Barnes v. Greater Baltimore Medical Center, Inc.

ZARNOCH, J. STATEMENT OF THE CASE In this appeal, we are confronted with another twist in the interpretation of the certificate requirement of the Healthcare Malpractice Claims Act (“HCMCA” or “the Act”), Maryland Code (1974, 2006 Rep. Vol., 2012 Supp.), Courts and Judicial Proceedings Article (“CJP”), §§ 3-2A-01-10. In the Circuit Court for Baltimore County, appellee/cross-appellant Greater Baltimore Medical Center (“GBMC”) 1 moved to dismiss appellants’/cross-appellees’, David A. Barnes and Laura A. Barnes, medical malpractice claim for failure to file a proper certificate of qualified expert. 2 GBMC argued that the expert report did not explain the expert’s opinions as required by the Act. This motion came not early in the proceedings, but on the eve of a second trial, when the expert had already testified at the first trial. 3 The circuit court denied the motion.

For reasons to be explained more fully, we affirm the court’s ruling and conclude that GBMC’s possession of the expert’s mistrial testimony before the second trial cured any lack of detail in the expert report. This case took another turn in the second trial after the jury found in favor of appellants, when the circuit court granted the motion for judgment notwithstanding the verdict (“JNOV”) of GBMC and appellees Dr. Jose Y. Rustía, and Charles Emergency Physicians, P.A. (“CEP”). Previously, appellees had ⁴⁶¹ moved for judgment as a matter of law at the close of the Barneses’ case and at the close of all evidence.

The court denied these motions and the jury found in favor of the Barneses and awarded damages of $1,123,000. In granting the JNOV motion, the court found that the Barneses did not provide legally sufficient evidence of causation. The Barneses appeal this ruling. On this issue, we conclude that the Barneses did produce sufficient evidence for the jury verdict and the circuit court erred in granting the JNOV.

We will therefore reverse the court’s ruling and order reinstatement of the jury verdict. As a final issue, GBMC appeals the denial of its motion for judgment, arguing that the Barneses did not produce sufficient evidence for the case to even proceed to the jury. For reasons that follow, we reject GBMC’s contentions. FACTS AND LEGAL PROCEEDINGS David Barnes went to see his primary care physician, Dr. Allen Halle, on January 26, 2005, because he was experiencing weakness in his right hand grip, numbness, and tingling in his right arm.

Dr. Halle was concerned that Mr. Barnes was having a transient ischemic attack (mini-stroke) or was in the beginning phases of a stroke. He called Mrs. Barnes and told her that her husband needed to go to the hospital immediately. Mrs. Barnes picked up her husband and drove him to GBMC. Dr. Halle also gave Mrs. Barnes a note that she was to give to the registration desk upon arrival.

The note stated that Dr. Halle wanted Mr. Barnes to have a “stroke work up.” Mr. Barnes arrived at GBMC around 5:20 p.m. He first saw the “quick look nurse,” Candance Starstrom, who determines where the patients should be routed and which patients should be seen by the triage nurse. The triage nurse performs a more thorough assessment. The Barneses told Nurse Starstrom that his primary care physician sent Mr. Barnes to the emergency room.

Nurse Starstrom also read Dr. Halle’s note. On the hospital assessment form, there is a space to indicate the priority of a patient’s condition, one being the ⁴⁶² most serious and four being the least. Nurse Starstrom circled that Mr. Barnes’ condition was a priority number one. Nurse Starstrom testified that priority number one “represents a potentially life threatening situation and should be automatically routed to the main emergency department.” She also wrote on the form that Mr. Barnes “had a weak right grip, tingling in the right hand, a numb right side, and that he had been seen by his primary care doctor and directed to the GBMC emergency room.” She then attached Dr. Halle’s note to the front of the form.

Mr. Barnes was sent to the triage nurse, Carol Stopa, at 5:49 p.m. Nurse Stopa testified that she did not see Dr. Halle’s note. The Barneses argued that Nurse Stopa changed the priority from one to four on the form, and crossed out the word “side” and changed it to “hand” so it said “numb right hand” instead of “numb right side.” Although she did not remember the incident, Nurse Stopa testified that the signature on the form was probably hers and some of the writing was hers. Nurse Stopa sent Mr. Barnes to the urgent care department (for less serious conditions), not the emergency department.

