                               UNPUBLISHED

                   UNITED STATES COURT OF APPEALS
                       FOR THE FOURTH CIRCUIT


                               No. 12-1195


MARY   T.    LACLAIR,    Individually   and    as   Personal
Representative of the Estate of Cameron J. LaClair, Jr.,

                  Plaintiff – Appellant,


           v.


SUBURBAN HOSPITAL, INCORPORATED,

                  Defendant – Appellee,

           and

PHYSICAL THERAPY AND SPORTS MEDICINE BINH M. TRAN, P.T., INC.;
CATHERINE L. COELHO, M.P.T., f/k/a Catherine Chamberlain;
SUBURBAN HOSPITAL FOUNDATION, INC.; SUBURBAN HOSPITAL HEALTHCARE
SYSTEM, INC.,

                 Defendants.



Appeal from the United States District Court for the District of
Maryland, at Greenbelt.     Peter J. Messitte, Senior District
Judge. (8:10-cv-00896-PJM)


ARGUED:   January 31, 2013                   Decided:   April 15, 2013


Before TRAXLER, Chief Judge, and KEENAN, and THACKER, Circuit
Judges.


Affirmed by unpublished per curiam opinion.
ARGUED: Patrick Michael Regan, REGAN ZAMBRI LONG & BERTRAM,
Washington, D.C., for Appellant.     Michael E. von Diezelski,
ADELMAN, SHEFF & SMITH, LLC, Annapolis, Maryland, for Appellee.
ON BRIEF: Jacqueline T. Colclough, REGAN ZAMBRI LONG & BERTRAM,
Washington, D.C., for Appellant.


Unpublished opinions are not binding precedent in this circuit.




                                2
PER CURIAM:

            Mary      T.    LaClair,           individually          and     as     personal

representative of the estate of her husband, Cameron J. LaClair,

Jr.,     appeals    the     district          court’s    order       finding       that      the

Appellee,    Suburban       Hospital,          Inc.   (“Suburban”),          and    Physical

Therapy    and     Sports   Medicine          (“PTSM”),     were     joint     tortfeasors

with respect to her husband’s injuries sustained while he was a

patient    at    Suburban.            Mr.     LaClair    was    first       injured       while

receiving physical therapy at PTSM.                     After undergoing surgery at

Suburban for that injury, he was further injured by the actions

of Suburban’s patient care technicians.                         Suburban asks us to

affirm    the    district       court’s        conclusion      that     it    is    a     joint

tortfeasor with PTSM because its actions did not constitute a

superseding cause of harm to Mr. LaClair.

            In unraveling this appeal, Maryland law directs us to

several provisions of the Restatement (Second) of Torts, each of

which is grounded in the idea that an intervening act is not a

superseding      cause     if    it    was     foreseeable      at    the    time       of   the

primary negligence.             Because the harm and injuries sustained at

Suburban were foreseeable consequences of the alleged negligence

of PTSM, Suburban’s actions were not a superseding cause of Mr.

LaClair’s       injuries.             Thus,     Suburban       and    PTSM        are     joint

tortfeasors, and we affirm.



                                               3
                                        I.

                                        A.

            On November 1, 2007, Mr. LaClair, a “vibrant former

CIA officer” in his mid-80s, J.A. 211, 1 sustained an injury while

receiving physical therapy at the PTSM facility (the “November 1

incident”).       He was attempting to secure himself in a piece of

exercise equipment and fell onto the floor, while his physical

therapist    had    stepped   away.         He   was    taken    by     ambulance     to

Suburban, where he was diagnosed with a cervical fracture and

dislocation.

            Dr.     Alexandros     Powers,       a     neurosurgeon,         performed

surgery    on     Mr.   LaClair   on   November        3,    2007.         The   surgery

entailed    Dr.    Powers   inserting    screws        and    rods    to    secure   Mr.

LaClair’s    spine.       According    to    Dr.     Powers,    the     surgery      “was

successful and proceeded without complication, and Mr. LaClair’s

prognosis at that time included a complete and total recovery

free from future cervical spine surgery.”                   J.A. 227.

