Blanca Prieto v. Total Renal Care, Inc.

B
            USCA11 Case: 19-13575      Date Filed: 02/12/2021    Page: 1 of 23



                                                                [DO NOT PUBLISH]

                  IN THE UNITED STATES COURT OF APPEALS

                           FOR THE ELEVENTH CIRCUIT
                             ________________________

                                   No. 19-13575
                             ________________________

                         D.C. Docket No. 1:18-cv-21085-MGC



BLANCA PRIETO,

                                                                   Plaintiff-Appellant,

versus

TOTAL RENAL CARE, INC.,

                                                                  Defendant-Appellee.

                             ________________________

                      Appeal from the United States District Court
                          for the Southern District of Florida
                            ________________________

                                  (February 12, 2021)

Before WILSON, LAGOA, and BRASHER, Circuit Judges.

PER CURIAM:

         Plaintiff Blanca Prieto (“Prieto”), as personal representative of the Estate of

Rodolfo Prieto, appeals from the district court’s order granting defendant Total

Renal Care, Inc., d/b/a Davita Dialysis Centers d/b/a Florida Renal Care’s (“TRC”),
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motion for judgment as a matter of law under Federal Rule of Civil Procedure 50(a)

on the issue of proximate causation. Specifically, the district court found that Prieto

failed to introduce evidence which afforded a reasonable basis for the conclusion

that TRC’s negligence more likely than not was a substantial factor in causing Mr.

Prieto’s injuries. Because Prieto failed to present any evidence that could support a

jury’s finding that TRC’s alleged negligence in failing to send Mr. Prieto home on a

stretcher more likely than not caused his injuries—an essential element of Prieto’s

medical malpractice claim—we conclude that the district court did not err in entering

judgment as a matter of law in TRC’s favor and affirm.

I.     FACTUAL AND PROCEDURAL HISTORY

       On January 2, 2016, Rodolfo Prieto (“Mr. Prieto”), a seventy-six-year-old

man, was injured when he fell from a wheelchair while being driven in a medical

transportation van from his dialysis appointment at one of TRC’s dialysis centers

back to the University Plaza Rehabilitation Center (“University Plaza”) where he

was living.

       On March 21, 2018, Prieto, as the personal representative of Mr. Prieto’s

estate, filed this lawsuit against TRC,1 alleging a claim for nursing negligence under

Florida Statute § 766.102 (“Count I”) and a claim for healthcare center liability


       1
         The company that owned the medical transportation van, identified by the district court
as American Ambulance, was not a party to the suit as Prieto had previously entered into a
settlement with American Ambulance.
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under Florida Statute § 766.106 (“Count II”). 2 In her complaint, Prieto alleged the

following facts. On January 2, 2016, Mr. Prieto was leaving TRC’s dialysis center

“by medical transport van, as he had done on countless prior occasions, and being

taken back to University Plaza.” During the drive back to University Plaza, “the

van’s brakes were suddenly applied which caused [Mr. Prieto] to fly forward, out of

his wheel chair, and sustain various injuries, to wit, a severely fractured right leg,

head lacerations, and hospitalization.” (emphasis in original omitted). Prieto alleged

that TRC

               negligently allowed [Mr. Prieto] to exit its facilities by
               wheelchair when his medical condition, as known by the
               Defendant, and as dictated and established by the
               Defendant, whose principal owner was [Mr. Prieto’s]
               actual treating nephrologist, required his daily, ongoing,
               and consistent transport to be by way of stretcher due to
               serious medical limitation/restrictions that made it unsafe
               for him to be transported in any other manner.

(emphasis in original omitted). Prieto also alleged that TRC’s “failure to render the

nursing care that would have consisted of making sure [Mr. Prieto’s] medical

transportation home was by stretcher . . . was a deviation from the standard of

nursing care, and was a breach in the nursing standard of care that fell below the



       2
            Because this case arises under diversity jurisdiction, we apply Florida medical
malpractice law. Ins. Co. of N. Am. v. Lexow, 

937 F.2d 569

, 571 (11th Cir. 1991) (“In a diversity
case, a federal court applies the substantive law of the forum state, unless federal constitutional or
statutory law is contrary.”).


