                  IN THE COURT OF APPEALS OF TENNESSEE
                             AT KNOXVILLE
                                     May 24, 2016 Session

             CATHERINE CRIGHT v. TIJUAN OVERLY, M.D. ET AL.

                      Appeal from the Circuit Court for Knox County
                          No. 2-9-14    William T. Ailor, Judge


                No. E2015-01215-COA-R3-CV-FILED-OCTOBER 17, 2016
                         _________________________________

Catherine Cright‟s husband passed away on August 4, 2008, due to complications arising
from a stent placement procedure. Cright1 subsequently filed a medical malpractice
action2 against Dr. Tijuan Overly, Knoxville Cardiovascular Group, P.C. (KCG), and
University Health Systems, Inc. (UHS) (collectively the defendants). Cright nonsuited
that action in April 2013 three days into trial. She later sent a notice letter to each of the
defendants advising them of her intent to refile her action. She neglected to attach a
HIPAA-compliant medical authorization. Thereafter, Cright refiled her complaint
against the defendants, all of whom filed a motion to dismiss because of her failure to
comply with the HIPAA-compliant authorization requirement set forth in Tenn. Code
Ann. § 29-26-121(a) (Supp. 2009). The trial court granted the motions. Cright appeals.
We affirm.

           Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Circuit Court
                               Affirmed; Case Remanded

CHARLES D. SUSANO, JR., J., delivered the opinion of the court, in which THOMAS R.
FRIERSON, II, and KENNY ARMSTRONG, JJ., joined.

Donna K. Holt, Knoxville, Tennessee, for the appellant, Catherine Cright.

James H. London, Heidi A. Barcus, and J. Spencer Fair, Knoxville, Tennessee, for the
appellees, Tjuan L. Overly, M.D., and Knoxville Cardiovascular Group, P.C., dba
University Cardiology.


       1
           When we refer to “Cright,” we are referring to Mrs. Cright.
       2
         Now referred to by statute as a “health care liability action.” Since this case was filed
when the term “medical malpractice” was still in effect, we will use that phrase throughout this
opinion.
Stephen C. Daves, Jeffrey R. Thompson, and Gina C. Sarli, Knoxville, Tennessee, for the
appellee, University Health System, Inc., doing business as University of Tennessee
Medical Center.

                                        OPINION

                                             I.

       On July 28, 2008, Dr. Overly performed a stent placement procedure on the
deceased at the University of Tennessee Medical Center (UTMC). During the course of
the procedure, Dr. Overly used the deceased‟s femoral artery as an access route when
placing the stent. The deceased was kept overnight for observation. The following
morning, Dr. Overly visited with the deceased and wrote the order for his discharge.
However, the discharge was delayed and eventually cancelled after the deceased
experienced blood pressure fluctuations, had groin pain, and was unable to urinate. Dr.
Overly was notified of these changes and told the attending nurse to give the deceased
medication and a fluid bolus. In addition, Dr. Overly requested that the deceased see a
urologist. As a result, the Chief Resident of Urology at UTMC examined the deceased
and ordered bladder fluid measurements and, depending on those measurements,
placement of a catheter. Once the fluid measurements were taken, a nurse inserted a
catheter into the deceased. Thereafter, a junior urology resident administered a
cystoscopy, which revealed that the deceased had a bladder mass. The catheter was
reinserted.

       The deceased continued experiencing pain, and the junior urology resident
prescribed pain medication. The Chief Resident of Urology was contacted and ordered a
CT scan of the deceased‟s abdomen to determine if his bladder had been injured during
the cystoscopy. The CT scan revealed that the deceased had suffered a retroperitoneal
hemorrhage. A nurse ordered a complete blood count (CBC) for the deceased. A few
hours later, Dr. Overly checked on the deceased and ordered (1) more pain medication;
(2) the administration of fluids; (3) the transfusion of two units of blood; and (4) repeated
CBCs on a monitoring schedule. Roughly one hour later, the junior urology resident
visited the deceased to check on his catheter. After examining him, the junior resident
gave the nurse a verbal order to obtain a consultation from vascular surgery regarding a
possible retroperitoneal bleed. A short time later, the deceased was rushed to surgery.
Prior to surgery, however, he experienced cardiac arrest and had to be revived. After
being revived, the deceased underwent an operation to repair his femoral artery, which
was punctured. Though the artery was repaired, the deceased suffered complications and
experienced organ damage. He was put on a respirator and eventually died on August 4,
2008.

                                             2
       On August 3, 2009, Cright mailed written notice of a potential medical
malpractice claim, along with a HIPAA-compliant authorization, to each of the
defendants. On November 30, 2009, Cright filed the original complaint in this action.
The case ultimately proceeded to trial on April 15, 2013. However, three days into trial,
Cright moved for a voluntary nonsuit, which the trial court granted on May 3, 2013.

