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Date: 10-16-2017

Case Style: Maxine Stewart as Personal Representative, etc. v. The Superior Court of San Bernardino County, St Joseph's Health, Real Party in Interest

Case Number: E067316

Judge: Ramoirez, P.J.

Court: California Court of Appeals Fourth Appellate District Division Two on appeal from the Superior Court, San Bernardino County

Plaintiff's Attorney: Carl A. McMahan and Mark J. Habeeb

Defendant's Attorney: Louise M. Douville and Edward J. Reid

Description: The petition in this case challenges a trial court order summarily adjudicating a
cause of action under the Elder Abuse and Dependent Adult Civil Protection Act (the
Act), a cause of action for fraud by concealment, and another for medical battery, while
allowing other claims, including one for medical negligence, to proceed to trial. Stewart
is the representative of Anthony Carter, a man who died after admission to a hospital
owned by real parties in interest. She alleges the hospital “denied and withheld from Mr.
Carter the right to refuse an unnecessary surgery, denied and withheld from Mr. Carter
the right to be involved in secret hospital meetings to invalidate his designated consent,
and denied and withheld from Mr. Carter his right to a second opinion prior to proceeding
with an unwarranted surgery that resulted in a hypoxic injury, brain damage, cardiac
arrest and his untimely death.” Having concluded the petition might have merit, we
stayed the action in the trial court and requested an informal response. Having received
and read the “return by verified answer” that was filed by real parties in interest, we then
set an order to show cause and requested further briefing on a specific issue.
parties in interest decided to stand on their informal response in lieu of filing another
brief, and Stewart declined to file a traverse.
We now explain why we conclude we must grant the petition. Furthermore, we
find it important to emphasize that elders have the right to autonomy in the medical
decision-making process. We therefore publish the portion of this opinion that discusses
the cause of action for elder abuse to explain how, in our view, a substantial impairment
of this right can constitute actionable “neglect” of an elder within the meaning of both the
little-invoked catchall definition contained in Welfare and Institutions Code
section 15610.57, subdivision (a)(1), and two of the types of neglect that are set forth in
Welfare and Institutions Code section 15610.57, subdivision (a)(2).
The operative pleading alleges the following:
2 Real parties in interest3 own and
operate a hospital called St. Mary Medical Center. On February 1, 2012, Carter, who was

Our order directed the parties to “specifically . . . address the applicability of
Winn v. Pioneer Medical Group, Inc. (2016) 63 Cal.4th 148, 161 (Winn), in light of the
fact that Carter appears to have been a patient in a facility owned by real parties in
We omit allegations that are unnecessary to the resolution of this petition,
including allegations pertaining to the wound care provided to Carter.
Real parties in interest are St. Mary Medical Center, St. Joseph Health System,
and David O’Brien, M.D. For ease of reference, we refer to these parties collectively as
“St. Mary.” We mean no disrespect.
78 years old and experiencing confusion, became a patient at St. Mary. He named
Stewart, who was at all relevant times a registered nurse with an active license, his
durable power of attorney for health care decisions during this admission.
Timothy A. Denton, M.D., one of St. Mary’s codefendants, told Stewart two days
after Carter’s admission that she should consider placing Carter in hospice care, as well
as inserting a gastronomy tube (g-tube). Stewart objected, and Dr. Denton agreed to
order a calorie count instead of a g-tube.
Some of the defendants, including real parties in interest, planned to perform
surgery and implant a pacemaker in Carter, in part because he was experiencing foursecond
gaps in his heartbeat. On February 7, 2012, Stewart canceled a pacemaker
procedure and told real parties in interest she thought the four-second pauses were related
to Carter’s sleep apnea. She requested a second opinion regarding Carter’s need for a
pacemaker and opined that he had never previously shown “ ‘clear indicators’ ” that he
needed one.
Also on February 7, 2012, Dr. Denton, real parties in interest, and others told
Stewart that Carter required a g-tube because he was not receiving adequate calories.
Petitioner asked them to try parenteral nutrition (TPN) instead of a g-tube, but they
“refused to consider and/or abide by this request.”
On February 17, 2012, real parties in interest and the other defendants informed
Stewart that a pacemaker procedure was scheduled for the following day. Stewart “stated

