Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca9-14-17050/USCOURTS-ca9-14-17050-0/pdf.json

Nature of Suit Code: 370
Nature of Suit: Other Fraud
Cause of Action: 

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FOR PUBLICATION

UNITED STATES COURT OF APPEALS

FOR THE NINTH CIRCUIT

PACIFIC RADIATION ONCOLOGY,

LLC, a Hawai’i limited liability

corporation; PRO ASSOCIATES, LLC,

a Hawai’i limited liability company;

JOHN LEDERER, M.D., individually

and as manager of the LLC’s

appearing for the Pacific Radiation

Oncology Physicians; LAETON

PANG, M.D.; EVA BIENIEK, M.D.;

VINCENT BROWN, M.D.; PAUL

DEMARE, M.D.; THANH HUYNH,

M.D.,

Plaintiffs-Appellants,

JOHN AND MARY DOE, 1 through 17,

Appellant-Intervenor,

v.

THE QUEEN’S MEDICAL CENTER, a

Hawai’i non-profit corporation;

QUEEN’S DEVELOPMENT CORP., a

Hawai’i for profit corporation;

NOREEN D.S.W. MOKUAU; WILLIAM

G. OBANA, M.D.; ARTHUR A.

USHIJIMA; MARK H. YAMAKAWA;

PAULA YOSHIOKA; SHARLENE K.

TSUDA; RICHARD C. KEENE;

CLINTON YEE; NALEEN M.

No. 14-17050

D.C. No.

1:12-cv-00064-

LEK-KSC

OPINION

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2 PAC. RADIATION ONCOLOGY V. QUEEN’S MED. CTR.

ANDRADE, M.D.; ERNEST H.

FUKEDA, JR.; ROBB OHTANI, M.D.;

NEIL J. HANNAHS; CHRISTINE M.

GAYAGAS; PETER K. HANASHIRO;

ROBERT K. NOBRIGA; ERIC K.

YEAMAN; JULIA C. WO; CAROLINE

WARD ODA; PETER HALFORD, M.D.;

BARRY WEINMAN, individually and

in their capacities as Officers and

Trustees of Queen’s Medical Center,

Defendants-Appellees.

Appeal from the United States District Court

for the District of Hawaii

Leslie E. Kobayashi, District Judge, Presiding

Argued and Submitted

October 15, 2015—Honolulu, Hawaii

Filed December 22, 2015

Before: Diarmuid F. O’Scannlain, Richard C. Tallman,

and Milan D. Smith, Jr., Circuit Judges.

Opinion by Judge Tallman

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PAC. RADIATION ONCOLOGY V. QUEEN’S MED. CTR. 3

SUMMARY*

Civil Procedure

The panel affirmed the district court’s denial of injunctive

relief sought by Pacific Radiation Oncology, LLC against

The Queen’s Medical Center.

Pacific Radiation Oncology, consisting of a group of

physicians specializing in radiation oncology, sued the

Queen’s Medical Center alleging unfair trade practices. 

During discovery, Pacific Radiation Oncology sought

injunctive relief against the Queen’s Medical Center alleging

that the Center’s review and use of patient records during

litigation violated the Health Insurance Portability and

Accountability Act of 1996, 42 U.S.C. § 1320d, and the

Hawaii Constitution art. 1, § 6. 

The panel held that the district court did not abuse its

discretion in denying Pacific Radiation Oncology’s motion

for a temporary restraining order or in the alternative for a

preliminary injunction. The panel followed the Eighth

Circuit and adopted the rule of Devose v. Herrington, 42 F.3d

470, 471 (8th Cir. 1994), which established that there must

exist a relationship between the injury claimed in a motion

for injunctive relief and the conduct alleged in the underlying

complaint. The panel held that in this case there was not a

sufficient nexus between Pacific Radiation Oncology’s claim

of injury to patients’ privacy in its motion for injunctive relief

* This summary constitutes no part of the opinion of the court. It has

been prepared by court staff for the convenience of the reader.

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and the unfair trade practice claims in its underlying

complaint.

COUNSEL

Clare E. Connors (argued), Mark S. Davis, and Michael K.

Livingston, Davis Levin Livingston, Honolulu, Hawaii, for

Plaintiffs-Appellants.

Jerry M. Hiatt (argued), and Mahilani E.K. Hiatt, Hiatt &

Hiatt, Honoka’a, Hawaii, for Appellant-Intervenor.

