LaCoste v. Pendleton Methodist Hospital, LLC and the Futility of the Coleman Factors
The most recent installment of the Louisiana Supreme Court’s interpretation of the Louisiana Medical Malpractice Act (LMMA), is LaCoste v. Pendleton Methodist Hospital, L.L.C. ___ So.2d. ____ (La. 9/5/07) 2007-CC-0008. In LaCoste, the Supreme Court, once again, narrowed the broad statutory definitions of “malpractice” and “healthcare” contained in the LMMA, and held that allegations of substandard care provided by a hospital in the wake of Hurricane Katrina did not fall within the ambit of the Act. The Court made this determination by utilizing its own “Coleman” factors, six criteria which the Court set out in the case of Coleman v. Deno, 01-1517 (La. 1/25/02), 813 So. 2d 303.
In LaCoste, a ventilator dependent patient, Althea LaCoste, was transported and admitted to Pendleton Memorial Methodist Hospital (Methodist) on August 28, 2005. Hurricane Katrina made landfall on August 29, 2005. Electrical power was lost, and Methodist’s emergency electrical generating system allegedly failed. The plaintiffs alleged that Ms. LaCoste’s ventilator became inoperable for lack of power. The plaintiffs further alleged that Methodist had an inadequate evacuation plan which contributed to Ms. LaCoste’s injuries and eventual death at the hospital.
The plaintiffs filed a Petition for Damages against Methodist alleging that the hospital committed negligent and intentional acts leading to the loss of electrical power and allowing flood waters to enter the hospital, all causing injury to and the death of Althea LaCoste.
Methodist filed an exception of prematurity because the plaintiffs filed suit in district court before submitting their claim to a medical review panel. The trial court denied the exception of prematurity finding that the plaintiffs’ claim did not sound in medical malpractice. The court found that the alleged negligent acts were directed to the alleged deficient design of the hospital. Methodist applied for supervisory writs to the Fourth Circuit Court of Appeal.
The Fourth Circuit Court of Appeal reversed the district court’s ruling and granted Methodist’s exception of prematurity. The Court of Appeal found that the issues regarding the hospital’s emergency generating equipment and evacuation were patient care issues that fell within the scope of the LMMA. The Court of Appeal found that the question of whether to evacuate a patient required consideration of the medical condition of the patient involved as to whether the transfer would likely result in better treatment or a transport causing injury. Further, the Court of Appeal found that the alleged failure of the hospital to have adequate emergency generator power was akin to the failure of a hospital to have necessary medical supplies to treat patients.
In reaching its conclusion, the Fourth Circuit relied on the LMMA’s definition of “medical malpractice” La.R.S. 40:1299.41(A)(8). The Fourth Circuit noted that the allegations in LaCoste directly affected the medical treatment of the patient. Accordingly, it sustained Methodist’s exceptions as to all allegations save those sounding in intentional tort.
The plaintiffs filed an application for supervisory writs to the Louisiana Supreme Court. In a 4-3 decision, the
Supreme Court characterized the plaintiffs’ petition as containing general tort allegations - not medical malpractice allegations. The majority opinion written by Chief Justice Calogero, analyzed the Coleman factors in concluding that the plaintiffs’ allegations sounded in general tort.
Likewise, the dissenting opinion written by Justice Knoll, analyzed the same five Coleman factors and reached the opposite conclusion that the plaintiffs’ allegations fell within the ambit of LMMA. The first Coleman factor is whether the particular wrong is “treatment related” or caused by a deviation of professional skill. The majority found that the plaintiffs’ allegations of misconduct did not relate to medical treatment, but instead related to the deficient design of the hospital. The three dissenting justices found that the application of the Coleman factors demonstrated that failure to provide a properly functioning life support system clearly sounded in malpractice as it was integral to the rendering of care and treatment by the healthcare provider to the patient.
The second Coleman factor is whether an expert medical opinion is required to determine whether the standard of care was breached. The majority rejected Methodist’s argument that expert medical evidence was necessary because emergency preparedness in the field of healthcare is vastly different from ordinary emergency preparedness. The majority held that proving a claim based on the complete inability to transfer a patient because of lack of emergency power, a poorly designed building, or inadequate protection from flood waters, did not require expert medical evidence. The dissent, however, found that medical experts were essential in determining the standard of care in implementing an emergency plan. Only physicians can issue transfer and acceptance orders, and determine the condition of a patient for transfer. The alleged negligence regarding transfer decisions and evacuation planning cannot likely be established without expert medical testimony.
The third Coleman factor is whether the pertinent act involved the assessment of a patient’s condition. The majority determined that engineers and administrators would not have needed to assess Ms. LaCoste’s medical condition in order to determine whether sufficient emergency power would be available or whether an evacuation should be implemented. The crux of Methodist’s argument that medical personnel needed to assess the patient’s condition in order to determine whether she should be admitted was irrelevant to the issue of the arrangements which the hospital had made before the storm.
