IN THE COURT OF APPEALS OF NORTH CAROLINA
No. COA19-350
Filed: 19 November 2019
Mecklenburg County, No. 18 CVS 5560
BETTY LOU DEMARCO, Plaintiff,
v.
CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY d/b/a CAROLINAS HEALTHCARE SYSTEM, CAROLINAS PHYSICIANS NETWORK, INC. d/b/a CABARRUS FAMILY MEDICINE, P.A., and CABARRUS FAMILY MEDICINE- HARRISBURG, CAROLINAS MEDICAL CENTER-NORTHEAST d/b/a NORTHEAST WOMEN’S HEALTH & OBSTETRICS, Defendants.
Appeal by plaintiff from order entered 7 January 2019 by Judge Adam M.
Conrad in Mecklenburg County Superior Court. Heard in the Court of Appeals
17 October 2019.
Stubbs & Perdue, P.A., by Matthew W. Buckmiller and Joseph Z. Frost, for plaintiff.
Alston & Bird, LLP, by Brian D. Boone, Michael R. Hoernlein, and Rebecca L. Gauthier, for defendants.
ARROWOOD, Judge.
Betty Lou Demarco (“plaintiff”) appeals from order granting motion of
Charlotte-Mecklenburg Hospital Authority, Carolinas Physicians Network, Inc., and
Carolinas Medical Center-Northeast (“defendants”) to dismiss plaintiff’s claims with
prejudice pursuant to N.C.R. Civ. P. 12(b)(6) (2019). For the following reasons, we
affirm in part, reverse in part, and remand. DEMARCO V. CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Opinion of the Court
I. Background
This case arises from an error in plaintiff’s medical records. Plaintiff’s
complaint alleges that she is a 76-year-old woman who receives disability
compensation from the U.S. Department of Labor’s Office of Worker’s Compensation
Programs (“OWCP”). Under OWCP policy, plaintiff is required to undergo annual
medical evaluations which are sent by plaintiff’s doctors to OWCP. In preparation
for an upcoming medical evaluation, plaintiff requested a copy of her medical record
from her previous annual evaluation from Dr. Katherine Foster (“Dr. Foster”), an
employee of defendants. One document in plaintiff’s medical record, titled “Problem
List,” catalogues instances in which her attending physicians have recorded her
various ailments over time, along with information concerning when the problem was
last updated and whether or not it is ongoing or resolved.
Upon receipt of her medical record, plaintiff discovered erroneous entries in
the Problem List. The Problem List contained two entries (“the erroneous entries”)
created in 2011 by Dr. Linda Bresnahan (“Dr. Bresnahan”), an employee of
defendants Charlotte-Mecklenburg Hospital Authority and Carolinas Medical
Center-Northeast. The erroneous entries indicated that plaintiff had been diagnosed
with “gonococcal infection (acute) of lower genitourinary tract” and “gonorrhea” in
2011, which were “resolved” in January of 2016. Plaintiff has neither been diagnosed
with nor treated for any sexually transmitted disease in her lifetime.
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Plaintiff contacted Dr. Bresnahan to address the erroneous entries, and Dr.
Bresnahan admitted that they had been “added to [her] chart erroneously in Dec[.]
2011[,]” “found no reason” why they were entered, and had no explanation for how
the erroneous entries had been added to her medical record. To address this mistake,
Dr. Bresnahan amended the Problem List for the erroneous entries by adding
language reflecting that the diagnoses had been “canceled” and “entered in error”
(hereinafter “the annotated entries”).
Thereafter, plaintiff repeatedly insisted that this solution was insufficient and,
per defendants’ privacy policy and the Health Insurance Portability and
Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936 (“HIPAA”)
regulations, requested an amendment of her medical record to completely erase the
annotated entries from her medical record. Defendants deemed their response
sufficient to address the problem and took no further action to change the Problem
List in plaintiff’s medical record.1 In January of 2018, Dr. Foster conducted plaintiff’s
annual medical evaluation for submission to OWCP. Dr. Foster sent OWCP the
medical evaluation along with the rest of plaintiff’s medical record, including the
annotated entries.
Defendants’ refusal to comply with plaintiff’s request to completely erase the
annotated entries from her medical record led plaintiff to file her complaint in the
1 Plaintiff notes that defendants did erase the annotated entries entirely after the filing of her complaint in the instant case.
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instant case, asserting claims of negligence, negligent infliction of emotional distress,
intentional infliction of emotional distress, and defamation. Defendants responded
by moving to dismiss the complaint with prejudice for failure to state a claim upon
which relief could be granted, pursuant to N.C.R. Civ. P. 12(b)(6). A hearing on this
motion was held at the 6 November 2018 civil session of Mecklenburg County
Superior Court. The trial court entered an order granting defendants’ motion, and
this appeal followed.