Mr. Barnes then saw Dr. Rustía, the emergency medicine physician who was on duty in the urgent care center. Dr. Rustía testified that he did not see Dr. Halle’s note, and if he had, he would have walked Mr. Barnes over to the main emergency department to have the stroke work up. Dr. Rustía ordered a wrist x-ray, diagnosed Mr. Barnes with carpal tunnel syndrome, gave him pain medication, prescribed an anti-inflammatory medication, and told him to follow up with a hand surgeon. As Mr. Barnes was leaving at around 6:20 p.m., Nurse Starstrom saw him in the parking lot and felt that he had not been there long enough to have a stroke work up.

She looked at Mr. Barnes’ assessment form and saw that he did not receive the work up. She told the charge nurse, Lori Hart, and Nurse Hart called Dr. Halle, who instructed her to call Mr. Barnes and have him return to the emergency room. She left a message on the Barneses’ answering machine at 6:40 ⁴⁶³ p.m. The Barneses live thirty to forty minutes from GBMC and returned to the hospital around 8:30 p.m.

Upon returning, Mr. Barnes received at least a partial stroke work up. The nurses started him on an IV, drew blood, conducted blood tests, ordered a CAT scan of the brain, and performed an electrocardiogram. Dr. Elias Abras was the emergency room physician who examined Mr. Barnes. He ruled out a hemorrhagic stroke based on the CAT scan.

After a few other tests, Dr. Abras concluded that Mr. Barnes needed to be admitted because he “needed more evaluation” and that the evaluation “ha[d] to be done by the attending physician.” Since Mr. Barnes had medical insurance through Kaiser Permanente, Dr. Abras testified that he needed a Kaiser hospitalist to admit Mr. Barnes. 4 The only Kaiser hospitalist on duty that evening was Dr. Vikesh Singh. Dr. Abras called Dr. Singh and asked him to come evaluate and admit Mr. Barnes. Dr. Singh said he would come as soon as possible. Dr. Abras continued to call Dr. Singh for several hours, but Dr. Singh never arrived.

Tired of waiting, Mr. Barnes wanted to go home. Dr. Abras claimed to have told Mr. Barnes that “he had a mini-stroke and it was important for him to follow up with Dr. Halle in the morning to complete the evaluation.” Mrs. Barnes said “I was never told a diagnosis.” 5 Dr. Abras discharged Mr. Barnes around 1:00 a.m. on January 27. The next day, Mrs. Barnes went to work. Mr. Barnes called Dr. Halle and told him about the previous day’s events.

Dr. Halle planned for Mr. Barnes to see a neurologist on January 31, and he planned for Mr. Barnes to have an MRI, a doppler study of his neck, and an echocardiogram within one week. But when Mrs. Barnes came home, Mr. Barnes was sitting in a recliner with his back to her. She asked about the doctor. He pointed to a piece of paper on her vanity.

Mrs. ⁴⁶⁴ Barnes looked at the note on vanity, but it was nothing but scribbles. So then she walked around so she could see Mr. Barnes and asked if he was okay. But he did not look okay: “[h]is mouth was all crooked.” At that point Mrs. Barnes’ cousin drove the Barneses to GBMC. Mr. Barnes had suffered a stroke.

The Barneses waived arbitration under CJP § 3-2A-06(B) and filed suit in the Circuit Court for Baltimore County against GBMC, Dr. Rustía, and CEP. 6 The Barneses filed a certificate of qualified expert and expert report, as required by CJP § 3-2A-04. Dr. Kenneth Larsen signed the certificate and report. He was later deposed. After several motions and additional discovery, a trial began on February 2, 2010 and Dr. Larsen fully testified at this trial.

After four days of trial, the circuit court had to declare an administrative mistrial because of a massive snow storm. The second trial was set to begin in March 2011. The defendants filed several more motions based on the events of the first trial, including one to prohibit Dr. Larsen from testifying regarding proximate cause. The day before the second trial started, GBMC moved to dismiss the case for failure to file a proper certificate of qualified expert.

GBMC argued that the report was insufficient because case law required that the report describe the standard of care, how the specific defendants violated the standard of care, and how the violation proximately caused the plaintiffs injuries. After a discussion of the case law, the circuit court denied the motion to dismiss, finding that GBMC was too late in filing the motion. During trial, one of the plaintiffs other experts, Dr. Marion Lamonte, testified regarding the breach of the standard of care and proximate cause. GBMC and Dr. Rustía believe that Dr. Lamonte’s proximate cause testimony did not include that Dr. Rustía should have admitted Mr. Barnes to the hospital.

