Title: Carroll v. Konits

State: maryland

Issuer: Maryland Supreme Court

Document:

Carroll v. Konits, No. 117, September Term, 2006
HEADNOTE:  In accordance with the Health Care Malpractice Claims Statute, Maryland
Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-04(b) of the Courts and Judicial
Proceedings Article, a certificate of qualified expert must contain the name of the licensed
professional about whom the qualified expert is speaking, a statement that the named
professional breached the standard of care, and that the departure from the standard of care
was the proximate cause of the plaintiff’s injuries.  The court is required to dismiss the claim,
without prejudice, when the documentation fails to satisfy these stated requirements.  
In the Circuit C ourt for Ba ltimore City
No. 24-C-05-011066
IN THE COURT OF APPEALS OF
MARYLAND
No. 117
September Term, 2006
____________________________________
MARY CARROLL
v.
PHILLIP H. KONITS, M.D. ET AL.
___________________________________
Bell C.J.
Raker
Cathell
Harrell
Battaglia
Greene
Wilner, Alan M . 
(Retired, specially assigned),
   
JJ.
____________________________________
Opinion by Cathell, J.
which Harrell, J., concurs.
Bell, C.J. and Greene, J., dissent.
____________________________________
Filed:   July 27, 2007
1 Prior to January 11, 2005, this office was known as the Health Claims Arbitration
Office.  Maryland Code (1974, 2006 Repl. Vol.), § 3-2A-03 of the Courts and Judicial
Proceedings Article (describing in the Editor’s note when the name change was made by the
General Assembly and when it was to take effect).  We refer to the office by its current name
throughout this opinion.
2 Various sources use different language to refer to the document that is to be filed
with a complaint alleging malpractice.  The relevant statute uses “certificate of qualified
expert.”  Other sources use “Certificate of Merit” in reference to the same document.  We use
“Certificate” herein.
This matter arises from a medical malpractice claim filed by Mary Carroll, appellant,
against Dr. Phillip H. Konits and Dr. Efem E. Imoke, appellees.  Carroll, in accordance with
applicable law, initially filed her complaint with the Health Care Alternative Dispute
Resolution Office (the “HCADRO”).1  Thereafter, the claim was transferred to the Circuit
Court for Baltimore City.  The Circuit Court dismissed the case on various grounds,
including, but not limited to, Carroll’s failure to submit a proper certificate of qualified
expert (“Certificate”)2 as required by the Health Care Malpractice Claims Statute (the
“Statute”), Maryland Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-04(b) of the
Courts and Judicial Proceedings Article.
Carroll filed a timely appeal to the Court of Special Appeals.  On January 2, 2007,
while the appeal was pending in the intermediate appellate court, this Court issued a writ of
certiorari on its own motion to review the following question:
“Did the Circuit Court err in finding that Mary Carroll’s expert witness
report and certification was legally insufficient, thereby dismissing the case?”
Carroll v. Konits, 396 Md. 524, 914 A.2d 768 (2007).
We hold that a Certificate is a condition precedent and, at a minimum, must identify
3 According to Taber’s Cyclopedic Medical Dictionary, 1734 (20th ed. 2005), porta
means:  “The point of entry of nerves and vessels into an organ or part.”  A catheter is:  “A
tube passed into the body for evacuating fluids or injecting them into body cavities.  It may
be made of elastic, elastic web, rubber, glass, metal, or plastic.”  Id. at 357.  To the non-
medical mind, the combination of these words may be somewhat confusing with respect to
the present context.  Apparently, however, the combination of these terms, in reference to the
procedure at issue, is standard practice in the medical community.
An information sheet provided to patients by the Duke Comprehensive Cancer Center
(which has no involvement in the present case), better explains the meaning of the term and
the operation of the device:
“[I]mplanted port for central venous access (porta-cath) allow[ing] a nurse to
inject or infuse medication into a long term catheter which has been placed in
a vein in the upper chest (just below the collar bone).  The catheter may stay
(continued...)
-2-
with specificity, the defendant(s) (licensed professional(s)) against whom the claims are
brought, include a statement that the defendant(s) breached the applicable standard of care,
and that such a departure from the standard of care was the proximate cause of the plaintiff’s
injuries.  In the case sub judice, the certificate was incomplete because it failed to specifically
identify the licensed professionals who allegedly breached the standard of care and failed to
state that the alleged departure from the standard of care, by whichever doctor the expert
failed to identify, was the proximate cause of Carroll’s injuries.  Therefore, because the
Certificate is a condition precedent, the Circuit Court for Baltimore City correctly granted
the appellees’ motion to dismiss the case and, accordingly, we affirm the judgment of the
Circuit Court for Baltimore City.
I. Factual and Procedural Background
On September 19, 2001, Dr. Imoke performed a unilateral mastectomy of Carroll’s
left breast.  As a part of the procedure, Dr. Imoke left a catheter3 inside Carroll’s chest so that
3(...continued)
in place for weeks or months.  This makes it unnecessary for the patient to
need an IV started every time it is necessary to give medication into a vein.
The catheter also makes it possible for blood to be drawn from the catheter and
not through vein sticks. . . .”   
A doctor would order a porta-cath inserted for “patients who will require medications to be
given into a vein many times over weeks or months [e.g. a patient undergoing
chemotherapy].  It also makes frequent blood draws for blood tests easier since the blood can
be taken from the catheter.  See http://cancer.duke.edu/pated/Materials/Procedures/
ImplantablePortInsertionCare.pdf, last visited on June 25, 2007.  Hereinafter we will use the
term catheter to refer to the device inserted into Carroll.
-3-
chemotherapy could be administered.  Carroll claims that she was not aware that the catheter
was inserted at the time that it occurred.  The catheter was supposed to be removed within
two months after Carroll completed chemotherapy.  Dr. Imoke, however, did not make a
follow-up appointment to remove the catheter.  Instead, he relied on Dr. Konits,  Carroll’s
oncologist, to inform him that Carroll had completed chemotherapy.
She completed chemotherapy on April 11, 2002.  The catheter was not removed,
however, until March 25, 2003–two and one-half years after it was initially inserted.  Carroll
asserts that she suffered pain and discomfort, a deep vein thrombosis, and chronic venous
stasis of the right arm with chronic lymph edema due to the catheter being left inside her
chest for a prolonged period of time.
On March 25, 2005, Carroll filed a complaint with the HCADRO.  She alleged that
Drs. Konits and Imoke were negligent in failing to communicate the need to have the catheter
removed in a timely manner.  Approximately four months later, on August 4, 2005, Carroll
filed a letter signed by Dr. Wanda J. Simmons-Clemmons, which purported to be a
4 Maryland Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-04(b)(1)(i) of the
Courts and Judicial Proceedings Article, allows a claimants a period of 90 days, from the
initial filing of the complaint, to file the Certificate.  Section 3-2A-04(b)(1)(ii) provides that:
“In lieu of dismissing the claim or action, the panel chairman or the court shall
grant an extension of no more than 90 days for filing the certificate required
by this paragraph, if:
  1.  The limitations period applicable to the claim or action has expired;
and
  2.  The failure to file the certificate was neither willful nor the result
of gross negligence.”
Thus, the time period in which Carroll must have filed her certificate is 180 days from the
filing of her initial complaint.  See also McCready Memorial Hosp. v. Hauser, 330 Md. 497,
508, 624 A.2d 1249, 1255 (1993) (concluding that the “90-day extension commences,
(continued...)
-4-
Certificate.  Dr. Simmons-Clemmons summarized a timeline of  Carroll’s medical treatments
and then wrote:
“In my professional opinion, there was no clear communication
to the patient that indicated she should seek medical attention in
the removal of the catheter from her chest after chemotherapy
was completed.  If this was done, it was not documented.
Secondly, there was mention made of an approximate time
chemo should be completed by Dr. Konits in his consult dated
January 31, 2002. The note was signed off by Dr. Ohio;
however, there was mention of completion of chemo in multiple
subsequent office visits.  Also, the patient was to follow-up with
Dr. Imoke in September 2002.  Again, no mention was made
that the patient should call sooner if and when chemo ended.
Neither was the patient recalled for her September 2002 follow-
up.  If this was done I do not have a copy of the documentation
of it.  Thirdly, it does appear that Mrs. Mary Carroll suffered
complications arising from having a catheter in place for too
long[,] i.e. A DVT and chronic venous stasis of the right arm
with chronic lymphedema.”
On October 3, 2005, after more than 180 days had elapsed from the time that Carroll
initially filed her complaint,4 Drs. Konits and Imoke filed a motion to dismiss the claim with
4(...continued)
without the necessity of a request, upon the expiration of the initial 90-day period and is only
available where the expert’s certificate is filed within the 90-day extension period, i.e., within
180 days of filing the initial complaint.”)
We note that in order to grant an extension the plain language of the statute requires
that both the statute of limitations has expired and that the failure to file the certificate was
neither willful nor the result of gross negligence.  The issue of whether the initial 90 day
extension was proper is not before this Court and we do not resolve it.  For a discussion of
when the granting of 90 day extension is appropriate see McCready, supra.
5 This extension occurred when there was nothing to extend.  The original 90 + 90,
i.e., 180 day period had already expired.
-5-
the HCADRO on the basis that Dr. Simmons-Clemmons’s documentation was deficient
under the requirements set forth in § 3-2A-04(b) of the Courts and Judicial Proceedings
Article.  Drs. Konits and Imoke claimed that Carroll failed to file a Certificate and that she
merely tendered an informal, unsworn letter.  On October 5, 2005, Carroll requested that, “in
the interest of justice[,]” the Director grant her an additional 60 days to correct the
deficiencies in the document filed.5  The Director acting, “in the interest of justice,” granted
Carroll’s request for additional time, giving her until December 1, 2005, to correct the
deficiencies.  On October 28, 2005, Carroll submitted an amended certification in an attempt
to cure the defects in the original submission.  The certificate again contained a summary of
Carroll’s medical visits and treatments and included the same language quoted supra, except
that Dr. Simmons-Clemmons altered the language from “it does appear that Mrs. Mary
Carroll suffered complications arising from having a catheter in place for too long” to
“having a catheter in place for longer than what is standard treatment[.]”  (Emphasis added).
Additionally, a new paragraph was added to the second letter that stated:
6 The trial judge did not specify that dismissal was without prejudice.  The effect of
failing to specify that dismissal was with or without prejudice is that the dismissal was
without prejudice.  See Maryland Rule 2-506(c) stating, in pertinent part, “[u]nless otherwise
specified in the notice of dismissal, stipulation, or order of court, a dismissal is without
prejudice . . . .”  Dr. Imoke filed a separate motion to dismiss which was granted with
prejudice.  The issue of the appropriateness of the granting of that motion with prejudice, is
not presented in this case.