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industry standard, and as such was the causation, proximate, and legal cause, and/or

the concurring cause, of [Mr. Prieto’s] injuries.” (emphasis in original omitted).

Prieto further alleged that she had complied with all pre-suit notice statutory

requirements for medical negligence causes of action, and she attached to the

complaint a November 10, 2017, affidavit of Nurse Erika Hall, an adult nurse

practitioner. 3

       As to Count I, Prieto alleged that TRC’s nursing staff’s failure to send Mr.

Prieto home on a stretcher

               was a breach of the prevailing standard of care, and the
               subsequent driving incident that took place during his
               transport from the Defendant’s facility back to his assisted
               living facility was the concurrent condition caused by the
               Defendant so that it can be said that a sudden vehicular
               stop by the transport vehicle alone would not have [led] to
               [Mr. Prieto’s] injury, but could only have occurred due to
               the Defendant’s failure to make sure that he was leaving
               their facility in a secure position via stretcher, and
               therefore the negligence condition created by the
               Defendant was the legal and proximate cause, and/or the
               concurring cause which caused [Mr. Prieto’s] injuries.

(emphasis in original omitted). As to Count II, Prieto alleged that TRC’s staff breach

of the standard of care owed to Mr. Prieto by sending him home on a stretcher “was




       3
          Among other things, Nurse Hall stated in her affidavit that “the nursing standard of care
was deviated by the Head RN of [TRC] in allowing Mr. Prieto to leave in a wheelchair” and that
“[i]f he had been sent home via a properly restrained stretcher . . . , he would not have sustained
injury from a sudden traffic stop.”
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the legal and proximate cause, and/or a concurring event that caused [Mr. Prieto’s]

right leg fracture.”

        TRC filed an answer denying all allegations of negligence, causation, and

damages and alleging numerous affirmative defenses, including that the entities and

individuals responsible for transporting Mr. Prieto from TRC’s facility on January

2, 2016, were responsible for an intervening and superseding negligent act not

subject to TRC’s control.

        Pursuant to a pretrial stipulation, damages were limited to Mr. Prieto’s pain

and suffering from the date of his injury until the time of his death. The matter then

proceeded to a three-day trial where Prieto presented the testimony of Dr. Hassan

Ali, Head Nurse Sergio Alfonso, and patient care technician Yureiesky Ventura

Valdez, as well as the testimony of Nurse Hall as an expert witness.4

       Dr. Ali was Mr. Prieto’s nephrologist and the medical director of Florida

DaVita Renal Center, which is a subsidiary of TRC. During trial, in portions of

deposition testimony read to the jury, Dr. Ali testified that Mr. Prieto’s health at the

time of the accident included “complications of diabetes,” such as diabetic

nephropathy, eye problems, heart disease, a below-the-knee left leg amputation, and




       4
           TRC states that there were other witnesses at trial, but that Prieto only had select portions
of the trial transcribed. In her initial brief and reply brief, Prieto relies only on the testimony of
Dr. Ali, Nurse Alfonso, and technician Ventura Valdez. In its answer brief, TRC discusses the
testimony of Nurse Hall. We are therefore only able to consider the testimony of these witnesses.
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amputation of several toes from his right foot. Mr. Prieto also suffered from “end-

stage renal disease.” The jury further heard from Dr. Ali’s deposition testimony that,

from November 2, 2015, through December 31, 2015, Dr. Ali had recommended

that Prieto be transported to and from dialysis by stretcher, and that a summary

treatment sheet showed that Prieto presented for his dialysis care on a stretcher and,

after treatment, was placed back on a stretcher eighteen times from November 2,

2015, through December 31, 2015. In his deposition testimony, Dr. Ali further

agreed that on January 2, 2016, Mr. Prieto should have been transported back home

by stretcher, and that TRC was responsible for Mr. Prieto “until he hits the door.”

       Dr. Ali also testified in person at trial. Dr. Ali testified that the medical facility

was not involved in “the mode of transportation” and that transportation of a patient

was arranged by the patient or the patient’s representative. Dr. Ali testified that Mr.

Prieto’s nursing home was the patient representative who arranged the

transportation. Relevant here, Dr. Ali did not offer an opinion as to whether Mr.

Prieto would have suffered injury had he returned on a stretcher that was bolted to

the van’s floor. Dr. Ali testified that he did not agree that on January 2, 2016, Mr.