But during Dr. Lamonte’s direct testimony, the Barneses’ ⁴⁶⁵ attorney asked “[a]nd had Dr. Rustía thought of a TIA [transient ischemic attack], what would the standard of care require Dr. Rustía to do?” GBMC’s attorney objected. After a bench conference, Dr. Lamonte testified “[h]e could have moved the patient to the main emergency department immediately and contacted the physician in charge of the main emergency department for acute work up and treatment or he could have called Admission himself, right then, and got the patient admitted.” GBMC’s attorney objected and the testimony was stricken. Later, at a bench conference, the judge said, “[Dr. Lamonte] never opined that Dr. Rustía should have admitted the patient.” The Barneses feel that Dr. Lamonte did end up testifying that GBMC and Dr. Rustía breached the standard of care in not admitting Mr. Barnes the evening of January 26. Dr. Lamonte testified, without objection, that “every hospital had a policy regarding admission of acute neurologic emergencies” because “the evaluation, management, [and] treatment cannot be performed on an outpatient basis.” She said “everybody would have put him in a hospital.” She also testified on cross examination, without objection: Q: All right and it’s likely, under the protocol, if Dr. Rustía had seen the note, the protocol would have been to send the patient to the emergency department, the main emergency department correct?

A: Yeah, or just admit him. He probably would have done that. The Barneses further believe that Dr. Lamonte testified that if Mr. Barnes had been admitted to GBMC, his stroke would have been prevented. She opined that bed rest, oxygen, and IV fluids would have prevented Mr. Barnes’ stroke or delayed it until the appropriate studies could be done and surgery initiated.

She further testified that Mr. Barnes would have received an endarterectomy if he would have been admitted, and this would have prevented the stroke. 7 Dr. Lamonte ⁴⁶⁶ opined that “it was most likely more than fifty percent his stroke would have been prevented” if he had been admitted to the hospital. She said the “normal sequence of events” for a patient with Mr. Barnes’ symptoms “is to get a patient’s head flat first, to give them intravenous fluids, to increase the volume that will go to their brain and to give them oxygen.” At the close of the Barneses’ case in chief, the defendants moved for judgment as a matter of law on causation grounds. They argued that there was no evidence establishing that if Dr. Rustía had sent Mr. Barnes to the main emergency room the first time he went to the hospital, Mr. Barnes would have been admitted for the additional treatment or undergone the testing that was necessary to prevent his stroke. The circuit court denied the motion.

The court said “there is no specific testimony ... from Dr. Lamonte saying two or three hours earlier presentation or admission to the hospital would have made a difference” but, “at this junction, I feel there is sufficient evidence there in looking at the case in a light most favorable to the Plaintiff on the causation issue to allow it to go forward.... ” The defendants renewed the motion for judgment at the close of evidence on the same grounds and the court again denied the motion. The jury found in favor of the Barneses and against GBMC, Dr. Rustía, and CEP in the amount of $1,123,000, consisting of $200,000 for loss of household services, $73,000 for future medical expenses, $750,000 in non-economic damages, and $50,000 for loss of consortium. The jury did not find Dr. Abras negligent. GBMC and Dr. Rustía moved for a post-trial JNOV.

The circuit court granted the motion, finding insufficient evidence of causation. The court stated, “this Court looks at whether Dr. Lamonte has a nexus between the violations of the standard of care as it relates to Nurse Stopa and Dr. Rustía and whether or not the ultimate stroke that Mr. Barnes clearly suffered on January the 27th was proven, preventable.” The court concluded, ⁴⁶⁷ [Dr. Lamonte’s] testimony on causation lacked foundation, did not provide legally sufficient testimony for the jury to find that as a result of the violation of the standard of care by Nurse Stopa and Dr. Rustía, that Mr. Barnes had a stroke and that if the had complied with the standard of care, that his stroke was preventable. The Barneses timely appealed the grant of the JNOV, and GBMC timely appealed the denial of its motion for judgment at the close of the evidence and its motion to dismiss for failure to file a proper certificate of qualified expert. QUESTIONS PRESENTED We are presented with three questions on appeal (one from appellants, the Barneses, and two from appellee GBMC), which we have reordered and recast as follows: 8 1.