Paul Alston (argued), William S. Hunt, Clyde J. Wadsworth,

and Claire Wong Black, Alston Hunt Floyd & Ing, Honolulu,

Hawaii; Daniel M. Mulholland III, Horty, Springer &

Mattern, P.C., Pittsburgh, Pennsylvania, for DefendantsAppellees.

OPINION

TALLMAN, Circuit Judge:

A court’s equitable power lies only over the merits of the

case or controversy before it. When a plaintiff seeks

injunctive relief based on claims not pled in the complaint,

the court does not have the authority to issue an injunction. 

During discovery of its unfair trade practices case, Appellant

Pacific Radiation Oncology, LLC (PRO) sought injunctive

relief against Appellee The Queen’s Medical Center (QMC)

arguing that QMC’s review and use of patient records

violated the Health Insurance Portability and Accountability

Act of 1996 (HIPAA), 42 U.S.C. § 1320d, and the Hawaii

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PAC. RADIATION ONCOLOGY V. QUEEN’S MED. CTR. 5

Constitution art. 1, § 6. The district court denied the

injunction because PRO’s complaint did not contain a claim

alleging improper review and use of confidential patient

information in violation of HIPAA and the Hawaii

Constitution. We affirm.

I

To understand the motion that is the subject of this

appeal, it is necessary to describe the deterioration of a nearly

forty-year professional relationship between PRO and QMC

and the extended litigation that occurred as a result.

A

PRO consists of a group of physicians specializing in

radiation oncology. PRO provided service to its patients at

QMC, and at one of QMC’s competitors, The Cancer Center

of Hawaii (TCCH), in which some PRO members held a

financial interest. But QMC is the only facility on Oahu with

an operating room licensed by the Nuclear Regulatory

Commission (NRC) for specialized radiation services to treat

cancer. During the course of their nearly forty-year

relationship, PRO physicians were allowed to meet with and

treat their patients at QMC in order to accommodate patient

preferences in choosing the location of treatment. However,

this relationship ended in 2011 when QMC decided to

transition to a closed-facility model. As a result, PRO

physicians could not practice at QMC at all unless they

accepted exclusive employment with QMC and divested any

interest they held in TCCH. PRO physicians, therefore,

would no longer retain hospital privileges that allowed access

to the NRC-licensed operating room which they used to treat

certain patients.

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In January of 2012 PRO brought suit against QMC

alleging that adopting the closed-facility model was merely

a pretext to prevent PRO physicians from competing with

QMC. The complaint filed against QMC alleged ten claims

for relief: (1) denial of procedural and substantive due

process; (2) violation of QMC bylaws and governing

regulations; (3) intentional tortious interference with

plaintiffs’ contractual obligations with competing facilities;

(4) intentional and tortious interference with prospective

business advantage; (5) intentional and tortious interference

with the professional and contractual relationship with

plaintiffs’ patients; (6) unfair, deceptive, anti-competitive,

and illegal trade practices in violation of Hawaii Revised

Statutes Chapter 480 arising out of QMC’s termination of

privileges; (7) unfair, deceptive, anti-competitive, and illegal

trade practices in violation of Chapter 480 arising out of

QMC’s violation of the anti-kickback statute; (8) unfair,

deceptive, anti-competitive, and illegal trade practices in

violation of Chapter 480 arising out of QMC’s attempt at

economic credentialing; (9) unfair, deceptive, anticompetitive, and illegal trade practices in violation of Chapter

480 arising out of QMC’s breach of its obligations under its

corporate integrity agreement between the Office of the

Inspector General of the U.S. Department of Health and

Human Services; and (10) breach of fiduciary duty and bad

faith owed to a partner. PRO initially requested injunctive

relief and damages related only to the termination of hospital

privileges.

In March 2012 the district court granted a preliminary

injunction to allow PRO physicians to continue treating

patients who needed access to the NRC-licensed operating

room at QMC. Pac. Radiation Oncology, LLC v. Queen’s

Med. Ctr., 861 F. Supp. 2d 1170 (D. Haw. 2012). In

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February 2014 we affirmed that preliminary injunction. Pac.

Radiation Oncology, LLC v. Queen’s Med. Ctr., 555 F. App’x

730 (9th Cir. 2014). Thereafter, QMC brought a

counterclaim against PRO alleging that PRO physicians were

unlawfully transferring patients from QMC to TCCH by

encouraging them to seek treatment there. Additionally,

QMC alleged that PRO physicians failed to inform patients

of their financial interests in TCCH when making these

referrals. Thus, QMC argues that it had a legitimate business

interest to move to a closed-facility model.

