In the State Court of Muscogee County

State of Georgia

JEREMY JONES

BETH JONES,

                  Plaintiffs,

— versus —

THE MEDICAL CENTER, INC.

PIEDMONT HEALTHCARE, INC.

VINCENT M. NICOLAIS, MD

SAMUEL OSEI-BONSU, MD

RADIOLOGY PARTNERS, INC.

JOSHUA KOERNER, DO

NOLEN MEDICAL CONSULTING LLC

CHERYL STEPHENS, MD

MANASA VALLURI, MD

TABITHA MILLER, RN

CHRISTINA ORR, RN

JOHN/JANE DOE 1-10,

                  Defendants

CIVIL ACTION

FILE NO. SC 2021 CV 001143

JURY TRIAL DEMANDED

HON. ANDY PRATHER

Plaintiff’s First Amended Complaint for Damages

Nature of Amendment

1.             This First Amended Complaint pleads additional factual averments in support of Plaintiffs’ claim for ordinary negligence by The Medical Center, Inc. Piedmont, Healthcare, Inc., and Radiology Partners, Inc. (collectively, the “Corporate Defendants”).

2.             The additional factual averments relate to aspects of hospital management that are not common knowledge and are relevant to Plaintiffs’ ordinary-negligence claim.

3.             The additional factual averments are particularly important in light of the Corporate Defendants’ motions to dismiss the ordinary-negligence claim. Those motions rely largely on a simplistic — and erroneous — view of how healthcare organizations work. The additional factual averments address some of the misconceptions that underlie the Corporate Defendants’ motions to dismiss.

4.             The additional factual averments better enable the Court to rule on the Corporate Defendants’ motions to dismiss without looking beyond the pleadings.

5.             The additional factual averments presented here are in addition to the averments in Plaintiffs’ prior complaint in this action. However, for the sake of convenience, this complaint repeats some of the prior factual averments concerning the ordinary-negligence claim.

6.             This complaint incorporates the Affidavit of Arnold Mackles, MD, MBA, attached as Exhibit 1.

Definitions

In the allegations below —

“hospital staff” refers to individuals who work at a hospital, regardless of employment status.

“managers” includes a hospital’s governing body as well as individuals who might be referred to as managers, administrators, or supervisors.

“management” includes actions of a hospital’s governing body as well as functions that might be referred to as “management,” “administration,” “supervision.”

“policies” refers to any written statement that lays out requirements for the conduct of hospital staff, either generally or for particular issues.

“professional” refers to an individual in a profession listed in OCGA 9-11-9.1.

“non-professional hospital manager” refers to a board member, manager, or administrator at a hospital who is not a licensed physician, a licensed nurse, or any other professional listed in OCGA 9-11-9.1(g), who does not apply medical judgment in his or her own work.

“sentinel event” refers to a patient safety event (not primarily related to the natural course of a patient’s illness) that results in death, severe harm (even if short-term), or permanent harm (even if not severe).

Principles of Hospital Management & Patient Safety

7.             The averments in this section (including its sub-sections) state general principles. Each of those principles applies in this case. 

8.             The averments in this section are drawn primarily from the Joint Commission accreditation standards for hospitals and from the United States Health & Human Services regulations for hospitals that participate in the Medicare program (which includes virtually all American hospitals).

9.             The averments in this section also draw from the sizable literature on hospital administration, patient safety, and quality improvement.

10.          The averments in this section largely address hospitals specifically. However, other healthcare organizations have analogous responsibilities, adapted to the circumstances in which they provide care.

The Scale of Harm from Medical Error

11.          Preventable medical error is the third leading cause of death in America.

12.          The Institute of Medicine’s 1999 report, To Err is Human, became, and still is, widely known in the healthcare industry, including by the healthcare organizations in this case.

13.          The Institute of Medicine’s 1999 report, To Err is Human, estimated that in American hospitals 44,000 to 98,000 patients died each year from medical errors — with a financial cost between 17 and 29 billion dollars.

14.          In 2010, the United States Department of Health & Human Services estimated that medical error contributed to the deaths of 15,000 patients every month (or 180,000 yearly) — including only Medicare patients.

