Washington Medical Malpractice Expert Testimony: Lessons From Ammons

Washington medical malpractice expert testimony is often essential for a patient seeking to prove that a doctor, hospital, or other health care provider was negligent. A recent unpublished Washington Court of Appeals decision, Ammons v. Kaiser Foundation Health Plan of Washington, No. 88600-2-I, illustrates what can happen when a plaintiff attempts to pursue medical negligence claims without expert evidence establishing the applicable standard of care and causation.

In Ammons, Division One affirmed summary judgment against a self-represented patient who alleged that a prescribed medication caused serious kidney problems and that hospital employees improperly inserted a catheter. The court concluded that both claims involved medical questions requiring expert testimony.

Importantly, Ammons is an unpublished opinion. It may be useful for understanding how one appellate panel applied established Washington law, but it does not have the precedential authority of a published Washington appellate decision.

What Happened in Ammons v. Kaiser?

Philip Ammons was a patient of nephrologist Dr. Duangporn Jitjai. According to the Court of Appeals, Ammons had several existing medical conditions, including high blood pressure, atrial fibrillation, diabetes, congestive heart failure, a recent stroke, anemia, and elevated creatinine levels.

Ammons had been taking losartan for high blood pressure. After he requested a change because of side effects, Dr. Jitjai prescribed olmesartan.

Several weeks later, Ammons learned that his creatinine level had increased significantly. Dr. Jitjai subsequently instructed him to stop taking olmesartan and seek urgent medical attention because he was experiencing a severe acute kidney injury.

Ammons went to Overlake, where he was admitted for acute-on-chronic kidney disease. During his treatment, he also experienced problems involving a catheter.

He later sued Kaiser and Dr. Jitjai, alleging that prescribing olmesartan caused his injuries. He also brought a medical negligence claim against Overlake based on allegations that hospital personnel used the wrong catheter size and improperly inserted it.

Kaiser and Overlake moved for summary judgment, arguing that Ammons lacked the medical expert testimony necessary to establish his claims.

The trial court granted the motions and ultimately dismissed the claims. The Court of Appeals affirmed.

Washington Medical Malpractice Expert Testimony and Chapter 7.70 RCW

Washington medical negligence claims involving injuries resulting from health care are governed by Chapter 7.70 RCW.

Under RCW 7.70.030, one recognized basis for recovery is an injury resulting from a health care provider’s failure to follow the accepted standard of care.

The requirements for proving that type of claim are addressed in RCW 7.70.040.

Among other things, the plaintiff must establish that the health care provider failed to exercise the degree of care, skill, and learning expected of a reasonably prudent health care provider in the relevant profession or class. The plaintiff must also establish that the failure was a proximate cause of the claimed injury.

Those requirements explain why Washington medical malpractice expert testimony frequently becomes critical.

Why Is Expert Testimony Usually Necessary?

Medical negligence cases often involve questions that an ordinary juror cannot reliably answer based solely on everyday experience.

For example:

Was a particular medication appropriate given the patient’s medical history?
Did prescribing that medication fall below the professional standard of care?
Did the medication actually cause the patient’s injury?
Was a particular catheter size medically appropriate?
Was the catheter inserted improperly?
Did an improper insertion cause the patient’s claimed injuries?

These are generally medical questions.

The Washington Supreme Court has explained that the applicable standard of care and proximate causation generally must be established through expert testimony. See Grove v. PeaceHealth St. Joseph Hospital, 182 Wn.2d 136, 143-44, 341 P.3d 261 (2014).

Medical facts ordinarily require expert testimony unless they are observable by a layperson and can be described without medical training. See Harris v. Robert C. Groth, M.D., Inc., 99 Wn.2d 438, 449, 663 P.2d 113 (1983).

Why Ammons Needed an Expert for the Medication Claim

Ammons argued that his renal problems would not have occurred if Dr. Jitjai had not negligently prescribed olmesartan.

The Court of Appeals concluded that this was not something a jury could properly infer without medical expertise.

Ammons already had a complicated medical history. Determining the purpose and effects of olmesartan, whether it was appropriate given his conditions, and what caused his acute kidney injury required specialized medical knowledge.

There was also competing medical evidence.

Kaiser’s nephrology expert, Dr. Henry Mroch, opined that Dr. Jitjai’s treatment was within the applicable standard of care and that olmesartan was not the proximate cause of Ammons’ acute kidney injury. According to the expert, the cause was an obstruction from a renal stone measuring 7.9 millimeters.

Without competent expert evidence supporting Ammons’ competing theory, the court concluded that he had not created the factual dispute necessary to avoid summary judgment.

Why the Catheter Claim Also Required Expert Testimony

Ammons’ claim against Overlake presented a somewhat different factual situation.

He alleged that hospital staff used an improperly sized catheter and inserted it incorrectly, causing significant pain and distress. He also alleged that a physician later adjusted the catheter and made a statement suggesting that it had been improperly positioned.

Even with those allegations, the Court of Appeals concluded that expert testimony was necessary.

