Undisputed “Impact” Satisfies Oklahoma COVID-19 Act Immunity (Ordinary Negligence Bar), While PREP Act Immunity Requires a Direct Causal Nexus to a Covered Countermeasure

I. Introduction

BURGESS v. INTEGRIS HEALTH EDMOND, INC. (2026 OK 54) arises from a wrongful death/medical negligence action brought by Robert and Karrie Burgess (“Parents”) after their 21-year-old son, Robert Blake Burgess (“Blake”), died of cardiac arrest as a consequence of pulmonary embolism with an underlying cause of COVID-19. Parents alleged that Integris Health Edmond (“Integris”), Emergency Services of Oklahoma, P.C. (“ESO”), and emergency physician Dr. Bret Langerman (collectively, “Providers”) failed to diagnose and treat Blake’s pulmonary embolism during his September 14, 2020 emergency-room visit.

The appeal presented three central issues:

  1. Whether Providers were immune from ordinary negligence liability under Oklahoma’s COVID-19 Public Health Emergency Limited Liability Act, 63 O.S.2020, § 6406 (the “COVID-19 Act”).
  2. Whether Providers were immune (and/or state-law claims preempted) under the federal Public Readiness and Emergency Preparedness Act (“PREP Act”), 42 U.S.C. § 247d-6d and § 247d-6e.
  3. Whether the trial court erred by directing a verdict against Providers on intervening/supervening causation (based on Blake’s later conduct).

II. Summary of the Opinion

The Oklahoma Supreme Court reversed the judgment for Parents and remanded for a new trial. It held:

  • Oklahoma COVID-19 Act: Providers were immune from ordinary negligence. The evidence established the Act’s “impact” requirement in § 6406(C)(1) as a matter of law, so Providers were entitled to a directed verdict on that element. The only liability question left for a jury under the Act should have been whether Providers’ conduct was gross negligence or willful or wanton misconduct under § 6406(C)(2).
  • PREP Act: Providers were not immune. The claims alleged a failure to diagnose/treat pulmonary embolism, not an injury causally linked to the administration or use of a covered countermeasure. The Court also held the PREP Act did not completely preempt the state-law claims and did not deprive the state court of authority to decide defensive preemption.
  • Intervening/Supervening cause: The trial court did not err in directing a verdict for Parents; Blake’s failure to seek follow-up care and refusal of transport did not meet Oklahoma’s supervening-cause test.

III. Analysis

A. Precedents Cited (and How They Drove the Court’s Framework)

1. Standards of review and court/jury allocation

  • Hayes v. Penkoski (2024 OK 49) and Dilliner v. Seneca-Cayuga Tribe (2011 OK 61): anchored de novo review for statutory interpretation and jurisdictional questions.
  • State ex rel. Okla. Dep’t of Pub. Safety v. Gurich (2010 OK 56): treated the applicability of statutory immunity as a question of law reviewed de novo, supporting the Court’s willingness to decide immunity issues independently on appeal.
  • Comp. Pubs., Inc. v. Welton (2002 OK 50), Bailey v. State ex rel. Bd. of Tests for Alcohol & Drug Influence (2022 OK 50), and Benedetti v. Cimarex Energy Co. (2018 OK 21): supplied the de novo standard for directed verdict rulings and emphasized the Court’s “plenary” authority to reexamine the legal sufficiency of evidence when a trial court removes (or fails to remove) issues from the jury.
  • Downing v. First Bank in Claremore (1988 OK 67) and Badillo v. Mid Century Ins. Co. (2005 OK 48): provided the directed-verdict lens—accepting favorable evidence for the non-movant—while also recognizing that when only one inference can be drawn, a court may (and sometimes must) decide the issue as a matter of law.

2. Oklahoma COVID-19 Act immunity and the “impact” element

  • Smith v. Deaconess Hosp. (2007 OK 45): reiterated that a party claiming immunity must show compliance with all statutory conditions—an organizing principle for § 6406(C)’s elements.
  • Austbo v. Greenbriar (2025 OK 85): the Court’s key interpretive precursor, defining § 6406(C)(1) as requiring that the patient was “in some way affected” by decisions/activities/staffing/capacity taken “in response to or as a result of” the COVID-19 emergency, and emphasizing the “impact” bar is low but not automatic.
  • Stricklen v. Mult. Inj. Tr. Fund (2024 OK 1) and Signature Leasing, LLC v. Buyer’s Grp., LLC (2020 OK 50): supplied statutory-construction rules used to address the ambiguity of “impact” and to frame legislative-intent analysis.
  • Video Gaming Techs., Inc. v. Rogers Cnty. Bd. of Tax Roll Corr. (2019 OK 83): used (by analogy) to underscore that mere assertions do not establish facts—important in contrasting the evidentiary failure in Austbo with the trial proof here.

