BURGESS v. INTEGRIS HEALTH EDMOND, INC.

OSCN Found Document:BURGESS v. INTEGRIS HEALTH EDMOND, INC. et al. BURGESS v. INTEGRIS HEALTH EDMOND, INC. et al. 2026 OK 54 Case Number: 122076 Decided: 06/30/2026 SUPREME COURT OF THE STATE OF OKLAHOMA Cite as: 2026 OK 54 , __ P.3d __ NOTICE: THIS OPINION HAS NOT BEEN RELEASED FOR PUBLICATION. UNTIL RELEASED, IT IS SUBJECT TO REVISION OR WITHDRAWAL. ROBERT BURGESS and KARRIE BURGESS, Individually, and as Parents and Next of Kin of ROBERT BLAKE BURGESS, Deceased, Plaintiffs/Appellees, v. INTEGRIS HEALTH EDMOND, INC., BRET S. LANGERMAN, D.O., and EMERGENCY SERVICES OF OKLAHOMA, P.C., Defendants/Appellants. APPEAL FROM THE DISTRICT COURT OF OKLAHOMA COUNTY HONORABLE RICHARD OGDEN, DISTRICT JUDGE ¶0 In the fall of 2020, Robert Blake Burgess (Blake), a 21-year-old man, contracted COVID-19. He began having chest pain, shortness of breath, and lightheadedness, and his mother took him to the emergency room. Twenty days after being treated and discharged, Blake died from cardiac arrest as a consequence of pulmonary embolism with an underlying cause of COVID-19. Blake's parents, Plaintiffs/Appellees, Robert Burgess and Karrie Burgess (Parents), brought this wrongful death/medical negligence action against Defendants/Appellants, Integris Health Edmond, Emergency Services of Oklahoma, P.C., and Dr. Bret Langerman (Providers). Following a jury verdict and monetary award to Parents, Providers appealed and we retained the appeal. We hold that Providers are immune from liability under Oklahoma's COVID-19 Public Health Emergency Limited Liability Act for ordinary negligence and were entitled to a directed verdict under 63 O.S.2020, § 6406 JUDGMENT OF DISTRICT COURT REVERSED REMANDED FOR NEW TRIAL. Jason A. Ryan and Patrick R. Pearce, Jr.; Ryan Whaley, Oklahoma City, Oklahoma, and Brad Miller and Jami Rhoades Antonisse, Miller Johnson Jones Antonisse White, PLLC, Oklahoma City, Oklahoma, for Plaintiffs/Appellees, Robert Burgess and Karrie Burgess. Brandon C. Whitworth and Emily Jones Ludiker, Rodolf Todd, Tulsa, Oklahoma, and Zachary Williams, Hall Booth Smith, P.C., Oklahoma City, Oklahoma, and Teresa Pike Tomlinson, Hall Booth Smith, P.C., Columbus, Georgia, for Defendants/Appellants Bret S. Langerman, D.O., and Emergency Services of Oklahoma, P.C. David A. Branscum and Patrick R.B. Sherry, Foliart, Huff, Ottaway Bottom, Oklahoma City, Oklahoma, and Catherine L. Campbell, Phillips Murrah P.C., Oklahoma City, Oklahoma, for Defendant/Appellant Integris Health Edmond, Inc. OPINION DARBY, J.: ¶ 1 The present case arises from a wrongful death/medical negligence action brought by Plaintiffs/Appellees Robert Burgess and Karrie Burgess (Parents), the parents of Robert Blake Burgess (Blake). Parents claim that Defendants/Appellants, Integris Health Edmond (Integris), Emergency Services of Oklahoma, P.C. (ESO), and Dr. Bret Langerman 63 O.S.2020, § 6406 ¶ 2 Providers each filed a motion to retain the appeal, and this Court granted the motions. I. BACKGROUND AND PROCEDURAL HISTORY A. Factual History ¶ 3 In the fall of 2020, Blake Burgess, a 21-year-old student at the University of Oklahoma, was exposed to COVID-19. He experienced flu-like symptoms for a few days, and then began to feel better. After about a week, he began to suffer from chest pain during exertion, shortness of breath, and feeling like he might pass out. Blake went to an urgent care clinic in Norman on September 11, 2020, where he tested positive for COVID-19. He received an inhaler and was instructed to quarantine. Blake's symptoms did not improve, and on September 14, 2020, his mother took him to the emergency room at Integris, where he complained of shortness of breath and sharp stabbing pain in his right chest. ¶ 4 The essential facts are not in dispute regarding the treatment provided to Blake at Integris. The emergency room physician, Dr. Langerman, examined Blake and determined that he had normal vital signs, normal oxygenation rate, normal lung sounds, and no signs of lightheadedness or dizziness. Blake had no indication of blood clots in the extremities which might travel to the lungs. Dr. Langerman found that Blake had pleuritic chest pain (brought on by coughing, moving, palpation), cough, congestion, and shortness of breath. ¶ 5 Providers performed an EKG on Blake which indicated an abnormality and possible ischemia (lack of blood flow to the heart muscle) consistent with right heart strain. Dr. Langerman testified that it would have been his normal practice to inform Blake of the abnormal EKG, but no such discussion was documented in Blake's chart. In addition, Blake received a chest x-ray which showed an opacity on Blake's right lung. Dr. Langerman interpreted the x-ray as showing no acute issues and he did not note it as abnormal. After Blake's discharge, a hospital cardiologist read the EKG, and a radiologist read the chest x-ray. Both determined what they observed showed abnormal results. Although the reports were