       On May 30, 2013, Cright again sent notice of a potential medical malpractice
claim to the defendants. A HIPAA-compliant authorization was not included with the
notices. Rather, the notice letters that the defendants received included the following
paragraph:

             Medical records of the entire UT Hospital admission at issue
             have previously been provided to you, as well as any other
             records you wished to obtain pursuant to an Agreed RAS
             Order entered in the original Knox County Circuit Court
             action under docket No. 2-5923-09.

(Bold font in original omitted.) Cright subsequently filed a new complaint against the
defendants on January 3, 2014.

      Dr. Overly and KCG filed a motion to dismiss, which raised the following
argument:

             [Cright] has failed to comply with the requirements of Tenn.
             Code Ann. § 29-26-121 (the “Notice Statute”) by: 1) failing
             to attach a medical authorization to the “notice letter” prior to
             filing the [c]omplaint in the instant action, required by Tenn.
             Code Ann. § 29-26-121(a)(2)(E); and 2) failing to
             demonstrate compliance with the Notice Statute by providing
             a certificate of mailing with the “notice letter” as required by
             Tenn. Code Ann. § 29-26-121(a)(4).

One week later, UHS filed a motion to dismiss, which also contended that Cright had
failed “to comply with the provisions of Tenn. Code Ann. § 29-26-121” by neglecting to
“submit a HIPAA-compliant medical records authorization with the pre-suit notice
letter.” Thereafter, Cright filed a motion to amend her complaint to include an affidavit
from her attorney, which stated, in pertinent part, as follows:




                                            3
               A [HIPAA]-compliant medical authorization was not
               attached, because the parties had previously entered an
               [a]greed [o]rder that the RAS3 service and record ordering
               procedure was to be the exclusive means for obtaining [the
               deceased‟s] medical records, to the exclusion of any medical
               authorizations previously provided. Pursuant to the RAS
               Order all [d]efendants had already received complete copies
               of all records in the possession of the other, as well as
               extensive records from many other health care providers
               predating the events at issue by many years. The complete
               record of the hospitalization at issue in this case was marked
               as an exhibit to Dr. Overly‟s deposition in 2010, was used
               throughout discovery of all other witnesses, and was marked
               for identification as an exhibit in the trial of this case that
               began in 2013.         Since [the deceased] died in that
               hospitalization, there are no additional “updated” medical
               records to be obtained from any [d]efendant.

(Footnote added.)

      The trial court conducted a hearing regarding the motions to dismiss and stated as
follows:

               It‟s clear from the record that there was no medical
               authorization filed with this case when it was refiled, that
               there was also no affidavit of pre-suit notice, there was also
               no certificate of mailing, which is required by [Tenn. Code
               Ann.§ 29-26-121]. Defendants agree that they used the same
               records that were used in the previous case to prepare for this
               case. However, the HIPAA authorization states clearly that it
               expires one year after it is signed. The RAS order states that
               it will be used in that particular case. It doesn‟t say that it can
               be used in any case, this case having a different docket
               number than the first one, even though the parties are the
               same.

               The Court is of the opinion that under the current state of the
               law, the motions to dismiss should be granted, the case will

      3
          Records Acquisition Services.

                                               4
              be dismissed without prejudice, as to all but the direct claims
              of negligence against [d]efendant [UHS] for its failure to
              supervise, monitor and enforce its own established policies,
              which will proceed under ordinary negligence.

The court subsequently entered an order dismissing all medical malpractice claims
against the defendants while also preserving a general negligence claim by Cright against
UHS. Prior to entry of the order, UHS filed an amended motion to dismiss and/or motion
to reconsider, contending that (1) all of Cright‟s claims against UHS were grounded
purely in medical malpractice and (2) any claim for simple negligence would be barred
by the statute of limitations. Cright filed a motion to reconsider the trial court‟s dismissal
of her medical malpractice claims. As the basis for this motion, Cright contended that (1)
the defendants could not demonstrate any actual prejudice stemming from her omission
of a HIPAA-compliant medical authorization; (2) the RAS order from the initial lawsuit
was still in effect; (3) the defendants did not plead noncompliance with the pre-suit notice
provisions contained in Tenn. Code Ann. § 29-26-121 in their answers, thereby waiving
that defense; and (4) Cright‟s motion for a mistrial in the initial action should have been
granted, which would have made a second pre-suit notice to the defendants unnecessary.

       The trial court held a hearing on all outstanding motions. With respect to UHS‟s
amended motion to dismiss and/or motion to reconsider, the trial court stated the
following:

              This Court has considered [UHS‟s] motion to reconsider with
              regard to [the] ruling that the case against [UHS] is a
              negligence case. The amended complaint from the 2009 case,
              which was the complaint filed in 2013, does make allegations
              with reference to policies and procedures that [Cright] claims
              were violated, and [Cright‟s] claims are system failures on the
              part of [UHS]. The Court is asked to determine whether this
              is a case that is a [medical malpractice] act case or a
              negligence case instead. [UHS] claims that there are not two
              separate torts committed toward [the deceased], and that
              policies not followed does not move the case from outside the
              realm of [medical malpractice] to straight negligence. The
              Court in making that determination has looked at the [medical
              malpractice] act, which from the sheer name of it is [medical
              malpractice], which deals with the care of patients. From
              everything that the Court has reviewed, the Court is of the
              opinion that the systems failure that [Cright] complains of

                                              5
            deals with the care of patients and as a result that this is a
            [medical malpractice] claim.