Prieto should have been transported home on a stretcher, and Prieto impeached Dr.

Ali with his deposition testimony on this issue. On redirect, Dr. Ali testified that

every one of his patients is a fall risk.




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      Prieto then presented the testimony of Nurse Alfonso and read portions of his

deposition to the jury. In his deposition, Nurse Alfonso agreed that Mr. Prieto was

the kind of patient who needed to be transferred by stretcher. During his trial

testimony, Nurse Alfonso clarified that the level of transportation for Mr. Prieto was

determined by his place of transportation. Nurse Alfonso testified that on the day of

his treatment, Mr. Prieto finished his dialysis in a “stable manner” and left in a

wheelchair. When asked by Prieto’s attorney whether it would have been better to

send Mr. Prieto out of the facility secured and strapped down on a stretcher, Nurse

Alfonso stated that his training was not in transportation.

      Prieto also called Nurse Hall, an adult nurse practitioner, to testify as an expert

in the field of nursing. Nurse Hall explained that she works for a company that

provides health care to inmates at the Hillsborough County Jail, and at any given

time, two to three of her patients at the jail are on dialysis. However, she testified

that she is not the person who initiates dialysis or monitors a patient while on

dialysis. Additionally, Nurse Hall acknowledged on cross-examination that her

patients are not transported outside the jail and that, while the jail uses stretchers and

wheelchairs, it has no vehicles. Therefore, she is not involved with transport

vehicles.

      Nurse Hall testified that Mr. Prieto was a fall risk. His chart from University

Plaza stated that for transfer, he has “total dependence” and needed three people to


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help him do things like getting into the shower or into bed. The chart also reflected

that Mr. Prieto had a severe medical condition that placed him at a high risk of

falling. Other documents showed that Mr. Prieto could not brace himself for a fall

and had impaired sitting balance. Nurse Hall also testified that a document entitled

“Side Rail Screen,” that was apparently from University Plaza, indicated that Mr.

Prieto needed to be in a stretcher that had side rails.

      Nurse Hall opined that everyone involved in Mr. Prieto’s care and treatment

knew he was a fall risk, and therefore, every person who came into contact with him

should have made sure he was safe and not going to fall. Nurse Hall also opined

that “every licensed person should have known through their nursing clinical

judgment, should have stopped and questioned the fact that this gentleman was not

in a stretcher when he was released from that [TRC] facility.” Nurse Hall further

testified that “[s]omeone should have questioned the fact that this gentleman freshly

off dialysis, four hours of rigorous dialysis was transferred from that dialysis chair

to a wheelchair.” When asked if there was anything done to protect Mr. Prieto “as

it relates to strapping him into the wheelchair itself,” Nurse Hall replied that “there

should have been some type of safety harness. When placing him into the van, there

should have been some secure mechanism to keep him from falling. However, I’m

not sure if that was actually done. . . .” In response to questioning, Nurse Hall

testified that the nursing care Mr. Prieto received from TRC “fell below the


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acceptable standard of nursing care towards securing and harnessing Mr. Prieto onto

a stretcher for return transport.”    Nurse Hall further testified that a licensed

professional should have “made sure that he was safely placed into a mechanism that

was going to keep him safe in transport,” or, at a minimum, he should have been

safely strapped in place in his wheelchair.

      On cross-examination, Nurse Hall admitted this case was not a fall case, and

that the “problem occurred in the transport van.” Nurse Hall also acknowledged that

while living in University Plaza, although Mr. Prieto had to be transferred from the

bed to the commode, or from the commode to the wheelchair, he moved around the

facility—for example, to go to his meals or get from point A to point B—in a

wheelchair. She also testified that a patient can be secured to a wheelchair and the

wheelchair in turn can be secured to the floor of a transport vehicle. She agreed that

it was the job of the transportation van’s driver to secure Mr. Prieto’s wheelchair to

the floor. Nurse Hall acknowledged that she did not know whether Mr. Prieto was

strapped into his wheelchair while he was in the TRC facility.

