Title: Lori Hofflander v. St. Catherine's Hospital, Inc.

State: wisconsin

Issuer: Wisconsin Supreme Court

Document:

2003 WI 77 
 
 
 
SUPREME COURT OF WISCONSIN 
 
 
 
 
 
CASE NO.: 
00-2467 
 
 
COMPLETE TITLE: 
 
 
Lori Hofflander,  
 
Plaintiff-Appellant-Cross Petitioner, 
Milwaukee County Department of Human Services,  
 
Plaintiff-Co-Appellant, 
 
v. 
St. Catherine's Hospital, Inc., Sentry 
Insurance, a Mutual Company, Patients 
Compensation Fund, Horizon Mental Health 
Management, Inc. and Columbia Casualty Company,  
 
Defendants-Respondents-Petitioners. 
 
 
 
 
REVIEW OF A DECISION OF THE COURT OF APPEALS 
2001 WI App 204 
Reported at:  247 Wis. 2d 636, 635 N.W.2d 13 
(Published) 
 
 
OPINION FILED: 
July 1, 2003   
SUBMITTED ON BRIEFS: 
        
ORAL ARGUMENT: 
September 5, 2002   
 
 
SOURCE OF APPEAL: 
 
 
COURT: 
Circuit   
 
COUNTY: 
Kenosha   
 
JUDGE: 
Mary Kay Wagner-Malloy   
 
 
 
JUSTICES: 
 
 
CONCURRED: 
ABRAHAMSON, C.J., concurs (opinion filed). 
BRADLEY, J., joins concurrence.   
 
DISSENTED: 
        
 
NOT PARTICIPATING:         
 
 
 
ATTORNEYS: 
 
For the defendants-respondents-petitioners St. Catherine’s 
Hospital, 
Inc., 
Sentry 
Insurance 
Company 
and 
Patients 
Compensation Fund, there were briefs by John A. Nelson, Timothy 
W. Feeley and von Briesen, Purtell & Roper, S.C., Milwaukee and 
oral argument by John A. Nelson. 
 
For the defendants-respondents-petitioners Horizon Mental 
Health Management, Inc. and Columbia Casualty Company, there 
were briefs by John K. Hughes and Gessler, Hughes, Socol, Piers, 
 
 
2
Resnick & Dym, Ltd., Chicago, Illinois, and oral argument by 
John K. Hughes. 
 
For the plaintiff-appellant-cross petitioner, there were 
briefs by Jerome A. Hierseman and Gray & End, L.L.P., Milwaukee 
and oral argument by Jerome A. Hierseman. 
 
For the plaintiff-co-appellant, there was a brief by Louis 
Edward Elder, principal assistant corporation counsel. 
 
An amicus curiae brief was filed by Timothy J. Aiken, David 
M. Skoglind and Aiken & Scoptur, S.C., Milwaukee for Wisconsin 
Academy of Trial Lawyers, with oral argument by Timothy J. 
Aiken. 
 
 
 
2003 WI 77 
NOTICE 
This opinion is subject to further 
editing and modification.  The final 
version will appear in the bound 
volume of the official reports.   
No.  00-2467   
(L.C. No. 
97-CV-1167) 
STATE OF WISCONSIN  
 
 
   : 
IN SUPREME COURT 
 
 
Lori Hofflander,  
 
          Plaintiff-Appellant- 
          Cross Petitioner, 
 
Milwaukee County Department of Human  
Services,  
 
          Plaintiff-Co-Appellant, 
 
     v. 
 
St. Catherine's Hospital, Inc., Sentry  
Insurance, a Mutual Company, Patients  
Compensation Fund, Horizon Mental Health  
Management, Inc. and Columbia Casualty  
Company,  
 
          Defendants-Respondents- 
          Petitioners. 
 
FILED 
 
JUL 1, 2003 
 
Cornelia G. Clark 
Clerk of Supreme Court 
 
 
 
 
 
REVIEW of a decision of the Court of Appeals.  Affirmed in 
part and reversed in part and cause remanded. 
 
¶1 
DAVID T. PROSSER, J.   This is a review of a published 
decision of the court of appeals.1  We are asked to address 
                                                 
1 Hofflander v. St. Catherine's Hosp., Inc., 2001 WI App 
204, 247 Wis. 2d 636, 635 N.W.2d 13. 
No. 00-2467 
 
 
2 
 
multiple issues related to injuries sustained by Lori Hofflander 
(Hofflander) during her December 1996 stay in the Behavioral 
Services Unit of St. Catherine's Hospital in Kenosha.  
¶2 
Hofflander was involuntarily committed to the hospital 
as a suicide precaution.  Two days later, she attempted to 
escape through a third-floor window in another patient's room, 
after ripping a loose air conditioner out of its window 
mounting.  As Hofflander climbed out of the window, she lost her 
grip and fell to the ground, sustaining severe injuries. 
¶3 
Hofflander 
sued 
the 
hospital 
and 
other 
named 
defendants to recover damages for these injuries.2  The Circuit 
                                                 
2 The defendants in this action are St. Catherine's Hospital 
and its named insurer, Sentry Insurance Company (collectively 
St. Catherine's), along with Horizon Mental Health Management, 
Inc., and its insurer, Columbia Casualty Company (collectively 
Horizon).  Horizon is under contract with St. Catherine's to 
manage the Behavioral Services Unit of the hospital.  The 
Wisconsin Patients Compensation Fund was also joined as a 
defendant pursuant to Wis. Stat. §  655.27(5)(1999-2000) and is 
liable to the extent that any damages exceed the maximum 
liability limits for which the defendant health care providers 
are insured.  See Wis. Stat. § 655.27(1)(1999-2000). 
No. 00-2467 
 
 
3 
 
Court for Kenosha County, Mary Kay Wagner-Malloy, Judge, granted 
the 
defendants' 
motions 
for 
summary 
judgment 
on 
all 
of 
Hofflander's substantive claims.  The court of appeals reversed 
on her claims of negligence and safe place violations and 
remanded the action for jury trial.  We granted the defendants' 
petition for review. 
¶4 
In 
Jankee 
v. 
Clark 
County, 
2000 
WI 
64, 
235 
Wis. 2d 700, 612 N.W.2d 297, we reaffirmed the rule that a 
                                                                                                                                                             
The Milwaukee County Department of Human Services is also a 
party in this case as a subrogee to Hofflander, having paid a 
portion 
of 
her 
medical 
expenses 
related 
to 
the 
alleged 
negligence of the defendants.  The circuit court's judgments in 
favor of St. Catherine's and Horizon included the taxation of 
costs against Milwaukee County.  Milwaukee County then filed a 
motion in opposition to the taxation of costs, claiming that the 
presented costs relate only to defending the action against 
Hofflander, not defending against Milwaukee County's claim of 
having paid medical expenses in her case.  After a hearing, the 
circuit court issued an order denying the motion, reasoning that 
the County's claim for costs is dependent upon whether the 
defendants were negligent and that Milwaukee County was "either 
in or out" of the litigation.  See Sampson v. Logue, 184 
Wis. 2d 20, 29, 515 N.W.2d 917 (Ct. App. 1994) (holding that a 
prevailing defendant is entitled to costs from all plaintiffs, 
including subrogated plaintiffs who elect not to participate at 
trial)(2-1 decision on whether to reach merits of this issue).  
Milwaukee County now appeals that order.   
Because we are remanding the underlying negligence cause of 
action to the circuit court, it remains possible for the 
plaintiffs (both Hofflander and Milwaukee County) to prevail on 
their claims.  Therefore, Milwaukee County is reinstated as a 
plaintiff-subrogee and we decline to address the merits of its 
position on taxable costs, as that issue is not yet ripe.  In 
doing so, we deny the defendants' motion, which was held in 
abeyance pending our decision on the merits of this case, to 
strike the brief and appendix filed by the Milwaukee County 
Department of Health and Human Services. 
No. 00-2467 
 
 
4 
 
person with mental disability has a duty to exercise ordinary 
care.  Such a person may be found contributorily negligent for 
his or her own injuries when the person fails to exercise 
ordinary care for his or her own safety.3  We also recognized, 
however, that a health care institution takes on a heightened 
duty of care when it assumes custody and control of a person 
with 
a 
mental 
disability. 
 
In 
these 
circumstances, 
the 
institution may lose its affirmative defense of contributory 
negligence even though the mentally disabled person caused her 
own injury.   
¶5 
The primary issue in this case is how the "custody and 
control rule" of Jankee, as applied to specific facts, affects 
the defendants' affirmative defense of contributory negligence.  
In determining this issue, we are urged to clarify and restate 
the applicable principles of tort law that we attempted to 
articulate in Jankee. 
¶6 
We reach the following conclusions.  First, genuine 
issues of material fact exist whether St. Catherine's Hospital 
and Horizon Mental Health Management knew or should have 
foreseen Lori Hofflander's risk of elopement from the hospital.  
The resolution of these disputed factual issues affects the 
respective defendants' duty of care and thus precludes the entry 
of summary judgment. 
                                                 
3 Hereinafter we will use the term "her" rather than "his or 
her" in the interest of simplicity in a case in which the 
plaintiff is a woman. 
No. 00-2467 
 
 
5 
 
¶7 
Second, if Lori Hofflander is able to establish that 
(1) the defendants assumed a special relationship with her that 
required a heightened duty of care; (2) the defendants should 
have known or foreseen her risk of elopement from the hospital; 
and (3) there is some evidence of the defendants' failure to 
exercise their heightened duty of care, then Hofflander's 
contributory negligence should be measured under a subjective 
duty of self-care.  This subjective duty of care requires the 
trier of fact to weigh Hofflander's mental state at the time of 
her accident, including her capacity to appreciate her own 
conduct. 
¶8 
Third, Lori Hofflander's claim under Wisconsin's safe 
place statute is barred because her own negligent conduct, 
rather than a loose air conditioning unit, caused her injury.  
Hofflander 
is 
barred 
from 
recovery 
under 
this 
theory, 
irrespective of whether she is deemed a trespasser at the time 
of her injury.  However, contrary to the court of appeals, we 
hold 
that 
a 
person 
involuntarily 
committed 
to 
a 
locked 
psychiatric 
unit 
may 
be 
deemed 
a 
trespasser 
under 
the 
traditional analysis for 
determining 
trespasser 
status in 
Wisconsin. 
¶9 
Finally, materials produced by the Joint Commission on 
Accreditation 
of 
Healthcare 
Organizations 
(JCAHO) 
while 
conducting site surveys of St. Catherine's Behavioral Services 
No. 00-2467 
 
 
6 
 
Unit were properly excluded from discovery based on the 
privilege granted under Wis. Stat. § 146.38 (1999-2000).4 
I. FACTUAL BACKGROUND 
¶10 Late in the evening of Saturday, December 28, 1996, 
Lori Hofflander was involuntarily committed to the Behavioral 
Services Unit (Unit) at St. Catherine's Hospital in Kenosha, 
under an emergency detention.5  She was taken to the hospital 
after Kenosha police had been dispatched to her apartment in 
response to reports that Hofflander was threatening suicide.  At 
the 
apartment, 
officers 
encountered 
Carol 
Underwood, 
Hofflander's mother, and Pam Stewart, one of Hofflander's 
friends, who had hurried to the apartment because Hofflander had 
made at least two suicide threats earlier in the evening.  Both 
women said that they had spoken to Hofflander's former husband, 
who said he had received a telephone call from Hofflander saying 
that she would be dead in one hour.  Police observed that 
Hofflander was uncooperative and had erratic mood swings.  She 
was also under the influence of alcohol and Valium, which is the 
drug that she had told Stewart she would use to kill herself.  
                                                 
4 All subsequent references to the Wisconsin Statutes are to 
the 1999-2000 volumes unless otherwise indicated.  Although 
Hofflander's injuries occurred in December 1996, the statutory 
sections relevant to the disposition of this case have not 
substantively changed since that date. 
5 Chapter 51 of the Wisconsin Statutes allows for the 
emergency detention of someone who is reasonably believed to be 
mentally ill, drug dependent, or developmentally disabled, if 
that person has manifested a substantial probability of harm to 
himself or herself or to others.  See Wis. Stat. § 51.15(1). 
No. 00-2467 
 
 
7 
 
Stewart advised police that Hofflander used cocaine and heroin; 
and at the hospital, a St. Catherine's security officer found 
some drug paraphernalia in a trash can in a bathroom used by 
Hofflander. 
¶11 In written statements, Underwood and Stewart declared 
that Hofflander had indicated on previous occasions that she 
wanted to kill herself, but Underwood noted: "I never called the 
police before."  Both women said that Hofflander desperately 
needed help.  Stewart also explained that Hofflander had been 
distraught about losing custody of her children and about some 
recent brushes with the law, including at least one alcohol-
related traffic arrest.  At the hospital, Hofflander was 
interviewed by an adult crisis counselor who advised that 
Hofflander was a good candidate for emergency detention. 
¶12 The following day, December 29, Dr. Ligay Ilagan-
Newman 
completed 
a 
history 
and 
physical 
examination 
of 
Hofflander at St. Catherine's.  She diagnosed Hofflander with 
dysthymia6 and borderline personality disorder.  Dr. Ilagan-
Newman determined that the suicide precaution initially ordered 
for Hofflander be discontinued.  She also noted that Hofflander 
was anxious to leave the facility because she wanted to move 
promptly into a different, less expensive apartment.  Hofflander 
was placed in Room 307B of the hospital's locked psychiatric 
                                                 
6 "Dysthymia" is "depression; despondency or a tendency to 
be despondent."  Random House Unabridged Dictionary 611 (2d ed. 
1993). 
No. 00-2467 
 
 
8 
 
unit, which is located on one wing of the hospital's third 
floor.  
¶13 According to hospital records, Pam Stewart notified 
the Unit that Sunday morning about Hofflander having called and 
threatened her, saying: "When I get out of here I'll get even."  
A second entry that morning indicates that another patient 
reported that Hofflander claimed she had a plastic glove and 
planned to kill herself with it.  A nurse subsequently found the 
glove on Hofflander's bed.7  According to the entry, Hofflander 
told the nurse: "If I want to kill myself I will.  I could break 
out of here if I want."  
¶14 On Monday, December 30, there was an entry at 10:30 
a.m., indicating that Hofflander denied suicidal ideation but 
acknowledged a plan "to flee as [she] has 5 warrants in Ill. for 
DUI, driving . . . revocation, failure to appear, etc."  At 2:40 
p.m., a social worker noted that "She is very concerned about 
the apartment she is living in, and is supposed to vacate before 
Jan. 1."  
¶15 At approximately 5:15 p.m. that day, Dr. Ashokkumar 
Shah, 
Hofflander's 
attending 
psychiatrist, 
interviewed 
Hofflander after reviewing Dr. Ilagan-Newman's assessment and 
all patient records prepared since Hofflander's admission.  Shah 
found Hofflander to be alert with labile affect, mildly 
irritable, and sarcastic.  Hofflander denied having drug and 
                                                 
7 Hofflander later testified that she had removed the glove 
from a garbage container in the Unit and used it to try to 
strangle herself. 
No. 00-2467 
 