            And as a result, the Court is amending its ruling and
            dismissing the complaint against [UHS], based on a finding
            that no part of the claims alleged against UHS sound in
            ordinary negligence.

As for Cright‟s motion to reconsider the dismissal of the medical malpractice claims
against the defendants, the trial court stated as follows:

            Based on a review of everything again, the Court understands
            [Cright‟s] dissatisfaction with the Court‟s previous ruling.
            The Court recognizes that the original suit being filed in May
            of 2009, voluntarily being dismissed or non-suited, with the
            order entered May 3 of 2013, the action was refiled on
            January 3 of 2014, which again was within one year of the
            non-suit. [Cright] again contends that [she] complied with
            the notice requirement of [Tenn. Code Ann. §] 29-26-121,
            based on the notice of the original suit in 2009, and also that
            the HIPAA compliant release was provided in the original
            2009 lawsuit. [Cright] on May 30, 2013[,] did give notice of
            her intention to refile this claim, which was sent by certified
            mail, return receipt. There was not the affidavit that is
            required by the statute that was filed. And as [Cright‟s
            attorney] admitted she prepared it, she just doesn‟t know what
            happened to it. The Court does not think that that, in and of
            itself, would be sufficient to dismiss this lawsuit.

            And the Court has reviewed the Hinkle [v. Kindred Hosp.,
            No. M2010-02499-COA-R3-CV, 2012 WL 3799215 (Tenn.
            Ct. App., filed Aug. 31, 2012)] and Foster [v. Chiles, 467
            S.W.3d 911 (Tenn. 2015)] decisions and believes that
            originally when [Cright] filed her suit in May of 2013 that
            [she] was of the opinion that she was complying with the law
            at the time. However, there was not a HIPAA compliant
            release supplied, even though [Cright] states that the medical
            records have been previously provided to the defendants in
            addition to other records pursuant to an agreed RAS order
            that was entered in the original Knox County Circuit Court

                                          6
             action. The court is still of the opinion that based on
             everything, that the Court ruled correctly based on the state of
             the law when the Court reviewed the case, and therefore, the
             Court overrules [Cright‟s] motion.

                                           II.

      Cright raises the following issues, as quoted verbatim from her brief:

             Was it error to dismiss [Cright‟s] claims for failure to provide
             a [HIPAA] authorization when the actual records had been
             produced, were no longer under [HIPAA] protection, and
             were freely used by the defendants to mount their defenses to
             this action?

             If there was no substantial compliance, is [Cright] entitled to
             a waiver, given the circumstances of this case?

             Was it error to dismiss all claims, when [the defendants] are
             liable under ordinary negligence?

(Numbering in original omitted.) Dr. Overly and KCG have raised an additional issue, as
quoted verbatim from their brief:

             Whether the motions in limine discussed by [Cright] are
             reviewable at this time.

(Numbering and italics in original omitted.)

                                           III.

        On the issue of a Tenn. R. Civ. P. 12.02(6) motion to dismiss, we are guided by
the following principles as articulated by the Supreme Court:

              A Rule 12.02(6) motion challenges only the legal sufficiency
             of the complaint, not the strength of the plaintiff‟s proof or
             evidence. Highwoods Props., Inc. v. City of Memphis, 297
             S.W.3d 695, 700 (Tenn. 2009); Willis v. Tenn. Dep't of
             Corr., 113 S.W.3d 706, 710 (Tenn. 2003); Bell ex rel. Snyder
             v. Icard, Merrill, Cullis, Timm, Furen & Ginsburg,

                                               7
P.A., 986 S.W.2d 550, 554 (Tenn. 1999); Sanders v.
Vinson, 558 S.W.2d 838, 840 (Tenn. 1977)). The resolution
of a 12.02(6) motion to dismiss is determined by an
examination of the pleadings alone. Leggett v. Duke Energy
Corp., 308 S.W.3d 843, 851 (Tenn. 2010); Trau-Med of Am.,
Inc. v. Allstate Ins. Co., 71 S.W.3d 691, 696 (Tenn. 2002);
Cook ex rel. Uithoven v. Spinnaker’s of Rivergate, Inc., 878
S.W.2d 934, 938 (Tenn. 1994); Cornpropst v. Sloan, 528
S.W.2d 188, 190 (Tenn. 1975). A defendant who files a
motion to dismiss “ „admits the truth of all of the relevant and
material allegations contained in the complaint, but . . .
asserts that the allegations fail to establish a cause of
action.‟ ” Brown v. Tenn. Title Loans, Inc., 328 S.W.3d
850, 854 (Tenn. 2010) (quoting Freeman Indus., LLC v.
Eastman Chem. Co., 172 S.W.3d 512, 516 (Tenn. 2005)); see
Edwards v. Allen, 216 S.W.3d 278, 284 (Tenn. 2007); White
v. Revco Disc. Drug Ctrs., Inc., 33 S.W.3d 713, 718 (Tenn.
2000); Holloway v. Putnam Cnty., 534 S.W.2d 292, 296
(Tenn. 1976).

