J. In this medical malpractice suit, plaintiff Brenda Kincaid appeals by right the trial court’s order dismissing her suit against defendants Robert J. Cardwell, M.D., and his practice, St. Clair Cardiovascular Surgeons, EL.C., on the grounds that her suit was untimely. On appeal, we conclude that Kincaid failed to rebut the evidence that her claims were untimely. For that reason, we affirm.
I. BASIC FACTS
On March 17, 2008, Kincaid dropped a piece of lumber while working and injured her left foot. She went to the hospital, but x-rays did not reveal any fractures. She then saw Anca Rusu-Lenghel, M.D., for pain in her foot on April 7, 2008, and was referred to a podiatrist, Laura LaMar, D.EM.
Kincaid saw LaMar on April 23, 2008, with complaints of “numbness, burning, and pain” in her left foot since the original injury. Kincaid’s foot had some discoloration and blisters at the time. LaMar referred Kincaid to Vernon Dencklau, D.O., but Kincaid ended up seeing one of Dencklau’s partners, Cardwell.
Kincaid saw Cardwell for the first time on April 25, 2008. Cardwell examined Kincaid’s foot and leg and noted that her “left great toe is discolored, tender, and has some edema.” He wrote that her “two smallest toes of the left [foot] have darkened areas, which are moderately firm.” Cardwell diagnosed Kincaid as having “traumatic foot injury, which has had poor healing likely secondary to compromised blood flow to her left lower extremity.” Kincaid had a lower extremity Doppler
Kincaid had the MRA on April 28, 2008. The MRA revealed some occlusion in Kincaid’s “left anterior tibial artery” and some narrowing of the “proximal posterior tibial arteries bilaterally,” but did not otherwise reveal significant “flow limiting stenosis” in the “lower extremity runoff.”
Cardwell examined Kincaid again on May 7, 2008. He noted a “persistent discoloration of her left great toe and two smallest toes.” He also discussed the MRA results with Kincaid and stated that there were mild signs of arterial disease in Kincaid’s “left posterior tibial” artery and “moderate to possibly severe” signs of disease in the “anterior tibial artery.” However, he noted that there was still good blood flow to her foot at the time. He instructed her to quit smoking and to return in two weeks.
Kincaid returned to Cardwell on June 6, 2008, with reports of severe pain. Cardwell performed a second Doppler study, which showed mild “diminished [blood] flow to [Kincaid’s] left ankle area” and that her “anterior tibial artery [was] occluded on the left.” He prescribed Keflex and Percocet and asked Kincaid to return for a follow-up.
Cardwell saw Kincaid again on June 16, 2008. He noted that she had “worsening discomfort and discoloration of her left fourth and fifth toes” and stated that it might be necessary to consider amputation because “there is nothing to revascularize” the foot.
Kincaid next saw Cardwell on July 9, 2008. At that time, Cardwell observed that Kincaid had gangrene in her great and fourth toes. He then referred her to Sadiq Hussain, M.D., for consideration of a left fourth toe amputation. Dencklau, who worked with Hussain, saw Kincaid on July 17, 2008, and determined that she had no bypassable vessels with which to revascularize her foot. As such, he recommended amputation. Dencklau amputated Kincaid’s left leg below the knee on July 21, 2008.
Kincaid sued LaMar; LaMar’s practice, Hodor and Frascone D.EM., EC.; Cardwell; and Cardwell’s practice, St. Clair Cardiovascular Surgeons, EL.C., on November 20, 2010, for malpractice. In her complaint, Kincaid alleged that for “several months leading up to the amputation,” defendants breached the applicable standards of care by failing to timely evaluate and treat Kincaid’s conditions, failing to refer her to other physicians, failing to warn about the risks, failing to perform appropriate tests, failing to follow up, failing to notify Kincaid’s other physicians that they “were not competent or qualified to treat” Kincaid, and failing to otherwise act reasonably.
Kincaid filed an amended complaint with substantially the same allegations in March 2011. However, she only named Cardwell and St. Clair Cardiovascular as defendants. The circuit court clerk entered an order in July 2011 dismissing Kincaid’s claims against Lamar and Hodor and Frascone for failure to serve them.
Kincaid died from lung cancer on October 23, 2011.
