FIFTH DIVISION MCFADDEN, P. J., BRANCH and BETHEL, JJ.
NOTICE: Motions for reconsideration must be physically received in our clerk’s office within ten days of the date of decision to be deemed timely filed. http://www.gaappeals.us/rules
October 23, 2017
In the Court of Appeals of Georgia A17A0709. GRAHAM v. REYNOLDS et al.
MCFADDEN, Presiding Judge.
This medical malpractice action arose from the death of Lakeither Marie
Thomas. Her husband, Curtis Thomas, and the representative of her estate, Anthony
Reynolds (collectively “the plaintiffs”), sued Dr. James A. Graham, an emergency
room physician, alleging that Graham had negligently misdiagnosed Thomas’s
cardiac condition, causing her death. Graham moved to dismiss the complaint for
failure to state a claim on the ground that the expert affidavit attached to the
plaintiffs’ complaint pursuant to OCGA § 9-11-9.1 was insufficient. See OCGA § 9-
11-9.1 (e) (if expert affidavit accompanying professional malpractice claim is
defective, complaint is subject to dismissal for failure to state a claim); Hewett v. Kalish, 264 Ga. 183, 184-185 (1) (442 SE2d 233) (1994) (same). Graham challenged
the competency of the affiant and the adequacy of the affidavit’s contents.
The trial court denied the motion to dismiss and we granted interlocutory
appellate review. There is no merit to either of Graham’s challenges to the affidavit.
So we affirm.
1. Facts and procedural history.
At this stage in the case the evidence has not been developed, and the following
factual recitation is taken from the plaintiffs’ complaint. The plaintiffs alleged that
Thomas went to the hospital emergency room on May 22, 2011, complaining of chest
pains and nausea. She had significant cardiac risk factors, including obesity, tobacco
use, and uncontrolled diabetes. On Graham’s orders, Thomas underwent an
electrocardiogram, among other procedures. Graham ultimately diagnosed Thomas
as having anxiety or panic attacks and discharged her from the hospital. At that time,
Thomas was still experiencing dry heaves and chest pains. Her symptoms worsened
at home and within a few hours she returned to the hospital in an ambulance. She
underwent another electrocardiogram. At that point, Graham recognized that Thomas
was in cardiac distress. She was placed in an ambulance to travel to another hospital
2 90 miles away for more comprehensive care. En route, Thomas suffered a massive
heart attack and died.
The plaintiffs alleged in their complaint that Graham had deviated from the
standard of care applicable to “physicians generally under similar conditions and like
surrounding circumstances,” that this deviation from the standard of care was both
negligent and grossly negligent, and that as a direct and proximate result Thomas was
misdiagnosed and died of a heart attack. The plaintiffs attached to their complaint the
affidavit of Dr. Frank A. Cuoco, a licensed medical doctor specializing in cardiology,
including cardiac electrophysiology. Cuoco opined that Graham’s care and treatment
of Thomas at the hospital “did not satisfy the standard of care exercised by the
medical profession generally under similar conditions and like surrounding
circumstances.” Specifically, he opined that Graham had misdiagnosed Thomas with
a panic attack and discharged her inappropriately “during an episode of Acute
Coronary Syndrome”; that, based on Thomas’s electrocardiogram and other
symptoms, Graham “should have, but failed to, diagnose [her] with an acute inferior
wall myocardial infarction and/or an acute ST-segment mycardial infarction”; that
upon such diagnosis, “appropriate intervention to restore coronary flow should have
been undertaken immediately”; that appropriate intervention would have included
3 specific actions and procedures described by Cuoco in the affidavit; that Graham’s
deviations from the standard of care proximately caused Thomas’s death; and that,
had Graham properly diagnosed Thomas, she “would have survived the episode of
Acute Coronary Syndrome she suffered on May 22, 2011.”