            Dr. Powers stated that, as of the morning of November

6, 2007, Mr. LaClair was “recovered and was to be discharged

[from Suburban] to a rehabilitation facility” the next day, and

“there was no plan or expectation for subsequent cervical spine


     1
       Citations to the “J.A.” refer to the Joint Appendix filed
by the parties in this appeal.



                                        4
surgeries due to the success of the November 3 surgery[.]”                        J.A.

228.     Later on November 6, Mr. LaClair was transferred from ICU

to a regular room, and his catheter was removed.                          He needed

assistance using the bathroom, and, after Mrs. LaClair called

several    times    for    assistance,       two     patient    care     technicians

responded.    Mr. LaClair used the bathroom, and the patient care

technicians attempted to reposition him in his hospital bed.

            Although      Suburban    claims    Mrs.     LaClair      “resort[s]    to

hyperbole when referring to the conduct of November 6,” and the

patient     care    technicians,        while        perhaps    negligent,        were

“performing    their      normal     duties    when     they    were     aiding    Mr.

LaClair and repositioning him in bed,” Br. of Appellee 6, Mrs.

LaClair    views    the    incident     as     out     of    bounds    because     her

husband’s “head was violently pushed against the side rail of

the bed and he cried out in pain,” Br. of Appellant 4.                            Mrs.

LaClair testified that one of the patient care technicians was

“very rough,” explaining, “her motions were gross motions.                        They

weren’t careful motions.           And I thought, with somebody with a

broken neck, I think I’d be careful, but there was none of

that.”    J.A. 362-63 (the “November 6 incident”).

            There    is    no   dispute       that     Mr.     LaClair    sustained

additional injuries as a result of the November 6 incident.                        Dr.

Powers examined Mr. LaClair and found “a fracture of the C7

endplate, dislocation at C6/C7, dislodging of the screws placed

                                         5
in previous surgery, ligament damage and hemorrhage, nerve root

injury at the level of C7 and C8 and spinal cord injury.”                        J.A.

228.     He determined Mr. LaClair could no longer be discharged on

November      7     as   previously    scheduled,        but   rather,      needed    to

undergo an additional surgery on November 8.                    Mr. LaClair later

underwent a third surgery on February 6, 2008, at Georgetown

University Hospital.             He spent nearly five months hospitalized,

underwent        plaster    casting    of    his    cervical    spine,      developed

bedsores, and ultimately required a feeding tube.

              Mrs. LaClair presented evidence to the district court

that   as    a     result   of   the   November     6    incident,    Mr.    LaClair’s

medical bills totaled over $1.05 million and had a projected

future      cost    of   $900,000.        Another       physician    testified       that

absent the November 6 incident, his medical and rehabilitation

expenses would have been only $75,000 to $125,000.

                                            B.

              The    LaClairs     filed     two    separate    lawsuits:       first,

against PTSM for injuries stemming from the November 1 incident

(filed March 19, 2009) (the “PTSM lawsuit”), and second, against

Suburban for “separate and distinct” injuries stemming from the




                                            6
November     6     incident      (filed    April      15,    2010)     (the    “Suburban

lawsuit”). 2

             The PTSM lawsuit alleged that PTSM was responsible for

not only the injuries and damages incurred from the November 1

incident at PTSM’s facility, but also the injuries and damages

incurred from the November 6 incident at Suburban.                        See J.A. 48

(PTSM Complaint) (“Plaintiff was taken via ambulance to Suburban

[]   where       he    was     diagnosed    with      a     cervical    fracture      and

dislocation.          Plaintiff remained at Suburban until November 13,

2007, where he underwent two surgical procedures to repair his

cervical     fracture,         among   other     things.”).      During       discovery,

however,     Dr.      Powers    testified       on   January    5,   2010,     that   the

injuries stemming from the November 1 incident were “separate,

distinct, and divisible” from those sustained by the November 6

incident.      Id. at 229, 262-329.

             Subsequently, the LaClairs settled with PTSM for $1

million on March 5, 2010.              The Settlement Agreement specifically

recognized that the LaClairs would be pursuing separate claims

against Suburban, in connection with the November 6 incident

alone:


     2
       Mr. LaClair passed away on November 4, 2011, during the
course of this litigation.   Mrs. LaClair took over as personal
representative of his estate and was substituted as Plaintiff on
January 25, 2012.