15.          In 2016, researchers at John Hopkins Medicine concluded that over 250,000 Americans die each year from medical errors.

16.          The John Hopkins study revealed that medical error ranks as the third-leading cause of death in the United States, behind only heart disease and cancer, and ahead of respiratory disease.

17.          Approximately one third of medical errors cause harm. Most medical errors do not cause harm. If all medical errors could be identified and addressed promptly — to prevent the same type of error from happening again — many if not all medical errors could be prevented before they cause serious harm.

System Failures as a Cause of Medical Error

18.          A hospital is a large, complex system.

19.          The complexity of hospital care creates potential for medical errors of various kinds — for example, inattention, failures of communication, lack of preparedness, mistaken assumptions that someone else is addressing a problem, and others. 

20.          Medical errors usually involve both (a) error by the individual clinicians directly involved in a patient’s care, and (b) system failures that create unnecessary potential for error. 

21.          For at least 20 years, it has been generally known among hospital managers — including the Corporate Defendants’ — that system failures contribute substantially to medical errors that hurt patients.

22.          Many types of medical errors are known and predictable — for example, medication errors, wrong-site surgeries, hospital-acquired infections, hospital-acquired pressure wounds, among others.  

23.          Many types of system failures that contribute to medical error are known and predictable — for example, failures of communication during patient hand-offs, silo-ing of responsibilities among physicians, cognitive biases of clinicians, overwork or understaffing, and an organizational culture that discourages people from raising concerns about patient safety.  

System-Level Solutions

24.          Human error in hospitals can be reduced by well-designed systems. And system failures in hospitals can be reduced by a culture of safety and a program of continuous improvement — continually working to expose vulnerabilities and to fix them before they hurt patients.

25.          Protecting patients’ safety requires identifying and fixing system failures and harmful parts of an organization’s culture. 

26.          Errors that cause serious harm can be reduced or eliminated by managing the manageable — the organizational factors lying within the direct spheres of influence of system operators and managers.

27.          Since at least as early as 2000, multiple governmental and private organizations have worked to find solutions to healthcare system failures, and to make tools available to hospital managers to address system failures.

Hospital Management

Management as a Distinct Discipline

28.          Large, complex organizations require managers to coordinate the activities of the individuals in the organization.

29.          A hospital is not a self-managing system. It requires active management.  

30.          Management of organizations is a specialized discipline, with its own field of study, its own set of theories and historical development, its own education and training requirements.

31.          Managers learn the work and issues affecting their own organization and industry, but managers apply knowledge and skills that have general application across industries.

32.          Managing a healthcare organization is not the same as practicing medicine or nursing. Managing involves different roles, different actions, different responsibilities. 

33.          Hospital managers need education, training, and skills different from those required to be a physician or nurse. Hospital managers must have education or training in management, but need not have gone to medical or nursing school. Physicians or nurses need not have training in managing organizations.

34.          Hospital managers require training in management processes that apply across industries — for example, Failure Mode & Effects Analysis, Root Cause Analysis, Continuous Process Improvement, and Culture of Safety.

35.          Hospital managers are not generally required to be physicians or nurses, except for specific positions such as Chief Medical Officer or Chief Nursing Officer.

36.          Training and certification programs for hospital managers do not require a person to be a physician or nurse. For example, to become a Fellow of the American College of Healthcare Executives, a person does not need to be a physician or nurse.

37.          Patient safety certifications do not require physician or nursing degrees or licenses. For example, to become a Certified Professional in Patient Safety (CPPS), a persons does not need to be a physician or nurse.

38.          Physicians and nurses typically are not required to study or become proficient in organizational management.

39.          Traditional medical education does not involve the study of organizational management theory or processes.

40.          Traditional medical education does not involve the study of management processes designed to reduce harm — for example, Failure Mode & Effects Analysis, Root Cause Analysis, Continuous Process Improvement, or Culture of Safety.

41.          Physicians and nurses working in a hospital typically have not studied healthcare organization management or obtained any degree or certification in it.