In considering a motion to dismiss, courts “ „must construe
the complaint liberally, presuming all factual allegations to be
true and giving the plaintiff the benefit of all reasonable
inferences.‟ ” Tigg v. Pirelli Tire Corp., 232 S.W.3d 28, 31-
32 (Tenn. 2007) (quoting Trau-Med, 71 S.W.3d at 696); see
Leach v. Taylor, 124 S.W.3d 87, 92-93 (Tenn. 2004); Stein v.
Davidson Hotel Co., 945 S.W.2d 714, 716 (Tenn. 1997);
Bellar v. Baptist Hosp., Inc., 559 S.W.2d 788, 790 (Tenn.
1978); see also City of Brentwood v. Metro. Bd. of Zoning
Appeals, 149 S.W.3d 49, 54 (Tenn. Ct. App. 2004) (holding
that courts “must construe the complaint liberally in favor of
the plaintiff by . . . giving the plaintiff the benefit of all the
inferences that can be reasonably drawn from the pleaded
facts”). A trial court should grant a motion to dismiss “only
when it appears that the plaintiff can prove no set of facts in
support of the claim that would entitle the plaintiff to relief.”
Crews v. Buckman Labs. Int’l, Inc., 78 S.W.3d 852, 857
(Tenn. 2002); see Lanier v. Rains, 229 S.W.3d 656, 660
(Tenn. 2007); Doe v. Sundquist, 2 S.W.3d 919, 922 (Tenn.
1999); Pemberton v. Am. Distilled Spirits Co., 664 S.W.2d

                                8
             690, 691 (Tenn. 1984); Fuerst v. Methodist Hosp. S., 566
             S.W.2d 847, 848 (Tenn. 1978); Ladd v. Roane Hosiery,
             Inc., 556 S.W.2d 758, 759–60 (Tenn. 1977). We review the
             trial court‟s legal conclusions regarding the adequacy of the
             complaint de novo. Brown, 328 S.W.3d at 855; Stein, 945
             S.W.2d at 716.

Webb v. Nashville Area Habitat for Humanity, Inc., 346 S.W.3d 422, 426 (Tenn. 2011).

      This case also involves a statutory interpretation, which is a question of law that
we also review de novo. Pratcher v. Methodist Healthcare Memphis Hosp., 407 S.W.3d
727, 734 (Tenn. 2013). The Supreme Court has previously explained our standard of
review:

             When interpreting a statute, our role is to ascertain and
             effectuate the legislature‟s intent. Sullivan ex rel. Hightower
             v. Edwards Oil Co., 141 S.W.3d 544, 547 (Tenn. 2004). We
             must not broaden or restrict a statute‟s intended meaning.
             Garrison v. Blickford, 377 S.W.3d 659, 663 (Tenn. 2012)
             (quoting U.S. Bank, N.A. v. Tenn. Farmers Mut. Ins. Co.,
             277 S.W.3d 381, 386 (Tenn. 2009)). We also presume that
             the legislature intended to give each word of the statute its
             full effect. In re Estate of Trigg, 368 S.W.3d 483, 490
             (Tenn. 2012). When statutory language is unambiguous, we
             accord the language its plain meaning and ordinary usage.
             Glassman, Edwards, Wyatt, Tuttle & Cox, P.C. v. Wade, 404
             S.W.3d 464, 467 (Tenn. 2013). Where the statutory language
             is ambiguous, however, we consider the overall statutory
             scheme, the legislative history, and other sources. Mills v.
             Fulmarque, Inc., 360 S.W.3d 362, 368 (Tenn. 2012);
             Colonial Pipeline Co. v. Morgan, 263 S.W.3d 827, 836
             (Tenn. 2008).

Stevens ex rel. Stevens v. Hickman Cmty. Health Care Servs., Inc., 418 S.W.3d 547,
553 (Tenn. 2013).



                                          IV.



                                           9
                                              A.

      Tenn. Code Ann. § 29-26-121(a) (Supp. 2009) provides as follows:

              (1) Any person, or that person‟s authorized agent, asserting a
              potential claim for medical malpractice shall give written
              notice of the potential claim to each health care provider that
              will be a named defendant at least sixty (60) days before the
              filing of a complaint based upon medical malpractice in any
              court of this state.