On January 3, 2012, Cardwell and St. Clair Cardiovascular moved for summary disposition under MCR 2.116(C)(7). Relying on Kincaid’s original notice of intent to sue, which Kincaid had sent on April 5, 2010, Cardwell and St. Clair Cardiovascular argued that Kincaid’s claim accrued on either April 25 or May 7,2008. With the tolling period provided during the notice
In response to the motion for summary disposition, Kincaid noted that she had not alleged any specific dates in her complaint for Cardwell’s breach of the standard of care; rather, she had generally alleged that defendants had breached the standard of care for “several months leading up to the below-the-knee amputation . . . .” Kincaid argued that the evidence showed that Cardwell had breached the standard of care— through undisclosed acts and omissions — on three appointment dates: June 6, June 16, and July 9, 2008. Using June 6, 2008, as the accrual date, Kincaid concluded that her suit was timely. She explained that she had two years from the accrual date to sue, which would be June 6, 2010. See MCL 600.5805(6). However, because the period of limitations was tolled for 182 days after she filed her notice of intent to sue on April 5, 2010, see MCL 600.5856(c), she had until December 7, 2010, to sue.
Cardwell and St. Clair Cardiovascular replied to Kincaid’s response on February 24, 2012. They argued that Kincaid was, in effect, relying on the doctrine of continuing wrongs and the last treatment rule, which had been abolished in Michigan. Because the record showed that Kincaid’s claims concerned breaches that initially occurred on April 25, 2008, they maintained that the court must use that date as the accrual date.
The trial court held a hearing on Cardwell and St. Clair Cardiovascular’s motion on March 5, 2012. At the hearing, Kincaid’s lawyer again argued that there were multiple accrual dates because each time Kincaid appeared for an appointment or treatment she had a worsened condition: “It was not the same diagnosis that was being given on each presentment.” The trial court determined that, on the basis of the claims stated in her notice of intent to sue, Kincaid’s malpractice claim accrued on April 25, 2008. Consequently, it agreed that Kincaid’s suit was untimely.
The trial court entered an order dismissing Kincaid’s claims under MCR 2.116(C)(7) on March 15, 2012. After the trial court denied Kincaid’s motion for reconsideration on April 13, 2012, Kincaid appealed in this Court.
II. SUMMARY disposition
A. STANDARD OF REVIEW
On appeal, Kincaid argues that the trial court erred when it determined that her medical malpractice claim accrued solely on April 25, 2008. Specifically, she contends that she adequately alleged discrete acts and omissions that occurred on each day of treatment. Since she sued within the period of limitations applicable to the breaches of the standard of care that occurred on the last two days of treatment, she maintains that her suit was timely. This Court reviews de novo a trial court’s decision on a motion for summary disposition. Barnard Mfg Co, Inc v Gates Performance Engineering, Inc,
B. MCR 2.116(C)(7)
Summary disposition under MCR 2.116(C)(7) is appropriate when the undisputed facts establish that the plaintiffs
C. THE PERIOD OF LIMITATIONS
A person cannot sue another “to recover damages for injuries to persons or property unless, after the claim first accrued to the plaintiff . .., the action is commenced within the periods of time prescribed” by statute. MCL 600.5805(1). The period applicable to medical malpractice is two years from the accrual date. MCL 600.5805(6). Kincaid sued to recover for her injuries on November 30, 2010. In order for her suit to have been timely, her claim would have had to have accrued not earlier than November 30, 2008, unless tolled.