Prior to the commencement of litigation in 2012, QMC

administrators identified 133 relevant patients from the

hospital’s own electronic record-keeping system who had an

initial consultation with a PRO physician at QMC but did not

return to QMC for radiation therapy. After bringing its

counterclaim, QMC served a subpoena on TCCH seeking

documents and information regarding those patients. 

Included in this subpoena was a list of 132 of the 133

identified patients’ names, patient numbers, and treating

physicians. However, when QMC filed the return of service

with the district court clerk on Thursday, July 10, 2014, it

filed the subpoena on the public docket with the complete

unredacted list of patient names, numbers, and treating

physicians. Upon realizing its error, QMC counsel

immediately notified the magistrate judge overseeing

discovery, the clerk restricted access to the document the next

business day, Monday, July 14, 2014, and the court granted

QMC’s ex parte motion to seal the document. So far as can

be determined, only QMC’s attorneys accessed the document

through PACER while it was publicly available.

PRO then filed a motion for a temporaryrestraining order,

or alternativelya preliminaryinjunction. PRO challenged not

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only the public filing of the patient list, but also QMC’s right

to review its own medical records that were the basis of the

list, and PRO sought to preclude QMC’s review of the

records sought from TCCH in the subpoena. PRO alleges

that QMC’s conduct violates HIPAA and the Hawaii

Constitution.

B

The district court denied PRO’s motion for injunctive

relief. It concluded that PRO’s complaint “does not contain

a claim alleging improper review and use of confidential

patient information in violation of HIPAA and the Hawaii

Constitution.” Pac. Radiation Oncology, LLC v. Queen’s

Med. Ctr., 47 F. Supp. 3d 1069, 1076 (D. Haw. 2014). The

court rejected PRO’s arguments that the claims for violation

of patient privacy are part of its Hawaii Revised Statutes

Chapter 480 claims because the allegations in those claims

did not refer to improper review and use of patient

information. Id. Acknowledging the seriousness of the

public disclosure, the court nonetheless held that the motion

“simply does not fit within the TRO [temporary restraining

order] analysis.” Id.

The district court then construed the motion as ultimately

presenting a discovery issue. Id. Specifically, the court

found that QMC had violated the terms of a previously

entered protective order when it publicly disclosed

identifiable patient information. Id. at 1078. For that

violation, the district court sanctioned QMC with PRO’s

reasonable attorneys’ fees and costs incurred in responding to

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the public filing.

1

Id. at 1080. To the extent that QMC

argued that its use of patient information was relevant to its

defenses and counterclaims against PRO, the district court

instructed the parties to confer on how to access this

information in compliance with the protective order, HIPAA,

and the Hawaii Constitution through the normal discovery

process overseen by the magistrate judge. Id. at 1081.2

PRO appealed the district court’s denial of injunctive

relief. We have jurisdiction under 28 U.S.C. § 1292(a)(1) to

review PRO’s appeal of that order.

1 The court reserved calculating the final amount to be awarded pending

the outcome of this appeal.

2 The magistrate judge found the information relevant to QMC’s claims

and defenses and held that if the patient information was deidentified it

would comply with HIPAA and the Hawaii Constitution. HIPAA clearly

allows for deidentification but it is unclear whether deidentification is

sufficient to comply with the more stringent privacy requirements

mandated by the Hawaii Constitution. When PRO appealed the magistrate

judge’s order, the district court reserved ruling on the issue and certified

questions to the Hawaii Supreme Court to resolve the state law legal

issues. Pac. Radiation Oncology, LLC v. Queen’s Med. Ctr., No. 12-

00064-LEK-KSC, 2015 WL 419654, at *11 (D. Haw. Jan. 30, 2015). The

first certified question is of particular relevance to this appeal, asking:

“[m]ay a third party who is in lawful possession of a patient’s confidential

medical records use, or be compelled to produce, these records in

litigation where the patient is not a party?” Certified Questions to the

Hawaii Supreme Court From the United States District Court for the

District of Hawaii at 8, Pac. Radiation Oncology, LLC v. Queen’s Med.

Ctr., No. 12-00064-LEK-KSC (2015), ECF No. 541. This question

addresses both QMC’s use of its own patient records and whether QMC

can request relevant patient records from TCCH. Resolution of that

discovery issue does not affect the merits of the ruling denying injunctive

relief.

