Wilkins v. Connecticut Childbirth & Women's Center

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KRISTIN WILKINS ET AL. v. CONNECTICUT
CHILDBIRTH AND WOMEN’S
CENTER ET AL.
(SC 18998)
Rogers, C. J., and Palmer, Zarella, Eveleigh, McDonald, Espinosa and
Robinson, Js.
Argued March 25—officially released December 9, 2014
Carey B. Reilly, with whom, on the brief, was David
M. Bernard, for the appellants (plaintiffs).
Matthew M. Sconziano, for the appellees
(defendants).
Opinion
EVELEIGH, J. The plaintiff Kristin Wilkins1 appeals
from the judgment of the Appellate Court affirming
the judgment of the trial court dismissing her medical
malpractice action against the defendants, Connecticut
Childbirth & Women’s Center (Connecticut Childbirth)
and Women’s Health Associates, P.C. (Women’s
Health), on the basis of the plaintiff’s failure to comply
with the requirements of General Statutes § 52-190a.2
Because the plaintiff brought this action against the
defendants principally on the basis of vicariously liabil-
ity for the alleged negligence of specified employees or
agents, namely, certain certified nurse-midwives, we
conclude that § 52-190a (a) required the plaintiff to sup-
ply an opinion letter authored by a similar health care
provider as defined by General Statutes § 52-184c (c),
namely, someone who is certified in the same specialty
as those nurse-midwives. Because the plaintiff provided
an opinion letter of a physician who is board certified
in obstetrics, which is the same specialty practiced by
the nurse-midwives, we conclude that the Appellate
Court improperly affirmed the judgment of the trial
court dismissing this action pursuant to § 52-190a (c).
Accordingly, we reverse the judgment of the Appel-
late Court.
The opinion of the Appellate Court sets forth the
following relevant facts and procedural history. ‘‘On
June 11, 2009, the plaintiff filed this medical malpractice
action based on alleged negligence on the part of
employees or agents of the defendants during the April
17, 2007 delivery of her child, and, subsequently, at
postpartum office visits. The plaintiff alleges in her com-
plaint that Connecticut Childbirth is a medical facility
that is staffed by various health care providers, includ-
ing physicians, [nurse-midwives], surgeons and nurses,
who specialize in providing obstetrical and gynecologi-
cal care. Women’s Health owned, operated, controlled
and/or had a financial interest in Connecticut Child-
birth. The plaintiff alleges that Katy Maker, Catherine
Parisi and Catherine Gallagher, who are certified
[nurse-midwives], and Carly Detterman, who was a reg-
istered nurse and midwife in training at the time treat-
ment was rendered to the plaintiff, were agents or
employees of the [defendants] who negligently failed
to diagnose and to treat a fourth degree tear of the
plaintiff’s vaginal tissue, perineal skin and anal sphinc-
ter at the time of delivery and during postpartum check-
ups. As a result of that alleged negligence, the plaintiff
has allegedly sustained severe and permanent injuries,
and consequently, her husband has sustained a loss of
her consortium.
‘‘With her complaint, the plaintiff submitted a good
faith certificate signed by her attorney, who represented
therein that he had made a reasonable inquiry into the
circumstances of the plaintiff’s claims and that, on the
basis of that inquiry, he believed in good faith that the
defendants and their servants, agents or employees had
been negligent in their treatment of the plaintiff. Addi-
tionally, the plaintiff submitted a document entitled
‘Physician’s Opinion Pursuant to [General Statutes §]
52-190a.’ The opinion letter was authored by a board
certified obstetrician and gynecologist, who opined, in
relevant part, that Maker, one of the certified [nurse-
midwives] who cared for the plaintiff, ‘departed from
the accepted standard of care when she failed to diag-
nose and repair the fourth degree tear following delivery
of the fetus and at the postpartum visits.’ In conclusion,
the author of the letter stated: ‘[I]t is my opinion that
there appears to be evidence of medical negligence on
the part of . . . Maker and Connecticut Childbirth and
Women’s Center.’
‘‘On August 6, 2009, the defendants filed a motion to
dismiss the plaintiff’s action, pursuant to § 52-190a (c),
on the ground that the physician opinion letter submit-
ted by the plaintiff failed to satisfy the requirements of
§ 52-190a (a) because the letter was not authored by a
similar health care provider, as defined in § 52-184c (c).
Because the care rendered to the plaintiff was provided
by certified [nurse-midwives] or, as the allegations per-
tain to Detterman, by a registered nurse, the defendants
argued that the plaintiff was required to submit an opin-
ion letter authored by a certified [nurse-midwife] or a
registered nurse in order to satisfy § 52-184c (c). The
plaintiff filed an objection, claiming that an obstetrician
‘is considered to be a ‘‘similar health care provider’’ for
purposes of . . . § 52-184c (c) when rendering an opin-
ion regarding the standard of care applicable to certified
[nurse-midwives] . . . and registered nurses . . .
engaged in supervising a patient’s labor and delivery
. . . .’ The plaintiff also argued that the defendants are
institutions to which § 52-184c does not apply, because
the definitions of ‘similar health care provider’ set forth
therein refer to individuals, not institutions. The [trial]
court agreed with the defendants, finding that the plain-
tiff’s action was based on the negligence of the individu-
als who cared for the plaintiff, and the defendants as
the employers of those individuals. On that basis, the
[trial] court concluded that the plaintiff was required,
pursuant to §§ 52-190a (a) and 52-184c (c), to submit
an opinion letter by an individual who is trained, experi-
enced and certified in [nurse-midwifery] or nursing.
Because the plaintiff failed to do so, the [trial] court
dismissed her action.’’ (Footnote omitted.) Wilkins v.
Connecticut Childbirth & Women’s Center, 135 Conn.
App. 679, 683–85, 42 A.3d 521 (2012). The plaintiff
appealed from the judgment of the trial court to the
Appellate Court.
On appeal to the Appellate Court, the plaintiff claimed
that the trial court improperly dismissed her complaint
on the ground that she did not submit an opinion letter
authored by a similar health care provider. Specifically,
the plaintiff claimed that the opinion letter that she
submitted, which was authored by an obstetrician, was
sufficient to meet the requirements of §§ 52-190a (a)
and 52-184c.3 Id., 685–86.
The Appellate Court affirmed the judgment of the trial
court, concluding that ‘‘[b]ecause the plaintiff failed to
submit an opinion letter authored by an individual who
is trained, experienced and certified in [nurse-mid-
wifery] or nursing, the court properly concluded that
she failed to meet the requirements of § 52-190a (a).’’