42.          Physicians and nurses working in a hospital — including the individual Defendants in this case — typically have limited knowledge of how the hospital is managed and frequently lack basic information about the hospital’s patient-safety and quality-improvement programs.

43.          Typically, a hospital’s governing board consists mainly of people who are neither physicians nor nurses.

44.          Typically, many of a hospital’s managers are neither physicians nor nurses. For example, many hospitals’ Chief Executive Officers are neither physicians nor nurses. Many hospital staff in formal patient safety roles are neither physicians nor nurses.

45.          Georgia does not issue a professional license for hospital managers (or for managers in any other industry).

46.          OCGA 9-11-9.1(g) does not include hospital managers in the list of professionals to which OCGA 9-11-9.1 applies.

47.          Non-professional hospital managers — because they are not medical professionals — do not apply medical judgment in their work.

48.          Where physicians or nurses occupy managerial roles, some of their duties include managerial tasks that do not require being a physician or nurse — for example, checking to make sure a certain policy has been communicated to hospital staff, or checking to make hospital staff has undergone certain training.

Non-Professional Managers & Patient Safety

49.          Clinicians treating patients are not in a position to fix problems with the systems and organizational culture in a hospital. 

50.          Patient safety is not solely the responsibility of the physicians and nurses treating a patient. 

51.          Hospital managers have responsibilities for protecting patient safety. Non-professional hospital managers have responsibilities for protecting patient safety. And hospital managers who are professionals have responsibilities for protecting patient safety even when acting in a non-professional, administrative role.

52.          Non-professional hospital managers — whose work does not involve medical judgment — play an important role in protecting patient safety.

53.          Competent, careful non-professional managers are essential to patient safety. Without non-professional managers who focus on patient safety, rates of medical error remain high. Clinicians cannot do it alone. Non-professional managers must do their part. 

54.          Hospitals are required by industry standards and Joint Commission accreditation requirements to analyze the causes of medical errors that hurt patients seriously. Typically, hospitals use “root cause analysis” — a management analytical process used in a variety of industries.

55.          When hospitals perform a root cause analysis of medical error that harmed a particular patient, frequently the chain of causation leads back to system or cultural failures for which non-professional managers are responsible.

56.          Negligence by non-professional managers can and does foreseeably cause harm to patients. Within the healthcare industry, this principle is accepted and well understood by clinicians and non-clinicians alike.

Responsibilities of Hospital Managers for Patient Safety

Generally

The Fact of Responsibility

57.          Federal regulations impose requirements on hospital managers concerning patient safety.

58.          The Joint Commission’s accreditation standards impose requirements on hospital managers concerning patient safety.

59.          Industry standards exist and indicate requirements for hospital managers concerning patient safety.

60.          Federal regulations, Joint Commission standards, and industry standards inform — but do not conclusively dictate — what counts as reasonable conduct by hospital managers under a given set of circumstances.

61.          The responsibilities discussed below arise in part from federal regulations, Joint Commission standards, and industry standards.

62.          Pursuant to industry standards: Non-professional hospital managers are responsible for the conduct of the hospital.

63.          Pursuant to industry standards: Non-professional hospital managers are responsible for overseeing the medical care provided by clinicians, regardless of whether the clinicians are hospital employees or contractors.

64.          Pursuant to industry standards: Non-professional hospital managers are responsible for the systems and organizational culture of the hospital — and for ensuring they protect patient safety.

65.          Non-professional hospital managers cannot pass the entire responsibility for patient safety onto clinicians. Managers cannot hide behind physicians and nurses.

Hospital Managers & Clinicians

66.          The hospital’s medical staff is accountable to hospital management.

67.          Non-professional hospital managers work with physicians and nurses, but managers are responsible for managing the hospital.

68.          Non-professional hospital managers — even though they are not physicians or nurses themselves — are responsible for managing the safety and efficacy of medical care provided at the hospital, and for managing improvement efforts.

69.          Both the non-professional managers and the clinicians are involved in patient safety. Both have a role in protecting patient safety. Both have responsibilities for protecting patient safety.

