DALTON SCOTT STAFFORD and KRISTINE MAJOR STAFFORD, Parents of JESSE TREY STAFFORD, Deceased, Plaintiffs/Appellants,
ANNE M. BURNS, M.D. and JOHN DOE BURNS, husband and wife; EMPOWER EMERGENCY PHYSICIANS, P.C., Defendants/Appellees.
from the Superior Court in Maricopa County No. CV2013-000019
The Honorable John Christian Rea, Judge
& Associates, Spring Lake, MI By B. Elliott Grysen
Co-Counsel for Plaintiffs/Appellants
& Roberts, P.C., Scottsdale By David L. Abney Co-Counsel
Skelton & Hochuli, P.L.C., Phoenix By Eileen Dennis
GilBride, Cristina M. Chait Counsel for Defendants/Appellees
Presiding Judge Kenton D. Jones delivered the Opinion of the
Court, in which Judge Randall M. Howe and Judge Donn Kessler
Dalton and Kristine Stafford (the Staffords) appeal the trial
court's orders denying their motions for new trial and
for relief from judgment following a jury verdict in favor of
Appellees (collectively, Dr. Burns) on the Staffords'
claims for medical malpractice and wrongful death after their
son, Jesse, died of a methadone overdose.
The Staffords argue the trial court erred in instructing the
jury, pursuant to Arizona Revised Statutes (A.R.S.) section
12-572(A),  that the Staffords bore the burden of
proof by clear and convincing evidence because, they contend,
Dr. Burns did not provide medical care "in compliance
with" the Emergency Medical Treatment and Active Labor
Act (EMTALA). See 42 U.S.C.A. § 1395dd (West).
As set forth below, we hold, as relevant here, the heightened
standard of proof for claims against a health professional
set forth in A.R.S. § 12-572(A) applies whenever the
acts or omissions plaintiff contends were deficient were
provided in the course of evaluating and treating a patient
in a hospital emergency department.
The Staffords also argue the court abused its discretion in
denying their motion for new trial based upon various
administrative and evidentiary rulings, for which we find no
Finally, the Staffords argue the trial court erred in
imposing sanctions pursuant to Arizona Rule of Civil
Procedure 68(g) because Dr. Burns' pretrial offer of
judgment was invalid in that it was not made in good faith.
We do not reach the merits of the Staffords' contention
because Rule 68(g) contains no such good faith requirement,
and we decline to impose one in contravention of the
rule's plain language and purpose.
For the reasons stated below, we affirm the trial court's
AND PROCEDURAL HISTORY
In the early morning hours of February 5, 2012, Jesse
presented at the emergency room of St. Joseph's Hospital
after having ingested an unknown quantity of methadone. After
several hours of testing, evaluation, and monitoring for a
possible methadone overdose, Dr. Burns took over Jesse's
care until he was discharged around 1:00 p.m. Jesse was found
dead the following day.
In January 2013, the Staffords filed a complaint against Dr.
Burns, asserting she negligently caused Jesse's death by
wrongfully determining his condition was stable and
discharging him prematurely. In response, Dr. Burns asserted
she complied with the standard of care and presented evidence
suggesting Jesse ingested additional methadone after his
discharge that ultimately caused his death.
After a twelve-day trial, the jury returned a defense
verdict. The Staffords' motions for new trial and for
relief from judgment were denied. The Staffords timely
appealed, and we have jurisdiction pursuant to A.R.S. §
12-120.21(A)(1) and -2101(A)(1), (2), and (5)(a).
Application of A.R.S. § 12-572(A)
A plaintiff must generally prove the elements of his medical
malpractice claim by a preponderance of the evidence. See
Harvest v. Craig, 195 Ariz. 521, 523, ¶ 10 (App.
1999) (citing Thompson v. Sun City Cmty. Hosp.,
Inc., 141 Ariz. 597, 608 (1984)). In 2009, however, our
legislature adopted A.R.S. § 12-572(A), which heightened
the burden of proving a malpractice claim against "a
health professional . . . who provides or who is consulted to
provide services to a patient of a licensed hospital in
compliance with [EMTALA]" to clear and convincing
evidence. EMTALA is a federal statute enacted to address the
growing concern that hospitals were routinely refusing
emergency medical treatment to individuals unable to pay for
services. See Eberhardt v. City of LA., 62 F.3d
1253, 1255 (9th Cir. 1995) (citing H.R. Rep. No. 241, 99th
Cong., 1st Sess. (1986), reprinted in 1986
U.S.C.C.A.N. 726-27); Scottsdale Healthcare, Inc. v.