3. PREP Act: preemption, causation, and countermeasure scope

  • Wilson v. Harlow (1993 OK 98) and Missouri-Kansas—Texas R. Co. v. State (1985 OK 108): supplied general Supremacy Clause framing for preemption doctrines.
  • Beneficial Nat’l Bank v. Anderson (539 U.S. 1 (2003)): supplied the “complete preemption” test (exclusive federal cause of action + procedures/remedies). The Court used this to reject complete preemption because Parents pleaded negligence, not PREP Act “willful misconduct.”
  • Mitchell v. Advanced HCS, L.L.C. (28 F.4th 580 (5th Cir. 2022)), Solomon v. St. Joseph Hosp. (62 F.4th 54 (2d Cir. 2023)), Maglioli v. Alliance HC Holdings LLC (16 F.4th 393 (3d Cir. 2021)), Martin v. Petersen Health Operations, LLC (37 F.4th 1210 (7th Cir. 2022)), and Goins v. Saint Elizabeth Med. Ctr., Inc. (2024 WL 229568 (6th Cir. Jan. 22, 2024)): grounded the Court’s conclusion that state courts may decide PREP Act immunity as an affirmative defense (defensive/ordinary preemption), and that the inquiry is whether the pleaded claims fall within the Act’s immunity.
  • Hudak v. Elmcroft of Sagamore Hills (58 F.4th 845 (6th Cir. 2023)) and Cagle v. NHC Healthcare-Maryland Heights, LLC (78 F.4th 1061 (8th Cir. 2023)): supported the understanding that PREP immunity is tied to claims causally connected to countermeasure administration/use (and does not automatically cloak all pandemic-era care).
  • Schleider v. GVDB Operations, LLC (121 F.4th 149 (11th Cir. 2024)) and Hampton v. California (83 F.4th 754 (9th Cir. 2023)): provided the “nexus”/causal-relationship requirement: the countermeasure must have played some role in producing the injury; “relating to” cannot be read boundlessly.
  • Franklin v. OU Med., Inc. (2025 OK 84): Oklahoma’s chief PREP Act comparator—PREP immunity applied where the injury was caused by a covered countermeasure’s administration/use (a cuffed tracheostomy tube that became dislodged). This case served as the “yes causation” model.
  • Mills v. Hartford Healthcare Corp. (298 A.3d 605 (Conn. 2023)) and Roos v. HealthPartners, Inc. (22 N.W.3d 211 (Minn. Ct. App. 2025)): reinforced that failure-to-diagnose/treat claims—even when COVID protocols exist—do not satisfy PREP Act causation absent a direct causal link to countermeasure administration/use.
  • Manyweather v. Woodlawn Manor, Inc. (40 F.4th 237 (5th Cir. 2022)): supported the distinction between claims about prioritization/allocation of countermeasures versus claims about non-use; the latter generally fall outside immunity.
  • Eaton v. Big Blue Healthcare, Inc. (480 F. Supp. 3d 1184 (D. Kan. 2020)): cited for the limiting proposition that using some countermeasures somewhere in a facility does not convert all claims arising there into PREP-immune claims.
  • Carmichael v. Beller (1996 OK 48) and Boyle v. ASAP Energy, Inc. (2017 OK 82): supplied summary-judgment standards used to affirm striking PREP immunity where the pleaded claims lacked the required causal relationship.
  • Cowen v. Walgreen Co. (2022 WL 17640208 (N.D. Okla. Dec. 13, 2022)) and Storment v. Walgreen, Co. (2022 WL 2966607 (D.N.M. July 27, 2022)): appeared in a footnote as examples of claims (vaccine injury) that do fall within PREP and CICP; the Court found them unpersuasive on the facts here.