viewable on Blake's on-line Integris patient portal, there is no evidence that anyone advised Blake directly of his abnormal EKG or chest x-ray. Blake's mother testified that Blake's discharge papers only mentioned chest pain and COVID. ¶ 6 Pulmonary embolism (PE) is a serious condition where one or more arteries in the lungs become blocked by a blood clot. ¶ 7 During the COVID-19 state of emergency, Integris implemented infection-control policies and procedures that included a "no visitor rule" for adult patients in the emergency room, limited entrance to designated areas, and related checkpoints staffed by a registration clerk. Integris' infection-control policy required the registration clerk to remain at the checkpoint unless another person was available to cover the station. On the night Blake was treated at the emergency room, the registration clerk had no one to relieve her, and she was not able to leave the checkpoint. ¶ 8 For patients with COVID-19, Integris also had heightened isolation procedures, requirements for caregivers to wear extra personal protection equipment (PPE), and additional infection-control steps for staff leaving a COVID-19 patient's room. Because Blake reported that he had tested positive for COVID-19, he was placed in a designated room under the hospital's isolation and infection-control policies. Only doctors and nurses were permitted to enter the area, and the registration clerk spoke with them by telephone. ¶ 9 After Blake was admitted to the emergency room, Blake's mother waited in her vehicle for approximately five minutes. She then returned to the registration desk and gave a handwritten note to the clerk advising that Blake had a family history of antithrombin III deficiency, ¶ 10 Blake's chart makes no mention of antithrombin III deficiency. Dr. Langerman determined that Blake's symptoms were due to his COVID-19 infection and released him to go home. Dr. Langerman also prescribed an anti-inflammatory drug and instructed Blake to continue to use his Albuterol inhaler. He also told Blake to follow up with his primary care physician in two days and to return to the ER sooner for any problems. Blake did not follow up with anyone. ¶ 11 Blake's symptoms continued to fluctuate until ten days later, on September 23, 2020, when he passed out after running up and down the stairs at his house, which prompted his roommates to call 911. The lead paramedic on the scene, William Chase Boyd, testified that when he arrived Blake was pale, but awake and alert, sitting upright on the couch. Blake advised Boyd that he now felt fine with no complaints, and that he had recently been diagnosed with COVID-19. Boyd evaluated Blake and concluded there was no indication of any critical condition. Boyd testified that nothing in Blake's presentation raised a concern that he was experiencing a PE. Blake adamantly refused to go by ambulance to the emergency room and stated that he felt comfortable staying home. Boyd testified that his standard approach is to try to convince each patient to go to the hospital ("you call we haul"). But after staying on the scene for a few minutes, he noted Blake was no longer pale, seemed to be improving, was acting appropriately for a 21-year old male, and was even joking around. Boyd testified that he was comfortable with Blake remaining at home. Blake signed a "Release for Patient's Refusal to Accept Medical Care or Transportation to a Medical Care Facility." ¶ 12 Five days later, on September 28, 2020, Blake's condition took a turn for the worse. He again passed out at his house and one of his roommates called 911. The paramedics transported Blake to Norman Regional Hospital. Blake died on October 4, 2020. His death certificate listed his cause of death as cardiac arrest as a consequence of pulmonary embolism with an underlying cause of COVID-19. B. Procedural History ¶ 13 Parents filed the present case for wrongful death and medical negligence and alleged Providers were negligent in failing to properly assess, diagnose and treat Blake for pulmonary embolism during his emergency room visit on September 14. Parents also alleged Providers' conduct was reckless and requested punitive damages. ¶ 14 On April 5, 2021, Providers filed a motion to dismiss for failure to state a claim upon which relief may be granted and for lack of subject matter jurisdiction and argued that they had immunity for treating Blake while he had COVID-19 under the Oklahoma COVID-19 Public Health Emergency Limited Liability Act (COVID 19 Act) and the Federal Public Readiness and Emergency Preparedness Act (PREP Act). Providers further argued for dismissal on the grounds that Parents had failed to exhaust their administrative remedies, and that the PREP Act preempts Plaintiffs' state-law claims. The trial court overruled the motion to dismiss. ¶ 15 In their answers to Parents' amended petition, Providers again asserted immunity under the PREP Act and the Oklahoma COVID-19 Act, this time raising the