Appeal from the order of the Superior Court dated September 29, 2006, at No. 819 MDA 2005 reversing the order of the Court of Common Pleas of Centre County at No. 200-2612 910 A.2d 68 (Pa. Super. 2006)
The opinion of the court was delivered by: Madame Justice Todd
CASTILLE, C.J., SAYLOR, EAKIN, BAER, TODD, McCAFFERY, JJ.
In this negligence action, Geisinger Medical Center ("Geisinger") and HealthSouth Corporation, formerly known as HealthSouth Rehabilitation Corporation and HealthSouth of Nittany Valley, Inc., t/d/b/a HealthSouth Nittany Valley Rehabilitation Hospital ("HealthSouth"), appeal the order of the Pennsylvania Superior Court reversing the trial court's grant of a compulsory non-suit in their favor and against Appellee Rodger A. Freed. Although on a basis different from that expressed by the Superior Court, we affirm.
On November 6, 1998, Freed was involved in a single-vehicle accident during which he suffered spinal cord injuries and was rendered paraplegic. Following the accident, Freed was hospitalized at Geisinger. On December 3, 1998, Freed was transferred to HealthSouth Nittany Valley Rehabilitation Hospital for rehabilitation therapy. While there, Freed developed pressure wounds, also known as bedsores, on his buttocks and sacrum. The pressure wounds ultimately became infected and, on January 10, 1999, Freed was returned to Geisinger for surgical debridement*fn1 and therapy. He remained at Geisinger until February 24, 1999, when he was again transferred to HealthSouth. On May 10, 1999, Freed was discharged to home.
On December 21, 2000, Freed filed a complaint against Geisinger and HealthSouth,*fn2 alleging that the nursing staff of both institutions failed to meet the nursing standard of care with regard to the treatment and prevention of pressure wounds on an immobilized patient. At a jury trial over which the Honorable Charles C. Brown, Jr. presided, Freed presented as an expert witness Linda D. Pershall, a registered nurse, to testify regarding the relevant nursing standard of care, as well as to causation. During direct examination, when Freed's counsel asked Pershall her opinion as to the cause of Freed's bedsores, Geisinger objected, and the trial court sustained the objection on the basis that Pershall was not a medical doctor and, therefore, was not qualified to give a medical diagnosis.*fn3 After Freed presented his case, Geisinger moved for a compulsory non-suit on the basis that Freed failed to present a prima facie case of negligence by not offering competent evidence of a causal connection between the alleged breach of the nursing standard of care and the development or worsening of Freed's pressure wounds, and the trial court granted the motion. In its opinion written pursuant to Rule 1925(a) of the Pennsylvania Rules of Appellate Procedure, the trial court, citing this Court's decision in Flanagan v. Labe, 547 Pa. 254, 690 A.2d 183 (1997), reasoned that Pershall was not qualified to offer an opinion as to the cause of Freed's pressure wounds because an opinion regarding the specific cause and identity of an individual's medical condition constitutes a medical diagnosis, which a nurse is prohibited from making under the Professional Nursing Law, 63 P.S. §§ 211 et. seq.*fn4
On appeal to the Superior Court, Freed argued, inter alia, that the trial court erred in precluding Pershall from testifying as to the cause of Freed's pressure wounds. In a published opinion, the Superior Court reversed the trial court's grant of a non-suit, holding that Pershall was competent to provide expert testimony on both the standard of nursing care and the issue of causation. Appellants now argue that the Superior Court's holding is in conflict with this Court's holding in Flanagan, and, therefore, must be vacated.
Preliminarily, we note that in order to establish a cause of action for medical malpractice, a plaintiff must demonstrate (1) a duty owed by the physician to the patient; (2) a breach of that duty by the physician; (3) that the breach was the proximate cause of the harm suffered; and (4) that the damages suffered were a direct result of the harm. Hightower-Warren v. Silk, 548 Pa. 459, 463, 698 A.2d 52, 54 (1997). Expert testimony generally is required in a medical malpractice action in order to establish the proper standard of care, the defendant's failure to exercise that standard of care, and the causal relationship between the failure to exercise the standard of care and the plaintiff's injury. Id.
