James R. Snell v. Behavioral Health Connections, Inc. UHS of Timberlawn, Inc., Universal Health Services, Inc., and Heather Cawthon ( 2022 )

Affirmed and Opinion Filed December 5, 2022
In The
Court of Appeals
Fifth District of Texas at Dallas
No. 05-20-00915-CV
JAMES R. SNELL, Appellant
V.
BEHAVIORAL HEALTH CONNECTIONS, INC.,
UHS OF TIMBERLAWN, INC., UNIVERSAL HEALTH SERVICES, INC.,
AND HEATHER CAWTHON, Appellees
On Appeal from the 44th Judicial District Court
Dallas County, Texas
Trial Court Cause No. DC-19-15454
MEMORANDUM OPINION
Before Justices Myers, Molberg, and Garcia
Opinion by Justice Molberg
Appellant James R. Snell appeals a take-nothing judgment on his false
imprisonment, invasion of privacy, assault and battery, and DTPA1 claims against
appellees Behavioral Health Connections, Inc. (BHC), UHS of Timberlawn, Inc.
(Timberlawn), Universal Health Services, Inc. (UHS), and Heather Cawthon. Snell
argues the trial court erred by denying his motion for summary judgment as to
1
See TEX. BUS. & COM. CODE §§ 17.41–.63 (Deceptive Trade Practices Act (DTPA)).
liability on his false imprisonment claims and by dismissing his claims for failing to
serve an expert report under the Texas Medical Liability Act (TMLA). 2 For the
reasons that follow, we affirm the trial court’s take-nothing judgment in this
memorandum opinion. See TEX. R. APP. P. 47.4.
I. BACKGROUND3
According to Snell:
Early on the morning of December 9, 2018, [he] became verbally
active, seeming disoriented and confused while a pedestrian on a
residential street in his neighborhood, possibly due to side effects from
a prescription anti-inflammatory medication. Someone contacted
police[,] who called paramedics, [and who, in turn,] gave [him] a drug
that put him to sleep [and] took him to the emergency room at Baylor
Hospital in Dallas.
While at Baylor, Snell first met Cawthon, a licensed professional counselor.
Snell’s lawsuit concerns events that began with the hospital-room
conversation between Cawthon and Snell on December 9, 2018, and concluded with
Snell’s December 27, 2018 discharge from a mental health facility.
Snell claims during the seventeen-day period between those two dates, he was
illegally held and effectively “imprisoned” at the facility. He also claims he was
physically restrained and forcibly medicated on two of those dates.
On appeal, quoting his own pleading, Snell identified his principal claim as
this: “[Appellees], le[d] by UHS, engaged in an unconscionable course of conduct
2
See TEX. CIV. PRAC. & REM. CODE §§ 74.001–.507 (TMLA); id. § 74.351 (expert reports).
3
The facts are well known to the parties, and we do not recite them except as necessary “to advise the
parties of the court's decision and the basic reasons for it.” TEX. R. APP. P. 47.4.
–2–
. . . to first obtain [him] for detention . . . and then continued detaining him for
[seventeen] days, [fourteen] of them without even a semblance of legal right for
doing so.”
Thus, the heart of Snell’s lawsuit is the legality of appellees’ actions
surrounding his involuntary commitment, an issue largely controlled by Chapter 574
of the Mental Health Code,4 which Snell cites many times in his pleading.
Snell sued BHC, UHS, and Cawthon in September 2019, asserting claims for
false imprisonment, invasion of privacy, and assault and battery in connection with
the December 2018 events. His original petition alleged, in part:
As result of the illegal acts of [BHC, UHS, and Cawthon], [Snell] was
first labeled dangerous, then detained against his will for 17 days at a
mental health facility. For those 17 days, his right to regularly
communicate with associates, friends, and family was cut off. He was
treated as incompetent. He was confined inside a mental health ward
that resembled a prison, not a hospital.
[Snell] was humiliated and ridiculed, particularly for protesting that he
was being falsely imprisoned. He was assaulted and drugged. He
suffered physically and mentally. When he finally was released, it took
months for him to feel “normal” again. The memory and consequences
of his ordeal still reduce the quality of his daily life.
This case concerns the utter disregard for laws and procedures put in
place by the State of Texas that protect people from being wrongly
committed to mental health facilities against their will. This is a false
imprisonment, assault, and invasion of privacy case based on [BHC,
UHS, and Cawthon’s] violation of those laws.