Ariz. Health Care Cost Containment Sys. Admin., 206
Ariz. 1, 6 n.6, ¶ 20 (2003) (citing Bryant v.
Adventist Health Sys./W., 289 F.3d 1162, 1165 (9th Cir.
2002)). The Staffords argue the trial court erred in
instructing the jury on the clear and convincing burden of
proof set forth in A.R.S. § 12-572(A) because, they
contend, Dr. Burns was not providing services "in
compliance with EMTALA" as another physician had already
performed the medical screening and determined Jesse did not
have an emergency medical condition. In response, Dr. Burns
argues A.R.S. § 12-572(A) applies to "all emergency
Although we review a trial court's denial of a motion for
new trial and its decision to give a jury instruction for an
abuse of discretion, we review de novo whether jury
instructions accurately state the law. Delbridge v. Salt
River Project Agric. Improvement & Power Dist., 182
Ariz. 46, 53 (App. 1994) (citing Suciu v. AMF AC Distrib.
Corp., 138 Ariz. 514, 520 (App. 1983)); State v.
Garcia, 224 Ariz. 1, 18, ¶ 75 (2010) (citing
State v. Martinez, 218 Ariz. 421, 432, ¶ 49
(2008)); see also State v. Rios, 217 Ariz. 249, 250,
¶ 5 (App. 2007). The interpretation and application of
statutes also present questions of law which we review de
novo. City of Phx. v. Glenayre Elecs., Inc., 240 Ariz.
80, 84, ¶ 8 (App. 2016) (citing First Fin. Bank,
N.A. v. Claassen, 238 Ariz. 160, 162, ¶ 8 (App.
The heightened burden of proof of A.R.S. § 12-572(A)
applies where services are provided "in compliance with
EMTALA." EMTALA applies to any individual who comes to a
hospital's emergency department for
treatment. 42 U.S.C.A. § 1395dd(a). Under
EMTALA, the hospital is required to provide appropriate
medical screening to determine if an emergency medical
condition exists. Id. If the patient has an
emergency medical condition, the hospital must either provide
"such further medical examination and such treatment as
may be required to stabilize the medical condition, "
or, if safe and appropriate, transfer the patient to another
facility for stabilizing care. 42 U.S.C.A. § 1395dd(b)(1).
For purposes of EMTALA, a patient is "stabilized"
when "no material deterioration of the condition is
likely, within reasonable medical probability, to result from
or occur during the transfer of the individual from a
facility." 42 U.S.C.A. § 1395dd(e)(3)(B).
gamut of services that may be necessary to comply with EMTALA
cannot readily be distilled into a universally applicable and
finite list, and therefore, the phrase cannot be read
narrowly. To adopt the Staffords' view, the burden of
proof against the health care provider would shift from clear
and convincing to a preponderance of the evidence the
instant: (1) the screening process is completed and reveals
the patient does not have an "emergency medical
condition" within the meaning of EMTALA, or (2) a
patient is stabilized to the point that his condition would
not deteriorate during a transfer. This sort of
interpretation is not practical in the context of a person
seeking emergency medical care. The evaluation and treatment
of a medical condition is necessarily a fluid process,
whereby a patient's status as serious or stable may
change from moment to moment. This is particularly true where
the condition qualifies as an emergency under EMTALA -
manifesting through acute symptoms, severe pain, and the risk
of serious dysfunction or bodily impairment.
do not read EMTALA to relieve the hospital emergency
department from re-screening, re-evaluating, and even
possibly re-treating a patient if his condition changes after
an initial status determination. Indeed, federal courts have
held a hospital's duty under EMTALA can continue up to
and even after a patient is admitted for inpatient care.
See,e.g., Bryant, 289 F.3d at 1168
(concluding EMTALA duty ends when a patient is admitted in
good faith for inpatient care); Thornton v. Sw. Detroit
Hosp.,895 F.2d 1131, 1134 (6th Cir. 1990) ("[O]nce
a patient is found to suffer from an emergency medical
condition in the emergency room, she cannot be ...