Opinion filed September 12, 2019

In The

Eleventh Court of Appeals __________

No. 11-18-00353-CV

__________

AMANDA MARIE COCI AND HEART OF TEXAS EMS, INC., 

D/B/A HEART OF TEXAS EMS, Appellants

V.

APRIL DOWER, Appellee

On Appeal from the 35th District Court

Brown County, Texas

Trial Court Cause No. CV1801020

O P I N I O N

This is an accelerated interlocutory appeal in a personal injury lawsuit that 

April Dower filed against Amanda Marie Coci and Heart of Texas EMS, Inc., d/b/a 

Heart of Texas EMS. In the trial court, Appellants claimed that Dower’s lawsuit 

constituted a health care liability claim and moved to dismiss Dower’s suit 

because she failed to serve an expert report and curriculum vitae pursuant to 
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Section 74.351(a) of the Texas Medical Liability Act (TMLA). See TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351 (West 2017). The trial court denied the motion,

and this interlocutory appeal followed. We affirm.

In her lawsuit, Dower alleged that she was injured in a single vehicle accident

that occurred while her minor daughter was being taken from Abilene Regional 

Medical Center to Cook Children’s Medical Center in Fort Worth, where the child 

was to undergo a medical procedure. Dower’s daughter was being transported in a 

Heart of Texas ambulance. Amanda Marie Coci, a Heart of Texas EMS employee, 

was the driver of the ambulance. Dower accompanied her daughter in the 

ambulance; Dower was neither a patient nor a recipient of any care. While en route, 

the ambulance left the roadway and collided with the protective barrier in the median 

between the eastbound and westbound lanes of Interstate Highway 20.

Dower sued Appellants for negligence and gross negligence, seeking damages 

for injuries she allegedly suffered as a result of the incident. Dower’s daughter is 

not a party to this suit and did not assert any claims or seek any damages. Dower 

alleged that Coci fell asleep while driving, which allegedly caused the ambulance to 

leave the roadway and strike the barrier.

In the negligence cause of action, Dower alleged that Coci (1) failed to keep 

a proper outlook, (2) failed to turn the ambulance to avoid the collision, (3) failed to 

give adequate warning, (4) failed to adequately use the brakes, (5) drove at an unsafe 

speed, (6) failed to maintain a safe distance, (7) failed to maintain a single lane, and 

(8) failed to monitor oncoming traffic.

The issue in this appeal is whether Dower’s claims constitute health care 

liability claims under the TMLA. If so, then Dower was required to serve an expert 

report and curriculum vitae in accordance with Section 74.351(a) of the TMLA. 
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The TMLA defines a health care liability claim as: 

[A] cause of action against a health care provider or physician for 

treatment, lack of treatment, or other claimed departure from accepted 

standards of medical care, or health care, or safety or professional or 

administrative services directly related to health care, which 

proximately results in injury to or death of a claimant, whether the

claimant’s claim or cause of action sounds in tort or contract.

CIV. PRAC.&REM. § 74.001(a)(13). If Dower’s claims constitute health care liability 

claims, then the trial court should have granted the motion filed by Appellants and 

dismissed Dower’s claims with prejudice because she did not file or serve an expert 

report within 120 days of Appellants filing their original answer. See id. § 74.351(b). 

Whether a claim is a health care liability claim under the TMLA is a question 

of law that we review de novo. Scott v. Weems, 575 S.W.3d 357, 363 (Tex. 2019).

In our review, we focus on the underlying nature of the cause of action, not the label 

given to the claim in the pleadings. Id. (explaining that “a party cannot avoid 

Chapter 74’s requirements and limitations through artful pleading”); see also Tex. 

W. Oaks Hosp., LP v. Williams, 371 S.W.3d 171, 176 (Tex. 2012) (“In seeking to 

distinguish ordinary negligence claims from [health care liability claims], the heart 

of these cases lies in the nature of the acts or omissions causing claimants’ injuries 

and whether the events are within the ambit of the legislated scope of the TMLA.”).

Appellants argue that Dower’s claims implicate the “safety” prong of 

Section 74.001(a)(13). Since “safety” is not defined by the TMLA, the Texas 

Supreme Court defined the common meaning of “safety” as the “condition of being 

untouched by danger; not exposed to danger; secure from danger, harm or loss.”

Ross v. St. Luke’s Episcopal Hosp., 462 S.W.3d 496, 501 (Tex. 2015) (internal 

quotation marks omitted). The court further explained that a safety standards-based 

claim against a health care provider constitutes a health care liability claim under the 
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TMLA if there is “a substantive nexus between the safety standards allegedly 

violated and the provision of health care”; the alleged departure need not actually be 

“directly related” to health care. Ross, 462 S.W.3d at 504. In other words, “[t]he 

pivotal issue in a safety standards-based claim is whether the standards on which the 

claim is based implicate the defendant’s duties as a health care provider, including 

its duties to provide for patient safety.” Id. at 505. 

