Jackson v. East Bay Hospital

• Citation: 246 F.3d 1248
• Decision Date: 19 April 2001
• Docket Number: No. 98-17152,SUCCESSOR-IN-,PLAINTIFFS-APPELLANTS,DEFENDANTS-APPELLEES,98-17152
• Parties: (9th Cir. 2001) BARBARA JACKSON,INTEREST, SURVIVING WIFE AND HEIR OF ROBERT JACKSON, DECEASED; SANDRA JACKSON, A MINOR, BY THROUGH HER GUARDIAN AD LITEM, MELINDA DALE, v. EAST BAY HOSPITAL; REDBUD COMMUNITY HOSPITAL DISTRICT; MIGUEL M. OLLANDA; SPENCER STEELE; ADVENTIST HEALTH, INC
• Court: United States Courts of Appeals. United States Court of Appeals (9th Circuit)

Page 1248

246 F.3d 1248 (9th Cir. 2001)

BARBARA JACKSON, SUCCESSOR-IN- INTEREST, SURVIVING WIFE AND HEIR OF ROBERT JACKSON, DECEASED; SANDRA JACKSON, A MINOR, BY THROUGH HER GUARDIAN AD LITEM, MELINDA DALE PLAINTIFFS-APPELLANTS, v. EAST BAY HOSPITAL; REDBUD COMMUNITY HOSPITAL DISTRICT; MIGUEL M. OLLANDA; SPENCER STEELE; ADVENTIST HEALTH, INC. DEFENDANTS-APPELLEES.

No. 98-17152

UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT

Argued and Submitted December 13, 2000

Filed April 19, 2001

[Copyrighted Material Omitted]

[Copyrighted Material Omitted] James M. Braden (argued), San Francisco, California, for the plaintiffs-appellants.

Mitchell C. Tilner (argued), Mary F. Dant, Encino, California, Thomas J. Donnelly, Sonja M. Dahl, Walnut Creek, California, for defendant-appellee Redbud Community Hospital District.

John S. Gilmore (argued), Sacramento, California, for defendant-appellee Adventist Health, Inc.

Appeal from the United States District Court for the Northern District of California Marilyn H. Patel, District Judge, Presiding D.C. No. CV-96-03276-MHP

Before: David R. Thompson, Diarmuid F. O'Scannlain, and A. Wallace Tashima, Circuit Judges.

Opinion by Judge O'Scannlain; Partial Concurrence and Partial Dissent by Judge Tashima

O'Scannlain, Circuit Judge

We must decide, among other questions, whether a hospital violates the Emergency Medical Treatment and Active Labor Act ("EMTALA") if it fails to diagnose the cause of a patient's emergency condition, but treats the symptoms identified, and concludes that the patient has been stabilized.

I.

This appeal arises out of Robert Jackson ("Jackson")'s visits to the Redbud Community Hospital ("Redbud") emergency room on April 2, 4, and 5, 1996, in Clearlake, California. Redbud entered into an "Association Agreement Regarding the Affiliation of Redbud Health Care District with Adventist Health Systems/West" (the "Association Agreement") which became effective on July 5, 1995. This agreement stated that the parties anticipated a future affiliation, and that Adventist Health Systems/West ("Adventist") would provide Redbud with administrative and financial services. On July 1, 1997, Adventist and Redbud entered into an"Agreement for Purchase and Sale of Assets" (the "Purchase Agreement"). Adventist currently operates Redbud.

On April 2, 1996, Jackson visited the Lake County Mental Health Department ("Lake County") to see a psychiatrist. Jackson previously had been diagnosed with psychotic disorder, borderline intellectual functioning, and pedophilia. The Lake County staff instructed Jackson to go to the Redbud emergency room to receive a medical clearance before returning to Lake County. At Redbud, a nurse took Jackson's medical history, vital signs, current medications and drug allergies. Half an hour later, Dr. Wolfgang Schug, a Redbud emergency room doctor, examined Jackson and ordered blood tests. Dr. Schug noted that Jackson was reporting hallucination, dizziness, and unsteadiness, and that he was taking Anafranil and Ativan.¹ Dr. Schug then diagnosed Jackson as suffering from acute psychosis; neither he, nor any other Redbud physician or employee, diagnosed Jackson as suffering from an emergency medical (as opposed to a psychological or psychiatric) condition.

Redbud did not offer psychiatric care to its patients, and the unwritten policy of the Redbud emergency room was that when a patient presented to the emergency room with psychiatric complaints, the patient would be examined to determine if there were any medical components to his problem. If a medical problem was found, it would take precedence over the psychiatric complaints. If no medical problem was found, the patient would be referred to a psychiatrist or to a mental health facility for an appropriate psychiatric follow-up. Dr. Schug arranged for Lake County (which provides psychiatric care) to see Jackson upon his release, where he was evaluated by Dennis Skinner, a Lake County employee.