                                            7
            In any future action against [Suburban], the
       plaintiffs agree to file a pre-trial motion with the
       court attempting to establish that the conduct of
       Suburban   .    .   .    constituted   superintervening
       negligence, and that these defendants are not joint
       tortfeasors with Suburban[.]      The purpose of this
       requirement is to obviate the need for [PTSM] to be
       named as [a] part[y] in any future litigation.

J.A. 179.

              The Suburban lawsuit, filed about six weeks after the

PTSM settlement, alleges that Mr. LaClair suffered injuries from

the November 6 incident that were separate and distinct from

those of the November 1 incident.                     This litigation settled on

May 31, 2011.         Pursuant to the Settlement Agreement between the

LaClairs and Suburban, however, the parties agreed to submit to

the district court the question of whether PTSM and Suburban

were    joint      tortfeasors       in   connection      with     the   November    6

incident, or whether those injuries were separate and distinct

such   that     Suburban     alone    would      be   liable.      Pursuant   to    the

Settlement         Agreement,    Suburban        agreed    to    make    an   initial

$650,000 payment to the LaClairs and further agreed to make an

additional payment of $600,000 in the event that the court found

PTSM and Suburban were not joint tortfeasors as to the November

6 incident.

                                            C.

              In    accord   with     the   PTSM      Settlement    Agreement,      the

LaClairs filed a pre-trial motion in the Suburban lawsuit on


                                            8
June 10, 2011, asking for judicial determination that Suburban

was a “successive tortfeasor” and therefore, not entitled to

joint tortfeasor credit for the November 6 incident.                  J.A. 140. 3

That same day, Suburban filed a memorandum explaining why it

should bear joint tortfeasor status with PTSM.

            The district court held a motions hearing on January

20,   2012,    and   decided   that        Suburban   was   indeed     a   joint

tortfeasor with PTSM such that Mrs. LaClair could not recover

additional damages.      The district court explained,

           [T]his was not highly extraordinary.    That this
      kind of thing could well have happened, even if the
      doctors did not see it or had seen it themselves. But
      a reasonable man knowing what they knew at the time
      would conclude that this sort of thing might happen.
      . . . I am persuaded by the fact that if what happens
      is reasonably close to the reason for the initial
      hospitalization, which is what this was, then you
      really do have a kind of a continuous flow here, and
      whatever negligence you have is really part and parcel
      of the initial negligence, too.
           And so I do conclude on these facts that the
      liability of the – the defendant, Suburban Hospital,
      is joined and not independent.

J.A. 771.      The court entered a short, one-page order to this

effect    on   January   24,   2012,        naming    Suburban   as    a   joint

tortfeasor “for reasons stated in the record.”              Id. at 797.       It

is from that order that Mrs. LaClair appeals.


      3
       Solely for purposes of the motion on the causation issue,
Suburban conceded that it was negligent on November 6, 2007, but
it continued to dispute all issues of causation and damages.



                                       9
                                    II.

           The parties submit that the district court’s order is

reviewed for clear error.          However, this analysis necessarily

involves deciding whether the district court correctly applied

Maryland law, and thus, we approach this appeal “by inspecting

factual findings for clear error and examining de novo the legal

conclusions derived from those facts.”           F.C. Wheat Mar. Corp. v.

United States, 663 F.3d 714, 723 (4th Cir. 2011).             A finding is

clearly erroneous when “although there is evidence to support

it, the reviewing court on the entire evidence is left with the

definite   and   firm   conviction        that     a   mistake     has     been

committed.”   Anderson v. City of Bessemer City, N.C., 470 U.S.

564, 573 (1985) (internal quotation marks omitted).

           Because   this   case    is    in     federal   court   based     on

diversity jurisdiction, the substantive law of the forum state —

in this case, Maryland — applies.              See Erie R.R. v. Tompkins,

304 U.S. 64, 78 (1938).     We should determine:

     how the [Court of Appeals of Maryland] would rule. If
     th[at]   [court]  has  spoken   neither  directly  nor
     indirectly on the particular issue before us, we are
     called upon to predict how that court would rule if
     presented with the issue.   In making that prediction,
     we may consider lower court opinions in [Maryland],
     the teachings of treatises, and the practices in other
     states.