4
See TEX. HEALTH & SAFETY CODE §§ 571.001–578.008 (Mental Health Code); id. §§ 574.001–.203
(Chapter 574, which addresses court-ordered mental health services).
–3–
In February 2020, Snell amended his petition, adding Timberlawn as a
defendant and adding a DTPA claim against all appellees. Snell’s amended petition
asserted the same four claims against all four appellees—false imprisonment,
invasion of privacy, assault and battery, and DTPA violations—all in connection
with the December 2018 events. In his amended petition, Snell claimed, for the
seventeen days between December 9, 2018, and December 27, 2018, appellees
“involuntarily detained [and] in effect imprisoned” him, “the first three days without
the requisite factual showing and for [fourteen] more days without legal authority of
any kind.”
In terms of the relationships between the parties, Snell’s amended petition
identified Cawthon as a licensed professional counselor and BHC employee,
Timberlawn as the owner of the mental health facility from which he was discharged,
UHS as the largest provider of facility-based mental health services in the United
States, and BHC and Timberlawn as wholly-owned UHS subsidiaries.
Each appellee answered. BHC, UHS, and Cawthon filed an answer on
October 18, 2019, and Timberlawn filing an answer on March 11, 2020.
In those answers, appellees generally denied Snell’s allegations, stated the
procedures and services performed were at all times and in all respects in conformity
with the applicable standard of care, identified appellees as healthcare providers as
–4–
defined by TMLA section 74.001(12),5 stated the case is subject to the TMLA, and
invoked the TMLA’s provisions.
On February 20, 2020, more than 120 days after BHC, UHS, and Cawthon
answered, and five days prior to Snell’s filing of his amended petition, BHC, UHS,
and Cawthon filed a motion to dismiss Snell’s claims. Appellees argued Snell’s
claims constitute health care liability claims (HCLCs)6 under the TMLA, asked the
trial court to dismiss his claims with prejudice for his failure to serve expert reports
under TMLA section 74.351,7 and asked for attorneys’ fees and costs.8 Snell
opposed that motion to dismiss and argued the TMLA does not apply. Snell did not
submit any evidence to accompany his response.9
On April 10, 2020, the trial court granted BHC, UHS, and Cawthon’s motion
to dismiss and scheduled a hearing for a determination on attorneys’ fees.
On April 28, 2020, Snell filed several items, including a motion to set aside
the dismissal of his false imprisonment claims against BHC, UHS, and Cawthon and
two separate summary judgment motions to establish liability on his false
imprisonment claims, with one motion on his false imprisonment claims against
BHC, UHS, and Cawthon—even though those claims had by then been dismissed—
5
See TEX. CIV. PRAC. & REM. CODE § 74.001(12) (defining “health care provider” under TMLA).
6
See TEX. CIV. PRAC. & REM. CODE § 74.001(13) (defining “health care liability claim” under TMLA).
7
See TEX. CIV. PRAC. & REM. CODE § 74.351 (TMLA expert report requirements).
8
BHC, UHS, and Cawthon attached an attorneys’ fee affidavit to their motion to dismiss.
9
The docket sheet reflects that the trial court held a hearing on BHC, UHS, and Cawthon’s motion to
dismiss. The record contains no hearing transcript and no indication the court admitted any evidence.
–5–
and another motion on his false imprisonment claims against Timberlawn. The trial
court denied Snell’s April 28, 2020 filings on June 19, 2020.
On August 11, 2020, more than 120 days after it filed an answer, Timberlawn
filed a motion to dismiss Snell’s claims, arguing, as BHC, UHS, and Cawthon had,
that Snell’s claims constitute HCLCs under the TMLA. Timberlawn asked the trial
court to dismiss his claims with prejudice for his failure to serve an expert report
under TMLA section 74.35110 and asked the court to award attorneys’ fees and costs
to Timberlawn.11 Snell opposed Timberlawn’s motion and argued the TMLA does
not apply. Snell did not submit any evidence to accompany his response, and none
was admitted, at least according to the record before us.12
The trial court granted Timberlawn’s motion to dismiss , as it had done with
BHC, UHS, and Cawthon’s earlier motion. The court’s order also indicated TMLA
section 74.351(b)(1) mandates an award of reasonable attorneys’ fees and court costs
and noted these were to be assessed at time of final judgment.
On October 5, 2020, the trial court entered a final take-nothing judgment on
Snell’s claims and awarded certain attorneys’ fees and costs of court to appellees.
Snell timely appealed.