 
9 
 
alcohol 
problems 
despite 
a 
positive 
drug 
screening 
and 
statements from her family and Stewart that she had been using 
controlled substances.  Dr. Shah determined that Hofflander did 
not have suicidal ideation or psychotic features.  The interview 
reportedly concluded at about 5:40 p.m., at which time Dr. Shah 
went to the Unit's nurses' station and began entering a notation 
of his plan to decrease her Valium, continue Prozac, and allow 
Hofflander to sign for voluntary outpatient treatment "once 
stable."8  Dr. Shah also requested that Nurse Cathy Witheril 
check on Hofflander to see if she was okay, because Hofflander 
had been irritable during the interview.  
¶16 Following 
Dr. 
Shah's 
request, 
Witheril 
went 
to 
Hofflander's room and discovered her putting on her high-top 
shoes using laces that she had made from tearing strips of 
elastic edgings from her bed sheet.  Witheril removed the shoes 
and laces.  She observed that Hofflander's room looked otherwise 
undisturbed.  Witheril claims that, upon returning to the 
nurses' station, she reported the shoelace incident to Dr. Shah, 
who was still writing up his orders for Hofflander.9  
                                                 
8 The parties dispute the significance of Dr. Shah's "once 
stable" comment.  Hofflander contends that this comment refers 
to her mental state at that time.  However, Dr. Shah has since 
filed an affidavit averring that, by saying "once stable," he 
was referring to his assessment of Hofflander's mood, not her 
capacity to control and appreciate her conduct. 
9 Dr. Shah has testified that he does not recall being told 
by Nurse Witheril about the shoelace incident. 
No. 00-2467 
 
 
10 
 
¶17 Approximately five minutes later, Hofflander appeared 
at the station, exhibiting a calm disposition.  She asked for 
her makeup and telephone numbers.  Shah directed the nurses not 
to give Hofflander any glass objects in accord with the Unit's 
policy, and the makeup was dispensed in a medicine cup.  The 
nurses observed Hofflander taking phone numbers from her purse 
and heading to the telephone lounge.  
¶18 Sometime Sunday or Monday, a patient in the Unit told 
Hofflander that if she wanted to leave the hospital, there was a 
loose air conditioner in the window in Room 309.10  At some point 
after the glove incident on Sunday, Hofflander began to 
contemplate escape and she eventually checked out the air 
conditioner in Room 309.11  It is not clear when Hofflander first 
checked out Room 309.  Specifically, it is not clear whether she 
inspected the room before or after she met with Dr. Shah. 
¶19 The circuit court found as undisputed facts that: 
[o]nce inside the room [Hofflander] checked the air 
conditioner mounted in the window and found that it 
was loose.  Thereafter, for the next 45 to 60 minutes 
or so and probably longer, Ms. Hofflander began to 
plan the details of her escape.  While doing so, she 
consciously made efforts to conceal her escape plans 
from the hospital staff.  She first went to the 
nurses' station and asked for her makeup because she 
                                                 
10 At no point did Hofflander advise any of the Unit's staff 
about the alleged condition of the air conditioner in Room 309.  
She also never told any of the staff that she intended to elope. 
11 Hofflander was told about the air conditioner no later 
than early afternoon Monday, because that is the time when the 
patient who told her about the air conditioner left the hospital 
for court. 
No. 00-2467 
 
 
11 
 
knew she was going to leave and wanted to fix her 
appearance.  She also started some laundry in an 
attempt to divert the nurses' attention.  Upon 
returning to her own room, Ms. Hofflander telephoned 
her friend and told her to meet her at the hospital 
with Ms. Hofflander's car.  Because the shoelaces for 
her shoes had been confiscated upon her admission, she 
then tore the elastic edges from a fitted sheet on her 
bed so she could make shoelaces for her own shoes.  As 
she was making these shoelaces, however, a nurse came 
into her room and took the elastic edging and the 
shoes. 
¶20 Although the record supports the court's findings of 
events, it is difficult to reconcile the timing of some of these 
events.  How could all these events have occurred after the 
interview with Dr. Shah, if the interview with Dr. Shah ended at 
approximately 5:40 p.m.?  Did Hofflander ask for makeup and 
telephone numbers before or after the improvised plastic 
shoelaces were removed?  Why does a report from the Kenosha 
Police 
Department 
indicate 
the 
Department's 
knowledge 
of 
Hofflander's fall at 5:52 p.m.? 
¶21 In any event, Hofflander entered Room 309 sometime 
around 6:00 p.m.  She brought bed sheets from the two beds in 
her room.  The current resident of that room was sleeping; 
Hofflander assumed he was under medication.  Once in the room, 
Hofflander decided to take the patient's overcoat to wear during 
her escape, since it was lighter in weight than her own coat.  
She then went to the window and began pulling the air 
conditioner towards her by its corners, splintering the wood 
mounting supporting it in the window, until the air conditioner 
crashed to the floor. 
No. 00-2467 
 
 
12 
 
¶22 Hofflander testified that she panicked immediately 
after the crash, believing that she might get caught.  She 
quickly peeked out the door to observe whether anyone was 
coming.12  Even though she saw no one approaching from the 
nurses' station, she feared that hospital staff would soon 
arrive to detain her.  Therefore, Hofflander hastily tied 
together the bed sheets she had brought with her, attempting to 
affix one end of the sheets to the corner of the window and the 
other end to one of her ankles.  As she attempted to exit the 
window and climb down, she lost her grip and fell from the 
third-story window.  Shortly thereafter, other nurses from the 
hospital found Hofflander in the bushes underneath the window 
with a bed sheet tied around her ankle.  As a result of her 
fall, 
Hofflander 
suffered 
multiple 
injuries, 
including 
a 
ruptured spleen and fractures to her ribs, pelvis, and arm. 
II. PROCEDURAL HISTORY 
¶23 Hofflander filed suit in Kenosha County Circuit Court 
against St. Catherine's and Horizon, along with their respective 
insurers, alleging negligence and safe place statute violations.  
Following discovery, St. Catherine's and Horizon moved for 
summary judgment, asserting that Hofflander's own negligence 
precluded her from recovery as a matter of law and that the safe 
place statute was inapplicable in this case.  Initially, the 
circuit court granted only Horizon's motion on the safe place 
                                                 
12 Hofflander testified that she saw some nurses at that 
station who were talking with each other but who did not 
otherwise seem aroused. 
No. 00-2467 
 
 
13 
 
claim.  Thereafter, this court issued its ruling in Jankee, 
causing Horizon and St. Catherine's to renew their motions for 
summary judgment.  Meanwhile, Hofflander moved for partial 
summary judgment, asserting that the "custody and control" rule 
set 
forth 
in 
Jankee 
applied 
to 
her, 
thereby 
expunging 
contributory negligence as a defense. 
¶24 After a hearing, the circuit court granted the 
defendants' motions, concluding that Hofflander's particular 
conduct and injury were not foreseeable and, therefore, the 
custody and control rule did not apply.  It further determined 
that Hofflander was not delusional or acting based on a sudden 
onset of mental illness and that her negligence exceeded the 
health care providers' negligence as a matter of law.  Finally, 
the circuit court held that the safe place statute was 
inapplicable because Hofflander was a trespasser at the time of 
her escape attempt and, additionally, the safe place statute 
does not encompass a plaintiff's own negligent acts. 
¶25 Hofflander appealed.  The court of appeals reversed in 
part and affirmed in part, and remanded the case for trial.  
Hofflander v. St. Catherine's Hosp., Inc., 2001 WI App 204, 247 
Wis. 2d 636, 635 N.W.2d 13.  The court affirmed the circuit 
court's pretrial order barring discovery of certain hospital 
records as privileged peer review documents.  Id., ¶36.  
However, the court of appeals ruled that both defendants had a 
special relationship with Hofflander under Jankee's custody and 
control rule and that issues of fact existed as to the 
No. 00-2467 
 
 
14 
 
foreseeability of Hofflander's particular injury.  Id., ¶23.  As 
to the safe place claim, the court held that there were 
questions of fact for a jury whether the loose air conditioner 
represented an unsafe condition and whether the defendants had 
constructive notice of the disrepair.  Id., ¶¶30-31.  The 
defendants petitioned this court for review of the court of 
appeals' decision regarding the negligence and safe place 
claims, while Hofflander cross-petitioned for review of the 
discovery dispute.  We granted review to each of the petitions. 
III. STANDARD OF REVIEW 
¶26 The review of a decision to grant summary judgment is 
a question of law that we consider de novo.  Jankee, 235 
Wis. 2d 700, ¶48.  Summary judgment shall be rendered when no 
genuine issues of material fact exist and the moving party is 
entitled 
to 
judgment 
as 
a 
matter 
of 
law.  
Wis. Stat. § 802.08(2).  We will reverse a summary judgment if a 
review of the record reveals disputed material facts or if there 
are undisputed material facts from which reasonable alternative 
inferences may be drawn.  See Grams v. Boss, 97 Wis. 2d 332, 
338-39, 294 N.W.2d 473 (1980).  Given the posture of this 
appeal, all facts and reasonable inferences therefrom are viewed 
in the light most favorable to the non-moving party.  See 
Kraemer Bros., Inc. v. U.S. Fire Ins. Co., 89 Wis. 2d 555, 567, 
278 N.W.2d 857 (1979). 
IV. CUSTODY AND CONTROL 
No. 00-2467 
 
 
15 
 
¶27 Hofflander's first theory of liability against St. 
Catherine's and Horizon is based upon common law negligence.  
First, Hofflander maintains that the staff on duty the night of 
her injury failed to act according to their duty of care by 
improperly supervising her.  Second, Hofflander contends that 
the 
Unit's 
policies 
and 
procedures 
were 
either 
grossly 
insufficient at accomplishing the staff's duty of care or that 
Unit personnel simply did not correctly follow established 
policies that were otherwise adequate. 
¶28 The parties agree that, if traditional rules of 
negligence 
apply, 
Hofflander's 
contributory 
negligence 
in 
bringing about her injuries exceeds the negligence of the 
defendants as a matter of law.  As a general rule, a plaintiff 
in Wisconsin cannot recover damages if the plaintiff's own 
negligence exceeds the negligence of the party against whom 
relief is sought.  See Wis. Stat. § 895.045; Peters v. Menard, 
Inc., 224 Wis. 2d 174, 193, 589 N.W.2d 395 (1999); Johnson v. 
Grzadzielewski, 159 Wis. 2d 601, 608, 465 N.W.2d 503 (Ct. App. 
1990). 
¶29 Hofflander asserts, however, that the affirmative 
defense of contributory negligence is not available to the 
defendants because these defendants assumed her duty of self-
care when she was committed to the hospital.  Hofflander's 
argument is based upon the "custody and control" rule that we 
established in Jankee.  Thus, Jankee serves as the foundation 
for our present analysis. 
No. 00-2467 
 
 
16 
 
¶30 In Jankee, Emil Jankee was a patient involuntarily 
committed to the Clark County Health Care Center (CCHCC) who was 
placed in a locked, long-term care ward for the chronically 
mentally disabled, on the basis of a domestic violence incident.  
Jankee, 235 Wis. 2d 700, ¶17.  Jankee was deemed a threat to 
harm others and, during the early part of his stay, he often 
displayed threatening and destructive behavior.  Id., ¶29.  
Although Jankee had a history of suicide attempts, it was 
determined that he was not a suicide risk during his stay, in 
part because of statements he made exhibiting an intent to avoid 
self-harm.  Id., ¶¶30-31, 100.  Likewise, Jankee was never 
determined to be an elopement risk.  Id., ¶¶30, 102.  A little 
more than a week after his admission to the CCHC, however, 
Jankee devised a plan and attempted to escape from the facility.  
Id., ¶¶35-37.  Late one night, he succeeded in partially opening 
a window in his third-floor room by prying off a specially 
installed safety-stop in the window.  Id., ¶37.  He then 
squeezed out of the window onto a roof, where he eventually fell 
from a brick ledge and sustained multiple injuries.  Id., ¶39. 
¶31 We engaged in a two-step analysis to determine how 
Jankee's own conduct affected his ability to recover damages 
from CCHCC related to his fall.  First, we established that, 
absent a few narrow exceptions,13 the reasonable person standard 
                                                 
13 The court acknowledged two exceptions to this general 
rule, neither of which is applicable to this case.  See Jankee 
v. Clark County, 2000 WI 64, ¶¶57-58, 78-87, 235 Wis. 2d 700, 
612 N.W.2d 297. 
No. 00-2467 
 
 
17 
 
of care applies to all mentally disabled plaintiffs when 
determining their level of contributory negligence.  Id., ¶75.  
Therefore, if a mentally disabled plaintiff's negligence in 
bringing about the plaintiff's own injury exceeds that of a 
defendant, a court must find that the contributory negligence 
bars recovery.  Id., ¶9.  We determined that Jankee's own 
negligence exceeded that of the defendants as a matter of law 
because (1) his hospitalization was due to his own failure to 
take medication that controlled his mental disability; and (2) 
he failed to exercise his duty of ordinary care when he tried to 
escape from the CCHCC.  Id. 
¶32 Notwithstanding this general rule, we also held that 
certain entities, such as a mental health facility, owe a 
heightened duty of care to prevent foreseeable injuries to 
mentally disabled patients when they have assumed custody and 
control over these persons.  Id., ¶¶92, 94 (citing Restatement 
(Second) of Torts §§ 314A, 315, & 319 (1965)).  As a result, we 
stated: 
When such a special relationship exists, the caregiver 
assumes the duty to provide reasonable care of the 
protected person to prevent harm.  This assumption of 
duty may absolve the protected person from the 
ordinary obligation of self-care, shift responsibility 
to the caregiver, and thereby expunge the affirmative 
defense of contributory negligence. 
Id., ¶92 (citation omitted). 
¶33 We enunciated the following test for determining 
whether a caregiver serving a mentally disabled patient can be 
No. 00-2467 
 
 
18 
 
liable for harm predominately caused by the patient's own 
actions: 
[A] 
plaintiff 
must 
show 
that: 
(1) 
a 
special 
relationship existed, giving rise to a heightened duty 
of care; and (2) the defendant caregiver could have 
foreseen the particular injury that is the source of 
the claim.  If the special relationship existed but 
the defendant caregiver could not have foreseen the 
particular 
injury, 
the 
affirmative 
defense 
of 
contributory negligence reenters the equation.  Even 
if the particular injury were foreseeable, the defense 
of contributory negligence should not be expunged if 
the 
defendant's 
exercise 
of 
care 
was 
not 
only 
reasonable but also fully responsive to the heightened 
duty with which the caregiver was charged. 
Id., ¶93.  Part of the rationale behind this test was that "[i]f 
a caregiver is unaware of a patient's propensity for self-
injury, the caregiver cannot assume the patient's duty of self-
care."  Id., ¶97; see also Restatement (Second) of Torts § 314A 
cmt. e ("defendant is not liable where he neither knows nor 
should know of the unreasonable risk, or of the illness or 
injury"). 
 
¶34 After fully considering the arguments in this case, we 
acknowledge that the test set out in paragraph 93 of Jankee is 
unclear and needs revision.  As a result, we have reexamined our 
premises in Jankee and now restate the law. 
A. Revision of Custody and Control Rule in Jankee 
 
¶35 A person who is mentally disabled is held to the same 
standard of care as one who has normal mentality.  An exception 
to this rule may exist when a mentally disabled person is under 
the protective custody and control of another.  When a mentally 
disabled plaintiff relies on this exception to seek recovery for 
No. 00-2467 
 
 
19 
 
a self-caused injury, the plaintiff must establish that (1) a 
special relationship existed between the defendant caregiver and 
the plaintiff, giving rise to a heightened duty of care; and (2) 
the defendant caregiver knew or should have foreseen the 
particular risk of harm that led to the plaintiff's injury.  If 
a special relationship existed but the defendant could not have 
foreseen the particular risk of harm, then the defendant is 
entitled to assert the affirmative defense of contributory 
negligence, and the fact finder should evaluate the comparative 
negligence of the parties using an objective standard of care.   
¶36 However, if a special relationship did exist, the 
particular risk of harm was foreseeable, and there is some 
evidence that the defendant caregiver failed to exercise the 
duty of care that was required under these circumstances, the 
finder of fact should compare the defendant's negligence to the 
plaintiff's contributory negligence using a subjective standard 
to evaluate the mentally disabled plaintiff's duty of self care.  
In this situation, if the mentally disabled plaintiff is able to 
show that she was totally unable to appreciate the risk of harm 
and 
the 
duty 
to 
avoid 
it, 
the 
plaintiff's 
contributory 
negligence should not be compared to the negligence of the 
defendant.  It should be expunged as a matter of law. 
 