Because the line between a safety standards-based claim that is not a health 

care liability claim and one that is a health care liability claim may not always be 

clear, the court in Ross identified a nonexclusive list of considerations that inform a 

determination as to whether such a claim is substantively related to the defendant’s 

provision of medical or health care, which we paraphrase as follows:

1. Whether the alleged negligence occurred in the course of the defendant’s 

performing tasks with the purpose of protecting patients from harm;

2. Whether the alleged injuries occurred in a place where patients were 

receiving care, so that the obligation of the provider to protect persons 

who require medical care was implicated;

3. Whether the claimant was seeking or receiving health care when the 

alleged injuries occurred;

4. Whether the claimant was providing or assisting in providing health care 

when the injuries occurred;

5. Whether the alleged negligence arises from safety standards that are part 

of the professional duties owed by the health care provider;

6. If an instrumentality was involved in the defendant’s alleged negligence, 

whether it was a type used in providing health care; and

7. Whether the alleged negligence implicated safety-related requirements set 

for health care providers by governmental or accrediting agencies.

See id. at 505. The Texas Supreme Court and the First Court of Appeals have further 

noted another relevant consideration: the extent to which expert testimony from a 
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health care professional is feasible or necessary to support the claim. See

Diversicare Gen. Partner, Inc. v. Rubio, 185 S.W.3d 842, 848 (Tex. 2005) (“The 

necessity of expert testimony from a medical or health care professional to prove a 

claim may also be an important factor in determining whether a cause of action is an 

inseparable part of the rendition of medical or health care services.”); City of 

Houston v. Hussein, No. 01-18-00683-CV, 2019 WL 1246417, at *8 (Tex. App.—

Houston [1st Dist.] Mar. 19, 2019, no pet. h.). We find this consideration helpful in 

our analysis of the case before us. 

When we examine those factors or considerations, we focus on the essence of 

the cause of action. Bain v. Capital Senior Living Corp., No. 05-14-00255-CV, 2015 

WL 3958714, at *3 (Tex. App.—Dallas June 30, 2015, pet. denied) (mem. op.). Are 

the claims ordinary negligence claims or are they health care liability claims as 

contemplated by the legislature when it provided for health care liability claims in 

the TMLA? Tex. W. Oaks Hosp., 371 S.W.3d at 176. When we focus on the essence 

of the cause of action, we “consider the alleged wrongful conduct and the duties 

allegedly breached.” Diversicare, 185 S.W.3d at 851. 

The essence of Dower’s negligence cause of action is not found in standards 

that arise from professional duties owed by Appellants as health care providers. 

Rather, Dower alleged that Coci failed to follow the rules of the road: negligent 

motor vehicle operation. See Hussein, 2019 WL 1246417, at *9. Dower has not 

asserted that Coci violated any safety standards arising from Appellants’ status as 

alleged health care providers. Although the injuries occurred in a health care setting, 

“the mere location of an injury in a health care facility or in a health care setting does 

not bring a claim based on that injury within the TMLA so that it is [a health care 

liability claim].” Ross, 462 S.W.3d at 504–05. Appellants have failed to show a 
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substantive nexus between Coci’s negligent driving, the safety standards allegedly 

violated in this case, and the provision of health care. See id. at 505. 

The dissent relies upon Bain and upon Sherman v. HealthSouth Specialty 

Hospital, Inc., 397 S.W.3d 869, 872–74 (Tex. App.—Dallas 2013, pet. denied), to 

support the statement that he “would hold that there is a substantive nexus to the 

provision of health care when a patient or a passenger escorting that patient is injured 

while being transported in an ambulance to a medical facility.” Although we agree 

that the statement would be true in certain cases, with all due respect, we believe that 

the statement deserves some limitation. That limitation must lie in the consideration 

of whether the essence of the claim is one for ordinary negligence or one for a health 

care liability claim. We do not believe that the fact that an ambulance was involved 

automatically morphs all claims into health care liability claims. We would point 

out that in Bain and Sherman, two of the cases upon which the dissent relies, the 

essence of the claims involved a failure to properly secure the claimants in 

wheelchairs before transporting the claimants; the manner in which the ambulance 

was being driven was not the essence of either cause of action.

In this case, the legal duties allegedly violated apply to every driver on the 

road; they are not unique to a health care provider driving an ambulance. See

Hussein, 2019 WL 1246417, at *9 (citing Ross, 462 S.W.3d at 505; Galvan v. Mem’l

Hermann Hosp. Sys., 476 S.W.3d 429, 431–33 (Tex. 2015)). It was Appellants’

burden in the trial court to show that the essence of Dower’s cause of action was a 

health care liability claim. See Reddy v. Veedell, 509 S.W.3d 435, 438 (Tex. App.—

Houston [1st Dist.] 2014, pet. denied) (burden is on the putative health care provider 

“to prove that the [claimant’s] causes of action are health care liability claims for 

which an expert report was required”). Based on the record before us, Appellants

did not meet that burden.
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We hold that the essence of Dower’s cause of action is one for ordinary 

negligence and is not a health care liability claim. Dower was, thus, not required to 

satisfy the expert report requirements of the TMLA. We overrule Appellants’ sole 

issue on appeal. 

We affirm the order of the trial court. 

JIM R. WRIGHT

SENIOR CHIEF JUSTICE

September 12, 2019

Panel consists of: Bailey, C.J.,

Stretcher, J., and Wright, S.C.J.1

Willson, J., not participating. 

 1

Jim R. Wright, Senior Chief Justice (Retired), Court of Appeals, 11th District of Texas at Eastland, 

sitting by assignment.