Carter’s capacity to execute the power of attorney is not at issue in this
that she would absolutely not consent to such a procedure” and again requested a second
The next day, real parties in interest and some of the other defendants, including
Dr. Denton, determined through St. Mary’s risk management department that they could
continue with the pacemaker procedure despite petitioner’s objection. Stewart had at no
time consented to this procedure and had instead expressly objected to it.
On February 22, 2012, Stewart contacted St. Mary to inquire about Carter and
learned he had not had breakfast because he was scheduled for surgery. Stewart again
objected to the pacemaker procedure. When Stewart arrived at St. Mary at approximately
noon, she was informed the surgery had occurred at 8:30 that morning. Stewart met with
several of real parties in interest’s representatives, who told her they had proceeded
without her consent because she was not acting in Carter’s best interests.
Carter went into cardiac arrest sometime on or about February 22, 2012. On
information and belief, this occurred because Carter did not need the pacemaker. The
pacemaker was surgically removed on February 24, 2012. Carter, who had experienced
brain damage, required acute skilled nursing care until his death on April 15, 2013.
Stewart named St. Mary, Dr. Denton, and others on several causes of action in the
operative pleading. St. Mary moved for summary adjudication of most of these causes of
action. As relevant to this petition, it argued the elder abuse claim failed because holding
an ethics committee meeting about Stewart’s power of attorney over Carter could not
amount to reckless neglect within the meaning of the Act. The fraudulent concealment
claim, St. Mary contended, failed because a hospital owes no fiduciary duty to a patient,
and the medical battery claim was allegedly insufficient because the hospital itself did not
perform the surgery and the doctors who performed the surgery were not hospital
For evidentiary support for these assertions, St. Mary largely relied on a
declaration from Mary Ransbury, R.N., a licensed registered nurse and wound care
specialist; we discuss this declaration post. Using the testimony of various deponents,
including Dr. Denton, St. Mary also established the following background facts and
Dr. Denton thought a pacemaker “was clearly indicated” for Carter due to “long
[cardiac] pauses” requiring intervention by a specialist. Dr. Denton therefore referred
Carter to another codefendant, Ramin Ashtiani, M.D., who eventually made the decision
to implant the pacemaker and then actually performed the pacemaker surgery.
When Stewart refused to consent to a pacemaker procedure, Dr. Denton asked St.
Mary’s risk management department for a consultation regarding concerns he had about
Carter’s power of attorney. The risk management department decided to convene an
ethics committee meeting. Dr. Denton, who participated in the meeting by phone,
“stressed the patient could die” if he did not receive a pacemaker and said he did not feel
Stewart was acting in his best interests because Dr. Denton knew Carter would “want
everything done to save his life.” There was a suspicion “that there might be a conflict
with Ms. Stewart.” After a meeting on a Friday afternoon, an “action plan” was reached
that “the power of attorney was valid.” However, the committee also concluded that
Stewart could be voided as Carter’s designee if she failed to authorize lifesaving
measures, because “the language of the power of attorney stated, in essence, that all
measures were to be taken to preserve [Carter’s] life.” At some point in time after the
meeting, Stewart was in fact voided as the designee of Carter’s power of attorney. At his
deposition, Dr. Denton admitted he did not consult with any doctor other than
Dr. Ashtiani about Carter’s pacemaker procedure. Instead, he contacted St. Mary’s risk
management department and said something like, “Please help me with this case. There
are lots of legal issues going on. There is a power of attorney that I think is problematic,
and I don’t have a clue what to do about this.”
Dr. Denton described the ethics committee’s role in the surgery as follows:
“[W]hat happens is that I provide risk management with information and they make a
decision about what to do. [¶] . . . [¶] For example, since I don’t implant pacemakers,
they will say ‘Go ahead. The pacemaker is indicated. It’s okay to do that.’ And then the
pacemaker can be done by the person doing the procedure.” For his part, Dr. Ashtiani,
when asked if the risk management department “gave [him] the green light” to perform
the pacemaker surgery, responded, “If medically necessary, from paper standpoint, we
are okay to do that.”
In conjunction with its argument regarding the cause of action for medical battery,
St. Mary also offered an admission form showing Carter had signed his name next to an
advisement that all “Physicians and Surgeons furnishing services to the patient . . . are
independent contractors and are not employees of the hospital.” St. Mary otherwise
relied on discovery responses and the aforementioned Ransbury declaration.
The bulk of this declaration addressed allegations that St. Mary failed to provide
adequate wound care to Carter, which does not concern us for the reasons stated in
footnote 2, ante. In fact, only the last paragraph of the Ransbury declaration discussed
the ethics committee meeting or the topic of Carter’s consent to the pacemaker surgery.
That paragraph reads: “Finally, plaintiffs allege in their operative Complaint that hospital
defendants fraudulently concealed from Maxine Stewart the fact that Mr. Carter was to
undergo pacemaker implantation surgery. Based on my review of the above-referenced
materials, I note that the sole determination of the Ethics Committee was that the Power
of Attorney was valid and that the Power of Attorney indicated that all life-saving
measures were to be done for Carter. The Ethics Committee did not decide whether or
not to operate on Mr. Carter. This decision to perform surgery was made by Dr. Ashtiani.
This stands to reason given that a patient’s surgeon is the one who determines whether a
surgical procedure is appropriate and should be performed, not the hospital staff where
the surgery is to take place. Accordingly, based on my review of the above noted
materials and my education, training and experience, I conclude that hospital defendants
had no duty to inform Maxine Stewart that Mr. Carter was to undergo surgery. If such a
responsibility existed under the circumstances it would be Dr. Ashtiani’s as he was
Carter’s treating physician and surgeon.”
Stewart filed written opposition to St. Mary’s summary judgment motion. She
generally argued that declarations from two medical experts, Vikram Rajan, M.D., and
Charles Pietrafesa, M.D., created triable issues of material fact regarding the standard of
care and causation. Dr. Pietrafesa, who focused most of his opinions on the ethics of
conducting an ethics committee meeting as occurred in this case, discussed in detail his
opinion “that the decision to implant a permanent pacemaker without appropriate
informed consent on this patient fell below the standard of care in the medical
community.”5 He was of the opinion that anyone who wanted to operate on Carter
without Stewart’s consent was required to obtain a court order, as well as that petitioner
or her representative should have been at the ethics committee meeting, which he called a
“sham.” Finally, Dr. Pietrafesa concluded that the act of “authorizing and proceeding
with this unnecessary surgery directly resulted in the patient’s cardiac arrest and resulting
death.” For his part, Dr. Rajan opined that Dr. Denton breached the standard of care by
informing St. Mary that the “surgery to implant a permanent pacemaker was a life
threatening condition that required immediate action.” In Dr. Rajan’s opinion, there was
no evidence that a pacemaker was needed on an emergency basis. Like Dr. Pietrafesa,
Dr. Rajan determined that the pacemaker surgery led to Carter’s death.

5 From 1992 to 2009, Dr. Pietrafesa served as the Executive Medical Director and
Chief Medical Officer at St. John’s Health Center in Santa Monica, California. In that
capacity, he was “responsible for the management of the ethic committee,” established
the hospital’s bioethics service, and “had consulting and direct line responsibility for the
day to day operations of the activities of the hospital’s bioethics function.”
In addition to the declarations of Dr. Pietrafesa and Dr. Rajan, Stewart relied in
part on evidence in the form of doctor’s notes6
from Carter’s medical file. These
establish the following:
Dr. Denton noted on the February 1, 2012 admission form that Carter had “a long
complex history” and described Carter’s social environment as “fairly supportive.” After
a consultation that occurred the day after Carter’s admission, a different doctor described
him as “markedly somnolent” and indicated that he “open[ed his] eyes only transiently.”
On February 6 or 7, 2012, Dr. Denton completed a doctor’s note regarding
“extensive discussions” he had with Stewart regarding Carter’s caloric intake on an
undisclosed date. The note reflects that Stewart asked to wait until after a calorie count
was completed before placing a g-tube, and that she still did not want a g-tube. She said
Carter was “taking in more calories now” after Dr. Denton indicated Carter was not
consuming adequate nutrition. Although Dr. Denton agreed to make a final decision
about g-tube placement later, he indicated he would ask to have Carter “observe[d]
during the intervals when the family is in the room.”
Rajeev Yelamanchili, M.D., is the doctor who had previously treated Carter for
sleep apnea, as alleged in the operative pleading. On February 7, 2012, Dr. Yelamanchili
consulted with Carter regarding “obstructive sleep apnea syndrome [(OSA)] with sinus
pauses”; he stated Carter had been diagnosed with “severe OSA . . . 2 years back.” He

