Case Title: Ex parte Lisa Mestas.

Citation: 

Docket Number: 1200362

State: alabama

Court: Alabama Supreme Court

Date: 2022-05-27T00:00:00Z

Document:
Rel: May 27, 2022 
 
 
 
 
 
 
 
Notice: This opinion is subject to formal revision before publication in the advance sheets of Southern 
Reporter.  Readers are requested to notify the Reporter of Decisions, Alabama Appellate Courts, 
300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334) 229-0649), of any typographical or other 
errors, in order that corrections may be made before the opinion is printed in Southern Reporter. 
 
 
SUPREME COURT OF ALABAMA 
 
OCTOBER TERM, 2021-2022 
 
_________________________ 
 
1200362 
_________________________ 
 
Ex parte Lisa Mestas   
 
PETITION FOR WRIT OF MANDAMUS   
 
(In re: David Lee Autrey, as personal representative of the 
Estate of Bridgette Ann Moore, deceased  
 
v.  
 
University of South Alabama Health Services Foundation et al.) 
 
(Mobile Circuit Court: CV-18-900096) 
 
SHAW, Justice. 
 
Lisa Mestas, a defendant below, petitions this Court for a writ of 
mandamus directing the Mobile Circuit Court to vacate its order denying 
1200362 
 
2 
 
her motion for a summary judgment in this wrongful-death/medical-
negligence action commenced by David Lee Autrey, as the personal 
representative of the estate of his wife, Bridgette Ann Moore, and to enter 
a summary judgment in Mestas's favor on the basis of State-agent 
immunity.  We grant the petition and issue the writ. 
Facts and Procedural History 
 
In May 2017, Autrey's wife, Moore, went to the University of South 
Alabama Medical Center ("USA Medical Center"), a hospital, to undergo 
a surgery required by the prior amputation of her right leg. The surgery 
was performed without incident, and Moore was transferred to a hospital 
room for recovery. At approximately 9:30 p.m. that night, nurses found 
Moore unresponsive. Attempts to revive her were unsuccessful, and 
Moore was pronounced deceased. It was later determined that Moore died 
as a result of opioid-induced respiratory depression ("OIRD"). 
 
Autrey commenced an action against the University of South 
Alabama Health Services Foundation, Mestas, and three nurses who 
were involved in Moore's postoperative care, alleging claims of medical 
1200362 
 
3 
 
negligence.1  Specifically, Autrey alleged, among other things, that the 
defendants, including Mestas, had departed from the applicable standard 
of care and were negligent in providing medical care to Moore, causing 
her death.  
 
Mestas answered and asserted various affirmative defenses, 
including immunity. She subsequently filed what she styled as a motion 
to dismiss or, in the alternative, a motion for a summary judgment, and 
then she filed a similar motion after Autrey filed an amended complaint 
(both motions are hereinafter referred to collectively as "the motion for a 
summary judgment").  Mestas's motion for a summary judgment 
included evidentiary exhibits and was supplemented by later filings.  
Mestas argued that, at all times relevant to Autrey's lawsuit, she was an 
employee of the University of South Alabama ("USA") and served as the 
Chief Nursing Officer ("CNO") for USA Health System, which included 
USA Medical Center, various clinics, and a children's hospital.  According 
to Mestas, as the CNO, her primary responsibilities were administrative 
in nature and she had not provided any direct patient care since 2010.  
 
 
1Autrey later amended the complaint to add USA Health Care 
Management, LLC, as a defendant.    
1200362 
 
4 
 
Mestas argued that because Autrey's claims against her arose from the 
line and scope of her employment with a State agency,2 and because she 
did not treat Moore, she was entitled to, among other things, State-agent 
immunity.   
 
In opposition to Mestas's motion for a summary judgment, Autrey 
argued that his action was against Mestas in her individual capacity and 
that she had not proven that she was entitled to State-agent immunity. 
In support of his filings, Autrey included various evidentiary exhibits, 
including the affidavit of Kimberly Arnold, the CNO for Northwest 
Medical Center in Bentonville, Arkansas.   
 
The trial court, considering the parties' arguments and evidence, 
denied the motion for a summary judgment.3  Mestas filed the instant 
 
 
2There appears to be no dispute that Mestas, as an employee of 
USA, is a State agent.  Ex parte University of South Alabama, 183 So. 3d 
915, 919 (Ala. 2015) ("USA is a State institution of higher learning and, 
as a matter of law, is a State agency …."). 
 
 
3The trial court stated in its order that it considered Mestas's 
motions as motions for a summary judgment; the order does not indicate 
the factual or legal findings on which its ruling was based. 
 
