Case Title: Tharp v. St. Luke's Surgicenter-Lee's Summit, LLC

Citation: 

Docket Number: SC96528

State: missouri

Court: Missouri Supreme Court

Date: 2019-02-26T00:00:00Z

Document:
SUPREME COURT OF MISSOURI
en banc 
THOMAS E. THARP, et al., 
  ) 
  ) 
Appellants/Cross-Respondents, 
  ) 
  ) 
v. 
  ) 
No.  SC96528 
  ) 
ST. LUKE’S SURGICENTER- 
  ) 
LEE’S SUMMIT, LLC, 
 
  ) 
  ) 
Respondent/Cross-Appellant. 
  ) 
APPEAL FROM THE CIRCUIT COURT OF JACKSON COUNTY 
The Honorable Kenneth R. Garrett, III, Circuit Judge 
St. Luke’s Surgicenter-Lee’s Summit LLC appeals the circuit court’s judgment 
against St. Luke’s, following a jury trial, on a negligent credentialing claim brought by 
Thomas E. Tharp and Paula M. Tharp.  The jury found in favor of the Tharps and awarded 
damages.  On appeal, St. Luke’s argues the Tharps failed to make a submissible case of 
negligent credentialing.  This Court agrees.  The circuit court’s judgment is reversed. 
Factual and Procedural History 
This case arises from a medical malpractice action against a surgeon operating out 
of St. Luke’s Surgicenter in Lee’s Summit.  In December 2011, Thomas Tharp underwent 
a laparoscopic cholecystectomy – a surgical procedure to remove his gallbladder.  The 
Opinion issued February 26, 2019
2 
Tharps allege the surgeon damaged Mr. Tharp’s hepatic duct and common bile duct during 
the procedure, causing bile leakage, inflammation, and liver damage.  The Tharps settled 
with the surgeon but proceeded to trial against St. Luke’s, alleging St. Luke’s negligently 
granted the surgeon staff privileges at its hospital.   
Mr. Tharp’s surgeon applied for staff privileges at St. Luke’s in 2005 and renewed 
his privileges several times thereafter.  Staff privileges allow physicians to utilize a 
healthcare facility to admit and treat patients as independent care providers rather than as 
employees of the facility.  Among other requirements, St. Luke’s requires physicians 
applying for staff privileges to disclose whether they have ever been sued for professional 
malpractice and, if so, the number of lawsuits they have defended.  Under St. Luke’s 
bylaws, failing to provide complete information in the application for staff privileges is 
grounds to automatically remove a physician from consideration.  Evidence presented at 
trial established Mr. Tharp’s surgeon had defended more lawsuits at the time he operated 
on Mr. Tharp than he had reported to St. Luke’s on his application.   
St. Luke’s filed a motion for directed verdict at the close of all evidence, arguing 
there was insufficient evidence to establish St. Luke’s breached any duty owed to 
Mr. Tharp.  St. Luke’s also argued its act of granting the surgeon staff privileges was not a 
proximate cause of Mr. Tharp’s injuries.  The circuit court overruled the motion for 
directed verdict.  The jury returned a verdict in favor of the Tharps.  St.  Luke’s then filed 
a post-trial motion for judgment notwithstanding the verdict (JNOV), again arguing the 
Tharps introduced insufficient evidence to support their claim of negligent credentialing.  
Again, St. Luke’s argued there was insufficient evidence to establish St. Luke’s breached 
3 
 
any duty owed to Mr. Tharp or St. Luke’s actions were the proximate cause of Mr. Tharp’s 
injuries.  The circuit court also overruled this motion. 
After the verdict, the circuit court entered judgment in favor of the Tharps.   
St. Luke’s filed a motion to modify the judgment, asking the circuit court to order damages 
awarded by the jury based on future medical expenses to be paid in periodic installment 
payments instead of a lump sum pursuant to § 538.220.1  The circuit court sustained  
St. Luke’s motion and amended its judgment accordingly.  The Tharps appeal the circuit 
court’s application of § 538.220.2, challenging the constitutional validity of this section, 
and St. Luke’s cross-appeals the circuit court’s overruling of its motions for directed 
verdict and JNOV. 
Jurisdiction 
The Tharps challenge the constitutional validity of § 538.220.2 as applied by the 
circuit court.  This Court has exclusive appellate jurisdiction over cases challenging the 
constitutional validity of a statute.  MO. CONST. art. V, § 3.  This Court adheres to the 
“important principle of not reaching constitutional issues unless necessarily required.”  
Hink v. Helfrich, 545 S.W.3d 335, 343 (Mo. banc 2018).  This Court, therefore, declines 
to reach the Tharps’ points because St. Luke’s appeal is dispositive. 
 