-6-
“It is my professional opinion that Mrs. Carroll sustained injury secondary to
below standard of care received in regards to removal of the Hickman catheter
after chemotherapy.  Please be advised that I do not devote more than 20
percent of my annual time to activities that directly involve personal injury
claims.”
On December 2, 2005, Dr. Konits renewed his motion to dismiss on the grounds that
the updated certificate still failed to meet the specific requirements of § 3-2A-04(b).  On or
about the same date, Carroll waived arbitration and the matter was transferred to the Circuit
Court for Baltimore City.
On December 30, 2005, Dr. Konits filed a motion to dismiss in the Circuit Court for
Baltimore City on the same grounds as the previous two – that the certificate and report did
not comply with the relevant provisions of the Statute.  On March 22, 2006, the Circuit Court
dismissed the case against Dr. Konits.6  This appeal ensued.
II.  Standard of Review
When an appellate court reviews a trial court’s grant of a motion to dismiss a
complaint:  “[T]he truth of all well-pleaded relevant and material facts is assumed, as well
as all inferences which can be reasonably drawn from the pleadings.”  Odyniec v. Schneider,
322 Md. 520, 525, 588 A.2d 786, 788 (1991).  Generally, dismissal at the trial court level will
7 The Newell Court expressly disapproved of language in Johnson that implied that
the appeals process used in under Workers’ Compensation Act was to be applied to claims
brought under the Health Care M alpractice Claims Statute.  The discussion therein on this
issue has no relevance to the case at bar.  See Newell, 323 Md. at 728-735, 594 A.2d 1158-
1161.
-7-
only be ordered if, after assuming the allegations and permissible inferences flowing
therefrom are true, the plaintiff would not be afforded relief.  McNack v. State, 398 Md. 378,
920 A.2d 1097, 1102 (2007) (citing Lloyd v. General Motors Corp., 397 Md. 108, 121, 916
A.2d 257, 264 (2007)).
III. Discussion
The Health Care Malpractice Claims Statute has consistently been interpreted by this
Court as an attempt by the General Assembly, in substantial part, to limit the filing of
frivolous malpractice claims.  See Witte v. Azarian, 369 Md. 518, 526, 801 A.2d 160, 165
(2002) (recognizing that the General Assembly passed the Statute as part of a “multi-phase
response to the malpractice insurance ‘crisis’ that arose in 1974 . . . .”);  McCready Memorial
Hosp. v. Hauser, 330 Md. 497, 500, 624 A.2d 1249, 1251 (1993) (“[T]he General Assembly
enacted the [Statute] in response to explosive growth in medical malpractice claims and the
resulting effect on health care providers’ ability to obtain malpractice insurance.”); Attorney
General v. Johnson, 282 Md. 274, 278-79, 385 A.2d 57, 60 (1978) (recognizing that: “[T]he
general thrust of the Act is that medical malpractice claims be submitted to arbitration as a
precondition to court action . . . .”) overruled on other grounds by Newell v. Richards, 323
Md. 717, 734, 594 A.2d 1152, 1161 (1991).7  What little legislative history remains from the
8 The Maryland State Bar Association, for example, recommended to the General
Assembly (it is unclear whether they did so directly or through the Committee):
“[T]he creation of a procedure which . . . would add an additional measure of
cost predictability by encouraging resolution of disputes prior to full-scale trial
in the courts.  This procedure would involve non-binding pre-trial screening
of all medical malpractice claims.  Our proposal is as follows:
(1) No person would have a cause of action for medical malpractice in
(continued...)
-8-
passage of the original Statute supports this interpretation.
On July 23, 1975, the President of the Senate and the Speaker of the House created
the Medical Malpractice Insurance Study Committee (the “Committee”) to craft and propose
solutions to the medical malpractice problems confronting the State.  State of Md. Medical
Malpractice Ins. Study Comm., Report to the President of the Senate and the Speaker of the
House, p. 1, (January 6, 1976).  The Committee consisted of six Senators, six Delegates,
medical experts, legal experts, hospital and insurance experts, and a representative from the
Governor’s office.  It “was charged with the task of seeking a permanent solution to the
myriad problems of medical malpractice insurance facing the physicians and patients of the
State of Maryland.”  Id.  The Committee’s report to the General Assembly was to be
“introduced for consideration by the General Assembly in its 1976 Session.”  Id. at 3.  After
reviewing position papers and conducting public hearings on the matter, the majority of the
Committee reached a consensus that it was interested in “some form of legislation mandating
arbitration.”  Id. at 2.  This consensus was due, in part, to the fact that almost all of the
testimony heard by the Committee “included recommendations for some type of mechanism
to screen malpractice claims prior to the filing of the suit.”8  Id. at 3 (emphasis added).
8(...continued)
Maryland prior to the submission of his claim to and the issuance of a
determination by a pre-trial screening panel. . . .”
Maryland State Bar Association, Report to the Special Committee to Consider Problems
Related to Medical Malpractice in Maryland, p. 3.
9 In Walzer v. Osborne, 395 Md. 563, 582, 911 A.2d 427, 438 (2006), we explained
the difference between a Certificate and an attesting expert’s report, saying:
“While it is arguably unclear from the Statute exactly what the expert report
(continued...)
-9-
Essentially, two types of screening mechanisms were suggested: “ (1) a medical review panel
and (2) an arbitration panel.”  Id. at 3.  The end result of these recommendations was the
adoption of the Health Care Malpractice Claims Statute in 1976, for “the purpose of
providing for a mandatory arbitration system for all medical malpractice claims in excess of
a certain amount[.]” 1976 Laws of Maryland, Chapter 235.  It is clear from a plain reading
of the original Statute and the existing legislative history that the General Assembly intended
the original Health Care Malpractice Claims Statute to screen–and to first substitute the
arbitration process as to malpractice claims–prior to the filing of lawsuits.
The Relevant Version of the Health Care Malpractice Claims Statute
The Health Care Malpractice Claims Statute, establishes exclusive procedures for
filing a civil action, in excess of a certain amount, against a health care provider.  Maryland
Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-02(a) of the Courts and Judicial
Proceedings Article.  This was true in 1976 and is still true today.  Since 1976, however,
other aspects of the Statute have been amended.  Relevantly, the 1986 amendment required
the filing of a Certificate and an attesting expert’s report. 9  See 1986 Laws of Maryland,
9(...continued)
should contain, common sense dictates that the Legislature would not require
two documents that assert the same information.  Furthermore, it is clear from
the language of the Statute that the certificate required of the plaintiff is merely
an assertion that the physician failed to meet the standard of care and that such
failure was the proximate cause of the patient-plaintiff’s complaints. . . .  It
therefore follows that the attesting expert report must explain how or why the
physician failed . . . to meet the standard of care and include some details
supporting the certificate of qualified expert. . . . [T]he expert report should
contain at least some additional information and should supplement the
Certificate.  Requiring an attesting expert to provide details, explaining how
or why the defendant doctor allegedly departed from the standards of care, will
help weed out non-meritorious claims and assist the plaintiff or defendant in
evaluating the merit of the health claim . . . .”
10 If the defendant does not dispute liability, no certificate is required.  § 3-2A-
04(b)(2)(ii).  In the present case, the appellees dispute liability.  Thus, the certificate was
required.
-10-
Chapter 640.  By enacting the 1986 amendment, the General Assembly determined that, in
the context of a medical malpractice claim, in order to maintain an action against a health
care provider, a plaintiff is required to file a Certificate and an attesting expert’s report in
addition to filing a complaint.  A plaintiff must file a “certificate of qualified expert” that
attests to the departure from the standard of care.10  § 3-2A-04(b)(1)(i)(1).  The statute also
requires that the certificate be filed with a “report of the attesting expert attached.”  § 3-2A-
04(b)(3)(i).  The penalty for failing to file the required certificate and report within 90 days
(subject to a 90 day extension and the possibility of an additional good cause extension) of
the filing of the complaint is dismissal without prejudice:
“Except as provided in subparagraph (ii) of this paragraph, a claim or action
filed after July 1, 1986, shall be dismissed, without prejudice, if the claimant
or plaintiff fails to file a certificate of a qualified expert with the Director
11 The determination of whether a Certificate and report are satisfactory, like the
determination of whether a complaint sufficiently states a legally cognizable claim, is a
determination to be made as a matter of law.  As such, the standard for determining whether
a Certificate or report is legally sufficient is the same as determining whether a complaint is
legally sufficient, i.e., dismissal is only appropriate if, after assuming the truth of the
assertions in the Certificate and report, and all permissible inferences emanating therefrom,
the requirements set forth in the Health Care Malpractice Claims Statute are not satisfied.
-11-
attesting to departure from standards of care, and that the departure from
standards of care is the proximate cause of the alleged injury, within 90 days
from the date of the complaint . . . .”
§ 3-2A-04(b)(1)(i)(1).  Although the statutory scheme is slightly more complex, it is clear
that unless the Certificate and the attached attesting expert’s report are filed within a
maximum of 180 days (absent the grant of a good cause extension), dismissal is mandatory.
Thus, just as a plaintiff in a medical malpractice claim must file a satisfactory complaint, he
or she must also file a satisfactory Certificate and report or risk dismissal.11
An underlying issue herein is whether the requirement to file a proper Certificate
operates as a condition precedent to the maintenance of a malpractice claim.  Many of our
cases have recognized that the arbitration process, as a whole, was designed to be a
condition precedent to the filing of a claim in a circuit court.  Witte, 369 Md. at 527, 801
A.2d at 166 (recognizing that a claimant must file with the HCADRO and comply with all
statutory provisions before proceeding to a circuit court); McCready, 330 Md. at 512, 624
A.2d at 1257 (finding that: “The Maryland Health Care Malpractice Claims Statute mandates
that claimants arbitrate their claims before the [HCADRO] as a condition precedent to
maintaining suit in circuit court.”);  Crawford v. Leahy, 326 Md. 160, 165, 604 A.2d 73, 75
-12-
(1992) (stating that: “The mandatory arbitration requirement does not divest courts of subject
matter jurisdiction over health claims, but rather creates a condition precedent to the
institution of a court action.   Upon fulfillment of the condition precedent, malpractice claims
may be heard in court.” (citations omitted) (quotations omitted)); Su v. Weaver, 313 Md. 370,
377, 545 A.2d 692, 695 (1988) (recognizing that: “The [Statute] substantially altered the
procedure in which a medical malpractice claim is brought against a health care provider by
requiring a malpractice claim to be submitted to a mandatory arbitration proceeding as a
condition precedent to maintaining such an action in the circuit court.”); Ott v. Kaiser-
Georgetown Community Health Plan, Inc., 309 Md. 641, 645, 526 A.2d 46, 48-49 (1987)
(stating that: “If a claimant wishes to reject an award and proceed with the cause of action,
the special procedures prescribed by the Act must be followed.”).