Graham moved to dismiss the action on the ground that Cuoco’s affidavit did
not meet the requirements of OCGA § 9-11-9.1 and OCGA § 24-7-702. OCGA § 9-
11-9.1 (a) provides that “[i]n any action for damages alleging professional
malpractice against [specified licensed professionals] the plaintiff shall be required
to file with the complaint an affidavit of an expert competent to testify, which
affidavit shall set forth specifically at least one negligent act or omission claimed to
exist and the factual basis for each such claim.” And OCGA § 24-7-702 (c) sets forth
specific competency requirements for experts in professional malpractice actions. “An
affiant shall meet the requirements of [OCGA § 24-7-702] in order to be deemed
qualified to testify as an expert by means of the affidavit required under [OCGA §]
9-11-9.1.” OCGA § 24-7-702 (e).
Graham challenged the plaintiffs’ expert affidavit in two respects. He argued
that Cuoco was not competent to testify and he argued that the affidavit did not
address gross negligence. At Graham’s request, the trial court held a hearing on
4 Graham’s motion, at which both sides gave argument but neither side presented
evidence. See generally OCGA § 24-7-702 (d) (trial court may hold hearing on expert
witness’s qualifications). Subsequently, the trial court entered an order rejecting both
of Graham’s challenges to the affidavit and denying his motion to dismiss. We
granted interlocutory review.
2. Competency of affiant.
Graham argues that the trial court should have dismissed the action because the
plaintiffs’ expert affiant, Cuoco, did not meet the competency requirements set out
at OCGA § 24-7-702 (c). “An affiant shall meet the requirements of [OCGA § 24-7-
702] in order to be deemed qualified to testify as an expert by means of the affidavit
required under Code Section 9-11-9.1.” OCGA § 24-7-702 (e).
“[T]he qualification of an expert witness under Rule 702 is generally a matter
committed to the sound discretion of the trial court.” Dubois v. Brantley, 297 Ga. 575,
578-579 (1) (775 SE2d 512) (2015) (citation omitted). See also Zarate-Martinez v.
Echemendia, 299 Ga. 301, 311 (3) (788 SE2d 405) (2016); Aguilar v. Children’s
Healthcare of Atlanta, 320 Ga. App. 663, 664 (739 SE2d 392) (2013). Although an
appellate court usually reviews a trial court’s order on a motion to dismiss de novo,
when the trial court has held a hearing on the competency of a witness to give
5 affidavit testimony in compliance with OCGA § 9-11-9.1, “our review determines
only whether the trial court has abused [his] discretion.” Bacon County Hosp. &
Health System v. Whitley, 319 Ga. App. 545, 546 (737 SE2d 328) (2013) (citations
and punctuation omitted). Contrary to Graham’s argument on appeal, “[i]t is
irrelevant whether or not evidence was offered at the hearing.” Craigo v. Azizi, 301
Ga. App. 181, 183 (1) (687 SE2d 198) (2009). As detailed below, the trial court did
not abuse his discretion in finding Cuoco competent to testify.
In a medical malpractice action, OCGA § 24-7-702 (c) requires, among other
things, that at the time the act or omission is alleged to have occurred, the expert “had
actual professional knowledge and experience in the area of practice or speciality in
which the opinion is to be given. . . .” OCGA § 24-7-702 (c) (2). Such knowledge and
experience must result from the expert having been regularly engaged in either
[t]he active practice of such area of specialty of his or her profession for at least three of the last five years, with sufficient frequency to establish an appropriate level of knowledge, as determined by the judge, in performing the procedure, diagnosing the condition, or rendering the treatment which is alleged to have been performed or rendered negligently by the defendant whose conduct is at issue;
OCGA § 24-7-702 (c) (2) (A), or
6 [t]he teaching of his or her profession for at least three of the last five years as an employed member of the faculty of an educational institution accredited in the teaching of such profession, with sufficient frequency to establish an appropriate level of knowledge, as determined by the judge, in teaching others how to perform the procedure, diagnose the condition, or render the treatment which is alleged to have been performed or rendered negligently by the defendant whose conduct is at issue[.]
OCGA § 24-7-702 (c) (2) (B).
The statute also requires, with certain exceptions not applicable here, that the
expert be a “member of the same profession” as the defendant. OCGA § 24-7-702 (c)
(2) (C) (i).
