Cota v. Adirondack Medical Center: Detailed Defense Expert Affidavits Required to Establish Lack of Causation in Misdiagnosis and Delayed-Treatment Malpractice Claims

Cota v. Adirondack Medical Center: Detailed Defense Expert Affidavits Required to Establish Lack of Causation in Misdiagnosis and Delayed-Treatment Malpractice Claims

I. Introduction

The Appellate Division, Third Department’s decision in Cota v. Adirondack Medical Center, 2025 NY Slip Op 07256 (Dec. 24, 2025), addresses two distinct strands of medical malpractice litigation:

  • hospital liability for a postpartum fall and post-fall diagnostic care; and
  • radiology malpractice based on an alleged misreading of an MRI that delayed the diagnosis of a coccyx fracture and allegedly led to painful, inappropriate physical therapy.

The opinion is significant for at least three reasons:

  1. It reaffirms the well-settled burden-shifting framework for summary judgment in medical malpractice actions, but applies it in a fact-intensive postpartum setting involving fall-risk assessment and postpartum ambulation.
  2. It articulates a demanding standard for defense expert affidavits on the issue of causation in misdiagnosis/delayed-treatment cases: an expert who ignores critical treatment details, ambiguously describes the records and imaging reviewed, or mischaracterizes key testimony cannot carry the defendant’s prima facie burden, even when the plaintiff offers no medical expert in opposition.
  3. It exposes a sharp division within the Third Department (a 3–2 split) on how rigorously appellate courts should scrutinize defense experts at the prima facie stage, particularly where the plaintiff’s theory includes allegedly harmful conservative treatment (here, physical therapy) following a misdiagnosis.

Defendants Adirondack Medical Center (“AMC”) and radiologist Matthew Smith both appealed from an order denying, in whole or in part, their motions for summary judgment. The court affirmed:

  • AMC – denial of summary judgment entirely affirmed (unanimously), allowing the malpractice claims relating to fall prevention and post-fall diagnosis to proceed.
  • Smith – denial of summary judgment on causation affirmed by a 3–2 majority, with a detailed dissent arguing the majority held Smith’s expert to an unduly exacting standard and that plaintiff’s lack of a counter-expert should have been fatal.

II. Summary of the Opinion

A. Parties and Core Allegations

  • Plaintiff: Amie Cota, who delivered a healthy infant at AMC on January 15, 2017.
  • Hospital defendant: Adirondack Medical Center (AMC).
    • Allegations: AMC negligently failed to prevent and respond appropriately to plaintiff’s post-delivery fall, resulting in or exacerbating a coccyx fracture.
  • Radiology defendant: Dr. Matthew Smith, radiologist employed by St. Lawrence Radiology Associates, P.C.
    • Allegations: Smith negligently failed to detect a coccyx fracture on a March 15, 2017 MRI, causing a delay in appropriate treatment and exposing plaintiff to painful and allegedly inappropriate physical therapy modalities.

B. Procedural Posture

After discovery and consolidation of related actions, AMC and Smith each moved for summary judgment dismissing the complaint as to them. Supreme Court (Farley, J.) in St. Lawrence County:

  • Denied AMC’s motion in its entirety.
  • Partially denied Smith’s motion, leaving the core causation-related malpractice claims against him intact.

AMC and Smith separately appealed.

C. Holdings

  1. AMC – summary judgment properly denied.
    The majority held that AMC made a prima facie showing through expert affidavits that its assessment of fall risk, level of assistance during ambulation, and decision not to order imaging were within the standard of care and not causative of plaintiff’s injuries. However, plaintiff’s own qualified experts created triable issues of fact, especially in light of:
    • conflicting accounts of the assistance provided for first ambulation postpartum,
    • evidence of dizziness, nausea, blood pressure changes suggesting fluid volume deficit, and
    • documented tailbone soreness after the fall.
    Summary judgment for AMC was therefore inappropriate.
  2. Smith – defense expert’s affidavit insufficient to establish lack of causation.
    The majority concluded that Smith’s orthopedic-spine expert failed to carry the initial burden on causation because his affidavit was:
    • conclusory,
    • failed to reckon with specific, allegedly harmful physical therapy modalities (manual coccyx manipulation and kinesiotaping),
    • ambiguous as to what imaging and records were actually reviewed, and
    • based on an incorrect or misleading reading of plaintiff’s testimony about the benefits of her eventual coccygectomy.
    Because Smith did not make a prima facie showing, plaintiff’s failure to submit a medical expert on causation did not justify summary judgment for him.
  3. Dissent (Garry, P.J., joined by Ceresia, J.) – would grant Smith full summary judgment.
    The dissent would find Smith’s expert opinion sufficient to shift the burden to plaintiff, emphasizing:
    • the conservative treatment protocol for tailbone pain (regardless of etiology),
    • the controversial and last-resort nature of coccygectomy, and
    • the absence of any plaintiff medical expert to show that earlier diagnosis would have altered treatment or outcome.