              (2) The notice shall include:

                                      *       *     *


              (E) A HIPAA compliant medical authorization permitting the
              provider receiving the notice to obtain complete medical
              records from each other provider being sent a notice.

(Emphasis added.) The Supreme Court has previously explained why a HIPAA-
compliant medical authorization is required in the pre-suit notice to defendants in medical
malpractice actions:

              [T]he purpose of Tenn. Code Ann. § 29-26-121(a)(2)(E) is
              not to provide defendants with notice of a potential claim.
              Instead, Tenn. Code Ann. § 29-26-121(a)(2)(E) serves to
              equip defendants with the actual means to evaluate the
              substantive merits of a plaintiff‟s claim by enabling early
              access to a plaintiff‟s medical records. Because HIPAA itself
              prohibits medical providers from using or disclosing a
              plaintiff’s medical records without a fully compliant
              authorization form, it is a threshold requirement of the statute
              that the plaintiff’s medical authorization must be sufficient to
              enable defendants to obtain and review a plaintiff’s relevant
              medical records. As a result, plaintiffs cannot satisfy Tenn.
              Code Ann. § 29-26-121(a)(2)(E) by simply notifying
              defendants that a healthcare liability claim may be
              forthcoming.



                                              10
Stevens, 418 S.W.3d at 555 (emphasis added; internal citations omitted).

        In the present action, it is undisputed that Cright failed to provide a HIPAA-
compliant medical authorization. Rather, Cright, when she served the defendants with
pre-suit notice of her intent to refile her action, referenced a 2010 agreed RAS order from
the initial action. Nevertheless, “[a] plaintiff‟s less-than-perfect compliance with Tenn.
Code Ann. § 29-26-121(a)(2)(E) . . . should not derail a healthcare liability claim.” Id.
Rather, “a plaintiff must substantially comply, rather than strictly comply, with the
requirements of Tenn. Code Ann. § 29-26-121(a)(2)(E).” Id. When determining whether
a plaintiff has substantially complied, “a reviewing court should consider the extent and
significance of the plaintiff‟s errors and omissions and whether the defendant was
prejudiced by the plaintiff‟s noncompliance.” Id. at 556.

        The 2010 agreed RAS order contained the following statement regarding how long
it would remain valid: “This Order . . . shall remain in effect until the final disposition of
the above-styled lawsuit.” (Emphasis added.) Three days into trial, Cright moved for a
voluntary dismissal of the original action, which the court granted on May 3, 2013. As a
result, the 2010 agreed RAS order ceased to remain effective on that date. Thus, the
2010 agreed RAS order that Cright is attempting to rely upon had been invalid for several
months prior to the filing of this case in January 2014. Despite this fact, Cright contends
in her brief that “[t]he record in this case demonstrates that no prejudice resulted to the
defendants from the claimed deficiency of the notice provided” because the defendants
had already accessed the deceased‟s medical records in the prior case. We disagree. “In
limited circumstances, HIPAA provides for the use or disclosure of medical records
without specific authorization „by the covered entity to defend itself in a legal action.‟ ”
Roberts v. Prill, No. E2013-02202-COA-R3-CV, 2014 WL 2921930, at *6 (Tenn. Ct.
App., filed June 26, 2014) (quoting 45 C.F.R. § 164.508(a)(2)(i)(C)) (emphasis in
original). “However, HIPAA generally provides that a covered entity may not „use or
disclose protected health information without‟ valid authorization.” Roberts, 2014 WL
2921930, at *6 (quoting 45 C.F.R. § 164.508(a)(1)) (emphasis in original). The case now
before us is not covered by one of the narrow exceptions that allows for use of a patient‟s
medical records without authorization. Ultimately, while the defendants had access to the
deceased‟s medical records after obtaining them during the initial action, they were not
entitled to use those records in the present case in the absence of a HIPAA-compliant
medical authorization entitling them to do so. With the substantial-compliance analysis
from Stevens in mind, we find that Cright‟s failure to provide a medical authorization in
this case is significant and would necessarily prejudice the defendants if this case
proceeded further.

                                             B.

                                             11
        Cright contends that, even if her pre-suit notice to defendants was deficient, she is
still entitled to a waiver for extraordinary cause. The Supreme Court has previously
discussed “extraordinary cause” in the context of Tenn. Code Ann. § 29-26-121:

              The statute does not define “extraordinary cause,” and the
              statute‟s legislative history does not indicate that the
              legislature intended to assign a meaning to that phrase other
              than its plain and ordinary meaning. “Extraordinary” is
              commonly defined as “going far beyond the ordinary degree,
              measure, limit, etc.; very unusual, exceptional; remarkable.”
              Webster’s New World Dictionary of the American Language,
              516 (1966); see also State v. Vikre, 356 S.W.2d 802, 804
              ([N.C. Ct. App.] 1987) (adopting dictionary definition of
              extraordinary cause as “going beyond what is usual, regular,
              common, or customary . . . of, relating to, or having the
              nature of an occurrence or risk of a kind other than what
              ordinary experience or prudence would foresee.” One legal
              scholar, commenting on Tennessee Code Annotated sections
              29-26-121 and 122, has noted that possible examples of
              “extraordinary cause” might include “illness of the plaintiff‟s
              lawyer, a death in that lawyer‟s immediate family, [or] illness
              or death of the plaintiff‟s expert in the days before the filing
              became necessary.”

