            If this opinion indicates that it is “FOR PUBLICATION,” it is subject to
                 revision until final publication in the Michigan Appeals Reports.




                           STATE OF MICHIGAN

                           COURT OF APPEALS



TONYA COOPER,                                                     UNPUBLISHED
                                                                  February 12, 2019
              Plaintiff-Appellant,

v                                                                 No. 337702
                                                                  Oakland Circuit Court
TRINITY HEALTH-MICHIGAN, doing business                           LC No. 2015-150774-NH
as ST. JOSEPH MERCY OAKLAND
HOSPITAL,

              Defendant,

and

ROMAN FRANKLIN, M.D., PC, and ROMAN
FRANKLIN, M.D.,

              Defendants-Appellees.


Before: CAMERON, P.J., and RONAYNE KRAUSE and TUKEL, JJ.

PER CURIAM.

        Plaintiff Tonya Cooper appeals by right the trial court’s order granting summary
disposition in favor of defendants, Roman Franklin, M.D., P.C., and Roman Franklin, M.D., in
this medical malpractice action. On appeal, plaintiff argues that the trial court improperly
granted defendants’ motion for summary disposition because there is a genuine issue of material
fact as to whether defendants’ alleged negligence was the proximate cause of plaintiff’s injury.
Specifically, plaintiff argues that there is a factual dispute as to whether her hematoma was
caused either by a misdiagnosis and six-month prescription unwarranted anti-coagulant
medication, or by a nurse’s unauthorized or improper intramuscular injection of Arixtra while
plaintiff was in the hospital. We agree. We therefore reverse and remand for further
proceedings.
                                       I. BACKGROUND

        In 2006 and 2008, plaintiff suffered from a transient ischemic attack, similar to a stroke.
In 2013, plaintiff suddenly lost hearing in her right ear. Her medical doctors could not discover
the cause of the hearing loss, and they referred plaintiff to Dr. Franklin, who specializes in
internal medicine, hematology, and oncology. Plaintiff visited Dr. Franklin on June 25, 2013,
where he conducted laboratory testing and prescribed the anticoagulant Lovenox. Plaintiff began
injecting herself with Lovenox in the stomach every day. When plaintiff’s laboratory results
came back, she tested positive for a genetic mutation that increases an individual’s risk of blood
clots. On July 1, 2013, Dr. Franklin saw plaintiff to review the laboratory results and diagnosed
her with thrombophilia, a condition where blood clots more easily, and he also listed Von
Willebrand’s Disease as a possible cause of plaintiff’s medical issues. Plaintiff also tested
“mildly positive” for a patent foramen ovale (PFO)—a hole in the heart that failed to close after
birth. Dr. Franklin ran tests at several other appointments, but the only actual diagnosis listed
was thrombophilia.

        Plaintiff continued to experience hearing loss, headaches, blurred vision, dizziness,
fatigue, joint and back pain, easy bruising, memory loss, and depression. On September 12,
2013, plaintiff underwent heart surgery to close the PFO. Her heart surgeon prescribed aspirin
and another anticoagulant called Plavix. On January 14, 2014, plaintiff was admitted to St.
Joseph’s Hospital for an unrelated reason. When conducting an examination, the doctor at St.
Joseph’s Hospital concluded plaintiff’s abdomen was “nontender” with “bowel sounds present.”
On January 15, 2014, Dr. Franklin discontinued Lovenox and prescribed a daily subcutaneous
injection of the anticoagulant Arixtra in the abdomen. Plaintiff received her fist subcutaneous
injection from hospital staff the same day. Before leaving, plaintiff was evaluated by two other
doctors, who noted that her abdomen was “[s]oft, nontender, nondistended, positive bowel
sounds in all the quadrants.”

       Plaintiff received subcutaneous injections from hospital staff over the next two days. On
January 17, 2014, an ultrasound was ordered because plaintiff complained of abdominal pain.
The ultrasound revealed:

       Heterogeneous, hypoechoic mass like lesion in the right lower quadrant of the
       abdomen without internal vascularity on Doppler images. This is [sic] finding is
       of uncertain etiology, but differential consideration includes an intra-abdominal
       hematoma. Further characterization by a contrast enhanced CT scan of the
       abdomen and pelvis is recommended. [Emphasis added.]

Doctors ordered that plaintiff was to receive no further injections on her right side. On January
18, 2014, a nurse administered an injection of Arixtra, which defendants assert was unauthorized
and improperly administered intramuscularly rather than subcutaneously. After that injection,
plaintiff underwent a CT scan the same day, which confirmed the existence of a hematoma,
consistent with the prior ultrasound.