1200362 
 
5 
 
petition for a writ of mandamus; this Court subsequently ordered 
answers and briefs.4 
Standard of Review 
 
"A writ of mandamus is an extraordinary remedy[] and 
is appropriate when the petitioner can show (1) a clear legal 
right to the order sought; (2) an imperative duty upon the 
respondent to perform, accompanied by a refusal to do so; (3) 
the lack of another adequate remedy; and (4) the properly 
invoked jurisdiction of the court." 
 
Ex parte BOC Grp., Inc., 823 So. 2d 1270, 1272 (Ala. 2001).   
 
As noted above, this petition challenges the denial of a motion for a 
summary judgment.    
"Although this Court generally will not review a trial court's 
denial of a summary-judgment motion, we will consider a 
challenge to a denial of a summary-judgment motion that is 
'grounded on a claim of immunity.' [Ex parte Wood, 852 So. 2d 
705, 708 (Ala. 2002).]  Our review in such a case is limited to 
the trial court's determination of immunity issues; we will not 
consider secondary arguments that a summary judgment was 
 
4Autrey has filed with this Court a motion to strike Mestas's reply 
brief because it exceeded the 3,000-word limitation for reply briefs 
related to petitions for extraordinary writs found in Rule 32(b)(3), Ala. R. 
App. P. Mestas's counsel acknowledges that the reply brief exceeded the 
word limitation found in Rule 32(b)(3), explaining that "while 
simultaneously working on another appellate brief from the same 
underlying case which was subject to the 7,000-word limitation in Rule 
28(j)(1), [Ala. R. App. P., she] mistakenly proceeded as though that 
limitation applied to this brief."  Autrey's motion is well taken, and 
Mestas's reply brief will not be considered. 
1200362 
 
6 
 
appropriate on other grounds or review the trial court's 
conclusions on other issues. … 
 
 
"In reviewing the denial of a summary-judgment motion 
asserting immunity, whether by petition for a writ of 
mandamus or by permissive appeal, this Court applies the 
following standard of review: 
 
"'If there is a genuine issue as to any material fact 
on the question whether the movant is entitled to 
immunity, then the moving party is not entitled to 
a summary judgment. Rule 56, Ala. R. Civ. P. In 
determining whether there is [an issue of] 
material fact on the question whether the movant 
is entitled to immunity, courts, both trial and 
appellate, must view the record in the light most 
favorable to the nonmoving party, accord the 
nonmoving 
party 
all 
reasonable 
favorable 
inferences from the evidence, and resolve all 
reasonable doubts against the moving party, 
considering only the evidence before the trial court 
at the time it denied the motion for a summary 
judgment. Ex parte Rizk, 791 So. 2d 911, 912 (Ala. 
2000).' 
 
"Wood, 852 So. 2d at 708." 
 
Ex parte Smith, 327 So. 3d 184, 187 (Ala. 2020). 
Discussion 
 
 In her petition, Mestas argues that she is entitled to State-agent 
immunity to the extent that Autrey's claims are asserted against her in 
1200362 
 
7 
 
her individual capacity.5  The rule for determining when a State agent 
sued in his or her individual capacity is entitled to State-agent immunity 
was restated in Ex parte Cranman, 792 So. 2d 392 (Ala. 2000) (plurality), 
and was adopted by a majority of this Court in Ex parte Butts, 775 So. 
2d 173 (Ala. 2000); that rule provides, in pertinent part: 
 
"A State agent shall be immune from civil liability in his 
or her personal capacity when the conduct made the basis of 
the claim against the agent is based upon the agent's 
 
 
"(1) formulating plans, policies, or designs; or 
 
 
"(2) exercising his or her judgment in the administration 
of a department or agency of government, including, but not 
limited to, examples such as: 
 
 
 
"…. 
 
 
 
"(d) hiring, firing, transferring, assigning, or  
 
supervising personnel; or 
 
 
"…. 
 
 
"Notwithstanding anything to the contrary in the 
foregoing statement of the rule, a State agent shall not be 
immune from civil liability in his or her personal capacity 
 
 
"(1) when the Constitution or laws of the United States, 
or the Constitution of this State, or laws, rules, or regulations 
 
 
5Although there is some discussion in the materials before us as to 
whether Mestas was sued in her official capacity, Autrey made clear in 
the trial court and in his answer to this petition that he is suing Mestas 
in her individual capacity. 
1200362 
 
8 
 
of this State enacted or promulgated for the purpose of 
regulating the activities of a governmental agency require 
otherwise; or 
 
 
"(2) when the State agent acts willfully, maliciously, 
fraudulently, in bad faith, beyond his or her authority, or 
under a mistaken interpretation of the law." 
 