Myers v. AMISUB (SFH), Inc., 382 S.W.3d 300, 310-11 (Tenn. 2012). In her brief,
Cright offers multiple explanations for why she believes extraordinary cause should be
found in this case. First, she argues that “[w]hile this is a refiled action after a non-suit,
and technically a „new‟ action, there were circumstances existing in this case that gave all
parties notice that the non-suit was not „the conclusion‟ of the controversy.” Second, she
asserts that “[t]he state of the law applicable at relevant times should be considered.”
Third, Cright claims that the 2010 agreed “RAS [o]rder reflected the past agreement of
the parties that took the records outside of the use of further HIP[A]A authorizations
altogether.” Fourth, she maintains that the defendants “had waived the opportunity to
raise the issue of any failure to comply with the notice statute because it was not properly
pled in either of their [a]nswers.” Fifth, Cright states that to “dismiss this case for a
HIP[A]A authorization when the defendants have freely utilized the records in their
defense of [Cright‟s] claims is against all logic and would be a severe injustice to . . .
Cright.” Finally, she notes the “judicial preference to have cases decided on their
merits.”

                                             12
       Regardless of how Cright wants to characterize the present action, it is still
separate and distinct from the prior action she voluntarily non-suited in 2013. While the
defendants may have anticipated that Cright would refile her medical malpractice claim,
such speculation is of no consequence and does not absolve Cright of the need to provide
a medical authorization in compliance with Tenn. Code Ann. § 29-26-121(a), a statutory
requirement that existed before both the initial action and the present action.
Furthermore, as we have already explained, the 2010 agreed RAS order is functionally
irrelevant to the present action as it ceased to remain in effect once the trial court granted
Cright a voluntary non-suit on May 30, 2013. Though Cright insists that this prior agreed
order should have some bearing on our extraordinary cause analysis, we disagree with
this assertion. There is nothing “extraordinary” in the facts of this case as that term is
defined in Myers, 382 S.W.3d at 310-11.

         Cright readily acknowledges that the defendants, by failing to include a defense in
their answers, did not waive their defense of failure to comply with the notice statute.
She even cites to an opinion authored by this Court supporting the defendants‟ position
on this issue. See Blankenship v. Anesthesiology Consultants Exch., P.C., 446 S.W.3d
757, 760 (Tenn. Ct. App. 2014) (“Because Tenn. R. Civ. P. 12.08 provides that
Defendant could have presented this defense even as late as „at the trial on the merits,‟ we
cannot find that Defendant waived the defense of failure to state a claim upon which
relief can be granted simply because Defendant engaged in discovery prior to filing its
motion. We note that Defendant gives an explanation as to its delay in raising this
defense. We, however, need not address this explanation as the clear language of Tenn.
R. Civ. P. 12.08 resolves this waiver issue.”). Despite that unambiguous holding, Cright
still insists that “there must be some consequence [for] a defendant[‟s] failure to properly
plead such a „threshold‟ issue.” Ultimately, Tenn. R. Civ. P. 12.08 is clear on this issue,
and we need not entertain Cright‟s request, which would run counter to established law.

        Finally, we are not persuaded by Cright‟s contention that dismissal because of the
absence of a medical authorization would be “against all logic” and would be a “severe
injustice” to her. Tenn. Code Ann. § 29-26-121(a) clearly sets forth what is required
when a party provides pre-suit notice of an impending medical malpractice claim. Cright
failed to comply with a significant part of those requirements, instead choosing to rely
upon a 2010 agreed RAS order from the prior action in place of a HIPAA-compliant
medical authorization. This failure by Cright is substantial given the fact that the agreed
order ceased to be effective several months before the present action was filed and would
not entitle the defendants to use of the deceased‟s medical records in this action. In our
view, it would be “against all logic” to hold that a long-invalid order is now operable and
sufficient to stand in place of a medical authorization that is required by statute. While

                                             13
we do not favor procedural dismissals, accepting Cright‟s argument would render a very
strained interpretation of Tenn. Code Ann. § 29-26-121(a) that would thwart the
Legislature‟s intent. Accordingly, we affirm the trial court‟s decision refusing to grant
Cright a waiver for her noncompliance due to extraordinary cause.

                                               C.