Although it is clear that the arbitration process is a condition precedent to the filing
of a claim in the Circuit Court, the question still remains whether § 3-2A-04 establishes that
the filing of a proper Certificate is a condition precedent to maintaining a claim for
malpractice.  In McCready, we stated that the Statute requires arbitration prior to pursuing
a claim in the circuit court and then said:  “A claimant’s filing of an expert’s certificate is an
indispensable step in the . . . arbitration process.”  330 Md. at 512, 624 A.2d at 1257
(emphasis added).  In other words, the arbitration process cannot occur without the filing of
a Certificate.  Thus, we conclude that the filing of a proper Certificate operates as a condition
precedent to filing a claim in Circuit Court because arbitration is a condition precedent to
12 In Georgia-Pacific Corp. v. Benjamin, 394 Md. 59, 904 A.2d 511 (2006), we
discussed the mandatory nature of conditions precedent, albeit in a different context.  There
we said:
“‘[A] condition precedent cannot be waived under the common law and a
failure to satisfy it can be raised at any time because the action itself is fatally
flawed if the condition is not satisfied.  This requirement of strict or substantial
compliance with a condition precedent is of course subject to abrogation by the
General Assembly.’”
Georgia-Pacific Corp., 394 Md. at 84, 904 A.2d at 526 (quoting Rios v. Montgomery County,
386 Md. 104, 127-28, 872 A.2d 1, 14 (2005).  A statute of limitations, on the other hand, is
designed to:
“‘(1) provide adequate time for diligent plaintiffs to file suit, (2) grant repose
to defendants when plaintiffs have tarried for an unreasonable period of time,
(continued...)
-13-
filing a claim in a Circuit Court and because the filing of a Certificate is an indispensable
step in the arbitration process, i.e., it must occur or the condition precedent is not satisfied.
Therefore, if a proper Certificate has not been filed, the condition precedent to maintain the
action has not been met and dismissal is required by the Statute once the allotted time period
has elapsed.  See Walzer, 395 Md. at 578, 911 A.2d at 435 (concluding that the Statute
mandates dismissal when the claimant fails to file the Certificate within the time period
allotted by the Statute);  Witte, 369 Md. at 533, 801 A.2d at 169 (stating that: “In the absence
of a certificate signed by a qualified expert on behalf of the claimant, the case cannot proceed
beyond the point at which the certificate is required . . . .”); Goicochea v. Langworthy, 345
Md. 719, 729, 694 A.2d 474, 480 (1997) (recognizing that: “Langworthy’s malpractice claim
. . . was dismissed by the [HCADRO] because he did not file the certificate of a qualified
medical expert attesting to the merit of his claim, as required by § 3-2A-04(b) . . . .
(Emphasis added)).12 
12(...continued)
and (3) serve society by promoting judicial economy.’”
Georgia-Pacific Corp., 394 Md. at 85, 904 A.2d at 526 (quoting Pierce v. Johns-Manville
Sales Corp., 296 Md. 656, 665, 464 A.2d 1020, 1026 (1983)).
We then summarized the difference between the two, saying:
“Further, ‘in contrast [to a condition precedent to maintaining an action], a
statute of limitations affects only the remedy, not the cause of action.’
Waddell[ v. Kirkpatrick], 331 Md. [52,] 59, 626 A.2d [353,] 353 [(1993)].  The
defense of limitations may be waived; however, a condition precedent to
liability may not be waived. Rios, 386 Md. at 127-28, 872 A.2d at 14.”
Georgia-Pacific Corp., 394 Md. at 85, 904 A.2d at 526.
-14-
Preservation for Appellate Review
As a threshold issue, Dr. Imoke contends that Carroll failed to preserve her arguments
for appellate review and that this Court should not address the merits of her arguments.  He
explains that Carroll conceded that she had not complied with the statutory requirements and
told the trial court that her expert was in the process of providing a certified statement.  Dr.
Imoke contends that Carroll did not submit a properly amended certified statement before the
Circuit Court dismissed the case, and is now arguing, for the first time on appeal, that the
amended letter complied with the statutory requirements.  As such, according to Dr. Imoke,
she failed to preserve these arguments for appellate review. 
We note that Carroll argued, before the Circuit Court, that her initial Certificate
complied with the statutory requirements and told the trial court that her expert was in the
process of providing an amended Certificate.  Despite the fact that Carroll’s arguments at the
trial level pertained to the initial Certificate, we conclude that the substance of her arguments
was sufficient to preserve for appellate review the issue of whether her Certificate complied
13 We point out that § 3-2A-02(d), provides that the Maryland Rules control the
practice and procedure arising from the Health Care Malpractice Claims subtitle.  Section 3-
2A-02(d), states that:
“Except as otherwise provided, the Maryland Rules shall apply to all practice
and procedure issues arising under this subtitle.”
Maryland Rule 1-204(a) provides in relevant part:
“When these rules or an order of court require or allow an act to be done at or
within a specified time, the court, on motion of any party and for cause shown,
may (1) shorten the period remaining, (2) extend the period if the motion is
filed before the expiration of the period originally prescribed or extended by
a previous order, or (3) on motion filed after the expiration of the specified
time period, permit the act to be done if the failure to act was the result of
excusable neglect. . . .”  (Emphasis added.)
-15-
with the requirements set forth in the Health Care Malpractice Claims Statute.
The Director’s Authority to Grant an Extension13
Dr. Konits argues that the Director did not have the discretion to grant Carroll an
extension of time because it was not filed within the 180-day period and good cause was not
established.  He argues, therefore, that this Court should not address the propriety of Dr.
Simmons-Clemmons’s purported Certificates of M erit.
Section 3-2A-04(b)(5) states that “[a]n extension of the time allowed for filing a
certificate of a qualified expert under this subsection shall be granted for good cause shown.”
Similarly, § 3-2A-05(j), states:
“Except for time limitations pertaining to the filing of a claim or response, the
Director or the panel chairman, for good cause shown, may lengthen or shorten
the time limitations prescribed in subsections (b) and (g) of this section and §
3-2A-04 of this article.”
Dr. Konits contends that no extension could be granted for good cause because Carroll
did not request the good cause extension within the 180-day period.  We rejected that exact
-16-
argument in Navarro-Monzo v. Washington Adventist Hosp., 380 Md. 195, 844 A.2d 406
(2004).  There we said:
“Appellees present the same argument to us that they raised in the
Circuit Court, namely, that § 3-2A-04(b)(1)(ii) permits but one 90-day
extension and that, if any further extension is to be sought under either § 3-2A-
04(b)(5) or § 3-2A-05(j), the extension must be sought before the expiration
of the 90-day extension granted under § 3-2A-04(b)(1)(ii).  Relying on
McCready, they aver that, once [the initial 90-day] extension period expires,
the claim must be dismissed.  Their reliance, and the Circuit Court’s reliance,
on McCready is misplaced.
. . .
“We expressly recognized . . . in McCready, [] that ‘there could
conceivably be instances where there might be “good cause” to grant a request
for an extension that was made after the initial ninety-day period in lieu of
dismissing the claim.’  McCready, 330 Md. at 506 n. 5, 624 A.2d at 1254 n.
5.  Indeed, §§ 3-2A-04(b)(5) and 3-2A-05(j) would have little or no meaning
unless read to permit good cause extensions over and above the mandatory
extension called for in § 3-2A-04(b)(1)(ii).”
Navarro-Monzo, 380 Md. at 200-04, 844 A.2d at 409-11.
In light of our resolution of this case, we will not resolve Dr. Konits’s contention that
the Director lacked good cause to grant  Carroll’s extension.  We did state in Navarro-
Monzo, 380 Md. at 205, 844 A.2d at 412, that:
“Although the arbitration process itself is not in the nature of an administrative
remedy, [the HCADRO] is an administrative agency within the Executive
Branch of the State Government (see CJP § 3-2A-03), and therefore its
Director, in administering that office, acts as an administrative official.  In
reviewing the administrative decisions of the Director, we must afford at least
the same deference that we afford to other administrative agencies in making
discretionary decisions, including, in the absence of some clear indication in
the record to the contrary, an assumption that the Director is aware of the law
controlling his/her conduct and acts in conformance with it.”
Additionally, we explained in McCready, that the good cause extensions are “malleable[,]”
14 Carroll filed the amended Certificate only one day after the Director granted the
extension.
15 We note a recent change in the law pertaining to the procedure for claims dismissed
under § 3-2A-04(B)(3) of the Statute.  The General Assembly enacted Chapter 324 of the
2007 Laws of Maryland to be inserted as § 5-118 in the Courts and Judicial Proceedings
Article.  Its purpose clause provides:
“FOR the purpose of authorizing the commencement of a new civil action or
claim if a prior action or claim for the same cause against the same
(continued...)
-17-
again, generally, leaving room for the Director’s discretion.  330 Md. at 509, 624 A.2d at
1255.  
While Carroll never mentioned the phrase “good cause,” in her request for an
extension, she explained that she had filed her Certificate in a timely manner, and that its
contents complied with the statutory provisions set forth in the Health Care Malpractice
Claims Statute.  She explained further that her attesting expert was already in the process of
amending the Certification to provide additional information that was already available to
her.14  Lastly,  Carroll asked the Director to grant an extension based on the interests of
justice.  In response, the Director utilized his discretionary powers to grant the extension
“upon review and consideration of Claimant’s Answer To Motion To Dismiss and in the
interest of justice[.]”  In accordance with the statutory language and consistent with our prior
case law, we believe that the General Assembly made it clear that the good cause extensions
are discretionary and without time limitations, so long as the Claimant demonstrates good
cause.  As indicated earlier, we need not and do not resolve the nature of the “good cause”
asserted in this case.15
15(...continued)
party or parties was commenced within the applicable period of
limitations, and was dismissed or terminated in a manner other than by
a final judgment on the merits without prejudice for failure to file a
certain report under certain circumstances . . . .”
2007 Laws of Maryland, Chapter 324.  The actual text to be inserted as § 5-118 of the Courts
and Judicial Proceedings Article states that:
“(A) (1) THIS SECTION DOES NOT APPLY TO A VOLUNTARY
DISMISSAL OF A CIVIL ACTION OR CLAIM BY THE PARTY WHO
COMMENCED THE ACTION OR CLAIM.
        (2) THIS SECTION APPLIES ONLY TO A CIVIL ACTION OR
CLAIM THAT IS DISMISSED ONCE FOR FAILURE TO FILE A REPORT IN
ACCORDANCE WITH § 3-2A-04(B)(3) OF THIS ARTICLE.