10
See TEX. CIV. PRAC. & REM. CODE § 74.351.
11
Timberlawn attached an attorneys’ fees affidavit to its motion.
12
The record is not entirely clear on whether the trial court held a hearing on Timberlawn’s motion to
dismiss or if it was decided by submission. The record contains no hearing transcript and no indication the
court admitted any evidence.
–6–
II. ISSUES AND ANALYSIS
In the “Issues Presented” section of his brief, Snell lists three topics, 13 each
relating to one central question: did the trial court err in dismissing Snell’s claims
against appellees for his failure to serve an expert report under the TMLA? Snell
argues the trial court did so but also argues the trial court erred by denying his
summary judgment motions as to liability on his false imprisonment claims. We
address both of Snell’s arguments below.14
A. Summary Judgment Denial
As indicated, Snell argues the trial court erred by denying his motions for
summary judgment as to liability on his false imprisonment claims. Appellees argue,
in part, that Snell “lacks standing” to appeal the trial court’s denial of his summary
judgment motions because summary judgment denials are generally not reviewable,
13
Snell’s “Issues Presented” section states:
1. Whether a mental health provider in the absence of consent to render treatment can
confine a Texas citizen against his will, then require the “patient” to present an expert
report showing negligence in the provider’s conduct.
2. Whether the filing of an Application for Court-Ordered Mental Health Services under
the Texas Mental Health Code commencing a case in a probate court represents an act of
“health care.”
3. Whether intentional tort claims brought against a mental health provider for violations
of the Texas Mental Health Code and the Texas Deceptive Trade Practices Act require
compliance with Chapter 74’s expert report requirement.
14
See TEX. R. APP. P. 38.9; Weeks Marine, Inc. v. Garza, 371 S.W.3d 157, 162 (Tex. 2012) (“An
appellant can preserve error ‘in the body of their appellate brief,’ even if it is not separately listed in the
notice of appeal or presented as an issue in the brief.”) (citation omitted); Davis Apparel v. Gale-Sobel, a
Div. of Angelica Corp., 117 S.W.3d 15, 19 (Tex. App.—Eastland 2003, no pet.) (noting that, under the
liberal rules of construction applicable to briefs, court could consider appellant’s alternative argument
pertaining to trial court’s ruling on an issue not expressly stated in its appellate issues).
–7–
and they cite as support United Parcel Service v. Tasdemiroglu, 25 S.W.3d 914, 916
(Tex. App—Houston [14th Dist.] 2000, pet. denied).
Snell argues that case does not apply because the general rule to which it
refers15 involves situations in which a party has appealed the denial of a motion for
summary judgment after a trial on the merits, a situation not present here. Instead,
Snell likens this case to cases where appellate courts have considered the denial of
an appellant’s motion for summary judgment when both parties have moved for
summary judgment, and he cites as support Cincinnati Life Insurance Company v.
Cates, 927 S.W.2d 625 (Tex. 1996); Holmes v. Morales, 924 S.W.2d 920 (Tex.
1996); and Jones v. Strauss, 745 S.W.2d 898, 900 (Tex. 1988). Those cases are
distinguishable, as only one party moved for summary judgment in this case.
Though Snell does not cite it, the case originating the principle upon which
Snell relies is Tobin v. Garcia, 316 S.W.2d 396 (Tex. 1958). The court stated:
As noted above, plaintiffs filed a motion for summary judgment in the
trial court which was overruled. In Rogers v. Royalty Pooling Co., [302
S.W.2d 938 (Tex. 1957)], where both parties filed motions for summary
judgment, and the trial court granted one motion and overruled the
other, this court held that in an appeal from the order granting a
summary judgment, the Court of Civil Appeals could not review the
order of the trial court overruling the other motion.
After a careful consideration of the matter we have come to the
conclusion that that case should be overruled. If the only order in the
trial court is one overruling a motion for summary judgment, then that
order is interlocutory and no appeal will lie therefrom. But when, as in
this case, both parties file motions for summary judgment and one such
15
See United Parcel Service, 25 S.W.3d at 916 (“The general rule is that a denial of a summary
judgment cannot be reviewed on appeal.”).
–8–
motion is granted, then the trial court’s judgment becomes final and
appealable, and on appeal the Court of Civil Appeals should determine
all questions presented. If reversible error is found, the court should
render such judgment as the trial court should have rendered . . . and if
the case is brought to this court and the judgment of the Court of Civil
Appeals is reversed, we should render such judgment as that court
should have rendered. . . . Rogers v. Royalty Pooling Co. is overruled.