 
                                                 
1  All statutory references are to RSMo 2000, as amended. 
4 
 
Standard of Review 
“The standard for reviewing a denied motion for JNOV is essentially the same as 
for reviewing the denial of a motion for directed verdict.”  Sanders v. Ahmed, 364 S.W.3d 
195, 208 (Mo. banc 2012).  “A case may not be submitted unless legal and substantial 
evidence supports each fact essential to liability.”  Id.  This Court views all evidence in the 
light most favorable to the jury’s verdict and draws all reasonable inferences in the 
plaintiff’s favor.  Id.  This Court must disregard all conflicting evidence and inferences.  
Id.  “A court may reverse the jury’s verdict for insufficient evidence only when there is a 
complete absence of probative fact to support the jury’s conclusion.”  Id. 
Analysis 
Generally, modern hospitals staff their facilities with two classes of physicians: staff 
physicians who are hospital employees and independent physicians to whom the hospital 
grants staff privileges.  Under this arrangement, physicians working under staff privileges 
are typically independent contractors, not hospital employees.  Injured patients in the past, 
therefore, had difficulty recovering against a hospital for injuries caused by an independent 
physician because the doctrine of respondeat superior does not apply to independent 
contractors.  See Central Trust and Inv. Co. v. Signalpoint Asset Mgmt., 422 S.W.3d 312, 
323 (Mo. banc 2014) (“An employer generally is not held vicariously liable … for the acts 
of its independent contractors, who are not considered employees for purposes of 
respondeat superior.”).  Beginning in the 1960s, however, courts began to realize hospitals 
are businesses that hire, utilize, and benefit from independent contractors similarly to other 
types of businesses.  See,e.g., Darling v. Charleston Comm. Mem. Hosp., 211 N.E.2d 253, 
5 
257 (Ill. 1965), cert. denied, 383 U.S. 986 (1966).  The trend toward allowing recovery 
against hospitals for injuries caused by independent physicians began to accelerate under 
the theory that “an employer is liable for an independent contractor’s negligence when the 
employer fails to exercise reasonable care in hiring a competent contractor.”  LeBlanc v. 
Research Belton Hosp., 278 S.W.3d 201, 206 (Mo. App. 2008) (internal quotations 
omitted) (emphasis added).  Indeed, this Court, citing Darling, explained, “The fact the 
defendant doctors here were not employees of the defendant hospital does not necessarily 
mean the hospital cannot be held liable for adverse effects of treatment or surgery approved 
by the doctors.”  Gridley v. Johnson, 476 S.W.2d 475, 484 (Mo. 1972). 
In Leblanc, the court of appeals recognized “Missouri precedent does not bar a 
negligence claim against a hospital for injuries caused by independent doctors authorized 
to practice in that hospital.”  278 S.W.3d at 206.  This theory is called negligent 
credentialing.  See id. at 204.  The theory focuses on whether a hospital gathered “all the 
pertinent information to make a reasonable decision as to whether physicians should have 
access to hospital facilities.”  Steven R. Weeks, Comment, Hospital Liability: The 
Emerging Trend of Corporate Negligence, 28 IDAHO L. REV. 441, 454 (1992).  Negligent 
credentialing “is merely the application of principles of common law negligence to 
hospitals in a manner that comports with the true scope of their operations.”  LeBlanc, 278 
S.W.3d at 207 (internal quotations omitted).  Accordingly, before a hospital can be held 
liable for an independent physician’s negligence, the plaintiff must show “the hospital’s 
duty owed to the patient, the breach of the duty, and the resulting injury from the breach.” 
LeBlanc, 278 S.W.3d at 207; see also Hoover’s Dairy, Inc. v. Mid-Am. Dairymen, Inc., 700 
6 
 
