CHCA Bayshore, L.P.(as Successor in Interest to CHCA East Houston, L.P.) D/B/A East Houston Regional Medical Center and Pasadena Bayshore Hospital, Inc. (As Successor in Interest to Sunbelt Regional Medical Center, Inc.) v. Amy Ramos and Richard Ramos

Opinion issued July 19, 2012.

In The

Court of Appeals
For The

First District of Texas
————————————
NO. 01-11-00764-CV
———————————
CHCA BAYSHORE, L.P. D/B/A EAST HOUSTON REGIONAL MEDICAL
CENTER AND PASADENA BAYSHORE HOSPITAL, INC., Appellants
V.
AMY RAMOS AND RICHARD RAMOS, Appellees

On Appeal from the 234th District Court
Harris County, Texas
Trial Court Case No. 2010-49225

DISSENTING OPINION

Because the claim of appellees, Amy and Richard Ramos, against appellants,

CHCA Bayshore, L.P., doing business as East Houston Regional Medical Center,

and Pasadena Bayshore Hospital, Inc., for negligent infliction of emotional distress
resulting from the mishandling of the remains of their unborn child is not a claim

in which they seek to establish “medical liability,” i.e., a “health care liability

claim” as actually defined by the Texas Legislature, I respectfully dissent. See

TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(13) (Vernon 2011).

Under chapter 74 of the Texas Civil Practice and Remedies Code, which is

expressly entitled, “Medical Liability,” the Texas Legislature defines a “[h]ealth

care liability claim” as

[A] cause of action against a health care provider or physician for
treatment, lack of treatment, or other claimed departure from
accepted standards of medical care, or health care, or safety or
professional or administrative services directly related to health
care, which proximately results in injury to or death of a claimant,
whether the claimant’s claim or cause of action sounds in tort or
contract.

Id. § 74.001(a)(13) (emphasis added). The legislature further defines “health

care” as

[A]ny act or treatment performed or furnished, or that should have
been performed or furnished, by any health care provider for, to, or
on behalf of a patient during the patient’s medical care, treatment or
confinement.

Id. § 74.001(a)(10) (emphasis added).

In regard to the term “directly related,” the restrictive adjective “related” is

defined as “belonging to the same family, group, or type; connected” and

“associated with the specified item or process, esp. causally: income-related

2
benefits.” THE NEW OXFORD AMERICAN DICTIONARY 1437 (2001). The restrictive

adverb “directly” is defined as

In a direct manner or way. . . . 1. b. Straightforwardly; pointedly;
simply; plainly; correctly; rightly . . . . 4. Completely, absolutely,
entirely, exactly, precisely, just. . . .

THE COMPACT OXFORD ENGLISH DICTIONARY 439 (2nd ed. 1993). In short,

“directly” means “with nothing or no one between.” THE NEW OXFORD AMERICAN

DICTIONARY 483.

Accordingly, in assessing whether the claim of a plaintiff brought against a

physician or health care provider is a “health care liability claim,” as meant by the

Texas Legislature in chapter 74 as one seeking to establish actual “medical

liability,” a court must very simply determine whether the plaintiff’s cause of

action is one “for” a physician or health care provider’s

(1) “treatment,”

(2) “lack of treatment, or”

(3) “other claimed departure from accepted standards of”

(a) “medical care, or”

(b) “health care, or”

(c) “safety or professional or administrative services directly
related to health care.”

TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(13) (emphasis added). In regard

to “other claimed departure[s] from accepted standards” of “safety or professional
3
or administrative services,” the plaintiff’s cause of action, by the legislature’s

express definition, must specifically be “directly related” to the provision of

“health care,” i.e.:

(1) An “act or treatment”

(a) “performed or furnished, or”

(b) “that should have been performed or furnished,”

(2) “by any health care provider”

(3) “for, to, or on behalf of a patient”

(4) “during the patient’s”

(a) “medical care,”

(c) “treatment,” or

(c) “confinement.”

Id. § 74.001(a)(10) (emphasis added).

Here, the Ramoses’ cause of action for negligent infliction of emotional

distress for the mishandling of the remains of their unborn child, which actually

occurred after Mrs. Ramos had already received properly administered medical

treatment, is not one seeking to establish liability for a “medical” injury to either

the unborn child or to Mrs. Ramos as patients. Their claim does not concern

“treatment” or “lack of treatment.” The Ramoses are not seeking medical-liability

damages for a “claimed departure from accepted standards” of “medical care” or

4
“health care.” Nor, contrary to the majority’s opinion, are they asserting a claim

against appellants for their “departure from accepted standards” of “safety or

professional or administrative services directly related to health care.” See id.