4. Jury instructions/advisory opinion limitation

  • Ball v. Wilshire Ins. Co. (2007 OK 80) and Scott v. Peterson (2005 OK 84): used to decline review of gross-negligence instruction language because, under the special interrogatories, the jury never reached gross negligence—making the issue hypothetical.

5. Intervening/supervening causation

  • Thompson v. Presbyterian Hosp., Inc. (1982 OK 87): supplied Oklahoma’s three-part supervening-cause test (independent; adequate alone; unforeseeable).
  • Long v. Ponca City Hospital, Inc. (1979 OK 32) and Champlin Oil & Ref. Co. v. Roever (1970 OK 217): framed the “cause vs. condition” analysis and emphasized foreseeability as the key to whether subsequent conduct supersedes prior negligence.
  • Okla. Dep’t of Secs. ex rel. Faught v. Wilcox (2011 OK 82) and Jernigan v. Jernigan (2006 OK 22): enforced preservation rules barring a new appellate theory about third-party emergency responders as intervening cause.

B. Legal Reasoning

1. Oklahoma COVID-19 Act: “Impact” can be resolved as a matter of law when undisputed

Section 6406(C) grants immunity for loss to a person with suspected/confirmed COVID-19 caused by acts/omissions during the emergency if: (1) the act/omission occurred while arranging/providing COVID-19 services for treatment of the person “impacted” by decisions/activities/staffing/capacity responding to the emergency; and (2) the act/omission was not gross negligence or willful or wanton misconduct. The Court—guided by Austbo v. Greenbriar—treated “impact” as a distinct factual predicate: the patient must be “in some way affected” by COVID-era operational decisions.

Here, trial evidence showed Integris’ COVID visitor restrictions and checkpoint staffing rules prevented Blake’s mother from entering and from ensuring delivery of a note disclosing a family history of antithrombin III deficiency. There was no conflicting evidence, and Dr. Langerman acknowledged that knowing this history would have altered his diagnostic approach (likely prompting CT angiography). From these undisputed facts, the Court held only one inference was reasonable: the COVID policies “impacted” Blake’s treatment under § 6406(C)(1).

That conclusion mattered procedurally. Once § 6406(C)(1) is satisfied as a matter of law, the COVID-19 Act bars ordinary negligence and leaves only § 6406(C)(2)’s heightened fault standards (gross negligence or willful/wanton misconduct) for a factfinder. The Court found reversible error because the jury was allowed to impose liability on an ordinary-negligence theory.

2. PREP Act: no immunity absent a direct causal relationship to administration/use of a covered countermeasure

The Court separated (a) whether the PREP Act ousted state authority (it did not) from (b) whether PREP immunity applied on the merits (it did not).

  • No complete preemption: The PREP Act’s exclusive federal cause of action is limited to injuries proximately caused by “willful misconduct.” Parents pleaded ordinary negligence, so the claims were not transformed into a federal cause of action under Beneficial Nat’l Bank v. Anderson.
  • State court may decide defensive preemption: Consistent with Solomon v. St. Joseph Hosp. and Maglioli v. Alliance HC Holdings LLC, a state court may decide whether the pleaded claims fall within PREP immunity; if not, “there is no federal law left to apply.”
  • No causation nexus: Applying Hampton v. California and Schleider v. GVDB Operations, LLC, the Court required a concrete causal relationship between the loss and the administration/use of a covered countermeasure. Parents alleged misreading results and failure to diagnose/treat PE—not injury caused by an x-ray, EKG, stethoscope, or medication as countermeasures. This matched Austbo v. Greenbriar Nursing Home No. Two, Inc. (no record support for countermeasure causation) and Mills v. Hartford Healthcare Corp. (delay/protocol background does not itself create PREP causation as pleaded).
  • “Failure to administer” is not “administration or use”: Citing Manyweather v. Woodlawn Manor, Inc., Hudak v. Elmcroft of Sagamore Hills, and Martin v. Petersen Health Operations, LLC, the Court emphasized that PREP immunity generally protects conduct tied to administering/using (or allocating) a countermeasure, not claims that a provider failed to take additional diagnostic steps.
  • Hospital COVID policies did not establish PREP causation: The Court rejected the attempt to treat infection-control policies as “administration” of countermeasures absent proof that the injury was directly related to countermeasure distribution/dispensing activities (drawing on Hudak v. Elmcroft of Sagamore Hills and the Secretary’s Declaration examples).