III. Factual and Procedural Background

A. The Delivery and Postpartum Fall

On January 15, 2017, in the early morning hours, plaintiff was admitted to AMC in active labor. Less than two hours later, she delivered a healthy infant:

  • No epidural.
  • No cesarean section.
  • No reported significant blood loss.
  • No pain medications or obstetrical interventions required.

Approximately two hours post-delivery, plaintiff attempted her first ambulation to the restroom. There is a factual dispute over:

  • the extent of assistance offered by the nurse, and
  • whether plaintiff complied with the nurse’s instructions.

What is undisputed:

  • Plaintiff successfully reached the restroom.
  • Upon exiting, she suffered a syncopal episode (fainting) and fell.
  • She awoke on the floor with the nurse on top of her, suggesting the nurse attempted to intervene mid-fall.
  • Post-fall, plaintiff reported tailbone soreness (as reflected in the nurse’s notes).
  • No diagnostic imaging was performed before she was discharged the next day.

B. Subsequent Diagnostic Workup and Treatment

  1. Initial ER CT Scan (post-discharge)
    After leaving AMC, plaintiff presented to a local emergency room:
    • CT scan of the lumbar spine: no fracture or dislocation identified.
    • Diagnosed with a sacral contusion.
    • Treated conservatively with NSAIDs, ice, and cushion support.
  2. Care with Primary Physician and March 15, 2017 MRI
    Plaintiff’s primary care physician continued to treat her and ordered additional imaging. On March 15, 2017, an MRI was performed at Canton Potsdam Hospital.
    • Radiologist Matthew Smith read the MRI as “unremarkable.”
    • Relying on Smith’s reading, the primary care physician prescribed physical therapy.
  3. Physical Therapy
    The physical therapy program included:
    • manual manipulation of the coccyx (producing “popping” and “exquisite” pain), and
    • kinesiotaping of the sacrum intended to draw the coccyx into flexion, which also caused significant pain while applied, though one note indicates plaintiff felt better after it was removed.
    Plaintiff described these aspects as extraordinarily painful.
  4. Tailbone Specialist and Diagnosis
    On May 5, 2017, a tailbone specialist:
    • diagnosed plaintiff with a coccyx compression fracture,
    • immediately discontinued physical therapy,
    • ordered additional imaging,
    • performed pain management injections, and
    • independently reviewed the March 2017 MRI, concluding the fracture was clearly visible.
    It later emerged that certain MRI views, including those showing the fracture, had been uploaded into Smith’s imaging system in an “allegedly improper manner.”
  5. Coccygectomy
    In September 2017, a spinal surgeon performed a coccygectomy (surgical removal of the coccyx). Plaintiff testified that:
    • before surgery: pain was “excruciating,” she could not sit, stand, lie down comfortably, or perform basic daily functions,
    • after surgery: pain became “more tolerable,” “not excruciating anymore,” and she was able to return to full-time work as a dental hygienist,
    • yet years later she continued to experience daily pain, with limited further improvement after the initial post-surgical change.

C. Litigation and Summary Judgment Motions

Plaintiff filed malpractice actions against AMC, Smith, and others, later consolidated. Her theories included:

  • AMC: negligent fall prevention; failure to recognize and appropriately respond to fall risk signs; inadequate assistance during first postpartum ambulation; failure to order imaging in the face of post-fall tailbone pain; resulting in or worsening a coccyx fracture and related sequelae.
  • Smith: negligent failure to identify a coccyx fracture on the March 2017 MRI; leading to:
    • delayed diagnosis and treatment, and
    • exposure to painful and (plaintiff claims) inappropriate physical therapy modalities.

After discovery, AMC and Smith sought summary judgment. Supreme Court denied AMC’s motion completely and granted Smith only limited relief (not relevant to the appeal). The defendants appealed.

IV. Legal Framework

A. Elements of Medical Malpractice and Summary Judgment

The court restated the familiar New York rule for medical malpractice:

  • To prevail, a plaintiff must show:
    1. a deviation from accepted medical practice, and
    2. that this deviation was a proximate cause of the injury.
  • On summary judgment, a defendant must make a prima facie showing that:
    • there was no deviation from the accepted standard of care, or
    • even if there was a deviation, it was not a proximate cause of the plaintiff’s injuries.
  • If the defendant meets this initial burden, the burden shifts to the plaintiff to present evidence—typically in the form of a medical expert affidavit—raising a triable issue of material fact.