§ 74.001(a)(13) (emphasis added). The Ramoses are not complaining about an

“act or treatment performed or furnished, or that should have been performed or

furnished, . . . for, to, or on behalf of a patient during the patient’s medical care,

treatment, or confinement.” See id. § 74.001(a)(10) (emphasis added). Thus,

their cause of action for the mishandling of their unborn child’s remains is not

“directly related” to the provision of health care to either the mother or the unborn

child. Their cause of action simply does not fall within the Texas Legislature’s

definition of a “health care liability claim.” The Ramoses are not at all seeking to

establish appellants’ medical liability for the negligent provision of “health care.”

They are seeking mental anguish damages because someone, after Mrs. Ramos had

received medical treatment, mixed up the remains of their unborn child with

another person’s toe.

Regardless of the plain language of the legislature’s definition of “health

care liability claim,” appellants assert that the Ramoses have sued them to establish

medical liability for a claimed departure from accepted standards of professional or

administrative services directly related to health care. In support of their assertion,

appellants rely upon Omaha Healthcare Center, L.L.C. v. Johnson, 344 S.W.3d

5
392, 394–95 (Tex. 2011) (holding that claim against nursing home regarding

patient’s death from spider bite “fell within the statutory definition of a health care

liability claim”), Yamada v. Friend, 335 S.W.3d 192, 196–98 (Tex. 2010) (holding

that claim against doctor for negligently advising water park regarding

defibrillators constituted health care liability claim), Marks v. St. Luke’s Episcopal

Hospital, 319 S.W.3d 658, 663–64 (Tex. 2010) (holding that claim against hospital

regarding patient’s fall caused by defective footboard on hospital bed constituted

health care liability claim), and Diversicare General Partner, Inc. v. Rubio, 185

S.W.3d 842, 849–55 (Tex. 2005) (holding that claim that hospital provided

inadequate supervision, leading to patient’s sexual assault by another patient,

constituted health care liability claim). Although appellants’ reliance on these

opinions is not entirely misplaced, the opinions are not controlling given the

unique allegations presented here. In the instant case, the alleged act of

negligence, i.e., the mishandling of the remains of the unborn child, occurred after

and not “during [a] patient’s medical care, treatment or confinement.” See TEX.

CIV. PRAC. & REM. CODE ANN. § 74.001(a)(10) (emphasis added). And the

Ramoses are not alleging an act of negligence regarding any testing done on the

remains.

6
 It is true that the Texas Supreme Court, rather than relying upon the express,

plain language of the legislature’s definition of “health care liability claim” as

outlined above, has instead established its own definition with a three-pronged test:

[A] health care liability claim consists of three elements. First, a
physician or health care provider must be the defendant. Second, the
suit must be about the patient’s treatment, lack of treatment or some
other departure from accepted standards of medical care or health care
or safety. And, third, the defendant’s act, omission, or other departure
must proximately cause the patient’s injury or death.

Marks, 319 S.W.3d at 662 (emphasis added).

The supreme court’s test is problematic1 given the fact that it makes no

reference to the restrictive adjective “related” with the more restrictive adverb

“directly,” i.e., “with nothing . . . between.” Instead, the supreme court more

generally states that anything that could be described to be “about” “safety”

qualifies as a health care liability claim.

Moreover, the supreme court’s definition of “health care liability claim,”

consisting of “three elements,” does not take into account the specific language
1
Former Texas Court of Criminal Appeals Presiding Judge John F. Onion warned
long ago about fashioning such tests:

We do not need another three-prong test, a two-step analysis or a
multi-stage standard in our decisional law. There are enough of
those now to decorate a Christmas tree.

Ex Parte Williams, 704 S.W.2d 773, 785 (Tex. Crim. App. 1986) (Onion, P.J.,
concurring in part and dissenting in part). His warning seems particularly
pertinent when it comes to construing the plain language actually used in our
constitution and statutes.

7
actually used by the legislature in its definition of “health care,” which includes an

“act” performed or furnished, or that should have been performed or furnished, by

a health care provider “for, to, or on behalf of a patient during the patient’s

medical care, treatment, or confinement.” TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.001(a)(10) (emphasis added). Such an “act,” in regard to a plaintiff’s cause of

action for “medical liability” for a claimed departure from accepted standards of

“safety or professional or administrative services directly related to health care,”

would necessarily include medical testing and diagnostic services, the collection

and proper dissemination of the patient’s status and test results and pertinent

information, and, in regard to a patient who is a danger to himself, proper restraint

or confinement of the patient for his safety. These services would constitute an

“act” by a health care provider “for, to, or on behalf of a patient during the

patient’s medical care, treatment, or confinement.” See id. (emphasis added).