¶37 Each principle in this revised statement of law 
requires comment. 
1. Duty of Care for Mentally Disabled Persons 
No. 00-2467 
 
 
20 
 
¶38 We affirm the principle that mentally disabled persons 
are generally held to the same reasonable person standard of 
care as other individuals.  Jankee, 235 Wis. 2d 700, ¶54.  This 
duty of care obligates all persons to exercise ordinary care for 
their own safety.  See Peters, 224 Wis. 2d at 192 (quoting Wis. 
Wis JI——Civil 1007).  Because a mentally disabled plaintiff 
normally operates under an objective standard of care, she is 
normally 
subject 
to 
the 
same 
principles 
of 
contributory 
negligence as a plaintiff who is not mentally disabled.  Jankee, 
235 Wis. 2d 700, ¶¶75-76. 
¶39 The Wisconsin Academy of Trial Lawyers, appearing as 
amicus 
curiae, 
argues 
that 
Jankee's 
establishment 
of 
an 
objective duty of care for mentally disabled persons represents 
a complete reversal of prior Wisconsin law.  The Academy points 
to the case of Karow v. Continental Insurance Co., 57 Wis. 56, 
15 N.W. 27 (1883), in which this court said: 
Of course, negligence involves a want of care in one 
who ought to bestow care.  It is an omission of duty.  
But the law imposes no duty——no obligation of care——
upon one who has no control over his mental faculties, 
and hence no control over his physical action.  Being 
under no obligation of care, and under no restraint of 
duty, and incapable of exercising either, it would be 
inapt, if not inaccurate, to say that, by his 
omission, an insane person was guilty of negligence. 
Id. at 63.  
¶40 This passage is no longer consistent with modern 
negligence theory.  Today, a mentally disabled person may be 
held liable for the damages caused by the person's "negligence" 
because all persons have a duty of ordinary care.  Coffey v. 
No. 00-2467 
 
 
21 
 
City of Milwaukee, 74 Wis. 2d 526, 537, 247 N.W.2d 132 (1976).  
The result in a typical negligence case today is the same as it 
would have been in 1883.  Only the analysis is different.   
¶41 Our court has never been in doubt that, as a general 
rule, an insane person is civilly liable for torts.  In Huchting 
v. Engel, 17 Wis. 237, 238 (1863), this court quoted with 
approval from Reeve's Dom. Rel. 258 that "a lunatic is as liable 
to compensate in damages as a man in his right mind."  In Karow, 
this court cited cases from four other states, including 
Vermont, where a court said that "no reason can be assigned why 
a lunatic should not be held liable."  Karow, 57 Wis. at 61 
(citing Morse v. Crawford, 17 Vt. 499 (1845)). 
¶42 Contemporary analysis may be traced to German Mutual 
Fire Insurance Society v. Meyer, 218 Wis. 381, 261 N.W.211 
(1935), where we held that insanity is not a defense for tort 
liability unless evil intent or express malice is required by 
the claim.  Id. at 385.  The court's opinion quoted extensively 
from Karow.  Id. at 386-87.  Then in Breunig v. American Family 
Insurance Co., 45 Wis. 2d 536, 173 N.W.2d 619 (1970), the court 
indicated that some forms of insanity are a defense and preclude 
liability for negligence, but not all types of insanity.  Id. at 
541.  The court stated: 
The effect of the mental illness . . . or disorder 
must be such as to affect the person's ability to 
understand and appreciate the duty which rests upon 
him . . . [for] ordinary care, or . . . it must affect 
his ability to control [his conduct] in an ordinarily 
prudent manner.  And in addition, there must be an 
absence of notice or forewarning to the person that he 
No. 00-2467 
 
 
22 
 
may be suddenly subject to such a type of insanity or 
mental illness. 
Id.  The court continued: 
We think the statement that insanity is no defense is 
too broad when it is applied to a negligence case 
where 
the 
driver 
is 
suddenly 
overcome 
without 
forewarning by a mental disability or disorder which 
incapacitates him from conforming his conduct to the 
standards 
of 
a 
reasonable 
man 
under 
like 
circumstances.  These are rare cases indeed. 
Id. at 543 (emphasis added). 
 
¶43 The implication of the Breunig analysis is that the 
reasonable person standard of care is normally applied "even to 
the mentally disturbed."  Burch v. Am. Family Mut. Ins. Co., 198 
Wis. 2d 465, 470, 543 N.W.2d 277 (1996).  This was made explicit 
in 
Gould 
v. 
American 
Family 
Mutual 
Insurance 
Co., 
198 
Wis. 2d 450, 543 N.W.2d 282 (1996), where the court said: 
 
It is a widely accepted rule in most American 
jurisdictions that mentally disabled adults are held 
responsible for the torts they commit regardless of 
their capacity to comprehend their actions; they are 
held to an objective reasonable person standard.  See 
generally, 
Restatement 
(Second) 
of 
Torts 
§ 283B 
(1965); W. Page Keeton et al., Prosser and Keeton on 
the Law of Torts, § 135 (1984). . . .  
 
When 
fault-based 
liability 
replaced 
strict 
liability, American courts in common law jurisdictions 
identified the matter as a question of public policy 
and maintained the rule imposing liability on the 
mentally disabled.  Although early case law suggested 
that 
Wisconsin 
followed 
this 
trend, 
this 
court 
specifically adopted the common law rule and the 
public policy justifications behind it in German Mut. 
Fire Ins. Soc'y v. Meyer, 218 Wis. 381, 385, 261 N.W. 
211 (1935). 
Id. at 456-57.  The court continued: 
No. 00-2467 
 
 
23 
 
 
The court of appeals erroneously perceived the 
underlying premise of Breunig to be that a person 
should not be held negligent where a mental disability 
prevents that person from controlling his or her 
conduct.  By limiting its holding to cases of sudden 
mental disability, the Breunig court chose not to 
adopt that broad premise.  We also decline to do so. 
Id. at 459 (citations omitted). 
¶44 Consequently, the assertion that a mentally disabled 
person can never be negligent is simply wrong.  As the Academy 
concedes, since 1971 Wisconsin has followed a pattern jury 
instruction, entitled "Negligence of Mentally Disturbed," that 
expressly states: "A person who is mentally disabled is held to 
the same standard of care as one who has normal mentality, and 
in your determination of the question of negligence, you will 
give no consideration to the defendant's mental condition."  Wis 
JI——Civil 1021 (emphasis added).  This is good law. 
2. Custody and Control Exception 
 
¶45 The custody and control rule recognized in Jankee is a 
specific exception to the general standard of ordinary care.  In 
Rockweit v. Senecal, 197 Wis. 2d 409, 541 N.W.2d 742 (1995), 
this court recognized that "'each individual is held, at the 
very least, to a standard of ordinary care in all activities.'"  
Id. at 419 (quoting Coffey, 74 Wis. 2d at 537).  We discussed 
the proper analysis of duty in Wisconsin as follows: "The duty 
of any person is the obligation of due care to refrain from any 
act which will cause foreseeable harm to others even though the 
nature of that harm and the identity of the harmed person or 
harmed interest is unknown at the time of the act."  Id. at 419-
20 (citing A.E. Inv. Corp. 
v. Link 
Builders, 
Inc., 62 
No. 00-2467 
 
 
24 
 
Wis. 2d 479, 483-84, 214 N.W.2d 764 (1974)).  The concomitant 
principle is that every person in all situations has a duty to 
exercise ordinary care for his or her own safety.  See Wis JI——
Civil 1007. 
 
¶46 The custody and control rule is an exception to 
standard negligence law because it contemplates the possibility 
of a heightened duty of care for a defendant and a lowered duty 
of self-care for a plaintiff. 
 
¶47 Nonfeasance torts, which entail a duty to do some act 
of commission to prevent harm,14 are not usually within the duty 
of ordinary care that people hold towards each other.  See 
Restatement (Second) of Torts § 314 cmt. c; W. Page Keeton et 
al., Prosser and Keeton on the Law of Torts § 56 (5th ed. 1984).  
Hence, the proposition that a defendant may be subject to a 
heightened duty of care must be understood as a special 
exception to the norm and be treated accordingly.  The 
requirement that a defendant knew or should have foreseen a 
particular risk of harm should not be viewed as inconsistent 
with this court's adoption of the minority Palsgraff rule, see 
A.E. Inv. Corp., 62 Wis. 2d at 483, because this requirement 
comes in the context of a heightened duty of care to protect 
                                                 
14 See Charles J. Williams, Fault and the Suicide Victim:  
When Third Parties Assume a Suicide Victim's Duty of Self-Care, 
76 Neb. L. Rev. 301, 303-04 (1997) ("The goal of tort law is to 
discourage unreasonable behavior.  The duty of care can 
encompass either the duty not to do some act that injures 
another (a misfeasance tort) or the duty to do some act to 
prevent injury to another (a nonfeasance tort)."). 
No. 00-2467 
 
 
25 
 
against the acts of others, not an ordinary duty of care in line 
with general tort principles. 
3. Basis of Liability 
 
¶48 A 
special 
relationship 
exists 
when 
a 
defendant 
caregiver 
assumes, 
voluntarily 
or 
otherwise, 
an 
enhanced 
responsibility to protect a vulnerable, mentally disabled person 
from foreseeable harms.  The defendant in these circumstances is 
empowered with custody and an extra measure of control over the 
person.  The heightened duty of care reflects the enhanced 
responsibility that attends this custody and control.  However, 
if a defendant in these circumstances were held liable for not 
protecting a person from unforeseeable harms, the defendant 
would effectively become an insurer. 
¶49 A hospital is not an insurer of its patients against 
all 
injuries 
inflicted 
by 
themselves. 
 
See 
Jankee, 
235 
Wis. 2d 700, ¶95 (citing Dahlberg v. Jones, 232 Wis. 6, 11, 285 
N.W. 841 (1939)).  A hospital or other caregiver "is only 
required to use such means to restrain and guard its patients as 
would seem reasonably sufficient to prevent foreseeable harms."  
Id.  (citing Dahlberg, 232 Wis. at 11).  The duty of a hospital 
is to exercise such care as the hospital knows, or should know, 
the patient's mental or physical condition requires.  Kujawski 
v. Arbor View Health Care Ctr., 139 Wis. 2d 455, 462-63, 407 
N.W.2d 249 (1987).  "Requiring a facility to be liable for any 
irrational behavior [by a patient] would impose an unreasonable 
burden on the [caregiver] and frustrate the objective of 
No. 00-2467 
 
 
26 
 
providing patients with a therapeutic environment free from 
prison-like restrictions."  Jankee, 235 Wis. 2d 700, ¶101 n.37.  
It would force caregivers to impose stringent safety measures, 
not to protect patients, but to avoid liability. 
4. Particular Risk of Harm 
¶50 A mentally disabled plaintiff who seeks to rely on a 
defendant's heightened duty of care must establish, among other 
things, that "(2) the defendant caregiver knew or should have 
foreseen the particular risk of harm that led to the plaintiff's 
injury."  See ¶35 above (emphasis added).  The former test in 
Jankee required proof that "(2) the defendant caregiver could 
have foreseen the particular injury that is the source of the 
claim."  Jankee, 235 Wis. 2d 700, ¶93 (emphasis added). 
¶51 The foreseeability prong of the former test proved to 
be confusing.  For example, use of the term "particular injury" 
led to debate whether the hospital should have foreseen 
Hofflander's attempt to escape from a third-floor window in 
another patient's room by tearing a loose air conditioner from 
its mounting.  Did all of these elements constitute the 
"particular injury" that St. Catherine's and Horizon should have 
foreseen?  Was the "particular injury" that the defendant should 
have foreseen even more "particular"——namely, a back injury or a 
leg injury as opposed to any injury? 
¶52 The Jankee opinion borrowed heavily from the analysis 
by Charles Williams in the Nebraska Law Review.  The wording of 
the foreseeability prong in the Williams article stated the 
No. 00-2467 
 
 
27 
 
proposition as follows: "For a plaintiff to prove a nonfeasance 
tort, the plaintiff must show that . . . (2) the harm that 
befell the plaintiff was of the type the defendant should have 
foreseen."  Charles J. Williams, Fault and the Suicide Victim:  
When Third Parties Assume a Suicide Victim's Duty of Self-Care, 
76 Neb. L. Rev. 301, 304 (1997).  Our new phrase, "particular 
risk of harm," is more consistent with the Williams formulation 
than the Jankee language. 
¶53 To illustrate, when 
a mental 
health 
institution 
assumes the custody and control of a mentally disabled person as 
a 
suicide 
precaution, 
the 
risk 
of 
suicide 
is 
clearly 
foreseeable.  The foreseeability of suicide requires the 
institution to act with a heightened duty of care to prevent 
this particular risk of harm——at least until the risk is no 
longer foreseeable.  Whether a particular risk of harm remains 
foreseeable for the entire duration of an institution's special 
relationship with a patient is a question of fact.  However, the 
mere passage of time will seldom be enough for an institution to 
substantially relax its heightened duty of care. 
¶54 There are other risks of harm in a mental health 
institution, including the risk of elopement, the risk of self-
injury other than suicide, and the risk of injury to other 
people such as staff members, visitors, and fellow patients.15  
                                                 
15 By listing these general risks of harm, we do not mean to 
suggest that this is an exhaustive list of harms that may be 
foreseeable under the custody and control rule.  We note merely 
that these appear to be the most cognizable risks in the context 
of mental health care providers. 
No. 00-2467 
 
 
28 
 
The custody and control rule does not signify that a caregiver 
is liable for any and all injuries sustained by a patient simply 
because one risk of harm was foreseeable.  Rather, our 
formulation is based on the proposition that the particular harm 
to which the mentally disabled person's claim relates should 
have been foreseeable. 
¶55 In Jankee, we explained that modern hospitals treating 
persons 
with 
mental 
disabilities 
focus 
on 
therapy 
and 
rehabilitation, not maximum security.  Jankee, 235 Wis. 2d 700, 
¶96 (citing Payne v. Milwaukee Sanitarium Found., Inc., 81 
Wis. 2d 264, 270, 260 N.W.2d 386 (1977)).  "A duty to restrain 
or guard a specific patient emerges only when a hospital has 
'knowledge of the propensity or inclination of the patient to 
injure (himself) (herself) or escape.'  Wis JI——Civil 1385.5; 
see also Wis JI——Civil 1385."  Id. 
 
No cause of action arises unless the hospital has 
notice of an individual patient's disposition to 
inflict self-injury.  Thus, a hospital is under no 
duty to take special precautions when there is no 
reason to anticipate one patient's escape or suicide.  
If a caregiver is unaware of a patient's propensity 
for self-injury, the caregiver cannot assume the 
patient's duty of self-care. 
Jankee, 235 Wis. 2d  700, ¶97 (citations omitted).  These 
passages explain our adherence to the adjective "particular" in 
front of the phrase "risk of harm." 
 