      At the conclusion of the second day of trial, Prieto rested. TRC moved ore

tenus for judgment in its favor under Rule 50, arguing that Prieto had not presented

testimony “that would suggest that had Mr. Prieto been in a stretcher, any different

result would have occurred.” TRC argued that “we don’t even have the connection

between the standard of care violation that’s alleged and medical causation.” Prieto


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responded that “not sending [Mr. Prieto] out in the stretcher is the negligence that

directly led to where he was.” The district court judge asked Prieto’s counsel if there

was “evidence that had the plaintiff been transported on a stretcher that the result

would have been different.”      Prieto’s counsel responded that Nurse Hall had

“provided an opinion that the nursing care by DaVita, by the defendant fell below

the . . .standard of care, and she also offered that had that not happened that would

have . . . cured the issue. There wouldn’t have been . . . harm.” The district court

deferred ruling on the motion until the next day so that Nurse Hall’s testimony could

be transcribed. The district court also noted that while Nurse Hall had opined in her

affidavit in opposition to summary judgement “that the result would have been

different had Mr. Prieto been sent back on a stretcher,” the affidavit had “no bearing

on what Ms. Hall’s testimony was here before the jury,” and that the determination

on a Rule 50 motion is based on the evidence presented in court.

      The following day, TRC argued that the transcript of Nurse Hall’s testimony

“is wholly bereft of any causation opinion” and that Nurse Hall offered no opinion

on causation. As a result, TRC asserted that Prieto had not made a prima facie

medical malpractice case, which, under Gooding v. University Hospital Building,

Inc., 

445 So. 2d 1015

(Fla. 1984), requires that a plaintiff establish a breach of the

standard of care and that “said breach proximately caused the damages claimed.”




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      In response, Prieto argued that, under Ruiz v. Tenet Hialeah Healthsystem,

Inc., 

260 So. 3d 977

(Fla. 2018), “if . . . medical negligence through a chain of events

reasonably leads to the harm, that is a question for the jury to decide,” and pointed

to Nurse Hall’s testimony that licensed professionals should have questioned why

Mr. Prieto was not leaving his treatment on a stretcher and that TRC “should have

taken more care to make sure that he left in the safest mechanism possible.”

      The district court stated that “[y]ou’ve established the breach of the duty” and

that “[y]ou’ve got enough there to get [breach of duty] to the jury. What we’re

talking about is causation.” Prieto responded that “the medical negligence—there’s

causation in the medical negligence and that causation proximately led to.” TRC

explained that it was not arguing that there was an intervening cause of negligence,

but rather, that there was no testimony on the element of causation, and that Ruiz did

not overrule Gooding or state that the element of causation “is not existent anymore.”

The district court again asked Prieto’s counsel if there was “evidence to support the

fact that the outcome would have been different had he been transported on a

stretcher.” Prieto responded that she had presented “plenty of evidence” that it was

foreseeable that Mr. Prieto would be “harmed in an accident during medical

transport” if he was not on a stretcher.

      The district court then ruled orally that “Ruiz did not overrule Gooding” and

that, based upon its reading of Gooding, Prieto had “failed to introduce evidence


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which affords a reasonable basis for the conclusion that it is more likely than not that

the conduct of [TRC] was a substantial factor in causing Mr. Prieto’s injuries.” The

district court explained that “[a] mere possibility of such causation is not enough”

and that “[t]his matter, as in Gooding, remains one of pure speculation or

conjecture.” The district court thus granted TRC’s Rule 50 motion.

      On August 19, 2019, the district court entered a written order, finding as

follows:

              For the reasons stated on the record during trial, the Court
              finds that Defendant is entitled to judgment as a matter of
              law because Plaintiff has failed to introduce evidence
              which affords a reasonable basis for the conclusion that it
              is more likely than not that the Defendant’s alleged
              negligence was a substantial factor in causing Rodolfo
              Prieto’s injuries. See Gooding v. Univ. Hosp. Bldg., Inc.,
              

445 So. 2d 1015

(Fla. 1984).

That same day, the district court entered final judgment in favor of TRC, and this

appeal ensued.

II.   STANDARD OF REVIEW

      We review de novo a district court’s order granting a party’s motion for

judgment as a matter of law and apply the same legal standard as the district court.

McGinnis v. Am. Home Mortg. Servicing, Inc., 

817 F.3d 1241

, 1254 (11th Cir. 2016);

London v. Fieldale Farms Corp., 

410 F.3d 1295

, 1300 (11th Cir. 2005).