       Cright goes on to contend that the trial court erred by dismissing all claims against
the defendants because she believes they are still liable under ordinary negligence.
Because the cause of this action originated prior to the 2011 amendments to the
Tennessee Medical Malpractice Act, the common law at that time is our guide to
distinguishing a medical malpractice claim from a claim sounding in ordinary
negligence.4 As all parties to this appeal note in their briefs, Estate of French v.
Stratford House, 333 S.W.3d 546 (Tenn. 2011), provides instructive insights into
delineating the difference between these two types of claims. Specifically, the Supreme
Court stated the following:

               Whether claims are characterized as ordinary negligence or
               medical malpractice affects the nature of the litigation. A
               medical malpractice claimant must establish the statutory
               elements through the testimony of an expert who meets the
               qualifications set forth in Tennessee Code Annotated section
               29-26-115(b). See Barkes v. River Park Hosp., Inc., 328
               S.W.3d 829, 833 (Tenn. 2010) (“Unless the negligence is
               obvious and readily understandable by an average layperson,
               expert testimony will be required to demonstrate the
               applicable standard of care and breach of that standard.”);
               Seavers v. Methodist Med. Ctr. of Oak Ridge, 9 S.W.3d 86,
               92 (Tenn. 1999) (“Expert testimony is required in medical
               malpractice cases to assist and to educate the trier of fact

       4
          “The General Assembly amended the Medical Malpractice Act in 2011 to modify the
definition of „health care liability action‟ to include „claims against state or a political
subdivision thereof.‟ Act of May 20, 2011, ch. 510 § 8, 2011 Tenn. Pub. Acts. 510, 1506
(codified as amended at Tenn. Code Ann. § 29-26-101(a) (2012)). The 2011 amended became
effective on October 1, 2011[.] . . . The 2011 amendment does not apply retroactively[.] See In
re D.A.H., 142 S.W.3d 267, 273-74 (Tenn. 2004) (explaining that all statutes are presumed to
apply prospectively unless otherwise stated but procedural or remedial statutes that do not affect
vested rights may apply retrospectively).” Cunningham v. Williamson Cnty. Hosp. Dist., 405
S.W.3d 41, 45 n.2 (Tenn. 2013).

                                               14
unless the alleged malpractice lies within the common
knowledge of lay persons.”). . . .

Because medical malpractice is a category of negligence, the
distinction between medical malpractice and negligence
claims is subtle; there is no rigid analytical line separating the
two causes of action. Draper v. Westerfield, 181 S.W.3d
283, 290 (Tenn. 2005); Gunter [v. Memphis Hous. Auth.],
121 S.W.3d [636,] 639 [(Tenn. 2003)] (quoting Weiner v.
Lenox Hill Hosp., 673 N.E.2d 914, 916 ([N.Y.] 1996)). In
Gunter, a suit involving allegations of negligence by a
laboratory with regard to a paternity test, this Court observed
that the distinguishing feature between ordinary negligence
and medical malpractice cases is whether “a plaintiff‟s claim
is for injuries resulting from negligent medical treatment.”
121 S.W.3d at 640. We embraced the standard set forth by
the New York courts for distinguishing an ordinary
negligence claim from one based upon medical malpractice:

        [W]hen a claim alleges negligent conduct which
        constitutes or bears a substantial relationship to
        the rendition of medical treatment by a medical
        professional, the medical malpractice statute is
        applicable. Conversely, when the conduct
        alleged is not substantially related to the
        rendition of medical treatment by a medical
        professional, the medical malpractice statute
        does not apply.

Id. at 641. . . .

Our Court of Appeals has further defined the standard set
forth in Gunter and reaffirmed in Draper:

        Medical malpractice cases typically involve a
        medical diagnosis, treatment or other scientific
        matters. The distinction between ordinary
        negligence and malpractice turns on whether the
        acts or omissions complained of involve a
        matter of medical science or art requiring

                               15
                    specialized skills not ordinarily possessed by
                    lay persons or whether the conduct complained
                    of can instead be assessed on the basis of
                    common everyday experiences of the trier of
                    fact.

             Peete v. Shelby Cnty. Health Care Corp., 938 S.W.2d 693,
             696 (Tenn. Ct. App. 1996) (quoting Graniger v. Methodist
             Hosp. Healthcare Sys., No. 02A01-9309-CV-00201, 1994
             WL 496781, at *3 (Tenn. Ct. App.[, filed] Sept. 9, 1994)). If
             the alleged breach of the duty of care set forth in the
             complaint is one that was based upon medical art or science,
             training, or expertise, then it is a claim for medical
             malpractice. If, however, the act or omission complained of
             is one that requires no specialized skills, and could be
             assessed by the trier of fact based on ordinary everyday
             experiences, then the claim sounds in ordinary negligence.
             See Conley v. Life Care Ctrs. of Am., Inc., 236 S.W.3d 713,
             729-30 (Tenn. Ct. App. 2007).

Estate of French, 333 S.W.3d at 555-56 (emphasis added).