6 Various doctor’s notes refer to Carter’s “girlfriend” or “wife.” The operative
pleading refers to Stewart as Carter’s “partner,” and one of Stewart’s experts referred to
her as Carter’s “life partner.” We follow the parties’ convention and infer that any
references to Carter’s partner, girlfriend, or wife are to Stewart.
suggested treating Carter’s apnea “to see how the sinus pauses are,” said he would be
“happy to follow [Carter] as an outpatient after discharge,” and indicated a repeat study
might need to occur because Carter had lost a significant amount of weight.
Dr. Yemanchili’s report concludes with: “If the follow up study fails to reveal evidence
of OSA with sinus pauses then permanent pacemaker will be indicated. I have informed
this to the wife and she is satisfied.”
On February 8, 2012, Arnab Biswas, DO, provided a consultation regarding
placement of a g-tube because Carter was “unable to take anything by mouth.”
Dr. Biswas noted Carter was “a very poor historian. He only grunts and mumbles and is
unable to provide any intelligible history.” Because Stewart was “unavailable,”
Dr. Biswas was forced to obtain much of Carter’s history from records and physical
examination. Dr. Biswas indicated that someone would discuss “risks and benefits of” gtube
placement with Stewart, as well as that “TPN would be a good short-term solution”
if a g-tube was intolerable or impossible.
The next doctor’s note in chronological order is signed by Dr. Denton and dated
February 18, 2012. After a notation that “[m]uch has happened over the last 24 hours,”
Dr. Denton described the ethics committee meeting and the decision reached thereat. He
then remarked: “Given this, [Stewart] was contacted by the nursing staff stating we are
going to be moving forward with appropriate care of this patient. [¶] What is also clear
is that Adult Protective Services has been called and are anxiously await [sic] my
interview with Adult Protective Services. [¶] So what we have now is, we now have the
freedom to provide appropriate care for this patient and today we will be trying to find
the appropriate calorie count.” After recounting that Carter was oriented to person but
not place or time, Dr. Denton opined that Carter “[c]learly” could not make decisions on
his own. He then wrote: “If the document is legal, if the power of attorney is legal, then
we will proceed appropriately. If the power of attorney is not legal, then we will proceed
appropriately with the exact same therapy.” The February 18, 2012 doctor’s note
concluded by indicating that Dr. Denton was waiting for a final calorie count but planned
to order g-tube placement and that he would “be making determination regarding the
appropriateness of permanent pacemaker placement, even though he has already had a 4
second pause.”
Dr. Ashtiani prepared a report after the pacemaker surgery on February 21, 2012.
He acknowledged Carter’s sleep apnea but stated, “it was determined that patient will
definitely benefit from pacemaker due to prevention of malignant form of arrhythmia and
its complications especially if it happens and provoked during episodes of sleep apnea.”
Next, Dr. Ashtiani commented that Stewart had previously revoked consent to the
pacemaker surgery and said he told Dr. Denton he “basically discharged [him]self from
the rest of the care for the patient.”
Dr. Ashtiani then wrote: “Again, I was contacted by Dr. Denton since he had
frequent and multiple discussions with the patient’s girlfriend due to different medical
issues and need for medical intervention and refusal of her to help the patient. She
provided with a paper stating as power of attorney which was obtained when the patient
was not alert and oriented, to be able to consent for that. Basically, this lady never had
any power of attorney, in order to have any legal thing about the case and she of course
did not seem to be his best advocate when he needed the most. For that reason, risk
management from the hospital got involved and they determined that we should proceed
to implant a pacemaker if medically is necessary. I had this discussion with Dr. Kyle as
well as Dr. O’Brien and he agreed upon the planned procedure based on this discussion.
I also spoke with Dr. Yelamanchili, the pulmonologist and he also agreed upon the
planned procedure and the logic behind the implantation of the device. For those
mentioned reason, we decided to proceed with the implantation of the device.” The final
sentence before the report’s conclusion section is: “I need to mention, the consent was
signed by two physicians which was advocated through risk management, myself, and
Dr. Denton.”
The final doctor’s order contained in our record was prepared by Carter’s
discharging physician, Huy Nguyen, M.D. The note explained that Dr. Denton had
admitted Carter, but that Dr. Nguyen “took over as the primary care physician on request
of [Stewart] who has verbal power of authority for second opinion.” After initially
deeming it inappropriate to remove the pacemaker as Stewart had requested, Dr. Nguyen
later consulted with Dr. Arshia Noori and decided to remove the pacemaker, after all.
This was because, “on review of the telemonitor strips, it looks like the RV lead was not
adequately . . . placed, is autocapturing and then it sent him into cardiac ventricular
In addition to these doctor’s notes and related records concerning Carter, Stewart
relied on deposition testimony from numerous witnesses when opposing St. Mary’s
summary judgment motion. Stewart herself testified that Carter first gave her authority to
make medical decisions on his behalf in 1998 or 1999. She said when she asked
Dr. Denton about trying TPN instead of a g-tube during Carter’s 2012 admission to St.
Mary, his response was, “Absolutely not.” He gave no reason. When asked whether,
based on her education and training as a nurse, Stewart had developed an impression as to
why Dr. Denton might have rejected TPN, her response was, “I believe he wanted
[Carter] to be put in a care facility.” Stewart confirmed that Carter had been seeing
Dr. Yelamanchili for sleep apnea “[f]or many years,” and she reported that, when
Dr. Denton first told her he recommended a pacemaker, she said, “That’s because he has
sleep apnea. . . . He needs to be on a CPAP machine.” Stewart’s “next step” was to
contact Dr. Yelamanchili, which she did “the next moment [she] was able to speak to
him.” When Stewart “told [Dr. Yelamanchili] that Dr. Denton wanted to put in a
pacemaker, [Dr. Yelamanchili] said, ‘We don’t need to do anything invasive. He needs a
CPAP machine.” Stewart then testified that a St. Mary employee called to tell her a
pacemaker surgery had been scheduled; Stewart “just told them, ‘I’m not consenting,’
and that [she] wanted a second opinion.”
One of the other deponents on whose testimony Stewart relied is Susan Alvarez,
who was asked by her director, Mia Bunch, to participate in the ethics committee meeting
“as a member of the risk management team.”
7 Alvarez explained that Dr. Denton called
Bunch, in her capacity as St. Mary’s risk manager, to discuss concerns he had regarding
Carter’s care. Sometime before noon on Friday, February 17, 2012, the ethics team,
including Alvarez, met in a conference room; Dr. Denton participated by telephone. The
meeting lasted approximately 20-30 minutes and included Alvarez, a case manager
named Minda, someone from social services, a woman named Mary, and a nonclinical
employee named John Perring-Mulligan. Avarez is “not clinical, either.” No one “from
[Carter’s] side” attended. Later the same day, Alvarez, Bunch, and Perring-Mulligan met
in the office of St. Mary’s CEO to discuss “what the concerns were.” Dr. Denton was not
present at all, but at least one attorney participated by telephone. After meeting for
“[m]aybe 20 minutes,” the “action plan,” or the determination that the power of attorney
was valid but that Stewart was voided as the designee, was made. In “the second part of”
this meeting, Bunch was to contact Dr. Denton and tell him about the action plan.
Alvarez explained that, on Tuesday, February 22, 2012, she, Bunch, Dr. O’Brien,
and others met with Stewart, who first learned that the pacemaker surgery had occurred.
As Alvarez admitted, “the surgery went forward anyway against Maxine Stewart’s
directive not to proceed.” In response to a question implying Dr. Denton had suggested
Stewart had some kind of financial motive for refusing the pacemaker, Alvarez stated:
“What I recall why he was talking about finances and he was saying that he knew—he