Kincaid could not sue without first giving Cardwell and St. Clair Cardiovascular notice of her intent to do so “not less than 182 days before the action is commenced.” MCL 600.2912b(l). In order to ensure that a plaintiff receives the full benefit of the applicable period, the Legislature provided that the period of limitations is tolled for the 182-day notice period, but only if the plaintiff gave the notice before the expiration of the period of limitations. See MCL 600.5856(c); Driver v Naini,
1. THE LAST TREATMENT RULE
Originally, the Legislature did not provide an accrual point for medical malpractice claims. See Morgan v Taylor,
In 1986, the Legislature abrogated the last-treatment rule for medical malpractice claims. See
Although the Legislature determined that the last-treatment rule should no longer govern the accrual of medical malpractice claims, it did not replace the last-treatment rule with a first-treatment rule; rather, the accrual date depends on the date of the specific act or omission that the plaintiff claims caused his or her injury. Similarly, while the Legislature referred to “the act or omission” that is the basis for “the claim,” MCL 600.5838a(1), the Legislature did not limit a plaintiff to asserting a single claim for medical malpractice for any given injury. Because a plaintiffs injury can be causally related to multiple acts or omissions, it is possible for the plaintiff to allege multiple claims of malpractice premised on discrete acts or omissions — even when those acts or omissions lead to a single injury — and those claims will have independent accrual dates determined by the date of the specific act or omission at issue. See, e.g., Brackins v Olympia, Inc,
2. McKINEY
In McKiney, the plaintiff, Susan McKiney, sought treatment from Dr. Lewis dayman, who was a medical doctor and dentist, for lesions on her tongue in 1989. dayman removed a cancerous growth
On December 2, 1993, different doctors tentatively diagnosed McKiney’s spots as cancer, and she related that information to dayman at an appointment on the next day. dayman continued to state his belief that the spots were not cancerous. McKiney did not return to dayman for treatment, but did speak with him on the phone several times from January to March 1994 about possible treatments. A biopsy in March 1994 revealed that McKiney had cancer, and McKiney sued dayman for malpractice on December 21, 1995. Id. at 199-200. After the trial court dismissed her claim as untimely under MCR 2.116(C)(7), McKiney appealed.
On appeal in this Court, McKiney argued that her claim was timely because she had continued to receive treatment advice from dayman by telephone through March 3, 1994. Id. at 201. In examining her argument, this Court explained that the date that dayman last treated McKiney was irrelevant because the Legislature had clearly rejected “the notion that the existence of a continuing physician-patient relationship by itself could extend the accrual date beyond the specific, allegedly negligent act or omission charged.” Id. at 203. Instead, the relevant accrual date was the date of the act or omission about which she complained. Id., citing MCL 600.5838a(l).
Turning to the acts and omissions that served as the basis of McKiney’s claim, the Court noted that McKiney had essentially alleged that dayman failed to properly diagnose her cancer and failed to properly treat her by conducting appropriate examinations or referring her to more competent healthcare providers. McKiney,
The Court in McKiney conceded that each treatment date through the visit on December 3, 1993, could — in theory — have served as a separate accrual date, but it is also impliedly held that a physician’s mere adherence to an initial misdiagnosis and erroneous treatment plan at later appointments was insufficient by itself to give rise to new accrual dates. Id. at 204. Although the Court assumed that dayman’s diagnoses and treatments in 1990, 1992, and 1993 “constituted separate acts or omissions that would represent new accrual dates,” it clarified that the record did not actually support the conclusion that the treatments were “new, distinct, and separate acts or omissions” because McKiney’s own testimony showed that dayman merely “adhered to the same diagnosis and treatment determinations” that he had previously made. Id. at 204 & n 4. Similarly, the Court held that McKiney’s telephone conversations with dayman through March 3, 1994, did not establish an accrual date in March 1994 because the record evidence again showed that dayman “merely adhered to
Under the decision in McKiney, courts cannot permit a plaintiff to revive the last-treatment rule by merely pleading that the defendant had an “on-going” or “continuing” duty to act throughout the duration of the patient-physician relationship. Nevertheless, the Court in that case did not address the nature of the pleadings or proofs that would be adequate to remove the case from one pleading a continuing-wrong theory. Likewise, although the court in McKiney held that a plaintiff could not revive the last-treatment rule by simply pleading that his or her physician continued to adhere to a mistaken diagnosis or treatment plan throughout the duration of the patient-physician relationship, it did not foreclose the possibility that continued adherence to a particular diagnosis or treatment plan might, under the facts, constitute a discrete negligent act or omission for purposes of determining the accrual date. Therefore, we shall now turn to the nature of the pleadings and proofs that a plaintiff must allege or support with evidence in order to establish that the physician’s adherence to an initial diagnosis or treatment plan constituted a discrete act or omission for purposes of establishing a later accrual date.
