Estate of Roy Sumrall and Estate of Della Sumrall v. Singing River Health System

IN THE COURT OF APPEALS OF THE STATE OF MISSISSIPPI

NO. 2018-CA-01260-COA

ESTATE OF ROY SUMRALL AND ESTATE OF APPELLANTS
DELLA SUMRALL

v.

SINGING RIVER HEALTH SYSTEM APPELLEE

DATE OF JUDGMENT: 08/07/2017
TRIAL JUDGE: HON. ROBERT P. KREBS
COURT FROM WHICH APPEALED: JACKSON COUNTY CIRCUIT COURT
ATTORNEY FOR APPELLANTS: ROBERT W. SMITH
ATTORNEYS FOR APPELLEE: BRETT K. WILLIAMS
JAMES EVERETT LAMBERT III
NATURE OF THE CASE: CIVIL - MEDICAL MALPRACTICE
DISPOSITION: AFFIRMED - 04/14/2020
MOTION FOR REHEARING FILED:
MANDATE ISSUED:

BEFORE BARNES, C.J., GREENLEE AND McDONALD, JJ.

GREENLEE, J., FOR THE COURT:

¶1. Roy and Della Sumrall (the Sumralls) filed a medical-malpractice claim against

Singing River Health System (Singing River) under the Mississippi Tort Claims Act

(MTCA), Mississippi Code Annotated sections 11-46-1 to -23 (Rev. 2002), for injuries

sustained to Della after the removal of a central venous catheter. After a bench trial, the

circuit court entered judgment in favor of Singing River. The Sumralls appealed from that

judgment to this Court, citing five errors. This Court reversed and remanded the case

(Sumrall I), finding the circuit court abused its discretion by allowing Singing River’s expert
witness to testify outside the scope of his designation.1 After a second bench trial, the circuit

court again entered judgment in favor of Singing River. It is from that order the Sumralls2

now appeal. Finding no error, we affirm the circuit court’s judgment.

FACTS AND PROCEDURAL BACKGROUND

I. Background

¶2. On February 23, 2012, sixty-eight-year-old Della Sumrall was admitted to Ocean

Springs Hospital (OSH), a facility owned and operated by Singing River, with severe

inflammation of the gallbladder3 and a pancreatic pseudocyst. In addition, Della suffered

from a litany of other co-morbidities, including diabetes, a renal artery stent, coronary artery

bypass grafting, coronary artery disease, a partially collapsed lung, chronic obstructive

pulmonary disease (COPD), and more. The record also shows that Della smoked heavily

prior to 2012. Although Della was considered a high risk for surgery, Dr. Edward Dvorak,

her attending physician, recommended removal of Della’s gallbladder and ordered a central

line be placed in her external jugular vein because of the expectation of a prolonged recovery

course.4 The surgery was successful.

1
Sumrall v. Singing River Health Sys., 189 So. 3d 661, 664, 670 (¶¶9, 32) (Miss. Ct.
App. 2015) (hereinafter “Sumrall I”).
2
The Sumralls died after the first trial, and their estates were substituted as parties.
3
Dr. Edward Dvorak testified that he had to convert from a “laparoscopic procedure,”
a minimally invasive procedure, to an “open procedure,” which involves a much larger
incision, due to the severity of inflammation in Della’s gallbladder. According to Dr.
Dvorak, the necessity of the conversion is “fairly rare.”
4
A “central line” or central venous catheter is a “a catheter passed through a
peripheral or central vein, ending in the superior vena cava or right atrium, for measurement

2
¶3. Nurse Chequita Steele, a registered nurse employed at OSH at the time of the

proceedings, was tasked with caring for Della from or around the time of her surgery to the

date of her discharge. Nurse Steele testified that Della had complained about not being able

to breathe while lying flat on her back and that she preferred to sit up.

¶4. On February 29, 2012, Dr. Dvorak ordered that Della be discharged to the

Comprehensive Rehabilitation Center (CRC) in Pascagoula.5 At the time, Della suffered

from a partially collapsed lung,6 pneumonia, and chronic COPD, and she required oxygen.

At or around 12:00 p.m., Nurse Steele reclined Della’s chair at an angle less than ninety

degrees. According to Nurse Steele’s trial testimony, Della had been reclined “somewhere

between 30 and 45 [degrees]. Probably closer to 45 [degrees].” Thereafter, Nurse Steele

informed Della about the need to remove the central line and the removal process. At or

around 4:10 p.m., Nurse Steele began the removal process. The record shows that Nurse

Steele removed the dressing that covered the central line’s insertion site, cut the sutures,

applied pressure to the site using gauze, instructed Della to take a breath and bear down, and

then removed the line. Nurse Steele testified that she held pressure over the removal sight

for approximately one minute. After one minute had elapsed, Della started gasping for

of central venous pressure or for infusion of hyperosmolar solutions.” PDR Medical
Dictionary 327 (3d ed. 2006). As noted by the parties, they are used to give medicines,
fluids, nutrients, or blood to patients.
5
Although Dr. Dvorak initially ordered for Della to be discharged, as she was
“medically ready,” there was further testimony that Della’s discharge order was later
rescinded because Della’s family members “were not comfortable” with Della’s discharge.
6
Della suffered from chronic atelectasis of the right upper lobe.

3
breath and became unresponsive.

¶5. Della was given emergency treatment in her room. Shortly after, Della was

transported to the intensive-care unit (ICU) where she was observed in respiratory arrest.

The respiratory arrest resulted in anoxic brain injury and with a degree of permanent

impairment. Due to her condition, a second central line was inserted while she was in the

ICU. Della’s condition improved over nineteen days, so she was ordered to be discharged

from the ICU to the nursing center. For discharge, her central line had to be removed. On

March 19, 2017, the discharge nurse placed Della in the Trendelenburg position,7 followed

protocol, and removed the central line without complication. Della ultimately departed OSH

on March 29, 2012.

¶6. On May 18, 2012, the Sumralls filed a medical-malpractice suit against Singing River.