Cranman, 792 So. 2d at 405. 
 
 
Autrey, quoting his complaint, contends that he alleged that Mestas 
"had the duty to provide reasonably proper and adequate medical care, 
nursing care, monitoring and/or treatment" to Moore but that she had 
"negligently breached those duties in one or more of the following 
respects," including: 
"'F. Negligently failing to train, educate and make the 
hospital's nursing staff aware of how to adequately assess a 
postoperative 
patient 
who 
is 
being 
administered 
pharmaceutical pain medications; 
 
"'G. Negligently failing to appropriately administer and 
provide for safety precautions in the treatment and care of 
Bridgette Ann Moore; 
 
"'H. Negligently failing to train, educate and make the 
hospital's nursing staff aware of the need for extra 
precautions in high-risk patient populations; 
 
"'I. Negligently failing to adopt, implement and/or follow 
policies, procedures, and protocols for the treatment and care 
of postoperative patients being administered pharmaceutical 
pain medications.' " 
 
1200362 
 
9 
 
Autrey's respondent's brief at 1.   
 
In her petition, Mestas argues that the evidence shows that, in 
serving as the CNO for USA Health System, which includes USA Medical 
Center, her duties were administrative in nature: 
"She testified that she 'had administrative responsibility for 
USA 
Medical 
Center' 
and 
described 
herself 
as 
an 
administrative/corporate employee. The description of her 
position identifies her as an administrative employee and sets 
out categories of responsibility which include the development 
of plans, systems and processes as well as maintenance of 
appropriate staffing, management of staff, evaluation of both 
the clinical and financial aspects of patient care, and 
involvement with credentialing processes and regulatory 
compliance.  It is evident from the broad and generalized 
nature of the functions included in the job description that 
Nursing Officer Mestas must exercise discretion while 
performing her duties; the job functions clearly relate to 
responsibilities which are administrative rather than 
ministerial in nature." 
 
Petition at 16 (exhibit citations omitted).6 
 
The "job description" Mestas references provides that the "job 
purpose" of the CNO is as follows: 
"Performs the primary functions of an Associate Health 
System Administrator in planning, organizing, directing, 
controlling, and evaluating all functions and activities. 
Develops and maintains programs that achieve and sustain 
 
 
6Mestas further notes in her petition that she did not provide 
patient care, did not render any medical care or treatment to Moore, and 
did not teach and train the other defendant nurses.   
1200362 
 
10 
 
the mission, philosophy and objectives of the University of 
South Alabama Health System for base hospital and system-
wide nursing functions that include inpatient and outpatient 
nursing areas." 
 
The "essential job functions" of the CNO are stated as follows: 
 
"1. Participates as a member of the leadership team in the 
organization's decision-making structure and process. 
  
".... 
 
"3. Develops and maintains an organizational plan for 
providing clinical care for patients that ensures the 
continuous and timely availability of those services. Develops 
standardized processes across the health system continuum 
to improve patient care and cost effectiveness. 
 
"4. Assures a sufficient and qualified number of staff is 
available to care for patient needs based on acuity and 
regulatory requirements. Assesses staffing needs across the 
health system continuum to effectively utilize staff for 
fluctuating volumes. 
 
"5. Establishes standards of clinical care and practice that are 
consistent with current research, outcome measures, and 
nationally recognized standards. This includes, but is not 
limited to, outcome measures, BCBS tiered program, state 
and national infection reporting requirements and evidence 
based medicine. Creates standardized processes across the 
health system continuum. 
 
"6. Assures compliance with regulatory agencies such as the 
Joint Commission, CMS, third party payers, as well as 
current federal and state laws. 
 
"7. Evaluates and develops systems for ongoing quality 
improvement in hospital processes, patient safety initiatives, 
1200362 
 
11 
 
and management of staff. Incorporates best practices across 
the health system continuum. 
 
"8. Serves as a leader and advocate for patient safety 
throughout the health system. 
  
"9. Develops and maintains a standardized process for 
budgeting that supports patient care needs while driving 
efficiency and cost containment. 
 
"10. Assists in evaluation and determination of new or current 
product lines. 
 
"11. Conducts and reviews cost to benefit analysis on clinical 
procedures to assure the services are appropriate for the 
patient population served both clinically and financially at all 
responsible clinical sites. 
 
"12. Develops and maintains a knowledge base related to 
medical staff credentialing regulatory requirements and 
processes." 
 