7 Some of the testimony from Alvarez and Bunch that Stewart used in opposing
the motion is identical to the testimony St. Mary used to establish the foundational facts
we described ante. We now summarize only that testimony from Stewart that is new.
knew [Carter], you know, through his office, basically like he’s cared for this patient, and
he just said that she—maybe it—it could be. I mean he really didn’t say why, but he said
financial, you know. You need to look at the financial aspect, or he mentioned something
about her taking control of money, but that’s when our person said, ‘That part we don’t
talk about.’ [¶] . . . [¶] John [Perring-Mulligan] basically shut that down.”
Bunch’s deposition testimony adds the following additional details. Neither Dr.
Ashtiani (the surgeon who implanted the pacemaker), Dr. Yelamanchili (the
pulmonologist who treated Carter for sleep apnea), nor Dr. Biswas (the author of the
“poor historian” doctor’s note) participated in the ethics process. Rather, “[i]t was
Dr. Denton, from an M.D. standpoint, that was involved in that decision.” Although she
would not speculate as to his meaning, Bunch admitted Dr. Denton, when told of the
action plan, spoke the words, “So my posterior is covered.” Bunch also authenticated a
note she had written, which reads, “Explained conversation with [power of attorney]
Maxine wanting second opinion. Dr. Denton stated, ‘I won’t do that.’ ”
Stewart also noted Dr. Denton’s deposition testimony established that he and Dr.
Ashtiani were both members of the same medical group when they provided care to
Carter. Her trial court brief in opposition to St. Mary’s motion alleged that “Dr. Denton
specifically pushed for the placement of a permanent pacemaker by Dr. Ashtiani, an
electrophysiologist, his partner and a surgeon in the same group.”
Finally, Stewart offered deposition testimony from Dr. Nguyen and Dr. Noori.
Both testified that Carter did not require a pacemaker on an emergency basis. Dr. Noori
explained that Carter went into cardiac arrest after a lead from the pacemaker dislodged.
Shortly before the hearing on St. Mary’s motion for summary judgment and/or
adjudication, the trial court heard a similar motion by Dr. Denton. Finding triable issues
of material fact existed regarding breach and causation, the court denied Dr. Denton’s
motion as to Stewart’s cause of action for professional negligence. The trial court found
the motion procedurally improper as to the elder abuse claim, but it summarily
adjudicated the cause of action for medical battery because Dr. Denton “did not
physically perform the unconsented surgery.” Finally, at least as relevant to this petition,
the trial court denied the motion as to Stewart’s cause of action for fraudulent
concealment. With respect to the latter ruling, the trial court explained: “the February
18, 2012 notes suggest [Dr.] Denton was prepared to ensure the procedure no matter what
by involving Adult Protective Services, [Dr.] Denton advocated for the surgery to the
committee, and [Dr.] Denton said ‘I won’t do that’ when asked about a second opinion.
Thus, a jury could infer that the failure to inform Stewart the surgery would occur was an
intentional effort to conceal the scheduling of the surgery.”
As previously indicated, the trial court granted St. Mary’s motion for summary
judgment and/or adjudication, but only as to the causes of action for elder abuse, medical
battery, and fraudulent concealment. The court explained it was granting the motion as to
the elder abuse claim because “[i]nterpreting the power of attorney then letting a . . .
surgery occur was not withholding care or not within custodial capacity.” With respect to
medical battery, the court’s ruling was “the same as . . . [Dr.] Denton’s case,” or that St.
Mary could not be liable because Dr. Ashtiani performed the surgery. The trial court
reasoned that St. Mary “didn’t direct anybody to do the procedure. Dr. Denton signed the
authorization. Ashtiani performed the procedure. Again, the hospital just offered an
opinion regarding the health directives in this case.” Despite denying summary
adjudication on the fraudulent concealment claim when Dr. Denton moved for summary
judgment, the trial court granted St. Mary’s motion as to that cause of action on the
theory that a hospital owes no fiduciary duty to one of its patients.
Stewart lodged evidentiary objections to St. Mary’s evidence in conjunction with
her opposition, and St. Mary, in reply, did the same with respect to Stewart’s evidence.
Our record contains no indication that the trial court ruled on these objections; any such
objections are therefore presumed overruled and preserved on appellate review. (Reid v.
Google, Inc. (2010) 50 Cal.4th 512, 534.) Stewart does not argue the merits of any of her
evidentiary objections in this court. St. Mary does, but only by including in the response
a “respectful[] request [that] this [c]ourt consider [its] written objections to Petitioners’
expert declarations and disregard the objectionable material therein.” We decline the
invitation, as “[t]his court is not inclined to act as counsel for . . . appellant and furnish a
legal argument as to how the trial court’s rulings . . . constituted an abuse of discretion.”
(Mansell v. Board of Administration (1994) 30 Cal.App.4th 539, 545-546.) We therefore
consider all the evidence in the record before us.
“A party may move for summary adjudication as to one or more causes of action
within an action . . . if the party contends that the cause of action has no merit, . . .”
(Code Civ. Proc., § 437c, subd. (f)(1).) “A motion for summary adjudication may be
made by itself or as an alternative to a motion for summary judgment and shall proceed in
all procedural respects as a motion for summary judgment.” (Id., subd. (f)(2).)
“A defendant making the motion for summary adjudication has the initial burden
of showing that the cause of action lacks merit because one or more elements of the cause
of action cannot be established or there is a complete defense to that cause of action.
[Citations.] If the defendant fails to make this initial showing, it is unnecessary to
examine the plaintiff’s opposing evidence and the motion must be denied. However, if
the moving papers establish a prima facie showing that justifies a judgment in the
defendant’s favor, the burden then shifts to the plaintiff to make a prima facie showing of
the existence of a triable material factual issue. In meeting this obligation, the plaintiff
may not rely on the mere allegations of its pleadings, but must ‘set forth the specific facts
showing that a triable issue of material fact exists as to that cause of action. . . .’
[Citation.] ‘There is a triable issue of fact if, and only if, the evidence would allow a
reasonable trier of fact to find the underlying fact in favor of the party opposing the
motion in accordance with the applicable standard of proof.’ ” (Intrieri v. Superior Court
(2004) 117 Cal.App.4th 72, 81-82 (Intrieri).)
Summary adjudication rulings may be reviewed by writ of mandate. (Code Civ.
Proc., § 437c, subd. (m)(1).) In this case, writ review is particularly warranted because a
second trial would be necessary if we required Stewart to wait until an appeal from the
final judgment before deciding that summary adjudication of the causes of action for
elder abuse, fraudulent concealment, and medical battery was improper. (Noe v. Superior
Court (2015) 237 Cal.App.4th 316, 324.) Although we independently review orders
granting summary adjudication, we still “ ‘must “consider all of the evidence” and “all”
of the “inferences” reasonably drawn therefrom [citation], and must view such evidence
[citations] and such inferences [citations], in the light most favorable to the opposing
party.’ [Citation.] The trial court’s stated reasons for granting summary adjudication are
not binding on the reviewing court, which reviews the trial court’s ruling, not its
rationale.” (Intrieri, supra, 117 Cal.App.4th at p. 81.)
1. The trial court erred in summarily adjudicating the elder abuse cause of
Stewart argues the trial court erred in summarily adjudicating her cause of action
for elder abuse because there are triable issues of material fact regarding whether “denial
of care and abuse of custodial power [occurred] with respect to the unauthorized surgical
procedure to implant a pacemaker.” In response, St. Mary asserts its act of conducting an
ethics committee meeting about the power of attorney was not an act implicating
custodial duties toward Carter.
Because, as we now explain, a reasonable jury could
find that St. Mary recklessly and/or fraudulently failed to meet its custodial obligations
toward Carter, Stewart’s position has more merit.
“[The Act] affords certain protections to elders and dependent adults. Section
15657 of the Welfare and Institutions Code provides heightened remedies to a plaintiff
who can prove ‘by clear and convincing evidence that a defendant is liable for physical
abuse as defined in Section 15610.63, or neglect as defined in Section 15610.57,’ and
who can demonstrate that the defendant acted with ‘recklessness, oppression, fraud, or
malice in the commission of this abuse.’ [Welfare and Institutions Code s]ection
15610.57, in turn, defines ‘[n]eglect’ in relevant part as ‘[t]he negligent failure of any
person having the care or custody of an elder or a dependent adult to exercise that degree
of care that a reasonable person in a like position would exercise.’ ” [Citation.]” (Winn,