These principles are anchored in precedents such as:

  • Mazella v Beals, 27 NY3d 694 (2016);
  • Schultz v Albany Med. Ctr. Hosp., 238 AD3d 1286 (3d Dept 2025);
  • Naylor v Ellis Hosp., 235 AD3d 1130 (3d Dept 2025);
  • Sovocool v Cortland Regional Med. Ctr., 218 AD3d 947 (3d Dept 2023);
  • Schwenzfeier v St. Peter's Health Partners, 213 AD3d 1077 (3d Dept 2023).

The general summary judgment standard—viewing evidence in the light most favorable to the nonmovant and giving that party the benefit of every reasonable inference—is drawn from Vega v Restani Constr. Corp., 18 NY3d 499 (2012).

B. Expert Affidavits and “Conclusory” Opinions

The opinion leans heavily on New York authority governing the sufficiency of expert affidavits in malpractice motions:

  • An expert affidavit is conclusory and legally insufficient
  • ignores important medical records,
  • rests on an incorrect understanding of the facts, or
  • fails to adequately explain the expert’s reasoning.

Key precedents include:

  • Carlton v St. Barnabas Hosp., 91 AD3d 561 (1st Dept 2012) – ignoring important records;
  • Micciola v Sacchi, 36 AD3d 869 (2d Dept 2007) – incorrect factual premise;
  • Guthier v DiPreta, 234 AD3d 1166 (3d Dept 2025) – inadequate explanation of reasoning;
  • Pullman v Silverman, 28 NY3d 1060 (2016) – conclusory expert opinions on causation insufficient;
  • Mylar v Niagara Falls Mem. Med. Ctr., 234 AD3d 1262 (4th Dept 2025);
  • Hoffman v Taubel, 208 AD3d 1099 (1st Dept 2022).

These authorities provide the doctrinal backbone for the majority’s rejection of Smith’s expert affidavit on causation.

V. Analysis of the Majority Opinion

A. Claims Against Adirondack Medical Center

1. AMC’s Prima Facie Showing

AMC relied on expert affidavits from:

  • a board-certified obstetrician-gynecologist, and
  • a certified registered nurse.

AMC’s experts conceded important points:

  • Plaintiff’s fall risk was documented as “low” at admission.
  • AMC’s own policy required observation while plaintiff ambulated.
  • Standard of care for assisting postpartum mothers to the restroom for their first post-delivery trip is a “one-person assist.”

However, from AMC’s perspective:

  • The nurse complied with hospital policy and the standard of care by remaining in the vicinity as a “stand-by assist.”
  • Discrepancies in the accounts of the level of assistance (hands-on vs stand-by) were immaterial because the nurse was nearby and monitoring plaintiff.
  • Reported shakiness and nausea after delivery were attributed to normal hormonal regulation postpartum, not to hypovolemia or any condition that should have alerted the nurse to a heightened fall risk.
  • Normal vital signs, absence of epidural, cesarean, major blood loss, or sleep deprivation meant there was no objective basis to anticipate syncope or to deviate from orders allowing ambulation one hour post-delivery.
  • AMC’s experts opined that plaintiff’s noncompliance with nursing directions was the cause of her fall and that additional precautions would not have prevented it.
  • On causation of the coccyx fracture itself, the physician expert suggested the fracture likely resulted from labor and delivery (especially the baby’s occiput posterior position and relatively rapid first-time delivery), rather than from the fall.

Regarding the post-fall diagnostic response:

  • The physician expert initially stated there was no documentation of tailbone pain post-fall, but AMC’s own records contradicted this (they documented “tailbone soreness”).
  • Even assuming tailbone soreness, the expert concluded that:
    • plaintiff’s ability to sit up in bed within an hour,
    • her later ambulation without complaint, and
    • absence of bruising or point tenderness the next day
    together rendered it consistent with the standard of care to forego imaging prior to discharge.

The Third Department held that AMC’s submissions were sufficient to establish prima facie entitlement to summary judgment as to:

  • fall prevention, and
  • post-fall diagnostic decision-making (including the decision against imaging).

2. Plaintiff’s Rebuttal and Triable Issues of Fact

In response, plaintiff offered expert affidavits from a physician and a nurse with comparable credentials to AMC’s experts. They contested AMC’s position on several key fronts:

  • Etiology of coccyx injury.
    • They opined that occiput posterior fetal positioning alone does not significantly increase the risk of coccyx bruising or fracture.
    • Other risk-enhancing factors—high birth weight and prolonged labor—were not present.
    • Thus, they implicitly challenged AMC’s theory that the fracture was birth-related rather than fall-related.
  • Fall risk assessment.
    • They treated plaintiff’s dizziness and nausea as signs of fluid volume deficit, a recognized risk factor for syncope and falls.
    • Hospital notes post-fall even reflected a possible nursing diagnosis of fluid volume deficit.
    • They observed a “spike” in plaintiff’s baseline blood pressure prior to the fall, further supporting a higher fall risk than AMC’s experts acknowledged.
  • Standard of care for ambulation assistance.
    • Given the elevated fall risk, they opined that the standard of care required the nurse to walk directly beside plaintiff at all times, with one arm in front and one arm behind her.
    • Merely remaining “in the vicinity” as a stand-by assist was inadequate in these circumstances.
    • They further opined that proper positioning would have reduced momentum during the fall and either prevented it or limited its severity, and may have avoided the nurse falling on top of plaintiff.
  • Post-fall diagnostic response.
    • Given documented tailbone soreness, they concluded that the standard of care required diagnostic imaging before discharge.

Viewing the record in the light most favorable to plaintiff and affording her every reasonable inference, the majority agreed with Supreme Court that genuine disputes of material fact existed. These included:

  • whether plaintiff was, in fact, at heightened risk of falling;
  • whether the nurse’s actual level and manner of assistance met the standard of care in those circumstances;
  • whether plaintiff’s actions constituted noncompliance or reasonably foreseeable ambulation given her symptoms; and
  • whether failure to order imaging after a documented fall and tailbone pain was a deviation from accepted practice and causative of harm.

Accordingly, the denial of AMC’s summary judgment motion was affirmed.

B. Claims Against Radiologist Matthew Smith

1. Plaintiff’s Theory and the Framing of the Issue on Appeal

Plaintiff’s core claims against Smith centered on causation, not on the existence of a deviation (the misreading of the MRI was effectively assumed for purposes of the motion). She alleged that:

  • Smith’s failure to diagnose the fracture on March 15, 2017:
    • delayed proper diagnosis and treatment, and
    • caused her to undergo painful and inappropriate physical therapy modalities (manual coccyx manipulation and kinesiotaping), which would have been altered or avoided had the fracture been timely recognized.

On appeal, the dispute narrowed to whether Smith, through his expert, met his initial burden of proving that his misdiagnosis did not cause any harm. Plaintiff submitted no medical expert affidavit on causation, so if Smith’s expert was adequate, the burden would have shifted and plaintiff’s opposition would have been insufficient.

2. Smith’s Expert Affidavit

Smith submitted an affidavit from a board-certified orthopedic surgeon with a spine subspecialty. That expert opined that:

  • Smith’s failure to identify the coccyx fracture had no impact on plaintiff’s:
    • treatment plan, or
    • ultimate outcome.
  • For tailbone pain (coccydynia), the etiology (e.g., fracture vs soft tissue injury) generally does not change the recommended course of conservative treatment.
  • Standard conservative modalities include:
    • NSAIDs,
    • pressure-relieving cushions,
    • rest,
    • ice/heat,
    • pelvic floor rehabilitation,
    • massage,
    • nerve stimulation, and
    • manual manipulation.
    These might be attempted, in his words, if “deemed appropriate.”
  • Thus, he concluded that plaintiff was “appropriately advancing through a progressive course of conservative methods” between March 15 and May 5, 2017, and her treatment would not have differed even had the fracture been recognized earlier.
  • He further opined that coccyx injuries can take up to a year to heal and that coccygectomy is a controversial, “absolute last resort” surgery that generally would not be performed as early as May 2017 (three months post-injury), so timely diagnosis would not have accelerated surgery.
  • Relying on plaintiff’s statement that nearly four years post-surgery she saw “little to no” improvement, he concluded that earlier surgery would not have improved her ultimate outcome.

On its face, this affidavit was designed to show that the alleged misdiagnosis did not cause:

  • any additional or different conservative treatment, or
  • any delay in appropriate surgery that mattered to outcome.

3. Majority’s Critique: Why the Affidavit Was Conclusory and Insufficient

The majority found three major defects in Smith’s expert opinion, each independently undermining its sufficiency as prima facie proof.

(a) Failure to Grapple with Actual Physical Therapy Modalities Used

While the expert acknowledged that plaintiff underwent physical therapy, he:

  • did not identify which specific modalities were used, and
  • did not explain how those particular modalities were appropriate for a patient with a coccyx fracture.

The record showed:

  • manual manipulation of the coccyx, eliciting “popping” and “exquisite” pain, and
  • kinesiotaping intended to draw the coccyx into flexion, causing significant pain while applied.

The expert instead offered only a generic list of “conservative methods” that may be used for coccydynia “generally” and hedged that they may be tried if “deemed appropriate,” without:

  • engaging with the specifics of plaintiff’s therapy, or
  • explaining why those particular techniques were “appropriate” treatment for a diagnosed coccyx fracture.