Did the circuit court err in denying GBMC’s motion to dismiss for failure to file a legally sufficient report from a qualified expert? 2. Did the circuit court err in granting appellees’ motion for judgment notwithstanding the verdict based on insufficient causation evidence? 3. Did the circuit court err in denying GBMC’s motions for judgment based on insufficient evidence? We answer the first and last questions in the negative and the second question in the affirmative.

We therefore affirm the decision of the circuit court denying the motion to dismiss, ⁴⁶⁸ reverse the judgment granting the motion for JNOV, and remand for reinstatement of the jury verdict. DISCUSSION I. Motion to Dismiss A. Relevant Facts When the Barneses brought suit against GBMC, they filed a certificate of qualified expert and an expert report, as required by CJP § 3-2A-04. The certificate and report were signed by Dr. Kenneth Larsen. Dr. Larsen’s report stated: It is my opinion to a reasonable degree of medical probability that the care and treatment of David Barnes by Jose Y. Rustía, M.D., Charles Emergency Physicians, P.A. and Greater Baltimore Medical Center departed from the applicable standards of care and that such departures are the proximate cause of the alleged injuries and damages.

Dr. Larsen was deposed and fully testified at the first trial. The trial testimony on standard of care and causation was, in part: Q: Does the standard of care require the triage nurse to read that note? A: Yes ... Q: I want to proffer to you that Nurse Stopa was the triage nurse and that she changed the priority from 1 to 4, sent the patient to Urgent Care.

Do you have an opinion to a reasonable degree of medical certainty as to whether that complied or didn’t comply with the standard of care? A: My opinion is that it does not comply with the standard of care. If you have taken a patient who was triaged by one of your patriot [sic ] nurses with significant experience in the Emergency Department that interviewed this patient and decided he needed the most urgent care of triage, and then you decide basically on your own that they need the least urgent care. You have a note in front of you sent by their doctor, a note on the chart that says why they were sent by the ⁴⁶⁹ doctor, yet, you make a decision on your own without consulting anybody, either the nurse who did the quick look who assigned the most priority or the doctor that wrote the note on the chart or anyone else in the department.

To go backward and downgrade this patient to the lowest priority and send him essentially to a minor care area does not comply with the standard of care. If she had gone and talked to Nurse Starstrom and the two of them put their heads together and decided that a change in triage priority was a reasonable thing to do, I would not have this particular criticism. She didn’t do that. She made this decision on her own without consulting either the physician that sent the patient or the nurse that saw him first. ...

Q: In order for a nurse to change the priority, what does the standard of care require the nurse to do? A: She has to look at all the available materials like what is written on the triage sheet in front of her and what is written on the note attached to it. She has to assess the patient, she has to talk to the patient and do some degree of examination. ... Q: Do you have an opinion as to where, if Nurse Stopa had read the note and followed the doctor’s order, Mr. Barnes would have been routed to?

A: He would have been sent to the main Emergency Department [ED] if it had not been changed. ... Q: Do you have an opinion to a reasonable degree of medical probability what would have happened to Mr. Barnes had he been routed correctly to the ED relative[ ] to care and treatment in the ED? A: I believe that if Mr. Barnes would have been sent originally to the main Emergency Department instead of the Urgent Care Center, he would have had all the tests done. [ ] Q: Going back to your question, had Mr. Barnes been directed to the correct main ED, do you have an opinion as to what the appropriate stroke workup would have been? ⁴⁷⁰ A: He would have done what he had done when he came back on his second visit, had a CAT-scan, the number of blood tests that had been done, and the electrocardiogram. He then would have been admitted to the hospital.

(Objections that were overruled omitted). After the mistrial and the day before the second trial, GBMC 9 filed a motion to dismiss based on the Barneses’ failure to attach a legally sufficient report to their certificate of qualified expert. 10 GBMC felt that the expert report that accompanied the certificate was insufficient because it merely stated that GBMC violated the standard of care and that the violations were the proximate cause of Mr. Barnes’ injuries, but did not go into any further explanation. The Barneses argued that the motion was filed too late, and GBMC responded that the HCMCA permits them to challenge the certificate at any time. The circuit court denied the motion, stating that, the purpose of those certificates of merit is to allow Defendants an opportunity to understand the basis for the claims against them and to properly defend and in this case I believe there has been adequate time over the last six years for the Defendants to have those opportunities to defend the case and prepare and I’m not going to dismiss the case at this junction on the grounds of a faulty certificate of merit. 11 GBMC contends that this ruling was improper because deficiencies in the certificate cannot be waived. ⁴⁷¹ B. Standard of Review This issue requires us to interpret the certificate requirement of the Health Care Malpractice Claims Act.