3. ESTABLISHING THE ACCRUAL DATE
A plaintiff must provide sufficient facts in his or her complaint to give the defendant notice of the claims against which he or she must defend: the plaintiff must provide a “statement of facts, without repetition, on which the pleader relies in stating the cause of action, with the specific allegations necessary reasonably to inform the adverse party of the nature of the claims the adverse part is called on to defend[.]” MCR 2.111(B)(1). Although there is no heightened standard of pleading for medical malpractice claims, cf. MCR 2.112(B)(1), Michigan courts have recognized that the complexity of medical malpractice litigation may require a greater degree of precision in pleading the facts constituting the claim in order to comply with the notice requirements set forth in MCR 2.111(B)(1). See Dacon v Transue,
In Dacon, our Supreme Court explained the importance of providing the defendant physicians with sufficient notice of the acts or omissions that allegedly caused the plaintiffs injuries. In that case, Walter Dacon, as the next friend of his daughter Ericca Dacon, sued the physicians who had treated Ericca for meningitis when she was nine months old. Dacon,
Thus, a plaintiff must plead facts that are sufficient to place the defendant physician on notice of the specific acts or omissions that the plaintiff believes caused his or her injuries. Id. Depending on the complexity of the acts or omissions at issue, this may require the plaintiff to identify with some degree of specificity how the physician breached the standard of care. See Martinez,
Even if a plaintiff fails to properly plead facts establishing that his or her physician’s continued adherence to a diagnosis or treatment plan constituted an applicable act or omission, it must be recalled that a plaintiff may generally erne defective pleadings by amendment before trial. See MCR 2.118(A)(2); Dacon,
With these general principles in mind, we shall now examine Kincaid’s complaint and the evidence that she presented in response to Cardwell and St. Clair Cardiovascular’s motion for summary disposition.
D. APPLYING THE LAW
1. THE EVIDENCE IN SUPPORT OF DISMISSAL
In her complaint, Kincaid referred to several generic acts and omissions that she alleged caused her injury; she alleged
Although Kincaid did not allege facts in her complaint that would have allowed Cardwell and St. Clair Cardiovascular to identify the specific date or dates on which Kincaid believed Cardwell breached the standard of care, Cardwell and St. Clair Cardiovascular did not move for a more definite statement or to strike the pleadings. MCR 2.115. Instead, they relied on Kincaid’s notice of intent to sue to establish the dates when Kincaid’s claim might have accrued. Because her notice was part of her malpractice “process” or “proceeding,” see Bush v Shabahang,
In her notice, Kincaid first stated the same generic assertions that Cardwell and St. Clair Cardiovascular should have timely evaluated and treated her, should have referred her for care and treatment, and should have warned her about the severity of her condition. But she also identified specific tests that Cardwell should have performed, the point at which Cardwell allegedly failed to properly diagnose her, and the point at which he should have warned her that he was not qualified to treat her and failed to refer her to someone who was qualified:
No later than April 23 [sic], 2008, Dr. Cardwell was required to perform [a] lower extremity angiography, or refer the patient and make certain that she underwent [a] lower extremity angiography by a competent physician, to identify the site of the occlusion(s), any collateral circulation, possible target vessels for bypass, and visualization of run-off vessels. Dr. Cardwell was also required to conduct duplex studies to assess the caliber and patency of the patient’s veins as soon as he could arrange same. Further, Dr. Cardwell was required to recognize the red flags of discoloration of her toes, re-injuries to the toes, numbness, tenderness and pain, on top of the clinical presentation including weak femoral pulses, weak pedal pulses and a hardly detectable pedal pulse on the left. No later than April 25, 2008, as soon as Dr. Cardwell learned that the patient had “potentially severe Arterial Occlusive Disease of the left lower extremity”, Dr. Cardwell was required to notify the patient that she needed urgent care and treatment, and that he was not competent or qualified to treat this patient for a severe Arterial Occlusive Disease of the left lower extremity. Further, as of that date, Dr. Cardwell was required to refer the patient for appropriate care and treatment by a competent and qualified vascular or other surgeon before gangrene or ischemic necrosis occurred.[3 ]
Finally, Kincaid alleged that at “all times” Cardwell was required to notify Kincaid and LaMar that he was not competent to treat Kincaid, that an MRA revealed that Kincaid’s “left. . . tibial artery” was likely occluded within the mid portion, but the “proximal portion appeared ‘widely patent[’], and that the patient was a candidate for a bypass or re-vascularization.” Similarly, she alleged that, at “all times,” Cardwell was “required to order appropriate wound care and antibiotics for the non-healing ulcers he saw when he first met Plaintiff.”