                                    10
Twin City Fire Ins. Co. v. Ben Arnold-Sunbelt Beverage Co., 433

F.3d   365,    369   (4th   Cir.   2005)       (internal     quotation     marks    and

citations omitted).

                                        III.

                                         A.

              PTSM will not be jointly liable for the November 6

incident “if it appears highly extraordinary and unforeseeable

that   the    plaintiffs’     injuries     [on       November   6]    occurred   as   a

result of [PTSM’s] alleged tortious conduct.”                    Pittway Corp. v.

Collins, 973 A.2d 771, 788 (Md. 2009).                  Accordingly, PTSM avoids

liability for the November 6 incident “only if the intervening

negligent      act,”    i.e.,   Suburban’s           conduct,   “is    considered     a

superseding cause of the harm to” Mr. LaClair.                       Id. at 789; see

also Morgan v. Cohen, 523 A.2d 1003, 1004-05 (Md. 1987) (“It is

a general rule that a negligent actor is liable not only for

harm that he directly causes but also for any additional harm

resulting from normal efforts of third persons in rendering aid,

irrespective of whether such acts are done in a proper or a

negligent manner.”).

              Maryland courts (and federal district courts sitting

in diversity) have addressed the superseding cause issue with

varying      results.       Pittway   is       the    seminal   Maryland    case      on

superseding      cause,     providing      a     framework      for    analyzing      an

argument that an intervening act cuts off the liability of an

                                         11
original     tortfeasor.        The   Court   of   Appeals     of     Maryland

explained:

     The defendant is liable where the intervening causes,
     acts, or conditions were set in motion by his earlier
     negligence, or naturally induced by such wrongful act
     . . . or even it is generally held, if the intervening
     acts or conditions were of a nature, the happening of
     which was reasonably to have been anticipated[.]

Pittway,     973   A.2d    at   789   (internal    quotation        marks   and

alteration omitted).       Pittway recognizes that Section 442 of the

Restatement (Second) of Torts establishes the test applied in

Maryland courts for analyzing superseding cause:

     The following considerations are of             importance in
     determining   whether  an   intervening          force  is  a
     superseding cause of harm to another:

           (a)   the fact that its intervention brings
           about harm different in kind from that which
           would otherwise have resulted from the
           actor’s negligence;

           (b) the fact that its operation or the
           consequences thereof appear after the event
           to be extraordinary rather than normal in
           view of the circumstances existing at the
           time of its operation;

           (c) the fact that the intervening force is
           operating independently of any situation
           created by the actor’s negligence, or, on
           the other hand, is or is not a normal result
           of such a situation;

           (d) the fact that the operation of the
           intervening force is due to a third person’s
           act or his failure to act;

           (e) the fact that the intervening force is
           due to an act of a third person which is
           wrongful toward the other and as such

                                      12
             subjects   the    third    person      to    liability          to
             him;

             (f) the degree of culpability of a wrongful
             act of a third person which sets the
             intervening force in motion.

Restatement (Second) of Torts § 442 (1965); Pittway, 973 A.2d at

789.

                                        B.

             We conclude that the district court did not err in

finding that Suburban and PTSM were joint tortfeasors.

                                        1.

            The majority of the Restatement Section 442 factors

weigh in favor of a conclusion that Suburban and PTSM were joint

tortfeasors.

                                        a.

            As to factor (a), above, Mrs. LaClair attempts to show

that the injuries sustained on November 6 were “separate and

distinct”     from    those     sustained      on     November         1,     and    thus,

“different in kind.”          See Br. of Appellant 3-9.                 We first note

that   we    would    be   hard-pressed        to     find       a     case       regarding

subsequent    negligent       medical   care     in      which       there    was    not   a

“separate and distinct” injury after the injury caused by the

initial actor’s negligence.             This, alone, does not lead us to

the conclusion that the negligent medical care is a superseding

cause of harm.       See Underwood-Gary v. Mathews, 785 A.2d 708, 713


                                        13
(Md.   2001)       (“[W]hen         a     physician         negligently      treats           the

plaintiff’s        injuries,       the        physician     becomes       liable       to     the

plaintiff to the extent of the harm caused by the physician’s

negligence.         Thus,    the        physician’s        negligent      treatment         is   a

subsequent     tort    for     which          both   the   doctor    and    the     original

tortfeasor are jointly liable.” (internal citations omitted)).