II. Discussion
Plaintiff argues that the trial court erred in dismissing her claims of
negligence, negligent infliction of emotional distress, and defamation pursuant to
Rule 12(b)(6), for failure to state a claim upon which relief can be granted.2 We
address each argument in turn.
A. Standard of Review
“We review appeals from dismissals under Rule 12(b)(6) de novo.” Arnesen v.
Rivers Edge Golf Club & Plantation, Inc., 368 N.C. 440, 448, 781 S.E.2d 1, 8 (2015)
(citations omitted).
Dismissal of an action under Rule 12(b)(6) is appropriate when the complaint fail[s] to state a claim upon which relief can be granted. [T]he well-pleaded material allegations of the complaint are taken as true; but conclusions of law or unwarranted deductions of fact are
2 Plaintiff has abandoned a fourth assignment of error on appeal regarding the trial court’s
dismissal of her claim for intentional infliction of emotional distress. See N.C.R. App. P. 28(a) (2019) (“Issues not presented and discussed in a party’s brief are deemed abandoned.”).
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not admitted. When the complaint on its face reveals that no law supports the claim, reveals an absence of facts sufficient to make a valid claim, or discloses facts that necessarily defeat the claim, dismissal is proper.
Id. at 448, 781 S.E.2d at 7-8 (internal quotation marks and citations omitted).
B. Negligence
Plaintiff first argues that dismissal of her negligence claim was improper
because her complaint adequately pleaded a legally viable claim against defendants.
We agree.
Under the common law, a person who has sustained injuries due to the negligent conduct of another may recover against the tortfeasor provided that the negligent behavior was the proximate cause of the injuries suffered. The elements of common law negligence . . . [are] as follows:
1. A duty, or obligation, recognized by the law, requiring the actor to conform to a certain standard of conduct, for the protection of others against unreasonable risks[;]
2. A failure on his part to conform to the standard required[;]
3. A reasonabl[y] close causal connection between the conduct and the resulting injury[; and]
4. Actual loss or damage resulting to the interests of another[.]
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Hutchens v. Hankins, 63 N.C. App. 1, 12-13, 303 S.E.2d 584, 591-92 (1983) (emphasis,
alterations, and internal citations omitted). We address whether plaintiff has
sufficiently pleaded each element of negligence in turn.
1. Duty
First, plaintiff’s complaint asserts that defendants owed a duty to her as their
patient “to exercise reasonable care, skill, and diligence to ensure that the protected
health information contained in Plaintiff’s medical records was accurate and correct,
and did not contain any erroneous diagnoses or treatments” and to “prevent . . .
dissemination of false, inaccurate, offensive, and derogatory protected health
information relating to Plaintiff to third parties[.]” Plaintiff’s complaint contends this
duty is based upon both common law principles and HIPAA.
It is well established that hospitals and doctors in their employ owe their
patients a duty to exercise the degree of care that a reasonable person would in
similar circumstances to prevent an unreasonable risk of harm to their patients.
Blanton v. Moses H. Cone Mem’l Hosp., Inc., 319 N.C. 372, 375, 354 S.E.2d 455, 457-
58 (1987) (citing Rabon v. Rowan Mem’l Hosp., Inc., 269 N.C. 1, 152 S.E.2d 485 (1967)
(general duty of care); Hoke v. Glenn, 167 N.C. 594, 83 S.E. 807 (1914) (duty of
reasonable care in selecting agents); Payne v. Garvey, 264 N.C. 593, 142 S.E.2d 159
(1965) (duty of reasonable care in maintaining equipment)). We have not had
occasion to consider whether or not this general duty of reasonable care extends to
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corrections of erroneously entered medical records. Plaintiff also argues that HIPAA
and defendants’ own privacy policy impose upon them a duty to take reasonable
measures in response to her request to correct erroneous entries in her medical
records.
Although the existence of such a duty is an issue of first impression for this
Court, we have previously held that HIPAA, its implementing regulations, and
hospital privacy policies may be used to plead a specific standard of care sufficient to
overcome dismissal under Rule 12(b)(6). See Acosta v. Byrum, 180 N.C. App. 562, 638
S.E.2d 246 (2006). In Acosta, a patient sued her treating hospital for negligence
because one of its doctors provided his access code for the patient’s medical records to
an unauthorized party, who then viewed the records and shared information therein.