On April 4, 1996, Jackson returned to the Redbud emergency room. A triage nurse took Jackson's medical history, vital signs, and current medications. An hour later, Dr. Miguel Ollada, a Redbud emergency room doctor, took a separate medical history and evaluated Jackson, who complained of a sore throat, chest pain while breathing, and dry heaves. Dr. Ollada also observed Jackson talking to himself. Dr. Ollada performed a complete physical exam, and ordered a battery of tests including an electrocardiogram, a urine screening, and a blood gas test. The urine analysis indicated the presence of a tricyclic antidepressant, such as the Anafranil Jackson was known to be taking. Dr. Ollada diagnosed Jackson as having chest contusions, hypertension, and pyschosis, but not drug toxicity. Dr. Ollada gave Jackson medications, and ordered a mental health consultation, to be conducted at Lake County. Lake County refused to evaluate Jackson, however, because he had been recently seen by its staff, who found him to be non-suicidal. Believing Jackson to be non-suicidal, and his condition to have stabilized, Dr. Ollada released Jackson from Redbud, and he instructed Jackson to return to Lake County the next morning.

At 3:45 a.m. on April 5, 1996, Jackson returned to the Redbud emergency room after his wife found him wandering in the road in the middle of the night. A nurse performed an initial medical evaluation, and Dr. Ollada performed another examination at 3:50 a.m. Dr. Ollada observed that Jackson was very agitated, but he also observed that Jackson had a regular heartbeat, and that he presented no other physical symptoms. Barbara Jackson told Dr. Ollada that she believed that her husband was suicidal, because she found him in the middle of the road, waving his hands. Dr. Ollada determined that Jackson was suffering from a psychological disorder which caused his agitation, but that he was not suffering from any physical disorders. Dr. Ollada prescribed and administered Haldol and Benadryl in an effort to sedate Jackson and to stabilize his condition.² Dr. Ollada ordered that Lake County be contacted regarding Jackson's condition.

Later in the morning of April 5, Susan Smith, a Lake County crisis worker, evaluated Jackson. Smith found that Jackson's condition met the criteria for involuntary psychiatric commitment, and she concluded that he suffered from a pyschological disorder, anxiety, and a dependent personality. Smith then asked Dr. Ollada to clear Jackson for a transfer to East Bay Hospital ("East Bay"), which functioned almost exclusively as a psychiatric hospital. Dr. Ollada found that Jackson's condition had stabilized (he was no longer agitated, and was sleeping), that he was not suffering from a life- threatening condition, and that a transfer to East Bay Hospital did not pose a risk to Jackson's condition.

At 9:15 a.m., Redbud transferred Jackson to East Bay, where he was seen by Dr. Spencer Steele, a psychiatrist who performed a psychiatric, but not a physical, examination of Jackson. At the time of the transfer, Dr. Ollada believed that Jackson's condition had been stabilized. Dr. Steele prescribed more Haldol for Jackson. Shortly before 2:00 p.m., the East Bay medical staff concluded that Jackson was so unable to control his own movements that he posed a danger to himself and others. At 2:00 p.m., Jackson went into cardiac arrest. East Bay staff began to perform CPR, and they ordered an ambulance to transfer Jackson to Brookside Hospital ("Brookside"). Jackson arrived at Brookside's emergency room at approximately 2:30 p.m. Jackson received emergency care at Brookside, but he was pronounced dead at 2:37 p.m. An autopsy determined that Jackson died from sudden cardiac arrhythmia, caused by acute psychotic delirium, which was in turn caused by clomipramine (Anafranil) toxicity. None of the doctors or nurses who saw Jackson at Redbud diagnosed him as suffering from Anafranil (or other drug) toxicity.

Barbara Jackson and Sandra Jackson, Jackson's wife and daughter ("Jackson's survivors" or "the survivors") filed suit against the physicians who treated Jackson, East Bay Hospital, Redbud, and Adventist in the Northern District of California. Their complaint asserted claims under EMTALA, California Health and Safety Code § 1317, and California state tort law.

In a May 15, 1998, order, the district court granted summary judgment to Redbud and Adventist on Jackson's survivors' EMTALA and § 1317 claims. The district court also held, as a matter of law, that the agreement between Redbud and Adventist did not make Adventist liable to Jackson as Redbud's joint tortfeasor or joint venturer. In an October 8, 1998, order, the district court declined to retain supplemental jurisdiction over the remaining state law claims. The district court dismissed those claims pursuant to 28 U.S.C. § 1367(c)(3), and it tolled the statute of limitations for these claims to permit Jackson's survivors to file a new action in state court. They re-filed in state court, where their case is still pending.³ The district court entered judgment dismissing Jackson's survivors' complaint in its entirety, and they filed this timely appeal.

II.

Congress enacted EMTALA, commonly known as the "Patient Anti-Dumping Act," in response to the growing concern about the provision of adequate medical services to individuals, particularly the indigent and the uninsured, who seek care from hospital emergency rooms. Congress was concerned that hospitals were dumping patients who were unable to pay for care, either by refusing to provide emergency treatment to these patients, or by transferring the patients to other hospitals before the patients' conditions stabilized. See H.R. Rep. No. 241, 99th Cong., 1st Sess., Part I, at 27 (1985), reprinted in 1986 U.S. Code Cong. & Admin. News 579, 605 ("The Committee is greatly concerned about the increasing number of reports that hospital emergency rooms are refusing to treat patients with emergency...