And it contains a provision specifying the preconditions for a physician’s
testimony about the negligence of other, non-physician medical professionals. OCGA
§ 24-7-702 (c) (2) (D). That provision is not applicable here.
In his appellate briefs, Graham argues that Cuoco did not satisfy these
requirements because he “is not a member of the same profession as [Graham]” and
he “does not meet the knowledge and experience requirement by virtue of having
recently practiced the profession . . . or recently taught it”. Neither of those arguments
provide grounds for reversal.
7 (a) Same profession.
We find no merit in Graham’s argument that he and Cuoco are not members of
the same profession. Both are licensed medical doctors. See OCGA § 9-11-9.1 (g)
(11) (listing “medical doctor” as a “profession” to which the affidavit requirement
applied). Graham and Cuoco have different specialities. But Graham offers no
authority whatsoever for the proposition that licensed medical doctors must have the
same specialty to be considered members of the same profession. To the contrary, we
have held that a medical doctor in one specialty may have the requisite knowledge
and experience under OCGA § 24-7-702 (c) (2) to give expert opinion testimony
regarding the acts or omissions of a medical doctor in another specialty. See MCG
Health v. Barton, 285 Ga. App. 577, 581-582 (1) (647 SE2d 81) (2007) (construing
predecessor to OCGA § 24-7-702); Cotten v. Phillips, 280 Ga. App. 280, 283-285
(633 SE2d 655) (2006) (same); see also Aguilar, supra, 320 Ga. App. at 665
(although ultimately finding proffered expert was not qualified, acknowledging that
medical doctor does not have to practice in same specialty as defendant medical
doctor to be qualified to submit expert affidavit).
(b) Recent practice or teaching.
8 Graham argues that Cuoco was not competent to give his opinion because he
did not have the requisite recent practice, OCGA § 24-7-702 (c) (2) (A), or teaching,
OCGA § 24-7-702 (c) (2) (B), in the area of emergency medicine. But the purpose of
this statutory requirement is to ensure that experts “have recent experience in the
areas about which they are opining. . . .” Zarate-Martinez, supra, 299 Ga. at 308 (2)
(a). As indicated above, the requirement
does not mean that the plaintiff’s expert must have knowledge in the same area of practice/specialty as the defendant doctor, but instead means that the expert must have knowledge and experience in the practice or speciality that is relevant to the acts or omissions that the plaintiff alleges constitute malpractice and caused the plaintiff’s injuries.
Bonds v. Nesbitt, 322 Ga. App. 852, 857 (3) (747 SE2d 40) (2013) (citation and
punctuation omitted). Pertinent to this case, the requisite recent practice or teaching
must “establish an appropriate level of knowledge . . . in . . . diagnos[ing] the
condition. . . .” OCGA § 24-7-702 (c) (2) (A) & (B). An expert has the appropriate
level of knowledge
to the extent the expert has sufficient knowledge about [diagnosing the condition] — however generally or specifically it is categorized, so long as it is the [condition] that the defendant is alleged to have [diagnosed]
9 negligently — to reliably give the opinions about the [diagnosis of the condition] that the expert proposes to give.
Dubois, supra, 297 Ga. at 587 (2).
The plaintiffs allege that Graham negligently diagnosed Thomas’s urgent
cardiac condition, resulting in his failure to provide appropriate treatment to her. In
his affidavit, Cuoco opined that Graham should have diagnosed the cardiac condition
from Thomas’s electrocardiogram report and other symptoms, and that his failure to
do so deviated from the applicable standard of care. Cuoco also indicated in his 2013
affidavit that since 2009 he had taught in the area of cardiac electrophysiology as a
faculty member at a state medical university. The allegations in the complaint and the
contents of Cuoco’s affidavit authorized the trial court to determine that Cuoco had
knowledge and experience in a practice or specialty relevant to Graham’s alleged
negligence. See Cotten, supra, 280 Ga. App. at 282-283 (trial court did not abuse
discretion in holding that vascular surgeon was qualified to testify as to orthopedic
surgeon’s failure to properly assess, monitor, and respond to patient’s vascular
condition during orthopedic treatment and surgery).