arguments as affirmative defenses. Parents moved for partial summary judgment on these affirmative immunity defenses on October 20, 2022. At the hearing on the motion, the parties agreed that the issue of whether treatment provided to Blake included any "covered countermeasures" which could invoke immunity under the PREP Act was a question of law for the court to determine. The trial court granted Parents' motion for partial summary judgment, finding no evidence of the use or administration by Providers of any "covered countermeasures" as that term is defined in the statutory text and/or the Federal Register and struck Providers' PREP Act immunity defense. The trial court determined, however, that material disputed facts precluded summary judgment on the applicability of the Oklahoma COVID-19 Act. ¶ 16 Providers moved for summary judgment on February 21, 2023, again asserting immunity under the Oklahoma COVID-19 Act. The trial court denied the motion. ¶ 17 The trial court conducted an eleven-day jury trial, beginning on February 5, 2024. The court denied Providers' motions for a directed verdict to grant Providers immunity as a matter of law under the Oklahoma COVID-19 Act. The court also denied Parents' motions regarding applicability of the COVID 19 Act. ¶ 18 Providers argued in favor of an intervening cause instruction based upon Blake's failure to obtain follow-up medical treatment and his refusal of transport to the emergency room on September 23rd. The court rejected Providers' arguments and granted Parents' motion for directed verdict on Providers' affirmative defense of intervening/supervening cause. The court did, however, instruct the jury on contributory negligence, and provided applicable verdict forms. The parties also agreed that special interrogatories ¶ 19 The jury returned a verdict in favor of Parents on February 22, 2024, awarding damages in the amount of ten million dollars ($10,000,000). The jury found Blake 25% contributorily negligent, Dr. Langerman 40% negligent, and Integris 35% negligent. The jury also found that Parents did not prove by clear and convincing evidence that Dr. Langerman acted in reckless disregard of the rights of others and was not subject to punitive damages. The trial court entered judgment for Parents and reduced the damages award to the sum of $7,500,000 to reflect the contributory negligence of Blake. Providers appealed, and this Court retained their appeal. ¶ 20 Dr. Langerman presses several propositions of error. First, regarding the PREP Act, he argues that the final judgment is void because 1) federal statutory immunity bars the claim, 2) the suit was defensively preempted by federal law, and 3) Parents failed to exhaust administrative remedies. Second, Dr. Langerman maintains that the trial court failed to apply the Oklahoma COVID-19 Act's required standard of liability, and the Act bars Plaintiff's ordinary negligence claims. Third, he argues the trial court erred in granting Parents' motion for directed verdict on the issue of intervening/supervening causation. ¶ 21 Integris also raises multiple issues on appeal. First, it claims that the trial court erred in its application of the Oklahoma COVID-19 Act because 1) the trial court improperly submitted issues of statutory interpretation to the jury, and the only fact question for the jury should have been whether Providers were grossly negligent or acted willfully and wantonly, and 2) the jury instructions on gross negligence did not accurately reflect the law. Second, Integris argues that the PREP Act provides immunity to Providers for their administration of "covered countermeasures" to Blake. II. STANDARD OF REVIEW ¶ 22 The present case involves issues of statutory interpretation by the trial court, which are subject to de novo review. Hayes v. Penkoski , 2024 OK 49 550 P.3d 931 de novo standard of review also applies to questions concerning the jurisdictional power of the trial court to act. Dilliner v. Seneca-Cayuga Tribe , 2011 OK 61 258 P.3d 516 de novo review. State ex rel. Okla. Dep't of Pub. Safety v. Gurich , 2010 OK 56 238 P.3d 1 ¶ 23 A trial court's ruling on a motion for directed verdict is subject to de novo review. Comp. Pubs., Inc. v. Welton , 2002 OK 50 49 P.3d 732 de novo . Bailey v. State ex rel. Bd. of Tests for Alcohol Drug Influence , 2022 OK 50 510 P.3d 845 de novo ). In exercising de novo review, "this Court possesses plenary, independent, and non-deferential authority to examine the issues presented." Benedetti v. Cimarex Energy Co. , 2018 OK 21 415 P.3d 43 III. ANALYSIS A. Oklahoma COVID-19 Act ¶ 24 On April 13, 2020, Oklahoma Governor Kevin Stitt declared a public health and safety emergency in all 77 Oklahoma counties due to the COVID-19 pandemic. 