Leann Putz v. State of Iowa d/b/a University of Iowa Health System

IN THE COURT OF APPEALS OF IOWA

No. 24-1710
Filed December 3, 2025

LEANN PUTZ,
Plaintiff-Appellant,

vs.

STATE OF IOWA d/b/a UNIVERSITY OF IOWA HEALTH SYSTEM,
Defendant-Appellee.
________________________________________________________________

Appeal from the Iowa District Court for Johnson County, Ian K. Thornhill,

Judge.

Plaintiff appeals the dismissal of her petition for medical malpractice for

failure to file a certificate of merit pursuant to Iowa Code section 147.140 (2024).

AFFIRMED.

Erin E. Jordan (argued) and Katie M. Naset of Hope Law Firm & Associates,

P.C., West Des Moines, for appellant.

Carolyn Russell Wallace (argued) and Jessica Tucker Glick of Phelan

Tucker Law L.L.P., Iowa City, for appellee.

Heard at oral argument by Greer, P.J., and Schumacher and Ahlers, JJ.
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GREER, Presiding Judge.

Not everything can speak for itself, especially when a layperson could not

have knowledge of whether proper surgical treatment was given without expert

testimony. After Leann Putz underwent vaginal hysterectomy surgery, she

experienced numbness in her foot and loss of motor function. She claims these

ailments stem from her surgery and they have negatively impacted her ability to

maintain an active lifestyle. Putz brought a lawsuit against the State of Iowa and

the University of Iowa Health System (collectively, State),1 arguing medical

malpractice because: Count I—the State failed to ensure surgical positioning,

operate in a way that would not cause permanent injury, and exercise ordinary

care and skill in the treatment of her; and Count II—there was a lack of informed

consent. The State moved to dismiss all claims. The district court granted the

motion to dismiss because her claims required expert testimony and the timely

filing of a certificate of merit. Putz appeals.2 We affirm the district court’s dismissal

finding that the medical negligence claims as pled required that Putz file a

certificate of merit.

I. Background Facts and Proceedings.

According to her pleadings, Putz sought medical treatment for urinary

incontinence and her physician and eventual surgeon recommended surgery.

Putz claims that before surgery she lived an active lifestyle running and lifting

1 The State noted in its motion to dismiss and in its brief on appeal that Putz was

incorrect when referring to the “‘University of Iowa Health System’ as an alternate
name (‘d/b/a’) of the State of Iowa. University of Iowa Health System is not a State
entity, but is rather a separate non-profit entity.”
2 Putz does not challenge the dismissal of her lack of informed consent claim,

limiting the appeal to her first medical malpractice claim.
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weights. On June 24, 2021, she was admitted to the University of Iowa Hospitals

and Clinics and underwent a vaginal hysterectomy, uterosacral colposuspension,

midurethral sling, and cystoscopy. Putz alleges after surgery she had numbness

in the plantar surface of her left foot and loss of motor function of the left foot. She

claims these symptoms are permanent and “[s]he is unable to perform any

exercise with shoes or to run any meaningful distance due to her symptoms.”

On March 15, 2024, Putz filed a petition claiming medical malpractice

against the State.3 In her petition raising a medical malpractice claim, she argued

that the State: (1) “failed to ensure proper surgical positioning,” (2) failed to operate

“in a way that would not cause permanent nerve injury,” and (3) “failed to exercise

the ordinary care and skill in keeping with their professions, and in the areas of the

professions in which they specialized, and in the manner in which they diagnosed,

cared for, treated, and otherwise rendered care to” her. She claimed her injuries

were the “direct and proximate result” of the State’s negligence.

The State answered on May 2, denying the allegations in Putz’s petition and

asserting affirmative defenses. Over sixty days passed, and Putz did not file

anything more. On July 16, the State moved to dismiss all claims and argued that

under Iowa Code section 147.140 (2024), Putz was required to file a certificate of

merit affidavit from a qualified expert within sixty days of its May 2 answer as all of

her claims required expert testimony.

On August 5, Putz filed her resistance to the motion to dismiss, arguing that

she was not required to file a certificate of merit because she was proceeding

3 Originally
she had additionally brought claims against three other previously
named defendants, but they have been dismissed from this action.
4

under the theory of res ipsa loquitur. The State replied on August 13, alleging that

Putz failed to plead res ipsa loquitur in her petition and that even if she had, her

claims could not be comprehended by a layperson without expert testimony. The

district court considered the State’s motion to dismiss without a hearing and

granted the motion. Putz appeals.

II. Error Preservation.

To start, we look at what issues were preserved for our review. “It is a

fundamental doctrine of appellate review that issues must ordinarily be both raised

and decided by the district court before we will decide them on appeal.” Meier v.

Senecaut, 641 N.W.2d 532, 537 (Iowa 2002). “When a district court fails to rule

on an issue properly raised by a party, the party who raised the issue must file a

motion requesting a ruling in order to preserve error for appeal.” Id.