We briefly comment on St. Mary’s assertion that “the sole determination [of the
ethics committee meeting] was that the Power of Attorney was valid and that the Power
of Attorney indicated that all life-saving measures were to be done for Carter,” which we
interpret to be an attempt by St. Mary to distance itself from the actual performance of
the surgery. Dr. Denton and Dr. Ashtiani, however, described a closer connection
between the ethics committee’s decision and the surgery itself. For example, Dr. Denton
testified that the result of the ethics committee meeting was that “the pacemaker can be
done by the person doing the procedure.” Dr. Ashtiani agreed that the ethics committee
gave him the “green light” to proceed with surgery. Finally, Dr. Ashtiani noted that “risk
management” told him he and Dr. Denton could sign the consent form when he
completed the report on Carter’s pacemaker surgery. There are at least triable issues of
material fact regarding the extent of St. Mary’s connection to the performance of the
actual surgery. For these reasons, we feel comfortable, in discussing the issues the
parties raise, indicating at times that St. Mary authorized Carter’s pacemaker surgery.
We emphasize, however, that the extent of St. Mary’s role in the actual performance of
the surgery is for a jury to determine.
supra, 63 Cal.4th at p. 152.) “The Act seems premised on the idea that certain situations
place elders and dependent adults at heightened risk of harm.” (Id. at pp. 159-160.)
However, the Winn court emphasized that the Act is “not meant to encompass
every course of behavior that fits either legal or colloquial definitions of neglect.” (Winn,
supra, 63 Cal.4th at p. 159.) Rather, “neglect [under the Act] requires a caretaking or
custodial relationship that arises where an elder or dependent adult depends on another
for the provision of some or all of his or her fundamental needs.” (Id. at p. 160.)
To us, it appears Carter depended on St. Mary to meet his basic needs in ways that
establish the type of custodial relationship described by the Winn court. In fact, we note
Carter’s admission to an acute care facility such as St. Mary, standing alone, would have
been sufficient to make him a “dependent adult” who would be entitled to the Act’s
protections even if he had not also qualified as an “elder” by virtue of his age. (Welf. &
Inst. Code, §§ 15610.23, subd. (b) [definition of “dependent adult”], 15610.27 [definition
of “elder”]; Health & Saf. Code, § 1250, subd. (a) [definition of “general acute care
hospital”].) The facts of this case further support our conclusion, as Carter was
experiencing confusion upon admission, and a doctor’s note prepared a week after
admission describes him as a “very poor historian” who could not provide a coherent
history and tended only to mumble and grunt. The record also shows that Carter at times
needed medical assistance, including a g-tube, to consume adequate calories. Finally, St.
Mary readily admits Dr. Denton told it that Carter’s health was poor enough that he
required a pacemaker on an emergency basis. For these reasons, we conclude St. Mary
had “care or custody of” Carter and therefore was obligated “ ‘to exercise that degree of
care that a reasonable person in a like position would exercise.’ [Citation.]” (Winn,
supra, 63 Cal.4th at p. 152.)
St. Mary does not and cannot deny that it had at least some amount of care and
custody over its own patient; rather, it asks us to make a care and custody determination
as to the specific circumstances surrounding the ethics committee meeting instead of as to
the relationship between Carter and St. Mary as a whole. The ethics committee meeting,
in St. Mary’s view, was not about the provision of medical care but instead involved only
the interpretation of Stewart’s power of attorney. Relying on both Winn and Covenant
Care, Inc. v. Superior Court (2004) 32 Cal.4th 771 (Covenant Care), St. Mary argues
such a nonmedical or administrative act cannot be deemed custodial, and cannot
constitute “neglect” under the Act. We now explain why neither case supports this
In the Winn court’s words, the type of relationship the Act contemplates is “a
robust caretaking or custodial relationship—that is, a relationship where a certain party
has assumed a significant measure of responsibility for attending to one or more of an
elder’s basic needs that an able-bodied and fully competent adult would ordinarily be
capable of managing without assistance.” (Winn, supra, 63 Cal.4th at p. 158.) Applying
this rule to the facts before it, the court found the provider of an outpatient clinic could
not have committed elder abuse against one of that clinic’s patients because no custodial
relationship was present. (Id. at p. 165.) The patient had received only “intermittent,
outpatient medical treatment,” and “[n]o allegations in the complaint supported an
inference that [she] relied on defendants in any way distinct from an able-bodied and
fully competent adult’s reliance on the advice and care of his or her medical providers.”
We do not see how Winn supports the suggestion that “when [St. Mary]
interpreted [Carter’s] Power of Attorney, [it was] no longer acting as care custodian[], but
rather as [a] healthcare provider[] focused on the undertaking of medical services.” In
fact, in our view, Winn supports the opposite conclusion. Here, St. Mary accepted Carter
as a patient with knowledge of his “confus[ed]” state, which left him a “poor historian,”
and its records show Carter at times required assistance with feeding. Moreover, the
ethics committee authorized the performance of surgery on Carter’s behalf on the
assumption that he lacked the ability to consent. In our view, St. Mary had accepted
responsibility for assisting Carter with acts for which “[o]ne would not normally expect
an able-bodied and fully competent adult to depend on another.” (Winn, supra, 63
Cal.4th at p. 158.)
We see no reason why the facts that the decision to allow Dr. Denton and Dr.
Ashtiani to sign the consent to the pacemaker surgery in Carter’s stead was made in a
setting that was more like a conference room than an examination room, or that St. Mary
sought advice from counsel rather than from a doctor other than Dr. Denton, must mean
that the ethics committee meeting served a noncustodial function. After all, “it is the
defendant’s relationship with an elder or a dependent adult—not the defendant’s
professional standing or expertise—that makes the defendant potentially liable for
neglect.” (Winn, supra, 63 Cal.4th at p. 158.) For these reasons, Winn better supports the
conclusion that the majority of St. Mary’s interactions with decedent were custodial. St.
Mary has cited no authority allowing or even encouraging a court to assess care and
custody status on a task-by-task basis, and the Winn court’s focus on the extent of
dependence by a patient on a health-care provider rather than on the nature of the
particular activities that comprised the patient-provider relationship counsels against
adopting such an approach.
In support of its position that the ethics committee meeting was simply an
administrative task that cannot constitute neglect under the Act, St. Mary relies heavily
on Covenant Care. There, the court wrote: “As used in the Act, neglect refers not to the
substandard performance of medical services but, rather, to the ‘failure of those
responsible for attending to the basic needs and comforts of elderly or dependent adults,
regardless of their professional standing, to carry out their custodial obligations.’
[Citation.] Thus, the statutory definition of ‘neglect’ speaks not of the undertaking of
medical services, but of the failure to provide medical care.” (Covenant Care, supra, 32
Cal.4th at p. 783, original italics; see Worsham v. O'Connor Hospital (2014) 226
Cal.App.4th 331, 337-338.) St. Mary argues that conducting the ethics committee
meeting amounts to the “undertaking of medical services” and is therefore not actionable
on an elder abuse theory. Because this holding from Covenant Care occurred in the
context of explaining the difference between claims under the Act and claims of “simple
or gross negligence by health care providers,” another way of phrasing St. Mary’s
contention is that, even if everything Stewart alleges is true with respect to St. Mary’s
treatment of Carter, the most she can prove is that St. Mary committed ordinary medical
malpractice.9 Any such suggestion is incorrect for the following reasons.
First, we are troubled that labeling this case one for no more than professional
negligence seriously undervalues the interest Carter had in consenting or objecting to the
surgery that, in the opinion of Stewart’s experts, contributed to his death. “More than a
century ago, the United States Supreme Court declared, ‘No right is held more sacred, or
is more carefully guarded, by the common law, than the right of every individual to
possession and control of his own person, free from all restraint or interference of others,
unless by clear and unquestionable authority of law. . . . “The right to one’s person may
be said to be a right of complete immunity: to be let alone.” [Citation.]’ [Citation.]
Speaking for the New York Court of Appeals, Justice Benjamin Cardozo echoed this
precept of personal autonomy in observing, ‘Every human being of adult years and sound
mind has a right to determine what shall be done with his own body. . . .’ [Citation.]
And over two decades ago, Justice Mosk reiterated the same principle for this court: ‘[A]
person of adult years and in sound mind has the right, in the exercise of control over his
body, to determine whether or not to submit to lawful medical treatment.’ ” (Thor v.
Superior Court (1993) 5 Cal.4th 725, 731 (Thor).)