¶56 In this case, the dispute is whether the defendants 
should have foreseen Hofflander's attempt to escape.  Did the 
defendants have notice from Hofflander's statements and actions 
No. 00-2467 
 
 
29 
 
and from other available evidence of the risk that Hofflander 
would try to elope?16  The fact that Hofflander was initially 
placed as a suicide risk does not mean that she could not later 
manifest such a risk of elopement, thereby triggering a duty to 
take 
focused 
preventive 
action.  
Conversely, 
Hofflander's 
placement as a suicide risk did not automatically make every 
other possible risk of harm to her foreseeable as a particular 
risk. 
 
¶57 It should be noted that the Behavioral Services Unit 
was a locked unit and that Hofflander did not attempt to elope 
from a window in her own room.  These facts show the Unit's 
consciousness of possible patient elopement and some of the 
steps taken to address this risk of harm.  It is a question of 
fact whether the defendants took sufficient steps to address 
this general concern.  Beyond that, the question is whether the 
defendants should have foreseen a particular risk of elopement 
for Hofflander that required them to undertake additional 
precautions to prevent her escape. 
5. Contributory Negligence——Objective Standard 
¶58 The mentally disabled plaintiff has the burden of 
establishing the two elements of (1) a special relationship; and 
(2) the foreseeability of a particular harm.  If a special 
                                                 
16 The evidence for this analysis will include information 
received by the hospital's staff from the attending physicians, 
members of the family, persons who brought the patient to the 
hospital, the conduct and statements of the patient while in the 
hospital, as well as all the circumstances under which the 
patient was admitted to the hospital.  See Wis JI——Civil 1385.5. 
No. 00-2467 
 
 
30 
 
relationship did not exist or if the defendant caregiver could 
not have foreseen the particular risk of harm, then the general 
rules of negligence apply.  The defendant may assert the 
affirmative 
defense 
of 
contributory 
negligence, 
with 
the 
plaintiff's duty of self-care measured under an objective 
standard of care.  Even though the plaintiff may be mentally 
impaired, the defendant should not face an increased risk of 
liability if a special relationship did not exist or if the risk 
of harm was not foreseeable.  The defendant's negligence, if 
any, should be judged by an ordinary standard of care and 
compared with the plaintiff's ordinary standard of self-care. 
6. Requirement of "Some" Negligence 
¶59 If (1) a special relationship existed between the 
defendant and the plaintiff; (2) the particular risk of harm was 
foreseeable; and (3) there is some evidence that the defendant 
failed to exercise the duty of care that was required under 
these circumstances, then the defendant may assert the defense 
of contributory negligence.  However, under these circumstances 
the plaintiff's conduct should be evaluated under a subjective 
standard of care.  This standard will permit the fact finder to 
weigh the plaintiff's capacity to appreciate the risk of harm 
and to act to avoid it. 
¶60 In Jankee we said: "Even if the particular [risk of 
harm] were foreseeable, the defense of contributory negligence 
should not be expunged if the defendant's exercise of care was 
not only reasonable but also fully responsive to the heightened 
No. 00-2467 
 
 
31 
 
duty with which the caregiver was charged."  Jankee, 235 
Wis. 2d 700, ¶93 (emphasis added).  The main thought in this 
inartfully worded sentence is that it takes more than having a 
heightened duty of care to be liable for negligence.  Negligence 
is different from strict liability because it requires a breach 
of duty——a failure to satisfy whatever obligation the law 
imposes.  In this instance, a breach of duty or want of care may 
not be determined solely by looking at a tragic result.   
¶61 The phrase "fully responsive" in Jankee was intended 
to imply that some failure by the defendant to exercise the duty 
of care required because of the special relationship and the 
foreseeable risk of harm is necessary to relieve the plaintiff 
of her objective standard of care.  There may be some attempted 
escapes or acts of self-destruction that are so extraordinary 
that the most conscientious caregiver could not have prevented 
them.  Once again, a health care institution is not an insurer 
against every possible act of its patients. 
7. Contributory Negligence——Subjective Standard 
¶62 An argument can be made that once the plaintiff has 
established (1) a special relationship; (2) the foreseeability 
of a particular harm; and (3) some failure of care on the part 
of the defendant, the plaintiff should prevail without any 
further requirement.  However, there will be situations in which 
a mentally disabled person is as able to appreciate danger as 
any other person and is able to control her actions.  When such 
a person persists in pursuing dangerous and seemingly irrational 
No. 00-2467 
 
 
32 
 
conduct, the person's duty of self-care should be judged by a 
subjective standard and compared with the defendant's duty of 
care. 
¶63 In Jankee the court resisted an appeal to employ a 
subjective standard to evaluate a mentally disabled plaintiff.  
We had recognized in Gould that mental impairments and emotional 
disorders come in many varieties and degrees.  Gould, 198 
Wis. 2d at 459. 
As the American Law Institute recognized in its 
Restatement 
of 
Torts, 
a 
legitimate 
concern 
in 
formulating a test for mentally disabled persons in 
negligence cases is "[t]he difficulty of drawing any 
satisfactory line between mental deficiency and those 
variations of temperament, intellect and emotional 
balance which cannot, as a practical matter, be taken 
into account in imposing liability for damage done."  
Restatement (Second) of Torts, § 283B, cmt. b.1. 
Id.  We added in Jankee that the administrative difficulties in 
employing a subjective standard include the possibility of 
fraudulent claims, in the sense that a mentally disabled person 
may try to overstate the extent of her disability, after the 
fact, to avoid the ramifications of her actions.  Jankee, 235 
Wis. 2d 700, ¶72.  We also noted that a subjective standard 
complicates the work of the fact finder in allocating fault, for 
one party is to be assessed by an objective standard, while the 
other is to be judged by a subjective standard.  Id., ¶70. 
¶64 Nonetheless, adherence to a strict objective standard 
of care for the plaintiff in the face of (1) a heightened duty 
of care for the defendant; (2) the foreseeability of a 
particular risk of harm to the plaintiff; and (3) some failure 
No. 00-2467 
 
 
33 
 
to satisfy the requisite standard of care on the part of the 
defendant, would fail to promote reasonable care and to deter 
negligence.  We fear that an objective standard of contributory 
negligence in these circumstances would leave some deserving 
mentally disabled patients uncompensated. 
8. Expungement of Contributory Negligence 
¶65 If the mentally disabled person is able to show that 
she was totally unable to appreciate the risk of harm and the 
duty to avoid it, then the trier of fact has nothing to compare 
to the defendant's negligence.  The plaintiff's contributory 
negligence should be expunged as a matter of law.  This 
principle is consistent with our ruling in Gould, where we 
affirmed the objective standard but precluded liability, as a 
matter of law, for an institutionalized mentally disabled 
patient who attacked his professional caretaker but who did not 
have the capacity to control or appreciate his conduct.  Gould, 
198 Wis. 2d at 453, 463. 
B. Application of Revised Test 
¶66 Having set out and explained the elements of our 
modified "custody and control" rule, we now apply it to the 
facts at hand.  We begin by acknowledging that, on the surface, 
the facts in this case are strikingly similar to those in 
Jankee.  Both cases involve an involuntarily committed patient 
in a hospital's locked psychiatric unit.  Both patients were 
injured during an attempted escape from a third-floor window of 
that unit.  Neither Jankee nor Hofflander was injured while 
No. 00-2467 
 
 
34 
 
attempting to harm another person or to commit suicide, which 
were the respective risks justifying each patient's involuntary 
commitment.  Additionally, both Hofflander and Jankee devised 
plans, although at varying degrees of complexity, to assist in 
their escape.  Finally, the claims of negligence in Jankee, that 
the caregiver "inadequately policed Jankee's ward, failed to 
maintain close observation over him, and neglected to perform 
its routine, custodial duties in the course of caring for 
Jankee," Jankee, 235 Wis. 2d 700, ¶91, all mirror the theories 
of negligence advanced by Hofflander.  These similarities are 
noted since we determined in Jankee that the patient's risk of 
elopement was not foreseeable as a matter of law.  Id., ¶103. 
¶67 With respect to special relationship, St. Catherine's 
concedes that, consistent with Jankee, a special relationship 
existed between it and Hofflander, giving rise to a heightened 
duty of care.  The mere fact that Hofflander was slated to be 
switched to voluntarily admission status does not overcome the 
reality 
that 
she 
had 
been 
involuntarily 
placed 
at 
St. 
Catherine's pursuant to Chapter 51 and that she was not informed 
of her pending change in status.  A special relationship under 
the custody and control rule existed between St. Catherine's and 
Hofflander at the time of her injuries. 
¶68 Horizon, however, continues to assert that it never 
possessed a special relationship with Hofflander.  The hospital 
contracts with Horizon to manage its psychiatric unit.  In this 
capacity, a Horizon manager supervises the Unit's nursing 
No. 00-2467 
 
 
35 
 
therapy staff and secretaries,17 monitors the Unit, and submits 
work orders if maintenance is needed.  Horizon also works with 
the hospital to recommend and approve policies for the Unit, 
including policies on how patient rounds are conducted, how 
environmental 
rounds 
to 
check 
for 
unsafe 
conditions 
are 
conducted, and what special suicide and elopement precautions 
are undertaken.  Since Horizon is merely the manager and not the 
owner or operator of the psychiatric unit, it claims that it 
never voluntarily takes custody or control over persons admitted 
to the Unit.  Horizon emphasizes that all the caregivers who 
attended to Hofflander were St. Catherine's employees and that 
no Horizon employee was on duty at the time of Hofflander's 
attempted escape. 
¶69 Notwithstanding these arguments, we disagree with 
Horizon's characterization of its relationship to patients in 
the Unit, including Hofflander.  In acting as the manager of a 
psychiatric unit, Horizon necessarily assumed the same duties as 
the hospital that houses the unit, at least with respect to the 
operational 
responsibilities 
of 
that 
unit.18 
 
Such 
                                                 
17 Horizon notes that it does not have supervisory or 
professional authority over the treating doctors on staff.  
Rather, these 
attending 
psychiatrists 
are 
outside private 
physicians with staff privileges who are employed neither by 
Horizon or St. Catherine's. 
18 We note that Horizon is not being sued based on the 
malpractice or other negligence of the attending medical staff 
in its treatment of Hofflander.  Rather, Horizon's obligations 
of care relate to its performance in properly managing the staff 
and environment of the Unit, which are directly implicated in 
Hofflander's claims against the defendants. 
No. 00-2467 
 
 
36 
 
responsibilities are evident in the record.  For example, 
Hofflander's caregivers all reported to a Horizon manager, who 
was also responsible for daily monitoring the Unit regarding 
work and safety issues.  Merely because Horizon itself did not 
take Hofflander into its restrictive custody and control does 
not erase the fact that Horizon voluntarily assumed management 
of 
a 
unit 
that 
serves 
mentally 
disabled 
patients, 
like 
Hofflander.  Therefore, we are in substantial agreement with the 
court of appeals that Horizon's role as manager of the Unit 
established 
a 
special 
relationship 
between 
Horizon 
and 
Hofflander, giving rise to a heightened duty of care.  See 
Hofflander, 247 Wis. 2d 636, ¶19. 
¶70 We now turn to the question of whether Hofflander's 
elopement risk was foreseeable by St. Catherine's or Horizon.19  
Although an appellate court cannot make its own findings of 
fact, Wurtz v. Fleischman, 97 Wis. 2d 100, 108, 293 N.W.2d 155 
(1980), this court searches the record to support the circuit 
court's findings of fact.  See Hamm v. Jenkins, 67 Wis. 2d 279, 
282, 227 N.W.2d 34 (1975). 
                                                 
19 There is no debate as to Hofflander's purpose in exiting 
through that window.  More pointedly, there is no factual 
dispute as to whether Hofflander's departure through the window 
in Room 309 was for the purpose of committing suicide.  As 
Hofflander herself has testified, and to which significant 
competent evidence supports, suicide was not her motivation in 
exiting 
from 
the 
window. 
 
We 
note, 
however, 
that 
had 
Hofflander's injuries resulted from her exiting the window for 
the expressed purpose of committing suicide, or if the factual 
record was unclear as to her purposes for leaving, the 
disposition of this case may very well be different. 
No. 00-2467 
 
 
37 
 
¶71 As explained above, the primary issue in this case is 
whether the defendants knew or should have foreseen Hofflander's 
propensity to escape.  Again, we begin our discussion with a 
recollection of Jankee.  Emil Jankee expressed to his wife on 
the night of his failed escape attempt that he "wanted to get 
out."  Jankee, 235 Wis. 2d 700, ¶34.  However, there were no 
allegations or evidence that Jankee's wife informed anyone else, 
particularly the hospital staff, of Jankee's comments.  The only 
statement made to the hospital's medical staff that might 
conceivably have indicated a disposition to escape was Jankee's 
comment on the evening of his elopement, "I'm tired of being 
used for a guinea pig around here.  Why don't you kick my ass 
out of here instead of giving me a bunch of medicine."  Id., 
¶34.  We concluded that this "statement did not serve to alert 
CCHCC that Jankee would injure himself in an attempted elopement 
from a third floor window."  Id., ¶102.  Other than this 
ambiguous comment, Jankee made no threats to escape while at the 
CCHCC.  Id., ¶101.20   
¶72 As in Jankee, certain material facts in this case 
indicate that the defendants could not have foreseen that 
                                                 
20 The fact that the Clark County Health Care Center knew 
that different patients had previously attempted to escape 
through its windows, and that the Center had conducted an 
investigation and reconfigured the windows to make them secure, 
see Jankee, 235 Wis. 2d 700, ¶¶23-27, only goes to the weighing 
of the caregiver's negligence.  To wit, it is a factor to aid in 
weighing whether the hospital met its duty.  This knowledge did 
not, however, affect the foreseeability of Jankee's particular 
elopement risk. 
No. 00-2467 
 
 
38 
 
Hofflander would attempt to escape.  Dr. Shah, Hofflander's 
attending psychiatrist, clinically assessed her no more than 30 
minutes before her escape, and he did not determine elopement 
precautions to be necessary.  In fact, he went so far as to 
reduce her medication dosage and to order a change of her status 
from Chapter 51 involuntary to voluntary admittee as soon as she 
calmed down.  There is no apparent evidence of Hofflander having 
previously attempted to escape from the Unit, of her loitering 
around exit doors, or of her trying to breach any door or 
window.  In addition, the express purpose for her placement in 
the Unit was suicide prevention and, prior to her attempted 
elopement, Hofflander's psychiatrists had, on two separate 
occasions, determined the threat of suicide had subsided. 
¶73 On the other hand, there is evidence that Hofflander's 
statements and conduct prior to and including the night of her 
elopement, along with other evidence in the record, reasonably 
implied a propensity to escape.  It is true that the precautions 
issued for Hofflander related only to a suicide attempt.  It is 
true that at no time during her admission was Hofflander 
formally deemed an elopement risk.  Yet these facts alone do not 
disprove the foreseeability of an attempted escape.  A risk to 
elope may develop independent of, and subsequent to, one's 
admission as a suicide risk, and an individual patient's 
proclivity to escape may be apparent to the Unit's staff, 
independent 
of 
any 
specific 
diagnosis 
by 
attending 
psychiatrists. 
No. 00-2467 
 