 
Mestas's duties, she alleges, fit within the Ex parte Cranman 
categories of "formulating plans, policies, or designs" and exercising 
"judgment in the administration of a department or agency of 
government."  792 So. 2d at 405. She further argues that she "was not 
personally involved" in educating or training the other defendant nurses 
because she was not one of the "Nurse Educators" for USA Medical 
Center. 
1200362 
 
12 
 
 
Autrey contends that the affidavit testimony of Kimberly Arnold, 
who, as noted above, is the CNO for an Arkansas hospital, contradicted 
Mestas's assertions that she performed only administrative duties.  
Arnold testified that the actions of CNOs like Mestas "directly affect 
patient care and patient safety."  She indicated that Mestas's "essential 
job functions," numbered five through eight above, were "mandatory and 
nondiscretionary requirements of the CNO at any hospital," including 
USA Medical Center. 
 
Arnold identified two publications by "the Joint Commission," a 
medical accrediting organization, discussing care for patients at risk for 
OIRD.  According to her, an August 2012 "Sentinel Event Alert" issued 
by the Joint Commission    
"identifies patients who are at higher risk for OIRD, and also 
identifies Effective Processes for protecting these patients 
from adverse outcomes. These processes include: (i) creating 
and implementing policies and procedures for the ongoing 
clinical monitoring of patients receiving opioid therapy; (ii) 
educating clinical staff about the potential effect of opioid 
therapy on respiratory depression; (iii) educating clinical staff 
on how to effectively protect patients receiving opioid therapy 
from respiratory depression; and (iv) assessing the clinical 
staffs understanding of how to identify and effectively protect 
patients receiving opioid therapy from injuries and deaths 
caused by respiratory depression." 
 
1200362 
 
13 
 
 
She further discussed another Joint Commission publication, 
issued in June 2015, described as a "safety advisory": 
"This safety advisory states: 'patients with [obstructive sleep 
apnea ('OSA')] can experience complications when receiving 
sedatives, such as opioid analgesia or general anesthesia. 
These medications diminish the protective arousal reflex 
triggered by bouts of hypoxia, thereby increasing the risk of 
prolonged periods of apnea and respiratory arrest.' This safety 
advisory further states: 'Staff and The Joint Commission’s 
Division of Healthcare Improvement sites the following 
concerns regarding OSA .... Failure to implement appropriate 
monitoring of patients with risk factors associated with OSA 
.... Lack of communication among health care providers 
regarding patients with OSA for potential risk factors 
associated with OSA .... Lack of postoperative evaluation and 
treatment for OSA.' This safety advisory further states: 
'Evaluate the patient's plan of care to ensure all precautions 
are taken while in your facility.'"  
 
 
Arnold testified that, based on those publications, Moore was 
known to be at high risk for OIRD, but Moore's medical chart did not 
indicate that she had been screened for respiratory-depression risk 
factors.  "One of the key reasons" no such screening occurred, according 
to Arnold, was that Mestas  
"failed to take the mandatory and non-discretionary steps of 
implementing clinical policies, procedures, education, or 
training designed to protect patients such as [Moore] from the 
known dangers of OIRD. By failing to implement these 
mandatory and non-discretionary clinical safety measures, 
Nurse Mestas failed to perform her 'essential job functions.' 
In particular, Nurse Mestas failed to 'assure compliance with 
1200362 
 
14 
 
regulatory agencies such as The Joint Commission'; failed to 
'develop ... patient safety initiatives' relative to OIRD; and 
failed to 'advocate for patient safety.' These essential job 
functions did not afford Nurse Mestas the leeway to ignore 
them or exercise her judgment as to whether to implement 
them and ensure compliance by the clinical nursing staff. 
Rather, these essential job functions are just as the name 
suggests -- essential. Stated another way, these essential job 
functions were required, mandatory, and non-discretionary 
parts of her position at the hospital." 
 
 
Arnold similarly testified that there was no plan of care to ensure 
that Moore was monitored for OIRD, and that that was attributable to 
Mestas's failure to perform her job functions, and she reiterated that 
Mestas's functions "were mandatory obligations that relate directly to the 
clinical safety of patients at CNO Mestas'[s] hospital. These functions 
were required in order to meet the standard of care for a CNO."  Finally, 
Arnold stated if "Mestas had adequately performed her essential job 
functions, and had implemented the type of safety processes that are 
endorsed in Joint Commission publications about protecting high risk 
patients from OIRD," then Moore's "death probably would have been 
prevented."7 
 