      As a result of the hematoma, plaintiff had to undergo surgery and also suffered nerve
damage that affects her mobility in her right lower extremity. On March 9, 2014, plaintiff


                                                -2-
consulted with Dr. Erin Cobain, who concluded that no laboratory testing suggested plaintiff had
Von Willebrand’s Disease, a history of easy bleeding, or any kind of hypercoagulable diagnosis.

        Plaintiff filed her complaint against defendants, alleging medical malpractice for
negligent care and treatment.       She alleged that Dr. Franklin misdiagnosed her with
hypercoagulable conditions and prescribed medications for a disease she did not have. In an
affidavit of meritorious claim, Dr. Leon C. Landau asserted that in his professional opinion,
defendants violated the applicable standards of care when Dr. Franklin misdiagnosed plaintiff
and prescribed her anticoagulation medications, which caused the hematoma and nerve damage.
Defendants filed two affidavits of meritorious defense by different doctors specializing in
internal medicine and hematology. According to the first affidavit, Dr. Franklin’s treatment was
entirely appropriate considering plaintiff’s medical history, especially the transient ischemic
attacks. The second affidavit concluded that Dr. Franklin’s treatment could not have
proximately caused plaintiff’s injuries. Trinity Health-Michigan also filed a third affidavit of
meritorious defense from another doctor, who again concluded that Dr. Franklin did not cause
plaintiff’s injuries.1

         On December 19, 2016, defendants filed a motion for summary disposition, arguing that
there were many factual errors in plaintiff’s complaint, and Dr. Franklin’s treatment was not
below the applicable standard of care. Further, defendant argued the actual cause of the
hematoma was likely an unauthorized intramuscular injection of Arixtra by a nurse at the
hospital, which was administered on or after January 18, 2014. In response, plaintiff argued that
because there was evidence that the hematoma was present before the injection, there was at least
a question of fact for the jury to decide. Defendants replied, arguing that plaintiff did not have
an abdominal hematoma when she was admitted to the hospital. Instead, they assert that the
hematoma was discovered after plaintiff received an unauthorized intramuscular injection of
Arixtra by the nurse at the hospital. Thereafter, plaintiff complained of stomach pain and
received the ultrasound. At the hearing on the motion for summary disposition, the trial court
concluded that plaintiff did not provide any evidence that explained a causal connection between
the medication and treatment she received from Dr. Franklin and the hematoma. For that reason,
the trial court granted defendants’ motion for summary disposition. This appeal followed.

                                 II. STANDARD OF REVIEW

        A grant or denial of summary disposition is reviewed de novo. Maiden v Rozwood, 461
Mich 109, 118; 597 NW2d 817 (1999). “In determining whether summary disposition is
appropriate, an appellate court must consider the entire record and construe reasonable
inferences arising from the evidence in a light most favorable to the nonmoving party.”
Michigan Twp Participating Plan v Federal Ins Co, 233 Mich App 422, 431-432; 592 NW2d
760 (1999) (emphasis added). At a summary disposition stage of proceedings, “there is a great
difference between an inquiry to determine whether or not there is an issue of fact and a trial to
decide a disputed issue of fact.” Durant v Stahlin, 375 Mich 628, 646-647; 135 NW2d 392


1
  The trial court granted Trinity Health-Michigan’s motion for summary disposition under MCR
2.116(C)(10), and plaintiff does not appeal that decision.


                                               -3-
(1965) (SOURIS, J). The non-moving party may rely on circumstantial evidence, so long as the
party’s theory of causation is more than merely plausible. Skinner v Square D Co, 445 Mich
153, 163-167; 516 NW2d 475 (1994), overruled in part on other grounds Smith v Globe Life Ins
Co, 460 Mich 446, 455 n 2; 597 NW2d 28 (1999). The non-moving party’s theory may be
deemed more persuasive if the moving party’s alternate theories are significantly less probable.
See id. at 167-169.