Tobin, 316 S.W.2d at 400–01. But as later explained in Ackermann v. Vordenbaum,
403 S.W.2d 362, 365 (Tex. 1966), the Tobin exception has limits, particularly in
cases following a final judgment or order of dismissal. The court stated:
Undoubtedly, the rule of practice adopted by [Tobin v. Garcia] is an
exception to the general rule that an order overruling a motion for
summary judgment is not subject to review upon appeal. . . . Such rule
was recognized in the interest of the prompt disposal of causes and its
operation has generally been attended with satisfactory results. [But]
the rule should not be so broadened as to produce confusion or
injustice. . . . However, our system of practice should not permit the
downfall of a cause because of an overruled motion for summary
judgment, which in the light of a conventional trial on the merits
appears to have been defectively defended against by insufficient
pleadings, depositions or affidavits. Many of the considerations
militating against the review of a trial court’s action overruling a
motion for summary judgment after the case has been tried in the
conventional manner before judge or jury are also applicable when the
final judgment appealed from is one of dismissal. The safer rule is one
restricting the [Tobin-Garcia] doctrine to its factual situation . . . , that
is, to cases in which motions for summary judgment have been filed by
all of the real parties at interest and the appeal is prosecuted from a
judgment granting one or more of them.
Id. (emphasis added).
Based on Ackermann, two of our sister courts have refused to consider an
order denying summary judgment in appeals following orders of dismissal. See
Bechem v. Reliant Energy Retail Servs., LLC, No. 01-18-00878-CV, 2019 WL
–9–
4065274, at *5 (Tex. App.—Houston [1st. Dist.] Aug. 29, 2019, pet. denied) (mem.
op.) (citing Ackermann and stating, “[W]hen a trial court denies a motion for
summary judgment and subsequently dismisses the case, as here, the order denying
the motion for summary judgment is not reviewable on appeal.”); Dolenz v. Tex. St.
Bd. of Med. Examiners, 899 S.W.2d 809, 812 (Tex. App.—Austin 1995, no pet.)
(citing Ackermann and stating, “[A]n appellate court cannot review a trial court’s
action overruling a motion for summary judgment when the trial court has rendered
an order of dismissal.”).
Like our sister courts did in those cases, based on similar circumstances here,
we conclude we may not review the trial court’s order denying Snell’s summary
judgment motions on his false imprisonment claims, as his appeal follows an order
of dismissal and final judgment on those claims. See Ackermann, 403 S.W.2d at
365; see also Bechem, 2019 WL 4065274, at *5; Dolenz, 899 S.W.2d at 812.16
B. Entry of Take-Nothing Judgment After Orders of Dismissal
Snell also argues the trial court erred by dismissing his claims for failing to
serve an expert report under TMLA section 74.351.17
16
Even if we could review that matter, we have recently concluded that where Chapter 574 applies, an
order of protective custody issued by a mental-health court is an absolute bar to a false-imprisonment claim.
See Loya v. Hickory Trail Hosp., L.P., No. 05-20-00378-CV, 2022 WL 17335694, at *14 (Tex. App.—
Dallas Nov. 29, 2022, no pet. (concluding, in a case involving allegations somewhat similar to Snell’s, that
Chapter 574 applied and the order of protective custody issued by the mental-health court was an absolute
bar to the claimant’s false-imprisonment claim).
17
See TEX. CIV. PRAC. & REM. CODE § 74.351(b).
–10–
1. TMLA and Section 74.351 Expert Reports
The TMLA requires that HCLC claimants, to avoid dismissal, serve an expert
report addressing liability and causation as to each defendant within 120 days after
the defendant files an original answer. Rogers v. Bagley, 623 S.W.3d 343, 348 (Tex.
2021); see TEX. CIV. PRAC. & REM. CODE § 74.351.
Section 74.351 of the TMLA states, in pertinent part:
(a) In a health care liability claim, a claimant shall, not later than the
120th day after the date each defendant’s original answer is filed or a
later date required under Section 74.353, serve on that party or the
party’s attorney one or more expert reports. . . .[18]
(b) If, as to a defendant physician or health care provider, an expert
report has not been served within the period specified by Subsection
(a), the court, on the motion of the affected physician or health care
provider, shall, subject to Subsection (c), enter an order that:
(1) awards to the affected physician or health care provider
reasonable attorney’s fees and costs of court incurred by the physician
or health care provider; and
(2) dismisses the claim with respect to the physician or health care
provider, with prejudice to the refiling of the claim.