The complaint alleged that Nurse Steele was “substandard and negligent” in removing the

first central line, which caused an air embolus, respiratory arrest, and anoxic brain damage.

The complaint also alleged that Singing River was vicariously liable for Nurse Steele’s

actions.

II. Sumrall I

¶7. After a bench trial, this Court held in Sumrall I that the circuit court abused its

discretion by allowing Dr. Corder to testify “inconsistent with, outside of, and beyond his

designation.” Sumrall I, 189 So. 3d at 669 (¶29). According to this Court, the circuit court’s

ruling that there was no applicable standard of care with regard to patient positioning during

7
The Trendelenburg position is defined as “a supine [position] in which the feet are
higher than the head.” PDR Medical Dictionary 1545 (3d ed. 2006).

4
the removal of a central line was against the “overwhelming weight of the evidence.” Id. at

670 (¶30). In addition, this Court held that Dr. Corder testified outside the scope of his

designation by stating that Della suffered from a stroke. Id. at 669 (¶28). Because of those

errors, this Court reversed and remanded the case further proceedings.8 Id. at 670 (¶32).

III. Sumrall II Trial

¶8. A second bench trial occurred on May 1, 2017, in the Jackson County Circuit Court.9

The parties submitted the first trial’s transcript into the record and re-introduced all of the

exhibits. The parties also agreed to redact Dr. Corder’s testimony from the record to comply

with the findings of this Court in Sumrall I. Dr. Corder was called to re-testify.10 The

following trial testimony, from Sumrall I and Sumrall II, is now before this Court:

8
Judge Virginia Carlton concurred in part and dissented in part. Judge Carlton
agreed with the majority regarding reversal but opined that liability should have been
rendered because (1) the circuit court erred by concluding that no duty was owed to Della,
and (2) Nurse Steele had testified outside the scope of her nursing expertise. Sumrall I, 189
So. 3d at 670-73 (¶¶33-39) (Carlton, J., concurring in part and dissenting in part).

Judge Jack Wilson, joined by Judge David Ishee, dissented. Judge Wilson agreed that
the circuit court abused its discretion by allowing Dr. Corder to testify in a manner
inconsistent with his pretrial disclosures and that there was insufficient evidence to support
the circuit court’s findings to the extent that the court relied on Dr. Corder’s undisclosed
opinions. However, Judge Wilson concluded that the circuit court made additional findings
that did not depend on Dr. Corder’s undisclosed opinions and that were independently
sufficient to support the judgment. Id. at 673-74 (¶¶40-43) (Wilson, J., dissenting).
9
The Sumrall I bench trial was held on December 9-11, 2013. During the first trial,
the Sumralls called six witnesses, and Singing River called three witnesses. The first trial’s
transcript, except Dr. Corder’s testimony, was re-introduced at the second trial, along with
all of the exhibits.
10
The parties’ briefs indicate that Dr. Corder’s testimony was redacted from the
record “by agreement of the parties.”

5
A. The Sumralls’ Case-in-Chief

¶9. The Sumralls presented two expert witnesses at the Sumrall I trial. Dr. Lidgia Vives

was tendered as an expert in the field of vascular neurology. Nurse Crystal Keller was

tendered as an expert in the field of nursing. Both experts were offered to present evidence

about the standard of care during central line removal. The experts testified that under the

generally accepted standard of care for central line removal, the nurse should (1) educate the

patient about the procedure; (2) place the patient in the Trendelenburg position; (3) instruct

the patient to hold his or her breath and bear down (the “Valsalva” maneuver11); (4) place

pressure on removal site with gauze; and (5) remove the catheter and continue to hold

pressure for approximately five minutes. According to Dr. Vives, Nurse Steele breached the

standard of care by not putting Della into the Trendelenburg or supine position while

removing the central line. Dr. Vives further concluded that Della suffered from an air

embolism as a result of the removal. According to Nurse Keller, Nurse Steele deviated from

the standard of care because she failed to “adequately assess” whether Della could tolerate

the Trendelenburg position, “adequately position” Della, and “adequately educate” Della on

the procedure. Both experts testified on cross-examination that if a hypothetical patient were

unable to tolerate the Trendelenburg position (i.e., difficulty breathing in that position or

intracranial pressure), then a position other than Trendelenburg (i.e., a position the patient

could tolerate) would be acceptable during the removal of a central line. They also testified

11
The Valsalva maneuver, which increases intrathoracic pressure, involves “any
forced expiratory effort (‘strain’) against a closed airway, whether at the nose and mouth or
at the glottis.” PDR Medical Dictionary 1151 (3d ed. 2006).

6
that there were indications that showed Della could tolerate the Trendelenburg position on

February 29, 2012. This was based in part on the fact that Nurse Jenna Blaine was

subsequently able to place Della in the Trendelenburg position on March 19, 2012.

¶10. Nurse Blaine also testified at the first trial. Nurse Blaine was a registered nurse who

was assigned to Della after the removal of the first central line. She testified that she

removed a second central line from Della’s left subclavian vein on March 19, 2012. When

asked about patient positioning, Nurse Blaine testified that she placed Della in the

Trendelenburg position. According to Nurse Blaine, Della was able to tolerate the

Trendelenburg position on that day. She further testified that if Della could not have

tolerated that position, she would have placed Della in a supine position or “raised the head

of the bed . . . until [Della] could [have] tolerate[d] it.”

¶11. Della’s daughters, Nina Musgrove and Tina Danley, also testified. Both daughters

testified as to their mother’s physical well-being prior to and after the February 29 incident.

Specifically, Musgrove testified that she was in the hospital room at the time Nurse Steele

removed the central line. According to Musgrove, her mother was sitting “straight up” at the

time the catheter was removed.

¶12. The Sumralls’ final witness at the first trial was Roy Sumrall. Roy testified about his

relationship with Della and her health following the incident. In addition, Roy testified about

a subsequent hospital trip that he and Della took in July 2012. During that visit, Della had

another central line inserted. The next month, Della was ordered to be discharged. Roy

testified that a doctor removed the central line while Della was in the Trendelenburg

7
position.12

¶13. The Sumralls also introduced the sworn depositions of Dr. John Weldon, a hospitalist

and full-time employee of Singing River; Dr. Frank Martin, the Medical Director of the

Ocean Springs Nursing Center;13 and Nurse Steele.