Reading Kincaid’s complaint in light of her notice, it appears that the discrete acts or omissions that serve as the basis for her malpractice claims against Cardwell and St. Clair Cardiovascular occurred before June 1, 2008. Each of the dates identified by Kincaid in her notice was before June 1, 2008. Kincaid’s notice shows that Cardwell’s failure to properly treat and diagnose her began on her first visit to him on April 25, 2008. It was at that point that he should have first realized that he was not competent to treat her condition and should, for that reason, have referred her to a qualified physician. It was also at that point that he should have ordered the specific tests identified in Kincaid’s notice. Kincaid also stated that Cardwell should have referred her to another physician and informed her and her treating physicians about his inability to treat her and about his findings to that point on May 7, 2008, which he did not do.
The general allegations that at “all times” Cardwell failed in certain regards cannot save Kincaid’s claims. She alleged that Cardwell had failed to inform her that he was not qualified and failed to order proper wound care at all times. But it was clear from her complaint that his failure to inform her and treat her wound arose on the first day of treatment and that he merely continued with this allegedly erroneous course of treatment. Merely alleging that a physician continued to adhere to a mistaken diagnosis or treatment plan at later appointments is insufficient to establish an independent act or omission on those later appointment dates. McKiney,
Here, however, Kincaid did not allege facts to establish that Cardwell breached the standard of care by continuing to adhere to an original diagnosis or treatment plan. Because Kincaid’s allegations, even when viewed in the light most favorable to her, cannot be interpreted as alleging discrete acts or omissions that occurred on specific dates after his first treatment, those general allegations must be understood to refer to acts or omissions that first occurred on April 25, 2008. All later acts and omissions involving the failure to inform, refer, and treat — in the absence of more specific allegations or evidence — are simply part of Cardwell’s continuing course of treatment and Kincaid could not rely on Cardwell’s continuing treatment alone to establish later accrual dates. Id. Finally, Kincaid’s allegation that at “all times” Cardwell failed to inform her or her physicians about the fact that an MRA revealed that she was a candidate for bypass also referred to an act or omission that occurred before June 1, 2008. As noted in her notice of intent to sue, Kincaid had the MRA on April 28, 2008, and her next visit with Cardwell was on May 7, 2008. Thus, Cardwell’s failure to properly inform Kincaid or her physicians about the MRA arose on or before May 7, 2008.
Kincaid’s complaint was so vague about the specific acts constituting malpractice (failing to treat, refer, inform, perform tests, notify, and act reasonably) and the dates that the acts occurred (referring to a period of “several months”) that it arguably failed to identify any act or omission by Cardwell with sufficient specificity to permit Cardwell to offer a defense. See Dacon,
In contrast to her complaint, Kincaid’s notice of intent to sue provided some additional details concerning the specific acts or omissions that supported her claims against Cardwell and St. Clair Cardiovascular. But, as discussed earlier, it is clear that each act or omission had to have occurred before June 1, 2008. Consequently, Cardwell and St. Clair Cardiovascular initially established that they were entitled to summary disposition under MCR 2.116(C)(7). And, as such, the burden shifted to Kincaid to show that there was — at the very least — a question of fact about whether her claims were timely. Zwiers,
2. KINCAID’S RESPONSE
In her reply brief, Kincaid relied in part on the very fact that her complaint was vague: “Plaintiff maintains that Defendants violated the standard of care for treatment provided several months leading up to Plaintiffs July 21, 2008 amputation . . . This broad reference to months, Kincaid maintained, must be interpreted in light of her recitation of the facts to conclude that each date of treatment involved separate acts and omissions. Despite attaching her medical records, letters by Card-well concerning her treatment, and her affidavit of merit, Kincaid did not meaningfully connect the evidence to any act or omission by Cardwell that occurred on or after June 1, 2008. Rather, it was apparently her position that, because Cardwell continued to treat her after June 1, 2008, the court must assume that her allegations applied equally to each treatment date. It was not the trial court’s responsibility to sift through the evidence attached to Kincaid’s response to determine whether it could identify specific acts or omissions that might give rise to a later accrual date. See Barnard Mfg,