In fact, after petitioner’s counsel responded to the tentative ruling with respect
to the cause of action for elder abuse at the hearing in the trial court, counsel for St. Mary
stated: “What counsel just finished describing was a rock-solid case for professional
This right, the right to personal autonomy, is the right St. Mary denied Carter by
authorizing Dr. Ashtiani and Dr. Denton to sign the consent for the pacemaker on
Carter’s behalf. This form was signed not only without Carter’s consent, but over the
objection of his designee. The California Supreme Court has described the right to
consent to medical treatment as “ ‘basic and fundamental,’ ” “intensely individual,” and
“broadly based.” (Thor, supra, 5 Cal.4th at pp. 735-736, 741.) The same court has also
emphasized that excusing the patient from a judicial proceeding regarding a surgery to be
performed over his objection “denie[s] fundamental due process.” (Id. at p. 733, fn 2.) It
is immaterial that a doctor has said the treatment is required to save the patient’s life.10

(Id. at p. 739.) Rather, “ ‘A doctor might well believe that an operation or form of
treatment is desirable or necessary, but the law does not permit him to substitute his own
judgment for that of the patient by any form of artifice or deception.’ ” (Id. at p. 736,
fn. omitted.) Finally, the patient’s reasons for refusing are irrelevant. “For selfdetermination
to have any meaning, it cannot be subject to the scrutiny of anyone else’s
conscience or sensibilities.” (Id. at p. 741.)
Here, it is undisputed that St. Mary authorized a surgery without the consent of
either Carter or Stewart. It is also undisputed that St. Mary gave no notice of the ethics
committee meeting to Carter or Stewart, and that it gave Stewart no notice that the

“Particularly when the restoration of normal health and vitality is impossible,
only the person whose moment-to-moment existence lies in the balance can resolve the
difficult and uniquely subjective questions involved. Regardless of the consequences, the
courts, the medical profession, and even family and friends must accept the decision with
understanding and compassion.” (Thor, supra, 5 Cal.4th at p. 741, fn. omitted.)
surgery was going to occur. Even if the reasonableness of Stewart’s objection were
something St. Mary could have taken into account when deciding to void Stewart as
Carter’s designee, there are triable issues of material fact on this issue. Stewart was not
an uneducated patient objecting to a procedure without explanation; instead, at the time
of Carter’s pacemaker surgery, she was a registered nurse, with knowledge of Carter’s
history, whom he had chosen repeatedly as the designee of his power of attorney, and
who requested a second opinion and suggested a specific possible alternative cause for
the gaps in Carter’s heartbeat. Moreover, there is evidence Dr. Yelamanchili agreed that
Carter’s sleep apnea might have been causing the problems that concerned Dr. Denton,
and Dr. Nguyen and Dr. Noori testified that the pacemaker was not medically necessary.
We have difficulty concluding that the deprivation of a right as important as personal
autonomy, if in fact St. Mary is found to have deprived Carter of that right, cannot
amount to more than professional negligence in the context of this case.
In a related contention, and relying exclusively on Cobbs v. Grant (1972) 8 Cal.3d
229, 239-240 (Cobbs), St. Mary argues the most Stewart can have proved is a cause of
action for failure to obtain informed consent, which is a type of negligence claim.
However, the type of claim Cobbs described in sounding in simple negligence was one in
which a patient consents to a procedure but later argues the consent was ill-informed due
to undisclosed risks. (Id. at pp. 239-240.) “The battery theory should be reserved for
those circumstances when a doctor performs an operation to which the patient has not
consented.” (Id. at p. 240.) That standard is undeniably met here, which confirms our
conclusion that Stewart has alleged and proved something more than a potential medical
malpractice claim.
Furthermore, we find the facts Stewart has alleged and proved could support not
just some formless cause of action that is something more than professional negligence,
but a cause of action for elder abuse, specifically. Any of the following three theories
supports this conclusion.
First, if Stewart proves to a jury that St. Mary failed to “exercise that degree of
care that a reasonable person in a like position would exercise” with respect to Carter
(Welf. & Inst. Code, § 15610.57, subd. (a)(1)), she will have shown that it engaged in
actions that constitute neglect under the Act.11
The above described evidence from
Stewart creates triable issues of material fact regarding whether St. Mary appropriately
respected Carter’s right to personal autonomy, and we have discussed the fundamental
nature of that right in detail. St. Mary has offered, and we have found, no reason why a
reasonable jury could not find that St. Mary was therefore unreasonable in discharging its
custodial obligations to Carter within the meaning of the Act.
In addition, a reasonable jury could find St. Mary committed neglect of an elder
within two of the specific categories described by statute. Neglect under the Act can

While the Act gives more specific examples of the types of acts that constitute
neglect of an elder, this list is nonexhaustive. (Welf. & Inst. Code, § 15610.57,
subd. (b).) We have found little discussion of the parameters of this catchall category in
the elder abuse cases we have read, but we presume the Legislature created it for a
purpose. That the right to autonomy possesses the type of fundamental importance we
have described makes it easier to conclude that this is a case that appropriately falls
within the catchall provision.
include, among other things, the “[f]ailure to provide medical care for physical and
mental health needs” (Welf. & Inst. Code, § 15610.57, subd. (b)(2)) and the “[f]ailure to
protect from health and safety hazards” (id., subd. (b)(3)). As discussed ante, the right to
personal autonomy regarding medical decisions is fundamental. (Thor, supra, 5 Cal.4th
at p. 741; see also Conservatorship of Wendland (2001) 26 Cal.4th 519, 532 [Thor
recognized fundamental right in the common law; later cases find the same right derives
from the California Constitution].) It seems to us, then, that respecting the patient’s right
to consent or object to surgery is a necessary component of “provid[ing] medical care for
physical and mental health needs.” (Welf. & Inst. Code, § 15610.57, subd. (b)(2).)
Conversely, depriving a patient of the right to consent to surgery could constitute a
failure to provide a necessary component of what we think of as “medical care.”
Finally, we think a reasonable jury could find St. Mary “fail[ed] to protect [Carter]
from health and safety hazards” (Welf. & Inst. Code, § 15610.57, subd. (b)(3)) by
authorizing the surgery in the way it did. Dr. Pietrefesa, who has over a decade’s
experience as the head of a hospital ethics committee, characterized the ethics committee
meeting that occurred here as a “sham” and stated St. Mary needed a court order to
authorize a surgery over Stewart’s objection. According to Dr. Pietrafesa, the
requirement for a court order is a “safeguard [that] is in place to protect the patient from
the abuse that occurred in this case.” Dr. Pietrafesa also concluded that St. Mary “was
required to have representation from Maxine Stewart and/or a representative from the
patient present at the meeting to present all the facts pertinent to the decision to ignore the
legally binding consent document executed by [Carter].” St. Mary’s only evidence on the
ethics of the procedure it followed comes from the declaration of Ransbury, a nurse,12
who concluded that Dr. Ashtiani and only Dr. Ashtiani had a duty to tell Stewart about
the surgery; she offered no opinion about whether St. Mary should have told Carter or
Stewart that it planned to consider the validity of the power of attorney at an ethics
committee meeting. There are at least triable issues of material fact regarding whether St.
Mary’s decision to authorize the surgery, without notice to Stewart and over her objection
and request for a second opinion, failed to adequately protect Carter from health and
safety hazards.
For the foregoing reasons, we find Stewart has at least shown the existence of
triable issues of material fact regarding whether custodial neglect within the meaning of
the Act occurred when St. Mary authorized Carter’s pacemaker surgery over Stewart’s
objection. We now turn to whether she has produced enough evidence that St. Mary “has
been guilty of recklessness, oppression, fraud, or malice in the commission of this”
neglect, so as to entitle her to the Act’s enhanced remedies. (Welf. & Inst. Code,
§ 15657.) Our task is made easier by the fact that we conclude, post, that the trial court
erred in summarily adjudicating the cause of action for fraudulent concealment. St. Mary
offers no reason why Stewart will have failed to have proved the required state of mind
should that eventuality occur.