S.W.2d 426, 431 (Mo. banc 1985) (holding the basic elements of a prima facie negligence 
claim are duty, breach of that duty, causation, and damages). 
Issue preserved for appellate review 
 
In response to St. Luke’s cross-appeal, the Tharps initially argue St. Luke’s failed 
to preserve its insufficient evidence claim.  “To preserve a question of submissibility for 
appellate review in a jury-tried case, a motion for directed verdict must be filed at the close 
of all the evidence ….”  Howard v. City of Kansas City, 332 S.W.3d 772, 790 (Mo. banc 
2011); see also Sanders 364 S.W.3d at 207 (“[I]f defendant chooses to put on evidence … 
[a] motion for directed verdict at the close of all evidence becomes the meaningful motion 
to preserve the issue….”).  Further, “in the event of an adverse verdict, an after-trial motion 
for a new trial or to set aside a verdict must assign as error the trial court’s failure to have 
directed such a verdict.”  Howard, 332 S.W.3d at 790 (internal quotations omitted).  
Accordingly, to preserve a jury-tried issue for appellate review, a party must include the 
issue in both a motion for directed verdict at the close of all evidence, if the defendant puts 
on evidence, and in a motion for JNOV.  Id. 
The Tharps do not dispute St. Luke’s made both a motion for directed verdict and a 
motion for JNOV.  Instead, the Tharps argue the motions were not sufficiently specific to 
preserve St. Luke’s insufficient evidence claim for appellate review.  Rule 72.01(a) states 
a motion for directed verdict “shall state the specific grounds therefor.”  The Rule 72.01(a) 
standard, however, is not a demanding one.  Indeed, this Court has held an oral motion for 
directed verdict which stated, “We think plaintiff failed to make a submissible case on 
issues of negligent causation”, sufficiently preserved the issue for appellate review.  
7 
 
Sanders, 364 S.W.3d at 208.  Here, St. Luke’s motion for directed verdict asserted in 
pertinent part, “[T]he evidence fails to satisfy all of the necessary elements of … negligent 
credentialing …. [T]here is no evidence that would support the conclusion that there was 
any breach of duty on the part of defendant that constituted a proximate cause of the event 
complained of.”  St. Luke’s motion for JNOV stated in pertinent part, “[P]laintiffs failed 
to present submissible evidence that [St. Luke’s] breached any legally-recognizable 
negligence duty …. [P]laintiffs’ evidence … fails to adequately demonstrate proximate 
cause.”  These specifically articulated grounds were sufficient to preserve St. Luke’s 
insufficient evidence challenge for appellate review. 
Insufficient evidence to support a finding of negligent credentialing 
St. Luke’s argues the circuit court erred in overruling its motion for JNOV because 
the Tharps failed to make a submissible case of negligent credentialing.  Specifically,  
St. Luke’s argues the evidence was insufficient to support a negligent credentialing claim 
because there was no evidence showing Mr. Tharp’s surgeon was incompetent to conduct 
the procedure he performed and credentialing the surgeon was not the proximate cause of 
Mr. Tharp’s injuries.  “A court may reverse the jury’s verdict for insufficient evidence only 
when there is a complete absence of probative fact to support the jury’s conclusion.”  
Sanders, 364 S.W.3d at 208. 
A.  Duty 
St. Luke’s must owe a duty to Mr. Tharp before it can be liable to him for 
negligence.  Hoover’s Dairy, 700 S.W.2d at 431; see also Leblanc, 278 S.W.3d at 207.  
“Whether a duty exists is purely a question of law.”  Lopez v. Three Rivers Elec. Coop.,Inc., 
8 
26 S.W.3d 151, 155 (Mo. banc 2000).  In general, “a duty exists when a general type of 
event or harm is foreseeable.”  Pierce v. Platte-Clay Elec. Co-op., Inc., 769 S.W.2d 769, 
776 (Mo. banc 1989).  The scope of a defendant’s duty is a question of law for the court to 
resolve.  See Harris v. Niehaus, 857 S.W.2d 222, 225 (Mo. banc 1993).  This Court has 
never before considered the scope of the duty hospitals owe to their patients when deciding 
whether to grant staff privileges to a physician.  The Restatement of Torts, however, is 
instructive:   
Section 411 of the Restatement of Torts reads in pertinent part: 
An employer is subject to liability for physical harm to third persons caused 
by his failure to exercise reasonable care to employ a competent and careful 
contractor: 
(a) to do work which will involve a risk of physical harm unless it is skillfully
and carefully done.
RESTATEMENT (SECOND) OF TORTS § 411 (AM. LAW INST. 1965) (emphasis added).  
Comment a to Restatement § 411 explains the words “competent and careful” in this 
context mean a contractor who has the “knowledge, skill, experience, and available 
equipment which a reasonable man would realize that a contractor must have in order to 
do the work which he is employed to do without creating unreasonable risk of injury to 
others.”  Id. cmt. a.   Applied in the context of credentialing physicians, a hospital, 
therefore, must “ensure the competency of its medical staff and the quality of medical care 
provided through prudent selection, review and continuing evaluation of the physicians 
granted staff privileges.”  Barry R. Furrow, Managed Care Organizations and Patient 
Injury: Rethinking Liability, 31 GA. L. REV. 419, 457 (1997) (internal quotations omitted).  
9 
 