In order to qualify as an expert witness in a given field, a witness normally need only possess more expertise than is within the ordinary range of training, knowledge, intelligence, or experience. Miller v. Brass Rail Tavern, Inc., 541 Pa. 474, 481, 664 A.2d 525, 528 (1995)). Thus, ordinarily, "the test to be applied when qualifying an expert witness is whether the witness has any reasonable pretension to specialized knowledge on the subject under investigation." Id. at 480, 664 A.2d at 528 (emphasis original).
In Flanagan, the appellant filed a medical malpractice action against the appellee, John F. Kennedy Memorial Hospital, alleging that he received substandard nursing care when he went to the hospital for treatment of a collapsed lung. The treatment involved the insertion of a tube into Flanagan's chest wall. According to Flanagan, following the insertion of the tube, the hospital's nursing staff failed to document his complaints of pain and responses to medication, and failed to monitor his breathing and palpate his chest, measures which would have led to earlier detection of the onset of subcutaneous emphysema. He asserted that the nursing staff's negligent care caused his condition to worsen.
At trial, Flanagan planned to introduce expert testimony of a registered nurse, who, in accordance with her expert report, intended to testify that "it is my nursing expert opinion, to a reasonable degree of nursing certainty, that all of the nurses . . . did not meet the standard with respect to their nursing care of Stephen Flanagan and as such were a substantial contributing factor in his progressively worsening subcutaneous emphysema." 547 Pa. at 256, 690 A.2d at 184-85. The hospital filed a pre-trial motion in limine to preclude the nurse from testifying as to the identity of Flanagan's medical condition and the causes thereof. The trial court granted the motion, concluding that the nurse's testimony went not only to the proper standard of nursing care - an appropriate subject for her testimony - but also to a medical opinion regarding the ultimate effect of that care, which the court determined called for a medical diagnosis that the nurse was statutorily precluded from rendering under the Professional Nursing Law. Finding that the exclusion of this testimony prevented Flanagan from establishing a prima facie case of malpractice, the trial court granted summary judgment in favor of the hospital. The Superior Court subsequently affirmed the trial court's order.
In affirming the Superior Court's decision on appeal, we first acknowledged that the nurse was well educated, highly experienced, and competent to provide expert testimony regarding applicable standards of nursing care. We also determined the nurse was qualified to offer opinion testimony regarding whether the nursing procedures followed in Flanagan's case were substandard. Id. at 257, 690 A.2d at 185. We held, however, that she was precluded from offering a medical opinion on the effect of the alleged substandard nursing procedures because "the normal test of competency is constrained by [the Professional Nursing Law] limiting the deemed competency of nurses." Id.
In the instant case, the Superior Court distinguished Flanagan on the basis that Pershall's testimony did not constitute a medical diagnosis. In doing so, the Superior Court found that the parties (1) agreed on the relevant medical diagnosis, i.e. pressure wounds; and (2) agreed that "by definition, the cause of pressure wounds is unrelieved pressure on a part of the body." Freed v. Geisinger Med. Ctr., 910 A.2d 68, 74 n.5 (Pa. Super. 2006).*fn5
The Superior Court thus opined that the only issue in dispute was "whether a breach of the standard of nursing care for an immobilized patient proximately caused the unrelieved pressure that in turn caused Appellant's pressure wounds to develop and/or worsen," an issue on which Pershall should not have been precluded from testifying. Id. Upon review, we conclude that the Superior Court's holding is, in fact, in conflict with Flanagan.
In concluding that Pershall's "education and experience provide her with 'more expertise than is within the ordinary range of training, knowledge, intelligence, or experience' concerning the cause of pressure wounds," and, as a result, that she was "competent to provide expert testimony not only on the standard of nursing care, but also on the causative relationship between breaches in the standard of care and [Freed's] pressure wounds," Freed, 910 A.2d at 75, the Superior Court relied on this Court's holding in Miller, supra, and its own decision in McClain v. Welker, 761 A.2d 155 (Pa. Super. 2000).
In McClain, the parents of two minor children filed a negligence action against their landlords, alleging the children suffered toxic lead poisoning as a result of ingesting lead-based paint from their rental home. The landlords filed a motion in limine to preclude the parents' expert, a scientist who had a Ph.D., but was not a medical doctor, from testifying as to the causal relationship between ingestion of lead and cognitive defects. Purportedly relying on Flanagan "for the proposition that only medical doctors could testify as to causation," 761 A.2d at 157, the trial court concluded that because the scientist did not have a medical degree, he was not ...