Id., 690.
The plaintiff filed a petition for certification to appeal,
which we granted, limited to the following question:
‘‘Did the Appellate Court properly determine that, in
this action against institutional defendants . . . § 52-
190a (a) required that the ‘similar health care provider’
opinion letter be authored by a person trained and expe-
rienced in [nurse-midwifery] or nursing, instead of
being written by a board certified obstetrician and gyne-
cologist?’’ Wilkins v. Connecticut Childbirth & Wom-
en’s Center, 305 Conn. 921, 47 A.3d 881 (2012).
On appeal to this court, the plaintiff asserts that the
Appellate Court improperly affirmed the judgment of
the trial court and improperly concluded that § 52-190a
(a) required the plaintiff to provide an opinion letter
authored by a person certified in nurse-midwifery or
nursing instead of a board certified obstetrician and
gynecologist. Specifically, the plaintiff claims that § 52-
190a (a) does not require a good faith opinion certifica-
tion for a claim against an institutional defendant. The
plaintiff further claims that, even if § 52-190a (a)
requires a good faith opinion certification for institu-
tional defendants, the opinion letter submitted from a
board certified obstetrician and gynecologist meets the
requirements of § 52-184c (c). The plaintiff also claims
that the use of a good faith opinion certification from
a physician who is board certified in obstetrics and
gynecology satisfies the purpose of § 52-190a (a). In
response, the defendants assert that the Appellate Court
properly affirmed the judgment of the trial court and
properly concluded that §§ 52-190a (a) and 52-184c (c)
required the plaintiff to provide an opinion letter
authored by a person certified in nurse-midwifery or
nursing. Specifically, the defendants claim that a good
faith opinion certification is required for an institutional
defendant and that, in the present case, a physician
who is board certified in obstetrics and gynecology
does not meet the definition of a ‘‘ ‘similar health care
provider’ ’’ in § 52-184c (c). Although we conclude that
the plaintiff was required to submit an opinion letter
in accordance with § 52-184c (c), we agree with the
plaintiff that her letter satisfied her obligations and,
accordingly, we reverse the judgment of the Appel-
late Court.
Before addressing the plaintiff’s claims on appeal, we
address the applicable standard of review, which is well
settled. ‘‘A motion to dismiss tests, inter alia, whether,
on the face of the record, the court is without jurisdic-
tion. . . . [O]ur review of the court’s ultimate legal con-
clusion and resulting [determination] of the motion to
dismiss will be de novo. . . . When a . . . court
decides a . . . question raised by a pretrial motion to
dismiss, it must consider the allegations of the com-
plaint in their most favorable light. . . . In this regard,
a court must take the facts to be those alleged in the
complaint, including those facts necessarily implied
from the allegations, construing them in a manner most
favorable to the pleader. . . . The motion to dismiss
. . . admits all facts which are well pleaded, invokes
the existing record and must be decided upon that
alone.’’ (Internal quotation marks omitted.) Gold v.
Rowland, 296 Conn. 186, 200–201, 994 A.2d 106 (2010).
Moreover, when the legal issue presented in connec-
tion with a motion to dismiss is one of statutory con-
struction, ‘‘[o]ur fundamental objective is to ascertain
and give effect to the apparent intent of the legislature.
. . . In other words, we seek to determine, in a rea-
soned manner, the meaning of the statutory language
as applied to the facts of [the] case, including the ques-
tion of whether the language actually does apply. . . .
In seeking to determine that meaning, General Statutes
§ 1-2z directs us first to consider the text of the statute
itself and its relationship to other statutes. If, after
examining such text and considering such relationship,
the meaning of such text is plain and unambiguous and
does not yield absurd or unworkable results, extratex-
tual evidence of the meaning of the statute shall not
be considered. . . . The test to determine ambiguity is
whether the statute, when read in context, is susceptible
to more than one reasonable interpretation.’’ (Internal
quotation marks omitted.) Tayco Corp. v. Planning &
Zoning Commission, 294 Conn. 673, 679, 986 A.2d 290
(2010). Further, in construing statutes, we presume that,
there is a purpose behind every sentence, clause or
phrase used in an act, and that no part of a statute is
superfluous. Lopa v. Brinker International, Inc., 296
Conn. 426, 433, 994 A.2d 1265 (2010).
I
We begin with the plaintiff’s claim that § 52-190a (a)
does not require a good faith opinion certification for
a claim against an institutional defendant. The plaintiff
asserts that there is a ‘‘gap’’ in the statute regarding
institutional defendants. In support of her position, the
plaintiff cites to the definition of ‘‘similar health care
provider’’ in § 52-184c (c), and asserts that it contains
attributes of health care providers that institutions can-
not possess, such as board certification, and uses the
pronoun ‘‘himself . . . .’’ In response, the defendants
assert that there is no gap in the statute and that reading
§ 52-190a (a) in a manner that does not require a good
faith opinion certification in cases against institutional
defendants would defeat the legislative purpose of § 52-
190a (a). We agree with the defendants that § 52-190a
(a) applies to claims against institutional defendants.
We begin with the language of § 52-190a (a), which
provides in relevant part as follows: ‘‘No civil action
. . . shall be filed to recover damages resulting from
personal injury or wrongful death occurring on or after
October 1, 1987, whether in tort or in contract, in which
it is alleged that such injury or death resulted from the
negligence of a health care provider, unless the attorney
or party filing the action or apportionment complaint
has made a reasonable inquiry as permitted by the cir-
cumstances to determine that there are grounds for a
good faith belief that there has been negligence in the
care or treatment of the claimant. The complaint, initial
pleading or apportionment complaint shall contain a
certificate of the attorney or party filing the action or
apportionment complaint that such reasonable inquiry
gave rise to a good faith belief that grounds exist for
an action against each named defendant or for an appor-
tionment complaint against each named apportionment
defendant. To show the existence of such good faith,
the claimant or the claimant’s attorney, and any appor-
tionment complainant or the apportionment complain-
ant’s attorney, shall obtain a written and signed opinion
of a similar health care provider, as defined in section
52-184c, which similar health care provider shall be
selected pursuant to the provisions of said section, that
there appears to be evidence of medical negligence
and includes a detailed basis for the formation of such
opinion. . . .’’