Stewart objected in the trial court that Ransbury lacked foundation to opine
about the committee meeting, but the trial court failed to rule on her objection. Because
Stewart does not argue the merits of her objections here, we do not pass on this issue.
We also conclude there are triable issues of material fact regarding whether St.
Mary’s actions qualified as reckless. “Recklessness, unlike negligence, involves more
than ‘inadvertence, incompetence, unskillfulness, or a failure to take precautions’ but
rather rises to the level of a ‘conscious choice of a course of action . . . with knowledge of
the serious danger to others involved in it.’ ” (Delaney v. Baker (1999) 20 Cal.4th 23,
31-32 (Delaney).)
We find uncontroversial the idea that any surgery on a 78-year-old man who has
been admitted to the hospital in such a state that St. Mary looked to his designee for
consent is potentially dangerous, and testimony from Dr. Noori, Dr. Nguyen, and Dr.
Rajan supports Stewart’s assertion that the surgery was never necessary. Also, and as
discussed ante, the evidence shows there are triable issues of material fact regarding
whether St. Mary adequately protected Carter from health and safety hazards when it
authorized the surgery without the participation of Stewart or anyone “from [Carter’s]
side,” even though it knew Stewart had offered an alternative explanation for the gaps in
Carter’s heartbeat and requested a second opinion on that issue. St. Mary’s suggestion
that it cannot be punished for listening to the advice of a doctor in good standing at the
hospital fails to account for its decision to structure the ethics committee meeting in an
entirely one-sided manner. (See Covenant Care, supra, 32 Cal.4th 771, 778 [elder abuse
plaintiffs alleged defendants concealed the deterioration of patient’s condition]; see also
Carter v. Prime Healthcare Paradise Valley LLC (2011) 198 Cal.App.4th 396, 405
[enhanced remedies warranted in Covenant Care in part because skilled nursing facility
“misrepresented and failed to inform [patient’s] children of his true condition”].)
For the foregoing reasons, the trial court erred in summarily adjudicating Stewart’s
cause of action for elder abuse. At oral argument, St. Mary’s counsel expressed concern
that our holding, especially with respect to the care and custody issue, will be interpreted
to mean that any act of negligence by a hospital will constitute elder abuse. We share no
such fear, since “ ‘ “cases are not authority for propositions not considered.” ’ ” (Loeffler
v. Target Corp. (2014) 58 Cal.4th 1081, 1134.) First, and as we have stressed
throughout, the right to autonomy in medical decision-making is uniquely fundamental;
we offer no opinion about how this petition would have resolved had Stewart alleged a
violation of a lesser right. Second, we were careful to describe the evidence introduced
by the parties on summary judgment in detail, to focus our inquiry on where and how
Stewart’s evidence created triable issues of material fact, and to stress that it is the jury’s
role to determine the extent of St. Mary’s role in the pacemaker surgery Dr. Ashtiani
performed on Carter. As we explained ante, when reviewing summary adjudication
orders we “ ‘must “consider all of the evidence” and “all” of the “inferences” reasonably
drawn therefrom [citation], and must view such evidence [citations] and such inferences
[citations], in the light most favorable to the opposing party.’ ” (Intrieri, supra, 117
Cal.App.4th at p. 81.) We have done so, and we have explained our views about how the
rules on which we rely apply to the evidence submitted with the summary judgment
motion. We need not make a prediction about how a court should rule in the future when
asked to apply today’s holding to a set of facts that is missing any of the elements that are
present here.
2. The trial court erred in summarily adjudicating the cause of action for
fraudulent concealment
Stewart argues the trial court erred in summarily adjudicating her cause of action
for fraudulent concealment on the sole ground that, based on the reasoning in Moore v.
Regents of University of California (1990) 51 Cal.3d 120, 133 (Moore), St. Mary did not
owe Carter a fiduciary duty. As we now explain, we agree.
“ ‘ “[T]he elements of an action for fraud and deceit based on concealment are:
(1) the defendant must have concealed or suppressed a material fact, (2) the defendant
must have been under a duty to disclose the fact to the plaintiff, (3) the defendant must
have intentionally concealed or suppressed the fact with the intent to defraud the plaintiff,
(4) the plaintiff must have been unaware of the fact and would not have acted as he did if
he had known of the concealed or suppressed fact, and (5) as a result of the concealment
or suppression of the fact, the plaintiff must have sustained damage.” ’ ” (Boschma v.
Home Loan Center, Inc. (2011) 198 Cal.App.4th 230, 248.) A duty to disclose will arise:
“ ‘(1) when the defendant is in a fiduciary relationship with the plaintiff; (2) when the
defendant had exclusive knowledge of material facts not known to the plaintiff; (3) when
the defendant actively conceals a material fact from the plaintiff; and (4) when the
defendant makes partial representations but also suppresses some material facts.’ ”
(LiMandri v. Judkins (1997) 52 Cal.App.4th 326, 336 (LiMandri).)
St. Mary argues it cannot be liable for fraudulent concealment because it owed
Carter no fiduciary duty under Moore. We question the applicability of Moore to this
case. There, a leukemia patient alleged causes of action against his physician and, among
others, a hospital for “using his cells in potentially lucrative medical research without his
permission.” (Moore, supra, 51 Cal.3d at pp. 124-125.) The court found these
allegations stated causes of action for breach of fiduciary duty and/or lack of informed
consent against the physician, Golde. (Id. at pp. 128-129.) With respect to the other
defendants, the court stated simply, without analysis or citation to authority: “In contrast
to Golde, none of these defendants stood in a fiduciary relationship with Moore or had
the duty to obtain Moore’s informed consent to medical procedures. If any of these
defendants is to be liable for breach of fiduciary duty or performing medical procedures
without informed consent, it can only be on account of Golde’s acts and on the basis of a
recognized theory of secondary liability, such as respondeat superior.” (Id. at p. 133.)
Participating in a process that allegedly failed to respect a patient’s right to personal
autonomy seems very different in kind, for purposes of fiduciary duty analysis, from
failing to disclose profits earned from a patient’s discarded tissue. (See Delaney, supra,
20 Cal.4th at p. 33 [purpose of the Act “is essentially to protect a particularly vulnerable
portion of the population from gross mistreatment in the form of abuse and custodial
We need not decide whether St. Mary owed Carter a fiduciary duty, however,
because a fiduciary duty is not the only circumstance giving rise to a duty to disclose.13

As we have already established, St. Mary also had a duty to disclose if it had sole
knowledge of material facts not known to Stewart, actively concealed at least one
material fact from her, or made a partial representation but suppressed at least one
material fact. (LiMandri, supra, 52 Cal.App.4th at p. 336.) Our independent review of
the record indicates there are triable issues of material fact regarding each of these
St. Mary knew it had authorized a pacemaker surgery to proceed over
Stewart’s objection because it made this the “action plan” after the ethic committee
meeting, and it knew it did not inform Stewart about the surgery. St. Mary also knew of
Stewart’s objection to the pacemaker procedure, and it chose to tell her about neither the
ethics committee meeting nor the upcoming surgery. The cause of action for fraudulent
concealment does not fail for lack of duty to disclose.