Id. at 565, 638 S.E.2d at 249. The patient’s complaint alleged that the defendant
hospital owed her a duty to conform to a standard of care established by HIPAA and
its own privacy policy, which it breached when its doctor gave his password to an
unauthorized individual. Id. The complaint did not mention any specific provisions
of HIPAA or the hospital’s privacy policy which established this standard of care. Id.
at 568, 638 S.E.2d at 250-51. We held that the patient was “not required in her
complaint to cite the exact rule or regulation. See N.C. Gen. Stat. § 1A-1, Rule 8. She
only must provide [defendants] notice of how she plan[ned] to establish the duty that
was negligently breached.” Acosta, 180 N.C. App. at 568, 638 S.E.2d at 251. The
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patient’s complaint sufficiently pleaded the element of duty for the purposes of Rule
12(b)(6) because it provided the hospital notice that she intended to use HIPAA and
the hospital’s own policy to establish the duty and standard of care. Id.
In Acosta, it was much more evident that the defendant’s conduct violated
several explicit prohibitions in HIPAA. However, we find the aforementioned
principle in Acosta applicable here. Plaintiff’s complaint likewise does not cite any
specific provisions of HIPAA or defendants’ privacy policy which establish their duty
to respond reasonably to her request to remove the annotated entries from her
medical record. As in Acosta, we hold that plaintiff’s complaint sufficiently pleads
defendants’ duty to adhere to a particular standard of care because it notifies
defendants that she plans to use HIPAA and defendants’ own privacy policy to
establish their duty to act reasonably in response to her request to remove an
erroneously entered diagnosis from her medical records.3
2. Breach
Accordingly, we also hold that plaintiff’s complaint adequately pleads breach
of duty. The complaint asserts that defendants failed to meet the alleged standard of
3 At oral argument, counsel for defendants suggested that HIPAA preempts tort claims arising from the creation and sharing of medical records. We need not address this argument because defendants did not raise it at trial. See N.C.R. App. P. 10(a)(1) (2019) (requiring parties to raise arguments and objections before trial court and obtain rulings thereon in order to preserve for appellate review); State v. Holliman, 155 N.C. App. 120, 123, 573 S.E.2d 682, 685 (2002) (“[W]here a theory argued on appeal was not raised before the trial court, the law does not permit parties to swap horses between courts in order to get a better mount in the appellate courts.”) (internal quotation marks and citations omitted).
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care by, among other things, adding annotations to the erroneous entries rather than
erasing them entirely. See Acosta, 180 N.C. App. at 568, 638 S.E.2d at 251 (implicitly
addressing breach in discussion of standard of care).
Defendants argue that they did not breach their duty to plaintiff as a matter
of law, citing Thornburg v. Long, 178 N.C. 589, 101 S.E. 99 (1919). In Thornburg, our
Supreme Court held that a doctor does not breach his common law duty of care when
he makes “an honest mistake or error of judgment in making a diagnosis . . ., where
there is ground for reasonable doubt as to the practice to be pursued.” Id. at 591, 101
S.E.2d at 100. The Supreme Court held that the defendant doctor was not liable for
misdiagnosing the patient plaintiff with syphilis, where the defendant had sent the
plaintiff’s blood sample to a laboratory for testing and returned a false indication of
the disease’s presence. Id. at 590, 101 S.E.2d at 99-100.
We find Thornburg distinguishable from the instant case. As plaintiff notes,
“Thornburg was a case involving an actual diagnosis that turned out to be false. . . .
[Here,] the False Entry appears to have been the product of negligent recordkeeping,
not the negligence of a particular doctor in reaching the wrong conclusion about a
patient’s actual signs and symptoms.” We decline to extend the rationale of
Thornburg beyond diagnosis to cover negligence in the preparation and maintenance
of a patient’s medical records.
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Furthermore, contrary to defendant’s assertion at oral argument, such medical
records do not belong to the doctor or the hospital who created them. Healthcare
providers are mere custodians of their patients’ medical records. Indeed, the
regulatory scheme implementing HIPAA makes clear that ultimate control over a
medical record lies with the patient, abridged only by enumerated exceptions. See,
e.g., N.C. Gen. Stat. § 8-53 (2017) (subject to enumerated exceptions, “medical records
shall be furnished only on the authorization of the patient”); N.C. Gen. Stat. § 90-
414.11 (2017) (recognizing patient’s rights to request restriction of use and disclosure
of medical records, access, inspect, and copy records, and request amendment of
medical records); 45 C.F.R. § 164.524(a)(1) (2019) (subject to enumerated exceptions,
“an individual has a right of access to inspect and obtain a copy of” her medical
records); 45 C.F.R. § 164.502(a) (2019) (subject to enumerated exceptions, healthcare
providers “may not use or disclose” patient’s medical records); see also Lowd v.