B. The Defense’s Case-in-Chief

¶14. Singing River called Nurse Steele as its first witness at the Sumrall I trial. Nurse

Steele testified about her recollection of the events that occurred on February 29, 2012.

According to Nurse Steele, she informed Della about removing her central line. She then

positioned Della somewhere between thirty and forty-five degrees, applied pressure to the

insertion site, and instructed Della to bear down and hold. The central line was removed, and

Nurse Steele stated that she continued to hold pressure on the site until Della lost

consciousness. Nurse Steele testified that Della had trouble lying flat in the days prior to

removal. According to Nurse Steele, Della had reiterated her inability to breathe in the

supine position on the day the line was removed.

¶15. Singing River’s second witness at the Sumrall I trial was Dr. Corder, an expert

witness. As discussed, his testimony was redacted from the record to comply with the

findings of Sumrall I. Dr. Corder was called to re-testify in Sumrall II. Dr. Corder was

tendered as an expert in the field of internal medicine and anesthesiology. Dr. Corder

testified that as an anesthesiologist and internist, he routinely placed and removed central

12
Roy did not know the doctor’s name.
13
Dr. Martin provided on-going care to Della after her discharge from OSH.

8
lines. He also testified that he placed a central line one day prior to re-offering his testimony

at trial. Dr. Corder stated that he was familiar with the policies and procedures with respect

to the insertion of central lines and the removal of central lines. He then testified to Della’s

medical history and co-morbidities. After, Dr. Corder testified that he disagreed with Dr.

Vives that Della suffered from air embolus. The circuit court sustained an objection

regarding the reason why Dr. Corder disagreed with Dr. Vives. According to the circuit

court, Singing River’s counsel had not disclosed such testimony. Dr. Corder then explained

the process of removing a central line. It reflected the same process given by Dr. Vives. Dr.

Corder testified that Nurse Steele’s positioning of Della at the time of removal was

appropriate. According to Dr. Corder, Della’s positioning at the time Nurse Steele removed

the central line was “consistent with what [he] suspect[ed] . . . her clinical conditions [were]

at that time.” The Sumralls’ attorney did not cross-examine Dr. Corder, and his testimony

concluded the second trial.

¶16. Singing River’s third witness at the first trial was Dr. Dvorak, Della’s attending

physician, who had removed Della’s gallbladder and ordered her discharge. Dr. Dvorak

testified that he thought it was unlikely that Della suffered from a venous air embolus

because the size of the catheter was “very small.”14 In addition, he and other hospital

personnel “never saw any evidence” of an air embolus. According to Dr. Dvorak, Della may

have experienced sudden cardiac arrest, a stroke, or a vagal episode15 when the central line

14
The catheter was a 7-French triple-lumen catheter.
15
Dr. Dvorak testified that a vagal episode occurs when “the heart rate pressure slows
down and the blood pressure becomes low.”

9
was removed, as opposed to an air embolus. At the conclusion of his testimony, the defense

rested.

¶17. On July 26, 2017, the Sumrall II circuit court entered its findings of fact and

conclusions of law. In the findings of fact, the circuit court determined, in part:

All of the facts and evidence presented to the [c]ourt clearly establish the
standard of care to be: (1) the nurse should educate the patient about the
procedure; (2) place the patient in the Trendelenburg position, which is
described as having the patient in a supine position where the site of the central
line insertion is below the heart; (3) have the patient take a deep breath, hold
and bear down (the [V]alsalva maneuver); (4) then, at removal, place gauze
with pressure at the removal site. The expert testimony and facts have
established that one of the steps in the standard of care is to place the patient
in the Trendelenb[u]rg position. The facts also establish, however, that such
a standard would not be absolute, and under the right circumstances, a position
other than Trendelenb[u]rg is acceptable. Therefore, even though
Trendelenb[u]rg is the standard, the intolerance of the plaintiff to that position
would allow for deviation from the standard without violation of the standard.

In the conclusions of law, the circuit court ruled, in part:

The central question at hand, besides the precise position of the plaintiff at the
time of the central line removal is the proper positioning of a patient for the
purpose of central line removal. In other words, there is no question that the
plaintiff claims improper removal of the central line by Nurse Steele due to the
alleged improper positioning of the plaintiff during the removal process. It is
the plaintiff’s burden to prove the applicable standard of nursing care with
regard to positioning during central line removal. Furthermore, the plaintiff
must show that the defendant breached the applicable standard of care in
relation to any exceptions inherent in the applicable standard of care. As
stated in the Findings of Fact above, the plaintiff proved the standard of
nursing care for the removal of a central line that would apply to the procedure
performed by Nurse Steele here is the four-part procedure discussed above.
The part of the standard at issue is whether Nurse Steele violated the standard
of care by not placing plaintiff in the Trendelenb[u]rg position before
removing the central line. The facts and evidence also showed the
Trendelenb[u]rg method allowed for variations, even allowing for patients to
not be reclined, depending on the patient’s tolerance as such the plaintiff
firmly established the duty was owed to comply with the standard of care.

10
While the plaintiff has offered sufficient proof of a standard of care, the
plaintiff would next have to prove a breach of that standard. Here, based upon
facts surrounding the medical condition of the plaintiff, she was unable to
tolerate the Trendelenb[u]rg position. The evidence, and even testimony of
plaintiff’s own experts, supports the fact that a position other than
Trendelenb[u]rg is acceptable under such circumstances. The facts and
evidence further shows the patient was within the exceptions of the applicable
standard of care and Nurse Steele complied with the appropriate standard in
regard to those exceptions. . . . [T]herefore, there is no breach of the standard
of care.

The Sumralls filed their second notice of appeal on August 24, 2018.