Such an “act” would not include routine facility pest control, janitorial services,

general maintenance of items like the footboard of a hospital bed, or security and

safety services not “directly related to health care.”

The Texas Legislature has, through its choice of plain language, manifested

its intent that chapter 74 of the Texas Civil Practice and Remedies Code apply only

to causes of action in which a plaintiff is seeking to establish actual and real

“medical liability,” as the statute itself is entitled. Such a cause of action must

8
really be one for an injury or death proximately caused by a health care provider or

physician’s actual

(1) “treatment,”

(2) “lack of treatment, or”

(3) “other claimed departure from accepted standards of”

(a) “medical care, or”

(b) “health care, or”

(c) “safety or professional or administrative services directly
related to health care.”

Id. § 74.001(a)(13) (emphasis added).

Regardless, consistent with its previous holdings in Diversicare and its

progeny, a majority of the Texas Supreme Court has recently held that “the safety

component of [health care liability claims] need not be directly related to the

provision of health care.” Tex. West Oaks Hosp. v. Williams, No. 10-0603, 2012

WL 2476807, at *11 (Tex. June 29, 2012) (emphasis added). In explaining the

basis of this extraordinary holding, the court asserts that the phrase “directly

related to health care” only modifies the terms immediately before it, i.e.,

“professional or administrative services.” Id. at *10–11. Thus, it concludes that

the phrase “directly related to health care” does not modify the word “safety.” Id.

at *11. Respectfully, as revealed above, the premise—the sole foundation—of the

court’s conclusion is objectively false.
9
 In order to reasonably conclude that the phrase “directly related to health

care” does not modify the word “safety,” one has to read the word “safety” as if it

were in a clause separate and apart from the clause “or safety or professional or

administrative services directly related to health care . . . .” The only way that one

might possibly read section 74.001(13) as does the majority of the supreme court

would be if the legislature had included a comma directly after the word “safety,”

intentionally separating it from the rest of the clause in which it is actually

included. And this the legislature did not do. As revealed above, a plain reading

of the section, as it is actually written, reveals that the legislature did not at all

intend to separate the word “safety” from the clause “or safety or professional or

administrative services directly related to health care . . . .” By the use of its plain

language in one clause, the legislature intended that the words “services directly

related to health care” modify the words “safety,” “professional,” and

“administrative.” If it had intended otherwise, it would not have included all of

these words in the same clause.

Accordingly, in order to constitute a “health care liability claim” as defined

by the Texas Legislature, a cause of action must be (1) “for treatment,” (2) for

“lack of treatment,” (3) for “other claimed departures from accepted standards of

medical care,” (4) for “other claimed departures from accepted standards of . . .

health care,” or (5) for “other claimed departures from accepted standards of”

10
safety services, professional services, or administrative services “directly related to

health care.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(13) (emphasis

added). In other words, contrary to the supreme court’s reading of the statute and

recent holding, the Texas Legislature has expressly provided that all claims to

establish “medical liability,” defined as “health care liability claim[s],” must be for

claims “directly related to health care.” See id.

As has been noted before by several members of the supreme court, its

construction and application of the legislature’s definition of “health care liability

claim” is in fact at odds with the express and plain language actually used by

legislature in defining the term. See Williams, 2012 WL 2476807, at *19–22

(Lehrmann, J., dissenting; joined by JJ. Medina and Willett); Johnson, 344 S.W.3d

at 396–99 (Lehrmann, J., dissenting; joined by J. Medina); Marks, 319 S.W.3d at

674–86 (Jefferson, C.J., concurring in part and dissenting part; joined by JJ. Green,

Guzman, and Lehrmann); Id. at 686–87 (Guzman, J., dissenting); Diversicare, 185

S.W.3d 842, 861-67 (O’Neill, J. dissenting; joined by JJ. Brister and Green). As

illustrated in these dissenting opinions, at least six of the current members of the

Texas Supreme Court have, at some time or another, disagreed with a majority of

the court’s construction and application of the term “health care liability claim.”

Nevertheless, the supreme court’s opinions, no matter how erroneous,

controversial, or divided that they may be, constitute binding precedent. And there

11
is a “strong presumption” against overruling precedent. Gutierrez v. Collins, 583

S.W.2d 312, 317 (Tex. 1979). Absent compelling reasons, courts should avoid

overturning their opinions because “the legitimacy of the judiciary rests in large

part upon a stable and predictable decision making process”; without adherence to

precedent, no question of law would ever be considered resolved. Weiner v.

Wasson, 900 S.W.2d 316, 320 (Tex. 1995).