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II

We review a district court’s grant or denial of a

preliminary injunction for an abuse of discretion. Pimentel v.

Dreyfus, 670 F.3d 1096, 1105 (9th Cir. 2012). We employ a

two part test: first, determining whether the trial court

identified the correct legal rule to apply to the requested relief

and second, determining whether the court’s application of

that rule was illogical, implausible, or without support from

inferences that may be drawn from facts in the record. Id.

“A decision based on an erroneous legal standard or a clearly

erroneous finding of fact amounts to an abuse of discretion.” 

Id.

III

A

The district court’s denial of PRO’s motion was not an

abuse of discretion because the motion for relief was

unrelated to the underlying complaint. A preliminary

injunction is appropriate when it grants relief of the same

nature as that to be finally granted. De Beers Consol. Mines

v. United States, 325 U.S. 212, 220 (1945). We have yet to

adopt a formal test for comparing the relief sought in a

preliminary injunction with the final relief sought in the

original complaint. Other circuits, however, have enunciated

a rule requiring a plaintiff to “establish a relationship between

the injury claimed in the party’s motion and the conduct

asserted in the complaint.” Devose v. Herrington, 42 F.3d

470, 471 (8th Cir. 1994).

Devose is illustrative of the exactitude by which courts

evaluate whether a motion for injunctive relief is related to

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the underlying claim. Though new assertions of misconduct

might support additional claims against a defendant, they do

not support preliminary injunctions entirely unrelated to the

conduct asserted in the underlying complaint. See id. In

Devose, a prisoner brought a 42 U.S.C. § 1983 action against

prison officials for violating his Eighth Amendment rights. 

Id. The prisoner then sought injunctive relief claiming prison

officials retaliated against him for bringing his lawsuit. Id.

The court held that the prisoner’s motion for injunctive relief

based on retaliation by prison officials was entirely different

and separate from the underlying conduct challenged in the

§ 1983 action. Id. The Eighth Circuit therefore affirmed the

district court’s denial of injunctive relief. Id.

The rule of Devose is already being applied by the lower

courts of our circuit. See, e.g., Mitchell v. Haviland, No.

2:09-cv-3012 JAM KJN P, 2014 WL 458218 at *2 (E.D. Cal.

Feb. 4, 2014) (denying a motion for injunctive relief alleging

retaliation against a prisoner for filing a § 1983 action under

Devose because it claimed new assertions of misconduct in a

different prison by different prison employees); Padilla v.

Nevada, No. 3:08-cv-410-LRH(RAM), 2011 WL 2746653 at

*8 (D. Nev. June 3, 2011) (noting that the Ninth Circuit has

not directly addressed this issue and applying Devose in

denying injunctive relief based on violations of plaintiff’s

First Amendment rights when the underlying complaint

alleged Eighth Amendment violations).

Furthermore, many of our sister circuits have either

adopted Devose explicitly or independently formulated an

identical rule. See Colvin v. Caruso, 605 F.3d 282, 299–300

(6th Cir. 2010); Little v. Jones, 607 F.3d 1245, 1251 (10th

Cir. 2010); Omega World Travel, Inc. v. Trans World

Airlines, 111 F.3d 14, 16 (4th Cir. 1997); accord Kaimowitz

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v. Orlando, 122 F.3d 41, 43 (11th Cir. 1997); Stewart v. U.S.

I.N.S., 762 F.2d 193, 198–99 (2nd Cir. 1985).

Persuaded by the logic behind Devose’s rule and the

pervasive application of the rule both within the district

courts of our circuit and our sister circuits, we now formally

adopt the rule of Devose. We hold that there must be a

relationship between the injury claimed in the motion for

injunctive relief and the conduct asserted in the underlying

complaint. This requires a sufficient nexus between the

claims raised in a motion for injunctive relief and the claims

set forth in the underlying complaint itself. The relationship

between the preliminary injunction and the underlying

complaint is sufficiently strong where the preliminary

injunction would grant “relief of the same character as that

which may be granted finally.” De Beers Consol. Mines,

325 U.S. at 220. Absent that relationship or nexus, the

district court lacks authority to grant the relief requested.

B

Applying this rule here, PRO’s motion for injunctive

relief does not have a relationship or nexus to the underlying

complaint. Therefore the district court properly refused to

grant the relief requested. PRO’s motion for injunctive relief

is based on potential misconduct entirely unrelated to its

unfair trade practices claims. PRO’s complaint alleges

multiple claims against QMC for violations of due process,

unfair and illegal trade practices, and other state law claims. 