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III.   ANALYSIS

       On appeal, Prieto argues that the district court erred in granting TRC’s Rule

50 motion for judgment as a matter of law. Federal Rule of Civil Procedure 50(a)

“allows the trial court to remove cases or issues from the jury’s consideration ‘when

the facts are sufficiently clear that the law requires a particular result.’” Weisgram

v. Marley Co., 

528 U.S. 440

, 448 (2000) (quoting 9A C. Wright & A. Miller, Federal

Practice and Procedure § 2521, at 240 (2d ed.1995)); see also, Fed. R. Civ. P. 50(a).

       Relevant to this appeal, “in order to survive a defendant’s motion for judgment

as a matter of law, offered at the conclusion of the plaintiff’s case, the plaintiff must

present evidence that would permit a reasonable jury to find in the plaintiff’s favor

on each and every element of the claim.” Bogle v. Orange Cnty. Bd. of Cnty.

Comm’rs, 

162 F.3d 653

, 659 (11th Cir. 1998); see also Collado v. United Parcel

Serv., Co., 

419 F.3d 1143

, 1149 (11th Cir. 2005) (“Judgment as a matter of law for

the defendant is due when there is insufficient evidence to prove an element of the

claim.”).

       Under Florida law, “[t]he elements of a medical malpractice claim are: ‘(1) a

duty by the physician, (2) a breach of that duty, and (3) causation.’” Cantore v. W.

Boca Med. Ctr., Inc., 

254 So. 3d 256

, 260 (Fla. 2018) (quoting Saunders v. Dickens,

151 So. 3d 434

, 441 (Fla. 2014)); see also Jackson Cty. Hosp. Corp. v. Aldrich, 

835 So. 2d 318

, 327–28 (Fla. Dist. Ct. App. 2002) (“To prevail in a medical malpractice


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case, a plaintiff must establish the standard of care owed by the defendant, the

defendant’s breach of the standard of care, and that such breach proximately caused

the alleged damages.”). “As to the element of causation, ‘Florida courts follow the

more likely than not standard of causation and require proof that the negligence

probably caused the plaintiff’s injury.’” 

Cantore, 254 So. 3d at 260

(quoting

Gooding, 445 So. 2d at 1018

). A plaintiff does not “sustain this burden of proof by

relying on pure speculation.” Cox v. St. Josephs Hosp. 

71 So. 3d 795

, 799 (Fla.

2011); see also Hessen for Use & Benefit of Allstate Ins. Co. v. Jaguar Cars, Inc.,

915 F.2d 641

, 647 (11th Cir. 1990) (“Florida has adopted a preponderance standard

for causation in . . . negligence . . . actions; a mere possibility of causation is not

enough.”); McCain v. Fla. Power Corp., 

593 So. 2d 500

, 504 (Fla. 1992) (stating

that when “reasonable persons could differ as to whether the facts establish

proximate causation[,] . . . the resolution of the issue must be left to the fact-finder,”

but that “[t]he judge is free to take this matter from the fact-finder” when the facts

are “unequivocal”).

      On appeal, Prieto argues that the district court erred in relying on Gooding in

entering judgment as a matter of law based on Prieto’s failure to introduce evidence

that would have afforded the jury a “reasonable basis for the conclusion that it is

more likely than not” that TRC’s failure to send Mr. Prieto home on a stretcher was

a substantial factor in causing his injuries. Specifically, Prieto argues that the district


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court should have instead relied upon Ruiz, which she asserts created an “exception”

to Gooding by providing that liability attaches to initial negligent actors who set in

motion a natural and continuous sequence of events that “bring about” the injuries

at issue. Prieto thus claims that, under Ruiz, the issue of proximate cause should

have gone to the jury because the testimony of Dr. Ali, Nurse Alfonso, and

technician Ventura Valdez concerning TRC’s negligence in failing to send Mr.

Prieto out of its facility on a stretcher identified the “catalyst” of what led to Mr.

Prieto’s injuries. Prieto’s argument, in essence, is that evidence of breach of the duty

of care alone is sufficient to establish causation under Florida law.