However, compelling reasons to overturn precedent do exist in limited

circumstances, such as when the preceding decision itself is incorrect or

unconstitutional, there is conflicting precedent, the decision has been undercut by

the passage of time, the precedent creates inconsistency and confusion, or the

decision consistently creates unjust results. See Hammock v. State, 46 S.W.3d 889,

892–93 (Tex. Crim. App. 2001); see also In re Columbia Med. Ctr. Of Las

Colinas, Subsidiary, L.P., 290 S.W.3d 204, 218 (Tex. 2009) (O’Neill, J.,

dissenting); Bowman Biscuit Co. v. Hines, 151 Tex. 370, 376, 251 S.W.2d 153,

155 (1952) (Garwood, J., dissenting).

Here, there are indeed compelling reasons for the Texas Supreme Court to

overrule Diversicare and its progeny. First, and most important, as outlined above,

the supreme court’s definition of “health care liability claim” is at odds with the

Texas Legislature’s actual definition; thus, it is objectively incorrect. Chief Justice

Jefferson has noted that, as the supreme court itself has “often explained,”

12
 Courts must take statutes as they find them. More than that, they
should be willing to take them as they find them. They should search
out carefully the intendment of a statute, giving full effect to all of its
terms. But they must find its intent in its language, and not elsewhere.
They are not the law-making body. They are not responsible for
omissions in legislation. They are responsible for a true and fair
interpretation of the written law. It must be an interpretation which
expresses only the will of the makers of the law, not forced nor
strained, but simply such as the words of the law in their plain sense
fairly sanction and will clearly sustain.

Diversicare, 185 S.W.3d at 860 (Jefferson, C.J., concurring in part and dissenting

in part) (quoting Simmons v. Arnim, 110 Tex. 309, 220 S.W. 66, 70 (Tex. 1920),

quoted in St. Luke’s Episcopal Hosp. v. Agbor, 952 S.W.2d 503, 505 (Tex. 1997),

RepublicBank Dallas, N.A. v. Interkal, Inc., 691 S.W.2d 605, 607 (Tex. 1985), and

Tex. Highway Comm’n v. El Paso Bldg. & Constr. Trades Council, 149 Tex. 457,

468, 234 S.W.2d 857, 863 (1950)). Straightforward statutory construction ensures

that everyone is able “to rely on the plain language of a statute to mean what it

says.” Fitzgerald v. Advanced Spine Fixation Sys., 996 S.W.2d 864, 866 (Tex.

1999). However, when courts “abandon the plain meaning of words,” their

“statutory construction rests upon insecure and obscure foundations at best.” State

v. Jackson, 376 S.W.2d 341, 346 (Tex. 1964) (quoting State Bd. of Ins. v. Betts,

158 Tex. 612, 615, 315 S.W.2d 279, 281 (1958)).

Second, as noted above, four of the five supreme court opinions addressing

the meaning and application of the terms “health care liability claim” and “health

care” have drawn well-reasoned dissents. In their dissent in Diversicare in 2005,
13
Justices O’Neill, Brister, and Green warned against too broad of an interpretation

of the definition of a “health care liability claim” and “sweep[ing] even ordinary

negligence claims into the ambit of [medical liability].” 185 S.W3d at 862–63

(O’Neill, J., dissenting; joined by JJ. Brister and Green). In 2010, Justice Guzman

further warned against “sweeping even simple negligence claims under the

umbrella of medical malpractice.” Marks, 319 S.W.3d at 686 (Guzman, J.,

concurring in part and dissenting part). She noted that the supreme court risked

“thwart[ing] the very purpose” of chapter 74, “which is to reduce the cost of

medical malpractice insurance in Texas so that patients can have increased access

to health care.” Id.

Recently, in Williams, Justices Lehrmann, Medina, and Willett warned that

the majority of the supreme court has created “[a] whole new world” by

misinterpreting the express language used by the legislature to define “health care

liability claim” as including claims not directly related to the provision of health

care. 2012 WL 2476807, at *18 (J. Lehrmann, dissenting; joined by JJ. Medina

and Willett). They noted that the court’s definition “is so broad that almost any

claim against a health care provider can now be deemed a health care liability

claim” even though the claim may not at all be one to establish medical liability.

Id. at *24. In response, the majority of the supreme court opined that the Williams

dissenters’ construction of the definition—requiring that a health care liability

14
claim actually be “directly related” to the provision of health care to establish

“medical liability”—is “nonsensical.” Id. at *10, 13–18. However, respectfully,

the court’s definition, when viewed objectively as illustrated above, does not

comport with reality.