Because PREP immunity did not apply, the Court also rejected Providers’ exhaustion argument: the compensation program process is not a prerequisite for claims that fall outside PREP coverage.

3. Intervening/supervening cause: patient noncompliance did not sever causation as a matter of law

Under Thompson v. Presbyterian Hosp., Inc., a supervening cause must be independent, adequate by itself, and not reasonably foreseeable. The Court concluded Blake’s failure to follow up and his refusal of transport did not meet that test. Providers’ alleged failure to diagnose PE remained a “but-for” causal factor; the later conduct was foreseeable given Blake was discharged with a COVID diagnosis and not told of abnormal EKG/x-ray readings. At most, Blake’s conduct presented a comparative-fault issue—one the jury actually applied by assigning Blake 25% negligence.

C. Impact of the Decision

1. Oklahoma COVID-19 Act litigation: “impact” is a low bar—but can be dispositive early (and may be decided as law)

The decision strengthens defendants’ ability to secure partial disposition in COVID-era malpractice cases by:

  • Treating the § 6406(C)(1) “impact” element as potentially resolvable as a matter of law where evidence is undisputed—limiting jury consideration to § 6406(C)(2)’s heightened culpability.
  • Clarifying that “impact” can arise from operational policies (visitor restrictions, checkpoint staffing rules) that disrupt information flow, even if the department is otherwise staffed and not in “surge” conditions at the moment of care.

2. PREP Act defenses in Oklahoma: a disciplined causation/nexus requirement

The Court aligns Oklahoma with multiple federal circuits by rejecting PREP immunity for “failure to diagnose/treat” theories lacking a direct causal relationship to countermeasure administration/use. Practically:

  • PREP immunity remains potent for claims like Franklin v. OU Med., Inc., where the countermeasure’s administration/use causes the injury.
  • But it will generally not convert ordinary malpractice claims into immune claims merely because COVID formed the clinical background or because a facility maintained infection-control protocols.

3. Causation defenses: comparative negligence will often do the work, not supervening-cause doctrine

By approving the trial court’s refusal to submit intervening/supervening cause (while allowing comparative negligence), the decision signals that post-discharge patient choices typically reduce damages via fault allocation rather than wholly severing causation—unless the strict Thompson criteria are met.

IV. Complex Concepts Simplified

  • Directed verdict: A ruling that removes an issue from the jury because, even viewing evidence favorably to the opponent, only one reasonable conclusion exists.
  • Statutory immunity (COVID-19 Act): A legislative bar to liability for ordinary negligence if statutory conditions are met; here, it shifts the case to a higher fault standard (gross negligence or willful/wanton misconduct).
  • “Impact” under § 6406(C)(1): Not a requirement of hospital overload or resource scarcity in the moment; it can be satisfied where COVID-response operational decisions affected the patient’s care “in some way.”
  • Complete preemption vs. defensive (ordinary) preemption: Complete preemption converts a state claim into a federal one (rare). Defensive preemption is an affirmative defense arguing federal law defeats the claim on the merits.
  • Covered countermeasure (PREP Act): Specific drugs, devices, tests, or other measures identified in the Secretary’s declaration; immunity requires more than their mere presence in a medical encounter.
  • PREP Act causation nexus: The injury must be caused by (or at least directly connected to) administering/using the countermeasure—not merely associated with pandemic-era conditions.
  • Intervening/supervening cause: A later event that fully breaks the causal chain only if it is independent, sufficient by itself, and unforeseeable.

V. Conclusion

BURGESS v. INTEGRIS HEALTH EDMOND, INC. crystallizes two complementary rules for pandemic-era healthcare litigation in Oklahoma: (1) under 63 O.S.2020, § 6406, undisputed evidence of COVID-response operational effects on a patient can satisfy the “impact” element as a matter of law, barring ordinary negligence and narrowing trials to gross negligence/willful-or-wanton misconduct; and (2) PREP Act immunity is not a general pandemic shield for malpractice—without a direct causal relationship between the loss and administration/use (or allocation) of a covered countermeasure, PREP immunity and its administrative-compensation pathway do not apply. The decision reallocates the fault inquiry: Oklahoma’s COVID-19 Act, not the PREP Act, is the principal immunity driver for ordinary-negligence claims arising from COVID-era operational restrictions, while comparative negligence—not supervening cause—will typically address post-discharge patient conduct.