This disconnect was particularly stark because, once the fracture was recognized, the tailbone specialist immediately discontinued physical therapy. The majority found it telling that Smith’s expert neither reconciled this decision with his view of standard care nor explained why the specialist’s discontinuation did not undermine his assertion that the therapy was appropriate.

In short, by failing to address the primary source of plaintiff’s claimed harm—specific, allegedly harmful PT interventions—the expert’s causation opinion was deemed conclusory.

(b) Ignoring or Minimizing Critical Records

The majority also faulted the expert for apparently ignoring critical aspects of the record:

  • He said only that he reviewed “available imaging,” without specifying whether this included the MRI views that clearly depicted the fracture.
  • He claimed to have reviewed “medical records” but gave no indication that he had actually examined the detailed PT records describing the modalities employed, frequency, and plaintiff’s reported pain responses.

The court held that whether this was an oversight or a deliberate choice was immaterial; in either case, his opinion effectively ignored the very treatment modalities that formed “the essence of plaintiff’s claim” against Smith.

This omission ran afoul of precedents such as Carlton and Micciola, where experts who ignore material records or rely on incorrect or incomplete facts are found to have provided legally deficient opinions.

(c) Misunderstanding or Mischaracterization of Plaintiff’s Testimony

Finally, the court found that the expert mischaracterized plaintiff’s testimony about the impact of her coccygectomy. The expert relied on her statement that she saw “almost four years [after the surgery] . . . I don’t see improvement” to assert:

  • that surgery did not improve her condition, and therefore,
  • earlier performance of the surgery would not have improved her outcome.

But in context, plaintiff also clearly testified that:

  • her pain post-surgery was “more tolerable” and “not excruciating anymore,” and
  • she regained the ability to work full-time and perform daily activities previously impossible due to pain.

The majority read this as unambiguous evidence that surgery did bring substantial improvement, though not complete resolution, and that the “little to no improvement” comment referred to the lack of additional progress after an initial period of relief—not to the absence of benefit from surgery itself.

By misconstruing this testimony, the expert’s conclusion that earlier surgery would not have improved plaintiff’s outcome rested on an incorrect understanding of the facts, making his causation opinion unreliable under cases like Micciola.

4. Consequence: No Prima Facie Showing, No Burden Shift

Having found Smith’s expert affidavit:

  • conclusory,
  • unsupported by a complete and accurate review of the records, and
  • premised on a misreading of plaintiff’s testimony,

the majority concluded that Smith failed to meet his initial burden on causation. As a result:

  • the burden never shifted to plaintiff to present her own expert, and
  • plaintiff’s lack of a causation expert did not justify summary judgment for Smith.

The court underscored this by referencing:

  • Pullman v Silverman, 28 NY3d 1060 (2016);
  • Mylar, 234 AD3d 1262; and
  • Hoffman, 208 AD3d 1099,

as cases where incomplete or conclusory defense expert affidavits were deemed insufficient to support summary judgment. It also cited the characterization of summary judgment as a “drastic remedy” in Matter of McNeil, 233 AD3d 1231 (3d Dept 2024) and Berkeley v Rensselaer Polytechnic Inst., 289 AD2d 690 (3d Dept 2001), reinforcing its reluctance to grant summary judgment on a compromised evidentiary foundation.

5. Pleadings, Notice, and Waiver (Footnote 2)

A critical procedural overlay concerned whether plaintiff was permitted to rely on a theory involving inappropriate physical therapy, given that:

  • her complaint and bill of particulars did not clearly spell out a PT-based theory of harm.

The dissent stressed this omission. The majority responded in Footnote 2:

  • Smith did not argue on appeal that plaintiff’s PT-based theory was barred by deficient pleadings; therefore, he waived that argument (citing Pompa v Burroughs Wellcome Co., 259 AD2d 18 [3d Dept 1999]; First Natl. Bank of Amenia v Mountain Food Enters., 159 AD2d 900 [3d Dept 1990]).
  • In any event, although the pleadings “may not be models of clarity,” they were sufficient to put Smith on notice of the claims:
    • plaintiff was extensively questioned at deposition about the PT issues, and
    • Smith’s own submissions below and on appeal revealed that he understood this to be “the crux of plaintiff’s claim” against him.

This portion of the opinion is an important, if secondary, statement about the flexible, notice-oriented approach to pleadings in malpractice cases and the necessity for defendants to preserve any objections to newly articulated theories.