On appeal, Putz brings four claims: (1) res ipsa loquitur applies to her

medical malpractice claim such that expert testimony is not required and thus she

is not required to file a certificate of merit under Iowa Code section 147.140; (2) res

ipsa loquitur is not a claim that must be pled separately; (3) the district court erred

limiting the res ipsa loquitur doctrine to cases where a foreign object is retained;

and (4) the district court erred “by finding that the res ipsa loquitur doctrine required

[her] to plead specific causation.”4 The State contests error preservation because

“[t]he district court did not rule that the doctrine of res ipsa loquitur (1) is a separate

4 At oral argument, the State conceded that it was not necessary for Putz to include

in her petition a specific causation theory under res ipsa loquitur. But, as we read
the district court ruling, it did not require Putz to specifically plead a theory of res
ipsa loquitur. Instead, the court found that even with a stated claim in the petition,
the doctrine of res ipsa loquitur was not applicable under these facts.
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claim that must be pled, rather than an evidentiary doctrine; (2) is limited to

retained foreign object cases; or (3) required [Putz] to plead specific causation.”

We find that the district court did not rule on her second, third, or fourth claim and

Putz did not move to enlarge the order, thus these claims were not preserved. We

turn to her sole surviving claim.

III. Standard of Review.

“We review rulings on motions to dismiss under Iowa Code

section 147.140(6) . . . for correction of errors at law.” Miller v. Cath. Health

Initiatives-Iowa, Corp., 7 N.W.3d 367, 372 (Iowa 2024) (citation omitted). “For

purposes of reviewing a ruling on a motion to dismiss, we accept as true the

petition’s well-pleaded factual allegations, but not its legal conclusions.” Struck v.

Mercy Health Servs.-Iowa Corp., 973 N.W.2d 533, 538 (Iowa 2022) (citation

omitted). “We construe the petition in its most favorable light, resolving all doubts

and ambiguities in the plaintiff’s favor.” Id. (cleaned up).

IV. Analysis.

Putz claims that res ipsa loquitur applies to her medical malpractice claim

such that expert testimony is not required and thus she need not have filed a

certificate of merit under Iowa Code section 147.140. The State contends the res

ipsa loquitur doctrine cannot apply because Putz’s claims require expert testimony

to show a breach of standard of care by these medical providers as the lack of

care is not so obvious to be within the common knowledge of a lay person.

“Res ipsa loquitur is Latin for ‘the thing speaks for itself.’” Banks v.

Beckwith, 762 N.W.2d 149, 151 (Iowa 2009) (citation omitted). To proceed under

the theory of res ipsa loquitur a plaintiff must present substantial evidence that:
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“(1) the injury was caused by an instrumentality under the exclusive control and

management of the defendant, and (2) that the occurrence causing the injury is of

such a type that in the ordinary course of things would not have happened if

reasonable care had been used.” Id. at 152 (citation omitted). When res ipsa

loquitur applies, expert testimony about the standard of care and breach is not

necessary because the professional breach is so blatant and obvious that the

average layperson understands the breach occurred without the specialized

testimony. Est. of Butterfield v. Chautauqua Guest Home, Inc., 987 N.W.2d 834,

841 (Iowa 2023) (“If a doctor operates on the wrong patient or amputates the wrong

limb, a plaintiff would not have to introduce expert testimony to establish that the

doctor was negligent.” (citation omitted)). But expert testimony is required to

establish the standard of care when the event at issue involved medical judgment.

Id.

In cases where “expert testimony is necessary to establish a prima facie

case” plaintiffs must submit “a certificate of merit affidavit signed by an expert

witness with respect to the issue of standard of care and an alleged breach of the

standard of care” within sixty days of the defendant’s answer. Iowa Code

§ 147.140(1)(a). Upon a motion to dismiss, plaintiffs who fail to comply with Iowa

Code section 147.140(1) shall have their claims requiring expert testimony

dismissed. Id. at § 147.140(6). “[T]he legislature enacted section 147.140 to

provide a mechanism for early dismissal with prejudice of professional liability

claims against healthcare providers when supporting expert testimony is lacking.”

Struck, 973 N.W.2d at 539.
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While Putz is correct that expert testimony is not always required when the

doctrine of res ipsa loquitur applies, simply asserting that res ipsa applies to your

claim is not enough to make it true. See Banks, 762 N.W.2d at 152; Perin v.

Hayne, 210 N.W.2d 609, 615 (Iowa 1973) (holding even though the plaintiff

provided expert testimony, there was not “any basis . . . for submission of res ipsa

loquitur” when a spinal surgery resulted in nerve injury that caused vocal cord

paralysis). Expert testimony has been required to establish technical matters that

are beyond the understanding of a layperson. Kennis v. Mercy Hosp. Med. Ctr.,

491 N.W.2d 161, 167 (Iowa 1992) (rejecting “plaintiff's claim that expert testimony

is not required under his res ipsa loquitur claim” when during an intestinal bypass

surgery a tube attached to the bladder became displaced and leaked urine into the

body); Forsmark v. State, 349 N.W.2d 763, 768–69 (Iowa 1984) (finding res ipsa

loquitur inapplicable when a brain injury occurred during heart surgery).

