West Virginia Intermediate Court of Appeals Clarifies Causation Standard in Medical Malpractice “Chain of Command” Cases

by Zachary Pyers Esq. and Kenton Steele, Esq.

In the case of Hernandez v. City Hospital, Inc., No. 25-ICA-224 (W. Va. Int. Ct. App. May 18, 2026), the West Virginia Intermediate Court of Appeals recently issued a significant decision addressing causation in medical malpractice cases, and reinforcing that expert testimony based on hospital escalation protocols may be sufficient to submit a case to a jury.

In Hernandez, the plaintiffs alleged that hospital nursing and care staff failed to properly escalate a patient’s worsening neurological condition following spinal surgery and failed to seek additional physician evaluation prior to discharge. According to the plaintiffs, these failures prevented additional diagnostic imaging and timely surgical intervention that could have improved the patient’s neurological outcome. The trial court granted summary judgment in favor of the hospital, concluding that the plaintiffs’ expert opinions regarding causation were speculative because they depended on assumptions about how other providers would have responded if escalation had occurred.

The Intermediate Court of Appeals disagreed and reversed, holding that the plaintiffs’ expert testimony was sufficient to create a genuine issue of material fact on causation. The court emphasized that, under West Virginia law, expert testimony need only establish causation in terms of reasonable probability and need not prove with certainty that the alleged negligence caused the injury. The court further explained that juries are permitted to draw reasonable inferences from expert testimony, particularly where those opinions are grounded in the applicable standard of care and institutional policies.

Central to the court’s analysis was the plaintiffs’ “chain of command” theory. Their experts opined that the hospital’s policies required staff to escalate significant clinical concerns and that, had this process been followed, it would have triggered further physician review, additional imaging, and ultimately an earlier surgical decompression. The experts further testified, to a reasonable degree of medical probability, that earlier intervention would have resulted in a greater than twenty-five percent chance of improved recovery. The court held that these interconnected opinions, taken together, were sufficient to permit a jury to infer causation without resorting to impermissible speculation.

In reaching this conclusion, the court distinguished prior cases in which expert testimony was excluded as speculative because it relied on unsupported assumptions or mere possibilities. Here, the experts’ opinions were tied to documented hospital policies, the patient’s clinical condition, and established standards of care. As a result, any perceived weaknesses or contingencies in the experts’ reasoning went to the weight of the testimony rather than its admissibility or sufficiency at the summary judgment stage.

The court also reaffirmed that questions of proximate cause are typically issues for the jury, particularly where competing expert opinions or differing inferences exist. Even though the treating providers testified that additional intervention was not necessary and would not have altered the outcome, the court held that this conflicting evidence did not eliminate the factual dispute but instead underscored the need for jury resolution.

The decision carries important implications for insurers and healthcare providers. It confirms that plaintiffs may advance causation theories based on failures to follow escalation or “chain of command” procedures where supported by qualified expert testimony framed in terms of probability. It also highlights the potential liability significance of internal policies and procedures, which may serve as a foundation for both standard-of-care and causation opinions. Finally, the ruling underscores the limited availability of summary judgment in complex medical malpractice cases involving competing expert testimony, particularly where the dispute centers on how healthcare providers would have responded to alternative clinical actions.

In sum, Hernandez reinforces that West Virginia courts will allow juries to evaluate causation where experts connect alleged failures in hospital escalation procedures to patient harm through a reasonable, policy-based chain of events, even where the ultimate outcome cannot be predicted with certainty. If you have any questions regarding this decision or have any questions concerning insurance coverage matters, please contact a member of our Medical Malpractice Practice Group.