      Prieto’s argument lacks merit. As explained below, we conclude that the

district court properly applied Gooding and that Ruiz created no exception to a

plaintiff’s obligation to introduce legally sufficient evidence of proximate causation

where the defendant’s negligent act or omission is not the primary cause of the

injury.

      In Gooding, the Florida Supreme Court set forth Florida’s standard on

proximate cause in medical malpractice 

cases. 445 So. 2d at 1020

–21. In that case,

the plaintiff brought a medical malpractice claim against the defendant hospital,

alleging that the hospital’s emergency room staff was negligent in not taking an

adequate history and treating the decedent’s abdominal aneurysm before he bled out

and went into cardiac arrest.

Id. at 1017.

At trial, the plaintiff presented expert


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testimony that the “emergency room staff violated accepted medical standards.”

Id. The plaintiff’s expert,

however, “failed to testify that immediate diagnosis and

surgery more likely than not would have enabled [the decedent] to survive.”

Id. The trial court

denied the defendant’s motion for directed verdict on causation and

instructed the jury that it could find for the decedent “if the hospital destroyed [the

decedent’s] chance to survive.”

Id. The jury found

the defendant liable, and the

defendant hospital appealed.

Id. The Florida district

court of appeal reversed,

holding that the trial court should have directed a verdict in favor of the defendant

because the plaintiff “could not meet the more likely than not test for causation.”

Id. at 1017–18.

      On review, the Florida Supreme Court affirmed the decision of the district

court of appeal and held that in a medical malpractice case, “[t]he plaintiff must

show that the injury more likely than not resulted from the defendant’s negligence

in order to establish a jury question on proximate cause. In other words, the plaintiff

must show that what was done or failed to be done probably would have affected the

outcome.”

Id. at 1020.

The Florida Supreme Court found that the plaintiff’s

evidence established that the defendant breached the applicable standard of care

when its emergency room staff failed to treat the decedent.

Id. at 1018

. 
Applying

the proximate cause standard to the facts of the case, however, the Florida Supreme

Court rejected the plaintiff’s contention that it had presented sufficient evidence “for


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a jury to find the hospital’s negligence more likely than not constituted a substantial

factor in [the decedent’s] death.”
 

Id. at 1018

. 
Instead, the Florida Supreme Court

found that the expert’s testimony “established a no better than even chance for [the

decedent] to survive” even if the decedent had been immediately diagnosed and

treated.
 Id. As such, “the 
hospital was entitled to a directed verdict because the

plaintiff failed to prove causation.”
 Id.

      In reaching its 
conclusion, the Florida Supreme Court set forth the standard

for proving proximate cause in negligence actions in Florida:

      In negligence actions Florida courts follow the more likely than not
      standard of causation and require proof that the negligence probably
      caused the plaintiff’s injury. Prosser explored this standard of proof as
      follows:

          “On the issue of the fact of causation, as on other issues essential
          to his cause of action for negligence, the plaintiff, in general, has
          the burden of proof. He must introduce evidence which affords a
          reasonable basis for the conclusion that it is more likely than not
          that the conduct of the defendant was a substantial factor in
          bringing about the result. A mere possibility of such causation is
          not enough; and when the matter remains one of pure speculation
          or conjecture, or the probabilities are at best evenly balanced, it
          becomes the duty of the court to direct a verdict for the
          defendant.”


Id. at 1018 
(citations omitted) (quoting Prosser, Law of Torts § 41 (4th ed.1971)).

      Here, the district court did not err in applying Gooding when granting TRC

judgment as a matter of law. As in Gooding, Prieto did not present evidence that


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TRC’s negligence more likely than not was a substantial factor in causing Mr.

Prieto’s injuries. None of the witnesses’ testimony upon which Prieto relies

addressed the issue of causation. Specifically, Prieto relies on the testimony of Dr.

Ali, Nurse Alfonso, and technician Ventura Valdez5 as identifying TRC’s

negligence in failing to send Mr. Prieto home in a stretcher. But while Dr. Ali’s and

Nurse Alfonso’s testimony could support a fact-finder’s conclusion that TRC

breached its duty of care—a contention TRC does not dispute on appeal—neither

witness offered any testimony that Mr. Prieto’s injuries more likely than not resulted

from TRC’s failure to send him home on a stretcher. Indeed, when Dr. Ali was asked

whether Mr. Prieto would have suffered “any injury” if he had been on a stretcher

which was bolted to the van’s floor, Dr. Ali did not express an opinion.