70.          Even where safety-related tasks must be carried out by physicians or nurses, non-professional managers play an important role in (a) assigning the task to the clinicians, (b) making sure the task gets done, (c) making sure the necessary resources (for example, time) are provided, (d) lending visible support to the project when useful, and (e) assessing the effectiveness of the task. That is, hospital managers manage many of the safety-related tasks performed by clinicians, although the managers do not personally perform the tasks.

71.          Where physicians or nurses have managerial roles (for example, Chief Medical Officer or Chief Nursing Officer), more senior managers are responsible for supervising those individuals’ managerial duties. A Chief Medical Officer, for example, is not a free agent unaccountable to more senior management.

72.          Non-professional hospital managers are not on their own, to invent solutions to system failures from scratch. To the contrary, hospital managers have tools and assistance available from multiple patient-safety organizations.

Overall Responsibilities

73.          Non-professional hospital managers (because they are not medical professionals) are not personally responsible for patient care, or for determining the substantive content of medical policies or of training programs, or for personally providing medical training. Rather, non-professional hospital managers are responsible for managing such activities — making sure they happen, and making sure they either work effectively or get fixed.

74.          Concerning medical care, non-professional hospital managers are responsible for (a) making sure need-assessments are performed to identify what policies or protocols should be created, (b) making sure policies and protocols are communicated effectively to hospital staff (instead of just papering the file), (c) making sure training is given so that hospital staff understand how to apply the policies and protocols in practice, (d) making clear that the policies and protocols must be followed (that is, that the policies and protocols are not bureaucratic formalities which staff can disregard), (e) monitoring compliance, and (f) ensuring remedial actions are taken where compliance problems arise. In the discussion below, statements that “non-professional managers must ensure” this or that, the manner in which managers “ensure” the outcome is to take the actions listed in this paragraph.

75.          Non-professional hospital managers must engage all hospital staff in actively seeking out problems in the hospital’s system and culture — and fixing the problems before they cause further harm.

76.          Non-professional hospital managers must ensure the hospital is actually implementing practices that protect patients. Just papering the file is not enough.

Some Specific Issues

Patient Rights & Grievance Process

77.          Non-professional hospital managers must ensure that whenever possible, each patient is informed of his or her rights (through a family member if necessary), in advance of furnishing or discontinuing patient care.

78.          The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment.

79.          Non-professional hospital managers must ensure that each patient is clearly informed of the procedure for submitting a written or verbal grievance to the hospital.

80.          Non-professional hospital managers must ensure that when a patient has filed a grievance, the patient is given written notice of the hospital’s decision — including the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

81.          Non-professional hospital managers must ensure that where medical error hurts a patient, the error is disclosed to the patient.

82.          The grievance process and disclosure of errors to patients are important to other patients’ safety, because these processes can identify types of medical errors that do not show up clearly in the hospital’s statistical data.

Supervision & Support for Lower-Level Providers

83.          Non-professional hospital managers must ensure that all hospital staff know their limits — that is, understand their appropriate scope of practice — and know when to get help from more qualified providers when necessary. This applies generally, but is particularly important for residents, physician assistants, and nurse practitioners whose scope of practice partially overlaps with that of fully trained physicians.

84.          Non-professional hospital managers must ensure that all hospital staff have the supervision and support they need from more qualified providers. This applies generally, but is particularly important for residents, physician assistants, and nurse practitioners whose scope of practice partially overlaps with that of fully trained physicians.

Culture of Safety

85.          Non-professional hospital managers must create a culture of safety throughout the hospital — a culture that emphasizes (a) reporting and addressing unsafe conditions before they cause harm, (b) eliminating attitudes that discourage lower ranking staff from raising concerns that might indicate errors by higher ranking staff, (c) continually identifying opportunities for improvement, and (d) continually improving. Joint Commission accreditation standards require such a culture of safety.

86.          Reporting of problems by front-line hospital staff is important, both because such reporting can identify types of medical errors that do not show up clearly in the hospital’s statistical data and because such reporting can often reveal problems in real time, when the problems can be corrected before the problems seriously hurt the patient.

87.          Since the majority of medical errors do not cause harm, a culture of safety that vigorously addresses “near misses” can eliminate many types of medical error before they cause future harm.