Section 52-190a (a) does not contain a definition of
‘‘health care provider.’’ Section 52-190a (a) incorporates
the definition of ‘‘similar health care provider,’’ pro-
vided in § 52-184c, but § 52-184c does not contain a
definition of ‘‘health care provider.’’ Instead, § 52-184c
(a) begins with the following phrase: ‘‘In any civil action
to recover damages resulting from personal injury or
wrongful death occurring on or after October 1, 1987,
in which it is alleged that such injury or death resulted
from the negligence of a health care provider, as defined
in section 52-184b . . . .’’ General Statutes § 52-184b
(a), in turn, defines health care provider as follows:
‘‘For the purposes of this section, ‘health care provider’
means any person, corporation, facility or institution
licensed by this state to provide health care or profes-
sional services, or an officer, employee or agent thereof
acting in the course and scope of his employment.’’ The
definition of ‘‘health care provider’’ in § 52-184b (a)
indicates that, by the use of the term ‘‘health care pro-
vider’’ in § 52-190a (a), the legislature intended to
include institutions within its requirements.
In construing statutes, courts also are ‘‘guided by the
principle that the legislature is always presumed to have
created a harmonious and consistent body of law . . . .
[T]his tenet of statutory construction . . . requires us
to read statutes together when they relate to the same
subject matter . . . . Accordingly, [i]n determining the
meaning of a statute . . . we look not only [to] the
provision at issue, but also to the broader statutory
scheme to ensure the coherency of our construction.’’
(Internal quotation marks omitted.) In re Jusstice W.,
308 Conn. 652, 663, 65 A.3d 487 (2012).
With this principle in mind, we turn to the definition
of ‘‘health care provider’’ in other related statutes. Gen-
eral Statutes § 52-184d, which is concerned with the
inadmissibility of an apology, also indicates that the
legislature intended to include institutions when it
chose the term ‘‘health care provider’’ for § 52-190a (a).
Section 52-184d (a) (1) provides as follows: ‘‘ ‘Health
care provider’ means a provider, as defined in subsec-
tion (b) of section 20-7b, or an institution, as defined
in section 19a-490, and includes a health care institution
or facility operated by the state . . . .’’ This definition
of ‘‘health care provider’’ supports the understanding
that, by its use of the term ‘‘health care provider’’ in
§ 52-190a (a), the legislature intended to include claims
of medical malpractice against institutional defendants
within the good faith certificate requirements of § 52-
190a (a).
The plaintiff asserts, however, that the fact that § 52-
184c contains attributes of health care providers that
institutions cannot possess, such as board certification,
and uses the pronoun ‘‘himself’’ demonstrates that the
legislature did not intend it to apply to institutional
defendants. As this court recognized in DiLieto v.
County Obstetrics & Gynecology Group, P.C., 265
Conn. 79, 92–93, 828 A.2d 31 (2003), ‘‘§ 52-184c reveals
that the statute consistently addresses two different
types of health care providers. The first is the ‘defendant
health care provider,’ that is, a health care provider
against whom the plaintiff makes a claim of professional
negligence. The second type is the ‘similar health care
provider.’ A similar health care provider is identified
as both the professional with reference to whom the
applicable standard of care is established, as set forth
in § 52-184c (a), (b) and (c), and as the expert who may
testify as a witness, as set forth in § 52-184c (d). The
definition of health care provider found in § 52-184b is
incorporated into § 52-184c only in subsection (a) with
reference to a defendant health care provider. There is
no explicit incorporation of the definition in § 52-184b
with reference to a similar health care provider any-
where in § 52-184c. This suggests to us that the legisla-
ture intended to incorporate the § 52-184b definition
only with reference to defendant health care providers,
and not with reference to similar health care providers.’’
(Emphasis omitted.)
Although we agree with the plaintiff that the statute
is not as clear as it could be in regards to claims brought
against institutions, the language cited by the plaintiff
reflects the practical reality that medical malpractice
can be committed only through the acts or omissions
of people, specifically, medical professionals. Thus,
when a medical malpractice action is brought against
an institution, the malpractice necessarily is committed
by the institution’s officers, employees or agents.
Accordingly, the ‘‘defendant health care provider’’ for
purposes of § 52-184c is the person who allegedly com-
mitted the medical malpractice, not the person or insti-
tution that ultimately may be held liable for that
malpractice. Indeed, such a focus conforms to the stan-
dard of care in a malpractice action, under which the
applicable standard of care is that of the professional
who committed the negligence, not the person or entity
ultimately liable for that negligence, such as when an
action is brought against a physician for the negligence
of his employee, a nurse.4
Furthermore, we reject the interpretation of § 52-190a
(a) urged by the plaintiff because it leads to absurd
results. Specifically, the position urged by the plaintiff
is that the requirement that a plaintiff submit a good
faith opinion certification may be avoided by naming
an institution as the defendant. It is axiomatic that ‘‘[w]e
must interpret the statute so that it does not lead to
absurd or unworkable results. See State v. Courchesne,
296 Conn. 622, 710, 998 A.2d 1 (2010) (‘it is axiomatic
that those who promulgate statutes . . . do not intend
to promulgate statutes . . . that lead to absurd conse-
quences or bizarre results’ . . .).’’ State v. Drupals, 306
Conn. 149, 165, 49 A.3d 962 (2012). The principal pur-
pose of § 52-190a is to avoid frivolous actions against
health care providers. It would frustrate the purpose
of the statute to allow an action to proceed against a
medical institution or facility in the absence of a good
faith certificate and opinion letter. Further, the plain-
tiff’s interpretation of § 52-190a (a), as it reads in con-
junction with related statutes, would render the
legislature’s use of the terms ‘‘institution,’’ ‘‘facility’’ or
‘‘corporation’’ superfluous. Accordingly, we conclude
that the requirements of § 52-190a (a) apply to claims
of medical malpractice brought against institutional
defendants.
II
Having concluded that § 52-190a (a) requires a good
faith opinion certification from a similar health care
provider in the present case, we next turn to the plain-
tiff’s claim that the Appellate Court improperly con-
cluded that her good faith opinion certification from a
board certified obstetrician and gynecologist did not
satisfy the requirements of § 52-184c. The plaintiff
asserts that the Appellate Court improperly applied the
requirements of § 52-184c (c) to her claim, whereas it
should have applied § 52-184c (b) or § 52-184c (d) to
her claim, both of which were satisfied. In response,
the defendants assert that the plaintiff was required to
meet the requirements of § 52-184c (c) and the good
faith opinion certification from a physician who is board
certified in obstetrics and gynecology does not meet
the requirements of § 52-184c (c) in the present case
because the claims related to care given by certified
nurse-midwives and a registered nurse. We agree with
the defendants that § 52-184c (c) applies, but agree with
the plaintiff that the good faith opinion certification in
the present case satisfied the requirements of § 52-184c
(c) and, in turn, § 52-190a.