63 O.S.2020, § 6406 C. A health care facility or health care provider shall be immune from civil liability for any loss or harm to a person with a suspected or confirmed diagnosis of COVID-19 caused by an act or omission by the facility or provider that occurs during the COVID-19 public health emergency, if: 1. The act or omission occurred in the course of arranging for or providing COVID-19 health care services for the treatment of the person who was impacted by the decisions, activities or staffing of, or the availability or capacity of space or equipment by, the health care facility or provider in response to or as a result of the COVID-19 public health emergency; and 2. The act or omission was not the result of gross negligence or willful or wanton misconduct of the health care facility or health care provider rendering the health care services. 63 O.S.2020, § 6406 63 O.S.2020, § 6406 63 O.S.2020, § 6406 ¶ 25 Before trial, the court denied Providers' motions for summary judgment on the applicability of the COVID-19 Act. Order 2, May 26, 2023; R. at 1618. At the close of evidence, the trial court also denied Parents' and Providers' opposing motions for directed verdict on applicability of the COVID-19 Act and ultimately submitted agreed-upon special interrogatories to the jury. ¶ 26 Providers must show compliance with all the statutory conditions to qualify for immunity from liability. Smith v. Deaconess Hosp. , 2007 OK 45 ¶ 27 Parents do not dispute that the requirements of § 6406(C) and (C)(1) were met for immunity, except for whether Blake was "impacted" as described in (C)(1). Parents maintain that Providers' acts and omissions which allegedly caused Blake's death were unrelated to the COVID-19 public health emergency. In support of their claim, Parents emphasize that the evidence showed that when Blake arrived the hospital was fully staffed and the emergency department was below capacity, with only six other patients. No other patient came in during the hour before Blake arrived, or for approximately 40 minutes thereafter. Regarding overall resources, the hospital was not dealing with any "surge" of COVID-19 patients, and Providers had the ability that night to run any blood tests or CT scans necessary to rule out pulmonary embolism. ¶ 28 But the COVID-19 Act's "impact" element is not necessarily focused on contemporaneous circumstances "impacting" Blake or his treatment as argued by Parents. The Act concerns the policies and procedures implemented by Providers and enforced by Providers, and their potential impact on Blake and his treatment. Findings regarding the factors argued by Parents would be decided by a jury on other claims. Those potential findings do not influence our holding today. ¶ 29 In our recent decision in Austbo v. Greenbriar , 63 O.S.2020, § 6406 2025 OK 85 ¶ 30 The modifications implemented by medical service providers in Oklahoma in response to the COVID-19 emergency were so widespread they affected, or impacted, a great number of medical patients to at least some degree. "It is plausible that many, if not most, COVID patients will have been affected by a facility's or a provider's decisions, activities, staffing, or capacity in response to or a result of the COVID-19 public health emergency." Id. Providers in this case were certainly among those making the hard decisions and implementing changes which impacted COVID patients who came to them for medical services. The issue we must decide is whether those changes specifically impacted Blake and his treatment when he came to the emergency room and saw Dr. Langerman. ¶ 31 We have held many times that if the words used in a statute are plain and unambiguous, legislative intent is deemed as expressed by the statutory language. Stricklen v. Mult. Inj. Tr. Fund , 2024 OK 1 542 P.3d 858 Id. , at ¶ 14, 542 P.3d, at 866. Regarding the COVID-19 Act, the intended meaning of "impact" is ambiguous because the meaning is susceptible to very different reasonable interpretations. See ibid. Our goal is to give effect to the intent of the legislature. Signature Leasing, LLC v. Buyer's Grp., LLC , 2020 OK 50 466 P.3d 544 ¶ 32 The legislature did not define "impact" within the Act. The Act does not offer the nature or degree of impact necessary to satisfy the requirement. After this case was decided in the trial court, this Court published our opinion in Austbo . In Austbo , we observed the COVID-19 Act imposes no materiality threshold regarding the severity of the impact on the patient. Austbo , 2025 OK 85 See id . The Act simply requires that Blake was "in some way affected" by Providers' decisions, activities, staffing, or capacity in response to or as a result of the greater COVID-19 public health emergency. Id. ¶ 33 The trial court in Austbo granted the defendants' motion for summary judgment and ordered that both the PREP Act and the COVID-19 Act immunized the defendants. But this Court reversed the trial court's order granting immunity under the COVID-19 Act on appeal because the defendants failed to submit evidence to support their argument the patient was impacted as the Act demands. Assertions alone are not enough on summary judgment. See Video Gaming Techs., Inc. v. Rogers