In any event, the harm brought about by the November 6 incident

was not so different from the type of harm that is likely to

result from an 86-year-old man’s fall from a piece of exercise

equipment, even assuming, as Mrs. LaClair would have us do, that

a   severe    spinal        cord        injury       resulted      from    Mr.     LaClair’s

repositioning in his bed.                 For these reasons, factor (a) weighs

in favor of Suburban.

                                                b.

             In addressing factor (b), the Restatement directs us

to look to Restatement (Second) of Torts § 435(2), Comments (c)

and (d).      Comment (c) provides, in part, “Where it appears to

the court in retrospect that it is highly extraordinary that an

intervening cause has come into operation, the court may declare

such a force to be a superseding cause.”                           Restatement (Second)

of Torts § 435(2) cmt. c (1965).                     Comment (d) provides, in part,

“The   court’s      judgment        as    to     whether     the    harm    is     a    highly

extraordinary       result     is       made     after     the   event     with    the       full

knowledge     of    all     that        has    happened.         This     includes          those

                                                14
surroundings of which at the time the actor knew nothing but

which the course of events discloses to the court.”                  Id. cmt. d.

Comment (d) continues:

       [The court] also follows the effects of the actor’s
       negligence as it passes from phase to phase until it
       results in harm to the plaintiff.     In advance, the
       actor may not have any reason to expect that any
       outside force would subsequently operate and change
       the whole course of events from that which it would
       have taken but for its intervention.   None the less,
       the court, knowing that such a force has intervened,
       may   see    nothing extraordinary   either   in  its
       intervention or in the effect which it has upon the
       further development of the injurious results of the
       defendant’s conduct.   This is particularly important
       where the intervening force is supplied by the act of
       a human being . . . , which is itself a reaction to
       the stimulus of a situation for which the actor is
       responsible.

Id.

              Mrs.      LaClair          presents   testimony      from      three

neurosurgeons        that    the    “application      of    [the   patient    care

technicians’] force to the body of an elderly, post-operative

cervical spine patient . . . had never before been witnessed or

known     to     them       in     all     their    years    of    practice      as

Neurosurgeons[.]”           Br. of Appellant 27 (citing J.A. 190, 222,

229).    However, as explained by Comment (d) above, PTSM may have

had no reason to expect that Mr. LaClair would be injured by

being repositioned in his hospital bed, but the proper way to

view    the    situation     is    after-the-fact:     “knowing    that   such   a




                                            15
force has intervened.”           Restatement (Second) Torts § 435 cmt. d

(emphasis added).

              For example, in Henley v. Prince George’s Cnty., the

Court of Appeals of Maryland explained the difference between

foreseeability when considering the existence of a duty and, as

here,       causation:        “Foreseeability       as     a        factor   in     the

determination of the existence of a duty involves a prospective

consideration of the facts existing at the time of the negligent

conduct.        Foreseeability       as    an    element       of   proximate     cause

permits a retrospective consideration of the total facts of the

occurrence[.]”         503 A.2d 1333, 1341 (Md. 1986) (emphases added).

Viewing the facts of this case retrospectively, there is “an

appropriate nexus” between the November 1 incident and injuries

and the November 6 incident and injuries such that it is “at

least   a    permissible       conclusion”       that    Mr.    LaClair’s    already-

injured spine would be further injured by being positioned into

a hospital bed.        Id. at 1342.

              Again,     we     agree     with    the     district       court     that

Suburban’s actions were not “so extraordinary as to bring about

a conclusion of separate intervening cause.”                        J.A. 766.     Thus,

factor (b) also weighs in favor of Suburban.




                                          16
                                      c.