Reynolds, 205 N.C. App. 208, 212-15, 695 S.E.2d 479, 482-84 (2010) (stating that
patient holds physician-patient privilege, which covers medical records; deeming
plaintiff’s medical records within his “possession, custody, or control” for discovery
purposes under N.C.R. Civ. P. 34 (2019)); State v. Smith, 248 N.C. App. 804, 808, 789
S.E.2d 873, 877 (2016) (implicitly holding defendant-patient had standing to
challenge admissibility of his medical records in criminal case).
3. Causation
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The test of proximate cause is whether the risk of injury, not necessarily in the precise form in which it actually occurs, is within the reasonable foresight of the defendant. Questions of proximate cause and foreseeability are questions of fact to be decided by the jury. Thus, since proximate cause is a factual question, not a legal one, it is typically not appropriate to discuss in a motion to dismiss.
Acosta, 180 N.C. App. at 568-69, 638 S.E.2d at 251 (alteration, internal citations, and
quotation marks omitted). Here, the complaint alleges that the harm plaintiff
suffered was a “direct and proximate result of Defendants’ negligence” and was
“reasonably foreseeable to Defendant[s.]” Because the complaint adequately recites
the element of causation, an issue of fact for the jury to decide, plaintiff has made a
sufficient pleading of causation under Rule 12(b)(6).
4. Damages
An allegation of damages is sufficient under Rule 12(b)(6) “so long as it
provide[s] the defendant notice of the nature and basis of plaintiff[’s] claim so as to
enable him to answer and prepare for trial.” Acosta, 180 N.C. App. at 570, 638 S.E.2d
at 252 (internal quotation marks omitted) (citing McAllister v. Ha, 347 N.C. 638, 646,
496 S.E.2d 577, 583) (1998)). Here, plaintiff’s complaint claims that defendants’
breach of duty caused her reputational harm, marital strife and loss of consortium,
and “severe and crippling economical [sic], physical, and emotional distress, . . . pain
and suffering, [and] lost opportunities[.]” This allegation is specific enough to allow
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defendants to prepare a defense as to each of the listed grounds of harm. Thus,
plaintiff has adequately pleaded damages.
Plaintiff’s complaint adequately pleads all four elements of negligence, stating
a claim upon which relief could theoretically be granted to her if proven. While we
express no opinion as to whether plaintiff can survive a motion for summary
judgment or prevail on the merits at trial, she has alleged sufficient facts to survive
a pre-answer motion to dismiss under Rule 12(b)(6). Therefore, the trial court erred
in granting defendants’ motion to dismiss her claim of negligence pursuant to Rule
12(b)(6). We reverse the portion of the trial court’s order dismissing plaintiff’s
negligence claim and remand for further proceedings on this matter.
C. Negligent Infliction of Emotional Distress
Second, plaintiff argues that the trial court erred in dismissing her claim for
negligent infliction of emotional distress. Plaintiff’s complaint alleges that
defendants’ negligence inflicted severe emotional distress upon her. Because plaintiff
has pleaded a viable claim for negligence arising from the same facts, we need only
consider whether her complaint adequately pleads damages in the form of “severe
emotional distress.”
“To state a claim for negligent infliction of emotional distress under North
Carolina law, the plaintiff need only allege that: ‘(1) the defendant negligently
engaged in conduct, (2) it was reasonably foreseeable that such conduct would cause
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the plaintiff severe emotional distress, and (3) the conduct did in fact cause the
plaintiff severe emotional distress.’ ” Sorrels v. M.Y.B. Hospitality Ventures of
Asheville, 334 N.C. 669, 672, 435 S.E.2d 320, 321-22 (1993) (alteration omitted)
(quoting Johnson v. Ruark Obstetrics, 327 N.C. 283, 304, 395 S.E.2d 85, 97 (1990)).
As discussed supra section B.3, the issue of proximate causation and foreseeability of
harm is inappropriate for consideration on a motion to dismiss per Rule 12(b)(6).
Thus, plaintiff’s complaint will pass muster under Rule 12(b)(6) if it sufficiently
pleads severe emotional distress as damages.