DISCUSSION

¶18. On appeal, the Sumralls claim that (I) Dr. Corder was not qualified to testify as to the

standard of care; (II) Dr. Corder’s testimony was not consistent with his pretrial disclosures;

(III) the circuit court’s findings of fact and conclusions of law are against the overwhelming

weight of the evidence; (IV) the circuit court did not follow the remand directives of Sumrall

I; and (V) there was cumulative error.

I. Expert-Witness Qualification

¶19. The Sumralls argue that the circuit court abused its discretion by ruling that Dr.

Corder, an anesthesiologist and internist, could testify as to the standard of care for removing

central lines. Dr. Corder was allowed to testify as an expert in the field of anesthesiology and

internal medicine and offer opinions regarding Della’s medical records, causation, and

whether Nurse Steele deviated from the applicable standard of care.

¶20. The standard of review for the admission or exclusion of expert testimony is abuse of

discretion. Kronfol v. Johnson, 283 So. 3d 1162, 1173 (¶22) (Miss. Ct. App. 2019) (citing

Patterson v. Tibbs, 60 So. 3d 742, 748 (¶19) (Miss. 2011)), cert. denied, 283 So. 3d 733

11
(Miss. 2019). “Absent abuse of discretion, a judge’s determination as to the qualifications

of an expert witness will remain undisturbed on appeal.” Hubbard v. Wansley, 954 So. 2d

951, 956 (¶11) (Miss. 2007). “It is generally not required that an expert testifying in a

medical malpractice case be of the same specialty as the doctor about whom the expert is

testifying.” Id. at 957 (¶13). However, the expert witness must demonstrate “[s]atisfactory

familiarity with the specialty of the defendant doctor” before the witness will be permitted

to testify and offer opinions “as to the standard of care owed to the plaintiff patient.” Id.

¶21. The issue was whether Dr. Corder was qualified to testify as to the “nursing standard

of care” for removing central lines. According to the Sumralls, Dr. Corder was not “tendered

[or] qualified as an expert in [the] nursing standard of care . . . .” We note that this

underlying issue was previously raised in Sumrall I. This Court addressed the matter by

stating:

Here, we are concerned with the second step [in the standard of care], i.e., the
proper positioning of the patient. We also note that there was testimony that
the removal of a central line may be done by both nurses and doctors. Thus,
there was no testimony that the standard of care for the removal of a central
line would be different depending on the type of medical profession. So we
reject the allegation that Singing River failed to present evidence of a separate
nursing standard of care. There was absolutely no evidence that a doctor or a
nurse would remove a central line differently.

Sumrall I, 189 So. 3d at 666 (¶14).

¶22. Dr. Corder was qualified to testify to the applicable standard of care. As mentioned

in Sumrall I, the record before us is devoid of any evidence showing that a medical doctor

would remove a patient’s central line differently than a registered nurse. The Sumralls’

expert, Dr. Vives, stated in her deposition that the standard of care for nurses and physicians

12
is the same. The record shows that prior to trial, the Sumralls made a similar argument—that

a medical doctor is qualified to testify to the applicable nursing standard of care—in a

response to Singing River’s motion to exclude Dr. Vives. In that response, the Sumralls

claimed that Dr. Vives was qualified to testify to the nursing standard of care for removing

a central line although she was a medical doctor because of her knowledge and familiarity

with relevant medical literature, the procedure, and because “the standards for central line

removal are the same for doctors and nurses.”

¶23. We find that Dr. Corder demonstrated “[s]atisfactory familiarity” with the procedure

required to remove a patient’s central line. Hubbard, 954 So. 2d at 957 (¶13). Dr. Corder

testified that he routinely placed and removed central lines. He also stated that he had

removed a central line the day before giving his trial testimony. Absent contrary evidence

in the record, we note that there may be some limited instances where the standard of care

applicable to medical doctors is the same standard of care applicable to nurses. Cf. Delta

Reg’l Med. Ctr. v. Venton, 964 So. 2d 500, 505 (¶¶9-12) (Miss. 2007) (receiving expert

testimony from both a medical doctor and a registered nurse about the applicable standard

of care in prevention of decubitus ulcers or bedsores). Here, the record is without evidence

showing that the standard of care for removing central lines differs between doctors and

nurses. Finally, Dr. Corder did not offer a standard of care different from the standard of

care presented by Dr. Vives or Nurse Keller. Instead, Dr. Corder agreed with Dr. Vives and

Nurse Keller about the standard of care but disagreed on whether Nurse Steele deviated from

that standard. For these reasons, we find that circuit court did not abuse its discretion by

13
finding that Dr. Corder was qualified to testify to the standard of care for removing a

patient’s central line.

II. Expert-Witness Designation

¶24. The Sumralls also argue that Dr. Corder’s expert testimony was not consistent with

his pretrial disclosures. Similar to expert qualifications, the standard of review is abuse of

discretion. Kronfol, 283 So. 3d at 1173 (¶22).

¶25. Our rules of civil procedure require a party, upon request, to disclose the identity of

each person expected to be called as an expert witness at trial, “the subject matter on which

the expert is expected to testify,” “the substance of the facts and opinions,” and “a summary

of the grounds for each opinion[.]” M.R.C.P. 26(b)(4)(A)(i)-(ii). As noted in Sumrall I, our

supreme court has held:

Compliance with the rule involves a fact-intensive comparison between the
subject matter contained in discovery responses and the subject matter of the
testimony given by the expert at trial. [Buskirk v. Elliott, 856 So. 2d 255, 264
(¶25) (Miss. 2003)]. This Court has found discovery violations and subsequent
exclusion of expert testimony to be proper when the experts testified as to a
subject matter different from the subject matter contained in discovery
responses. See, e.g., Colthrap v. Canesale, 733 So. 2d 780, 786 [(¶27)] (Miss.
1999) (trial court committed reversible error by admitting expert testimony
supporting additional theory of plaintiff’s injury not revealed during
discovery); T.K. Stanley Inc. v. Cason, 614 So. 2d 942, 950-51 (Miss. 1992)
(trial court erred in admitting expert testimony regarding permanent disability,
as it was a separate subject matter from causation). However, this Court has
established that “where the stated subject matter in the response necessarily
includes the subject matter testified to at trial, it is an abuse of discretion to
exclude the expert’s testimony.” Buskirk, 856 So. 2d at 264 [(¶25)].