Continual Performance Improvement

88.          Non-professional hospital managers must ensure that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained. Federal regulations and the Joint Commission accreditation standards require such a program.

89.          Non-professional hospital managers must create a system to proactively identify system failures and problems with the organizational culture — and fix them before they cause future harm.

90.          Non-professional hospital managers must ensure the hospital tracks quality and safety indicators, including adverse patient events.

91.          Non-professional hospital managers must ensure that the hospital identifies adverse patient events, analyzes their causes, and implements preventive actions and mechanisms that include feedback and learning throughout the hospital.

Communication and Hand-offs

92.          Non-professional hospital managers must ensure that where multiple providers are involved in a patient’s care, protocols are in place to ensure proper communication between providers — to avoid communication gaps that lead to medical error.

93.          Non-professional hospital managers must ensure that communication protocols are effective, to prevent communication gaps that lead to medical error.

Responsibility and Silo-ing

94.          Non-professional hospital managers must ensure that where multiple providers are involved in a patient’s care, protocols are in place to ensure that responsibilities are clearly understood — to prevent confusion about who is responsible for what, which can lead to medical error.

95.          Non-professional hospital managers must ensure that protocols for assigning responsibility are effective, to prevent confusion that leads to medical error.

Sentinel Events

96.          A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness) that results in death, severe harm (even if short-term), or permanent harm (even if not severe).

97.          If an event is arguably a sentinel event, then hospital managers must treat it as a sentinel event.

98.          Careful identification, investigation, and analysis of patient safety events, as well as strong corrective actions that improve systems, are essential to protect patients.

99.          Non-professional hospital managers must ensure that all sentinel events are identified and investigated by a comprehensive systematic analysis.

100.       Non-professional hospital managers must ensure that a corrective action plan is implemented to prevent similar events from happening again.

101.       After creating a corrective plan after a sentinel event, non-professional hospital managers must follow up to ensure the plan is implemented effectively.

A Partial List of Purely Managerial Tasks for Patient Safety

Very Generally

102.       Non-professional hospital managers can and must learn what is required of a hospital.

103.       Non-professional hospital managers can and must work competently and carefully to ensure that the hospital is doing what is required of it.

104.       Non-professional hospital managers can and must communicate effectively to hospital staff what the hospital’s governing body expects of the staff.

105.       Non-professional hospital managers can and must assign tasks to clinicians.

106.       Non-professional hospital managers can and must make sure that tasks they assign are actually done.

107.       Non-professional hospital managers can and must evaluate the performance of the hospital and hospital staff on assigned tasks.

108.       Non-professional hospital managers can and must organize and oversee the provision of services at the hospital by clinicians.

Capacities of Hospital Generally

109.       For each of the services provided by the hospital, non-professional hospital managers can organize and oversee efforts (a) to determine whether the hospital is able and ready to provide the service safely and effectively, and (b) to remedy any deficiencies identified. And non-professional managers are responsible for doing so.

110.       For each of the services provided by the hospital, non-professional hospital managers can organize and oversee efforts (a) to determine whether the hospital is able and ready to address any known complications that may require acute care, and (b) to remedy any deficiencies identified — especially for known complications that can cause serious, permanent injury. And non-professional managers are responsible for doing so.

Policies Generally

111.       Non-professional hospital managers can organize and oversee efforts to identify what policies are needed. And non-professional managers are responsible for doing so. However, non-professional managers typically cannot and should not determine the substantive content of policies.

112.       Non-professional hospital managers can ensure that policies adopted by the hospital are effectively communicated to all relevant members of the hospital staff. And non-professional managers are responsible for doing so.

113.       Non-professional hospital managers can ensure that all relevant members of the hospital staff understand the policy and are able and ready to implement it. And non-professional managers are responsible for doing so.

114.       Non-professional hospital managers can communicate effectively to all relevant members of the hospital staff that policies adopted by the hospital must be followed. And non-professional managers are responsible for doing so.

115.       Non-professional hospital managers can monitor compliance with hospital policies. And non-professional managers are responsible for doing so.