VI. Precedents Cited and Their Influence

A. Core Med-Mal and Summary Judgment Cases

  • Mazella v Beals, 27 NY3d 694 (2016) – Reaffirms that plaintiffs must prove both deviation and proximate cause; widely cited baseline standard.
  • Schultz v Albany Med. Ctr. Hosp., 238 AD3d 1286 (3d Dept 2025) – Third Department application of the summary judgment burden in med-mal; cited here to support the description of defendant’s initial burden and prima facie proof.
  • Naylor v Ellis Hosp., 235 AD3d 1130 (3d Dept 2025) – Similar use; underscores that, once a defendant produces competent expert proof, the plaintiff must respond with an expert to raise triable issues—unless, as here with Smith, the defendant fails to meet its initial burden.
  • Sovocool v Cortland Regional Med. Ctr., 218 AD3d 947 (3d Dept 2023) & Schwenzfeier, 213 AD3d 1077 (3d Dept 2023)
    • Both emphasize that where a defendant presents a detailed, fact-grounded expert affidavit, plaintiff must respond in kind; by contrast, in Cota, the majority found Smith’s showing defective at the outset.
  • Vega v Restani Constr. Corp., 18 NY3d 499 (2012) – Standard for viewing evidence in light most favorable to the nonmovant; supports denial of AMC’s motion where competing expert opinions create factual issues.

B. Cases on Conclusory Expert Affidavits and Record Review

  • Carlton v St. Barnabas Hosp., 91 AD3d 561 (1st Dept 2012) – Expert oath is insufficient if it fails to address key medical records; applied here to Smith’s failure to address PT details.
  • Micciola v Sacchi, 36 AD3d 869 (2d Dept 2007) – An expert opinion grounded on an incorrect understanding of facts lacks probative value; applied to Smith’s expert’s misreading of plaintiff’s postsurgical testimony.
  • Guthier v DiPreta, 234 AD3d 1166 (3d Dept 2025) – Reiterates the need for clear reasoning within an expert affidavit, not bare conclusions.
  • Pullman v Silverman, 28 NY3d 1060 (2016) – High Court’s rejection of conclusory defense expert opinions on causation; key authority for majority’s holding that Smith’s expert failed to shift the burden.
  • Mylar v Niagara Falls Mem. Med. Ctr., 234 AD3d 1262 (4th Dept 2025) & Hoffman v Taubel, 208 AD3d 1099 (1st Dept 2022)
    • Both emphasize that incomplete, generalized statements about standard of care or causation are insufficient; Cota cites them to situate its strict treatment of Smith’s expert in an established body of law.

C. “Drastic Remedy” and Appellate Hesitance

  • Matter of McNeil, 233 AD3d 1231 (3d Dept 2024) & Berkeley v Rensselaer Polytechnic Inst., 289 AD2d 690 (3d Dept 2001)
    • Reinforce that summary judgment is a “drastic remedy” and should be granted only where the movant’s proof is clear, complete, and uncontroverted; supports the majority’s reluctance to grant Smith summary judgment on a contested and incompletely analyzed record.

D. Dissent’s Authorities: Need for Plaintiff Experts on Causation

The dissent (Garry, P.J.) cited additional cases to support the view that, once a defendant makes a prima facie showing, a plaintiff generally must offer expert evidence on causation:

  • Fiore v Galang, 64 NY2d 999 (1985) – A medical expert may not always be required if causation is obvious to laypersons; but when causation involves complex medical questions, expert evidence is needed.
  • Macey v Hassam, 97 AD2d 919 (3d Dept 1983) & Duffen v State of New York, 245 AD2d 653 (3d Dept 1997)
    • In complex cases, such as whether earlier diagnosis or different treatment would have changed medical outcomes, lay inference is insufficient; plaintiff must present expert proof.
  • Zuckerman v City of New York, 49 NY2d 557 (1980) – Unsupportable hearsay and speculation cannot defeat summary judgment.
  • Longtemps v Oliva, 110 AD3d 1316 (3d Dept 2013) & Suib v Keller, 6 AD3d 805 (3d Dept 2004)
    • Illustrate that where the defense establishes lack of causation through expert proof, plaintiff’s failure to rebut with her own expert warrants summary judgment.

The majority did not question these principles; rather, it found them inapplicable because, in its view, Smith’s expert never crossed the prima facie threshold.

VII. The Partial Concurrence and Dissent

A. The Dissent’s Core Disagreements

Presiding Justice Garry (joined by Justice Ceresia) agreed with the majority as to AMC, but parted ways on Smith. The dissent’s principal points were:

  1. Pleadings Did Not Fairly Encompass a “Harmful Physical Therapy” Theory.
    The dissent noted:
    • plaintiff’s complaint and bill of particulars did not articulate a claim based on improper physical therapy;
    • the PT-based theory appeared only briefly in plaintiff’s memorandum opposing summary judgment; and
    • in the absence of properly pleaded allegations identifying specific PT modalities as unwarranted, it was unreasonable to fault Smith’s expert for not itemizing or justifying each PT technique in his affidavit.
  2. Defense Expert’s Causation Opinion Was Sufficiently Detailed.
    The dissent viewed the expert’s discussion of:
    • the general irrelevance of etiology (cause) to the conservative treatment of tailbone pain, and
    • the conservative, last-resort status of coccygectomy,
    as a sound basis to conclude that:
    • plaintiff’s treatment between March 15 and May 5, 2017 would not have changed even with a timely fracture diagnosis, and
    • earlier surgery was not indicated and would not have been performed.
  3. Manual Manipulation Is Standard Conservative Care Even for Fractures.
    The dissent highlighted that Smith’s expert explicitly noted manual manipulation as a standard conservative modality for tailbone pain “even when the source of that pain is a fracture.” Thus, in the dissent’s view, the majority’s criticism that the expert did not justify manual manipulation in the context of a fracture was misplaced.
  4. Controversial Nature of Coccygectomy and Limited Post-Surgical Benefit.
    The dissent stressed:
    • coccyx injuries take up to a year to heal;
    • coccygectomy is highly controversial and associated with significant complications, often never recommended; and
    • plaintiff’s own testimony showed a prolonged, painful recovery and ongoing daily pain despite surgery.
    From this, the dissent concluded that even if the surgery provided some measure of improvement, it was not clear that earlier surgery would have materially altered her long-term prognosis, and Smith’s expert was entitled to draw that conclusion.
  5. Plaintiff’s Lack of Expert on Causation Was Fatal Once Burden Shifted.
    The dissent reasoned that questions such as:
    • whether particular PT modalities were medically appropriate for a coccyx fracture, and
    • whether earlier diagnosis would have changed conservative or surgical management,
    are not within lay competence and require medical expert input. Because plaintiff provided no such expert on causation, she could not rebut Smith’s showing, and summary judgment should have been granted to Smith.

B. Practical Implications of the Split

The 3–2 division reveals an important tension:

  • Majority approach: Demands highly tailored, record-specific defense expert affidavits in misdiagnosis/delay cases, especially where the plaintiff alleges harmful treatment downstream of the misdiagnosis (e.g., aggressive PT). Any gaps or mischaracterizations may prevent a prima facie showing and thereby allow plaintiffs to proceed without their own expert at the summary judgment stage.
  • Dissenting approach: Accepts a more generalized, treatment-protocol-based expert opinion as sufficient to establish lack of causation, particularly when:
    • the plaintiff’s pleadings do not clearly flag the contested treatment modalities, and
    • the plaintiff offers no medical expert at all.

For practitioners, this split signals that in the Third Department, at least for now, the majority’s stricter standard governs and defense experts must be especially meticulous in:

  • identifying all treatment modalities in issue,
  • demonstrating familiarity with and analysis of the specific records, and
  • accurately characterizing the plaintiff’s testimony.

VIII. Impact and Practical Significance

A. For Defense Counsel and Experts in Misdiagnosis / Delayed-Treatment Cases

Cota sends a clear message about defense expert affidavits:

  • Generalities are dangerous. Simply listing generic conservative treatments for a condition (e.g., coccydynia) and asserting that they would have been used regardless of diagnosis may be insufficient if the plaintiff claims harm from particular modalities.
  • Engage with the actual record. Experts must:
    • explicitly state which records and imaging they reviewed (ideally including all films, not just “available imaging”), and
    • demonstrate familiarity with and evaluation of specific interventions (e.g., manual manipulation, kinesiotaping) and the patient’s responses.
  • Accurate testimony characterization is critical. Selective quotation that misrepresents context—especially regarding the impact of major events like surgery—risks undermining the entire opinion.
  • Address all claimed harms. If plaintiff claims that misdiagnosis led both to:
    • delay in diagnosis and surgery, and
    • harmful interim treatment (e.g., PT),
    a defense expert must tackle each dimension separately and thoroughly.

Failure on these fronts may mean the defendant never shifts the burden, allowing a plaintiff without a causation expert to survive summary judgment, as occurred here.

B. For Plaintiffs’ Counsel

The decision underscores several plaintiff-side opportunities and cautions:

  • Scrutinize defense affidavits. Plaintiffs can defeat summary judgment not only by presenting their own experts, but also by carefully demonstrating:
    • misstatements of fact,
    • failure to review critical records, or
    • failure to address key treatment events.
  • Plead with sufficient breadth. Although the majority was forgiving of plaintiff’s somewhat imprecise pleadings, it was critical that the record (depositions, motion papers) showed defendant had notice of the PT-based theory. As a practical matter, plaintiffs should:
    • expressly plead harm from specific treatments or modalities caused by misdiagnosis, and
    • detail these in their bills of particulars.
  • Use depositions to expand factual theories. The majority’s reliance on deposition questioning as evidence of notice suggests that robust exploration of treatment details at deposition can mitigate some pleading imperfections.

