By Damian D. Capozzola, Esq., and Jamie Terrence, RN
News
In a professional negligence case, an appellate court affirmed summary judgment in favor of a healthcare provider after the plaintiffs failed to present admissible expert evidence on both breach of care and causation. The case arose from injuries sustained by a newborn in the neonatal intensive care unit (NICU), where an intravenous (IV) infiltration allegedly led to third-degree burns requiring a skin graft and, likely, long-term deformities. The plaintiffs claimed the attending nurse failed to perform required hourly checks or properly document the IV site, which delayed detection of the infiltration.
The plaintiffs submitted affidavits from a registered nurse expert in support. However, the trial court excluded the affidavits for multiple reasons: They failed to attach referenced medical records, did not establish the expert’s qualifications under state law, and were submitted too late in the litigation. The court also found the plaintiffs had not refuted the medical records indicating that proper IV checks were performed.
On appeal, the court upheld these rulings. The appellate decision is a reminder of the strict evidentiary requirements for expert testimony in medical negligence cases. Without competent expert evidence on causation or breach, the plaintiffs could not meet their burden of proof. The appellate court affirmed dismissal of the case in its entirety.
Background
This case concerns a professional negligence claim brought by two parents on behalf of their infant child against a healthcare provider following injuries sustained while the child was hospitalized in a NICU. The plaintiffs alleged that a nurse’s failure to properly monitor an IV line led to a severe infiltration injury, resulting in permanent harm.
On Jan. 6, 2020, the infant patient was receiving total parenteral nutrition (TPN) and lipid emulsion through an IV line placed at the top of the child’s left forearm. The patient was being cared for by a registered nurse who had been employed in the NICU for approximately six months. According to medical records, the nurse inspected the IV site at both 6 a.m. and 7 a.m. She documented that it appeared intact, dry, and free from redness or swelling. However, during a nursing shift change around 7:25 a.m., another nurse observed that the site was red, inflamed, and swollen. By 7:40 a.m., the original nurse documented that the IV site was swollen and leaking. At 8:25 a.m., a record entry noted that IV infiltration had occurred.
The child’s mother was told that the infiltration caused third-degree burns that would require a skin graft and likely lead to deformities as the child grew. The nurse allegedly expressed regret and acknowledged she would receive additional training.
The plaintiffs filed a lawsuit against the healthcare provider in January 2022, asserting that the nurse failed to comply with the applicable standard of care. They claimed that the nurse failed to perform required hourly IV site checks and failed to properly document her observations. The plaintiffs claimed that the infiltration could have been identified sooner and that earlier intervention would have prevented the severity of the injury. To support their claim, the plaintiffs submitted an expert affidavit from a registered nurse with decades of NICU experience. The expert opined that the nurse’s care fell below the standard in several ways, including the failure to make hourly electronic documentation and to observe and report early signs of infiltration, such as swelling, redness, and leakage.
The defendant denied the allegations and moved for summary judgment following the close of discovery. The defendant argued that the relevant nursing notes, which had been produced during discovery, showed that the nurse had conducted hourly IV checks, as required. The defendant argued that the plaintiffs had access to these records for nearly two years, had been granted multiple extensions of discovery, and had still failed to offer an alternative theory of negligence or provide a qualified expert opinion on causation.
In response, the plaintiffs questioned the authenticity of the nursing records, claiming that they may have been incomplete or altered. They argued that these notes were missing from earlier record productions and were only disclosed in full in May 2022. The plaintiffs also submitted a revised affidavit from their expert, who now opined that the infiltration injury would have taken more than an hour to develop. The expert concluded that if the nurse had checked the IV site at 6:00 a.m. and 7:00 a.m., as the records reflected, then she must have missed clear signs of infiltration.
The defendant challenged the admissibility of the revised affidavit on multiple grounds. First, the affidavit failed to attach the medical records it referenced, contrary to Georgia law requiring that all documents relied upon in summary judgment affidavits be included. Second, the defendant argued that the expert’s affidavit lacked a proper foundation under Georgia’s expert qualification statute. The defendant argued that the expert did not demonstrate that she was actively engaged in NICU nursing at the time of the incident or during three of the prior five years and did not show the specific knowledge needed to offer opinions on causation related to IV infiltrations. Finally, the defendant argued the affidavit was untimely and should be excluded as a sanction.
The trial court granted summary judgment in favor of the defendant. It found that the plaintiffs failed to present evidence disputing the nurse’s compliance with the hourly check requirements and failed to submit a qualified expert opinion on causation. The court noted that the expert’s affidavits lacked attached records, did not show qualifications to opine on causation, and were submitted too late in the litigation process.
On appeal, the plaintiffs challenged the exclusion of their expert’s affidavits and the trial court’s entry of summary judgment. The Court of Appeals affirmed. It held that the trial court acted within its discretion in excluding the affidavits for noncompliance with procedural rules and for lack of demonstrated qualifications. The court stated that in medical negligence cases, expert testimony on causation must be grounded in specialized knowledge, and the expert must clearly demonstrate the qualifications necessary to opine on the cause of injury.