Kincaid’s lawyer did make a belated effort to correct these deficiencies at oral argument on the summary disposition motion; it was then that Kincaid’s lawyer first alleged that Cardwell’s continued adherence to a mistaken diagnosis constituted a breach of the standard of care. Kincaid’s lawyer began by distinguishing the facts in McKiney from Kincaid’s case; she explained that in McKiney, the plaintiff did not present any evidence that there were new symptoms that gave rise to a new duty:
There was nothing new presented. There was no new diagnosis that he was giving. Conversely in our case here each time the — each time Plaintiff presented to the Doctor’s officer she was showing a worsening symptom. So the first time she presented, yes, she had discoloration of the — in her toes and they had did [sic] all these tests, et cetera. The next time she presentedshe had further discoloration of the toes. They were doing the femoral pulses. One time she had [a] femoral pulse in the left leg. Next time they had the femoral pulse but there was no pedal/push action. Then you keep going to June 6th and then June 16th she’s worsening in her discomfort. She’s worsening in her presentment. She’s getting gangrene in the toes and still the Defendant, the Defendant Doctor did not refer her out and did not - failed to diagnose that she had a serious problem with her foot.
In reviewing a motion for summary disposition, this Court must determine whether the trial court erred on the basis of the arguments and evidence properly presented to the trial court. Barnard Mfg,
III. CONCLUSION
Kincaid did not allege facts in her pleadings that adequately placed Cardwell and St. Clair Cardiovascular on notice of any acts or omissions that occurred on or after June 1, 2008, that might have given rise to liability. As such, her claims were untimely on the face of her pleadings. Moreover, in response to Cardwell and St. Clair Cardiovascular’s properly supported motion for summary disposition under MCR 2.116(C)(7), Kincaid failed to present evidence to establish a question of fact about whether Cardwell committed an act or omission on or after June 1, 2008. Therefore, the trial court did not err when it concluded that, under the undisputed facts, Kincaid’s claims were untimely and should be dismissed under MCR 2.116(C)(7).
Affirmed. As the prevailing parties, Cardwell and St. Clair Cardiovascular may tax their costs. MCR 7.219(A).
Notes
We have derived the facts relating to Kincaid’s doctor’s visits from her medical records, which she attached to her brief in response to the motion for summary disposition.
The Court in Morgan ultimately concluded that the legislative version of the last-treatment rule was more expansive than the common-law version because it referred to the date the professional discontinued treating or “ ‘otherwise serving’ ” the patient. See Morgan,
We have quoted the ninth paragraph of § 2 from Kincaid’s notice of intent to sue, which is headed “Applicable Standard of Practice.” However, Kincaid used substantially the same language to describe the manner in which Cardwell breached the standard of care and the action that he should have taken to achieve compliance.
By way of some nonexhaustive examples, it might have been a breach of the standard of care for Cardwell to continue to adhere to an initial diagnosis or treatment plan in the face of evidence that Kincaid’s symptoms had worsened or had not improved as expected under the initial treatment plan or after he received new test results. Similarly, if Cardwell failed to physically examine Kincaid at a subsequent visit and, as a result, did not have information that would have caused a reasonable physician to revise his or her diagnosis and treatment plan, the failure to conduct an examination might also constitute a distinct breach.
As already noted, Cardwell and St. Clair Cardiovascular did not move to strike the complaint or ask for a more definite statement. See MCR 2.115. Cardwell and St. Clair Cardiovascular similarly failed to plead facts in support of their statute of limitations defense; they merely asserted that Kincaid’s complaint “may he barred in whole or part by the Statute of Limitations” without pleading any facts that, if left unrebutted, would show that Kincaid’s claims were untimely. See MCR 2.111(F)(3); see also Shank v Woodworth,
Although Barnard Mfg concerned the shifting burden applicable to a motion for summary disposition under MCR 2.116(0(10), we believe that this same analysis applies to factual questions involving a motion for summary disposition under MCR 2.116(C)(7).