(B) IF A CIVIL ACTION OR CLAIM IS COMMENCED BY A
PARTY WITHIN THE APPLICABLE PERIOD OF LIMITATIONS AND IS
DISMISSED OR TERMINATED IN A MANNER OTHER THAN BY A
FINAL JUDGMENT ON THE MERITS WITHOUT PREJUDICE, THE
PARTY MAY COMMENCE A NEW CIVIL ACTION OR CLAIM FOR
THE SAME CAUSE WITHIN AGAINST THE SAME PARTY OR PARTIES
ON OR BEFORE THE LATER OF:
(1) THE EXPIRATION OF THE APPLICABLE PERIOD OF
LIMITATIONS; OR 
(2) 1 YEAR 6 MONTHS 60 DAYS FROM THE DATE OF THE
DISMISSAL; OR
(3) AUGUST 1, 2007, IF THE ACTION OR CLAIM WAS
DISMISSED ON OR AFTER NOVEMBER 17, 2006, BUT BEFORE JUNE 1,
2007 OR TERMINATION.”
2007 Laws of Maryland, Chapter 324.
Chapter 324 also provides how this enactment is to be construed in relation to the date
it became effective:
“SECTION 2.  AND BE IT FURTHER ENACTED, That this Act shall
be construed to apply only prospectively and may not be applied or interpreted
to have any effect on or application to any action or claim dismissed or
terminated before the effective date of this Act for which a final judgment has
been rendered and for which appeals, if any, have been exhausted before the
effective date of this Act.
“SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall
take effect October  June 1, 2007.”
(continued...)
-18-
15(...continued)
2007 Laws of Maryland, Chapter 324.  The issues now being presented in the case sub judice
are not affected by this new statute.    
16 Carroll cites Cloverfields Improvment Association, Inc. v. Seabreeze Properties,
Inc., 32 Md. App. 421, 431-32, 362 A.2d 675, 682 (1976), in which the intermediate
appellate court relied on Black’s Law Dictionary 166 (3d ed. 1933) for the definition of the
word “attest.”
17 Carroll cites Ballentine’s Law Dictionary (1969) for the definition of the word
“certify.”
-19-
The Certificate and the Report
We now turn to the parties’ arguments regarding the Certificate and the attesting
expert’s report.  Carroll does not challenge the existence of the condition precedent
requirement discussed, supra.  Instead, she presents arguments of definition, i.e., that nothing
in the statutory scheme defines the words “certificate” or “attesting,” that the statute does not
require a specific format, and that the words “certify” and “attest” do not actually have to
appear in the certification or report.  She also contends that the plain meaning of the word
“attest,” is “to affirm to be true or genuine,”16 and that Dr. Simmons-Clemmons submitted
a document in which she “attested” to her professional opinions in accordance with this
definition.  In addition, Carroll asserts that the plain meaning of the word “certify” only
requires an affirmation in writing.17  Therefore, according to Carroll, the court erred when
it dismissed the case based on a lack of formal attestation or certification.
Furthermore, according to Carroll, there is no stated requirement in § 3-2A-04 that the
initial certification and report actually set forth that the expert is a “qualified expert” or that
18 Section 3-2A-02(c)(2)(ii)(A) and (B) provide in relevant part:
“(ii) 1. In addition to any other qualifications, a health care provider
who attests in a certificate of a qualified expert or testifies in relation to a
proceeding before a panel or court concerning a defendant’s compliance with
or departure from standards of care:
     A. Shall have had clinical experience, provided consultation relating
to clinical practice, or taught medicine in the defendant’s specialty or a related
field of health care, or in the field of health care in which the defendant
provided care or treatment to the plaintiff, within 5 years of the date of the
(continued...)
-20-
those qualifications have to be explained in the certificate.  She also argues that there is no
requirement in § 3-2A-04 that the expert use the words “proximate cause,” or “reasonable
degree of certainty.”  She contends  that even though Dr. Simmons-Clemmons did not use
either of those terms, the certification makes clear that “the lack of communication by
appellees to Carroll concerning the removal of the catheter was the cause of her injuries.”
Lastly, Carroll contends that all of Drs. Konits and Imoke’s assertions fail because they are
not supported by the plain language of the statute.
Appellees argue that Dr. Simmons-Clemmons’s documentation was deficient under
the pertinent provisions the Health Care Malpractice Claims Statute for a multitude of
reasons, any one of which justified the Circuit Court’s dismissal of Carroll’s claim.  They
contend that neither of the submissions from Dr. Simmons-Clemmons certified that she had
clinical experience in the field practiced by Drs. Konits and Imoke within five years from the
date of the alleged negligence, as is required by § 3-2A-02(c)(2)(ii)(A), and that both letters
failed to certify that Dr. Simmons-Clemmons is Board Certified in the same or related
specialty as Drs. Konits and Imoke, as required by § 3-2A-02(c)(2)(ii)(B).18  Drs. Konits and
18(...continued)
alleged act or omission giving rise to the cause of action; and
    B. Except as provided in item 2 of this subparagraph, if the defendant
is board certified in a specialty, shall be board certified in the same or a related
specialty as the defendant.”
19 Section 3-2A-04(b)(3)(i) provides, as relevant:
“The attorney representing each party, or the party proceeding pro se, shall file
the appropriate certificate with a report of the attesting expert attached.”
-21-
Imoke also argue that Dr. Simmons-Clemmons failed to provide any reference to her
training, education, professional experience, practice area, field of specialty, and Board
Certifications; her letters merely contained the initials “M.D.” after her signature.  Dr. Konits
avers that “[t]he facial deficiencies of [Dr. Simmons-Clemmons’s] letter/certificate are only
exacerbated by the failure of [Carroll] to file an expert report from the certifying doctor as
mandated by [§] 3-2A-04(b)(3) . . . .”19
Dr. Konits also argues that neither of Carroll’s letters identified the health care
professional(s) against whom her claims applied.  Dr. Konits notes that the letters reference
five physicians -- Dr. Konits, Dr. Imoke, Dr. Ohio, an unidentified cardiologist, and an
unidentified primary care physician.  Furthermore, according to Dr. Konits, both letters failed
to articulate opinions to a reasonable degree of medical probability, as is required by
Maryland law.  Dr. Konits contends that Dr. Simmons-Clemmons’s letter is not an
appropriate “Certification” or “Attestation” of expert opinions but, instead, was an informal
letter addressed to Carroll’s attorney from Dr. Simmons-Clemmons.  Dr. Konits further
contends that Carroll’s initial letter from Dr. Simmons-Clemmons was deficient because the
-22-
physician failed to state the amount of professional time spent in testimonial activities for
personal injury claims and Dr. Imoke also asserts that the initial letter was deficient because
Dr. Simmons-Clemmons failed to attest to the departures from the standards of care.
Statutory Construction
This case requires us to construe several provisions of the Health Care Malpractice
Claims Statute and is primarily a matter of statutory interpretation.  The first  provision
relevant to the case sub judice is § 3-2A-04(b) of the Courts and Judicial Proceedings Article.
This section states, in pertinent part:
    “(b) Filing and service of certificate of qualified expert. -- Unless the sole
issue in the claim is lack of informed consent:
(1) (i) 1. Except as provided in subparagraph (ii) of this paragraph, a
claim or action filed after July 1, 1986, shall be dismissed, without prejudice,
if the claimant or plaintiff fails to file a certificate of a qualified expert with
the Director attesting to departure from standards of care, and that the
departure from standards of care is the proximate cause of the alleged injury,
within 90 days from the date of the complaint;
. . .
(2) (i) A claim or action filed after July 1, 1986, may be adjudicated in
favor of the claimant or plaintiff on the issue of liability, if the defendant
disputes liability and fails to file a certificate of a qualified expert attesting to
compliance with standards of care, or that the departure from standards of care
is not the proximate cause of the alleged injury, within 120 days from the date
the claimant or plaintiff served the certificate of a qualified expert set forth in
paragraph (1) of this subsection on the defendant.
. . .
(3) (i) The attorney representing each party, or the party proceeding pro
se, shall file the appropriate certificate with a report of the attesting expert
attached.
. . .
(4) A health care provider who attests in a certificate of a qualified
-23-
expert or who testifies in relation to a proceeding before an arbitration panel
or a court concerning compliance with or departure from standards of care may
not devote annually more than 20 percent of the expert’s professional activities
to activities that directly involve testimony in personal injury claims.
(5) An extension of the time allowed for filing a certificate of a
qualified expert under this subsection shall be granted for good cause shown.”
Maryland Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-02 of the Courts
and Judicial Proceedings Article is also relevant and states, in pertinent part:
       “(2) (i) This paragraph applies to a claim or action filed on or after January
1, 2005.
(ii) 1. In addition to any other qualifications, a health care provider who
attests in a certificate of a qualified expert or testifies in relation to a
proceeding before a panel or court concerning a defendant’s compliance with
or departure from standards of care:
       A. Shall have had clinical experience, provided consultation
relating to clinical practice, or taught medicine in the defendant’s specialty or
a related field of health care, or in the field of health care in which the
defendant provided care or treatment to the plaintiff, within 5 years of the date
of the alleged act or omission giving rise to the cause of action; and
        B. Except as provided in item 2 of this subparagraph, if the
defendant is board certified in a specialty, shall be board certified in the same
or a related specialty as the defendant.
     2. Item (ii)1.B of this subparagraph does not apply if:
            A. The defendant was providing care or treatment to the plaintiff
unrelated to the area in which the defendant is board certified; or
         B. The health care provider taught medicine in the defendant’s
specialty or a related field of health care.”
The rules of statutory construction are well settled in this State.  This Court recently
outlined those rules in Walzer v. Osborne, 395 Md. 563, 571-74, 911 A.2d 427, 431-33
(2006), where we stated:
“‘The cardinal rule of statutory construction is to ascertain and effectuate the
intent of the Legislature.’  Mayor and Town Council of Oakland v. Mayor and
Town Council of Mountain Lake Park, 392 Md. 301, 316, 896 A.2d 1036,
-24-
1045 (2006); Chow v. State, 393 Md. 431, 443, 903 A.2d 388, 395 (2006)
(citations omitted) . . . .
“As this Court has explained, ‘[t]o determine that purpose or policy, we
look first to the language of the statute, giving it its natural and ordinary
meaning.’  State Dept. of Assessments and Taxation v. Maryland-Nat’l Capital
Park & Planning Comm’n, 348 Md. 2, 13, 702 A.2d 690, 696 (1997);
Montgomery County v. Buckman, 333 Md. 516, 523, 636 A.2d 448, 452
(1994)[.]  We do so ‘on the tacit theory that the Legislature is presumed to
have meant what it said and said what it meant.’  Witte v. Azarian, 369 Md.