 
39 
 
¶74 Hofflander argues that the Unit's staff was well aware 
that she was an elopement risk.  She points to numerous actions 
and statements by her suggesting that her conduct was materially 
different from Jankee's.  For instance, hospital records 
indicate that on December 29th Hofflander declared that she 
could break out of the Unit if she wanted to.  Also on the 29th, 
Hofflander called her friend Pam Stewart and threatened to get 
even with her "when I get out of here," a conversation reported 
in the patient notes.  Furthermore, after Dr. Ilagan-Newman 
removed Hofflander from suicide precaution, she wrote in her 
report that "[t]he patient, at this time is anxious to leave the 
facility because she wants to relocate herself into a smaller 
apartment for financial reasons."  Similarly, on the afternoon 
of the 30th, Hofflander told a nurse that she was concerned 
about the apartment she had been living in and that she was 
supposed to vacate by January 1, less than two days later.  
According 
to 
hospital 
records, 
Hofflander 
had 
previously 
acknowledged that she planned to "flee," as apparently she had 
outstanding criminal warrants in Illinois.  Throughout her stay 
Hofflander was described by the medical staff as uncooperative, 
hostile, and volatile.  This behavior, while not uncommon for 
involuntarily committed mentally disabled patients, may have 
provided clues of Hofflander's desire to leave. 
¶75 Turning 
to 
the 
circumstances 
just 
prior 
to 
Hofflander's attempted elopement, there are additional facts 
that could reasonably support a finding of foreseeability.  
No. 00-2467 
 
 
40 
 
There is testimony that Dr. Shah expressly told Nurse Witheril 
to watch Hofflander closely and to check up on her.  Immediately 
thereafter, Nurse Witheril discovered Hofflander attempting to 
lace up her shoes using torn strips of bed sheet as laces.  
Hofflander asserts that all these events made it foreseeable to 
the staff of St. Catherine's that she might escape.  Cf. Mounds 
Park Hosp. v. Von Eye, 245 F.2d 756 (8th Cir. 1957) (sustaining 
jury verdict that hospital was negligent in permitting patient 
to escape by jumping from second floor window after doctors had 
ordered that the patient should be observed closely). 
¶76 Horizon's ability to foresee Hofflander's particular 
elopement risk may be imputed from the Unit's staff if an agency 
relationship existed between Horizon and St. Catherine's in 
which Horizon was acting as a principal.  Horizon argues that 
its contractually based, administrative role is one of an agent, 
not a principal.  It argues that a principal's knowledge cannot 
be imputed to its agent in order to hold the agent liable for 
negligence, unless that knowledge is communicated to the agent.  
See Hunt Trust Estate v. Kiker, 269 N.W.2d 377, 382 (N.D. 1978); 
see also Restatement (Second) of Agency § 350 cmt. b (1958).  
Therefore, if acting as an agent, Horizon cannot be treated as 
having knowledge of any of the indications of Hofflander's 
propensity to escape.   
¶77 Unfortunately, the nature of the Horizon and St. 
Catherine's agency relationship is not entirely clear from the 
No. 00-2467 
 
 
41 
 
record.21  Furthermore, in earlier proceedings in the circuit 
court, Horizon itself attempted to argue that, if there were a 
master-servant relationship, it was acting as a master to St. 
Catherine's role as servant.22  Therefore, in remanding this 
action, we instruct the finder of fact to ascertain the factual 
circumstances of Horizon's relationship to St. Catherine's and 
determine whether Horizon was acting as a principal with respect 
to the staff of the St. Catherine's Behavioral Services Unit. 
¶78 We conclude that the undisputed facts in this case are 
sufficiently different from the facts in Jankee and that summary 
judgment in favor of the defendant caregivers is inappropriate.  
There are enough issues of material fact for a jury to 
reasonably 
conclude 
that 
Hofflander's 
elopement 
risk 
was 
foreseeable by the defendants.23  We emphasize, however, that 
Hofflander carries the burden of proving that the particular 
                                                 
21 As both parties concede, the issue of agency was not 
addressed in either the circuit court proceedings or in front of 
the court of appeals.  Moreover, the contract between St. 
Catherine's 
and 
Horizon, 
which 
establishes 
the 
latter's 
administrative duties within the hospital's Behavioral Services 
Unit, is not a part of the record. 
22 If this were true, it would conclusively establish that 
St. Catherine's was Horizon's agent for purposes of this case.  
See Arsand v. City of Franklin, 83 Wis. 2d 40, 50, 264 
N.W.2d 579 (1978) ("a servant is necessarily an agent, but an 
agent is not invariably a servant"). 
23 We note that in support of each parties' motions for 
summary judgment, both Hofflander and the defendants have 
offered 
testimony 
from 
expert 
witnesses 
regarding 
the 
foreseeability of Hofflander's conduct. 
No. 00-2467 
 
 
42 
 
risk of her elopement was foreseeable by the defendants.24  We 
also conclude that disputed issues of material fact exist 
regarding the agency relationship between Horizon and St. 
Catherine's and that these issues preclude us from deciding 
whether Horizon is potentially subject to liability under 
Hofflander's claims of negligence. 
¶79 If the trier of fact determines that Hofflander's 
elopement risk was foreseeable by the defendants, either 
directly or through imputation, then it must make the additional 
determination whether the defendants failed to satisfy their 
duty of care.  Hofflander points to several indicia of 
negligence by the Unit's staff.  First, Hofflander notes that 
approximately five minutes after Nurse Witheril had confiscated 
Hofflander's shoes and laces, she left for her dinner break.  
Witheril testified that, before leaving, she informed one or 
more of her replacement nurses of Hofflander's status, including 
the shoelace incident, and of Dr. Shah's request to check on 
Hofflander.  The nurses with whom Witheril claimed she talked 
deny any recollection of such an order.  Hofflander argues that 
                                                 
24 Foreseeability of elopement must be established by a 
preponderance of the evidence and may not be inferred solely 
from a patient's status as an involuntarily committed patient.  
There is no general rule that all mentally ill patients (even 
those involuntarily admitted to a psychiatric unit) should be 
presumed to be an escape risk as a matter of law.  As testified 
by St. Catherine's staff, involuntarily committed patients 
commonly indicate a desire to leave.  Furthermore, professional 
psychiatric staff are often not moved by behavior of the type 
exhibited by Hofflander to issue heightened precautions, as was 
exhibited by Dr. Shah's responses in this case. 
No. 00-2467 
 
 
43 
 
regardless of whether Witheril failed to pass along instructions 
or the replacement nurses failed to heed them, the result was 
negligent monitoring of Hofflander.  It was only a matter of 
minutes after this shift change that Hofflander fell from the 
window in Room 309. 
¶80 Second, Hofflander points to her ability to freely 
enter into another patient's room, which was located relatively 
close to the nurses' station, and her ability to do so shortly 
after nurses were instructed to watch her.  This was more 
evidence, she argues, of inadequate supervision. 
¶81 Third, Hofflander emphasizes that the air conditioner 
in Room 309 was permitted by the Unit's staff to fall into such 
a state of disrepair that a patient of Hofflander's size was 
able to remove it from the window without the assistance of 
tools or another person.25  Then, after the air conditioner 
crashed to the ground, presumably producing a loud noise, none 
of the nurses on staff responded.  Finally, she argues that the 
hospital staff failed to properly conduct environmental checks 
of the patient's rooms on the afternoon and evening of December 
30, 
and 
to 
discover 
the 
alleged 
looseness 
of 
the 
air 
conditioner. 
¶82 Based on these allegations, it is possible that a jury 
might determine that the defendant caregivers failed to exercise 
                                                 
25 The defendants of course aver that there is no evidence 
in the record that the staff knew of the alleged defective air 
conditioning 
unit 
or 
that 
the 
condition 
existed 
for 
a 
significant period of time so as to establish constructive 
notice. 
No. 00-2467 
 
 
44 
 
the care that the hospital knew, or should have known, the 
patient's 
mental 
condition 
required. 
 
See 
Kujawski, 
139 
Wis. 2d at 462-63. 
¶83 If the defendants, either separately or collectively, 
are deemed at least partially negligent in failing to satisfy 
their heightened duty of care, then the trier of fact must also 
determine Hofflander's contributory negligence, as measured 
under a subjective duty of care.  This duty of care requires the 
fact finder to weigh Hofflander's mental state at the time of 
her accident, including her capacity to appreciate her own 
conduct.  If Hofflander did not possess a disability that 
rendered her utterly incapable of conforming her conduct to the 
standards of ordinary care, then contributory negligence can be 
attributed to her, taking into account whatever diminished 
capacity she may have had.  See Jankee, 235 Wis. 2d 700, ¶84; 
see also Champagne v. United States, 513 N.W.2d 75 (N.D. 1994) 
(holding that fault comparison between health care provider and 
patient with diminished mental capacity should take into account 
the extent of patient's diminished capacity to care for his or 
her own safety). 
¶84 A person's involuntary commitment under Chapter 51 
does not necessarily establish that the person is so mentally 
disabled that she has lost her mental capacity.  Not all types 
of insanity "vitiate responsibility for a negligent tort," 
Breunig, 45 Wis. 2d at 541, and not all types of diminished 
mental capacity preclude contributory negligence.  Persons are 
No. 00-2467 
 
 
45 
 
placed pursuant to an emergency Chapter 51 detention if there is 
reason to believe that they are mentally ill and that they pose 
a 
threat 
of 
harm 
to 
themselves 
or 
others. 
 
See 
Wis. Stat. § 51.15.  But, frequently, persons committed in this 
manner do not have their mental state comprehensively diagnosed 
by a medical professional until after their initial commitment.  
It may be that such a person's mental condition is temporary or 
that the person's behavior is a manifestation of other causes, 
including controlled substances.  Furthermore, a person who is 
"suicidal" is not ipso facto mentally ill, much less insane.  
See Karow, 57 Wis. at 59 ("The mere fact that a man commits 
suicide does not even raise a presumption of insanity at the 
time").  If the fact finder determines that Hofflander did not 
suffer from any indicia of mental illness, then even under a 
subjective analysis she must, in effect, be held to the ordinary 
reasonable person standard of care.  In other words, a 
subjective standard of care under the custody and control rule 
permits evaluations of a plaintiff's mental capacity but does 
not presume that the plaintiff is, in fact, mentally deficient. 
¶85 Although there is evidence in the record to indicate 
that Hofflander was not severely mentally ill at the time of her 
No. 00-2467 
 
 
46 
 
attempted elopement,26 we are reluctant to rule as a matter of 
law that, under a subjective standard of care, her negligence 
exceeded 
that 
of 
the 
caregivers. 
 
Such 
comparisons 
of 
negligence, 
especially 
when 
based 
on 
determinations 
of 
subjective capacity, are well suited for a fact finder.  See 
Kull v. Sears, Roebuck & Co., 49 Wis. 2d 1, 11, 181 N.W.2d 393 
(1970); Cirillo v. City of Milwaukee, 34 Wis. 2d 705, 716, 150 
N.W.2d 460 (1967).  Since there is expert testimony in the 
record stating that Hofflander was not competent enough to 
appreciate the dangerousness of her attempted escape, along with 
other evidence questioning her mental capacity, determination of 
Hofflander's negligence must be made by the trier of fact upon 
remand. 
 
¶86 For the foregoing reasons, we affirm the court of 
appeals' 
decision 
to 
remand 
this 
action 
for 
a 
factual 
determination of whether Hofflander's injuries occurred while 
she engaged in a foreseeable risk of harm and whether those 
injuries were caused by the defendants' negligence.  If both of 
these questions are answered in the affirmative, then the fact 
                                                 
26 For example, Dr. Ilagan-Newman's history and physical 
report of Hofflander, conducted the day after she was admitted, 
states under the heading of "Mental Status Examination" that, 
while Hofflander projects her life's misery, "She does not 
present any delusions.  She is not hallucinating.  She presents 
more personality profile of one, I would say, borderline 
features.  There is no specific suicide ideation elicited and 
she is orientated in all spheres."  In addition, the defendant 
caregivers have produced expert opinions indicating that, at the 
time of the incident, Hofflander was not suffering from a mental 
illness or disease such that she could not control or appreciate 
her conduct in attempting to elope. 
No. 00-2467 
 
 
47 
 
finder must also decide whether Hofflander's own negligence 
exceeded that of the defendants, applying a subjective duty of 
self-care to assess Hofflander's conduct. 
V. SAFE PLACE STATUTE 
¶87 Hofflander 
also 
seeks 
relief 
under 
Wis. Stat. § 101.11,27 Wisconsin's safe place statute.  Under 
this statute, "owners of a place of employment or a public 
building have the duty to repair or maintain the premises in as 
safe a condition as the nature of the premises reasonably 
permits."  McGuire v. Stein's Gift & Garden Ctr., Inc., 178 
Wis. 2d 379, 398, 504 N.W.2d 385 (Ct. App. 1993) (citing Dykstra 
v. Arthur G. McKee & Co., 92 Wis. 2d 17, 26, 284 N.W.2d 692, 697 
(Ct. App. 1979), aff'd, 100 Wis. 2d 120, 301 N.W.2d 201 (1981)).  
The safe place standard imposes a more stringent duty of care 
than the ordinary care otherwise applicable to one's conduct.  
Barry v. Employers Mut. Cas. Co., 2001 WI 101, ¶18, 245 
                                                 
27 Wisconsin Stat. § 101.11(1) provides: 
Every employer shall furnish employment which 
shall be safe for the employees therein and shall 
furnish a place of employment which shall be safe for 
employees therein and for frequenters thereof and 
shall furnish and use safety devices and safeguards, 
and 
shall 
adopt 
and 
use 
methods 
and 
processes 
reasonably adequate to render such employment and 
places of employment safe, and shall do every other 
thing 
reasonably necessary to protect 
the 
life, 
health, safety, and welfare of such employees and 
frequenters.  Every employer and every owner of a 
place of employment or a public building now or 
hereafter constructed shall so construct, repair or 
maintain such place of employment or public building 
as to render the same safe. 
No. 00-2467 
 
 
48 
 
Wis. 2d 560, 630 N.W.2d 517; Topp v. Cont'l Ins. Co., 83 
Wis. 2d 780, 788, 266 N.W.2d 397 (1978).  However, comparative 
negligence remains applicable to alleged violations of the safe 
place statute.  D.L. v. Huebner, 110 Wis. 2d 581, 645, 329 
N.W.2d 890 (1983) (citing Presser v. Siesel Constr. Co., 19 Wis. 
2d 54, 119 N.W.2d 405 (1963)).  As a result, the statute does 
not render an owner or employer an insurer of persons on the 
owner's property, McGuire, 178 Wis. 2d at 398, nor does it 
create a duty that is breached simply because the premises could 
be made safer, see Gross v. Denow, 61 Wis. 2d 40, 46, 212 
N.W.2d 2 (1973) (citing Paaske v. Perfex Corp., 24 Wis. 2d 485, 
490, 129 N.W.2d 198 (1964)). 
¶88 The application of § 101.11 to this case raises two 
issues.  First, did the defendants violate the safe place 
statute on account of the alleged loose condition of the air 
conditioner, or did Hofflander's own negligent conduct cause her 
injury?  Second, was Hofflander a trespasser in Room 309, the 
location from which she attempted to escape, thereby diminishing 
the defendants' duty of care to her under the statute?  We 
address each of these issues in turn. 
¶89 To succeed in a claim under the safe place statute, 
Hofflander bears the burden of showing that (1) there was an 
unsafe condition associated with the structure; (2) the unsafe 
condition caused Hofflander's injury; and (3) the caregivers had 
either actual or constructive notice of the unsafe condition 
before Hofflander's injury.  See Topp, 83 Wis. 2d at 787-88 
No. 00-2467 
 