As we explained previously in this opinion, § 52-190a
(a) requires in relevant part that, ‘‘[t]o show the exis-
tence of such good faith, the claimant or the claimant’s
attorney . . . shall obtain a written and signed opinion
of a similar health care provider, as defined in section
52-184c, which similar health care provider shall be
selected pursuant to the provisions of said section, that
there appears to be evidence of medical negligence
and includes a detailed basis for the formation of such
opinion. . . .’’
First, we must address the threshold question of what
subsection of § 52-184c; see footnote 3 of this opinion;
applies in evaluating the good faith opinion certification
in the present case. In Bennett v. New Milford Hospital,
Inc., 300 Conn. 1, 23, 12 A.3d 865 (2011), we concluded
that § 52-184c (b) establishes ‘‘the qualifications of a
similar health care provider when the defendant is nei-
ther board certified nor in some way a specialist, and
§ 52-184c (c) [establishes] those qualifications when the
defendant is board certified, ‘trained and experienced
in a medical specialty, or holds himself out as a special-
ist . . . .’ General Statutes § 52-184c (c).’’ In Bennett
v. New Milford Hospital, Inc., supra, 23–24, we relied
on the allegation in the plaintiff’s complaint ‘‘that the
defendant ‘specializes in the field of emergency medi-
cine,’ ’’ to conclude that the good faith opinion certifica-
tion had to be authored by a similar health care provider
as defined by § 52-184c (c). Subsection (d) of § 52-184c,
however, addresses whether a health care provider may
testify as an expert in a medical malpractice action. In
Bennett v. New Milford Hospital, Inc., supra, 21, we
further concluded that ‘‘in cases of specialists, the
author of an opinion letter pursuant to § 52-190a (a)
must be a similar health care provider as that term is
defined by § 52-184c (c), regardless of his or her poten-
tial qualifications to testify at trial pursuant to § 52-
184c (d).’’
In the present case, the plaintiff alleged in her com-
plaint that the defendants ‘‘specializ[e] in obstetrics
. . . .’’ More significantly, it is undisputed that the certi-
fied nurse-midwives whose actions form the basis of the
plaintiff’s complaint held themselves out as specialists.
Following our reasoning in Bennett, we conclude that
the good faith opinion certification had to be authored
by a similar health care provider as defined by § 52-
184c (c).
Having concluded that § 52-184c (c) applies to the
present case, we must look at who constitutes a ‘‘similar
health care provider’’ for purposes of § 52-184c (c).
Section 52-184c (c) provides as follows: ‘‘If the defen-
dant health care provider is certified by the appropriate
American board as a specialist, is trained and experi-
enced in a medical specialty, or holds himself out as a
specialist, a ‘similar health care provider’ is one who:
(1) is trained and experienced in the same specialty;
and (2) is certified by the appropriate American board
in the same specialty; provided if the defendant health
care provider is providing treatment or diagnosis for a
condition which is not within his specialty, a specialist
trained in the treatment or diagnosis for that condition
shall be considered a ‘similar health care provider’.’’
In the present case, the plaintiff brought claims of
medical malpractice against Connecticut Childbirth and
Women’s Health, two institutional defendants, under a
theory of vicarious liability, for the alleged actions of
their employees. The employees whose actions are spe-
cifically named in the plaintiff’s complaint are certified
nurse-midwives and a registered nurse. The plaintiff’s
complaint asserts that she suffered injuries related to
pregnancy, childbirth and postpartum care due to the
negligence of the defendants and their ‘‘servants,
agents, apparent agents and/or employees . . . .’’ The
plaintiff alleged in her complaint that the defendants
‘‘specializ[e] in obstetrics . . . .’’ See Bennett v. New
Milford Hospital, Inc., supra, 300 Conn. 21.
The defendants assert, and the Appellate Court con-
cluded, that, ‘‘the plain language of §§ 52-190a (a) and
52-184c (c) dictates that a ‘similar health care provider’
with respect to the plaintiff’s health care providers
would be one who is trained and experienced in [nurse-
midwifery] or nursing and is certified in [nurse-mid-
wifery] or nursing.’’ Wilkins v. Connecticut Child-
birth & Women’s Center, supra, 135 Conn. App. 687–88.
The plaintiff counters that, even if § 52-184c (c) applies
to her claim, in light of the purpose behind §§ 52-190a
and 52-184c (c), the good faith opinion certification in
the present case from an physician who is board certi-
fied in obstetrics and gynecology and who has trained
and supervised nurse-midwives satisfies the require-
ments of the statute. We conclude that the text of the
statute accommodates a circumstance in which two
different types of medical professionals are board certi-
fied in the same medical specialty. To the extent that
the statute is ambiguous as to this question, we agree
with the plaintiff that a construction that deems a medi-
cal professional who is board certified in the same
specialty but has greater training and experience, satis-
fies the purpose of the requirement of the opinion letter.
Under this construction, a board certified obstetrician
and gynecologist is a similar health care provider for
purposes of § 52-184c (c).
Our understanding of the terms of § 52-184c (c) are
informed by the purpose of the opinion letter require-
ment in § 52-190a. In Wilcox v. Schwartz, 303 Conn.
630, 640–42, 37 A.3d 133 (2012), this court explained
as follows: ‘‘§ 52-190a originally was enacted as part of
the Tort Reform Act of 1986. See Public Acts 1986, No.
86-338, § 12. The original version of the statute required
the plaintiff in any medical malpractice action to con-
duct a reasonable inquiry as permitted by the circum-
stances to determine that there are grounds for a good
faith belief that there has been negligence in the care
or treatment of the [plaintiff] and to file a certificate
that such reasonable inquiry gave rise to a good faith
belief that grounds exist for an action against each
named defendant. General Statutes (Rev. to 1987) § 52-
190a (a). The original statute did not require the plaintiff
to obtain the written opinion of a similar health care
provider that there appeared to be evidence of medical
negligence . . . but permitted the plaintiff to rely on
such an opinion to support his good faith belief. . . .