Graham argues that our decisions in Bonds v. Nesbitt, supra, 322 Ga. App. 852,
and Aguilar v. Children’s Healthcare of Atlanta, supra, 320 Ga. App. 633, compel a
10 different result. They do not. In both cases, the trial courts found that the proffered
experts were not qualified to testify and we affirmed on the ground that the trial
courts did not abuse their discretion in so ruling. Bonds, supra at 858-859 (3);
Aguilar, supra at 666. So those cases were in a very different procedural posture from
this case. Here, the trial court determined that Cuoco was competent to testify. We
find no abuse of discretion in that ruling.
3. Adequacy of contents of affidavit.
Graham argues that the trial court should have dismissed the action because the
plaintiffs’ expert affidavit was inadequate for not asserting that Graham was grossly
negligent. But such assertion was not required for the affidavit to meet the
requirements of OCGA § 9-11-9.1.
OCGA § 9-11-9.1 imposes a pleading requirement, not an evidentiary
requirement. Thompson v. Ezor, 272 Ga. 849, 852 (2) (536 SE2d 749) (2000); Sawyer
v. DeKalb Medical Center, 234 Ga. App. 54, 57 (2) (506 SE2d 197) (1998). Its
purpose is to “reduce the number of frivolous malpractice suits being filed, not to
require a plaintiff to prove a prima facie case entitling him to recover. . . .” Sawyer,
supra at 56 (2); see also Oller v. Rockdale Hosp., __ Ga. App. __, __ (1) (b) (__ SE2d
__) (Case No. A17A1208, decided Aug. 14, 2017). “Accordingly, an expert affidavit
11 which would be insufficient to satisfy the evidentiary standards of OCGA § 9-11-56
[regarding summary judgment] may nevertheless be sufficient to satisfy the pleading
standards of OCGA § 9-11-9.1.” Sawyer, supra at 57 (2) (citations and punctuation
omitted); see also Thompson, supra at 852 (2); Williams v. Hajosy, 210 Ga. App. 637,
638 (1) (436 SE2d 716) (1993). Plaintiffs are given a wide berth to conform to the
statutory requirements, Phoebe Putney Mem. Hosp. v. Skipper, 235 Ga. App. 534, 535
(510 SE2d 101) (1998), and in ruling on a motion to dismiss based on an allegedly
defective affidavit, a court should construe the affidavit “most favorably to the
plaintiff and all doubts should be resolved in [the] plaintiff’s favor, even if an
unfavorable construction of the affidavit may be possible[,] so long as such
construction does not detract from [the statutory] purpose. . . .” Hewett, supra, 264
Ga. at 184 (1) (citation omitted). “[F]or a complaint to be subject to dismissal for
failure to state a claim, the affidavit must disclose with certainty that the plaintiff
would not be entitled to relief under any state of provable facts.” Sawyer, supra at 56
(2) (emphasis omitted). We review de novo the trial court’s ruling on whether the
affidavit met the pleading requirements of OCGA § 9-11-9.1. See Washington v. Ga.
Baptist Medical Center, 223 Ga. App. 762, 765 (2) (478 SE2d 892) (1996), reversed
12 in part on other grounds by Porquez v. Washington, 268 Ga. 649 (492 SE2d 665)
(1997).
To satisfy OCGA § 9-11-9.1, an expert affidavit must set forth “at least one
negligent act or omission claimed to exist and the factual basis for each such claim.”
OCGA § 9-11-9.1 (a) (3). Applying the standard set forth above, Cuoco’s affidavit
met this requirement — it set forth acts and omissions by Graham that, in Cuoco’s
opinion, breached the applicable standard of care. But citing Georgia’s emergency
medical care statute, OCGA § 51-1-29.5 (c), Graham argues that in this case it was
not enough for the affidavit to set forth a negligent act or omission. That Code section
provides that
[i]n any action involving a health care liability claim arising out of the provision of emergency medical care in a hospital emergency department . . . , no physician or health care provider shall be held liable unless it is proven by clear and convincing evidence that the physician or health care provider’s actions showed gross negligence.