        Furthermore, although Prieto on appeal does not address or discuss the

testimony of her expert, Nurse Hall, a review of Nurse Hall’s testimony shows that

she did not testify that Mr. Prieto’s injuries more likely than not resulted from TRC’s

failure to have Mr. Prieto leave in a stretcher. Instead, Nurse Hall opined only as to


        5
          In her initial brief, Prieto states that she is relying on the trial testimony of Dr. Ali, Nurse
Alfonso, and technician Ventura Valdez. Prieto, however, does not provide this Court with any
citations to the specific trial testimony upon which she relies. Indeed, even though Prieto states
that she relies on the testimony of technician Ventura Valdez, no part of technician Ventura
Valdez’s testimony is even referenced in Prieto’s statement of facts. Where an appellant’s
argument does not contain citations to the parts of the record upon which she relies, this Court has
found the issue abandoned. See Singh v. U.S. Att’y Gen., 
561 F.3d 1275
, 1278–79 (11th Cir. 2009).
On this basis alone, we could find Prieto’s argument as to the sufficiency of the evidence
abandoned. However, in the interest of completeness and because TRC’s brief relies on the
testimony of Nurse Hall, we have considered all the trial testimony presented above.
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TRC’s breach of the acceptable standard of nursing care because of its failure to

place Mr. Prieto on a stretcher. Evidence of breach of duty of care is not enough to

succeed on a claim of medical malpractice, see 
Gooding, 445 So. 2d at 1018
–19;

Hollywood Med. Ctr., Inc. v. Alfred, 
82 So. 3d 122
, 125–26 (Fla. Dist. Ct. App. 2012)

(holding that the defendant was entitled to directed verdict on claim for medical

malpractice where the plaintiff established that emergency room nurses breached the

nursing standard of care but “no one testified that the nurses’ failure to act affected

[the decedent’s] outcome”), and where there is insufficient evidence to prove an

essential element of a claim—here, proximate cause—the defendant is entitled to

judgment as a matter of law under Rule 50(a), see 
Bogle, 162 F.3d at 659
.

      Prieto’s argument that Ruiz compels a different result also fails. In Ruiz, the

Florida Supreme Court quashed the Third District Court of Appeal’s decision in Ruiz

v. Tenet Hialeah Healthsystem, Inc., 
224 So. 3d 828 
(Fla. Dist. Ct. App. 2017),

because the intermediate appellate court applied the incorrect proximate causation

standard. 260 So. 3d at 977 
In Ruiz, the plaintiff, Ruiz, filed a medical malpractice

action against Dr. 
Lorenzo. 260 So. 3d at 980
. When Ruiz’s wife, Espinosa, was

scheduled for surgery, Dr. Lorenzo, who was not assigned to Espinosa, performed

the pre-anesthesia evaluation.
 Id. at 979–80. 
Dr. Lorenzo reviewed Espinosa’ EKG

report, which flagged the test result as abnormal.
 Id. at 979. 
Dr. Lorenzo failed to

review all of Espinosa’s lab results, which also showed abnormal results. See
 id. at


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980. After Dr. Lorenzo saw her for three to five minutes, Espinosa’s assigned

anesthesiologist took over and started the pre-anesthesia evaluation over. Dr.

Lorenzo did not inform Espinosa’s surgeons about the abnormal EKG or lab results.


Id. During the surgery, 
Espinosa lost a large amount of blood and passed away after

suffering from cardiac arrest. See
 id. at 980, 983.

      Ruiz filed suit against the doctors involved in Espinosa’s treatment, including

Dr. Lorenzo.
 Id. at 980. 
As to Dr. Lorenzo, Ruiz alleged that he breached the

standard of care by not fully reviewing Espinosa’s chart, not ordering a second EKG,

and not telling the surgeons about the abnormal lab results.
 Id. at 981. 
Had these

things been done, Ruiz alleged that the surgery would have been cancelled because

Espinosa’s underlying condition of multiple myeloma would have been discovered.