518, 525, 801 A.2d 160, 165 (2002).  ‘When the statutory language is clear, we
need not look beyond the statutory language to determine the Legislature’s
intent.’ Marriott Employees Fed. Credit Union v. MVA, 346 Md. 437, 445, 697
A.2d 455, 458 (1997).  ‘If the words of the statute, construed according to their
common and everyday meaning, are clear and unambiguous and express a
plain meaning, we will give effect to the statute as it is written.’  Jones v. State,
336 Md. 255, 261, 647 A.2d 1204, 1206-07 (1994).  In addition, ‘[w]e neither
add nor delete words to a clear and unambiguous statute to give it a meaning
not reflected by the words the Legislature used or engage in forced or subtle
interpretation in an attempt to extend or limit the statute’s meaning.’  Taylor
v. NationsBank, N.A., 365 Md. 166, 181, 776 A.2d 645, 654 (2001).  ‘“If there
is no ambiguity in th[e] language, either inherently or by reference to other
relevant laws or circumstances, the inquiry as to legislative intent ends . . . .”’
Chow, 393 Md. at 443-44, 903 A.2d at 395.
“If the language of the statute is ambiguous, however, then ‘courts
consider not only the literal or usual meaning of the words, but their meaning
and effect in light of the setting, the objectives and purpose of [the] enactment
[under consideration].’  Fraternal Order of Police v. Mehrling, 343 Md. 155,
174, 680 A.2d 1052, 1062 (1996) (quoting Tucker v. Fireman’s Fund Ins. Co.,
308 Md. 69, 75, 517 A.2d 730, 732 (1986)).  We have said that there is ‘“an
ambiguity within [a] statute”’ when there exist ‘“two or more reasonable
alternative interpretations of the statute.”’  Chow, 393 Md. at 444, 903 A.2d
at 395 (citations omitted).  When a statute can be interpreted in more than one
way, ‘“the job of this Court is to resolve that ambiguity in light of the
legislative intent, using all the resources and tools of statutory construction at
our disposal.”’  Id.
‘If the true legislative intent cannot readily be determined from
the statutory language alone, however, we may, and often must,
resort to other recognized indicia – among other things, the
structure of the statute, including its title; how the statute relates
to other laws; the legislative history, including the derivation of
-25-
the statute, comments and explanations  regarding it by
authoritative sources during the legislative process, and
amendments proposed or added to it; the general purpose behind
the statute; and the relative rationality and legal effect of various
competing constructions.’
Witte, 369 Md. at 525-26, 801 A.2d at 165.  In construing a statute, ‘[w]e
avoid a construction of the statute that is unreasonable, illogical, or
inconsistent with common sense.’  Blake v. State, 395 Md. 213, [224,] 909
A.2d 1020, [1026] (2006) (citing Gwin v. MVA, 385 Md. 440, 462, 869 A.2d
822, 835 (2005)).
“In addition, ‘“the meaning of the plainest language is controlled by the
context in which it appears.”’ State v. Pagano, 341 Md. 129, 133, 669 A.2d
1339, 1341 (1996) (citations omitted).  As this Court has stated, 
‘[b]ecause it is part of the context, related statutes or a statutory
scheme that fairly bears on the fundamental issue of legislative
purpose or goal must also be considered.  Thus, not only are we
required to interpret the statute as a whole, but, if appropriate,
in the context of the entire statutory scheme of which it is a
part.’
Gordon Family P’ship v. Gar On Jer, 348 Md. 129, 138, 702 A.2d 753, 757
(1997)  (citations omitted).  Lastly, ‘[s]tatutes in derogation of the common
law are strictly construed, and it is not to be presumed that the legislature by
creating statutory assaults intended to make any alteration in the common law
other than what has been specified and plainly pronounced.’. . . ‘Most statutes,
of course, change the common law, so that principle [of narrow construction]
necessarily bends when there is a clear legislative intent to make a change.’
Witte, 369 Md. at 533, 801 A.2d at 169.”
Walzer, 395 Md. at 571-74, 911 A.2d at 431-33 (some citations omitted).
As stated, supra, § 3-2A-04(b)(1)(i)(1) of the Courts and Judicial Proceedings Article,
requires that:
“[A] claim or action filed after July 1, 1986, shall be dismissed, without
prejudice, if the claimant or plaintiff fails to file a certificate of a qualified
expert with the Director attesting to departure from standards of care, and that
the departure from standards of care is the proximate cause of the alleged
injury.”  (Emphasis added.)
20 Appellees articulated at oral argument seven specific requirements that Carroll must
have satisfied before her Certificate could be complete under the Health Care Malpractice
Claims Statute and Carroll argued that she complied fully with the requirements of the
Statute based on the its plain language.  We agree that Carroll failed to comply with certain
statutory provisions that are required.
-26-
Appellees interpret the above language as requiring the purported Certificate submitted by
Dr. Simmons-Clemmons attest to a breach of the standard of care and that the breach was the
proximate cause of Carroll’s injuries.20  We agree.  The ordinary meaning of the word
“attest” is “[t]o bear witness; testify” or “[t]o affirm to be true or genuine[.]”  Black’s Law
Dictionary 138 (8th ed. 1999).  Reading § 3-2A-04(b)(1)(i)(1) in conjunction with this
definition, we conclude that the language of this provision is clear and unambiguous and we
need not resort to statutory interpretation.  According to the plain language, a Certificate,
under § 3-2A-04(b), must contain the qualified expert’s affirmation as to two separate
conditions – (1) that the defendant-physician departed from the standards of care, and (2) that
such a departure was the proximate cause of plaintiff’s alleged injury.
In examining Dr. Simmons-Clemmons’s purported replacement Certificate, we
conclude that even if she had satisfied the first stated requirement, she failed to satisfy the
second requirement.  The pertinent language of Dr. Simmons-Clemmons’s second certificate,
in which she discussed her professional medical opinion in reference to Carroll’s medical
care, is as follows:
“[I]t does appear that Mrs. Mary Carroll suffered complications arising from
having the catheter in place for longer than what is standard treatment[,] (i.e.
a DVT and chronic venous stasis of the right arm with chronic lymph
edema.[)]”
21 We recognize that “proximate cause” is a legal term.  We do not think, however,
that its meaning, in this context, is so obtuse that a person would need to spend a great deal
of time studying the definition to understand its meaning.  With respect to proximate cause,
we have said:
“Variously stated, the universally accepted rule as to the proximate
cause is that, unless an act, or omission of a duty, or both, are the direct and
continuing cause of an injury, recovery will not be allowed.  The negligent acts
must continue through every event and occurrence, and itself be the natural
and logical cause of the injury.  It must be the natural and probable
consequence of the negligent act, unbroken by any intervening agency, and
where the negligence of any one person is merely passive, and potential, while
the negligence of another is the moving and effective cause of the injury, the
(continued...)
-27-
Dr. Simmons-Clemmons explained in the Certificate that the catheter was in place for
“longer than what is standard treatment” and that the treatment that Carroll received was
“below standard of care[.]”  The first condition under § 3-2A-04(b), arguably, may have been
satisfied.
As to the second and unsatisfied requirement, Dr. Simmons-Clemmons stated that:
“It is my professional opinion that Mrs. Carroll suffered injury secondary to
below standard of care received in regards to removal of the Hickman catheter
after chemotherapy.”
We assume that when Dr. Simmons-Clemmons stated that Carroll’s injury was “secondary
to below standard of care[,]” that she meant the treatment given to Carroll fell below the
standard of care.  Notwithstanding this assumption, Dr. Simmons-Clemmons failed to state,
with clarity, that the treatment Carroll received or failed to receive, fell below the standard
of care and was the proximate cause of her injuries.  In fact, at no point, did she state that the
alleged departure from the standard of care was the proximate cause of Carroll’s injuries.21
21(...continued)
latter is the proximate cause and fixes the liability.”
Bloom v. Good Humor Ice Cream Co., 179 Md. 384, 387, 18 A.2d 592, 593-94 (1941)
(citations omitted).  Alternatively, Black’s Law Dictionary 234 (8th ed. 2004), provides a
generally applicable definition of proximate cause:
“1.  A cause that is legally sufficient to result in liability; an act or omission
that is considered in law to result in a consequence, so that liability can be
imposed on the actor.  2. A cause that directly produces an event and without
which the event would not have occurred.”
-28-
Drs. Konits and Imoke also interpret the language of § 3-2A-04(b) as requiring that
the Certificate identify the specific individual or individuals who breached the standard of
care.   According to Drs. Konits and Imoke, the purported Certificate is incomplete because
it fails to identify specifically the licensed professionals against whom Dr. Simmons-
Clemmons’s claims applied.  Again, we agree.
Maryland law requires that the Certificate mention explicitly the name of the licensed
professional who allegedly breached the standard of care.  See Witte, 369 Md. at 521, 801
A.2d at 162 (explaining that “unless . . . the claimant files with the [Health Care Alternative
Dispute Resolution Office] a certificate of a qualified expert attesting that the defendant’s
conduct constituted a departure from the standard of care and that the departure was the
proximate cause of the alleged injury, the claim must be dismissed . . .”) (emphasis added);
McCready, 330 Md. at 500, 624 A.2d at 1251 (articulating that “the plaintiff must file a
Certificate of Qualified Expert (expert’s certificate) attesting to a defendant’s departure from
the relevant standards of care which proximately caused the plaintiff’s injury”) (emphasis
added); Watts v. King, 143 Md. App. 293, 306, 794 A.2d 723, 731 (2002) (stating that
-29-
claimants are “required to file a certificate of a qualified expert attesting that the licensed
professional against whom the claim was filed breached the standard of care.”) (emphasis
added); D’Angelo, 157 Md. App. at 646, 853 A.2d at 822 (concluding that the expert’s
certificate must include the name of the licensed professional against whom the claims were
brought because, without that information, “the certificate requirement would amount to a
useless formality that would in no way help weed out non[-]meritorious claims.”).  We
believe that this requirement is consistent with the General Assembly’s intent to avoid non-
meritorious claims.  Moreover, it is reasonable because the Certificate would be rendered
useless without an identification of the allegedly negligent parties.  When a Certificate does
not identify, with some specificity, the person whose actions should be evaluated, it would
be impossible for the opposing party, the HCADRO, and the courts to evaluate whether a
physician, or a particular physician out of several, breached the standard of care.
In the instant case, Dr. Simmons-Clemmons filed a certificate that included the names
of five different physicians, two of whom are the named defendants in this case.  The report
mentioned Dr. Imoke and Dr. Konits, but also mentioned a Dr. Ohio, an unnamed
cardiologist, and an unnamed primary care physician.  Dr. Simmons-Clemmons then stated
very generally that “there was no clear communication to the patient . . . .”  In so doing, Dr.
