F. App’x 952, 954 (11th Cir. 2017)
(unpublished) (“When the causal link between alleged injuries and
the incident at issue is not readily apparent to a lay person, expert
medical testimony as to medical causation is typically required.”).
And, relying on our unpublished case law, this rule has become
well-accepted and oft-applied among district courts in our Circuit.
See, e.g., Mann v. Carnival Corp., 385 F. Supp. 3d 1278, 1285 (S.D. Fla.
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 10 of 16

-- 10 of 16 --

22-11569 Opinion of the Court 11
Apr. 22, 2019) (“Courts have recognized that soft-tissue injuries,
such as lower back pain are not a readily observable medical
condition[] and, therefore, expert testimony as to the cause of such
injuries is required.” (quotation omitted)); Landivar v. Celebrity
Cruises, Inc., 584 F. Supp. 3d 1150, 1159–60 (S.D. Fla. Feb. 8, 2022)
(“Only expert testimony can support a finding of medical causation
if the causal connection between the breach and the harm is not
readily observable or susceptible to evaluation by lay persons.”
(quotation omitted)); Taylor v. Royal Caribbean Cruises Ltd., 437 F.
Supp. 3d 1255, 1261 (S.D. Fla. Feb. 4, 2020) (“In cases where injuries
are not readily observable or susceptible to evaluation by lay
persons, expert testimony is required to establish medical
causation.” (quotation omitted)). This body of case law, however,
does not bind our instant analysis. Lenis v. U.S. Att’y Gen., 525 F.3d
1291, 1292 n.3 (11th Cir. 2008) (“Because these opinions were
unpublished . . . they have no precedential value.”); Washington v.
Rivera, 939 F.3d 1239, 1244 n.8 (11th Cir. 2019) (“[D]istrict court
opinions are not binding precedent.”).
Tracing this rule back to its roots, we find that our
unpublished cases (as well as the district court cases in our Circuit)
generally cite Allison v. McGhan Medical Corporation, 184 F.3d 1300
(11th Cir. 1999), for the rule that non-observable injuries require
medical expert testimony to prove causation. See, e.g., Rivera, 711
F. App’x at 954–55. Allison, however, interpreted Georgia’s
substantive negligence law—rather than common law negligence
or maritime negligence. 184 F.3d at 1320 (applying Georgia law
and concluding that because whether “breast implants can and did
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 11 of 16

-- 11 of 16 --

12 Opinion of the Court 22-11569
cause systemic disease in Allison is not a natural inference that a
juror could make through human experience,” medical expert
testimony was necessary in order to prove causation). Thus,
before we cement the non-observable injury rule from Allison in
our maritime law, we make sure that such reliance is proper.
Without a controlling maritime principle, as is the case here,
“courts may apply state law provided that the application of state
law does not frustrate national interests in having uniformity in
admiralty law.” Coastal Fuels Mktg., Inc. v. Fla. Express Shipping Co.,
Inc., 207 F.3d 1247, 1251 (11th Cir. 2000); see also Steelmet, Inc. v.
Caribe Towing Corp., 779 F.2d 1485, 1488 (11th Cir. 1986) (“One
must identify the state law involved and determine whether there
is an admiralty principle with which the state law conflicts, and, if
there is no such admiralty principle, consideration must be given
to whether such an admiralty rule should be followed.”). Looking
to Florida negligence law,8 we find the same rule: non-readily
observable injuries require expert medical evidence to prove
causation. See Crest Prods. v. Louise, 593 So. 2d 1075, 1077 (Fla. 1st
DCA 1992) (“Lay testimony is legally insufficient to support a
finding of causation where the medical condition involved is not
readily observable.” (quotation omitted and alteration adopted));
see also Wausau Ins. Co. v. Tillman, 765 So. 2d 123, 124 (Fla. 1st DCA
8 According to Willis’s complaint, Royal Caribbean has its principal place of
business in Florida and “[t]he acts of [Royal Caribbean] set out in th[e]
[c]omplaint occurred in whole or in part in this county and/or state.” Florida
law is further appropriate because neither party disputes the application of
Florida law. Coastal Fuels, 207 F.3d at 1252 n.1.
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 12 of 16

-- 12 of 16 --

22-11569 Opinion of the Court 13
2000) (collecting cases). Thus, we wind up with the rule we started
with—Allison’s conclusion that non-readily observable injuries
require medical expert testimony to prove causation. 184 F.3d at
1320.
There is no indication that this rule would “frustrate
national interests in having uniformity in admiralty law.” Coastal
Fuels, 207 F.3d at 1251. In fact, other states in our Circuit follow
this rule, or one similar. The non-readily observable injury rule is
a fixture of Georgia law (as covered in this opinion). See, e.g.,
Allison, 184 F.3d at 1320. And Alabama courts have applied it as
well, but not in the causation context. See, e.g., Cajun Operating Co.
v. Elijah, 163 So. 3d 1037, 1041 (Ala. Civ. App. 2014) (“Although
some injuries that are observable to the jury do not require expert
evidence to permit the jury to determine that the injuries are
permanent, vision injuries such as the nonobservable complaints
raised by Elijah are not matters of common knowledge from which
a layperson could infer their permanence.”).
Accordingly, we formally recognize in the maritime context
that non-readily observable injuries require medical expert
testimony to prove causation. Tesoriero, 965 F.3d at 1178 (“[I]n the
absence of an established federal maritime rule, we may borrow
from a variety of sources in establishing common law admiralty
rules to govern maritime liability where deemed appropriate.”
(quotation omitted)).
With the law established, we turn back to Willis’s injury and
her supporting causation evidence. While her complaint
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 13 of 16