Sumrall I, 189 So. 3d at 668 (¶23) (quoting Canadian Nat’l/Ill. Cent. R.R. v. Hall, 953 So.

2d 1084, 1097 (¶44) (Miss. 2007)).

14
¶26. We start by comparing the subject matter of Dr. Corder’s designation and the subject

matter of his trial testimony. Prior to trial, Singing River disclosed in its “Second Amended

Designation” that Dr. Corder would testify that Nurse Steele did not deviate from the

standard of care while removing Della’s central line. The designation stated that Dr.

Corder’s opinions would “contradict any opinions on standard of care and/or causation as

stated” by Dr. Vives and Nurse Keller. It also explained that his opinions were based in part

on the medical records and documents, deposition transcripts, his experience, his training,

his educational background, relevant medical literature, and the pleadings filed in the case.

¶27. Upon careful review of Dr. Corder’s trial testimony, the transcript shows that Dr.

Corder testified to the same subject matter as his disclosure. Dr. Corder testified that he was

familiar with central lines and the required procedures for placing and removing central lines.

He testified that he had reviewed the Sumralls’ complaint, medical records, the (pretrial)

disclosures, witness depositions, various institutions’ central line policies and procedures,

additional physicians’ records, the nursing home’s records, and Dr. Vives’s and Nurse

Keller’s trial testimonies. He also explained the manner in which Nurse Steele removed

Della’s central line and testified that her conduct was appropriate under the applicable

standard of care, especially given Della’s medical history and physical well-being at the time

it was removed.

¶28. In their reply brief, the Sumralls claim that the circuit court’s ruling contradicts our

holding in King v. Singing River Health System, 158 So. 3d 318, 323 (¶23) (Miss. Ct. App.

2014). In that case, this Court affirmed the trial court’s decision to exclude the plaintiffs’

15
expert, a neurologist who had extensive experience treating strokes, because the expert’s

opinions were not based on reliable data. Id. at 328-29 (¶45). The trial court in King ruled

that the neurologist’s opinions were unreliable because they lacked support in relevant

medical literature. Id. at 324 (¶28). The plaintiff argued that although the neurologist expert

testified at odds with the medical literature, his opinions overcame the conflict by reference

to his own experience as a doctor. Id. at 326 (¶35). This Court disagreed, holding that

“where a theory has been studied in the medical literature and an expert’s opinion is

challenged for being contrary to the medical literature, there must be some support in the

medical literature for a medical expert’s opinion or some basis for believing that the medical

literature is wrong.” Id. at (¶36).

¶29. We find King distinguishable from the instant case. In King, the plaintiff’s expert’s

testimony was inconsistent with the relevant medical literature. This Court held that it was

improper for the neurologist to overcome that inconsistency by strictly relying on his personal

experience as a doctor. Here, Dr. Corder agreed with the Sumralls’ experts regarding the

applicable standard of care. As to patient positioning, the record shows that the relevant

medical literature demonstrates that a patient may be situated in a position other than

Trendelenburg if the patient cannot tolerate that position. As such, Dr. Corder’s opinion was

not at odds with the relevant medical literature in this case.

¶30. On these facts, we cannot say that Dr. Corder testified outside the subject matter for

which he was designated by Singing River. “[D]iscovery responses regarding experts do not,

indeed cannot include everything that an expert witness will state at trial.” Walker v. Gann,

16
955 So. 2d 920, 929 (¶24) (Miss. Ct. App. 2007) (internal quotation marks omitted) (quoting

Peterson v. Ladner, 785 So. 2d 290, 295 (¶20) (Miss. Ct. App. 2000)). As required by Rule

26(b)(4)(A), Singing River’s pretrial disclosure identified Dr. Corder as an expert witness,

gave notice of the subject matter in which he was to testify, stated his opinions and bases for

those opinions, and a summary for how he came to those conclusions. Therefore, we find

that the circuit court was within its discretion to conclude that Dr. Corder was properly

designated.

III. Weight of the Evidence

¶31. In their third assignment of error, the Sumralls contend the circuit court’s findings of

fact and conclusions of law were against the overwhelming weight of the evidence.

Specifically, the Sumralls argue that it was error for the circuit court to conclude that Della

was unable to tolerate the Trendelenburg position.

¶32. “In reviewing the decision of a trial judge sitting without a jury, this Court may only

reverse when the findings of the trial judge are manifestly wrong or clearly erroneous.”

Greenwood Leflore Hosp. v. Bennett, 276 So. 3d 1174, 1178 (¶10) (Miss. Ct. App. 2018)

(quoting Sacks v. Necaise, 991 So. 2d 615, 619 (¶6) (Miss. Ct. App. 2007), cert. denied, 258

So. 3d 287 (Miss. 2018)). “A circuit court judge sitting without a jury is accorded the same

deference with regard to his findings as a chancellor, and his findings are safe on appeal

where they are support by substantial, credible, and reasonable evidence.” Sumrall I, 189 So.

3d at 664 (¶10) (internal quotation marks omitted) (quoting City of Jackson v. Brister, 838

So. 2d 274, 277-78 (¶13) (Miss. 2003)). Further, we must “recognize that the trial judge,

17
sitting in a bench trial as the trier of fact, has the sole authority for determining the credibility

of the witnesses.” City of Jackson v. Lipsey, 834 So. 2d 687, 691 (¶14) (Miss. 2003).

¶33. A plaintiff seeking to recover for medical malpractice “must show by a preponderance

of the evidence that the defendant had a legal duty, that he or she breached that duty by

failing to conform to the required standard of care, that the breach proximately caused the

injury, and that damages were suffered.” Hill v. Warden, 796 So. 2d 276, 280 (¶10) (Miss.

Ct. App. 2001). The plaintiff must also show, by expert testimony, that the physician or

medical personnel violated the applicable standard of care. See Palmer v. Biloxi Reg’l Med.