C. For Hospitals and Obstetrical/Postpartum Practice

On the AMC side, Cota is a cautionary tale for postpartum care:

  • Fall risk can evolve after admission. An initial low-risk designation is not necessarily dispositive if new signs emerge (dizziness, nausea, vital sign changes).
  • Written policies matter—but so do circumstances. AMC’s policy requiring observation during ambulation and the standard of a “one-person assist” were not in dispute, but the quality of assistance in light of evolving risk was central.
  • Post-fall complaints should trigger careful evaluation. Here, documented tailbone soreness after a fall, despite relatively benign exam findings, created a triable issue on whether imaging was required.

The decision may encourage:

  • more conservative assistance standards for first postpartum ambulation in patients with symptomatic hypotension, dizziness, or suspected fluid imbalance, and
  • more frequent consideration of imaging when a fall is accompanied by focal pain, especially in anatomically fragile areas like the coccyx.

IX. Complex Concepts Simplified

A. Summary Judgment and Prima Facie Burden

  • Summary judgment is a pre-trial ruling where the court decides a case (or part of it) without a trial because there are no real disputes about important facts and the moving party is entitled to judgment as a matter of law.
  • Prima facie showing means a party has put forward enough evidence that, if unchallenged, would entitle it to win on a particular issue.
  • In med-mal defense:
    • The defendant must initially provide an expert affidavit showing no negligence or no causation.
    • Only if that is done does the burden “shift” to plaintiff to produce counter-expert evidence.

B. Proximate Cause vs. Etiology

  • Etiology means the cause of a medical condition (e.g., was a fracture caused by childbirth or by a fall?).
  • Proximate cause in law asks:
    • Did the defendant’s negligence substantially contribute to the injury or to a worsening of it?
  • In Cota:
    • For AMC, the question included whether nursing care and diagnostic decisions caused a fall and/or failure to detect a fracture.
    • For Smith, the key was not just whether he missed the fracture, but whether that miss caused:
      • harmful PT, delay in surgery, or a worse long-term outcome.

C. “Conclusory” Expert Opinions

  • An expert opinion is “conclusory” when it:
    • states an ultimate conclusion (“the delay did not affect outcome”) without clearly explaining why,
    • does not show engagement with the full medical record, or
    • rests on selectively quoted or misunderstood facts.
  • Courts are wary of granting summary judgment based on such opinions because they do not allow meaningful testing of the expert’s logic.

D. Coccydynia and Coccygectomy

  • Coccydynia – Pain in the coccyx (“tailbone”), which can arise from trauma, childbirth, or idiopathic causes.
  • Coccygectomy – Surgical removal of the coccyx, typically considered only after:
    • prolonged conservative treatment (medications, cushions, PT, injections) has failed, and
    • pain remains severe and disabling.
  • In this case, the temporal relationship between diagnosis, conservative treatment, and surgery—and the benefits and risks of earlier vs. later surgery—was central to the causation debate.

X. Conclusion

Cota v. Adirondack Medical Center is a fact-sensitive decision with broad doctrinal implications. In affirming the denial of summary judgment to both the hospital and the radiologist, the Third Department:

  • reaffirmed the traditional burden-shifting framework of medical malpractice summary judgment,
  • highlighted the importance of nuanced, individualized expert analyses in postpartum fall and imaging decisions, and
  • most notably, set a high bar for defense expert affidavits on causation in misdiagnosis and delayed-treatment cases, especially where harmful intervening treatments (such as physical therapy) are alleged.

The majority’s analysis makes clear that a defense expert must:

  • engage with the specific treatments and injuries at issue;
  • demonstrate a comprehensive review of the relevant records and imaging; and
  • accurately characterize the patient’s testimony and clinical course.

Where these requirements are not met, as with Smith’s expert here, the defendant may fail even to shift the burden—allowing a plaintiff to survive summary judgment without an opposing medical expert. At the same time, the divided court underscores an ongoing debate within New York’s appellate courts about how demanding this prima facie standard should be, and how strictly pleadings and expert affidavits should be read.

Going forward, Cota will likely be invoked in:

  • challenging or defending summary judgment motions in delayed-diagnosis and misread-imaging cases;
  • guiding the preparation of detailed, record-based expert affidavits; and
  • shaping hospital and postpartum protocols regarding ambulation assistance and post-fall imaging decisions.

Its central lesson is straightforward but demanding: in complex medical malpractice litigation, particularly where causation is contested, precision and completeness in expert analysis are indispensable to obtaining summary judgment.

Case Details

Year: 2025
Court: Appellate Division of the Supreme Court, New York

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