                            III. ESTABLISHMENT OF CAUSATION

       Causation in a tort action requires a plaintiff to establish both factual causation and
proximate causation. Johnson v Vanderkooi, 502 Mich 751, 768; 918 NW2d 785 (2018). “The
cause in fact element requires proof that ‘ “but for” the defendant’s actions, the plaintiff’s injury
would not have occurred.’ ” Id., quoting Skinner, 445 Mich at 163. “Determining proximate
causation requires an examination of the foreseeability of consequences and of whether a
defendant should be held legally responsible for the consequences of the defendant’s conduct.”
Id. There can be more than one proximate cause. See O’Neal v St. John Hosp & Med Ctr, 487
Mich 485, 496-497 (HATHAWAY, J., joined by WEAVER, J.), 552-553 (YOUNG, J., joined by
CORRIGAN, J.); 791 NW2d 853 (2010). Therefore, a plaintiff must only “introduce evidence
permitting the jury to conclude that the act or omission was a cause” of the plaintiff’s injuries,
not necessarily “the sole catalyst.” Craig v Oakwood Hosp, 471 Mich 67, 87; 684 NW2d 296
(2004) (emphasis in original).

                        IV. DEFENDANTS’ THEORY OF CAUSATION

        As noted, plaintiff’s theory of the case is that she suffered an intramuscular rectus sheath
hematoma because of the unwarranted anticoagulant medication prescribed by Dr. Franklin.
Defendants argue that the hematoma was caused by a nurse inadvertently administering an
intramuscular, rather than subcutaneous, injection of anticoagulant medication at the hospital.
Defendants rely on medical literature stating that anticoagulation therapy “can directly causa
[sic] rectus sheath hematoma by accidental intramuscular injection of LMWH[2].” However, the
day before the allegedly improper injection, plaintiff had received an ultrasound examination in
response to her complaints of abdominal pain. When the ultrasound report is considered in the
light most favorable to plaintiff as the non-moving party, it indicates that the hematoma was
already present. Therefore, the trier of fact could conclude that defendants’ theory of causation
is simply impossible.

                          V. PLAINTIFF’S THEORY OF CAUSATION

                                     A. “But For” Causation

       In contrast, the same medical literature describes rectus sheath hematomas as rare, but
explains that “anticoagulation is the most frequent predisposing factor” and that they are “a well-
recognized complication of anticoagulant therapy.” The literature strongly implies that rectus


2
    LMWH stands for low molecular weight heparin, a class of anticoagulant medicine.


                                                -4-
sheath hematomas require both a predisposing factor and a precipitating factor, even in
hematomas that otherwise seem to be spontaneous. However, it also impliedly uses the two
terms synonymously. In either event, the literature clearly establishes that plaintiff’s improper
anticoagulation medication was at least a foreseeable predisposing factor and necessary for the
hematoma to have occurred. Consequently, the evidence shows more than a mere possibility that
the improper anticoagulation therapy was a “but for” factual cause of plaintiff’s rectus sheath
hematoma.

                                      B. Proximate Causation

        Additionally, the literature implies that improper anticoagulation therapy alone can
directly cause rectus sheath hematomas. However, even presuming that reads too much into the
literature, it further states that the precipitating factors can include “trivial” external trauma and
“any abdominal wall medication injections (eg, insulin).” It is well-known that insulin is
injected subcutaneously. In other words, sufficient predisposition would directly cause any
number of ordinary, innocuous, foreseeable, and inevitable acts to trigger a hematoma. As our
Supreme Court has observed,

       [s]ince there are risks that can be foreseen but would not be avoided by a
       reasonable person, for liability to attach the harm must be of a kind that defendant
       should have avoided or it must be shown that defendant’s actions presented an
       unreasonable risk of harm. [Jones v Detroit Med Ctr, 490 Mich 960, 960; 806
       NW2d 304 (2011).]

The literature clearly shows that Dr. Franklin’s actions presented an unreasonable risk of harm.
Even if a rectus sheath hematoma was not a guaranteed outcome, our Supreme Court has found a
genuine question of fact regarding proximate causation where a doctor improperly prescribed a
medication known to potentially cause a dangerous allergic reaction despite such reactions being
rare and individually unpredictable. See Id. at 961. Similarly, the evidence here establishes a
genuine question of fact whether Dr. Franklin’s anticoagulant therapy proximately caused
plaintiff’s hematoma.

                                  C. Affidavits from Dr. Landau

        Defendants contend that plaintiff failed to articulate any specific causal link between Dr.
Franklin’s prescription and plaintiff’s hematoma. We disagree, finding that the affidavit of merit
from Dr. Leon C. Landau, originally attached to plaintiff’s complaint and later also attached to
plaintiff’s response to defendants’ motion for summary disposition, sufficiently establishes
causation. We therefore need not address defendants’ assertion that Dr. Landau’s revised and
updated affidavit, submitted in support of plaintiff’s motion for reconsideration, is not properly
in evidence.