TEX. CIV. PRAC. & REM. CODE § 74.351. Section 74.351 defines various terms,
including by defining “[c]laim” as “a health care liability claim.” TEX. CIV. PRAC.
& REM. CODE § 74.351(r)(2). While “health care liability claim” is not defined in
section 74.351, it is defined in the TMLA, which states:
18
See TEX. CIV. PRAC. & REM. CODE § 74.351(b).
–11–
“[h]ealth care liability claim” means a cause of action[19] against a
health care provider[20] or physician for treatment, lack of treatment, or
other claimed departure from accepted standards of medical care,[21] or
health care,[22] or safety or professional or administrative services
directly related to health care,[23] which proximately results in injury to
or death of a claimant, whether the claimant’s claim or cause of action
sounds in tort or in contract.
TEX. CIV. PRAC. & REM. CODE § 74.001(a)(13).
19
The TMLA does not define “cause of action,” but the phrase generally “refers to the ‘fact or facts
entitling one to institute and maintain an action, which must be alleged and proved in order to obtain relief.’”
In re Jorden, 249 S.W.3d 416, 421 n.19 (Tex. 2008) (orig. proceeding) (quoting A.H. Belo Corp. v. Blanton,
129 S.W.2d 619, 621 (Tex. 1939)).
20
“Health care provider” is defined as “any person, partnership, professional association, corporation,
facility, or institution duly licensed, certified, registered, or chartered by the State of Texas to provide health
care,” and includes various positions and roles. See TEX. CIV. PRAC. & REM. CODE § 74.001(a)(12)(A)–
(B) (definition includes a registered nurse, dentist, podiatrist, pharmacist, chiropractor, optometrist, health
care institution, or health care collaborative certified under Texas Insurance Code chapter 848, as well as
an officer, director, shareholder, member, partner, manager, owner, or affiliate of a health care provider or
physician, and an employee, independent contractor, or agent of a health care provider or physician acting
in the course and scope of the employment or contractual relationship).
21
The TMLA defines “[m]edical care” as “any act defined as practicing medicine under Section
151.002, Occupations Code, performed or furnished, or which should have been performed, by one licensed
to practice medicine in this state for, to, or on behalf of a patient during the patient’s care, treatment, or
confinement.” TEX. CIV. PRAC. & REM. CODE § 74.001(a)(19). The Texas Occupations Code defines
“[p]racticing medicine” as “the diagnosis, treatment, or offer to treat a mental or physical disease or disorder
or a physical deformity or injury by any system or method, or the attempt to effect cures of those conditions,
by a person who (A) publicly professes to be a physician or surgeon; or (B) directly or indirectly charges
money or other compensation for those services.” TEX. OCC. CODE § 151.002(a)(13).
22
“Health care” is defined as “any 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.” TEX. CIV. PRAC. & REM. CODE § 74.001(a)(10).
23
“Safety” is not defined in the TMLA but, in connection with an earlier version of the Act, the Texas
Supreme Court referred to “safety” according to its common meaning as “the condition of being ‘untouched
by danger; not exposed to danger; secure from danger, harm or loss.’” Diversicare Gen. Partner, Inc. v.
Rubio, 185 S.W.3d 842, 855 (Tex. 2005) (quoting Safety, BLACK’S LAW DICTIONARY 1336 (6th ed. 1990)).
“Professional or administrative services” are defined as “those duties or services that a physician or health
care provider is required to provide as a condition of maintaining the physician’s or health care provider’s
license, accreditation status, or certification to participate in state or federal health care programs.” See TEX.
CIV. PRAC. & REM. CODE § 74.001(a)(24). “‘Directly related’ means an ‘uninterrupted, close relationship
or link between the things being considered.’” Coming Attractions Bridal & Formal, Inc. v. Tex. Health
Res., 595 S.W.3d 659, 665 n.23 (Tex. 2020) (quoting Weems, 575 S.W.3d at 365). Finally, the Texas
Supreme Court held that the phrase “directly related to health care” modifies the terms immediately before
it—professional or administrative services—but not the word safety. See Tex. W. Oaks Hosp., L.P. v.
Williams, 371 S.W.3d 171, 185 (Tex. 2012).
–12–
Recently, in Lake Jackson Medical Spa, Ltd. v. Gaytan, 640 S.W.3d 830 (Tex.