Because the plaintiffs failed to submit admissible expert testimony on both breach and causation, which were two essential elements of their claim, the appellate court concluded that summary judgment was proper. It affirmed the dismissal of the case.
What This Means for You
This case highlights how the legal system approaches medical malpractice allegations and underscores the important role documentation, expert testimony, and procedural compliance play in defending or defeating a claim.
Here, it is first important to note that TPN with lipids is a complex group of solutions that can quickly cause irritation to the veins of an adult if not administered slowly and cautiously. In a newborn, damage can occur within minutes. These risks often can be managed by using the larger umbilical vessels still patent in the newborn. Hourly checks of a NICU patient receiving TPN peripherally likely would be insufficient to prevent harm. In addition, the medical record itself often does not show much more than a check mark to indicate that a complex multi-step procedure or process has taken place. Narrative descriptions, when documented, give a true picture (or at least a better picture) of what the nurse sees during an assessment. Too often (at best) the assessment and all its complexities or (at worst) an omitted assessment becomes a check mark. Expanded documentation is preferable.
The lawsuit alleged that a NICU nurse failed to perform required hourly IV checks, leading to a delay in recognizing an infiltration and resulting in permanent harm to a newborn. The plaintiffs relied on a registered nurse expert who opined that the standard of care was breached and that the child’s injuries would have been less severe had the IV been checked more thoroughly.
But a poor outcome alone does not establish liability. In professional negligence cases, plaintiffs must prove that a provider deviated from the standard of care and that the deviation caused the injury. Both elements generally require expert testimony. Courts consider these medical and legal issues too complex for lay juries to evaluate without expert testimony.
Here, the plaintiffs’ case fell apart because their expert affidavit did not meet Georgia’s legal requirements. First, the expert referenced the child’s medical records but failed to attach them to her affidavit. Courts must be able to evaluate the basis for an expert’s opinions, and when the underlying records are not attached or incorporated into the case record, the testimony can be excluded. Although two pages of nursing notes eventually were included in the record, they were not submitted with the expert’s affidavit, and the court could not assume their relevance or completeness.
Second, the expert did not clearly establish her qualifications. Under Georgia law, an expert in a medical malpractice case must show active practice or experience in the relevant field during the time period in question. The affidavit vaguely stated that the expert had worked in a NICU since the 1980s and had experience with IV maintenance, but she did not specify whether she had actively practiced in this area in the years leading up to the incident, nor did she establish recent, direct experience with IV infiltrations. Without this foundation, the court had no assurance that she was qualified to speak on the relevant standard of care or causation.
That issue of causation proved decisive. Even assuming a breach of the standard of care, a malpractice plaintiff must show that the breach caused the injury. The expert claimed that IV infiltrations like the one in this case would take over an hour to develop, implying that a proper hourly check should have caught it earlier. But she did not explain how she reached this conclusion or point to supporting data, clinical experience, or literature. Without a clear, experience-based explanation, her opinion lacked the evidentiary weight needed to survive summary judgment.
The medical documentation also played a central role. The nurse’s notes showed that the IV site was checked at 6 and 7 a.m. and that no problems were observed. Another nurse noted issues at 7:25 a.m., and infiltration was documented shortly afterward. Although the plaintiffs raised concerns about the authenticity of the records, they provided no evidence to support those claims. Courts generally presume medical records are accurate unless there is specific evidence to the contrary. Here, the records were consistent and unchallenged by any factual proof.
Timing issues further undermined the plaintiffs’ case. The revised expert affidavit, offering new opinions about causation, was submitted after discovery had closed and after the defense had moved for summary judgment. The trial court struck the affidavit as untimely under Georgia’s discovery rules, which allow courts to exclude evidence submitted in violation of deadlines.
For medical professionals, this case demonstrates how thorough and accurate documentation can serve as a strong defense in malpractice litigation. Real-time charting not only supports continuity of care but also provides legal protection. When chart entries are consistent and complete, they carry considerable weight in court. Documentation often is the most trusted evidence of what occurred.
The decision also underscores that not all expert opinions are legally sufficient. Courts carefully evaluate whether an expert has the right experience, training, and credentials. They also evaluate whether that expertise directly relates to the conduct at issue. Experts must clearly link their conclusions to established facts and explain how their background qualifies them to render those opinions. Vague assertions or assumptions will not survive scrutiny. Again, it is important to involve informed counsel in such matters.
In sum, this case reinforces that a medical malpractice claim requires more than a poor outcome or allegations of wrongdoing. Plaintiffs must present a coherent, evidence-based theory of both breach and causation, supported by a properly qualified expert. When they fail to do so, the legal system offers protections to healthcare professionals, including dismissal at the summary judgment stage.
Reference
- Decided on June 17, 2025, in the Court of Appeals of Georgia, Case No. A25A0223.
Damian D. Capozzola, Esq., The Law Offices of Damian D. Capozzola, Los Angeles.
Jamie Terrence, RN, President and Founder, Healthcare Risk Services, Former Director of Risk Management Services (2004-2013), California Hospital Medical Center, Los Angeles.
In a professional negligence case, an appellate court affirmed summary judgment in favor of a healthcare provider after the plaintiffs failed to present admissible expert evidence on both breach of care and causation.
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