Cnty. Bd. of Tax Roll Corr. , 2019 OK 83 ¶ 34 This Court continues to interpret the COVID-19 Act to require that a patient was "impacted," as we have described, as one element of immunity. We also continue our view that showing the patient was "impacted" is not a high bar. But demonstrating the impact is not automatic. The providers in Austbo failed to show the necessary impact because they did not comply with District Court Rule 13 and submit evidentiary material to support their assertions that the plaintiff/patient was in fact impacted. ¶ 35 In the present case, the evidence admitted at trial showed that Integris made several decisions and altered its activities and staffing in its emergency department in response to or as a result of the COVID-19 public health emergency. These decisions and alterations included prohibiting visitors from accompanying adult patients, requiring the registration clerk to remain at the entry checkpoint, and following enhanced infection-control practices for COVID-19 patients. ¶ 36 Integris' COVID-19 policy changes prohibited Blake's mother from accompanying him into the emergency department patient room and providing information directly to medical providers regarding Blake's family history of a hereditary blood clotting disorder. Blake's mother therefore gave a handwritten note to the registration clerk regarding the history of antithrombin III deficiency in Blake's family and then asked the clerk to take the note to the emergency doctor treating Blake. Integris' COVID-19 policy required the clerk to remain at the entry checkpoint unless another person was available to cover the station, another person was not available, and this prevented the clerk from hand-delivering the note. The record includes no evidence that anybody ever delivered the note to Dr. Langerman or communicated the information in the note to the medical staff. Blake's chart makes no mention of antithrombin III deficiency. The procedures Integris implemented in response to the COVID emergency stopped the note, and Blake's mother, at the checkpoint. This impacted Blake and his medical treatment. ¶ 37 Dr. Langerman testified that had he known of Blake's family history of antithrombin III deficiency (AT III), his differential diagnosis and medical decision-making would have been different: Q. Do you agree that if someone comes into the ER and you note chest pain and shortness of breath and AT III, that person's high risk of PE? A. If you have those three things in combination, yes, that would -- that would raise your suspicions. Q. You bet. They go right to the CT angiogram, right? A. Likely. Q. All right. And what we think we call it CT with contrast? [sic] A. Yes. CT or CT with contrast. Q. All right. But certainly -- I think you would certainly ask more questions of that person if you found out that they had an AT III history, right? A. That's correct. Q. Even if -- even if the AT III that you knew about with shortness of breath and chest pain was just that a family member in direct lineage, like a parent had, you'd ask questions? A. I would ask questions. Q. More questions? A. More questions. Trial Tr. vol. III, 212--13. ¶ 38 When faced with a motion for directed verdict, "a trial court must consider as true all of the evidence favorable to the party against whom the motion or demurrer is directed, together with all inferences that reasonably may be drawn therefrom, and must disregard all conflicting evidence favorable to the movant." Downing v. First Bank in Claremore , 1988 OK 67 756 P.2d 1227 ¶ 39 There are no controverted material facts regarding this issue. And, "[w]here only one inference can reasonably be drawn from the evidence as to a material issue relating to a party's claim or defense, it is not error for a trial court to remove said issue from the jury's consideration and to direct a verdict thereon." Badillo v. Mid Century Ins. Co. , 2005 OK 48 121 P.3d 1080 ¶ 40 Where the elements in § 6406(C) and (C)(1) are satisfied as a matter of law, the inquiry turns to paragraph (C)(2). The only question that should have gone to the jury on Providers' COVID-19 Act defense was whether Providers' acts or omissions which allegedly harmed Blake were the result of gross negligence or willful or wanton misconduct. See 63 O.S.2020, § 6406 ¶ 41 We hold that the trial court committed reversible error when it denied Providers' motion for directed verdict on 63 O.S.2020, § 6406 B. The Public Readiness and Emergency Preparedness (PREP) Act i. The PREP Act History and Immunity Protections ¶ 42 Providers assert that the federal Public Readiness and Emergency Preparedness Act (PREP Act), currently codified at 42 U.S.C. § 247d-6d and § 247d-6e, Id . Once the Secretary makes such a declaration, the PREP Act provides immunity to "covered persons" for the administration or use of "covered countermeasures" in response to the declared state of emergency. 