Simmons-Clemmons failed to state with sufficient specificity which physician or physicians
breached the standard of care and which physician or physicians were allegedly responsible
for Carroll’s injuries.  Equally egregious, however, is that the Certificates failed to state what
-30-
the standard of care was or how Dr. Imoke or Dr. Konits departed from it.
What was the standard of care expected of them?  What duty did either have in regard
to removing the catheter?  Was Dr. Konits, the oncologist, supposed to remove the catheter,
inserted surgically by Dr. Imoke, upon the termination of chemotherapy?  Was he supposed
to call Dr. Imoke to inform him that the chemotherapy had been completed?   Was he
supposed to tell Carroll to call Dr. Imoke?  Was Dr. Imoke supposed to call Dr. Konits from
time to time to check on the progress of the chemotherapy?  Was he supposed to call Carroll
from time to time for that purpose?  Was he supposed to tell  Carroll to call him when she
completed chemotherapy? 
The Certificate stated that “the patient was to follow-up with Dr. Imoke in September,
2002[]" – a year after the mastectomy – but it does not indicate where that information came
from or whether Dr. Konits was, or should have been, aware of that fact.  The Certificate
stated that there was “mention made of an approximate time chemo[therapy] should be
completed by Dr. Konits in his consult dated January 31, 2002,” but it does not say when that
time was, or how it related to the anticipated followup with Dr. Imoke in September, 2002.
Interestingly, the complaint indicates that chemotherapy was completed in April, 2002, but
the Certificate does not note that fact.
The Certificate adds that Carroll was not “recalled for her September 2002 follow-
up.”  Was Dr. Konits responsible for that?  Was Dr. Imoke responsible for that?  Did Carroll
know she was supposed to follow up with Dr. Imoke?  There is no indication that either
-31-
defendant acted as Carroll’s primary care physician.  Was that unidentified doctor supposed
to keep track of the chemotherapy and alert Carroll to the need to have the catheter removed?
Was either defendant supposed to communicate with Carroll’s primary care physician in this
regard?
A general assertion, such as the one made by Dr. Simmons-Clemmons, that there was
“no clear communication to the patient” by unspecified doctors regarding the timing of the
removal of the catheter is deficient in two respects.  Dr. Simmons-Clemmons did not explain
in the Certificate the requisite standard of care owed to Carroll.  Simmons-Clemmons also
failed to state which doctor, or doctors, owed Carroll a specific duty under that standard.
Without such statements by Dr. Simmons-Clemmons, the deficiencies in both the first and
second Certificate go well beyond the issue of identity and proximate cause.  The Certificates
are wholly lacking in any assertion that either defendant departed from an applicable standard
of care.  They do not even come close to complying with the statutory requirement.
We therefore conclude that the alleged Certificate was also deficient in this respect
and that the Circuit Court was correct in dismissing the case on the grounds that Carroll
failed to file a proper Certificate.  This conclusion is in accordance with this Court’s
interpretation of the application of the statutory requirements for the filing of medical
malpractice claims.
Our cases are consistent with this conclusion.  In McCready, we stated that:
“The basic procedures for initiating and maintaining a claim under the Statute
are clear and simple.  The Statute requires that a person with a medical
-32-
malpractice claim first file that claim with the Director of the Health [Care
Alternative Dispute Resolution] Office[]. § 3-2A-04(a). Thereafter, the
plaintiff must file a certificate of qualified expert (expert’s certificate) attesting
to a defendant’s departure from the relevant standards of care which
proximately caused the plaintiff’s injury. § 3-2A-04(b)(1)(i).”
330 Md. at 500-01, 624 A.2d at 1251; Odyniec, 322 Md. at 533, 588 A.2d at 792 (in the
context of explaining the operation of the statute, we opined that:  “The Act requires a
claimant at the commencement of the action to file a certificate prepared by a qualified expert
stating that the practitioner departed from the standard of care and that such departure was
the proximate cause of the injury. . . .”); see also D’Angelo, 157 Md. App. at 634, 649, 853
A.2d at 824 (outlining the steps for bringing a medical malpractice claim).
Even if we were to have found an ambiguity in the Statute, which we do not, the
legislative history surrounding the enactment of the 1986 legislation supports our holding.
That year, the General Assembly was again confronted with a medical malpractice crisis.  In
response, the Assembly enacted changes to almost every section in the Health Care
Malpractice Claims Statute, including the one relevant to the present case--§ 3A-02-04.  As
relevant to this case, the General Assembly inserted the following language into § 3A-02-04:
“(1) A CLAIM FILED AFTER JULY 1, 1986, SHALL BE
DISMISSED, WITHOUT PREJUDICE, IF THE CLAIMANT FAILS TO
FILE A CERTIFICATE OF A QUALIFIED EXPERT WITH THE
DIRECTOR ATTESTING TO DEPARTURE FROM STANDARDS OF
CARE . . ., AND THAT THE DEPARTURE FROM STANDARDS OF
CARE . . . IS THE PROXIMATE CAUSE OF THE ALLEGED INJURY,
WITHIN 90 DAYS FROM THE DATE OF THE COMPLAINT.
. . .
“(3) THE ATTORNEY REPRESENTING EACH PARTY, OR
THE PARTY PROCEEDING PRO SE, SHALL FILE THE APPROPRIATE
-33-
CERTIFICATE WITH A REPORT OF THE ATTESTING EXPERT
ATTACHED.  DISCOVERY IS AVAILABLE  AS TO THE BASIS OF THE
CERTIFICATE.”
1986 Laws of Maryland, Chapter 640.
Referring to the 1985 “Joint Report of the Executive/Legislative Task Force on
Medical Malpractice Insurance,” the Summary of Committee Report stated that the:
“Task Force voted to adopt the concept of a certificate of merit by a vote of 17
to 0, and the concept of a certificate of a meritorious defense by a vote of 11
to 8.  This provision is designed to reduce the number of frivolous claims and
defenses.”
Summary of Committee Report, S.B. 559, p. 4 (emphasis added).  That the Certificate
requirement was intended to curtail frivolous malpractice claims could only be more clearly
demonstrated if the General Assembly had placed the above emphasized language in § 3-2A-
04 itself.  Although this statement alone is enough to persuade us that the General Assembly
intended the new provision of § 3-2A-04 to limit frivolous lawsuits, the evolution of certain
language in S.B. 559 is additional evidence of such intent.
The above underlined portions of subparagraph one indicate amendments to the
original version of S.B. 559.  According to the Summary of Committee Report, the Judicial
Proceedings Committee added language to the original bill that required the certifying expert
to state:  “THAT THE DEPARTURE FROM STANDARDS OF CARE . . . IS THE
PROXIMATE CAUSE OF THE ALLEGED INJURY[.]”  This language, requiring a specific
statement of causal connection, was clearly intended to be another way (the first being the
Certificate itself) to substantiate the merit of the claim being filed.  Because this language
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remained in the final version of S.B. 559, the one that was enacted into law, the requirement
is further evidence of the General Assembly’s desire to make sure claims being filed were
not frivolous.  The thrust of the two 1986 amendments is to substantiate the claim being filed.
Moreover, the 1986 amendments are consistent with the intent of the original enactment in
1976, i.e., to screen malpractice claims prior to the filing of suit.
In light of our conclusion that the plain language of § 3-2A-04 requires the filing of
a proper Certificate and proper attesting expert’s report, we need not address the other issues
raised by the parties.
IV.  Conclusion
For the foregoing reasons, we hold that a Certificate is a condition precedent and at
a minimum, must identify with specificity, the defendant(s) (licensed professional(s)) against
whom the claims are brought, include a statement that the named defendant(s) breached the
applicable standard of care, and that such a departure from the standard of care was the
proximate cause of the plaintiff’s injuries.  In the case sub judice, the certificate was
incomplete because it failed to specifically identify the licensed professionals who allegedly
breached the standard of care and failed to state that the alleged departure from the standard
of care, by whichever doctor, or doctors, the expert failed to identify, was the proximate
cause of Carroll’s injuries.  Therefore, because the Certificate is a condition precedent, the
Circuit Court for Baltimore City correctly granted the appellees’ motion to dismiss the case
and, accordingly, we affirm the judgment of the Circuit Court for Baltimore City.
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Judge Harrell joins in the judgment only.
JUDGMENT OF THE CIRCUIT
COURT 
FOR 
BALTIMORE
C I T Y  
A F F I R M E D .
APPELLANT TO PAY THE
COSTS.
IN THE COURT OF APPEALS OF
MARYLAND
No. 117
September Term, 2006
MARY CARROLL
v.
PHILLIP H. KONITS, M.D., ET AL.
Bell, C.J.
Raker
Cathell
Harrell
Battaglia
Greene
Wilner, Alan M. (retired, specially assigned),
JJ.
Concurring Opinion by Harrell, J.
       Filed: July 27, 2007
-37-
I reluctantly concur in the result reached by the Majority opinion.   Although I agree
generally with the Dissent’s analysis of the sufficiency of Dr. Simmons-Clemmons’ 27
October 2005 letter report, I do not think it is the appropriate report to analyze in this case.
Both the Majority opinion and the Dissent glide smoothly past the fact that Carroll  failed to
present any cause, let alone good cause, to the Health Claims Alternative Dispute Resolution
Office (HCADRO) for the needed extension of time to supplement her 3 August 2005 report.
The August 3 report asserts that Dr. Simmons-Clemmons completed a review of the medical
records in formulating her report.  Her Answer To Motion To Dismiss before the HCADRO,
in which she requested, “in the interest of justice,” an extension of time to file ultimately
what was to become the October 27 version, offered absolutely nothing in the way of good
cause for an extension.  She did not claim any factual or legal basis for not being in a position
for her certifying doctor’s August 3 report to have included everything required to be
included there.  Accordingly, the grant of the “good cause” extension by the HCADRO, on
this record, was clearly erroneous as a matter of law and arbitrary and capricious as lacking
any factual basis for good cause.
Confining consideration to the August 3 version (the only report properly before the
Court), I am unable to join the Dissent, which places great weight in its analysis on the
substantive additions found only in the October 27 version.  In the important concluding lines
of the August 3 report, the doctor states:
Thirdly, it does appear that Mrs. Mary Carroll suffered complications
arising from having a catheter in place for too long, i.e. A DVT
-2-
and chronic venous stasis of the right arm with chronic lymph
edema.
(emphasis added).