            Considering     the     cross-referencing        set    forth    in

Restatement (Second) Section 442, factors (c), (e), and (f) 4 boil

down to the same core inquiries:               whether Suburban’s actions

were “a normal consequence of a situation created by the actor’s

negligent     conduct,” 5   and    whether    the   manner    in   which    the

intervening     act   was   done     was     “extraordinarily      negligent.”

Restatement (Second) Torts §§ 443, 447(c) (1965).

            First, clearly, Mr. LaClair would not have sustained

the injuries on November 6 if PTSM’s negligence had not put him

in the hospital in the first place. 6               And the district court



     4
       As to factor (d), the district court dismissed this factor
as irrelevant to the inquiry, but it only appeared to analyze
the “failure to act” portion of § 442(d).       See J.A. 767-68.
While this may have been legal error, even assuming factor (d)
weighs in favor of Mrs. LaClair, the balance of the factors
nonetheless weighs in favor of Suburban.
     5
       The comments to factor (c) explain that the “situation
created by the actor’s negligence” means any situation that the
original tortfeasor’s actions were a substantial factor in
bringing about.   See Restatement (Second) of Torts §§ 447(c),
442(c) cmt. d.
     6
       Indeed, the LaClairs themselves believed the November 6
incident to be a foreseeable consequence of the November 1
incident.   They recognized as much in their initial complaint
against PTSM, which sought to hold PTSM liable for “two surgical
procedures” at Suburban.      J.A. 48 (emphasis added).       In
addition,   on   July    12,   2009,   the   LaClairs   answered
interrogatories and listed the following as caused by the PTSM’s
negligence: admission to Suburban from November 1 to November
13, 2007; admission to the rehabilitation center from November
13 to November 30; admission to Georgetown University for
(Continued)
                                      17
found, “the act, . . . the putting back in bed is not itself

extraordinary.”            J.A.   767.        Mrs.        LaClair’s      attorney

agreed.     See id. at 709 (The Court: “[T]he objective anyway was

to put this man back in bed.        That’s not unforeseeable; correct?

Mr. Regan:      Yes.”).     The district court did not err in finding

that it is a “normal consequence,” (i.e., foreseeable) that a

cervical spine patient might sustain additional spinal injuries

at the hands of medical professionals.

            As to the manner in which the negligent act was done,

we should consider the injuries and the degree of culpability of

the   patient     care    technicians.      Even     if    the     patient     care

technicians were “very rough,” J.A. 362, that does not quite get

us to the level of “extraordinarily negligent.”                       Restatement

(Second) of Torts § 447(c).         Indeed, Maryland courts have held

that original tortfeasors are liable for more significant harm

inflicted          by         intervening            negligent            medical

professionals.       See    Underwood-Gary,   785     A.2d    at   713       (“[An]

original tortfeasor is liable for additional harm caused by a

treating     physician’s      improper      diagnosis        and     unnecessary

surgery[.]      This rule is based on the premise that the negligent

actor, by his or her conduct, has placed the plaintiff in a



surgery from February 5 to February 25, 2008; and home nursing
care from April 2008 to July 2009. See id. at 64-78.



                                     18
position of danger and should answer for the risks inherent in

treatment and rendering aid.” (citing Restatement (Second) of

Torts § 457 cmt. c, illus. 1)); Richards v. Freeman, 179 F.

Supp. 2d 556, 560-61 (D. Md. 2002) (where physicians negligently

performed surgeries that left car accident victim with a right

arterial    tear    in    her        heart,   finding      physicians    and    original

defendant    driver       to    be     “joint”     yet    “subsequent    tortfeasors”

under    Maryland’s       Uniform       Contribution        Among   Tort-Feasors      Act

(UCATA)); see also Morgan, 523 A.2d at 1008 (stating that under

the UCATA, an original tortfeasor and a negligent health care

provider could be considered concurrent tortfeasors concurring

in producing the additional harm).