2022), the court stated:
As we have repeatedly observed, this definition [of HCLC] includes
three basic elements: (1) the defendant must be a physician or health
care provider; (2) the claim must concern “treatment, lack of treatment,
or a departure from accepted standards of medical care, or health care,
or safety or professional or administrative services directly related to
health care”; and (3) the defendant’s conduct must proximately cause
the claimant’s injury or death.
Id. at 840 (quoting Tex. W. Oaks Hosp., LP v. Williams, 371 S.W.3d 171, 179–80
(Tex. 2012)).
2. Standard and Scope of Review
The court also stated:
Whether a pleading asserts a health care liability claim presents a
question of law courts review de novo. Baylor Scott & White, Hillcrest
Med. Ctr. v. Weems, 575 S.W.3d 357, 363 (Tex. 2019). To answer that
question, we must focus on the claim's “underlying nature . . . rather
than its label.” Id. To determine the claim’s underlying nature, we
must consider the “entire court record,” including “the pleadings,
motions and responses, and relevant evidence properly admitted.”
Loaisiga v. Cerda, 379 S.W.3d 248, 258 (Tex. 2012).
Id. at 836.
We “look first to the pleadings,” Loaisiga, 379 S.W.3d at 259, and consider
the underlying nature and gravamen of the plaintiff’s claim, not its label, focusing
on “whether the gravamen of [the plaintiff’s] complaint is a ‘claimed departure from
accepted standards of medical care, or health care, or safety or professional or
administrative services directly related to health care.’” Weems, 575 S.W.3d at 363–
–13–
64 n.21 (quoting TEX. CIV. PRAC. & REM. CODE § 74.001(a)(13), and citing
CHRISTUS Health Gulf Coast v. Carswell, 505 S.W.3d 528, 534 (Tex. 2016)).
As indicated, we are to look at the “entire court record,” see Lake Jackson
Med. Spa, 640 S.W.3d at 836; Loaisiga, 379 S.W.3d at 258, including an amended
petition filed after a motion to dismiss, except when procedural rules prohibit such
a filing. See Lake Jackson Med. Spa, 640 S.W.3d at 839.24
Unlike that case, see id. at 836–39, here, the parties do not dispute whether
we are to consider Snell’s original petition, amended petition, or both. But the
court’s reasoning in Lake Jackson Medical Spa suggests we may consider both, as
both pleadings are part of the “entire court record.” See id. at 839 (stating an
amended petition “nevertheless comprises part of the ‘entire court record’ courts
should consider” when making the determination whether claims are HCLCs).
Thus, as part of the entire record, we consider Snell’s original petition and amended
petition when determining whether his claims are HCLCs.
3. TMLA’s Rebuttable Presumption
In Loaisiga, the court held that the TMLA “essentially creates a presumption
that a claim is an HCLC if it is against a physician or health care provider and is
24
In the context of a dispute regarding whether an amended petition could be considered, the court
stated, “Except when our procedural rules prohibit such a filing, courts deciding a section 74.351 dismissal
motion should consider an amended petition when determining the claims’ underlying nature.” Lake
Jackson Med. Spa, 640 S.W.3d at 839.
–14–
based on facts implicating the defendant’s conduct during the course of a patient’s
care, treatment or confinement.” Loaisiga, 379 S.W.3d at 256. The court also stated:
But the presumption is necessarily rebuttable. In some instances the
only possible relationship between the conduct underlying a claim and
the rendition of medical services or healthcare will be the healthcare
setting (i.e., the physical location of the conduct in a health care
facility), the defendant’s status as a doctor or health care provider, or
both.
Id.
4. Application
a. Rebuttable Presumption Applies
As a threshold matter, we must determine whether the rebuttable presumption
applies in this case. Appellees argue it does and made this argument in the trial
court, in their appellate brief, and at oral argument in this appeal. Snell disputed
this in his response to BHC, UHS, and Cawthon’s motion to dismiss but did not
address this issue in his appellate briefs or at oral argument.
There is no dispute that appellees are health care providers. And, while Snell
maintains he did not consent to treatment, there appears to be no dispute that Snell
was a patient, at least as “patient” is defined in the Mental Health Code. See TEX.