116.       Non-professional hospital managers can remedy failures to comply with hospital policies. And non-professional managers are responsible for doing so.

Culture of Safety

117.       Non-professional hospital managers can ensure that patient safety is the top priority for all hospital staff. And non-professional managers are responsible for doing so.

118.       Non-professional hospital managers can ensure that all hospital staff are enabled and expected to raise concerns about any aspect of patient safety until the concerns are addressed — and to do so without fear of reprisals. And non-professional managers are responsible for doing so.

119.       Non-professional hospital managers can ensure that differences in authority or status do not discourage any hospital staff from raising concerns about any aspect of patient safety. And non-professional managers are responsible for doing so.

120.       Non-professional hospital managers can ensure that patients or their families are encouraged to raise concerns about patient care. And non-professional managers are responsible for doing so.

121.       Non-professional hospital managers can ensure that concerns about patient safety — whether raised by patients or by hospital staff — are addressed appropriately. And non-professional managers are responsible for doing so.

122.       Non-professional hospital managers can ensure that problems affecting patient safety — including problems that do not lead to harm — are used as opportunities to learn and improve. And non-professional managers are responsible for doing so.

123.       Non-professional hospital managers can organize and oversee efforts to identify the causes of patient-safety problems. And non-professional managers are responsible for doing so.

124.       Non-professional hospital managers can organize and oversee efforts to identify and implement changes to prevent patient-safety problems from happening again, after they have been reported and investigated. And non-professional managers are responsible for doing so.

Training Generally

125.       Non-professional hospital managers can organize efforts to find out whether hospital staff have the knowledge and skills they need for patient care. And non-professional managers are responsible for doing so.

126.       Non-professional hospital managers can organize efforts to identify education and skills training that would improve hospital staff’s ability to provide patient care. And non-professional managers are responsible for doing so.

127.       Non-professional hospital managers can organize efforts to provide necessary or useful education and skills training for hospital staff. And non-professional managers are responsible for doing so. Typically, however, non-professional managers cannot and should not either determine the substantive content of the training or conduct it.

128.       Non-professional hospital managers can ensure that hospital staff participate appropriately in the education and skills training provided to them. And non-professional managers are responsible for doing so.

129.       Non-professional hospital managers can organize efforts to evaluate the effectiveness of education and skills training provided to hospital staff. And non-professional managers are responsible for doing so.

Performance Improvement Generally

130.       Non-professional hospital managers can organize and oversee a continuous performance improvement program. And non-professional managers are responsible for doing so.

131.       Non-professional hospital managers can organize and oversee ongoing, proactive risk assessments — to make sure that they are performed, that they lead to action plans, and that the action plans are implemented and effective. And non-professional managers are responsible for doing so.

132.       Non-professional hospital managers can organize and oversee the collection of statistical data to identify problems that may harm patient safety. And non-professional managers are responsible for doing so.

133.       Non-professional hospital managers can organize and oversee the analysis of data that indicate potential patient-safety problems. And non-professional managers are responsible for doing so.

134.       Non-professional hospital managers can organize and oversee the implementation of changes to address patient-safety problems that arise from analysis of statistical indicators. And non-professional managers are responsible for doing so.

Accountability for Hospital Managers

135.       Negligence by hospital managers can contribute substantially to medical error that hurts patients.

136.       It would be dangerous to exempt managers from accountability for their own negligence. That would remove an important incentive for managers to work diligently to create systems that protect patients.

137.       The law does not exempt hospital managers from accountability for their own negligence.

Non-Professional Management at The Corporate Defendants

In the following averments:

“professional” refers to an individual who is a professional listed in OCGA 9-11-9.1(g).

“non-professional” refers to an individual who is not a professional listed in OCGA 9-11-9.1(g).

Non-Professional Individuals

138.       The Corporate Defendants’ governing bodies have responsibilities for patient safety.

139.       Multiple members of the Corporate Defendants’s governing bodies are not professionals listed in OCGA 9-11-9.1(g). 

140.       By failing in their responsibilities for patient safety, the non-professional members of the Corporate Defendants’s governing bodies can cause harm to patients, including Jeremy Jones.