[T]he purpose of the original version of § 52-190a was
to prevent frivolous medical malpractice actions. See
Bruttomesso v. Northeastern Connecticut Sexual
Assault Crisis Services, Inc., 242 Conn. 1, 15, 698 A.2d
795 (1997) ([t]he purpose of the legislation is to inhibit
a plaintiff from bringing an inadequately investigated
cause of action, whether in tort or in contract, claiming
negligence by a health care provider).
‘‘In 2005, the legislature amended § 52-190a (a) to
include a provision requiring the plaintiff in a medical
malpractice action to [show the existence of the claim-
ant’s good faith belief that grounds exist for an action
by] obtain[ing] the written opinion of a similar health
care provider that there appears to be evidence of medi-
cal negligence . . . . See Public Acts 2005, No. 05-275,
§ 2 . . . . Dias v. Grady, [292 Conn. 350, 357, 972 A.2d
715 (2009)]. The 2005 legislation was part of a compre-
hensive effort to control significant and continued
increases in malpractice insurance premiums by
reforming aspects of tort law, the insurance system and
the public health regulatory system. Bennett v. New
Milford Hospital, Inc., [supra, 300 Conn. 18].
‘‘As we also observed in Dias with regard to the
legislative history of the 2005 legislation, Michael D.
Neubert, an attorney representing the Connecticut State
Medical Society at a hearing before the [J]udiciary
[C]ommittee, stated that the [written opinion require-
ment] was intended to ensure that there’s a reasonable
basis for filing a medical malpractice action under the
circumstances. It would help eliminate some of the
more questionable and meritless claims filed under the
present statutory scheme. Conn. Joint Standing Com-
mittee Hearings, [Judiciary, Pt. 18, 2005 Sess.], p. 5539.
[Neubert] also stated that the [requirement obviously
was not going to impact the majority of cases and] was
targeting [only the cases on the margins] . . . where
attorneys, based on their own judgment and maybe in
good faith have misread what an [expert has] told them
. . . . Very often you hear what you want to hear as
an attorney, or interpret [what has] been told to you
as you want to interpret it. . . . [I]f the [physician is]
not willing to sign on the dotted line, maybe [that is]
a good indication that this [is not] a good case to bring.
. . . If part of what [we are] trying to do here is elimi-
nate those cases [that] should not be in the system then
I think this serves to do it. Id., p. 5553; see also Conn.
Joint Standing Committee Hearings, Judiciary, Pt. 19,
2005 Sess., p. 5743, written testimony of Neubert (the
present statutory scheme does not adequately [e]nsure
that an attorney filing a medical malpractice action has
a reasonable basis to believe that the defendants have
violated the standard of care in causing the plaintiff
injury). Dias v. Grady, supra, 292 Conn. 358 n.7.
‘‘Two legislators echoed Neubert’s view that the writ-
ten opinion requirement was intended primarily to
reduce the number of frivolous medical malpractice
actions by requiring a plaintiff to obtain an opinion
from a similar health care provider substantiating the
plaintiff’s good faith belief that there had been negli-
gence in the plaintiff’s care and treatment. See Conn.
Joint Standing Committee Hearings, Judiciary, Pt. 18,
2005 Sess., p. 5545, remarks of Senator John A. Kissel
(stating that written opinion requirement would greatly
improve on then current practice of [the plaintiff’s]
attorney just sort of signing off in good faith); see also
48 S. Proc., Pt. 14, 2005 Sess., p. 4433, remarks of Senator
Edward Meyer (observing that written opinion require-
ment would deal with . . . [the] bad cases). Relying in
large measure on Neubert’s testimony, we concluded
in Dias that the legislative history indicates that [the
written opinion requirement] was intended to address
the problem that some attorneys, either intentionally
or innocently, were misrepresenting in the certificate
of good faith the information that they had obtained
from experts. Dias v. Grady, supra, 292 Conn. 357–58.’’
(Footnote omitted; internal quotation marks omitted.)
As the foregoing demonstrates, §§ 52-190a and 52-
184c (c) were implemented to prevent frivolous medical
malpractice actions by requiring a medical professional
with expertise in the particular medical field involved
in the claim to offer his or her professional opinion
that the standard of care was breached in a particular
instance. In the present case, the plaintiff submitted a
good faith opinion certification from an obstetrician
and gynecologist who certified that he has instructed
and supervised certified nurse-midwives and is familiar
with the standard of care applicable to them and that
the plaintiff’s claims fell within his realm of expertise
as a board certified obstetrician and gynecologist.
In the complaint, the plaintiff alleged that Connecti-
cut Childbirth is ‘‘a professional corporation licensed
to do business by the state of Connecticut comprised
of physicians, [nurse-midwives], surgeons, nurses and
other professional health care providers specializing in
obstetrics . . . .’’ The plaintiff further alleged that
Women’s Health is ‘‘a professional corporation licensed
to do business by the state of Connecticut comprised of
physicians, [nurse-midwives], [and] other professional
health care providers specializing in obstetrics . . . .’’
This court has previously determined that it is appro-
priate to look to the allegations of the plaintiff’s com-
plaint to frame the requirements for who constitutes a
similar health care provider for purposes of the good
faith opinion certification. See Bennett v. New Milford
Hospital, Inc., supra, 300 Conn. 23–24 (‘‘[b]ecause the
plaintiff brought this action against the defendant in
his capacity as a specialist in emergency medicine, we
conclude that § 52-190a [a] required the plaintiff to sup-
ply an opinion letter authored by a similar health care
provider as defined by § 52-184c [c]’’). Thus, the ques-
tion is whether a board certified obstetrician and gyne-
cologist and a certified nurse-midwife practice and are
certified in the same medical specialty.5
Stedman’s Medical Dictionary defines obstetrics as
‘‘[t]he specialty of medicine concerned with the care
of women during pregnancy, parturition [while giving
birth], and the puerperium [after birth].’’ Stedman’s
Medical Dictionary (28th Ed. 2006) p. 1354; see also
Merriam-Webster’s Collegiate Dictionary (11th Ed.
2003) (defining ‘‘obstetrics’’ as ‘‘a branch of medical
science that deals with birth and with its antecedents
and sequels’’). Stedman’s Medical Dictionary defines a
midwife as ‘‘[a] person qualified to practice midwifery,
having received specialized training in obstetrics and
child care.’’ Stedman’s Medical Dictionary, supra, p.