In the concluding lines of the October 27 report, Dr. Simmons-Clemmons revised somewhat
and supplemented this language:
Thirdly, it does appear that Mrs. Mary Carroll suffered complications
arising from having a catheter in place for longer than what is
standard treatment, i.e. a DVT and chronic venous stasis of the
right arm with chronic lymph edema.  It is my professional
opinion that Mrs. Carroll sustained injury secondary to below
standard of care received in regards to removal of the Hickman
catheter after chemotherapy.  Please be advised that I do not
devote more than 20 percent of my annual time to activities that
directly involve personal injury claims.
(emphasis added).
Without the modified and added language in the October 27 report, the Dissent’s
reasoning does not hold up:
In examining Dr. Simmons-Clemmons’s amended Certificate, it is clear that
she satisfied the two stated requirements [departure from
standard of care and proximate cause].  The pertinent language
of Dr. Simmons-Clemmons’s second certificate, in which she
discusses her professional medical opinion in reference to Mrs.
Carroll’s medical care, is as follows:
[I]t does appear that Mrs. Mary Carroll suffered complications arising from having the
catheter in place for longer than what is standard treatment[,] (i.e. a DVT and chronic
venous stasis of the right arm with chronic lymph edema.[)]
It is my professional opinion that Mrs. Carroll suffered injury secondary to below
standard of care received in regards to removal of the Hickman catheter after
chemotherapy.
Dr. Simmons explained in the Certificate that the catheter was in place for
-3-
“longer than what is standard treatment” and that the treatment
that Mrs. Carroll received was “below standard of care.”  She
therefore satisfied the first condition.
As to the second requirement, Dr. Simmons-Clemmons stated that “there
was no clear  communication to the patient that indicated she
should seek medical attention in the removal of the catheter
from her chest after chemotherapy was completed,” and further
that Mrs. Carroll “suffered injury secondary to below standard
of care received in regards to removal of the Hickman catheter
after chemotherapy.”  
Dissent, slip op. at 1-2.
Accordingly, I am compelled to join the judgment reached by the Majority in this case.
In the Circuit Court for Baltimore City
No. 24-C-05-011066
ARGUED: 4/11/07
E-MAILED: 6/29/07
IN THE COURT OF APPEALS OF MARYLAND
No. 117
September Term, 2006 
_________________________________________
MARY CARROLL
v.
PHILLIP H. KONITS, M.D., ET AL
_________________________________________
Bell
Raker
Cathell
Harrell
Battaglia
Greene
Wilner, Alan M. (Retired, Specially Assigned),
   JJ.
_________________________________________
Dissenting Opinion by Greene, J.
             which Bell, C.J. joins
_________________________________________
Filed:    July 27, 2007
I agree with the majority that Mrs. Carroll preserved for appellate review her
arguments concerning the propriety of Dr. Simmons-Clemmons’s Certificate and also that
the Director had the authority and discretion to grant Mrs. Carroll’s extension.  I also agree
that a Certificate must identify the health care provider against whom the claim is brought,
and the certifying expert must attest to facts that support the allegation that the health care
provider’s conduct breached the applicable standard of care and that such a departure from
the standard of care proximately caused the plaintiff’s injuries.  In this case, however, I
believe that Mrs. Carroll submitted a Certificate that satisfied those minimum requirements.
Therefore, the Circuit Court was incorrect to grant the appellees’ motion to dismiss the case
and, accordingly, I would reverse the judgment of the Circuit Court for Baltimore City.
 As stated supra,  § 3-2A-04(b)(1)(i) of the Courts & Judicial Proceedings Article
states that
a claim or action filed after July 1, 1986, shall be dismissed, without
prejudice, if the claimant or plaintiff fails to file a certificate of
a qualified expert with the Director attesting to departure from
standards of care, and that the departure from standards of care
is the proximate cause of the alleged injury. . . .
(Emphasis added.)   The majority interprets this language as requiring that the Certificate
contain the qualified expert’s affirmation that the defendant-physician departed from the
standards of care and that such a departure was the proximate cause of plaintiff’s alleged
injury.  I agree with that interpretation.
In examining Dr. Simmons-Clemmons’s amended Certificate, it is clear that she
satisfied the two stated requirements.  The pertinent language of Dr. Simmons-Clemmons’s
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second certificate, in which she discusses her professional medical opinion in reference to
Mrs. Carroll’s medical care, is as follows:
[I]t does appear that Mrs. Mary Carroll suffered complications arising from
having the catheter in place for longer than what is standard
treatment[,] (i.e. a DVT and chronic venous stasis of the right
arm with chronic lymph edema.[)]
It is my professional opinion that Mrs. Carroll suffered injury secondary to
below standard of care received in regards to removal of the
Hickman catheter after chemotherapy.  
Dr. Simmons-Clemmons explained in the Certificate that the catheter was in place for
“longer than what is standard treatment” and that the treatment that Mrs. Carroll received was
“below standard of care.”  She therefore satisfied the first condition. 
As to the second requirement, Dr. Simmons-Clemmons stated that “there was no clear
communication to the patient that indicated she should seek medical attention in the removal
of the catheter from her chest after chemotherapy was completed,” and further that Mrs.
Carroll “suffered injury secondary to below standard of care received in regards to removal
of the Hickman catheter after chemotherapy.”  While Dr. Simmons-Clemmons never used
the term “proximate cause” to explain the cause of Mrs. Carroll’s injuries, she stated specific
facts which causally linked the health care providers’ breach of the standard of care to Mrs.
Carroll’s injuries.  The substance of what Dr. Simmons-Clemmons said is obvious and is
evidence of the cause of Mrs. Carroll’s injuries.  
It is well settled that several negligent acts may work together to cause an injury, and
that each person whose negligent act is a cause of an injury may be legally responsible.  See
1The majority recognizes that “proximate cause” is a legal term but states that “[w]e
do not think, however, that its meaning, in this context, is so obtuse that a person would need
to spend a great deal of time studying the definition to understand its meaning.”  I agree with
this statement.  I disagree, however, that an affirmation from an attesting physician that a
defendant-health care provider acted in such a way that makes clear that his or her conduct
was the proximate cause of a plaintiff’s alleged injury, fails to satisfy the statutory
requirements simply because it fails to include the magic words, proximate cause.  I believe
that the substance of the statement is more important than the inclusion of the specific legal
terminology or conclusion.  
-3-
Atlantic Mutual Insurance Co. v. Kenney, 323 Md. 116, 127, 591 A.2d 507, 512 (1991)
(“Negligence which constitutes a proximate cause of an injury need not necessarily be the
sole cause . . . .  In order to be a proximate cause, the negligence must be 1) a cause in fact,
and 2) a legally cognizable cause.”); see also Petersen v. Underwood, 258 Md. 9, 17, 264
A.2d 851, 855 (1970).  Moreover, proximate cause is a legal term and not a medical term.
Dr. Simmons-Clemmons’s certification of facts, with regard to causation, was consistent with
the statutory requirements of § 3-2A-04(b) that the person making the certification must be
a health care provider and attest to the facts that support the allegation that a health
provider’s conduct breached the standard of care and the departure from the standard of care
proximately caused the alleged injury.1
As stated supra, the purpose of the Certificate is to reduce the number of non-
meritorious claims being submitted to the Health Care Alternative Dispute Resolution Office.
Dr. Simmons-Clemmons, through her attestation, demonstrated that Drs. Konits and Imoke
failed to communicate with each other and that such a failure caused M rs. Carroll’s catheter
to remain in place for more than two years longer than what is standard medical procedure.
2Recently, in Barber v. Catholic Health Initiatives, Inc., 174 Md. App. 314, 921 A.2d
811 (2007), the intermediate appellate court examined previous health care claims cases of
this State, including this Court’s decision in Walzer, and determined that the identity of the
physicians who allegedly breached the standard of care must be discernable from the
Certificate, and that a failure to do so will result in dismissal.  In that case, the claimant
named all twelve defendants in the original claim and defined them collectively as the
“Health Care Providers.”  The court determined that it was clear from the Certificate, about
whom the physician was speaking, when the attesting physician explained that the “Health
Care Providers” breached the standard of care.  The court stated that “[t]he Certificate cannot
(continued...)
-4-
Dr. Simmons-Clemmons also makes clear that because the catheter was left in place for so
long, Mrs. Carroll suffered injuries.  I would therefore hold that Mrs. Carroll also satisfied
the second stated requirement.
The majority also interprets the language of § 3-2A-04(b) as requiring that the
Certificate identify the specific individual or individuals who breached the standard of care.
I agree.  I disagree with the majority, however, that Mrs. Carroll’s Certificate is incomplete
because it fails to comply with this requirement.  I acknowledge that Dr. Simmons-
Clemmons filed a statement that included the names of five different physicians, only two
of whom are the named health care providers/appellees in this case.  The Certificate,
however, specifically mentioned Dr. Imoke and Dr. Konits and made clear that the physicians
failed to communicate to Mrs. Carroll that her catheter needed to be removed after she
completed chemotherapy.  Mrs. Carroll made clear that Dr. Imoke was the health care
provider who placed the catheter inside her chest and that Dr. Konits’s failure to contact Dr.
Imoke and make him aware that the catheter could be taken out, resulted in it being left
inside her chest for two and one-half years.2  I would therefore conclude that the Certificate
2(...continued)
be analyzed in a vacuum; it must be considered in the context of the Statement of Claim that
it supported, which had already been filed with the HCAO.” The court noted, however, that
“[t]o be sure, if appellants had re-named in the Certificate each person or entity listed in the
Statement of Claim, this appeal would have been avoided” (slip op. at 42).  I agree that the
inclusion of the specific names is the better practice, as Dr. Simmons-Clemmons indicated
in her Certificate. 
-5-
satisfied the requirements in this regard and the Circuit Court was therefore incorrect to
dismiss the case on the grounds that Mrs. Carroll failed to file a proper Certificate.  The
purpose of the statute is to weed out non-meritorious claims, not to dismiss meritorious
claims for frivolous reasons.
The majority does not address the other contentions made by Drs. Konits and Imoke.
I believe it is important for the Court to address these contentions.  Drs. Konits and Imoke
contend that the Certificate must state that Dr. Simmons-Clemmons spends no more than 20
percent of her professional time on personal injury-related litigation, that she is board
certified in the same fields as Drs. Konits and Imoke and that she has a similar medical
background to Drs. Konits and Imoke.  I would reject these contentions.  The 20 percent
declaration is not at issue in this case because Dr. Simmons-Clemmons explicitly stated in
her amended certificate that she spends no more than 20 percent of her time on personal
injury claims.  Notwithstanding, I do not read the Health Care Malpractice Claims Statute
to require that the Certificate include any of this information.  Section 3-2A-04(b)(4) states
that:
A health care provider who attests in a certificate of a qualified expert or who
testifies in relation to a proceeding before an arbitration panel or
-6-
a court concerning compliance with or departure from standards
of care may not devote annually more than 20 percent of the
expert’s professional activities to activities that directly involve
testimony in personal injury claims.  