“[T]o establish severe emotional distress . . ., the plaintiff must show an
emotional or mental disorder, such as, for example, neurosis, psychosis, chronic
depression, phobia, or any other type of severe and disabling emotional or mental
condition which may be generally recognized and diagnosed by professionals trained
to do so.” Sorrels, 334 N.C. at 672, 435 S.E.2d at 322 (internal quotation marks and
citation omitted). An allegation of severe emotional distress is sufficient to overcome
dismissal under Rule 12(b)(6) so long as it provides the defendant with “notice of the
nature and basis of plaintiff[’s] claim so as to enable him to answer and prepare for
trial.” Acosta, 180 N.C. App. at 570, 638 S.E.2d at 252 (internal quotation marks and
citation omitted). We have found an allegation of severe emotional distress sufficient
where the plaintiff’s claim that the defendant’s negligence caused “severe emotional
distress, humiliation, and mental anguish[,]” when considered with the plaintiff’s
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other factual allegations, provided the defendant adequate notice with which to
prepare a defense. Id.
In the instant case, plaintiff’s claim for negligent infliction of emotional
distress alleges that defendants’ negligence has caused plaintiff to suffer “severe and
grievous mental and emotional suffering, fright, anguish, shock, nervousness, and
anxiety” in light of her advanced age and the sordid nature of the erroneously
recorded affliction. Additionally, the factual allegations of the complaint specify that
the notion that defendants will continue to share the annotated entries in its
communications with OWCP has caused her to “develop[ ] depression, stress, anxiety,
unbridled fear, and emotional distress” which have manifested in other maladies such
as loss of hair, sleeplessness, extreme exhaustion, decreased energy levels, and
paranoia. Because these allegations are sufficient to provide defendants with enough
notice to prepare their defense as to severe emotional distress, the trial court erred
in dismissing plaintiff’s claim for negligent infliction of emotional distress. We
reverse the portion of the trial court’s order granting defendants’ motion to dismiss
and remand for further proceedings on this claim for relief.
D. Defamation
Third, plaintiff contends that the trial court erred in granting defendants’ Rule
12(b)(6) motion to dismiss her defamation claim. We disagree.
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“In order to recover for defamation, a plaintiff must allege that the defendant
caused injury to the plaintiff by making false, defamatory statements of or concerning
the plaintiff, which were published to a third person.” Craven v. Cope, 188 N.C. App.
814, 816, 656 S.E.2d 729, 732 (2008) (internal quotation marks and citation omitted).
“If a statement cannot reasonably be interpreted as stating actual facts about an
individual, it cannot be the subject of a defamation suit.” Id. at 817, 656 S.E.2d at
732 (citation omitted). “In determining whether a statement can be reasonably
interpreted as stating actual facts about an individual, courts look to the
circumstances in which the statement is made.” Id. (citation omitted). The truth of
an allegedly defamatory statement is a complete defense to an action for defamation.
Long v. Vertical Techs., Inc., 113 N.C. App. 598, 602-603, 439 S.E.2d 797, 801 (1994)
(citation omitted).
In the instant case, plaintiff’s complaint alleges that defendants defamed her
by sending her medical records including the annotated entries to OWCP. Plaintiff
contends that the initial language of diagnosis accompanied by the annotation that
the diagnosis was “entered in error” “suggest[s] that Plaintiff[ ] once presented to
Defendant[s] with signs or symptoms of a pelvic/vaginal inflammatory ailment, was
diagnosed with gonorrhea, and was later determined to have some other ailment
other than gonorrhea.” We disagree.
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The excerpt of plaintiff’s medical record before us on appeal consists entirely
of a Problem List in which her attending physicians have recorded her various
ailments over time, along with information concerning when the problem was last
updated and whether it is ongoing or resolved. The Problem List does not support
plaintiff’s contention because no other entries suggest that plaintiff once had some
other ailment presenting symptoms similar to those of gonorrhea. Moreover, the five
year span between the initial entry of diagnosis and subsequent correction does not
suggest that plaintiff was subsequently diagnosed and treated for some other ailment
based upon the same symptoms.
The annotated entries, viewed in the context of the Problem List in its entirety,
are reasonably interpreted to state that Dr. Bresnahan entered records of diagnoses
for “gonococcal infection (acute) of lower genitourinary tract” and “gonorrhea” in 2011,
that were last updated in 2016 to reflect that these entries were “cancelled” because
they were “entered in error.” A statement which acknowledges its own falsity is true,
and thus immune from liability for defamation. Because plaintiff has failed to plead
that defendants communicated a false statement, we affirm the trial court’s order
dismissing plaintiff’s defamation claim pursuant to Rule 12(b)(6).
III. Conclusion
For the foregoing reasons, we affirm that portion of the trial court’s order
dismissing plaintiff’s defamation claim, reverse those portions dismissing plaintiff’s
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claims for negligence and negligent infliction of emotional distress, and remand for
further proceedings not inconsistent with this opinion.
AFFIRMED IN PART; REVERSED IN PART AND REMANDED.
Judges COLLINS and HAMPSON concur.
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