HEALTH & SAFETY CODE § 571.003(16) (defining “[p]atient” as “an individual who
is receiving voluntary or involuntary mental health services under this subtitle.”).25
“Patient” is not defined in the TMLA. Although Snell claims Cawthon did not seek his consent as a
25
patient, and he denies providing it, the record regarding the facts and circumstances surrounding their
interaction implies otherwise. See Lake Jackson Med. Spa, 640 S.W.3d at 841–42 (stating, even in the
absence of an express authorization, a physician-patient relationship may be implied through conduct and
–15–
Finally, the record shows all of Snell’s claims are based on facts implicating
appellees’ conduct in the course of his care, treatment or confinement. For example,
in Snell’s response to Timberlawn’s motion to dismiss, Snell stated the “legal
foundation of [his] claims lies in Timberlawn’s [v]iolation of express provisions of
the Texas Mental Health Code” and stated the factual basis of his claims are
principally set forth in paragraphs sixty-three through seventy-seven of his amended
petition. Those paragraphs refer to Snell’s December 10, 2018 transfer to the mental
health facility and to various events Snell alleges did or did not occur during his
confinement while there, including an alleged lack of a probable cause hearing, a
failure to discharge him on December 13, 2018, as he argues was required, and to
him twice being physically restrained and drugged against his will, once on
December 14, 2018, and once on December 20, 2018.
circumstances demonstrating the parties’ agreement). In an affidavit Snell submitted in connection with
his summary judgment motions, Snell described his and Cawthon’s December 9, 2018 interaction as
follows, stating, in part:
While at Baylor, at approximately two p.m. that afternoon, I recall being visited by a
woman I believed was a doctor working for Baylor. Other than possibly introducing herself
as a “doctor,” the woman did not otherwise identify herself or state her purpose. I later
learned that the “doctor” who visited me was Defendant Heather Cawthon, LPC, Ph.D.
(“Cawthon”). I have since learned she was employed by other Defendants in this case.
...
Cawthon’s visit lasted only a few minutes. She asked me a series of questions, all of which
I answered.
Based on these circumstances, where their interaction occurred in a hospital room, and when Snell
apparently willingly answered all of Cawthon’s series of questions while believing her to be a doctor, we
conclude, despite Snell’s arguments to the contrary, that a healthcare provider-patient relationship existed
between Cawthon, and by relation, with BHC, her alleged employer. See id.
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Based on this record, we conclude the rebuttable presumption applies here.
See Pruett v. Pittman, No. 05-13-00634-CV, 2014 WL 2807983, at *2–3 (Tex.
App.—Dallas June 18, 2014, no pet.) (mem. op.) (concluding presumption applied
in case alleging psychiatric evaluation and report were fraudulent, which appellant
claimed caused him injury by requiring him to remain confined in mental hospital
for longer than necessary and to take psychotropic drugs he alleged he did not need).
b. Was Presumption Rebutted?
When, as here, the presumption applies, the burden shifts to Snell to rebut it
by showing his claims are not based on the defendant’s departure from accepted
standards of medical care or health care. See Lake Jackson Medical Spa, 640 S.W.3d
at 844 (citation omitted). “To decide whether the claimant has met that burden, we
‘first determine whether expert medical or health care testimony is needed to
establish the requisite standard of care and breach.’” Id. (citation omitted). If expert
testimony is required, the claim is a HCLC. Id. (citation omitted). But while “[t]he
necessity of expert testimony prevents the claimant from rebutting the [TMLA’s]
presumption . . . depending on the ‘totality of the circumstances,’ a claimant might
not rebut the presumption even when expert testimony is not required[,]” as a claim
constitutes an HCLC “when the conduct complained of is an ‘inseparable or integral
part of the rendition of health care.’” Id. (citations omitted).
In Lake Jackson Medical Spa, the court concluded that expert testimony was
required, but the court also concluded that even if expert testimony was not required,
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the claims at issue there were HCLCs because all of the conduct about which the
claimant complained was inseparable from the rendition of health care. Id. While
the case involved complaints regarding voluntary dermatological care, not an
involuntary mental health commitment, the court’s analysis in Lake Jackson Medical
Spa is instructive. The court stated, in part:
[Claimant] alleges that the defendants failed to “properly evaluate” her
skin condition “pursuant to established standards of dermatological
care,” [and] failed to “properly assess, document, and/or request” her
medical history. . . . The proper and applicable standards of
“dermatological care,” reliance on medical histories, . . . as well as
whether defendants’ conduct fell below those standards, are all matters
that require expert testimony; indeed, it “would blink reality” to
conclude otherwise. Tex. W. Oaks, 371 S.W.3d at 182.
Lake Jackson Med. Spa, 640 S.W.3d at 845.