            Kyte v. McMillion, 259 A.2d 532 (Md. 1969), cited by

Mrs. LaClair, does not change this result.                       There, a young woman

was involved in a car wreck due to a negligent driver, and she

was taken to the hospital and treated for broken bones.                               Upon

admission     to    the        hospital,       a   physician        ordered    a   blood

transfusion,        but        the     nurse       used     the     wrong      type    of

blood.      See id. at 533.               As a result of this mistake, the

plaintiff suffered “bleak prospects of future pregnancies” and

was     projected    to        have    “difficult         gestation    from    both    an

emotional and physical point of view.”                     Id.    The plaintiff filed

suit     against    the        hospital       first,      ultimately     reaching      an

agreement and signing a release as to damages stemming only from

                                              19
the blood transfusion.               See id. at 533-34.             Later, when the

plaintiff   filed     suit        against   the     allegedly     negligent     driver,

McMillion, the court held that McMillion was not included in the

release and thus, the damages awarded to the plaintiff from the

hospital should not be credited to McMillion.                     Id. at 543.

            Notably,        the    Maryland       Court    of   Special    Appeals   has

limited this case to its facts as “the Court [in Kyte] was

careful    to    point      out    that     the    injuries      [broken     bones   and

inability       to   have     children]       were        peculiarly      separate   and

divisible[.]”        Sullivan v. Miller, 337 A.2d 185, 191 (Md. Ct.

Spec. App. 1975).            Even the Kyte court itself declared, “It

should be understood . . . that the decision announced herein

goes no further than the unusual facts and circumstances of this

case.”    See Kyte, 259 A.2d at 543. 7

            Therefore, we cannot say that the negligence of the

patient care technicians, either in manner or consequence, was




     7
       In this appeal, Suburban also contends that the settlement
with PTSM already took into account the damages arising from the
November 6 incident, and points to the LaClairs’ answers to
interrogatories on July 12, 2009, in the PTSM lawsuit. See
supra, note 7.     However, while this argument may have some
merit, we do not rely on it because it appears that the LaClairs
shifted gears in the middle of their litigation with PTSM (and
after the interrogatory answers were filed) due to the testimony
of Dr. Powers. Moreover, reliance on this basis is unnecessary
given the weight of other factors in favor of Suburban.



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abnormal    or   extraordinary.              Thus,    factors    (c),     (e),    and   (f)

weigh in favor of Suburban.

                                             2.

            Examining the Restatement Section 442 factors does not

end   our   inquiry.          The    Court    of     Appeals    of   Maryland     further

explains that Section 447 of the Restatement (Second) of Torts

illuminates these factors:

        “The fact that an intervening act of a third person is
        negligent in itself or is done in a negligent manner
        does not make it a superseding cause of harm to
        another which the actor’s negligent conduct is a
        substantial factor in bringing about, if

            (a) the actor at the time of his negligent
            conduct should have realized that a third
            person might so act, or

            (b) a reasonable man knowing the situation
            existing when the act of the third person
            was done would not regard it as highly
            extraordinary that the third person had so
            acted, or

            (c)   the  intervening   act   is  a   normal
            consequence of a situation created by the
            actor’s conduct and the manner in which it
            is done is not extraordinarily negligent.”

Pittway, 973 A.2d at 789 (quoting Restatement (Second) of Torts

§   447).       Thus,    “a     superseding        cause   arises       primarily       when

unusual and extraordinary independent intervening negligent acts

occur    that    could    not       have   been    anticipated       by   the    original

tortfeasor.”             Id.        (internal        quotation       marks       omitted).

Therefore, courts should look to both the foreseeability of the


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harm suffered by the plaintiff, as well as the foreseeability of

the intervening act itself.          See id. at 792.

            Any   doubt     that    the    Restatement     Section   442    factors

weigh in favor of Suburban is resolved by an analysis of Section

447:   PTSM should have realized that an elderly man injured by a

fall from its own exercise equipment would have to go to the

hospital,    would      receive      medical       care,    and   may      possibly

experience negligent medical care there.               Mr. LaClair’s ultimate

injuries    and   the      manner    in    which    they    occurred    were    not

extraordinary,       nor      were        these    unfortunate       consequences

unforeseeable.

                                          IV.

            For   the      foregoing       reasons,   the    judgment      of   the

district court is

                                                                        AFFIRMED.




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