1212. That dictionary, in turn, defines midwifery as
‘‘[i]ndependent care of essentially normal, healthy
women and infants by a midwife, prepartally, intrapar-
tally, postpartally and/or obstetrically in a hospital, birth
center, or home setting . . . .’’ Id. Similarly, the Dic-
tionary of Modern Medicine indicates that the field of
medicine relevant to a midwife is obstetrics and, in
turn, defines a midwife as ‘‘[a] formally-trained person,
usually a registered nurse, who assists in childbirth;
midwifery is undergoing a renaissance, and provides
obstetric services for lower income women, and is a
delivery option chosen by some upper income women
who desire a greater involvement in childbirth . . . .’’
Dictionary of Modern Medicine (J. Segen ed., 1992)
p. 450.
It is also important to look at the statutory scheme
governing nurse-midwives in Connecticut. The statu-
tory scheme requires that a nurse-midwife work in con-
junction with a certified obstetrician and gynecologist.
Specifically, General Statutes § 20-86b provides in rele-
vant part as follows: ‘‘Nurse-midwives shall practice
within a health care system and have clinical relation-
ships with obstetrician-gynecologists that provide for
consultation, collaborative management or referral, as
indicated by the health status of the patient. . . .’’ Gen-
eral Statutes § 20-86a (1) also provides as follows:
‘‘ ‘Nurse-midwifery’ means the management of women’s
health care needs, focusing particularly on family plan-
ning and gynecological needs of women, pregnancy,
childbirth, the postpartum period and the care of new-
borns, occurring within a health care team and in
collaboration with qualified obstetrician-gynecolo-
gists.’’ (Emphasis added.) The statutory requirement
that a nurse-midwife work in conjunction with an obste-
trician and gynecologist, combined with the explicit
representation in the good faith opinion certification
that the obstetrician in the present case had experience
supervising nurse-midwives, demonstrates that the
obstetrician satisfied the requirements for a ‘‘similar
health care provider’’ under § 52-184c (c). The defen-
dants would have us impose a requirement in the statute
that the opinion letter be authored by an identical
‘‘health care provider’’ and not a ‘‘similar health care
provider.’’ Such a definition would frustrate the wording
of the statute. The statutory scheme requiring a nurse-
midwife to have clinical relationships for consultation
and collaboration with an obstetrician-gynecologist
indicates that an obstetrician-gynecologist who has
worked with nurse-midwives would be able to provide
a medical opinion as to whether there is a good faith
basis for believing that the standard of care for nurse-
midwives was not followed.6
Furthermore, the defendants conceded at oral argu-
ment before this court that nurse-midwives practice
obstetrics.7 The defendants also were unable to identify
any obstetrical procedure that a nurse-midwife is
trained and board certified to perform that an obstetri-
cian is not trained and board certified to perform.
Instead, the defendants pointed to the fact that a physi-
cian is certified by the American Board of Obstetrics
and Gynecology, whereas a nurse-midwife is certified
by the American College of Nurse-Midwives and, more
specifically, the American Midwifery Certification
Board. In addition, the defendants pointed to the fact
that an obstetrician can perform certain procedures
that are beyond a nurse-midwife’s scope of practice.
See General Statutes § 20-86b (recognizing possible
referral to obstetrician when care of patient is not
within nurse-midwives’ scope of practice). We are not
persuaded that these considerations are relevant to
determining whether an obstetrician is a similar health
care provider to a certified nurse-midwife under § 52-
184c (c). First, § 52-184c (c) simply provides that the
similar health care provider must be ‘‘certified by the
appropriate American board in the same specialty
. . . .’’ It does not provide that the author of the opinion
letter must be certified by the same board as the defen-
dant health care provider, but rather the same specialty.
Both the American Midwifery Certification Board and
the American Board of Obstetrics and Gynecology pro-
vide certification in the same specialty, obstetrics.
Although it is possible that the legislature never consid-
ered whether two boards could provide certification in
the same specialty, to construe the statute to permit
such a result seems wholly consistent with the purpose
of the opinion letter requirement. Second, although an
obstetrician’s training in that specialty undoubtedly
exceeds that of a certified nurse-midwife in terms of
the type of procedures that may be performed and the
type of patients that may be treated, there is nothing
in the record that would indicate that the standard of
care for the two professionals would differ substan-
tively with respect to those matters that fall within the
scope of both professionals’ certification. Accordingly,
it is wholly consistent with statute’s purpose to allow
an opinion letter to be provided from a medical profes-
sional whose qualifications in a specialty exceed those
of the medical professional alleged to be negligent.8
Thus, the present case is wholly distinguishable from
Bennett v. New Milford Hospital, Inc., supra, 300 Conn.
17. In that case, the physician who was alleged to have
been negligent and the author of the opinion letter were
not certified in the same specialty. Id., 23–24. In the
present case, the author of the opinion letter and the
allegedly negligent medical professional were both
board certified in the same specialty, obstetrics.9
On the basis of the foregoing, we conclude that the
plaintiff fulfilled the requirements of §§ 52-184c (c) and
52-190a by submitting a good faith opinion certification
from a board certified obstetrician and gynecologist.10
The judgment of the Appellate Court is reversed and
the case is remanded to that court with direction to
reverse the judgment of the trial court and to remand
the case to the trial court with direction to deny the
defendants’ motion to dismiss and for further proceed-
ings according to law.
In this opinion PALMER, McDONALD and
ESPINOSA, Js., concurred.
1
As noted by the Appellate Court: ‘‘Kristin Wilkins’ husband, Billy Wilkins,
filed a claim for loss of consortium. [That] claim is derivative of his wife’s
malpractice claims, and, consequently, their claims on appeal are identical
. . . .’’ Wilkins v. Connecticut Childbirth & Women’s Center, 135 Conn.
App. 679, 680 n.1, 42 A.3d 521 (2012). For the sake of clarity, we hereafter
refer in this opinion to Kristin Wilkins as the plaintiff.
2
General Statutes § 52-190a provides: ‘‘(a) No civil action or apportion-
ment complaint shall be filed to recover damages resulting from personal
injury or wrongful death occurring on or after October 1, 1987, whether in
tort or in contract, in which it is alleged that such injury or death resulted
from the negligence of a health care provider, unless the attorney or party
filing the action or apportionment complaint has made a reasonable inquiry
as permitted by the circumstances to determine that there are grounds for
a good faith belief that there has been negligence in the care or treatment
of the claimant. The complaint, initial pleading or apportionment complaint
shall contain a certificate of the attorney or party filing the action or appor-
tionment complaint that such reasonable inquiry gave rise to a good faith
belief that grounds exist for an action against each named defendant or for
an apportionment complaint against each named apportionment defendant.