Determining the appropriate catheter size, proper placement, correct insertion procedure, and medical cause of the resulting pain involved matters outside ordinary lay knowledge.

The fact that the catheter was later adjusted also did not, by itself, establish negligence.

As the Washington Supreme Court explained in Reyes v. Yakima Health District, 191 Wn.2d 79, 89, 419 P.3d 819 (2018), negligence cannot simply be inferred from a bad result.

Can Res Ipsa Loquitur Eliminate the Need for a Medical Expert?

Sometimes a plaintiff can establish an inference of negligence through the doctrine of res ipsa loquitur.

The phrase essentially refers to circumstances in which the nature of an occurrence itself permits an inference of negligence.

In Miller v. Jacoby, 145 Wn.2d 65, 74, 33 P.3d 68 (2001), the Washington Supreme Court identified three requirements. The occurrence producing the injury must ordinarily not happen without negligence; the injury must have been caused by an instrumentality within the defendant’s exclusive control; and the injury-producing occurrence must not have resulted from the plaintiff’s contribution.

But the doctrine does not turn every unexpected medical outcome into evidence of malpractice.

Why Res Ipsa Loquitur Did Not Apply in Ammons

For the medication claim, the Court of Appeals reasoned that Ammons’ renal failure could have occurred without negligence because he had several underlying medical conditions.

More importantly, understanding the medication, its effects, and its relationship to those other medical conditions required medical training.

The catheter claim had a similar problem.

Pain during catheter insertion could occur without negligence, and determining the proper catheter size, placement, and insertion procedure involved medical expertise.

The court therefore concluded that res ipsa loquitur did not eliminate the need for expert testimony on either claim.

Expert Testimony Can Determine Whether a Case Survives Summary Judgment

The procedural posture of Ammons is important.

The case was decided on summary judgment, not after a jury trial.

Under Washington CR 56, summary judgment may be appropriate when there is no genuine issue of material fact and the moving party is entitled to judgment as a matter of law.

Once defendants in a medical negligence case demonstrate that the plaintiff lacks evidence necessary to establish an essential element of the claim, the plaintiff cannot ordinarily rely only on allegations.

When expert testimony is required to establish standard of care or causation, the absence of competent expert evidence can therefore result in dismissal before the case ever reaches a jury.

That is one reason obtaining appropriate expert review can be a crucial part of litigating a Washington medical malpractice claim.

Self-Represented Plaintiffs Must Follow the Same Rules

Another aspect of Ammons is worth noting: Ammons represented himself on appeal.

The Court of Appeals reiterated the established rule that self-represented litigants are generally bound by the same procedural and substantive rules that apply to attorneys.

That can have serious consequences in technically complicated litigation.

Medical malpractice cases can involve expert disclosures, medical records, declarations, discovery, evidentiary requirements, causation standards, summary judgment procedures, and appellate rules. Representing oneself does not eliminate those requirements.

Ammons Is an Unpublished Opinion and Is Not Binding Precedent

There is an important limitation on the significance of Ammons: Division One designated the decision as unpublished.

An unpublished Washington Court of Appeals opinion does not carry the same precedential authority as a published appellate decision.

Washington GR 14.1 governs citation to unpublished opinions. Certain unpublished Washington Court of Appeals opinions filed on or after March 1, 2013, may be cited as nonbinding authority when the requirements of the rule are satisfied.

That means Ammons should not be described as creating a new binding rule that every Washington court must follow.

Persuasive Value Is Not Precedential Value

The distinction is important for anyone reading about court decisions online.

An unpublished opinion may still be informative. It can show how an appellate panel applied existing statutes and published precedent to a particular factual situation.

But the controlling principles discussed in Ammons come from sources such as Chapter 7.70 RCW and published Washington Supreme Court decisions including Grove, Harris, Miller, and Reyes.

In other words, Ammons is useful as an illustration of those rules—not as a substitute for binding authority.

What Ammons Illustrates About Washington Medical Malpractice Claims

Although the decision is unpublished, Ammons illustrates an important practical reality: Washington medical malpractice expert testimony can determine whether a negligence claim survives summary judgment.

A patient’s belief that a medical provider made a mistake, even when based on a serious or unexpected medical outcome, may not be enough to establish professional negligence.

Where the issues involve specialized questions concerning medications, treatment decisions, medical procedures, standard of care, or medical causation, qualified expert testimony will generally be necessary.

There are circumstances in which expert testimony may not be required, and doctrines such as res ipsa loquitur can apply in appropriate cases. But those exceptions depend heavily on the particular facts.

Speak With a Washington Attorney About a Medical Negligence Claim

Medical negligence cases involve specialized evidentiary and procedural requirements, and the absence of necessary expert evidence can result in dismissal at the summary judgment stage.

Anyone evaluating a potential medical malpractice claim should consider the applicable standard of care, causation evidence, medical records, expert requirements, and filing deadlines as early as possible.

Contact Blanford Law today at ken@blanfordlaw.com or 253-720-9304 for guidance on your legal matter.