Time has now proven beyond all doubt that the dissenters were right—the

definition of “health care liability claim” as used by the supreme court in

Diversicare and its progeny has swallowed up virtually every cause of action to be

made against a physician or health care provider no matter how far removed it may

be from the actual provision of health care for, to, or on behalf of a patient during

the patient’s medical care, treatment, or confinement. See id. at *18 (Lehrmann, J.,

dissenting) (noting that supreme court’s holding that “employee’s claims against

his employer for providing an unsafe workplace and inadequate training are health

care liability claims” reveals that “‘[a] whole new world [of health care liability

claims], hinted by opinions in the last few years, is here.’”) (quoting In re McAllen

Med. Ctr., Inc., 275 S.W.3d 458, 470 (Tex. 2008) (Wainwright, J., dissenting)); see

also Johnson, 344 S.W.3d at 396 (Lehrmann, J., dissenting) (“In holding that

inadequate pest control [constitutes] a health care safety violation, the Court

essentially declares that all injuries in a health care setting are subject to chapter

74, without explicitly saying so. As a result of the Court’s holding, any patient

injured in a hospital will be required to file an expert report even though the injury

15
is entirely unrelated to the delivery of health care services. If it had been the

Legislature’s intent to subject all claims against health care providers to the statute,

‘it would have defined a “health care liability claim” to be any claim against a

physician or health care provider in a medical or health care setting.’”) (quoting

Drewery v. Adventist Health Sys./Tex., Inc., 344 S.W.3d 498, 503 & n.4 (Tex.

App.—Austin 2011, pet. filed)).

Third, the Texas Supreme Court’s definition of “health care liability claim”

is not only at odds with the Texas Legislature’s actual definition, it has necessarily

proven unworkable, resulting in inconsistency, confusion in its application, and

more litigation.

Finally, as illustrated by the above dissenting opinions, the application of the

supreme court’s definition of what constitutes a “health care liability claim” has

consistently created manifestly unjust results. Legitimate, ordinary, and simple

negligence and premises-liability claims, not at all related to the provision of health

care, have been dismissed simply because the plaintiffs did not hire an “expert” to

write a report detailing what would be quite obvious to lay persons. See Johnson,

344 S.W.3d at 396 (J. Lehrmann, dissenting) (“In holding that a spider bite in a

nursing home [constitutes] a health care liability claim for which an expert report is

required, the Court reaches a result that is contrary to the Legislature’s intent,

belies common sense, and contorts the role of experts in health care litigation.”).

16
The bottom line is that the supreme court’s objectively incorrect definition of

“health care liability claim” is being used as a “gotcha” to dismiss ordinary and

simple negligence and premises-liability claims that, as alleged, are not frivolous

and have merit.

In other words, although an “expert” report in ordinary negligence and

premises-liability cases made against physicians or health care providers is not at

all necessary to evaluate whether a plaintiff’s claim is frivolous, the plaintiff, given

the supreme court’s definition, must nevertheless hire an “expert” to write a report

and then provide the meaningless report to defense counsel for the sole purpose of

avoiding the dismissal of the lawsuit. The requirement of such a meaningless act

truly places form over substance, belittles the practice of law, and serves only to

undermine the Rule of Law. It certainly does not serve to uphold the integrity and

legitimacy of our judicial institutions. See Weiner, 900 S.W.2d at 320.

Accordingly, I respectfully request that the Texas Supreme Court overrule

Diversicare and its progeny, adopt the Texas Legislature’s actual definitions of

“health care liability claim” and “health care” as quoted and outlined above, and

put an end to the manifestly unjust results that necessarily flow from requiring

plaintiffs to serve upon defense counsel a meaningless “expert” report for ordinary

negligence and premises-liability claims made against physicians and health care

providers.

17
 Even if the supreme court declines to overrule Diversicare and its progeny,

the Ramoses’ factually-specific claim for negligent infliction of emotional distress

is not controlled by Diversicare and its progeny. Contrary to the majority’s

opinion, the trial court’s order denying appellants’ motion to dismiss the Ramoses’

claim should be affirmed because the Ramoses are not asserting a claim against

appellants for their departure from accepted standards of professional or

administrative services directly related to health care. See TEX. CIV. PRAC. &

REM. CODE ANN. § 74.001(a)(13) (emphasis added). They simply are not

complaining about an “act or treatment performed or furnished, or that should have

been performed or furnished, . . . for, to, or on behalf of a patient during the

patient’s medical care, treatment, or confinement.” See id. § 74.001(a)(10)

(emphasis added).

Terry Jennings
Justice

Panel consists of Justices Jennings, Massengale, and Huddle.

Justice Jennings, dissenting.

18