On the other hand, the dissenting justices determined that the alleged wrongdoing inherently involved the medical assessment and evaluation of Ms. LaCoste’s condition. The patient’s condition could affect the decision to evacuate if certain emergency equipment, such as a back up ventilator, would be required. Ms. LaCoste’s initial assessment indicated the need for a ventilator, and it was the failure to provide a working ventilator which allegedly resulted in her death.
The fourth criteria of Coleman is whether the incident occurred in the context of a physician/patient relationship, or within the scope of activities which a hospital is licensed to perform. The majority noted that the alleged lack of sufficient emergency power, the building’s inadequate design and structure, and the failure to have a mandatory evacuation plan in place did not involve a physician/patient relationship within the meaning of the LMMA. The majority noted that there was no allegation in the petition that a medical decision by any physician or nurse resulted in the failure to transfer the patient.
The dissenting justices, however, rejected the plaintiffs’ contentions that the defective design of the hospital and the failure to plan for evacuation did not involve a physician/patient relationship. The dissent found that the transfer of a patient, especially one in need of critical care, is not conducted by an engineer, a design professional, or an administrator. Physicians alone are licensed to perform these functions and decisions. The dissenting justices found that the central issue in the case was Methodist’s alleged failure to provide adequate treatment and care which are activities that a hospital is licensed to perform.
The fifth Coleman factor is whether the injury would have occurred if the patient had not sought treatment. The court found this factor somewhat difficult to evaluate. While the majority noted that, in a general sense, any wrong that a patient suffers in a hospital would not have occurred if the patient had not entered the facility; all wrongs suffered by patients in these settings are not necessarily related to medical malpractice. The majority concluded that the wrongs as alleged in the petition were neither treatment related nor the result of a dereliction of professional medical skill.
The dissenting justices observed that if Ms. LaCoste had not been taken to the hospital for treatment of pneumonia and placed on a ventilator, she would not have been subject to the alleged failure of life saving care. The lack of power accelerated the condition for which Ms. LaCoste was admitted and sought treatment; thus, the alleged negligence directly affected her treatment and outcome. The dissenting justices found that this factor weighed well in favor of the defendant’s position.
The sixth Coleman factor was not considered by the Court. The Court of Appeal’s determination that the plaintiffs’ allegations of intentional tort need not be submitted to a medical review panel was undisputed.
In analyzing the Coleman factors, the four justices in the majority found that all five Coleman factors militated in favor of a general tort claim. The three dissenting justices found that all five factors weighed in favor of a medical malpractice claim.
A major drawback to strictly interpreting the Coleman factors (aside from limiting the broad statutory definitions of “malpractice” and “healthcare”), is that they are not useful in analyzing compound allegations, i.e., allegations that contain elements of medical malpractice, but set in the context of general tort negligence. Allegations which do not clearly constitute traditional concepts of malpractice, but which fall within the broad statutory definitions of the LMMA can be “spun” either way when analyzed under the Coleman factors. The proof that the Coleman factors lead to more confusion than guidance is the fact that, in LaCoste, four Louisiana Supreme Court justices found that the first five Coleman factors lead to the conclusion that the allegations sounded in general tort, while the three dissenting justices used those same five factors to find coverage under the LMMA.
As a practical matter, insurance carriers rarely offer general liability insurance policies to healthcare facilities which do not exclude patients from coverage. Decisions such as LaCoste have the potential to subject hospitals not only to uncapped damages but also to claims for which no insurance coverage is available.
It is the opinion of the authors that “medical malpractice” should be statutorily redefined. This was proposed in the Louisiana Legislature in House Bill No. 281, April 30, 2007, which stated, in part, as follows:
“Malpractice means any unintentional tort or any breach of contract based on health care or related services rendered, or which should have been rendered, by a health care provider to a patient, including the failure to render health care or related service timely and the handling of a patient, including transporting, monitoring, assisting, loading, and unloading of a patient, whether or not in the course of medical care or treatment…” (Emphasis added.)
Although this bill has not been enacted into law, it highlights the need for clarification of the scope of the LMMA. The authors suggest that unless the legislature acts to clarify the definitions and scope of the LMMA, courts will continue to use the Coleman factors to narrow the definition of “malpractice.” If this trend continues, hospitals will be increasingly faced with uncapped and uninsured exposure arising from alleged injuries to patients.
Mr. Luquet is a partner at Breazeale, Sachse & Wilson, practicing in the area of medical malpractice litigation. Ms. Toso is of counsel to Breazeale, Sachse & Wilson, practicing in the area of medical malpractice litigation.