        Cright alleged in her complaint that Dr. Overly and KCG were negligent by doing
the following:

             (a) failing to adequately follow-up with examinations and
             appropriate testing when symptoms of the known
             complication of internal bleeding manifested on July 29,
             2008;

             (b) failing to timely recognize the symptoms of internal
             bleeding and obtain appropriate consultations and/or
             treatment;

             (c) failing to adequately communicate with other physicians
             and/or nurses regarding [the deceased‟s] condition;

             (d) failing to follow up on the results of the [u]rology consult,
             or give report of the status of [the deceased‟s] condition to the
             on-call cardiology resident, or to request the cardiology

                                            16
             resident on call to follow up and monitor [the deceased‟s]
             condition through the night;

             (e) failing to timely obtain a consult from a vascular surgeon
             to examine and assist in the monitoring of [the deceased]
             once the signs and symptoms of internal bleeding manifested
             on June 29, 2008, or an emergen[cy] consult on June 30,
             2008[;]

             (f) failing to recognize the significance of and/or properly
             treat [the deceased‟s] prolonged, severe and deepening shock
             at 8:00am, even after the results of the CT scan were known
             to Dr. Overly and he claims to have recognized that [the
             deceased] was in hypovolemic shock from blood loss, and
             had been in shock for many hours.

All of these claims against Dr. Overly and KCG pertain to examining the deceased for
signs of internal bleeding and his subsequent treatment. It appears quite clear to us that
analyzing each of these allegations would require specialized medical knowledge that a
lay person would not ordinarily possess. In our view, a regular person without an
advanced medical background would hardly be able to assess symptoms of internal
bleeding, much less determine the severity of the deceased‟s condition or decide whether
treatment was rendered in a timely manner. Accordingly, all of these claims sound in
medical malpractice, and the trial court was correct in designating them as such. As for
UHS, Cright alleged the following negligent acts:

             (a) failing to recognize the symptoms of internal bleeding and
             request examination of [the deceased] by appropriate
             physicians;

             (b) failing to adequately monitor [the deceased‟s] condition
             and make appropriate entries in his chart for reference by
             other nurses and physicians;

             (c) failing to adequately report [the deceased‟s] condition to
             appropriate physicians;

             (d) failing to seek direction from appropriate health care
             providers;



                                           17
             (e) failing to communicate to appropriate physicians the
             seriousness and/or severity of [the deceased‟s] condition;

             (f) failing to timely communicate to appropriate physicians
             the results reported on the CT scan of July 29, 2008;

             (g) failing to promptly carry out the orders that were given the
             morning of June 30;

             (h) failing to timely request the vascular surgery consultation
             on the morning of July 30, 2008;

             (i) failing to seek assistance from appropriate personnel if
             nursing reports to physicians regarding [the deceased‟s]
             condition were not receiving adequate physician response;

             (j) failing to follow its own policies, procedures, and the
             standards of acceptable practice it has set for itself and
             advertises to the public [that it] will apply to patients treated
             at its facility[;]

             (k) failing to have proper systems in place to insure: proper
             training of nurses caring for patients at risk for internal
             bleeding; adequate communication of critical results on
             imaging studies to appropriate physicians; and proper
             documentation and communication of critical blood pressure
             readings to physicians.

As with Cright‟s allegations against Dr. Overly and KCG, these claims against UHS also
sound in medical malpractice. Recognizing symptoms of internal bleeding, accurately
updating the deceased‟s medical chart, knowing what physicians should be contacted
about the deceased‟s condition, carrying out specific orders to treat the deceased, and
realizing when the deceased should have obtained a vascular surgery consultation are all
tasks that an ordinary person would be unable to accomplish without an advanced
medical background. Similarly, we believe that knowing whether hospital procedures,
training, documentation, and communication were proper would be beyond the scope of
an ordinary person‟s basic understanding. Accordingly, the trial court was correct in
determining that these claims fit within the framework of medical malpractice as opposed
to negligence.



                                            18
                                           D.

       Lastly, Cright contends that two “motions in limine are ripe for review and should
be granted.” One of these motions sought to prevent any of the defendants from
“attempting to „shift blame‟ to any non-party in light of the fact that no defendant has
ever pled comparative fault.” The other aimed to stop “Dr. Overly and/or others [from]
present[ing] irrelevant testimony about how he correctly performed the stent procedure
the day before the negligence occurred.” Despite Cright‟s arguments, this issue has been
rendered moot based upon our decision to affirm the trial court‟s rulings as to as to (1)
Cright‟s failure to comply with the pre-suit notice provisions of Tenn. Code Ann. § 29-
26-121(a) and (2) the fact that all of her claims against the defendants sound in medical
malpractice. Accordingly, we decline to address the issue.

                                           V.

       The trial court‟s grant of the motions to dismiss is affirmed. Costs on appeal are
assessed to the appellant, Catherine Cright. This case is remanded, pursuant to applicable
law, for collection of costs assessed by the trial court.



                                                  _______________________________
                                                  CHARLES D. SUSANO, JR., JUDGE




                                           19