Snell’s claims are somewhat analogous, because he claims, in essence, that
Cawthon failed to properly evaluate him on December 9, 2018, and that his
involuntary commitment, physical restraint, and forcible medication that then
followed from her evaluation violated the standards established by Chapter 574 of
the Texas Mental Health Code. In his original and amended petitions, for example,
Snell claims “Cawthon could not have reasonably concluded from the [December 9,
2018] interview that [Snell] was violent or likely to cause serious harm to himself or
anyone else.” In his amended petition, he also claims “Cawthon appears to have
violated several provisions of Section 681.041 (“Code of Ethics”) of the Rules
Relating to the Licensing and Regulation of Professional Counselors (Texas
Administrative Code)[,]” and “used her license in gaining access to [him] at Baylor.”
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Given the record here, one might well determine it would “blink reality” to
conclude that Snell’s claims are not matters that require expert testimony. See id.,
640 S.W.3d at 845; Tex. W. Oaks, 371 S.W.3d at 182; see also Pruett, 2014 WL
2807983, at *4 (concluding, in a case involving allegations somewhat similar to
Snell’s, “appellant must present expert testimony to prove his claims because they
implicate the standard of care relevant to the assessment of a mental patient,
obtaining consent to conduct a psychiatric evaluation, and diagnosing a psychiatric
condition”).
But even if we agreed, as Snell argues, that no expert testimony is required,
we conclude, based on the record here, the conduct about which Snell complains is
“an inseparable or integral part of the rendition of health care,” and as such, his
claims constitute HCLCs. See Lake Jackson Med. Spa, 640 S.W.3d at 846
(concluding appellant did not rebut the presumption his claim was an HCLC); see
also Loya, 2022 WL 17335694, at *5 (stating the claimant “cannot maintain such a
claim without reference to [the provider’s] standard of care”); Pruett, 2014 WL
2807983, at *3–4 (concluding claims “implicat[ing] how [the psychiatrist]
conducted the psychiatric evaluations, whether he followed proper procedures,
whether he obtained appellant’s consent before conducting the evaluations, and his
diagnosis and recommendations for treatment” were “inseparable from appellant’s
health care.”); Broxterman v. Carson, 309 S.W.3d 154, 158 (Tex. App.—Dallas
2010, pet. denied) (concluding claims for medical malpractice, various intentional
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torts, and statutory and civil rights violations were HCLCs when the focal point of
appellant’s claims was her treatment while hospitalized at mental health facility and
the essence of her claims was negligence in the rendition of health care services;
stating, “The fact that some of the alleged acts were done knowingly or indifferently
does not change the nature of the claim.”); Groomes v. USH of Timberlawn, Inc.,
170 S.W.3d 802, 805–06 (Tex. App.—Dallas 2005, no pet.) (concluding trial court
properly determined claims for false imprisonment, intentional infliction of
emotional distress, and abuse of process were HCLCs because allegations regarding
improper detention and administration of medication were “inextricably
intertwined” with medical treatment and provision of medical care).
We are mindful of the serious and important liberty interests at stake in this
and similar cases. But on the record before us, we have no choice but to conclude
the trial court did not err in dismissing Snell’s claims against appellees for his failure
to serve an expert report under the TMLA.
III. CONCLUSION
We overrule Snell’s issues and affirm the trial court’s judgment.
200915f.p05 /Ken Molberg/
KEN MOLBERG
JUSTICE
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Court of Appeals
Fifth District of Texas at Dallas
JUDGMENT
JAMES R. SNELL, Appellant On Appeal from the 44th Judicial
District Court, Dallas County, Texas
No. 05-20-00915-CV V. Trial Court Cause No. DC-19-15454.
Opinion delivered by Justice
BEHAVIORAL HEALTH Molberg. Justices Myers and Garcia
CONNECTIONS, INC., participating.
UHS OF TIMBERLAWN, INC.,
UNIVERSAL HEALTH SERVICES,
INC., AND HEATHER CAWTHON,
Appellees
In accordance with this Court’s opinion of this date, the judgment of the trial
court is AFFIRMED.
It is ORDERED that appellee BEHAVIORAL HEALTH CONNECTIONS,
INC., UHS OF TIMBERLAWN, INC., UNIVERSAL HEALTH SERVICES,
INC., AND HEATHER CAWTHON recover their costs of this appeal from
appellant JAMES R. SNELL.
Judgment entered this 5th day of December 2022.
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