The complaint does not contain a claim for improper review

and use of confidential patient information in violation of

HIPAA and the Hawaii Constitution. PRO’s complaint

relates only to the retention of hospital privileges and

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collection of damages from unfair competition and related

theories.

Besides merely asserting that the claims are related or

incorporated into its complaint, PRO fails to explain how the

privacy claims underlying the motion for injunctive relief

relate to the unfair trade practices claims in its complaint. 

See Devose, 42 F.3d at 471. Instead, PRO relies on

generalized notice pleading requirements in an attempt to

justify how evidence of QMC’s privacy violations is relevant

to claims of unfair trade practices. We are not persuaded. 

QMC’s particular use of private patient medical information

may have some relevance to those claims. That use may have

contemporaneously violated HIPAA and the Hawaii

Constitution and might arguably support a new claim against

QMC by PRO or the patients whose privacy may have been

compromised.3See id. However, that does not turn PRO’s

claims of unfair trade practices into separate and distinct

claims that QMC violated HIPAA and the Hawaii

Constitution.4 Despite PRO’s arguments to the contrary,

PRO cannot point to any violation of privacy claims or any

conduct implicating a violation of patient privacy in its

complaint because there are none.

Finally, PRO itself admitted in the district court that its

motion for injunctive relief has nothing to do with the

3 We assume, but do not decide, that PRO has standing to assert the

privacy rights of its patients. Nor do we address whether HIPAA contains

a private right of action.

4 We are equally unpersuaded by PRO’s attempts at oral argument to

link by incorporation the claims of violation of patient privacy with their

claims of violation of QMC’s bylaws.

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underlying claim. Reply Mem. in Supp. of Pls.’ Mot. for

TRO or in the Alternative for Prelim. Inj. at 1, Pac. Radiation

Oncology, LLC v. Queen’s Med. Ctr., 47 F. Supp. 3d 1069

(2014) (No. 12-00064), ECF No. 260 (“The merit or lack of

merit of the claims and defenses of either party is not before

the Court.”). PRO is not asking for relief of the same nature

it may ultimately be granted in its lawsuit against QMC. See

De Beers Consol. Mines, 325 U.S. at 220. Instead, PRO is

seeking to enjoin QMC’s use of private patient information

— a remedy that will not be provided if PRO succeeds in its

underlying unfair trade practices suit.

Though the district court did not explicitly consider

Devose in denying PRO’s motion for injunctive relief, the

court properly denied the motion because it was unrelated to

the underlying complaint. The district court stated that PRO

could not prove the likelihood of success requirement of the

preliminaryinjunction analysis because the privacyviolations

alleged in the motion were not contained within the actual

complaint. Additionally, the district court correctly noted

that the issue presented in the motion “does not fit within the

TRO analysis” and properly denied injunctive relief. Though

the district court did not refer to Devose explicitly, it applied

the same analysis and came to the same legal conclusion. 

There was no abuse of discretion in denying PRO’s motion.

PRO might have sought leave to amend its complaint to

include a claim of violation of its patients’ privacy rights

under HIPAA and the Hawaii Constitution. Or PRO and its

patients might have brought a separate suit against QMC. 

PRO did neither. What we have before us is merely a

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discovery dispute in disguise as an interlocutory appeal.5

PRO cannot respond to QMC’s discovery request by seeking

injunctive relief unrelated to the claims set forth in the

underlying suit.

IV

We hold the district court did not abuse its discretion in

denying PRO’s motion for a temporary restraining order or in

the alternative for a preliminary injunction. We follow the

Eighth Circuit and adopt the rule of Devose — there must

exist a relationship between the injury claimed in a motion

for injunctive relief and the conduct alleged in the underlying

complaint. There was not a sufficient nexus between PRO’s

claim of injury to patients’ privacy in violation of HIPAA and

the Hawaii Constitution in its motion for injunctive relief and

the unfair trade practice claims in its underlying complaint. 

The district court properly ruled that PRO’s motion for

injunctive relief was unrelated to its underlying complaint. 

PRO cannot seek interim equitable relief of a nature it is not

seeking in the final adjudication of its lawsuit.

AFFIRMED.

5 A discovery dispute that will be resolved by the district court once it

receives guidance from the Hawaii Supreme Court.

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