To show the existence of such good faith, the claimant or the claimant’s
attorney, and any apportionment complainant or the apportionment com-
plainant’s attorney, shall obtain a written and signed opinion of a similar
health care provider, as defined in section 52-184c, which similar health
care provider shall be selected pursuant to the provisions of said section,
that there appears to be evidence of medical negligence and includes a
detailed basis for the formation of such opinion. Such written opinion shall
not be subject to discovery by any party except for questioning the validity
of the certificate. The claimant or the claimant’s attorney, and any apportion-
ment complainant or apportionment complainant’s attorney, shall retain the
original written opinion and shall attach a copy of such written opinion,
with the name and signature of the similar health care provider expunged,
to such certificate. The similar health care provider who provides such
written opinion shall not, without a showing of malice, be personally liable
for any damages to the defendant health care provider by reason of having
provided such written opinion. In addition to such written opinion, the court
may consider other factors with regard to the existence of good faith. If
the court determines, after the completion of discovery, that such certificate
was not made in good faith and that no justiciable issue was presented
against a health care provider that fully cooperated in providing informal
discovery, the court upon motion or upon its own initiative shall impose
upon the person who signed such certificate or a represented party, or both,
an appropriate sanction which may include an order to pay to the other
party or parties the amount of the reasonable expenses incurred because
of the filing of the pleading, motion or other paper, including a reasonable
attorney’s fee. The court may also submit the matter to the appropriate
authority for disciplinary review of the attorney if the claimant’s attorney
or the apportionment complainant’s attorney submitted the certificate.
‘‘(b) Upon petition to the clerk of the court where the civil action will be
filed to recover damages from personal injury or wrongful death, an auto-
matic ninety-day extension of the statute of limitations shall be granted to
allow the reasonable inquiry required by subsection (a) of this section. This
period shall be in addition to other tolling periods.
‘‘(c) The failure to obtain and file the written opinion required by subsec-
tion (a) of this section shall be grounds for the dismissal of the action.’’
3
General Statutes § 52-184c provides: ‘‘(a) In any civil action to recover
damages resulting from personal injury or wrongful death occurring on or
after October 1, 1987, in which it is alleged that such injury or death resulted
from the negligence of a health care provider, as defined in section 52-184b,
the claimant shall have the burden of proving by the preponderance of the
evidence that the alleged actions of the health care provider represented a
breach of the prevailing professional standard of care for that health care
provider. The prevailing professional standard of care for a given health
care provider shall be that level of care, skill and treatment which, in light
of all relevant surrounding circumstances, is recognized as acceptable and
appropriate by reasonably prudent similar health care providers.
‘‘(b) If the defendant health care provider is not certified by the appropriate
American board as being a specialist, is not trained and experienced in a
medical specialty, or does not hold himself out as a specialist, a ‘similar
health care provider’ is one who: (1) Is licensed by the appropriate regulatory
agency of this state or another state requiring the same or greater qualifica-
tions; and (2) is trained and experienced in the same discipline or school
of practice and such training and experience shall be as a result of the
active involvement in the practice or teaching of medicine within the five-
year period before the incident giving rise to the claim.
‘‘(c) If the defendant health care provider is certified by the appropriate
American board as a specialist, is trained and experienced in a medical
specialty, or holds himself out as a specialist, a ‘similar health care provider’
is one who: (1) Is trained and experienced in the same specialty; and (2) is
certified by the appropriate American board in the same specialty; provided if
the defendant health care provider is providing treatment or diagnosis for
a condition which is not within his specialty, a specialist trained in the
treatment or diagnosis for that condition shall be considered a ‘similar health
care provider’.
‘‘(d) Any health care provider may testify as an expert in any action if
he: (1) Is a ‘similar health care provider’ pursuant to subsection (b) or (c)
of this section; or (2) is not a similar health care provider pursuant to
subsection (b) or (c) of this section but, to the satisfaction of the court,
possesses sufficient training, experience and knowledge as a result of prac-
tice or teaching in a related field of medicine, so as to be able to provide
such expert testimony as to the prevailing professional standard of care in
a given field of medicine. Such training, experience or knowledge shall be
as a result of the active involvement in the practice or teaching of medicine
within the five-year period before the incident giving rise to the claim.’’
4
It is important to note that § 52-190a applies only to claims of medical
malpractice, not ordinary negligence. See, e.g., Shortell v. Cavanagh, 300
Conn. 383, 393, 15 A.3d 1042 (2011) (‘‘If an expert is needed to establish
the standard of care, a fortiori, an opinion letter is required from a similar
health care provider. It is likewise both consistent and logical to hold that
if an expert is not required to establish the medical standard of care, an
opinion letter is not required under § 52-190a.’’); Multari v. Yale New Haven
Hospital, Inc., 145 Conn. App. 253, 259–61, 75 A.3d 733 (2013) (examining
allegations in complaint to determine whether plaintiff alleged ordinary
negligence, not subject to opinion letter requirement, or medical malpractice,
subject to opinion letter requirement); Nichols v. Milford Pediatric Group,
P.C., 141 Conn. App. 707, 711–16, 64 A.3d 770 (2013) (same); Votre v. County
Obstetrics & Gynecology Group, P.C., 113 Conn. App. 569, 575–80, 966 A.2d
813 (2009) (same). Accordingly, not every claim against a medical institution
necessarily is subject to the good faith opinion certification requirement.
In the present case, the plaintiff alleges: (a) negligent provision of medical
care and treatment by medical personnel; and (b) negligent hiring/supervi-
sion and negligent failure to promulgate policies by the defendant institu-
tions. There is no doubt that the former sounds in medical malpractice. The
plaintiff has not claimed that her allegations of institutional negligence do
not sound in medical malpractice and, therefore, are not subject to the
opinion letter requirement. Accordingly, we need not consider whether,
even if the opinion letter is insufficient as to the allegations based on
vicarious liability, the plaintiff would be entitled to proceed on her allegations
of institutional negligence.