Accordingly, St. Luke’s owes a duty to its patients to credential only competent and careful 
physicians because it is foreseeable that incompetent or generally careless physicians could 
injure St. Luke’s patients.  See Platte-Clay Elec. Co-op., 769 S.W.2d at 776; see also Baker 
v. Scott Cty. Milling Co., 20 S.W.2d 494, 499 (Mo. 1929) (“concluding the duty rests on 
the employer to select a skilled and competent contractor”).  Because Mr. Tharp was  
St. Luke’s patient, St. Luke’s owed him this duty. 
B.  Breach 
 
St. Luke’s must breach a duty owed to Mr. Tharp to be liable for negligence.  A 
defendant breaches its duty when it “fail[s] to exercise reasonable care to perform [its] 
undertaking.”  Hoover’s Dairy, 700 S.W.2d at 433; see also Chavez v. Cedar Fair, LP, 450 
S.W.3d 291, 294 (Mo. banc 2014) (“The common law ordinary negligence rule requires a 
defendant to exercise the degree of care of a reasonable person of ordinary prudence under 
similar circumstances ….”).  As noted above, a hospital’s undertaking – its duty – is to 
credential competent and careful physicians.  See Baker, 20 S.W.2d at 499; RESTATEMENT 
(SECOND) OF TORTS § 411.  A hospital, therefore, fulfills its duty by using reasonable care 
to credential competent and careful physicians.  See Hoover’s Dairy, 700 S.W.2d at 433; 
Chavez, 450 S.W.3d at 294.  Accordingly, St. Luke’s did not breach its duty to the Tharps 
unless it failed to use reasonable care to determine whether Mr. Tharp’s surgeon was 
qualified and therefore should be granted staff privileges.  Hoover’s Dairy, 700 S.W.2d at 
433; see also Lee v. Pulitzer Pub. Co., 81 S.W.3d 625, 634 (Mo. App. 2002) (“In Missouri, 
an employer will be held liable for the negligent action of an independent contractor when 
the employer fails to exercise reasonable care to hire a competent contractor.”) 
10 
(emphasis added); Sullivan v. St. Louis Station Assoc’s, 770 S.W.2d 352, 356 (Mo. App. 
1989) (concluding employer must exercise reasonable care in selecting “skilled and 
competent” contractor) (emphasis added); RESTATEMENT (SECOND) OF TORTS § 411; 
LeBlanc, 278 S.W.3d at 206 (“concluding an employer is liable for an independent 
contractor’s negligence when the employer fails to exercise reasonable care in hiring a 
competent contractor”) (internal quotations omitted) (emphasis added).   
The Tharps contend St. Luke’s breached its duty by credentialing Mr. Tharps’ 
surgeon because the surgeon did not list all the lawsuits he had defended over his career in 
his application for staff privileges as required by St. Luke’s bylaws.  The Tharps’ evidence 
supporting their negligence theory focuses on St. Luke’s failure to follow its bylaws, but 
their evidence fails to address the surgeon’s qualifications.  It is true, had St. Luke’s 
followed its bylaws by rejecting the surgeon’s application for failing to list his entire 
litigation history, Mr. Tharps’ surgeon would not have received staff privileges at St. 
Luke’s.  However, St. Luke’s failure to follow its bylaws, alone, is insufficient to show St. 
Luke’s breached its duty to credential a competent and careful surgeon.  Even though the 
surgeon did not list every lawsuit he had defended in his career, there was no evidence 
showing he was unqualified due to the number of lawsuits the surgeon had defended.  In 
fact, the Tharps’ own expert admitted there was “no magical number” of lawsuits that 
denotes a surgeon is unqualified to practice medicine.  Indeed, a physician’s specialty can 
have a dramatic impact on how frequently the physician is sued over the course of his or 
her career.  See Anupam B. Jena, et al., Malpractice Risk According to Physician Specialty, 
11 
356 NEW ENGLAND J. MED. 629, 632 (2011).2  The Tharps presented evidence St. Luke’s 
deviated from its bylaws, but there was no evidence showing St. Luke’s credentialed an 
unqualified surgeon.  The record is devoid of any evidence Mr. Tharp’s surgeon lacked the 
knowledge, skill, and experience necessary to operate on patients like Mr. Tharp “without 
creating unreasonable risk of injury.”3  RESTATEMENT (SECOND) OF TORTS § 411.  Without 