Id. The intermediate appellate 
court affirmed the trial court’s granting of a directed

verdict in favor of Dr. Lorenzo, “concluding that no competent, substantial evidence

in the record would allow a reasonable factfinder to conclude Dr. Lorenzo was the

‘primary cause’ of Espinosa’s death.”
 Id. (quoting Ruiz, 224 
So. 3d at 830).

      On review, the Florida Supreme Court quashed the decision because it was

“inconsistent with [the Florida Supreme Court’s] precedent regarding the proximate

causation standard,” as Florida “law does not require an act to be the exclusive or

even the primary cause of an injury in order for that act to be considered the

proximate cause of the injury: rather, it need only be a substantial cause of the


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injury.”
 

Id. at 982–83.


Relying on its decision in Sardell v. Malanio, 
202 So. 2d

746 
(Fla. 1967), the Florida Supreme Court explained that an initial negligent actor

who is not the primary cause of the injury to the plaintiff is not shielded from liability

where the act that injures the plaintiff “was merely a direct, natural and continuous

sequel to the initial act.” 
Ruiz, 260 So. 3d at 982 
(quoting 
Sardell, 202 So. 2d at

747
). Thus, while “Dr. Lorenzo’s conduct was not the primary cause of Espinosa’s

death, . . . he may nonetheless be liable for his part in it if his failure to read and

report the abnormal test results substantially contributed to causing it.”
 Id. at 982–

83. 
For that reason, the Florida Supreme Court concluded that the intermediate

appellate court erred when it concluded that Dr. Lorenzo was entitled to a directed

verdict based on the fact that he was not the primary cause of Espinosa’s death.
 Id.

at 983. 
The Florida Supreme Court explained that its precedent made “clear that Dr.

Lorenzo cannot prevent Ruiz from establishing proximate cause merely by showing

his actions or omissions were not the primary cause of Espinosa’s death.”
 Id. Citing

to Gooding, 
the Florida Supreme Court explained that, “to foreclose liability on the

grounds of causation, Dr. Lorenzo’s acts or omissions must not have substantially

contributed to Espinosa’s death as part of a natural and continuous sequence of

events which brought about that result.”
 Id.

      Based on the 
applicable Florida law at issue here, we conclude that the district

court did not err in failing to apply Ruiz when ruling on TRC’s motion for judgment


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as a matter of law and Prieto is not entitled to relief on this point. First, TRC did not

argue that it was entitled to judgment as a matter of law because it was not the

“primary cause” of Mr. Prieto’s injuries. Rather, TRC argued that that judgment as

a matter of law was appropriate because there was no evidence at all to support the

element of proximate cause. For that reason alone, Ruiz does not apply here.

      Second, Ruiz does not, as Prieto suggests, allow proximate cause to be inferred

from the breach of a duty of care alone where the defendant is an initial negligent

actor whose act or omission is not the primary cause of the injury. Instead, Ruiz

makes clear that even where a defendant’s act or omission is not the primary cause

of the injury, a plaintiff maintains her burden of proof to establish proximate

causation. See
 id. (explaining that a 
defendant is entitled to a directed verdict when

there is no “competent, substantial evidence in the record which would permit a

reasonable factfinder to reach a conclusion” that the defendant’s acts or omissions

substantially contributed to the plaintiff’s injuries); see also 
Sardell, 202 So. 2d at

747 
(“It remains the burden of the petitioners, Sardell, to prove that the act of [the

initial negligent actor] was the proximate cause of the injury.”).

      Third, Ruiz did not craft an “exception” to Gooding for initial negligent actors

who set in motion a natural and continuous sequence of events that bring about the

plaintiff’s injuries. Indeed, Ruiz relied upon Gooding for the statement of law that




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in order to show proximate cause, a defendant’s conduct must have substantially

contributed to the injury. See 
Ruiz, 260 So. 3d at 982
–83.

IV.   CONCLUSION

      The law in Florida is clear that a plaintiff in a negligence action cannot sustain

the burden of proof on causation by relying on pure speculation. See 
Cox, 71 So. 3d

at 799
. Because Prieto failed to present any evidence that could support a jury’s

finding that TRC’s alleged negligence in failing to send Mr. Prieto home on a

stretcher more likely than not caused his injuries—an essential element of Prieto’s

medical malpractice claim—we conclude that the district court did not err in entering

judgment as a matter of law in TRC’s favor and affirm.

      AFFIRMED.




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