 
49 
 
(citing 
Fitzgerald 
v. 
Badger 
State 
Mut. 
Cas. 
Co., 
67 
Wis. 2d 321, 326, 227 N.W.2d 444, 446 (1975)).  All three 
elements must be proven to obtain recovery under the statute.  
Id. 
¶90 The court of appeals blurred this analysis by adopting 
a Michigan test for determining the existence of an unsafe 
condition and by eliminating the element of causation.  See 
Hofflander, 247 Wis. 2d 636, ¶¶29-30.  Citing two Michigan court 
decisions 
applying 
a 
Michigan 
statute 
comparable 
to 
Wis. Stat. § 101.11,28 the court of appeals stated that "when 
determining whether an unsafe condition exists on the premises, 
we must consider the use or purpose the premises serve."  Id., 
¶30 (citing Lockaby v. County of Wayne, 276 N.W.2d 1, 2-3 (Mich. 
1979), and Bush v. Oscoda Area Sch., 275 N.W.2d 268, 273 (Mich. 
1979)).  The court instructed the circuit court to focus not on 
Hofflander's act of removing the air conditioner, but on the 
state of repair of the air conditioner itself.  Hofflander, 247 
Wis. 2d 636, ¶30.  Utilizing this focus, the court of appeals 
declared that, in this case, "there exists a question of fact 
for a jury to determine whether a loose air conditioning unit, 
located in a room used by mentally disturbed patients, was an 
unsafe condition . . . ."  Id. (emphasis added). 
¶91 Wisconsin's safe place statute governs only unsafe 
physical conditions of premises.  It does not involve reckless 
                                                 
28 See Mich. Comp. Laws § 691.1406 (2000) (applying only to 
public buildings owned and operated by governmental agencies). 
No. 00-2467 
 
 
50 
 
or negligent acts of persons on the premises.  See Stefanovich 
v. Iowa Nat. Mut. Ins. Co., 86 Wis. 2d 161, 166-71, 271 
N.W.2d 867 (1978) (discussing cases applying this rule); see 
also Korenak v. Curative Workshop Adult Rehabil. Ctr., 71 
Wis. 2d 77, 84, 237 N.W.2d 43 (1976).  This "acts of operation" 
rule is well established in Wisconsin case law.29 
¶92 The Michigan test employed by the court of appeals is 
not wholly inconsistent with Wisconsin law.  For instance, in 
1953 this court considered the sufficiency of a complaint 
alleging that a hospital had violated the safe place statute by 
failing to maintain a window and window screen in a safe 
condition, so that when a four-year-old patient pressed against 
the screen, it gave way and he fell five floors out of the 
window.  Wright v. St Mary's Hosp. of Franciscan Sisters, 
Racine, 265 Wis. 502, 61 N.W.2d 900 (1953).  We ruled that the 
complaint stated a cause of action, saying: 
The acts complained of in this case might not 
constitute negligence if the patient were a normal 
adult, but the duty here was to a small child.  The 
standards of care to be complied with by the defendant 
are fixed by statute, which impose a duty beyond that 
imposed by common law. 
                                                 
29 Cases that have expressed and affirmed this rule include: 
Leitner v. Milwaukee County, 94 Wis. 2d 186, 195, 287 N.W.2d 803 
(1980); Korenak v. Curative Workshop Adult Rehabil. Ctr., 71 
Wis. 2d 77, 84, 237 N.W.2d 43 (1976); Barth v. Downey Co., Inc., 
71 Wis. 2d 775, 779-780, 239 N.W.2d 92 (1976); Gross v. Denow, 
61 Wis. 2d 40, 47, 212 N.W.2d 2 (1973); Gilson v. Drees Bros., 
19 Wis. 2d 252, 257, 120 N.W.2d 63 (1963); L. G. Arnold, Inc. v. 
Indus. Comm., 267 Wis. 521, 525-526, 66 N.W.2d 176 (1954); 
Deaton v. Unit Crane & Shovel Corp., 265 Wis. 349, 352-353, 61 
N.W.2d 552 (1953). 
No. 00-2467 
 
 
51 
 
 
It is contended that the screen mentioned in the 
complaint was to keep flies and insects out and not 
keep patients in the hospital.  That is probably true.  
The ultimate question in this case is whether the 
defendant should have guarded an open window in a 
children's ward in order to render the building safe. 
Id. at 505-06. 
¶93 Six years later in Wisconsin Bridge & Iron Co. v. 
Industrial Commission, 8 Wis. 2d 612, 99 N.W.2d 817 (1959), we 
considered a case in which a roofer fell through a hole in a 
roof.  The hole had been created by a general contractor who put 
unprotected canvas over the hole.  The court observed that the 
"safe-place statute requires the employer . . . to anticipate 
what the premises will be used for and to inspect them to make 
sure they are safe."  Id. at 618. 
¶94 In both of these cases, however, the unsafe condition 
was the sole responsibility of the employer.  The injured party 
did nothing to create the unsafe condition.  The same cannot be 
said here.  In directing the circuit court not to focus on 
Hofflander's act of removing the air conditioner, the court of 
appeals disregarded the "acts of operation" rule that is a 
central tenet of Wisconsin safe place law.  There is no doubt 
that an unsafe condition existed after the air conditioner was 
ripped from the window.  The unsafe condition was the open 
window.  Lori Hofflander acted to create the open window and 
acted to elope through the open window.  A loose air conditioner 
did not cause Hofflander's injury. 
¶95 The "intended use" or "purpose of premises" test, as 
defined by the court of appeals, eliminates a good part of 
No. 00-2467 
 
 
52 
 
Hofflander's required burden of proof.  It eviscerates the "acts 
of operation" principle and wipes out causation.  The only 
factual questions that the court of appeals stated must be 
determined by a jury on remand are "whether a loose air 
conditioning unit, located in a room used by mentally disturbed 
patients, was an unsafe condition and, if so, whether St. 
Catherine's 
and 
Horizon 
had 
constructive 
notice 
of 
it."  
Hofflander, 247 Wis. 2d 636, ¶30.  By this language, the court 
of appeals appeared to disallow any inquiry into Hofflander's 
causation of her injury.  The court of appeals withdrew from the 
fact finder's consideration the reality that Hofflander's acts, 
not an unsafe condition associated with the structure, caused 
her injury.  The result is strict liability,30 a result not 
intended by the safe place statute.   
¶96 The safe place statute merely affects the level of 
one's duty of care; it does not alter the analysis of 
causation.31  "It is well established in Wisconsin that the safe-
place statute does not create a cause of action.  'It merely 
lays down a standard of care and if those to whom it applies 
                                                 
30 Strict liability operates such that a mere breach of a 
duty 
creates 
liability 
without 
any 
need 
to 
establish 
foreseeability 
and 
without 
any 
need 
to 
show 
or 
compare 
negligence.  See, e.g., Green v. Smith & Nephew AHP, Inc., 2001 
WI 109, 245 Wis. 2d 772, 629 N.W.2d 727 (explaining how the 
purpose of strict liability was to alter the focus onto whether 
the product is unreasonably dangerous, not on the plaintiff 
proving the traditional elements of negligence).   
31 See Bean v. United States, 219 F. Supp. 8, 10 (E.D. Wis. 
1963); Ruplinger v. Theiler, 6 Wis. 2d 493, 495, 95 N.W.2d 254 
(1959). 
No. 00-2467 
 
 
53 
 
violate the provisions thereof they are negligent.'"  Krause v. 
Veterans of Foreign Wars Post No. 6498, 9 Wis. 2d 547, 552, 101 
N.W.2d 645 (1960) (quoting Ermis v. Fed. Windows Mfg. Co., 7 
Wis. 2d 549, 555, 97 N.W.2d 485 (1959)).  Therefore, even if we 
were to agree that the existence of a "loose" air conditioner in 
a room used by mentally disturbed patients was, per se, an 
unsafe condition, the court of appeals' analysis was incomplete.  
The issue of whether that condition caused the injuries 
sustained must be separately addressed.   
¶97 When addressing this issue, the undisputed facts of 
this case show that the air conditioner did not cause any direct 
harm.  This is not an instance where an air conditioner was in 
such a state of disrepair that, without reckless or negligent 
action by anyone, it fell from its mounting and caused harm.  
Instead there was negligent action by the plaintiff.  This is 
what makes the case completely different from Wright and 
Wisconsin Bridge & Iron.  But for Lori Hofflander grabbing and 
tearing the air conditioner out from its mounting in the window, 
the air conditioner was reasonably "safe," even assuming that 
the screws supporting the air conditioner were loose or too 
short.32  Under these facts, there can be no viable claim under 
Wis. Stat. § 101.11. 
                                                 
32 It is true that Hofflander, who weighed approximately 100 
pounds at the time of the event, was able to tear out the 120-
pound air conditioner.  However, it was not as if she exerted no 
effort in removing the unit.  In order for her to remove the air 
conditioner, she had to strenuously pull on the air conditioner, 
causing the wooden frame affixing the unit to the window to 
splinter. 
No. 00-2467 
 
 
54 
 
¶98 In reaching its conclusion, the court of appeals 
rejected the defendants' reliance on Barth v. Downey Co., 71 
Wis. 2d 775, 239 N.W.2d 92 (1976), as controlling.  Hofflander, 
247 Wis. 2d 636, ¶29.  In Barth, the plaintiff, who was an 
employee for a subcontractor charged with removing ceiling-high 
ventilation ducts, climbed into a duct after having weakened its 
adjacent supports.  Barth, 71 Wis. 2d at 776-77.  While the 
employee was in the duct, the bottom of the supported section on 
which he was kneeling tore apart, causing him to fall and suffer 
injuries.  Id. at 777.  We held that the situation constituted 
an act that was unsafe rather than a condition that was unsafe, 
under § 101.11(1).  Id. at 779.  The court of appeals did not 
attempt to distinguish Barth from this case.  It offered a 
different analysis based upon a different rule.  However, just 
as the ceiling duct in Barth did not become unsafe until the 
plaintiff had weakened its support, so too the air conditioner 
did not constitute an unsafe condition until Hofflander removed 
it. 
¶99 We need not decide, at this time, whether the 
"intended use" or "intended purpose" doctrine, as employed in 
Michigan, is ever a proper component of Wis. Stat. § 101.11(1)'s 
requirement that "premises [be] kept as free from danger as the 
nature of the place will reasonably permit."  See Gould v. 
No. 00-2467 
 
 
55 
 
Allstar Ins. Co., 59 Wis. 2d 355, 361, 208 N.W.2d 388 (1973).33  
The fact that the safe place statute does not cover the types of 
active negligence that Hofflander performed eliminates the need 
to definitively answer that question in the context of this 
case.34  
¶100 In several cases in which we determined that the safe 
place statute did not apply, other, more traditional negligence 
was likely present.  See, e.g., L. G. Arnold, Inc. v. Indus. 
Comm., 267 Wis. 521, 66 N.W.2d 176 (1954); Deaton v. Unit Crane 
& Shovel Corp., 265 Wis. 349, 353, 61 N.W.2d 552 (1953).  If the 
nature of a premises provides opportunities for a person to 
engage in negligent or intentional acts of self-destruction and 
if the party in control of that premises has a heightened duty 
to protect the person against that risk, then liability may 
                                                 
33 We note that a requirement that premises be kept as free 
from danger as the nature of the place will reasonably permit 
could conflict with contemporary notions of the desirability of 
creating a therapeutic atmosphere, rather than a high security 
atmosphere, in mental health facilities.  See Jankee, 235 
Wis. 2d 700, ¶71. 
34 Likewise, we need not decide the parties' competing 
arguments with respect to the presence of constructive notice. 
The defendants argue that they did not obtain any notice, 
constructive 
or 
otherwise, 
of 
any 
disrepair 
to 
the 
air 
conditioner.  Hofflander asserts that this lack of notice was 
the result of the staff's collective failure to conduct 
"environmental" checks of the Unit's rooms, as required under 
its own policies.  We concede that there are material issues of 
disputed fact with respect to whether St. Catherine's or Horizon 
had constructive notice of the air conditioner's disrepair.  
Hofflander, 247 Wis. 2d 636, ¶31.  However, since we conclude 
that no unsafe condition under the safe place statute existed 
independent of Hofflander's actions, our resolution of the 
notice issue is unnecessary to the disposition of this case. 
No. 00-2467 
 
 
56 
 
result.  But the liability will result from negligence under the 
custody and control doctrine, not negligence under the safe 
place statute.  Cf. Deaton, 265 Wis. at 353 ("The safe-place 
statute has no application to such acts of operation, and the 
issue of the crane operator's negligence should have been 
submitted to the jury on the basis of common-law negligence.").  
Therefore, Hofflander's appropriate theory of liability falls 
within the general common law negligence domain, which merely 
gets Hofflander, and this court, back to where we started.  
¶101 In sum, we hold that § 101.11 does not apply to unsafe 
conditions caused by an injured party's own negligence or 
recklessness——even in the setting of a locked psychiatric ward.  
If 
a 
structure's 
alleged 
disrepair 
requires 
reckless 
or 
negligent conduct by the plaintiff to achieve injury to herself, 
then the initial disrepair may not be construed as having caused 
the injury.  Hofflander is precluded from recovering under her 
safe place claim as a matter of law, since her negligence——an 
unsafe act, not an unsafe condition——caused her injury. 
¶102 Given our preceding holding, the defendants need not 
succeed on their affirmative defense of trespass in order to bar 
Hofflander's safe place claim.  "As a general rule, when our 
resolution of one issue disposes of a case, we will not address 
additional issues."  Hull v. State Farm Mut. Auto. Ins. Co., 222 
Wis. 2d 627, 640 n.7, 586 N.W.2d 863 (1998).  Nonetheless, we 
feel compelled to address the court of appeals' handling of this 
issue. 
No. 00-2467 
 
 
57 
 
¶103 Property owners possess a lesser duty of care to 
trespassers upon their property than they do to employees, 
guests, or frequenters of their property.  See Prosser and 
Keeton on the Law of Torts § 58 at 397.  This lesser duty merely 
requires owners to refrain from willful, wanton, or reckless 
conduct directed towards the trespasser.  See Nalepinski v. 
Durner, 259 Wis. 583, 586, 49 N.W.2d 601 (1951); see also Wis 
JI——Civil 8025.  Since Hofflander has not alleged that the 
defendants 
willfully, 
wantonly, 
or 
recklessly 
caused 
her 
injuries, a finding that she was a trespasser while she was 
within Room 309, or while she was in the window of that room, 
would absolve the defendants from liability under the safe place 
statute.   
¶104 Hofflander was not an employee of the defendants.  She 
was not a "frequenter" if she was a trespasser, because 
trespassers are expressly excluded from the definition of 
"frequenter."  See Wis. Stat. § 101.01(06).35  As a result, if 
Hofflander were viewed as a trespasser while she was in Room 
309, she would fall outside the two classes of people allowed 
recovery under the safe place statute.  
                                                 
35 "'Frequenter' means every person, other than an employee, 
who may go in or be in a place of employment or public building 
under circumstances which render such person other than a 
trespasser." 
 