evidence showing a reasonable investigation into the surgeon’s background and 
qualifications would have revealed he was unqualified to perform laparoscopic 
2  In a study of more than 40,000 physicians, totaling nearly a quarter-million – physician 
years of experience, the authors found, “[t]he proportion of physicians facing a 
[malpractice] claim each year ranged from 19.1 percent in neurosurgery, 18.9 percent in 
thoracic–cardiovascular surgery, and 15.3 percent in general surgery to 5.2 percent in 
family medicine, 3.1 percent in pediatrics, and 2.6 percent in psychiatry,” thereby 
demonstrating the dramatic impact a physician’s specialty has on his or her likelihood to 
encounter a malpractice claim.  Jena¸ et al., supra at 629. 
3  The dissent claims the Tharps presented evidence of incompetence by way of their expert 
who testified about the surgeon’s record of other surgeries, including one which a patient 
died.  Although this is evidence the surgeon fell below the standard of care in the past, 
falling below the standard of care “is evidence of ordinary negligence, but not 
incompetency.”  Tendai v. Mo. Bd. of Reg. for Healing Arts, 161 S.W.3d 358, 371 (Mo. 
banc 2005) (overruled on other grounds).  “‘Incompetency,’ as this Court has said, is a state 
of being," which, to prove, requires more than evidence of prior negligent conduct. 
Albanna v. State Bd. of Reg. for Healing Arts, 293 S.W.3d 423, 436 (Mo. banc 2009).  Even 
acts of repeated negligence do not support finding a surgeon is incompetent when there is 
no evidence that shows a surgeon generally lacks a professional ability.  Albanna, 293 
S.W.3d at 435.  Accordingly, to establish incompetence, there must instead be evidence of 
the surgeon’s state of being, which shows the surgeon lacks the “knowledge, skill, 
experience, and available equipment which a reasonable man would realize that a 
contractor must have in order to do the work which he is employed to do without creating 
unreasonable risk of injury to others.”  RESTATEMENT (SECOND) OF TORTS § 411 cmt. a. 
Despite the dissent’s claims, the Tharps’ expert never testified the surgeon was 
incompetent or lacked the knowledge, skill, and experience necessary to operate on patients 
like Mr. Tharp without creating an unreasonable risk of injury.  
12 
cholecystectomies, there is no evidence St. Luke’s breached its duty to the Tharps to 
credential competent and careful physicians. 
C. Causation
Even if a plaintiff establishes a breach of duty, a successful negligence claim 
requires the plaintiff to also prove the breach caused the plaintiff damage.  Hoover’s Dairy, 
700 S.W.2d at 431.  To prevail on their negligence claim, therefore, the Tharps must present 
evidence that credentialing Mr. Tharp’s surgeon caused Mr. Tharp’s injuries.   
In all negligence cases, Missouri courts require the plaintiff to prove the defendant’s 
acts were both the actual and proximate cause of the plaintiff’s damage.  Callahan v. 
Cardinal Glennon Hosp., 863 S.W.2d 852, 862 – 63 (Mo. banc 1993).  Actual cause means 
causation in fact.  Id. at 861.  The test for actual cause asks whether the plaintiff would 
have been injured but for some conduct on the defendant’s behalf.  Id. at 862.    Proximate 
cause, also known as legal cause, means “the injury must be a reasonable and probable 
consequence of the act or omission of the defendant.”  Id. at 865.  “Proximate cause 
inquires into the scope of foreseeable risk created by the defendant’s act or omission.”  Nail 
v. Husch Blackwell Sanders, LLP, 436 S.W.3d 556, 563 (Mo. banc 2014).  The proximate
cause requirement ensures events that are “too far removed from the ultimate injury or 
damage” do not provide a basis for liability even if they are causal in fact.  Callahan, 863 
S.W.2d at 865.4   
4  This Court, in Callahan, illustrated this concept by explaining, “[C]arried to the 
ridiculous, ‘but for’ the mother and father of the defendant conceiving the defendant and 
bringing him into this world, the accident would not have happened.  Obviously, this is not 
a basis for holding the mother and father liable.”  863 S.W.2d at 865.   
13 
 