141.       The Corporate Defendants’ managerial staffs have responsibilities for patient safety.

142.       Multiple members of the Corporate Defendants’s managerial staffs are not professionals listed in OCGA 9-11-9.1(g). 

143.       By failing in their responsibilities for patient safety, the non-professional members of the Corporate Defendants’s managerial staffs can cause harm to patients, including Jeremy Jones.

144.       The Corporate Defendants’s administrative staffs have responsibilities for patient safety.

145.       Multiple members of the Corporate Defendants’s adminstrative staffs are not professionals listed in OCGA 9-11-9.1(g). 

146.       By failing in their responsibilities for patient safety, the non-professional members of the Corporate Defendants’s administrative staffs can cause harm to patients, including Jeremy Jones.

Professionals Performing Non-Professional Tasks

147.       If a task can be properly performed by a non-professional, then that task does not require the person performing it to be a professional. It is a “non-professional” task.

148.       Generally, multiple agents of the Corporate Defendants who are licensed professionals listed in OCGA 9-11-9.1(g) have responsibilities that can be performed by non-professionals. Such responsibilities are “non-professional” responsibilities.

149.       More specifically, multiple agents of the Corporate Defendants who are licensed professionals listed in OCGA 9-11-9.1(g) have responsibilities pertaining to patient safety that can be performed by non-professionals. Such responsibilities are “non-professional” responsibilities. By performing those responsibilities negligently, the Corporate Defendants’s agents can and do cause harm to patients, including Jeremy Jones.

150.       Multiple agents of the Corporate Defendants who are licensed professionals listed in OCGA 9-11-9.1(g) have one or more of the responsibilities listed above in the sub-section “A Partial List of Purely Managerial Tasks for Patient Safety.” By performing those responsibilities negligently, the Corporate Defendants’s agents can and do cause harm to patients, including Jeremy Jones.

Management & Patient Safety Failures in This Case

Note: Plaintiffs have had only incidental discovery concerning management and patient safety failures. The following allegations are based on inferences from the known facts.

151.       The Corporate Defendants are mismanaged.

152.       The mismanagement of the Corporate Defendants puts patients at risk and contributed to injury to Jeremy Jones.

153.       Non-professional managers at the Corporate Defendants were able to perform the managerial tasks indicated below, and were responsible for performing those tasks, but neglected or performed them negligently:

a.    Non-professional managers failed to ensure that hospital staff were empowered, trained, and required to raise concerns about patient safety, and to press those concerns until they were addressed appropriately.

b.    Non-professional managers failed to ensure that medical staff were trained on allocation of responsibility in multi-physician care settings — to prevent necessary care from being provided because each physician wrongly assumed another was providing the needed care.

c.     Non-professional managers failed to ensure that resident-supervision policies were communicated to all relevant staff, failed to ensure proper training on the policies, and failed to monitor compliance and remedy non-compliance.

d.    Non-professional managers failed to ensure that properly vetted practices and training concerning the duties of on-call physicians were communicated to the physicians performing on-call duties.

e.     Non-professional managers failed to ensure that properly vetted practices and training concerning appropriate consults for patient emergencies were communicated to medical staff.

f.      Non-professional managers to failed to ensure that a proper patient-grievance process was implemented at the hospital.

g.    Non-professional managers to failed to ensure that a proper sentinel-event process was implemented at the hospital.

154.       Professionals employed by the Corporate Defendants, while acting in a non-professional capacity, participated in the same managerial negligence discussed in the preceding paragraph and sub-paragraphs.

155.       The foregoing violations foreseeably caused harm to Jeremy Jones.

156.       The foregoing violations likely do not exhaust the failures by the Corporate Defendants that contributed to Mr. Jones’s otherwise unnecessary amputation.

January 10, 2022

Respectfully submitted,

/s/ Lloyd N. Bell                    

Georgia Bar No. 048800

Daniel E. Holloway

Georgia Bar No. 658026

BELL LAW FIRM

1201 Peachtree St. N.E., Suite 2000

Atlanta, GA 30361

(404) 249-6767 (tel)

bell@BellLawFirm.com

dan@BellLawFirm.com