Wis. Stat. § 101.01(6) 
(emphasis 
added).  
Generally, the duties of an owner to a frequenter are those 
prescribed by the safe place act and the principles of common 
law negligence.  Monsivais v. Winzenried, 179 Wis. 2d 758, 764, 
508 N.W.2d 620 (Ct. App. 1993). 
No. 00-2467 
 
 
58 
 
¶105 Under Wisconsin law, a trespasser is "a person who 
enters or remains upon land in the possession of another without 
a privilege to do so created by the possessor's consent or 
otherwise."  Antoniewicz v. Reszczynski, 70 Wis. 2d 836, 843, 
236 N.W.2d 1 (1975) (adopting the Restatement (Second) of Torts 
§ 329 definition of trespasser).  Saint Catherine's and Horizon 
argue that Hofflander did not have expressed or implied 
permission to enter the room of another patient or to enter the 
windowsill from which she exited.  As a result, they maintain 
that she was acting as a trespasser at the time she was injured.  
See Grossenbach v. Devonshire Realty Co., 218 Wis. 633, 638, 261 
N.W.2d 742 (1935); McNally v. Goodenough, 5 Wis. 2d 293, 300-01, 
92 N.W.2d 890 (1958). 
¶106 Hofflander responds, and the court of appeals agreed, 
that a person involuntarily placed in a locked psychiatric unit 
may never, as a matter of law, be considered a trespasser.  
Hofflander, 247 Wis. 2d 636, ¶¶27-28.  The court of appeals 
reasoned that "psychiatric wards are often host to patients who 
are uncooperative, unpredictable and unable to assume the 
ordinary duty of self-care and protection.  They may be expected 
to enter areas that are forbidden and potentially hazardous."  
Id., ¶27. 
¶107 We do not dispute the court's description of the 
general nature of psychiatric wards and the expectancies of 
patients' actions therein.  However, we disagree that the legal 
effect of this characterization is to automatically eliminate 
No. 00-2467 
 
 
59 
 
Hofflander's ability to be a trespasser.  The court of appeals' 
adoption of this bright-line rule, stating that a person 
involuntarily committed to a psychiatric unit can never be a 
trespasser within that unit, is unwarranted.  Such a rule 
conflicts with this court's pronouncement in Jankee, reaffirmed 
today, that mentally ill persons have a duty to exercise 
ordinary reasonable care in their actions.  It also conflicts 
with the criminal law.36 
¶108 Wisconsin courts have previously refused to grant 
exceptions to the general rules of trespass based on the 
diminished mental capacity of the trespasser.  In Monsivais v. 
                                                 
36 Hofflander and the court of appeals make much of a 
hypothetical situation in which a mental patient gains access to 
an unlocked medicine cabinet.  According to the court of 
appeals: 
[I]f 
we 
were 
to 
follow 
the 
reasoning 
of 
St. 
Catherine's and Horizon, 
a patient who 
ingested 
quantities of drugs from an unlocked medicine cabinet 
would have no safe place claim because of his or her 
status as a trespasser.  It simply is not reasonable 
or sound public policy to absolve a hospital from safe 
place liability in such circumstances. 
Hofflander, 247 Wis. 2d 636, ¶27.  This statement was made in 
the context of rebutting the defendants' use of Hofflander's 
alleged trespasser status as an affirmative defense to the safe 
place claim.  We believe that invoking this hypothetical in the 
context of the safe place act is misplaced.  An unlocked 
medicine cabinet should be analyzed under common law negligence 
and, in the context of a case like this one, under the custody 
and control rule.  It is clearly foreseeable in a psychiatric 
ward that an accessible, unlocked medicine cabinet could be 
invaded by one of the patients.  The patient's status as a 
trespasser 
would 
have 
little 
effect 
on 
the 
caregiver's 
negligence. 
No. 00-2467 
 
 
60 
 
Winzenried, 179 Wis. 2d 758, 508 N.W.2d 620 (Ct. App. 1993), the 
court of appeals decided that a tavern's patron was a trespasser 
when, while searching for a restroom, he entered through an 
unlocked basement door into the basement stairs of the tavern.  
Id. at 769.  The court properly excluded from its legal calculus 
the fact that the injured party was severely inebriated.  Id. at 
762.  Likewise, this court has recognized the general rule "that 
children of tender age may be trespassers even though too young 
to be chargeable with contributory negligence."  Baumgart v. 
Spierings, 2 Wis. 2d  289, 293, 86 N.W.2d 413 (1957).  Although 
the doctrine of attractive nuisance often obviates a young 
child's status as trespasser, courts nonetheless recognize that 
they may have this status.  See Nechodomu v. Lindstrom, 273 Wis. 
313, 327, 77 N.W.2d 707 (1956).  The only valid concern when 
determining a plaintiff's status as a trespasser is whether, at 
the time of injury, the plaintiff has entered into an area of 
the premises that the plaintiff lacked a right, either as an 
employee or frequenter, to be present.  Subsumed within this 
decision is whether such right existed by express or implied 
consent to enter the area.  See Reddington v. Beefeaters Tables, 
Inc., 72 Wis. 2d 119, 124, 240 N.W.2d 363 (1976). 
¶109 Whether Hofflander was trespassing immediately before 
her injuries could not be decided as a matter of law at this 
time, as the parties continue to contest whether Hofflander had 
No. 00-2467 
 
 
61 
 
an implied invitation to enter the room of another patient.37  If 
such an implied invitation existed, then, at least with respect 
to Hofflander entering Room 309, she should be treated as a 
frequenter, not a trespasser.  Hofflander adds that, with 
respect to her entry into the windowsill, it is the safe place 
violation itself that created the means for trespass and, 
therefore, the hospital cannot reasonably expect to be absolved 
of safe place liability when the patient trespassed into the 
window.  At best, these are genuine issues of material fact for 
a jury to determine, and this principle is not to be deviated 
from merely because the trespass occurred within a hospital's 
psychiatric unit. 
¶110 In sum, a person involuntarily committed to a locked 
psychiatric 
unit 
may 
be 
deemed 
a 
trespasser 
under 
the 
appropriate circumstances.  The court of appeals erred in 
finding that, as a mater of law, Hofflander was not a trespasser 
when she was either in another patient's room or on the 
windowsill in that room.  However, since we conclude that 
Hofflander's own negligent conduct caused her injury, rather 
than 
the 
preexisting 
condition 
of 
the 
air 
conditioner, 
Hofflander's safe place act claim is barred irrespective of 
whether Hofflander is properly deemed a trespasser. 
VI. DISCOVERY OF JCAHO SURVEYS 
                                                 
37 Generally, where there is a genuine issue of fact as to 
whether a person had implied consent and is therefore a 
frequenter and not a trespasser, the resolution of that issue 
should be made by a jury.  See Wis JI——Civil 1901. 
No. 00-2467 
 
 
62 
 
¶111 Because this case must be remanded to determine 
factual questions related to the parties' negligence, we must 
also address Hofflander's cross-petition for review of a 
discovery matter. 
¶112 During 
pretrial 
discovery, 
Hofflander 
sought 
production of the records from site surveys conducted by the 
Joint 
Commission 
on 
Hospital 
Accreditation 
of 
Healthcare 
Organizations 
(JCAHO) 
regarding 
St. 
Catherine's 
Behavioral 
Services Unit.  Saint Catherine's refused to disclose these 
materials, asserting that the surveys were properly subject to 
privilege under Wis. Stat. § 146.38.38  The circuit court agreed 
                                                 
38 Wisconsin Stat. § 146.38 provides in the pertinent parts: 
(1m) No person who participates in the review or 
evaluation of the services of health care providers or 
facilities or charges for such services may disclose 
any information acquired in connection with such 
review or evaluation except as provided in sub. (3). 
(2) All organizations or evaluators reviewing or 
evaluating the services of health care providers shall 
keep a record of their investigations, inquiries, 
proceedings and conclusions.  No such record may be 
released to any person under s. 804.10(4) or otherwise 
except as provided in sub. (3).  No such record may be 
used in any civil action for personal injuries against 
the 
health 
care 
provider 
or 
facility; 
however, 
information, documents or records presented during the 
review or evaluation may not be construed as immune 
from discovery under s. 804.10(4) for use in any civil 
action merely because they were so presented.  Any 
person who testifies during or participates in the 
review or evaluation may testify in any civil action 
as to matters within his or her knowledge, but may not 
testify as to information obtained through his or her 
participation in the review or evaluation, nor as to 
any conclusion of such review or evaluation. 
No. 00-2467 
 
 
63 
 
with St. Catherine's and denied Hofflander's motion.  The court 
of appeals subsequently affirmed this order.  Hofflander, 247 
Wis. 2d 636, ¶36.  Hofflander renews her arguments and petitions 
this court to instruct the circuit court, upon remand, to permit 
discovery of the JCAHO surveys that predate her injuries. 
¶113 In most instances, discovery disputes remain within 
the circuit court's discretion.  See Braverman v. Columbia 
Hosp., Inc., 2001 WI App 106, ¶11, 244 Wis. 2d 98, 629 N.W.2d 66 
(citing Franzen v. Children's Hosp. of Wis., 169 Wis. 2d 366, 
376, 485 N.W.2d 603 (Ct. App. 1992)).  Appellate courts will 
uphold a discretionary decision if the circuit court applied the 
relevant law to the facts of record while using a process of 
logical reasoning.  Id.  However, when a circuit court's 
discretionary ruling is based upon an error of law, the court 
has erroneously exercised its discretion.  Id.  The correct 
meaning of § 146.38, including its proper scope, presents a 
question of law, which this court reviews de novo.  See State ex 
rel. Badke v. Greendale Vill. Bd., 173 Wis. 2d 553, 569, 494 
N.W.2d 408 (1993). 
                                                                                                                                                             
Wis. Stat. § 146.38.  Subsection (3) of § 146.38 provides for 
limited circumstances in which disclosure shall occur, none of 
which are applicable in the present case. 
No. 00-2467 
 
 
64 
 
¶114 Hofflander contends that the JCAHO surveys provide 
information relevant to her claims39 and that they are not 
properly privileged under § 146.38.  According to Hofflander, 
the survey materials are exempt from privilege because the 
surveys were conducted by an outside agency that is unrelated to 
St. Catherine's and because the surveys were undertaken prior to 
the incident generating her injuries, not in response to it.  
¶115 Hofflander's first basis for compelling disclosure, 
that JCAHO is not the kind of organization covered by the 
statute, is unsupported by the statute's plain language as well 
as prior case law interpreting the term "organizations" under 
the statute.  Although there is no definition of "organization" 
in § 146.38, an entity constitutes an organization when it is 
determined to have at least some of the attributes commonly 
understood 
for 
that 
term; 
namely, 
a 
relatively 
constant 
membership, a body of officers, a purpose, and a set of 
regulations.  Frazen, 169 Wis. 2d at 379-80.  Hofflander directs 
this court to State ex rel. Good Samaritan Medical Center v. 
Moroney, 123 Wis. 2d 89, 365 N.W.2d 887 (Ct. App. 1985), for the 
proposition that decisions made by entities "one step removed" 
                                                 
39 Hofflander 
notes 
that 
these 
site 
surveys 
review 
conformity to a facility's policies and procedures, which she 
claims 
were 
not 
followed 
by 
the 
defendants 
and 
thereby 
contributed to her injuries.  Hofflander also asserts that these 
materials may overcome the defendants' claim that they did not 
have any notice of environmental defects within the Unit.  While 
some information within these records may be probative of 
Hofflander's claims, the issue disputed is one of privilege, not 
relevancy. 
No. 00-2467 
 
 
65 
 
from the actual peer review process are not privileged.  Id. at 
99.  Moroney held that conclusions by a hospital's own governing 
body are not privileged under § 146.38, since they were based on 
a peer review process independently conducted by internal review 
committees.  Id. at 100.40  
¶116 We conclude that JCAHO is the type of organization 
contemplated under Wis. Stat. § 146.38(2).  In the present case, 
the JCAHO survey materials constitute the record of the peer 
review evaluation.  As the court of appeals has previously 
stated, "that statute clearly envisions entities beyond the 
health care provider itself participating in the review and 
evaluation process."  Braverman, 244 Wis. 2d 98, ¶31 (holding 
that reports generated by a Wisconsin Department of Health and 
Family Services review of a private hospital's quality assurance 
system were privileged).  The type of review performed by the 
JCAHO for St. Catherine's is well within the ambit of § 146.38's 
protections. 
¶117 Similarly, 
Hofflander's 
assertion 
that 
§ 146.38 
governs only reviews and evaluations of health care provider 
services 
addressing 
specific, 
prior 
incidents 
is 
simply 
unfounded.  Hofflander reaches this conclusion because the 
                                                 
40 In particular, the disputed discovery in Moroney was 
primarily over written applications for reappointment submitted 
by a staff physician and over an inquiry into whether the 
hospital had ever limited that doctor's medical privileges, 
which were based on review and recommendation by a credentials 
committee.  State ex rel. Good Samaritan Med. Ctr. v. Moroney, 
123 Wis. 2d 89, 97-100, 365 N.W.2d 887 (Ct. App. 1985). 
No. 00-2467 
 
 
66 
 
review undertaken by the Department of Health and Family 
Services (Department) in Braverman happened to be in response to 
the 
hospital's 
specific 
concerns 
over 
certain 
infections 
following surgery.  Id., ¶7.  However, the reactive nature of 
that review was not dispositive of the dispute over privilege.  
Rather, the court anchored its holding on a rejection of 
Braverman's contention that other statutes, which related to the 
Department's duties to publicly disseminate its investigations 
of diseases, essentially preempted the otherwise applicable 
force of § 146.38.  Id., ¶29-31.  There was no dispute in 
Braverman as to the circuit court's application of Franzen and 
Mallon v. Campbell, 178 Wis. 2d 278, 504 N.W.2d 357 (Ct. App. 
1993), to find that the Department's materials from the 
investigation were properly privileged under § 146.38. 
¶118 In addition, Hofflander's attempt to employ the facts 
of Braverman to create an artificial distinction is based on a 
misconstruction of the language of the statute.  The privilege 
afforded under § 146.38(2) applies to records produced from the 
"investigations, inquiries, proceedings and conclusions" of 
reviewing 
organizations. 
 
Wis. Stat. § 146.38(2). 
 
These 
materials are distinguishable from information presented to 
evaluators 
during 
a 
review 
and 
from 
matters 
within 
the 
No. 00-2467 
 
 
67 
 
evaluators' own knowledge.  Franzen, 168 Wis. 2d at 377-78.41  
These latter two sets of information, which are not privileged, 
are not distinguished by the timing of their creation, but by 
the source of their production.  Hofflander seeks the JCAHO 
reports presented to the hospital containing the organization's 
conclusions from its review, not the records presented by St. 
Catherine's to aid the review.  It is only the latter type of 
information 
that 
would 
be 
exempt 
from 
privilege 
under 
§ 146.38(2).  Id. at 377-78. 
¶119 Finally, we decline to read into § 146.38 unstated 
limitations on the privileged nature of materials under the 
statute.  The purpose of JCAHO reports is to enable hospitals to 
improve their services above the minimum levels set by the 
state.  The reports are "the record of a health care review 
program organized and operated to help improve the quality of 
health care."  See Moroney, 123 Wis. 2d at 97.  The evaluations 
go to the core of why protection is afforded under the statute.  
"[Wisconsin] Stat. § 146.38 was 'enacted to protect the 
                                                 
41 Franzen established the framework for determining whether 
a party can assert privilege under § 146.38(2).  First, a court 
must determine whether the disputed materials are (1) records of 
investigations, inquiries, proceedings and conclusions; (2) 
information, documents or records presented during the review; 
or (3) matters within a person's knowledge.  Franzen v. 
Children's 
Hosp. 
of 
Wis., 
169 
Wis. 2d 366, 
377-78, 
485 
N.W.2d 603 (Ct. App. 1992).  It is only the first category of 
materials that is privileged from discovery under § 146.38, id. 
at 378, and, therefore, circuit courts must make findings 
distinguishing between category (1) and categories (2) and (3).  
See Braverman v. Columbia Hosp., Inc., 2001 WI App 106, ¶17, 244 
Wis. 2d 98, 629 N.W.2d 66. 
No. 00-2467 
 
 
68 
 
confidentiality of the peer review process,' and to promote 
frank discussion among physicians to improve the overall quality 
of services they provide."  Hofflander, 247 Wis. 2d 636, ¶34 
(quoting Moroney, 123 Wis. 2d at 98).  To permit discovery of 
these materials would subvert the central purpose of § 146.38 
and its counterpart statute, Wis. Stat. § 146.37,42 which is to 
encourage hospitals to perform quality-control reviews aimed at 
improving, 
prospectively, 
their 
services. 
 