Comment b to § 411 of the Restatement of Torts explains, “The employer of a 
negligently selected contractor is subject to liability … for physical harm caused by his 
failure to exercise reasonable care to select a competent and careful contractor, but only 
for such physical harm as is so caused” by the employer’s failure to use reasonable care 
in selecting the contractor.  RESTATEMENT (SECOND) OF TORTS § 411, cmt. b (emphasis 
added).  Further, “if the incompetence of the contractor consists in his lack of skill and 
experience…the employer is subject to liability for any harm caused by the contractor’s 
lack of skill [or] experience …. but not for any harm caused solely by the contractor’s 
inattention or negligence.”  Id. (emphasis added).  The Restatement, therefore, does not 
allow recovery against a contractor’s employer if the contractor simply causes harm of any 
type or in any manner.  Rather, courts must ask “whether the precise manner of a particular 
injury was a natural and probable consequence of [the employer’s] negligent act.”  Lopez, 
26 S.W.3d at 156.  Therefore, to prove causation under the negligent credentialing theory, 
a plaintiff must show: (1) but for the hospital’s breach of its duty to credential a competent 
and careful physician, the plaintiff would not have been injured; and (2) the plaintiff’s 
injuries were a natural and probable consequence of the breach of this duty.  Otherwise, 
there is nothing to link a hospital’s act of credentialing a physician to the patient’s injuries.   
When a physician injures a patient, he or she may be liable to the patient for 
negligence or other tort.  The hospital, however, cannot be liable for the physician’s 
negligence under a theory of negligent credentialing unless the patient’s injuries were the 
result of the hospital’s breach of a duty it owes to the patient.  Because a hospital’s duty to 
its patients is to credential competent and careful physicians, a hospital’s act of 
14 
credentialing a physician is not the proximate cause of a patient’s injuries unless the 
injuries are a consequence of receiving treatment from an unqualified physician.  If a 
surgeon injures a patient while operating, not because he or she lacks the general 
competence or care necessary to perform the procedure, but rather because the surgeon 
simply was negligent in that particular instance, the patient’s injuries are not the natural 
and probable consequence of credentialing the surgeon.  After all, even a supremely 
qualified, competent, and careful physician may nevertheless injure a patient through an 
isolated negligent act.  See Tendai v. Mo. State Bd. of Registration for Healing Arts, 161 
S.W.3d 358, 369 (Mo. banc 2005) (overruled on other grounds).  In this circumstance, 
recovery against the physician may be appropriate because the physician is the one at fault, 
but recovery against the hospital is not appropriate because the hospital bears no fault if it 
credentialed a competent and generally careful physician.  Accordingly, a plaintiff cannot 
establish the causation element of a negligent credentialing claim unless there is evidence 
showing the patient’s injuries were the natural and probable consequence of the surgeon’s 