-- 13 of 16 --

14 Opinion of the Court 22-11569
references her injuries in only general terms (e.g., “Plaintiff was
injured about Plaintiff’s body and extremities”), she later provided
sworn testimony that her lawsuit is based on injuries to her neck:
[Royal Caribbean Counsel]: Can you tell me what
injuries you’re claiming to have suffered in the
accident on the [cruise ship] in May of 2019?
[Willis]: What injuries? Well, I hurt my neck. I’m
told I have herniated discs, and I have something
leaning on a nerve. I hurt my neck, the discs in my
neck.
. . .
[Royal Caribbean Counsel]: Okay. Any other injuries
that you’re claiming aside from your neck pain that
radiates to your head, shoulders, and arms?
[Willis]: And back, top back.
[Royal Caribbean Counsel]: Top of your back?
[Willis]: Not from that accident.
Neither party disputes that her complained-of neck injury is a non-
observable injury.
Her first two pieces of evidence (her own testimony about
her neck injury and the MRI itself) are clearly not medical expert
testimony and thus are not sufficient to establish proximate cause.
Willis herself is not a medical expert. Similarly, her MRI—
although performed by a medical doctor who noted, among other
things, that Willis had disc herniations and bulging discs in her
neck—does not touch on anything other than the condition of her
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 14 of 16

-- 14 of 16 --

22-11569 Opinion of the Court 15
neck and, therefore, cannot be considered an expert explanation
regarding causation. Willis’s final piece of evidence, her physician’s
letter, lacked any discussion of, or reference to, causation of her
neck injury altogether. While the letter creates a baseline (i.e.,
Willis had been seen on a regular basis without complaining of
neck pain prior to the incident) and analyzes the MRI to state that
it “show[s] multi-level disc disease of the cervical spine,” nothing
links Willis’s disc disease to her fall on the cruise ship. The letter
simply lacks the necessary specificity to establish proximate cause
as it pertains to non-readily observable injuries like Willis’s neck
injury.9 And because proximate cause is a necessary element for
Count I (general negligence) and Count II (negligent failure to
warn), the district court correctly granted summary judgment.
B. Vicarious Liability
Finally, the district court determined that because Willis was
unable to adduce evidence sufficient to create a genuine issue of
material fact as to causation, Willis’s vicarious liability claim
(Count III) also necessarily failed. Because vicarious liability still
requires causation, see Yusko, 4 F.4th at 1167–68, and Willis lacks
evidence to satisfy that element, her claim that the district court
9 Willis’s additional argument that she should have been permitted to testify
as to damages misses the mark because, as analyzed above, it is clear that she
cannot satisfy the other necessary elements of her negligence-based claims.
See generally Sorrels v. NCL (Bahamas) Ltd., 796 F.3d 1275, 1279–80 (11th Cir.
2015) (listing the four elements, each of which a plaintiff must satisfy, in order
to prevail on a claim under maritime negligence law).
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 15 of 16

-- 15 of 16 --

16 Opinion of the Court 22-11569
erred in holding that she did not present sufficient evidence in
support of her vicarious liability claim is a non-starter.10
IV. Conclusion
The district court got it right. We conclude, after clarifying
our law, that the district court was correct in determining that
Willis failed to adduce sufficient evidence to create a genuine issue
of material fact as to medical causation because she had no medical
expert opinion evidence regarding the proximate cause of her non-
observable neck injury. Thus, each of Willis’s three negligence-
based claims necessarily failed and the district court correctly
granted summary judgment to Royal Caribbean.
AFFIRMED.
10 Willis argues that notice (which the district court determined she was unable
to satisfy because her prior incident evidence was not “substantially similar”
to her factual situation) is not a required element of vicarious liability, so her
claim should be allowed to proceed. See Yusko, 4 F.4th at 1167 (“[T]he notice
requirement does not—and was never meant to—apply to maritime
negligence claims proceeding under a theory of vicarious liability.”). But the
lack of a notice requirement does not matter in this case because Willis still
has to show that the injury was caused by the actions of Artyushenko, and at
that point she runs into the same problem analyzed above.
USCA11 Case: 22-11569 Document: 31-1 Date Filed: 08/14/2023 Page: 16 of 16

-- 16 of 16 --