St. Mary argues Stewart only alleged it failed to disclose the date of the surgery
in her operative pleading and may not now allege it also committed fraudulent
concealment by failing to disclose the scheduling of the ethics committee meeting. Even
if the complaint must be read so sparingly, the distinction makes no difference to our
“ ‘Although the determination of duty is primarily a question of law, its
existence may frequently rest upon’ ” the nature and extent to which a plaintiff proves the
facts allegedly creating a duty to be true. (Silva v. Union Pacific Railroad Co. (2000) 85
Cal.App.4th 1024, 1029.) Here, we say there are triable issues of material fact regarding
the existence of a duty because whether such a duty exists depends on the nature and
extent of Stewart’s proof of the facts we are about to summarize. At present, we find
only that she has presented enough evidence to take the issue to a jury.
Nor does it fail, as St. Mary argues, for lack of proof of fraudulent intent, as we
find no gap in the evidence on this issue. The trial court denied Dr. Denton’s motion for
summary adjudication of this claim because it found there were triable issues of material
fact regarding whether “the failure to inform Stewart the surgery would occur was an
intentional effort to conceal the scheduling of the surgery.” It appears much the same
analysis applies to St. Mary, which is the party that actually made the decision not to
advise Stewart of the ethics committee.
Although Dr. Denton was the only clinical person who took part in the first ethics
committee meeting, we think it fair to infer that the risk management team would have
reviewed the doctor’s notes contained in its own file on Carter; otherwise, it seems the
ethics committee meeting would have no purpose but to simply rubber stamp whatever
procedure Dr. Denton recommended. To at least some readers, these notes will likely
reflect an increasing level of animosity between Stewart and Dr. Denton, with Carter’s
admission note indicating his home environment was “fairly supportive,” while a note
from a consultation only five or six days later said Dr. Denton wanted Carter observed
while his family was with him. This second note memorialized a consultation in which
Dr. Denton “extensive[ly]” discussed his recommendation for placement of a g-tube, and
Stewart still said she did not want one. It is a reasonable inference that conflicts such as
these are what led to the involvement of Adult Protective Services, which was, according
to a doctor’s note by Dr. Denton, “anxiously awaiting” an interview with him. In
addition, a note from Dr. Yemanchili indicated there may have been some merit to
Stewart’s suggestion that Carter be treated for sleep apnea before a surgery occurred.
Since the discussion about Carter’s power of attorney reached St. Mary’s CEO, it appears
multiple layers of people at the hospital had a reason to read these notes, if they intended
to conduct a fair and adequate review before making an ethics committee decision. To a
reasonable jury, these notes might be an indication that St. Mary ignored cause for
concern about Dr. Denton’s impartiality.
In addition, Bunch, who is a director of risk management, knew Dr. Denton’s
response when she told him of the action plan was that his “posterior was covered,” as
well as that his response to Stewart’s request for a second opinion was simply, “I won’t
do that.” Finally, St. Mary knew Dr. Denton made some kind of allegation that Stewart
had a financial motive for refusing to consent to the pacemaker surgery because, at the
ethics committee meeting, Perring-Mulligan had to “shut that down” when Dr. Denton
broached the topic. Again, a jury could infer that St. Mary had particular reason to
ensure that Stewart was involved in the process of authorizing the pacemaker surgery, or
that she had notice that a surgery had been scheduled, but instead deliberately decided to
exclude her from the process.
Perhaps a reasonable jury would view these facts and think St. Mary was
innocently blindsided by a misguided doctor, as St. Mary’s response implies. But it
seems to us a reasonable jury could instead conclude that St. Mary intentionally
concealed the surgery because it and Dr. Denton had become weary of Stewart’s habit of
refusing what Dr. Denton thought was necessary treatment. In other words, there are
triable issues of material fact regarding St. Mary’s intent in concealing facts from
Stewart, just as there are regarding its duty to disclose those same facts. The trial court
therefore erred in summarily adjudicating the fraudulent concealment claim.
3. The trial court erred in summarily adjudicating the cause of action for
medical battery
The trial court summarily adjudicated the cause of action for medical battery
solely because Dr. Ashtiani, not St. Mary, actually performed the pacemaker surgery.
Petitioner argues there are triable issues of material fact regarding St. Mary’s connection
to the surgery. We again agree.
“Battery is an offensive and intentional touching without the victim’s consent.”
(Kaplan v. Mamelak (2008) 162 Cal.App.4th 637, 645 (Kaplan).) The elements of a
cause of action for medical battery are: (1) That the defendant either performed a
medical procedure without the patient’s consent or performed a medical procedure that is
substantially different from one to which the plaintiff consented; (2) that the plaintiff
suffered harm; and (3) that the defendant’s actions were a substantial factor in causing the
plaintiffs’ harm. (CACI No. 530A.)
The record in this case belies St. Mary’s suggestion that it had no connection to
the performance of the surgery simply because Dr. Ashtiani, an independent contractor,
made that decision. As we have already described in footnote 8, ante, Dr. Denton and
Dr. Ashtiani both testified that the decision of the ethics committee was the event that
allowed the surgery to occur. Moreover, Dr. Ashtiani’s comment in the postoperative
report—“I need to mention, the consent was signed by two physicians which was
advocated through risk management, myself, and Dr. Denton”—could easily be
interpreted to mean that St. Mary specifically advised Dr. Ashtiani to sign the consent
form, without which the surgery likely could not proceed at all.
Neither party has cited authority defining how distant the connection a defendant
has to the touching that occurs when a doctor performs surgery, to which the patient has
not consented, may be before the plaintiff loses a right to a cause of action for medical
battery. “In the absence of any definitive case law [setting the boundary St. Mary
asserts], we conclude the matter is a factual question for a finder of fact to decide.”
(Kaplan, supra, 162 Cal.App.4th at p. 647.) There are triable issues of material fact
regarding whether St. Mary was sufficiently involved in the process of allowing the
pacemaker surgery on Carter to have “performed a medical procedure” within the
meaning of CACI No. 503A.

Outcome: Let a peremptory writ of mandate issue, directing the Superior Court of San
Bernardino County to vacate the October 3, 2016 order granting summary adjudication of Stewart’s causes of action for elder abuse, fraudulent concealment, and medical battery, and to substitute an order denying the motion as to those causes of action. The temporary stay we issued is to dissolve upon the filing of this opinion.

Stewart is directed to prepare and have the peremptory writ of mandate issued,
copies served, and the original filed with the clerk of this court, together with proof of service on all parties. Petitioner is awarded her costs on appeal.

Plaintiff's Experts:

Defendant's Experts:


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