general incompetence or carelessness. 
Here, the Tharps’ evidence supports a finding of actual cause because but for 
St. Luke’s credentialing the surgeon in violation of its bylaws, Mr. Tharp’s surgeon would 
not have operated on him.  The evidence, however, does not support a finding of proximate 
cause because Mr. Tharp’s injuries were not within “the scope of foreseeable risk” created 
by St. Luke’s act of credentialing Mr. Tharp’s surgeon.5  Nail, 436 S.W.3d at 563.  The 
5   Under St. Luke’s bylaws, failing to provide complete information in the application for 
staff privileges is grounds to automatically remove a physician from consideration.  This 
15 
Tharps failed to offer any evidence showing Mr. Tharp’s surgeon was unqualified to 
perform laparoscopic cholecystectomies and the surgeon’s incompetency or general 
carelessness was the proximate cause of Mr. Tharp’s injuries. Because there was no 
evidence showing Mr. Tharp’s surgeon was unqualified in this manner and, therefore, 
likely to injury any patient, there was insufficient evidence to support a finding St. Luke’s 
act of credentialing the surgeon caused Mr. Tharp’s injuries.  Accordingly, there was 
insufficient evidence to support their negligent credentialing claim.6 
requirement does not appear to be limited to information related to the physician’s 
qualifications.  Thus, St. Luke’s failure to follow this bylaw requirement may offend other 
purposes beyond ensuring the qualifications of the physicians it credentials.
6 Although not raised in this appeal, the verdict director submitting the negligent 
credentialing claim was also deficient because it did not require the jury to find Mr. Tharp’s 
surgeon to be unqualified. "[A] not-in-MAI jury instruction must follow substantive law 
by submitting the ultimate facts necessary to sustain a verdict." Johnson v. Auto Handling 
Corp., 523 S.W.3d 452, 463 (Mo. banc 2017) (internal quotations omitted). Ultimate facts 
are facts the jury must find to return a verdict for the plaintiff. See Lasky v. Union Elec. 
Co., 936 S.W.2d 797, 800 (Mo. banc 1997) (“The instruction must hypothesize the facts 
essential to the plaintiff's claim.”). To hold a hospital liable for negligent credentialing, the 
ultimate facts a jury must find are: (1) the hospital credentialed an incompetent or generally 
careless physician; (2) the hospital was thereby negligent; and (3) as a direct result of such 
negligence, the plaintiff suffered damage. Litigants pursuing a negligent credentialing 
claim must not only present evidence of the physician's incompetence, but must also 
include this finding in the verdict director. 
16 
Conclusion 
The Tharps failed to make a submissible case of negligent credentialing.  The circuit 
court’s judgment is reversed, and, pursuant to Rule 84.14, judgment is entered in favor of 
St. Luke’s. 
___________________ 
W. Brent Powell, Judge
Fischer, C.J., Wilson, Russell, Breckenridge and Stith, JJ., concur; 
Draper, J., dissents in separate opinion filed. 
1 
SUPREME COURT OF MISSOURI
en banc 
THOMAS E. THARP, et al., 
  ) 
  ) 
Appellants/Cross-Respondents, 
  ) 
  ) 
v. 
  ) 
No.  SC96528 
  ) 
ST. LUKE’S SURGICENTER- 
  ) 
LEE’S SUMMIT, LLC, 
 