42 U.S.C. § 247d 6d(a)(1). ¶ 43 The full text of the PREP Act's immunity provision states as follows: Subject to the other provisions of this section, a covered person shall be immune from suit and liability under Federal and State law with respect to all claims for loss caused by, arising out of, relating to, or resulting from the administration to or the use by an individual of a covered countermeasure if a declaration under subsection (b) has been issued with respect to such countermeasure. Id . In March 2020, the Secretary declared that the spread of SARS-CoV-2 and the resulting disease COVID-19 constituted a public health emergency, and activated the PREP Act for covered countermeasures related to the pandemic (Declaration). ii. PREP Act Preemption ¶ 44 Providers argue that the trial court lacked subject matter jurisdiction because the PREP Act provides complete federal preemption of Parents' state-law claims. Providers also argue that the Parents' suit was defensively preempted by the PREP Act. We address these arguments together. ¶ 45 The doctrine of complete preemption arises from the Supremacy Clause of the United States Constitution, U.S. Const. Art. VI, cl. 2, and "invalidates any state law that contradicts or interferes with an Act of Congress." Wilson v. Harlow , 1993 OK 98 860 P.2d 793 Missouri--Kansas--Texas R. Co. v. State , 1985 OK 108 712 P.2d 40 Beneficial Nat'l Bank v. Anderson , 539 U.S. 1, 8 , 123 S. Ct. 2058, 2063 (2003). To establish complete preemption, Congress must have intended the federal statute to provide "the exclusive cause of action for the claim asserted and also set forth procedures and remedies governing that cause of action." Id. ¶ 46 The PREP Act creates an exclusive federal cause of action against covered persons for injuries "proximately caused by willful misconduct." 42 U.S.C. § 247d-6d(d)(1). It defines "willful misconduct," as "an act or omission that is taken (i) intentionally to achieve a wrongful purpose; (ii) knowingly without legal or factual justification; and (iii) in disregard of a known or obvious risk that is so great as to make it highly probable that the harm will outweigh the benefit." Id . § 247d-6d(c)(1)(A). The PREP Act's definition of willful misconduct "shall be construed as establishing a standard for liability that is more stringent than a standard of negligence in any form or recklessness." Id . § 247d-6d(c)(1)(B). Before bringing an action in federal court, a person asserting a willful-misconduct claim must first exhaust administrative remedies via a specified compensation fund process. Id . § 247d-6e(d)(1). Parents' petition alleges ordinary medical negligence, not willful misconduct, thus it is not completely preempted by the PREP Act. ¶ 47 A defendant may invoke defensive preemption as an affirmative defense "to defeat a plaintiff's state-law claim on the merits by asserting the supremacy of federal law." Mitchell v. Advanced HCS, L.L.C. , 28 F.4th 580, 585 (5th Cir. 2022) (citations omitted). The rule of ordinary preemption created by the PREP Act provides immunity to covered persons from all federal and state claims for loss caused by the administration or use of covered countermeasures. Hudak v. Elmcroft of Sagamore Hills , 58 F.4th 845, 855 (6th Cir. 2023); see also Cagle v. NHC Healthcare-Maryland Heights, LLC , 78 F.4th 1061, 1067 (8th Cir. 2023). Explaining that state courts may properly consider whether immunity applies, the Second Circuit has clarified the inquiry as follows: State courts addressing immunity defenses under the PREP Act are required to answer only whether the plaintiff's claims fall within the PREP Act's immunity provision. See 42 U.S.C. Section 247d-6d(a)(1) If the answer is no, as the district court found, there is no federal law left to apply and the case can proceed under state law. Solomon v. St. Joseph Hosp., 62 F.4th 54 , 61 n.4 (2d Cir. 2023) (emphasis added). ¶ 48 In the present case, Providers assert that where Congress has provided suit immunity, a state court may not exercise jurisdiction over the matter. But the state court has jurisdiction to evaluate whether the PREP Act preempts the claims under ordinary preemption rules. Id. ; Maglioli v. Alliance HC Holdings LLC , 16 F.4th 393 , 412--13 (3d Cir. 2021). The immunity provision of the PREP Act would still apply to qualifying claims, whether they are brought in state or federal court. Solomon , 62 F.4th, at 62 . In this respect, immunity under the PREP Act is an affirmative defense which may be determined in state court. Martin v. Petersen Health Operations , LLC, 37 F.4th 1210, 1214 (7th Cir. 2022); Goins v. Saint Elizabeth Med. Ctr., Inc. , 2024 WL 229568 , at *5 (6th Cir. Jan. 22, 2024). ¶ 49 We recognize that this procedural approach aligns with the PREP Act's express preemption clause, which prohibits enforcement of any state law or legal requirement which is different from, or conflicts with, the PREP Act's immunity provisions. who qualifies for immunity under the PREP Act cannot proceed in state court. But where a state