        A mere statement of correlation does not establish causation, nor does a conclusory
assertion that a defendant’s breach caused the plaintiff’s injury. Ligons v Crittenton Hosp, 490
Mich 61, 77-78; 803 NW2d 271 (2011). However, affidavits of merit are read as a whole, and
they are expected to be read by “sophisticated parties, knowledgeable in the field of medicine,
and presumably in possession of reasonably illuminating records pertaining to the [plaintiff’s]

                                                 -5-
treatment…” Esselman v Garden City Hosp, 284 Mich App 209, 221-222; 772 NW2d 438
(2009). Dr. Landau’s affidavit of merit stated, in relevant part:

       As a direct and foreseeable consequence of the negligence of the above-listed
       health care providers, Ms. Cooper took inappropriate and non-indicated
       medication for a prolonged period of time which caused her blood to dangerously
       thin. Consequently, she suffered an intra-abdominal bleed and hematomas. The
       pooling of the blood caused nerve compression which resulted in nerve injury,
       including, but not limited to, a lumbosacral plexus injury. She required surgery to
       evacuate the hematoma, extended hospitalization, and rehabilitation. She
       continues to suffer pain and disability on a daily basis and must take regular pain
       medication. [(emphasis added).]

A fair reading of the above paragraph is that the improper anticoagulant medication prescribed
by Dr. Franklin caused dangerous blood thinning, which caused a hematoma, which in turn
caused other injuries. This statement is neither conclusory nor tautological. Even without
defendants’ own medical literature, plaintiff has sufficiently articulated a direct causal link and
mechanism of action between defendants’ conduct and plaintiff’s injuries to withstand summary
disposition. See Durant, 375 Mich at 646-647.

                        D. Response to Motion for Summary Disposition

        Finally, we disagree that plaintiff failed to respond adequately to the motion for summary
disposition.

       “Under MCR 2.116(G)(4), a party opposing a motion for summary disposition is required
to respond with affidavits or other evidentiary materials to show the existence of a factual
dispute, rather than relying on the allegations or denials in the pleadings.” McCart v J Walter
Thompson USA, Inc, 437 Mich 109, 115; 469 NW2d 284 (1991). The non-moving party may not
merely promise to produce evidence at trial, id., or fail to cite or offer any evidence whatsoever.
Barnard Mfg v Gates Performance, 285 Mich App 362, 374-375; 775 NW2d 618 (2009).
However, the non-moving party may rely on facts found in “ ‘[a]ffidavits, depositions,
admissions, or other documentary evidence.’ ” McCart, 437 Mich at 115, quoting MCR
2.116(G)(3) (alteration by the McCart Court). Furthermore, summary disposition may be
inappropriate even if the non-moving party fails to submit a properly-supported response. White
v Taylor Distributing Co, Inc, 275 Mich App 615, 626-627; 739 NW2d 132 (2007).

        Here, it is clear that plaintiff’s response to defendants’ motion for summary disposition
was amply supported. Defendants’ motion vaguely asserted that plaintiff’s theory of causation
was speculative; the motion was otherwise premised on defendants’ alternate theory, discussed
in part IV above. In response, plaintiff relied on the facts asserted by defendant and quoted from
evidentiary materials provided by defendant to show that defendant’s alternate theory was totally
unsupported. Nothing in MCR 2.116(G)(4) precludes a non-moving party from making use of
the moving party’s own evidence, and MCR 2.116(G)(3) clearly permits the non-moving party to
rely on any documentary evidence in the record. Finally, plaintiff also provided another copy of
Dr. Landau’s affidavit of merit, which as discussed above in part V.C, set forth a non-speculative
theory of causation, especially in light of the evidence provided by defendant. Plaintiff’s

                                                -6-
response to defendant’s motion for summary disposition did not “rest upon the mere allegations
or denials of his or her pleading.” MCR 2.116(G)(4).

                                       VI. CONCLUSION

        Upon review of the entire record, drawing reasonable inferences in favor of the non-
moving party, and recognizing that plaintiff is not obligated to prove her case at this stage of the
proceedings; we find that plaintiff has established a genuine question of fact whether the
improper anticoagulant medication prescribed by Dr. Franklin factually and proximately caused
plaintiff’s intramuscular rectus sheath hematoma. We therefore reverse the trial court’s grant of
summary disposition in favor of defendants, and remand for further proceedings. We do not
retain jurisdiction. Plaintiff, being the prevailing party, may tax costs. MCR 7.219(A).

                                                             /s/ Thomas C. Cameron
                                                             /s/ Amy Ronayne Krause




                                                -7-