 
7Mestas testified that the Joint Commission documents were 
intended to be informative only and did not contain any mandatory rules 
or regulations from the Joint Commission that would have required her 
to implement policies or procedures based on them at USA Medical 
1200362 
 
15 
 
 
Autrey points out that Mestas admitted that she did not implement 
Joint Commission guidance relative to OIRD and that, according to 
Arnold, that amounted to a failure to abide by her job functions.  He 
reemphasizes that Mestas's job functions, according to Arnold, were 
"mandatory and nondiscretionary" requirements of a CNO.  He further 
argues that Arnold's affidavit establishes that Mestas's role as a CNO 
was not purely administrative because, according to Arnold's affidavit, 
CNOs "are a type of healthcare service provider" and their actions 
"directly affect patient care and patient safety."  He then concludes: 
"Nurse Arnold's testimony demonstrates that Nurse Mestas did not prove 
her affirmative defense[] of … State-agent immunity …." Autrey's 
respondent's brief at 18. 
 
Mestas is a State agent, and her job functions in creating standards 
of care and practice, assuring compliance with those standards, 
evaluating and developing systems for quality improvement, and 
advocating for patient safety are all actions in formulating plans and 
 
Center. She further explained that any policies or procedures that are 
put into place concerning patient care and safety are first discussed by a 
patient-care committee, which is led by her assistant CNO, and are then 
implemented following committee vote. 
1200362 
 
16 
 
policies and exercising judgment in the administration of an agency for 
which Ex parte Cranman provides immunity.  The evidence shows that 
Mestas performs administrative functions governing how clinical staff, 
including nurses, provide care to patients, including any care that might 
have been informed by the Joint Commission publications.  To the extent 
that Arnold's testimony shows that Mestas had a duty to implement Joint 
Commission guidance and failed to do so in a way that contributed to 
Moore's death, that is relevant only as to whether Mestas was negligent 
in performing her functions, not as to whether the performance of her 
functions is protected by State-agent immunity in the first place.8  
Autrey's answer and respondent's brief do not establish that Mestas's 
alleged acts or omissions in this case were not the type of conduct covered 
by State-agent immunity. 
 
Autrey also cites caselaw holding that decisions involving the 
treatment of medical patients generally do not fit within a category of 
conduct for which Ex parte Cranman provides immunity.  See  Dunnam 
 
 
8Autrey does not contend that Mestas acted "willfully, maliciously, 
fraudulently, in bad faith, beyond … her authority, or under a mistaken 
interpretation of the law," in which cases State-agent immunity under 
Ex parte Cranman may not apply. 792 So. 2d at 405. 
1200362 
 
17 
 
v. Ovbiagele, 814 So. 2d 232, 237 (Ala. 2001) (noting that there is "a 
general rule that medical professionals who are employed by the State 
are not entitled to immunity solely because the regular performance of 
their work requires the exercise of discretion. Rather, immunity is 
conferred only when a state agent meets one of the criteria set out in [Ex 
parte] Cranman."); Ex parte Rizk, 791 So. 2d 911, 914 (Ala. 2000) 
(holding that doctor's treatment of a patient during an emergency 
caesarean-section delivery did "not fit within any of the categories of 
immune State-agent conduct").  Wimpee ex rel. Johnston v. Stella, 791 
So. 2d 915, 918 (Ala. 2000) (holding that two doctors' medical treatment 
during the delivery of a child did not fit within any of the categories of 
immune State-agent conduct); Ex parte Flynn, 776 So. 2d 99, 101-02 (Ala. 
2000) (holding that a nurse, to the extent that she may have been called 
upon to use her judgment in implementing a doctor's orders, was not 
engaged in any category of conduct recognized as immune by Ex parte 
Cranman); and Ex parte Cranman, 792 So. 2d at 406 ("The conduct of the 
physicians, in their treatment of [the patient], does not fit within any 
category of conduct recognized by the restated rule as immune.").  
Although this case does involve allegations that a health-care provider 
1200362 
 
18 
 
breached the applicable standard of care, unlike in the cases cited, 
Mestas's relevant job functions fall under a category of conduct 
specifically identified as warranting immunity under Ex parte Cranman. 
Conclusion 
 
Mestas has demonstrated that she is entitled to State-agent 
immunity and that she has a clear legal right to the relief sought.  
Therefore, we grant her petition and issue the writ; the trial court is 
directed to enter an order granting her motion for a summary judgment.   
 
PETITION GRANTED; WRIT ISSUED.   
 
Bolin, Wise, Bryan, Sellers, and Mitchell, JJ., concur.  
Parker, C.J., and Mendheim and Stewart, JJ., concur in the result.