The other applicable provision as to Drs. Konits and Imoke’s contentions is § 3-2A-
02(c), entitled “Establishing liability of health care provider; qualifications of persons
testifying,” part (2)(ii)(1.), which states that any health care provider who attests in a
Certificate to a defendant-health care provider’s departure from the standards of care:
       A. Shall have had clinical experience, provided consultation relating to
clinical practice, or taught medicine in the defendant’s specialty
or a related field of health care, or in the field of health care in
which the defendant provided care or treatment to the plaintiff,
within 5 years of the date of the alleged act or omission giving
rise to the cause of action; and
     B. Except as provided in item 2 of this subparagraph, if the defendant is
board certified in a specialty, shall be board certified in the same
or a related specialty as the defendant.
The above-quoted language from § 3-2A-04(b)(4) and § 3-2A-02(c)(2)(ii)(1.) demonstrates
the General Assembly’s intent to place limitations on the qualifications of experts who attest
to a defendant’s breach of a standard of care and that such a breach proximately caused the
plaintiff’s injuries.  By requiring that experts have similar training and are board certified in
the same field(s) as the defendant-health care providers about whose behavior the expert is
attesting, clearly, the Legislature sought to ensure that the attesting experts are qualified to
render an opinion about the defendant-health care providers’ alleged departure from the
standards of care.
The General Assembly stated that attesting health care providers “may not devote
-7-
annually more than 20 percent,” “shall have had clinical experience,” and “shall be board
certified in the same or a related specialty” not that they must attest to the fact that they do
not devote annually more than 20 percent, have the same clinical experience and are board
certified in the same field as the defendant.  I would therefore decline to hold that the
General Assembly intended for such statements to be included in the Certificate and that
without such statements, the claim must be dismissed on the grounds that the Certificate is
deficient.  
We explained in Debbas v. Nelson, 389 Md. 364, 383, 885 A.2d 802, 814 (2005) that
[t]he strictly limited time period provided for securing a valid Certificate . . .
demonstrates the General Assembly’s intention that the findings
and opinions contained therein would be preliminary. To
interpret the statute otherwise might effectively preclude many
malpractice suits from ever proceeding on the merits.
Parties can instead obtain this information through discovery.  As stated by the Maryland
Trial Lawyers Association, which filed an Amicus Curiae brief, “a simple interrogatory
would discover the information that [Dr.] Konits asks to be amended into § 3-2A-04(b), and
. . ., under § 3-2A-04(b)(3)(ii), such discovery always was contemplated by the Legislature.”
See Md. Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-04(b)(3)(ii) of the Courts
& Judicial Proceedings Article  (stating that “[d]iscovery is available as to the basis of the
certificate”).  As we stated in Koons Ford v. Lobach, 398 Md. 38, 62-63, 919 A.2d 722, 737
(2007):
If [the Legislature] intended otherwise, then it certainly had, and still has, the
ability to say so.  As we have previously explained, however,
3Claimants must arbitrate in good faith and a failure to do so will result in dismissal
of the claim.  See  Karl v. D avis, 100 Md. App. 42, 50, 639 A.2d 214, 218 (1994) (stating
that “[t]o allow less than a legitimate good faith attempt before the [Health Care Alternative
Dispute Resolution Office] to satisfy the mandatory condition precedent would clearly thwart
the legislative intent that all claims of medical negligence over the appropriate jurisdictional
amount be fairly presented and tried before the [Health Care Alternative Dispute Resolution
Office]”).
-8-
“[i]t is not the task of the Judiciary to re-write the Statute . . . .
The court’s charge in interpreting a statute is to determine the
intent of the Legislature, not to insert language to change the
meaning of a statute.” Walzer, 395 Md. at 584-85, 911 A.2d at
439-40 (citations omitted). 
I would  conclude that the information regarding the attesting expert’s professional attributes
is not required to be contained in the Certificate.  That is, a claimant can get into court
without it; however, I stress that it would be the better practice to include such information
in the Certificate so that claimants can avoid unnecessary challenges to the qualifications of
the person who submitted the document.  Moreover, if the attesting health care provider fails
to meet these statutory professional requirements, it would appear that the claimant is not
arbitrating in good faith,3 as is required.  Karl v. Davis, 100 Md. App. 42, 50, 639 A.2d 214,
218 (1994).  The issue before us in this case, however, is what must be included within the
four corners of the Certificate for it to be valid, not who is qualified to attest to a Certificate.
Furthermore, Drs. Konits and Imoke argue that Mrs. Carroll’s purported Certificate
is incomplete because Dr. Simmons-Clemmons did not state that her opinions are based upon
a reasonable degree of medical probability.  Essentially, the doctors, by this contention, raise
issues of admissibility and reliability with regard to the Certificate.   Nothing in the language
-9-
of the Health Care Malpractice Claims Statute, however, requires that such an assertion be
made in the Certificate.  There exists a test for admitting into evidence an expert medical
opinion.  See Maryland Rule 5-702 (addressing the testimony by experts at trial); Trimble v.
State, 300 Md. 387, 404, 478 A.2d 1143, 1151 (1986) (stating that the party seeking to elicit
an opinion must establish that the witness is qualified to express it and that the trial judge
must decide that issue as a preliminary matter of law).  There also exists a requirement that
the expert’s opinion be held to a “reasonable degree of medical probability” to ensure that
the expert’s opinion is more than speculation or conjecture.  See Karl, 100 Md. App. at 51-
52, 639 A.2d at 219 (stating that “[w]hile [an] expert opinion must be based upon more than
mere speculation, it need not be expressed with absolute certainty . . . . We have required
expert opinions to be established within a reasonable degree of probability.”)  See also Fink
v. Steele, 166 Md. 354, 363, 171 A. 49, 53 (1934); Charlton Bros. Transportation v.
Garrettson, 188 Md. 85, 94, 51 A.2d 642, 646 (1947). 
Drs. Konits and Imoke also construe this Court’s holding in Walzer v. Osborne, 395
Md. 563, 911 A.2d 427 (2006), to mean that, in all circumstances, two separate documents
must be filed - a Certificate and an attesting expert report, and that, because Dr. Simmons-
Clemmons filed only one document, it is deficient.  The Court said in Walzer that the expert’s
report must be attached to the Certificate.  We based that conclusion on our reading of the
statutory language of § 3-2A-04(b)(3)(i) that “[t]he attorney representing each party, or the
party proceeding pro se, shall file the appropriate certificate with a report of the attesting
4In those cases where a Certificate is filed and subsequently there is filed in the case,
a report to supplement the Certificate, the subsequent filing of a report may be made for the
express purpose of completing the Certificate and thereby incorporating the report as an
attachment to the previously filed Certificate.  To avoid dismissal of the underlying claim,
however, the subsequent filing must be timely. 
-10-
expert attached” (emphasis added).   
In this case, Mrs. Carroll failed to attach a separate document, an attesting expert
report, to the Certificate that she submitted to the Health Care Alternative Dispute Resolution
Office.  Notwithstanding, as clarification of our decision in Walzer, and in response to the
appellees’ contention in this case, while it is clear that the Legislature intended for the
attesting expert report to be attached to the Certificate, consistent with that statutory mandate,
I see no reason why both documents may not comprise separate parts of a single document
and thereby become incorporated into one document, just as a report attached to the
Certificate, at the time of the initial filing, would be a complete certification.4  The
Legislature’s intent in enacting the Health Care Malpractice Claims Statute was to weed out
non-meritorious claims by requiring claimants to submit certain information to the Health
Care Alternative Dispute Resolution Office.  There is no reason why an attesting expert
report, or Certificate, if filed with the intent to incorporate a previously filed report or
Certificate, or a Certificate containing a section that includes the attesting expert’s report, is
not a complete certification of merit, just as a report attached to the Certificate would be a
complete certification.  The essence of the statutory requirement is that the Certificate is not
complete unless there is a timely certification and report filed in the Health Claims case.  
-11-
As the majority points out, we explained in Walzer, 395 Md. at 583, 911 A.2d at 438-
39, that
the attesting expert report must explain how or why the physician failed or did
not fail to meet the standard of care and include some details
supporting the certificate of qualified expert . . . .  Accordingly,
the expert report should contain at least some additional
information and should supplement the Certificate. Requiring an
attesting expert to provide details, explaining how or why the
defendant doctor allegedly departed from the standards of care,
will help weed out non-meritorious claims and assist the
plaintiff or defendant in evaluating the merit of the health claim.
. . .
In Walzer,  395 Md. at 568, 911 A.2d at 430, the attesting physician stated simply that:
Based on my training, expertise and review of the records, it is my opinion
that there were deviations from the standards of care and said
deviations were the proximate result of Claimant Keith
Osborne’s injury. 
In that case, the attesting physician failed to include any information about how the physician
deviated from the standard of care and how the said deviations from the standard of care
caused Mr. Osborne’s injury; we therefore held that the Certificate was deficient because it
lacked the information that would have constituted an attesting expert report.  In this case,
Dr. Simmons-Clemmons included enough information, in accordance with Walzer, within
the four corners of her Certificate, thereby supplementing the certification consistent with
the statutory requirements of § 3-2A-04(b) and § 3-2A-04(b)(3)(I).  Although, for purposes
of clarity, she could have titled the document, “Certificate of Qualified Expert and Report,”
it amounts to our exalting form over substance to invalidate the Certificate because of that
-12-
omission.  In addition to stating that Drs. Konits and Imoke breached the applicable standard
of care and that their breach caused Mrs. Carroll’s injuries, Dr. Simmons-Clemmons stated
that the physicians failed to communicate effectively with Mrs. Carroll, regarding the timely
removal of the catheter, and that the physicians failed to remove the catheter in a timely
manner.  She explained that Mrs. Carroll received treatment that fell below the standard of
care “in  regards to removal of the Hickman catheter after chemotherapy.”  I would therefore
conclude that Dr. Simmons-Clemmons successfully satisfied, within one document, the
statutory requirements of the Certificate and attesting expert report, as explicated by this
Court in Walzer.
I would also reject Drs. Konits and Imoke’s contention that the Certificate must be a
“formal” document, and not in letter form, as was the case here.  Nowhere in the Health Care
Malpractice Claims Statute does it require that the attesting expert’s affirmations be
contained in a “formal” document; the statute simply requires that the attesting health care
provider specifically identify the health care provider about whom he or she is speaking, and
that the certifying health care provider attest to the other health care provider’s departure
from the standard of care and that such a departure proximately caused the plaintiff’s injuries.
I respectfully dissent.  Chief Judge Bell authorizes me to state that he joins the views
expressed in this dissent.