5
The dissenting justice states that ‘‘[t]he analysis under . . . § 52-184c
(c) (2) expressly requires certif[ication] by the appropriate American board
in the same specialty . . . .’’ (Emphasis in original; internal quotation marks
omitted.) The dissenting justice further states ‘‘that the legislature’s use of
the article ‘the,’ rather than the more expansive ‘an,’ in modifying the phrase
‘appropriate American board’ demonstrates that the defendant and the opin-
ion letter author must, in fact, be certified by the same board and, ergo,
members of the same profession.’’ We disagree. The legislature did not use
the term ‘‘same board,’’ rather it used the term ‘‘the appropriate American
board . . . .’’ General Statutes § 52-184c (c). It could have easily used the
term ‘‘same board’’ but chose not to do so. Indeed, it did use the term
‘‘same’’ when referring to ‘‘same specialty . . . .’’ General Statutes § 52-
184c (c). Accordingly, we conclude that § 52-184c (c) does not require the
similar health care provider to be certified by the same board as the health
care provider who is alleged to have been negligent.
Moreover, we disagree with the dissent’s conclusion that the similar health
care provider and the health care provider who is alleged to have been
negligent must be ‘‘members of the same profession.’’ The term ‘‘profession’’
is not used anywhere in § 52-190a or § 52-184c. We refuse to add terms to
the statutory language.
Accordingly, we reject the dissent’s construction of § 52-184c (c) so as
to require that the similar health care provider be licensed by the same
board and be in the same profession as the health care provider who is
alleged to have been negligent because such a construction alters the lan-
guage of the statute.
6
The dissent discounts the statutory scheme requiring nurse-midwives to
‘‘practice within a health care system and have clinical relationships with
obstetrician-gynecologists that provide for consultation, collaborative man-
agement or referral . . . .’’ General Statutes § 20-86b. Instead, the dissent
relies on the fact that the licensing and board certification requirements for
nurse-midwives are separate and distinct from those required for obstetri-
cian-gynecologists. We disagree. The fact remains that nurse-midwives can-
not practice independently in Connecticut, but, are required to practice with
a certified obstetrician-gynecologist. This legislative mandate supports our
conclusion that the obstetrician-gynecologist who provided the good faith
certificate in the present case was a similar health care provider.
7
Indeed, that such a proposition is indisputable is reflected in case law.
In Ali v. Community Health Care Plan, Inc., 261 Conn. 143, 150, 801 A.2d
775 (2002), wherein a certified nurse-midwife had been found negligent, this
court considered whether the trial court properly had instructed that jury
that the standard of care to be applied in the case was that of a ‘‘reasonably
prudent nurse-midwife engaged in the practice of obstetrics and gynecol-
ogy.’’ (Emphasis altered.) Although this court’s resolution of that question
turned on the evidence presented in that case, it is instructive that the
plaintiff’s expert, a board certified obstetrician and gynecologist, testified
that a certified nurse-midwife is a practitioner of obstetrics and gynecology.
Id., 151. Apparently, the defendant in that case did not offer evidence to
call this characterization into question. Thus, the issue in the case was not
whether the certified nurse-midwife practiced in this field. Rather, it was
whether, by stating the standard of care in relation to a ‘‘reasonably prudent
nurse-midwife,’’ rather than a ‘‘reasonably prudent professional,’’ the trial
court instructed the jury that it was to hold the certified nurse-midwife to
a lower standard than other practitioners engaged in the field of obstetrics
and gynecology. Id., 149–50; see also Robbins v. Physician for Women’s
Health, LLC, Superior Court, judicial district of New London, Docket No.
5002633 (October 16, 2007) (44 Conn. L. Rptr. 315, 316–17) (The defendant,
a certified nurse-midwife ‘‘is trained and experienced in the same specialty
as the opinion writer in this case, an obstetrician-gynecologist. Both are
trained and experienced in providing prenatal care for pregnant women and
providing assistance/medical care to women during childbirth. Furthermore,
both are certified in the same specialty of providing medical care to women
prior, during, and after childbirth. Lastly, the court is persuaded by the
opinion writer’s assertion that he/she has ‘supervised midwives’ and that
he/she is ‘informed about the level of obstetric care they are expected
to furnish.’ ’’).
8
The defendants seem to suggest that reading the statutes so as to allow
an obstetrician and gynecologist to provide a good faith certificate for a
claim of medical malpractice involving a certified nurse-midwife would lead
to an absurd result because a certified nurse-midwife could then provide
a good faith certificate for a claim of medical malpractice involving an
obstetrician and gynecologist. As we explained in this opinion, the statutory
scheme in Connecticut requires a nurse-midwife to be supervised by and
practice in conjunction with an obstetrician and gynecologist, there is no
statute requiring that an obstetrician and gynecologist work in conjunction
with a nurse-midwife. Accordingly, there may be a basis to distinguish
between these two professionals for purposes of the opinion letter, at least
insofar as those patients and procedures for which an obstetrician is
required. In the present case, however, we need not decide whether a nurse-
midwife would be able to opine as to the appropriate standard of care for
an obstetrician and gynecologist.
9
The dissent also relies on Bennett v. New Milford Hospital, Inc., supra,
300 Conn. 17, to argue that, while an obstetrician-gynecologist may be able
to testify in a case of this nature, he or she could not provide the good faith
certification. Bennett is simply not applicable to this case because it involved
a good faith certification authored by a general surgeon that related to the
alleged malpractice of a physician whom the plaintiff had alleged was a
specialist in emergency medicine. The dissent appears to agree with us that
the specialty at issue in the present case is obstetrics, and that obstetrician-
gynecologists and nurse-midwives both have the same specialty—obstetrics.
Therefore, the discussion in Bennett regarding whether two health care
providers practice in the same specialty is not applicable to the present case.
Moreover, as this court has recognized many times, the purpose of § 52-
190a was to prevent frivolous malpractice actions. See, e.g., id., 12. It was not
intended to serve as a sword to defeat otherwise facially meritorious claims.
10
The fact that the plaintiff’s complaint leaves open the possibility of
negligence of other employees of the defendants or specifically alleges
negligence on the basis of the institution’s failure to promulgate policies
and procedures is not relevant to our present analysis. The plaintiff need
not address every allegation of negligence in the opinion letter. Under § 52-
190a (a), the attorney or claimant must obtain a written and signed opinion
of a similar health care provider as defined in § 52-184c to show the existence
of a good faith belief that there has been negligence in the treatment of the
claimant. Section 52-190a (a) does not specify that the attorney or claimant
must obtain a good faith opinion certification regarding every defendant.
Therefore, a good faith opinion certification of someone who qualifies as
a similar health care provider for purposes of any of the defendants satisfies
the requirements of § 52-190a (a).