A question of statutory interpretation is reviewed de novo. Walter v. Gunter, 367 Md. 386, 392 , 788 A.2d 609 (2002). Thus, we determine if the circuit court was legally correct in its interpretation of the Act. Wash.

Suburban Sanitary Comm’n v. Phillips, 413 Md. 606, 618 , 994 A.2d 411 (2010). If we find that the circuit court correctly interpreted the HCMCA to permit the denial of the motion to dismiss, then we must also determine if the specific facts support the denial. This we also review de novo. Gomez v. Jackson Hewitt, Inc., 427 Md. 128, 142 , 46 A.3d 443 (2012).

Furthermore, “an appellate court will affirm a circuit court’s judgment on any ground adequately shown by the record, even one upon which the circuit court has not relied or one that the parties have not raised.” Pope v. Board of Sch. Comm’rs, 106 Md.App. 578, 591 , 665 A.2d 713 (1995). In other words, we can affirm the trial court if it reached the right result for the wrong reasons. Id.

C. The Current State of the Certificate of Qualified Expert Requirement We begin with a discussion of the Act’s certificate requirement. A plaintiff filing a suit that falls under the Act, 12 such as the Barneses’ claim, must provide a certificate of qualified expert or his case will be dismissed without prejudice. 13 The ⁴⁷² expert is qualified only if he meets certain requirements, which include not devoting annually more than twenty percent of the expert’s professional work to activities that directly involve testimony in personal injury claims, CJP § 3-2A-04(b)(4), and “hav[ing] had clinical experience, provided consultation relating to clinical practice, or taught medicine in the defendant’s specialty or a related field of health care, or in the field of health care in which the defendant provided care or treatment to the plaintiff, within 5 years of the date of the alleged act or omission giving rise to the cause of action.” CJP § 3-2A-02(c)(2)(ii)(A). The Act also requires that along with the certificate, the plaintiff must include an expert report. 14 Many appellate opinions have interpreted these provisions. The Court of Appeals has concluded that the expert’s report is part of the certificate requirement.

Walzer v. Osborne, 395 Md. 563, 579 , 911 A.2d 427 (2006). Thus, the statute requires dismissal when the plaintiff fails to file a certificate or fails to file a report. Id. at 578 , 911 A.2d 427 . Additionally, the appellate courts have determined that there is no distinction between failing to file a certificate and failing to meet the certificate requirements; failure to file a proper certificate is tantamount to failing to file at all and requires dismissal without prejudice.

Id. at 582 , 911 A.2d 427 ; D’Angelo v. St. Agnes Healthcare, Inc., 157 Md.App. 631, 645 , 853 A.2d 813 (2004). A plaintiff can fail to file a proper certificate and report in many different ways, some being: when a certificate is not ⁴⁷³ filed, when a report is not attached to the certificate, Walzer, 395 Md. at 579 , 911 A.2d 427 , when the certificate does not clearly identify the defendant(s), D’Angelo, 157 Md.App. at 652 , 853 A.2d 813 , when the certifying expert does not meet the requirement of working or teaching in the same field as the defendant, Breslin v. Powell, 421 Md. 266, 299 , 26 A.3d 878 (2011), and when the certificate or report does not clearly explain what standard of care was owed and how the defendants violated the standard, Carroll v. Konits, 400 Md. 167, 198 , 929 A.2d 19 (2007). Not only does an insufficient certificate or report require the court to dismiss the claim, the Court of Appeals has also interpreted the certificate requirement to be a condition precedent to filing a medical malpractice claim in circuit court. Id. at 181 , 929 A.2d 19 .

As a condition precedent, “a failure to satisfy it can be raised at any time because the action itself is fatally flawed if the condition is not satisfied.” Id. Thus, the Court has permitted a defendant to challenge a certificate or report for the first time after waiving arbitration and filing an answer and pretrial motions. Kearney v. Berger, 416 Md. 628, 653-54 (2010). Under the guidance of this case law, we turn to the issue raised by this case.