Ctr. Inc., 564 So. 2d 1346, 1335 (Miss. 1990).

¶34. In ruling from the bench, the circuit court found that the Sumralls “proved the

standard of nursing care for the removal of a central line.” The court stated:

All of the facts and evidence presented to the [trial court] clearly establish the
standard of care to be: (1) the nurse should educate the patient about the
procedure; (2) place the patient in the Trendelenb[u]rg position, which is
described as having the patient in a supine position where the site of the central
line insertion is below the heart; (3) have the patient take a deep breath, hold
and bear down (the [V]alsalva maneuver); (4), then, at removal, place gauze
with pressure at the removal site. The expert testimony and facts have
established that one of the steps in the standard of care is to place the patient
in the Trendelenb[u]rg position. The facts also establish, however, that such
a standard would not be absolute, and under the right circumstances, a position
other than Trendelenb[u]rg is acceptable. Therefore, even though
Trendelenb[u]rg is the standard, the intolerance of the plaintiff to that position
would allow for deviation from the standard without violation of the standard.

After reviewing the parties’ briefs, it appears neither party disputes the circuit court’s

standard of care for removing a central line as articulated by the circuit court. Rather, the

Sumralls argue that Nurse Steele (and Singing River) breached the standard of care by not

18
properly positioning Della in the Trendelenburg position. In that regard, the circuit court

found:

While the [Sumralls] ha[ve] offered sufficient proof of a standard of care, the
[Sumralls] would next have to prove a breach of that standard. Here, based
upon facts surrounding the medical condition of [Della], she was unable to
tolerate the Trendelenb[u]rg position. The evidence, and even testimony of
[the Sumralls’] own experts, supports the fact that a position other than
Trendelenb[u]rg is acceptable under such circumstances. The facts and
evidence further shows the patient was within the exceptions of the applicable
standard of care and Nurse Steele complied with the appropriate standard in
regard to those exceptions. . . . [T]herefore, there is no breach of the standard
of care.

¶35. At trial, the Sumralls’ first expert, Dr. Vives, testified that the care rendered to Della

fell below the standard of care because Nurse Steele failed to place Della in either the

Trendelenburg or a supine position during removal of the central line. Dr. Vives based her

testimony in part on a subsequent procedure, which this Court addresses later in this section.

However, Dr. Vives testified on cross-examination that a collapsed lung and pneumonia

could make it difficult for a patient to breathe. And she testified that it is “acceptable” to

place a patient in a position above supine if the patient cannot tolerate either the

Trendelenburg or a supine position. Dr. Vives conceded that she witnessed a previous

patient, who was educated of the risk, having a central line removed while in a position

above supine.

¶36. The Sumralls’ second expert, Nurse Keller, testified that Nurse Steele breached the

standard of care because “she failed to adequately position [Della] properly.” Similar to Dr.

Vives, Nurse Keller testified on cross-examination that a patient who cannot tolerate either

Trendelenburg or a supine position, should be placed in a position “as much as they can

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tolerate.”

¶37. In response to Dr. Vives and Nurse Keller, Dr. Corder, the expert for Singing River,

testified that Nurse Steele acted appropriately and met the standard of care in removing

Della’s central line. Dr. Corder stated that it was reasonable to believe that Della could not

lie flat on her back, especially given the recent, large upper-abdominal procedure she

endured, her history of COPD, bad lung function, chronic interstitial disease, partially

collapsed lung, chronic bronchitis, and pneumonia. In regard to the abdominal procedure,

Dr. Corder noted that Dr. Dvorak could not perform the surgery laparoscopically. Instead,

Della’s physicians had to “open” her abdominal section. Della’s doctors noted in the medical

records that Della’s gallbladder was “auto amputated,” which meant her gallbladder was

necrotic. Dr. Corder also stated that generally abdominal procedures such as gallbladder

surgery have a “marked effect” on pulmonary physiology. He explained that since Della

suffered from preexisting pulmonary disease, it was not unreasonable to think that Della had

a hard time lying flat on her back. In his opinion, Dr. Corder found that placing Della

between thirty and forty-five degrees was consistent with her clinical conditions at the time

of removal. He stated that a doctor or nurse should not lay someone flat on his or her back

to perform the removal procedure if the patient cannot tolerate that position because it would

“induce panic” and likely cause the patient to become “short of breath.”

¶38. As mentioned above, the Sumralls and their experts contend that Della could tolerate

the Trendelenburg position because she was placed in that position after Nurse Steele

removed the first central line. The record indicates that following the February 29 incident,

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a second central line was inserted into Della. Nearly three weeks later on March 19, Nurse

Blaine was ordered to remove that line. The record shows that Nurse Blaine placed Della

in the Trendelenburg position and removed her central line without complication.

¶39. But the record further shows that Della’s overall condition improved from the removal

of the first central line on February 29 to the removal of the second central line on March 19.

Della suffered from “right upper lobe atelectasis,” or a partially collapsed lung, at the time

Nurse Steele removed the central line on February 29. On February 25, or four days prior

to the removal, Della’s radiology report indicated “chronic volume loss in the right upper

lobe” that appeared to be “more prominent over the past 24 hours.” On March 3, 2012, or

three days after the removal, Della’s physician documented no change in her partially

collapsed lung, as well as hyperinflation in the left lung. On March 4, 2012, Della’s

condition started to show improved “atelectatic” changes in the right upper lobe of her lung.

Over the following two weeks, Dr. John Weldon noted overall improvement in Della’s

physical condition. On March 16, Dr. Weldon detailed, “Ms. Sumrall really looks about as

good as I have seen her all week. She is not looking overly sedated. She is a bit more

interactive. She denies chest pain or shortness of breath.” Three days later after that

progress report, Nurse Blaine removed Della’s second central line.