court determines the PREP Act's immunity does not apply , then an ordinary negligence claim poses no conflict, and is not preempted via the PREP Act's express terms. We hold that the PREP Act does not completely preempt Parents' claims in the present case. Nor does the PREP Act preclude the state trial court from determining whether the claims are defensively preempted by the Act's immunity provisions. iii. PREP Act Immunity Does Not Apply in the Present Case ¶ 50 We turn next to Providers' argument that the trial court erred in its interpretation of the PREP Act, and that the trial court's judgment is void due to the federal statutory immunity and defenses contained in the PREP Act. On this point, we must determine whether the PREP Act's immunity protection extends to Providers. We hold that it does not. ¶ 51 In construing a statute, we will not consider only one word or phrase, but will propend all relevant provisions "to ascertain and give effect to the legislative intent and the public policy underlying the intent." Am. Airlines, Inc. v. State, ex rel. Oklahoma Tax Comm'n , 2014 OK 95 341 P.3d 56 Lancaster v. State , 1967 OK 84 426 P.2d 714 The general rules that apply in construing a statute are that the legislative intent must govern, and to arrive at the legislative intent, the entire act must be considered; a construction should be given the act which is reasonable and sensible, and should not be construed so that it would lead to an inconsistency between different parts as they bear upon each other. Lancaster , 1967 OK 84 ¶ 52 The intent of the PREP Act is described as follows: Congress enacted the PREP Act in 2005 "[t]o encourage the expeditious development and deployment of medical countermeasures during a public health emergency" by allowing the HHS Secretary "to limit legal liability for losses relating to the administration of medical countermeasures such as diagnostics, treatments, and vaccines." Cannon v. Watermark Ret. Cmtys., Inc. , 45 F.4th 137 , 139 (D.C. Cir. 2022) (quoting Kevin J. Hickey, Cong. Rsch. Serv., LSB10443, The PREP Act and Covid-19, Part 1: Statutory Authority to Limit Liability for Medical Countermeasures ). The PREP Act serves as an emergency response to the COVID pandemic, with the purpose of emboldening caregivers to provide certain approved forms of care with the assurance that they will not face liability for doing so. See Estate of Maglioli v. Andover Subacute Rehabilitation Center I , 478 F. SupP.3d 518, 529 (D.N.J. 2020) aff'd sub nom. Estate of Maglioli v. Alliance HC Holdings, LLC , 16 F.4th 393 (3d Cir. 2021). a. Causation ¶ 53 Parents argue there was no claim or evidence presented which established that Blake's death was caused by the administration or use of a stethoscope, chest x-ray, or EKG. They contend that the PREP Act's causation requirement is not satisfied in the present case and we agree. ¶ 54 For PREP Act protection to apply, the PREP Act's immunity provision specifies that the loss must be "caused by, arising out of, relating to, or resulting from" the administration to or use by an individual of a covered countermeasure. 42 U.S.C. § 247d-6d(a)(1). The next subsection in the PREP Act, entitled "Scope," further limits the immunities provided: The [PREP Act's] immunity ... applies to any claim for loss that has a causal relationship with the administration to or use by an individual of a covered countermeasure, including a causal relationship with the design, development, clinical testing or investigation, manufacture, labeling, distribution, formulation, packaging, marketing, promotion, sale, purchase, donation, dispensing, prescribing, administration, licensing, or use of such countermeasure. 42 U.S.C. § 247d-6d(a)(2)(B). ¶ 55 The PREP Act's plain language requires "some nexus -- some 'causal relationship' -- between the claimed loss and the administration or use of a covered countermeasure." Schleider v. GVDB Operations, LLC , 121 F.4th 149, 162 (11th Cir. 2024). The Ninth Circuit has explained that the phrases in the PREP Act's immunity provision -- "caused by," "arising out of," and "resulting from" -- all connote some type of direct causal relationship: At the very least, then, for PREP Act immunity to apply, the underlying use or administration of a covered countermeasure must have played some role in bringing about or contributing to the plaintiff's injury . It is not enough that some countermeasure's use could be described as relating to the events underpinning the claim in some broad sense. Hampton v. California , 83 F.4th 754, 764 (9th Cir. 2023) (emphasis added). ¶ 56 This Court analyzed the PREP Act's causation requirement in two recent decisions -- Franklin v. OU Med., Inc. , 2025 OK 84 582 P.3d 1127 Austbo v. Greenbriar Nursing Home No. Two, Inc. , 2025 OK 85 Franklin , we held that the PREP Act's causation requirement was satisfied. In Austbo , we held that it was not. ¶ 57 In Franklin , a disabled adult patient who had been dependent on a