D. Analysis GBMC argues that the Barneses’ expert report lacked any detail. It asserts that the report failed to specify the standard of care applicable to GBMC, did not explain how GBMC deviated from the standard of care, failed to state what should have been done to comply with the standard, and did not explain how GBMC caused Mr. Barnes’ harm. 15 We ⁴⁷⁴ understand that, based on the appellate courts’ interpretations of the Act, those may have been deficiencies in the report and reasons to dismiss the case before the mistrial. 16 However, we conclude that dismissal was not required in this case, although for a slightly different reason than the circuit court articulated. We express no view on whether GBMC was too late in filing and therefore waived any argument that the certificate requirement was not met, but instead find GBMC’s challenge lacked merit because the hospital possessed Dr. Larsen’s testimony and ample detail from the mistrial before the second trial. The trial testimony cured the report’s apparent lack of detail because Dr. Larsen’s testimony explained exactly what GBMC argued was absent from the expert report: the standard of care that was required of Nurse Stopa, how Nurse Stopa did not follow the standard of care, and how her failure to follow the standard led to Mr. Barnes’ injury.

Because ⁴⁷⁵ there was a mistrial, the report and the testimony essentially became one. GBMC had the report and the testimony when it made its motion at the beginning of the second trial. Thus, it was proper for the judge to deny the motion to dismiss. No previous appellate opinion directly addresses whether the Act allows for the possibility that subsequent events will cure an allegedly faulty report.

Thus, we look to the Act and try to determine the intent of the legislature. Mayor of Oakland v. Mayor of Mountain Lake Park, 392 Md. 301, 316 , 896 A.2d 1036 (2006). Analysis of a statute frequently requires consideration of the text, the purpose of the statute, and the consequences of the interpretation. To elaborate on each of these factors: Text is the plain language of the relevant provision, typically given its ordinary meaning, viewed in context, considered in light of the whole statute and generally evaluated for ambiguity.

Legislative purpose, either apparent from the text or gathered from external sources, often informs, if not controls, our reading of the statute. An examination of interpretive consequences, either as a comparison of the results of each proffered construction or as a principle of avoidance of an absurd or unreasonable reading grounds the court’s interpretation in reality. Buckley v. Brethren Mut. Ins.

Co., 207 Md.App. 574, 584-85, 53 A.3d 456 (2012), cert. granted, 430 Md. 11 , 59 A.3d 506 (2013). The text of the statute only states that a case will be dismissed when a certificate is not filed without any further explanation. Because the statute is unclear on its application to the circumstances presented here, we can look to legislative purpose to determine whether a cure is permitted under the plain meaning of a statute. See Breslin, 421 Md. at 294 , 26 A.3d 878 .

We conclude that the legislative purpose of the statute supports our conclusion that the Act permits a cure, at least under the facts of this case. Finding that Dr. Larsen’s testimony at the first trial, and before the beginning of the second trial, cured the alleged ⁴⁷⁶ deficiencies in Ms expert report serves the purpose of the certificate requirement. The purpose of the certificate requirement is to “weed out, shortly' after suit is filed, non-meritorious medical malpractice claims.” D’Angelo, 157 Md. App. at 645 , 853 A.2d 813 . Demanding that the plaintiff provide the defendant and the trial court with enough information to determine if the claim has merit and requiring the plaintiff to support his claim with an expert report help serve the purpose of the Act.

Kearney, 416 Md. at 658 , 7 A.3d 593 . Accordingly, rejectmg insufficient certificates and reports ensures that non-meritorious claims do not find their way to court. For example, in D’Angelo , the plaintiffs certificate did not identify the medical professional(s) who had violated the standard of care. 157 Md.App. at 652 , 853 A.2d 813 . Thus, he did not provide enough information to support his claim, and it was properly dismissed.

Id. Similarly, in Carroll , the Court of Appeals affirmed the dismissal of the plaintiffs case because the expert report did not provide the litigants with information on the appropriate standard of care and how it was violated. 400 Md. at 196-200 , 929 A.2d 19 ; See generally Walzer, 395 Md. at 583 , 911 A.2d 427 (finding the expert report “must explain how or why the physician failed or did not fail to meet the standard of care” because it would “help weed out non-meritorious claims and assist the plaintiff or defendant in evaluating the merits of the health claim or defense.”). Unlike D’Angelo, where the litigants and the court could not have known who the plaintiff had a claim against, or Carroll , where the defendant could not evaluate the plaintiffs claim because the expert report did not explain how the standard of care was violated, in this case, the Barneses had provided all the information necessary to evaluate their claims before trial. Dr. Larsen was directly examined and GBMC’s attorney had cross examined him in the first trial regarding his reasoning of how GBMC’s nurse violated the