¶40. The testimony and evidence at trial supports a finding that Nurse Steele (and Singing

River) did not breach the standard of care by not positioning Della in the Trendelenburg

position. Nurse Steele was charged with caring for Della prior to her gallbladder surgery and

until the date of discharge on February 29. While Nurse Steele cared for Della, Nurse Steele

21
noticed Della had trouble ambulating, breathing, and was requiring oxygen. In her deposition

testimony, Nurse Steele recounted a specific incident that occurred prior to removal in which

she and other nurses were assisting Della with getting into bed. Nurse Steele stated that

Della was unable to lie flat on her back, so she and the other nurses “angled” her body in

order to lift her into the bed. Additionally, Nurse Steele testified that she only remembered

one occasion in which Della was lying in the supine position prior to removal. At trial, Nurse

Steele reiterated that Della had difficulty lying flat on her back. According to Nurse Steele,

Della expressed difficulty with lying down on the day the central line was removed.

¶41. According to Dr. Vives, doctors and nurses employ some subjectivity in determining

whether a patient can tolerate a certain position. Nurse Keller agreed with Dr. Vives and

added that objective indicators also play a role, such as the patient’s respiratory rate, heart

rate, and blood pressure.

¶42. The record is replete with testimony and other evidence supporting the circuit court’s

decision that Della could not tolerate the Trendelenburg position on the day of removal. As

mentioned above, Della suffered from a wide-ranging medical history that included

numerous co-morbodities that affected her respiratory system. Della endured, among other

things, bouts of pneumonia, COPD, diabetes, asthma, sleep apnea, kidney disease, arthritis,

coronary artery disease, a partially collapsed lung, and high blood pressure. Further, there

is supporting evidence that shows that Della was having difficulty lying flat during the days

leading up to removal and on the day the central line was removed. There is also sufficient

evidence demonstrating that Della’s overall physical condition improved by the time Nurse

22
Blaine removed Della’s second central line.

¶43. At trial, the circuit court was tasked with determining the weight and credibility of the

evidence and resolving the conflicting evidence. The circuit court found Dr. Corder to be

credible, and his testimony gave credence to Singing River’s theory that Della could not

tolerate the Tredelenburg position. See Lipsey, 834 So. 2d at 691 (¶14). Upon review, this

Court “must accept[] that evidence which supports or reasonably tends to support the

findings of fact made below, together will all reasoning inferences which may be drawn

therefrom and which favor the lower court’s findings of fact.” Univ. Med. Ctr. v. Martin,

994 So. 2d 740, 747 (¶26) (Miss. 2008) (internal quotation marks omitted). In doing so, it

is clear that the circuit court did not manifestly err in this case. Bennett, 276 So. 3d at 1178

(¶10). “While enough evidence exists in the record such that reasonable minds may disagree,

substantial, credible, and reasonable evidence exists to support the trial court’s judgment”

in favor of Singing River. Tabitha Prayer v. Greenwood Leflore Hosp., 183 So. 3d 877, 884

(¶23) (Miss. 2016).

IV. Compliance with Directives on Remand

¶44. The Sumralls claim that the circuit court failed to follow this Court’s mandate on

remand. It is well settled that “[t]he mandate issued by an appellate court is binding on the

trial court on remand.” G.B. Boots Smith Corp. v. Cobb, 911 So. 2d 421, 423 (¶6) (Miss.

2005) (citing Dunn v. Dunn, 695 So. 2d 1152, 1155 (Miss. 1997)). “Where [an appellate

court] has already decided a specific issue in a case on a prior appeal, the trial court has been

found to be in error where, on remand, it has refused to follow [the appellate court’s] opinion

23
and directions.” Nelson v. Bonner, 13 So. 3d 880, 883 (¶5) (Miss. Ct. App. 2009) (citing

Dunn, 695 So. 2d at 1155).

¶45. In Sumrall I, this Court held:

Therefore, we find that the trial court abused its discretion in allowing Dr.
Corder to testify inconsistent with, outside of, and beyond his designation.
First, we find that the trial court’s finding that “as a matter of fact . . . there is
no recognized applicable standard of nursing care with regard to patient
positioning during the removal of a central line” and “without an applicable
standard of care, there can be no breach of such,” was not supported by
substantial credible, and reasonable evidence. Second, we find that the trial
court’s finding that “[i]t was either an air embolism or perhaps a cardiac event
along with a stroke” was not supported by substantial, credible, and reasonable
evidence.

Further, we find that the Sumralls offered expert testimony, support by
extensive medical literature, to indicate that there was a standard of care for
a nurse to remove a central line. We recognize that the standard of care may
include some variation in proper positioning of the patient depending upon her
condition. However, the trial court’s finding that there is no standard of care
is against the overwhelming weight of the evidence and must be reversed.
Hence, we reverse the trial court’s judgment and remand for further
proceedings consistent with this opinion.

Sumrall I, 189 So. 3d at 669-70 (¶¶29-30).

¶46. The case was re-tried on May 1, 2017. By agreement, the parties submitted the first

trial’s transcript into the record. The parties also reintroduced all of the exhibits from the

first trial. Furthermore, upon remand, the parties redacted Dr. Corder’s trial testimony to

comport with this Court’s instruction. Dr. Corder was then called to re-testify.

¶47. Dr. Corder was tendered as an expert in the field of internal medicine and

anaesthesiology. As discussed, Dr. Corder testified that he disagreed with Dr. Vives and

Nurse Keller. He also testified that he disagreed that Della suffered from air embolus. A

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subsequent objection was sustained by the circuit court regarding the reason why Dr. Corder

disagreed with Dr. Vives. According to the circuit court, such testimony was not disclosed

by Singing River’s counsel. Dr. Corder also testified that Della suffered from chronic

atelectasis, or collapsed lung, of the right upper lobe. In addition, Dr. Corder testified that

Della suffered from other breathing complications. According to Dr. Corder, Della’s

positioning at the time Nurse Steele removed the central line was “consistent with what [he]

suspect[ed] . . . her clinical conditions [were] at that time.” The Sumralls’ attorney did not

ask any questions on cross-examination. And no questions were asked on redirect. Dr.

Corder’s testimony concluded the second trial.