  ) 
  ) 
Respondent/Cross-Appellant. 
  ) 
DISSENTING OPINION 
While the principal opinion would make a persuasive closing argument at trial on 
behalf of St. Luke’s Surgicenter-Lee’s Summit, LLC (hereinafter, “St. Luke’s”), I believe 
the principal opinion reaches beyond the standard of review in order to overturn the 
jury’s verdict.  I disagree with its analysis, and therefore, I dissent. 
St. Luke’s challenges the circuit court’s judgment overruling its post-trial motion 
for judgment notwithstanding the verdict (hereinafter, “JNOV”).  The standard of review 
of the denial of a JNOV is essentially the same as the overruling of a motion for directed 
verdict.  Klotz v. St. Anthony’s Medical Center, 311 S.W.3d 752, 769 (Mo. banc 2010).  
“A case may not be submitted unless each and every fact essential to liability is 
predicated on legal and substantial evidence.”  Moore v. Ford Motor Co., 332 S.W.3d 
2 
749, 756 (Mo. banc 2011) (quoting Investors Title Co. v. Hammonds, 217 S.W.3d 288, 
299 (Mo. banc 2007)).  To determine whether the evidence was sufficient to support the 
jury’s verdict, an appellate court views the evidence in the light most favorable to the 
verdict and the plaintiff is given the benefit of all reasonable inferences.  Keveney v. Mo. 
Military Acad., 304 S.W.3d 98, 104 (Mo. banc 2010).  This Court will reverse a jury’s 
verdict for insufficient evidence only where there is a complete absence of probative fact 
to support the jury’s conclusion.  Klotz, supra. 
The principal opinion finds Thomas E. Tharp and Paula M. Tharp’s (hereinafter, 
“the Tharps”) negligent credentialing claim was insufficient as a matter of law because 
they failed to present evidence showing Mr. Tharp’s surgeon was incompetent generally.  
Demonstrating Mr. Tharp’s surgeon was incompetent generally was not required, as in 
fact, the primary question to be established by the evidence and put to the jury was, and 
is, did the hospital sufficiently investigate and act upon any indication of incompetency.1  
See Larson v. Wasemiller, 738 N.W.2d 300, 306-09 (Minn. 2007); Frigo v. Silver Cross 
Hosp. & Med. Ctr., 377 Ill. App. 3d 43, 72 (2007).  Therefore, this assertion by the 
principal opinion mischaracterizes the evidence presented to the jury.  
The Tharps presented the expert testimony of a professor of health care 
administration, specializing in health care credentialing, and a medical doctor, 
1 While the principal opinion recognizes a hospital must “ensure the competency of its 
medical staff” when granting staff privileges, the opinion then proceeds to evaluate 
whether Mr. Tharp’s surgeon was unqualified.  Being competent and being qualified are 
two separate inquires that are not equivalent determinations.   
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specializing in hepatobiliary and pancreas surgery.2  The health care administration 
expert found St. Luke’s fell “very much below” the standard of care in credentialing Mr. 
Tharp’s surgeon.  (Emphasis added).  Specifically, the expert testified to records of other 
surgeries Mr. Tharp’s surgeon conducted that should have been included in his 
credentialing application but were not.  The expert further testified to the circumstances 
surrounding some of those omitted surgeries, including one wherein the twenty-two year 
old female patient died.  Additionally, the medical doctor opined Mr. Tharp’s surgeon fell 
below the standard of care in Mr. Tharp’s surgery.   
It “is the responsibility of the jury, not the court, ‘to determine the credibility of 
witnesses, resolve conflicts in testimony, and weigh evidence.’”  Cox v. Kansas City 
Chiefs Football Club, Inc., 473 S.W.3d 107, 126 (Mo. banc 2015) (quoting State v. 
Letica, 356 S.W.3d 157, 167 (Mo. banc 2011)).  “The jury is the sole judge of the 
credibility of witnesses,” and, as this Court has recently become fond of reiterating, it is 
free to believe or disbelieve any, all, or none of a witness’ testimony.  Keveney, 304 
S.W.3d at 105 (quoting Altenhofen v. Fabricor, Inc., 81 S.W.3d 578, 584 (Mo. App. 
W.D. 2002)).   
Contrary to the principal opinion, the jury was presented evidence that Mr. 
Tharp’s surgeon was incompetent generally and incompetent in this case specifically, 
hence supporting the Tharps’ claims.  Because there was not a complete absence of 
                                                 
2 This is surgery on the gallbladder, liver, and pancreas. 
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probative fact to support the jury’s conclusion, as demanded by this Court’s standard of 
review, I would affirm the circuit court’s denial of St. Luke’s motion for JNOV. 
___________________________ 
GEORGE W. DRAPER III, JUDGE