OCGA § 51-1-29.5 (c). In Ndlovu v. Pham, 314 Ga. App. 337 (723 SE2d 729) (2012),
we referred to but did not decide the issue of the interplay between the pleading
requirement of OCGA § 9-11-9.1 and the evidentiary requirement of OCGA § 51-1-
29.5. That issue is now squarely before us.
13 We are not persuaded by Graham’s argument that, under OCGA § 51-1-29.5,
the plaintiffs were required to submit an affidavit asserting that Graham’s acts and
omissions constituted gross negligence. First, such a ruling would conflict with the
plain language of OCGA § 9-11-9.1, which merely requires an affidavit setting forth
an act of negligence, OCGA § 9-11-9.1 (a) (3), and “does not require that specific
language be employed.” Minster v. Pohl, 206 Ga. App. 617, 621 (4) (a) (426 SE2d
204) (1992). Moreover, we have held that OCGA § 9-11-9.1 does not require an
affiant to specifically opine that the act constituted negligence. Bowen v. Adams, 203
Ga. App. 123, 124 (416 SE2d 102) (1992). Per force OCGA § 9-11-9.1 does not
require an affiant to specifically opine that the act constituted gross negligence, even
if the plaintiff will have to prove gross negligence to prevail on summary judgment
or at trial. This comports with the § 9-11-9.1 affidavit’s function as a pleading
requirement, not an evidentiary requirement. Nothing in OCGA § 51-1-29.5 purports
to modify the usual standard for dismissal for failure to state a claim based on a
defective OCGA § 9-11-9.1 affidavit. Cf. Nguyen v. Southwestern Emergency
Physicians, 298 Ga. 75, 84 (3) (779 SE2d 334) (2015) (noting that OCGA § 51-1-
29.5, which requires plaintiffs who bring malpractice claims based on emergency
14 medical care in a hospital emergency department to meet a higher standard and
burden of proof to prevail, did not purport to modify summary judgment standard).
Moreover, gross negligence is a degree of negligence, and
[a]s a general rule, when facts alleged as constituting gross negligence are such that there is room for difference of opinion between reasonable people as to whether or not negligence can be inferred, and if so whether in degree the negligence amounts to gross negligence, the right to draw the inference is within the exclusive province of the jury.
Abdel-Samed v. Dailey, 294 Ga. 758, 765 (3) (755 SE2d 805) (2014) (citations and
punctuation omitted). “‘Gross negligence’ is defined as the absence of even slight
diligence, and slight diligence is defined in OCGA § 51-1-4 as ‘that degree of care
which every man of common sense, however inattentive he may be, exercises under
the same or similar circumstances.’” Id. (citations and punctuation omitted).
Construing the affidavit most favorably to the plaintiffs and resolving all
doubts in their favor, as we must do on a motion to dismiss, see Hewett, supra, 264
Ga. at 184 (1), we cannot say that Cuoco’s affidavit discloses with certainty that the
plaintiffs would not be entitled to relief under any state of provable facts. See Sawyer,
supra, 234 Ga. App. at 56 (2). To the contrary, the affidavit discloses that although
Thomas’s electrocardiogram revealed that she was experiencing a serious cardiac
15 condition requiring immediate intervention, Graham told her that she was having an
anxiety attack and sent her home. Even under the heightened burden imposed by
OCGA § 51-1-29.5 (c), these facts (if proved) could authorize a jury to find gross
negligence. See Abdel-Samed, supra, 294 Ga. at 765-766 (3) (evidence that
emergency room physician diagnosed patient as requiring emergency hand surgery
but then either made no effort to transfer patient to hand surgeon or waited more than
five hours to contact hand surgeon could support jury finding of gross negligence).
Consequently, the trial court did not err in denying Graham’s motion to dismiss the
case for failure to state a claim.
Judgment affirmed. Branch and Bethel, JJ., concur.