Moroney, 
123 
Wis. 2d at 98; see also Hofflander, 247 Wis. 2d 636, ¶36 
("Wisconsin Stat. § 146.38 is designed to encourage candid and 
voluntary 
studies 
and 
programs 
used 
to 
improve 
hospital 
conditions and patient care.").  Limiting § 146.38's privilege 
to evaluations undertaken after a mishap and directed to that 
mishap would be a destructive policy not intended by the 
legislature. 
¶120 For the foregoing reasons, we agree with the court of 
appeals that the JCAHO is an organization that performs 
                                                 
42 Wisconsin Stat. § 146.37 provides civil immunity for 
participants involved in such review and evaluation, stating in 
part: 
Except as provided in s. 153.85, no person acting 
in good faith who participates in the review or 
evaluation of the services of health care providers or 
facilities or the charges for such services conducted 
in connection with any program organized and operated 
to help improve the quality of health care . . . is 
liable for any civil damages as a result of any act or 
omission by such person in the course of such review 
or evaluation. 
Wis. Stat. § 146.37(1g). 
No. 00-2467 
 
 
69 
 
functions equivalent to a peer review committee and that it 
provides information concerning how hospitals may improve their 
health care services.  Hofflander, 247 Wis. 2d 636, ¶36.  
Accordingly, we concur with the court of appeals' affirmance of 
the circuit court's ruling that the JCAHO materials are immune 
from disclosure to Hofflander, pursuant to § 146.38. 
VII. CONCLUSION 
¶121 We hold that genuine issues of material fact exist 
regarding whether the defendants knew or should have foreseen 
Hofflander's risk of elopement from the hospital.  We also hold 
that, if this risk was foreseeable and some evidence of 
negligence by the defendants existed with respect to their duty 
to protect against that risk, then any contributory negligence 
on behalf of Hofflander must be measured under a subjective duty 
of self-care. 
¶122 We also hold that Hofflander is barred from recovering 
under her safe place claim because her own negligence created 
the unsafe condition in Room 309.  The premises itself was not 
unsafe under the safe place statute.  In addition, we expressly 
reject the proposition that a person involuntarily committed to 
a locked psychiatric unit may never be considered a trespasser 
anywhere within that unit.  Finally, we conclude that the JCAHO 
site surveys conducted for St. Catherine's are privileged, 
undiscoverable materials under Wis. Stat. § 146.38. 
 
No. 00-2467 
 
 
70 
 
 
By the Court.—The decision of the court of appeals is 
affirmed in part and reversed in part, and the cause is remanded 
to the circuit court for proceedings consistent with this 
opinion. 
 
 
No.  00-2467.ssa 
 
1 
 
 
¶123 SHIRLEY S. ABRAHAMSON, CHIEF JUSTICE   (concurring).  
I agree with the majority opinion that the cause must be 
remanded to the circuit court.  I also agree with much of the 
majority 
opinion's 
analysis 
about 
a 
defendant 
caregiver's 
standard of care when it has custody and control over another 
person.   
¶124 I write separately to make three points.  First, I 
believe it is a mischaracterization to describe a defendant 
caregiver's standard of care in situations of custody and 
control as a heightened duty.  The duty is simply to exercise 
ordinary (reasonable) care under the circumstances.  Second, and 
most importantly, I disagree with the majority opinion's 
conclusion that a plaintiff under a defendant caregiver's 
custody and control can be contributorily negligent when the 
risk of harm is foreseeable.  Third, I urge this court to adopt 
the 
rule 
accepted 
in 
many 
jurisdictions 
and 
extend 
the 
subjective standard to all other cases in which a defense of 
contributory negligence is raised against a mentally ill 
plaintiff.  
I. STANDARD OF CARE FOR CAREGIVER WITH CUSTODY AND CONTROL 
¶125 The 
majority opinion 
concludes that 
a 
defendant 
caregiver with custody and control over a plaintiff will be 
liable 
for 
a 
plaintiff's 
self-inflicted 
injuries 
if 
the 
plaintiff can show: (1) a special relationship existed between 
the parties amounting to custody and control; (2) the particular 
risk of harm was foreseeable; and (3) there was some failure of 
No.  00-2467.ssa 
 
2 
 
care on the part of the defendant.43  Adhering to Jankee, the 
majority opinion states that this custody and control rule is an 
exception to standard negligence law because it contemplates the 
possibility of a heightened duty of care for a defendant.44  I 
would not state the standard of care in this way.   
¶126 I conclude that the rule in Wisconsin is that there is 
one standard of care, and the standard of care in each case is 
to exercise ordinary care under the circumstances.45  Thus, a 
defendant caregiver who has assumed responsibility for a 
mentally 
disabled 
person 
and 
knows 
or 
should 
know 
the 
proclivities and capacities of that person must exercise 
ordinary care to prevent foreseeable harm (or a particular risk 
of harm, as the majority opinion states).46  As the court stated 
in Kujawski v. Arbor View Health Care Ctr., 139 Wis. 2d 455, 
                                                 
43 Majority op., ¶62. 
44 Majority op., ¶46. 
45 Osborne v. Montgomery, 203 Wis. 223, 233, 234 N.W. 372 
(1931).  The court stated in that case: 
From a multitude of cases and a long consideration of 
this 
entire 
field, 
courts 
have 
arrived 
at 
the 
conclusion that in the absence of a standard declared 
by statute or previous decision, before liability can 
be predicated upon the acts of the defendant, it must 
appear that he has failed to exercise that degree of 
care which the great mass of mankind exercises under 
the same or similar circumstances, which is usually 
designated "ordinary care."  
See also Wis JI——Civil 1005 ("A person is negligent when 
(he)(she) fails to exercise ordinary care.  Ordinary care is the 
care 
which 
a 
reasonable 
person 
would 
use 
in 
similar 
circumstances."). 
46 Majority op., ¶50-54. 
No.  00-2467.ssa 
 
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462-63, 407 N.W.2d 249 (1987): "The general rule in Wisconsin is 
that a hospital must exercise such ordinary care as the mental 
and physical condition of its patients, known or should have 
been known, may require."47  This standard includes ordinary care 
to prevent the patient from harming herself by her own acts or 
in escaping if the risk of harm is foreseeable.48 
¶127 For example, a defendant caregiver who knows or should 
know that the protected person is suicidal or will try to escape 
must exercise ordinary care to prevent the foreseeable harm 
resulting from suicide or escape.  If the caregiver exercises 
ordinary care under these circumstances (ordinarily a question 
of fact), the caregiver is not negligent.49   
II. CONTRIBUTORY (COMPARATIVE) NEGLIGENCE  
OF THE PROTECTED PERSON 
¶128 The majority opinion also concludes that a defendant-
caregiver found liable under its three-part test may assert the 
affirmative defense of the plaintiff's contributory negligence.50  
                                                 
47 See 
also 
Cramer 
v. 
Theda 
Clark 
Mem. 
Hosp., 
45 
Wis. 2d 147, 149, 172 N.W.2d 427 (1969); Dahlberg v. Jones, 232 
Wis. 6, 11, 285 N.W.2d 841 (1939); Boles v. Milwaukee County, 
150 Wis. 2d 801, 808, 443 N.W.2d 679 (Ct. App. 1989); see also 
Wis JI——Civil 1385.5 ("Negligence: Hospital: Duty of Employees: 
Suicide or Injury Resulting from Escape or Attempted Suicide") 
("Reasonable care is that care which a person of ordinary 
intelligence and prudence would provide under the same or 
similar circumstances considering the patient's physical and 
mental condition."). 
48 See Klein v. BIA Hotel Corp., 49 Cal. Rptr. 2d 60, 64 
(Ct. App. 1996); see also Tomfohr v. Mayo Found., 450 N.W.2d 
121, 124 (Minn. 1990). 
49 Majority op., ¶60.  
50 Majority op., ¶36. 
No.  00-2467.ssa 
 
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That is, the majority opinion compares the negligence of the 
protected person (a subjective test to determine whether the 
standard of ordinary care for one's own protection was breached) 
with the negligence of the caregiver (an objective test to 
determine whether the caregiver breached its standard of 
ordinary care under part I above).51  I disagree with this 
conclusion. 
¶129 I 
believe 
that 
contributory 
negligence 
is 
not 
attributable to the protected person under these circumstances.  
Rather, I conclude, as did the Jankee majority and dissenting 
opinions, 
that the 
caregiver's responsibility 
to exercise 
ordinary care for a foreseeable risk of harm "may absolve the 
protected person from the ordinary obligation of self-care, 
shift responsibility to the caregiver, and thereby expunge the 
affirmative duty of contributory negligence."52 
¶130 Professor Charles F. Williams, in his article Fault 
and the Suicide Victim: When Third Parties Assume a Suicide 
                                                 
51 The majority opinion states: 
[T]here will be situations in which a mentally 
disabled person is as able to appreciate danger as any 
other person and is able to control her actions.  When 
such a person persists in pursuing dangerous and 
seemingly irrational conduct, the person's duty of 
self-care should be judged on a subjective standard 
and compared with the defendant's duty of care. 
Majority op., ¶62. 
52 Jankee v. Clark County, 2000 WI 64, ¶92, 235 Wis. 2d 700, 
612 N.W.2d 297; see also Wis JI——Civil 1385.5  Comment; Wis JI——
Civil 1021 ("Negligence of Mentally Disabled") Comment ("Duty of 
Caregiver") (quoting this language and citing Jankee).   
No.  00-2467.ssa 
 
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Victim's Duty of Self-Care, 76 Neb. L. Rev. 301, 315 (1997), 
(upon which the majorities here and in Jankee rely), explains 
that when a caregiver has assumed custody and control of a 
protected person and knows (or should know) of the risk of harm 
to that protected person (e.g., suicide), the caregiver has 
assumed 
the 
protected 
person's 
duty 
of 
self-care. 
 
The 
reasonableness of the protected person's conduct in causing the 
foreseeable harm, whether measured by a subjective or objective 
standard, is therefore irrelevant and has no effect on the 
defendant's negligence.53  Contributory negligence, according to 
Professor Williams, is no defense for the caregiver.  I agree. 
¶131 Courts in other jurisdictions have similarly concluded 
that a protected person's "contributory negligence" plays no 
role under the described circumstances.  The Minnesota Supreme 
Court, for example, has explained that comparative fault is 
duplicative when the fact finder is asked to determine whether 
                                                 
53 Charles F. Williams, Fault and the Suicide Victim: When 
Third Parties Assume a Suicide Victim's Duty of Self-Care, 76 
Neb. L. Rev. 301, 313, 318 (1997) (plaintiff’s contributory 
negligence is irrelevant); see also Susan O'Neal, Contributory 
Negligence in Medical Malpractice: Recent Application in the 
Context of Suicidal Patient, 69 Miss. L.J. 925, 941 (1999); 
Daniel W. Berglund, Note, Torts: Taking the "I" Out of Suicide: 
The Minnesota Supreme Court's Alarming Extension of Duty in 
"Exceptional Relationships"—Sandborg v. Blue Earth County, 28 
Wm. Mitchell L. Rev. 1307, 1318-19, 1322 (2002). 
For cases applying this reasoning, see, e.g., Winger v. 
Franciscan Med. Ctr., 701 N.E.2d 813, 818-20 (Ill. Ct. App. 
1998); Tomfohr, 450 N.W.2d at 125; Cowan v. Doering, 545 A.2d 
159, 167 (N.J. 1988);  Hunt v. King County, 481 P.2d 593, 598 
(Wash. Ct. App. 1971). 
No.  00-2467.ssa 
 
6 
 
the harm incurred was reasonably foreseeable by the caregiver.54  
Or to put it another way, if the caregiver breaches the standard 
of care, it means the risk of harm is foreseeable and the fact 
that the protected person might have contributed to the injury 
through negligence or even intentional conduct does not change 
the caregiver's negligence.  
¶132 Moreover, this approach is in keeping with our 
previous cases recognizing that a patient's duty to exercise 
ordinary care in a patient-doctor relationship is extremely 
limited.  "[T]he very patient-doctor relation assumes trust and 
confidence on the part of the patient and would require an 
unusual set of facts to render a patient guilty of contributory 
negligence when the patient relies on the doctor."55   
¶133 The majority opinion does not adequately explain why 
it is departing from Jankee, from Professor Williams, and from 
case law.  Professor Williams describes the majority's approach 
as confused.56  I do too. 
III. SUBJECTIVE STANDARD OF CONTRIBUTORY NEGLIGENCE  
                                                 
54 Sandborg v. Blue Earth County, 615 N.W.2d 61, 65 (Minn. 
2000); Tomfohr, 450 N.W.2d at 125. 
55 Brown v. Dibbel, 227 Wis. 2d 28, 48-49, 595 N.W.2d 358 
(1999).  
In cases in which the patient is negligent after the 
doctor's 
negligent 
treatment 
was 
administered, 
the 
later 
negligence is not contributory negligence that bars the action 
but goes to mitigation of damages.  Schulz v. Tasche, 166 Wis. 
561, 564-65, 165 N.W. 292 (1917). 
56 Williams, supra note 53, at 307 (permitting defense of 
contributory negligence in cases of custody and control does not 
deter unreasonable conduct, which is the goal of tort law). 
No.  00-2467.ssa 
 
7 
 
IN OTHER CIRCUMSTANCES 
¶134 I agree with the majority opinion that when the risk 
of harm in a case in which a caregiver has custody and control 
over 
a 
protected 
person 
is 
not 
foreseeable 
under 
the 
circumstances, the caregiver who has custody and control owes a 
protected person the same duty of care that it owes to any and 
all people.57  Under these circumstances, the affirmative defense 
of contributory negligence reenters the equation.58   
¶135 I disagree with the majority opinion, however, when it 
concludes that the protected person's contributory negligence 
should, under these circumstances, be measured by an objective 
standard.59  I would follow the majority trend under these 
circumstances (as I did in my Jankee dissent) and measure the 
protected person's contributory negligence by a subjective 
standard.60 
¶136 For the reasons set forth, I agree with remanding the 
cause to the circuit court but disagree with the majority 
opinion's approach to the "negligence" of the protected person. 
                                                 
57 Majority op., ¶¶48, 49, 55-57.  
58 Majority op., ¶¶31, 65.  
59 Majority op., ¶35. 
60 Jankee, 
235 
Wis. 2d 700 
¶¶116-17 
(Abrahamson, 
C.J., 
dissenting); Williams, supra note 53, at 315. 
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8 
 
¶137 I am authorized to state that Justice ANN WALSH 
BRADLEY joins this concurrence.   
 
No.  00-2467.ssa 
 
 
 
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