tracheostomy since she was two years old was admitted to OU Medical Center with a severe COVID-19 infection and COVID pneumonia. Due to the patient's dropping oxygen levels, she was placed on a ventilator which required her uncuffed tracheostomy tube to be replaced with a cuffed tracheostomy tube. While a nurse was cleaning the patient, the cuffed tracheostomy tube became dislodged and the patient's airway was blocked, causing her to suffer acute hypoxia and an anoxic brain injury. The patient's mother sued the OU medical providers, and the trial court dismissed the claim based on PREP Act immunity. The Court of Civil Appeals reversed the trial court and held that the defendants were not immune from suit. ¶ 58 This Court granted certiorari and vacated COCA's opinion. Franklin , 2025 OK 84 Id ., at ¶ 29, 582 P.3d, at 1135. We next considered whether the plaintiff alleged an injury which was caused by the administration of the covered countermeasure. The plaintiff's petition asserted "that dislodgement of the tracheostomy (the countermeasure) was the cause-in-fact" of the patient's brain injury. Id ., at ¶ 42, 582 P.3d, at 1137. We recognized that dislodgement was "a plainly foreseeable risk of using and administering a cuffed tracheostomy" which further bolstered the argument for the existence of a causal relationship. Ibid . Although the defendants may have been negligent for causing the tracheostomy to dislodge, we concluded that the patient's injury could not be divorced from the administration of a covered countermeasure. Id ., ¶ 44, 582 P.3d, at 1138. Thus, the PREP Act's causation requirement was satisfied, and the PREP Act's immunity protections precluded the plaintiff's claims. Id ., ¶ 48, 582 P.3d, at 1138. ¶ 59 In Austbo , an elderly patient with COVID-19 and Alzheimer's disease was transferred from the hospital to the defendant skilled nursing home, where she stayed for eighteen days. During her stay, her condition deteriorated, and she suffered from respiratory failure requiring oxygen supplementation, worsening mental status, decreased oral intake, renal failure, pressure wounds, and other health problems. Her physician noted that treatment options were extremely limited due to her severe dementia. Although the physician recommended hospice care, her family took her home without arrangements for home health care or hospice. The next day, the patient returned to the hospital and was admitted to the ICU. She received oxygen supplementation and treatment for multiple pressure wounds. Her providers recommended a feeding tube, but the family declined. The family took the patient home again, this time under hospice care, where she died nine days after being discharged. The patient's surviving spouse sued Greenbriar and the facility's attending physician for negligence and wrongful death. The district court granted summary judgment for the defendants, holding both the PREP Act and the Oklahoma COVID-19 Act immunized the defendants. ¶ 60 On appeal, we reversed the district court's grant of summary judgment. Austbo , 2025 OK 85 Id. The claims did not involve COVID-19. The defendants argued that the measures they used to treat the patient's COVID-19 may have side effects and cause the patient's deterioration, weakness, and unwillingness to eat or drink. The record, however, contained no factual support for this argument. We determined that summary judgment was improper because the defendants had presented no material facts nor any other evidence demonstrating a causal relationship between the patient's death and the countermeasures administered by the defendants. Id ., ¶ 23, 588 P.3d, at 886. ¶ 61 With regard to the claims asserted here, the present case is more like Austbo than Franklin . Parents do not allege that the Provider's physical provision of an x-ray, EKG, or use of a stehoscope played a role in bringing about Blake's death. Rather, they claim that Dr. Langerman misread Blake's x-ray and negligently failed to diagnose and treat Blake for pulmonary embolism; even though Blake had indicative symptoms, an abnormal EKG, and his x-ray results showed an opacity on Blake's right lung. Assuming arguendo that the diagnostic tests (x-ray and EKG), examinations, or drugs administered to Blake qualify as covered countermeasures under these circumstances, Parents do not claim the administration of those measures caused any loss or injury to Blake. Unlike Franklin , the record here contains no evidence that the tests, or their administration, caused Blake's pulmonary embolism or in any way resulted in his death. There is no requisite direct causal relationship between Blake's death and the use or administration of a covered countermeasure. ¶ 62 In Franklin we also discussed Mills v. Hartford Healthcare Corp. , 298 A.3d 605 (Conn. 2023). Like the present case, Mills involved the defendants' alleged failure to diagnose and treat a life-threatening condition suffered by a patient with COVID-19. In Mills , the plaintiff