¶48. After the second trial, the circuit court entered its findings of fact and conclusions of

law on July 26, 2017. The findings of fact read, in part:

All of the facts and evidence presented to the Court clearly establish the
standard of care to be: (1) the nurse should educate the patient about the
procedure; (2) place the patient in the Trendelenburg position, which is
described as having the patient in a supine position where the site of the central
line insertion is below the heart; (3) have the patient take a deep breath, hold
and bear down (the [V]alsalva maneuver); (4) then, at removal, place gauze
with pressure at the removal site. The expert testimony and facts have
established that one of the steps in the standard of care is to place the patient
in the Trendelenb[u]rg position. The facts also establish, however, that such
a standard would not be absolute, and under the right circumstances, a position
other than Trendelenb[u]rg is acceptable. Therefore, even though
Trendelenb[u]rg is the standard, the intolerance of the plaintiff to that position
would allow for deviation from the standard without violation of the standard.

In addition, the conclusions of law read, in part:

The central question at hand, besides the precise position of the plaintiff at the
time of the central line removal is the proper positioning of a patient for the
purpose of central line removal. In other words, there is no question that the
plaintiff claims improper removal of the central line by Nurse Steele due to the

25
alleged improper positioning of the plaintiff during the removal process. It is
the plaintiff’s burden to prove the applicable standard of nursing care with
regard to positioning during central line removal. Furthermore, the plaintiff
must show that the defendant breached the applicable standard of care in
relation to any exceptions inherent in the applicable standard of care. As
stated in the Findings of Fact above, the plaintiff proved the standard of
nursing care for the removal of a central line that would apply to the procedure
performed by Nurse Steele here is the four-part procedure discussed above.
The part of the standard at issue is whether Nurse Steele violated the standard
of care by not placing plaintiff in the Trendelenb[u]rg position before
removing the central line. The facts and evidence also showed the
Trendelenb[u]rg method allowed for variations, even allowing for patients to
not be reclined, depending on the patient’s tolerance as such the plaintiff
firmly established the duty was owed to comply with the standard of care.

While the plaintiff has offered sufficient proof of a standard of care, the
plaintiff would next have to prove a breach of that standard. Here, based upon
facts surrounding the medical condition of the plaintiff, she was unable to
tolerate the [sic] position. The evidence, and even testimony of plaintiff’s own
experts, supports the fact that a position other than Trendelenb[u]rg is
acceptable under such circumstances. The facts and evidence further shows
the patient was within the exceptions of the applicable standard of care and
Nurse Steele complied with the appropriate standard in regard to those
exceptions. . . . [T]herefore, there is no breach of the standard of care.

¶49. After careful review, we find that the circuit court complied with this Court’s mandate

in Sumrall I on remand.

V. Cumulative Error

¶50. Finally, the Sumralls claim that they were denied a fair trial due to cumulative error.

“The cumulative-error doctrine states that multiple errors, which alone may not require

reversal, may constitute reversible error if the cumulative effect of the errors resulted in an

unfair trial.” Lacoste v. Lacoste, 197 So. 3d 897, 913 (¶58) (Miss. Ct. App. 2016) (citing

Blake v. Clein, 903 So. 2d 710, 732 (¶68) (Miss. 2005)).

¶51. In their brief, the Sumralls cite eight errors that they allege together constitute

26
cumulative error.16 This exact argument was briefed and brought before this Court in

Surmall I. The Sumrall I court provided:

In addition, we recognize that the Sumralls have also challenged a number of
the trial court’s discovery and pretrial rulings under the issue they refer to as
“cumulative error.” Because we have decided to reverse and remand this case
for further proceedings, we find the issues raised in the cumulative-error
section are now moot. Furthermore, we are of the opinion that the Sumralls
have raised these issues only as to the finding of cumulative error and do not
ask this Court to reverse the trial court’s ruling on each individual issues.
Had the Sumralls so intended, they would have provided citations to legal
authority and included these as separate issues. As a result, we make no
ruling as to these separate issues.

Sumrall I, 189 So. 3d at 670 (¶31) (emphasis added). After review, we find that the effect

of the alleged errors cited by the Sumralls did not amount to an unfair trial. Six of the eight

alleged errors pertained to pretrial matters. We find no error within these issues. The

seventh alleged error, whether Dr. Corder was qualified to testify as an expert, was discussed

in section (I) of this opinion. The eighth alleged error, whether the circuit court’s decision

was against the weight of the evidence, was discussed in section (III). Therefore, these issues

are without merit.

CONCLUSION

¶52. In conclusion, we find that the Dr. Corder was properly qualified to testify to the

16
Those errors were: (1) the circuit court “refused to enforce [a] duly served
subpoena and notice of deposition”; (2) the circuit court required fact witnesses to be paid
a reasonable hourly fee; (3) the circuit court “refused to award . . . attorney’s fees”; (4) the
circuit court “denied [the Sumralls’] motion in limine as to undisclosed medical opinions”;
(5) the circuit court denied the Sumralls’ motion “to exclude [Singing River’s] expert
opinions”; (6) the circuit court denied the Sumralls partial summary judgment; (7) the
circuit court permitted Dr. Corder to testify as an expert; and (8) the circuit court’s decision
was against the overwhelming weight of the evidence.

27
standard of care for removing central lines. We also find that his trial testimony was

consistent with Singing River’s pretrial designation. Upon careful review, we find that there

is substantial credible evidence in the record to support the circuit court’s finding that Della

could not tolerate the Trendelenburg position on the day Nurse Steele removed the first

central line. Therefore, the circuit court did not err by finding that Nurse Steele did not

deviate from the applicable standard of care. We finally find that the circuit court followed

the directives of this Court on remand and that the alleged cumulative errors cited by the

Sumralls did not result in an unfair trial. For those reasons, we affirm.

¶53. AFFIRMED.

BARNES, C.J., J. WILSON, P.J., WESTBROOKS, TINDELL, McDONALD,
McCARTY AND C. WILSON, JJ., CONCUR. CARLTON, P.J., DISSENTS
WITHOUT SEPARATE WRITTEN OPINION. LAWRENCE, J., NOT
PARTICIPATING.

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