As in Struck, we begin with a review of the Putz’s claims in her petition.

Struck, 973 N.W.2d at 540–41. Putz pled that the medical providers “fell below the

standard of care” in these ways: “failed to ensure proper surgical positioning to

prevent injury,” “failed to operate . . . in a way that would not cause permanent

nerve injury,” and “otherwise failed to exercise the ordinary care and skill in

keeping with their professions.” Those theories address medical skill and

judgment and thus, as to those claims, we cannot conclude that Putz has a claim

where it would be obvious to a layperson that a breach occurred without

specialized testimony. So, we find Putz cannot survive dismissal under these

theories. Because these claims involved alleged “professional negligence” claims

and Putz did not file a certificate of merit, she effectively pleaded herself out of
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court. See id. at 541. Thus, as to the allegations found in Putz’s petition, a

certificate of merit with expert testimony as to the standard of care was required to

prove up the claim. Id. at 540 n.6.

Still resting on her request to apply the res ipsa loquitur doctrine, Putz

contends this case falls under an exception to the rule requiring a certificate of

merit. See Perin, 210 N.W.2d at 613 (recognizing three means to prove physician

negligence: (1) through expert testimony; (2) by evidence the lack of care was so

obvious to be within the layperson’s knowledge; and (3) by evidence the medical

provider injured a part of the body not involved in the treatment). Putz argues, but

for this surgery, she was not experiencing these leg and foot symptoms in an area

different than the part of her body involved in her surgery. As Putz urges, it is

common knowledge that it is improper for medical personnel to permanently

damage a patient’s lower extremities when performing a hysterectomy. See Wiles

v. Myerly, 210 N.W.2d 619, 624, 629 (Iowa 1973) (noting that “[i]nfliction of a burn

on the patient’s buttocks is not a normal or usual result” from surgery for correction

of a vascular circulatory problem “if due care is exercised in the performance of

the operation”).

So, does Putz’s allegation that her vaginal hysterectomy surgery resulted in

numbness and loss of motor function to her foot and leg require expert medical

testimony on the issue of a breach of the standard of care?

Section 147.140(1)(a) establishes that a certificate of merit is
required when a plaintiff pleads (1) an “action for personal injury or
wrongful death,” (2) “against a health care provider,” (3) which is
“based upon the alleged negligence in the practice of that profession
or occupation or in patient care,” and (4) “includes a cause of action
for which expert testimony is necessary to establish a prima facie
case.”
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Struck, 973 N.W.2d at 540. We find that this is not a case within the realm of a

layperson’s understanding, and thus this claim requires expert testimony. Contrast

Butterfield, 987 N.W.2d at 841 (proving an example of medical malpractice within

the understanding of a layperson as surgeon operating on the wrong limb) with

Forsmark, 349 N.W.2d at 768–69 (finding heart surgery resulting in a brain injury

beyond the scope of a layperson’s understanding).

We do not find that the connection between the alleged negligence related

to the surgery and the allegations of symptoms in her foot and leg is so blatant that

expert testimony is not required. Instead, Putz attempts to utilize the doctrine to

infer that some action produced her injury without knowing what that act is. “The

doctrine of res ipsa loquitur does not raise any inference as to what did occasion

the injury; but, after the evidence has established the thing which did occasion the

injury, then under certain circumstances, this doctrine will raise an inference of

negligence.” Wilson v. Paul, 176 N.W.2d 807, 809 (Iowa 1970) (cleaned up). Or

put another way, the doctrine of res ipsa loquitur “permits an inference that the

known act which produced the injury was a negligent act, but it does not permit an

inference as to what act did produce the injury. Negligence manifestly cannot be

predicated of any act until you know what the act is.” Tamco Pork II, LLC v.

Heartland Co-op, 876 N.W.2d 226, 235 (Iowa Ct. App. 2015) (citation omitted).

Here, the focus is on what the medical providers did or did not do during the

surgery, all of which relates back to professional skill and knowledge. That link

back to professional care and treatment, as opposed to a blatant action which a

layperson could know was outside of the physician’s lack of care, does not allow
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for the res ipsa loquitur rule to serve as an “avenue for recovery.” Jones v. Mercy

Hosp., No. 24-0139, 2025 WL 703183, at *8 (Iowa Ct. App. Mar. 5, 2025).

The district court did not error in finding that Putz was required to file a

certificate of merit to provide expert testimony on the issue of an alleged breach of

the standard of care and that dismissal of the claim was proper under

section 147.140(6). We affirm the district court’s dismissal of this claim.

V. Conclusion.

We affirm because the district court correctly found that Putz was required

to provide expert testimony for her claims. Thus, under Iowa Code

section 147.140, Putz was required to file a certificate of merit. Because Putz

failed to do so, she failed to comply with Iowa Code section 147.140(6). Her

remaining claims were not preserved for our review. We affirm the dismissal of

Putz’s petition.

AFFIRMED.