The Final Word on School Health Services:
Cedar Rapids CSD v. Garret F.

Facts and Case History

When he was four years old, Garret’s spinal column was severed in a motorcycle accident.  There was no adverse effect on his mental capacities.  He is ventilator dependent and needs someone nearby at all times.  In 1993, mother requested the school district to be financially liable for one-to-one school nursing services while Garret was at school.  The school district denied this and thought at that time they were not responsible for services they felt were “medical.” Garret was the only ventilator dependent pupil in this district of 17,500 students.  Mother requested a hearing and during the proceedings, the school district admitted the services were capable of being provided by a non-physician.  The administrative hearing officer held that the school district had to provide the services, for this reason, according to the Tatro case.  The school district then appealed the hearing officer’s administrative decision in federal court, and the court upheld the hearing officer’s ruling, granting the parent’s motion for summary judgment.  The Court of Appeals affirmed, using the Tatro “bright line” test, since it was undisputed that Garret could not attend school if the services were not provided.

The Supreme Court Opinion

District’s Position

In its petition, the school district asked the Supreme Court to overrule the appellate court in favor of a “multi factored” test, not a “bright line” test.  The Supreme Court held in favor of the Appellate Court because, they said, the text of the related services definition is very clear, and here, the district did not challenge the idea that Garret needed the services requested.  The court further commented in a footnote that they see no reason to either revise Tatro or rewrite the U.S. Department of Education’s regulations, which favor the test used by the Appellate Court.  The court therefore held that the in school services, while more extensive and expensive, must be provided, and further that Garret’s needs were no more “medical” then those needed by Amber Tatro in her case.  [1999 WL 104410*4.]

“Continuous” and “Complex” (Translation: Expensive)

The school district used an argument that the services were required in a complex form and they were necessarily “continuous.” Yet the court said unequivocally that “the district’s multi factor test is not supported by any recognized source of legal authority.” Just because “continuous” services may be more costly and require more personnel does not make them any more “medical” under Tatro.  [Footnote 8 at 1999 WL104410*5.]

Limitations of “Existing” Staff

The court further stated that the “district cannot limit educational access simply by pointing to the limitations of existing staff.  The district must hire specially trained personnel as required by law.”   As to this problem of existing school staff being unable to meet all of their responsibilities and provide for Garret too, the concept was dismissed out of hand.  As in Honig, the U.S. Supreme Court declined to read into the law a definition that was not present.  The court was remarkably consistent here.  Note also footnote 9 (at 1999 WL104410*5) which mentions that Garret had a teaching assistant who also was a qualified LPN.  In Iowa, the State Board of Nursing has held that RN’s can delegate responsibilities to LPNs.

The court further held that school districts cannot use cost itself in the definition of related of related services.  This would be “judicial law making without any guidance from Congress.” Citing Rowley, as courts always do, the court further required that districts must “open the door” of opportunity to all qualified children.  There is no “onerousness” exception.


The analysis in this case is just as simple as that found in the Tatro case: is meaningful access to the public schools assured?  This is not about the “level of education that a school must finance once access is attained.” To be specific, the services at issue were as follows:

  1. Ventilator checks;
  2. Ambubag (manual breathing assistance) when ventilator is being maintained and as needed;
  3. Urinary bladder catheterization;
  4. Suctioning of tracheotomy tube as needed;
  5. Getting Garret into a reclining position five minutes during every hour; and
  6. Assistance from someone who is familiar with emergency procedures, in other words, at least an LPN.

The court held that regardless of how expensive or complex (the dissent points out that the services will cost the school district $18,000 per year), the services must be provided if Garret is to remain in school.  It was held that the district is required to provide these services and further, that the Neely and Detsel cases (appellate cases favoring the approach of the district) have now been abrogated.


The U.S. Supreme Court has now adopted the Tatro “bright line” test: if a related service is required to enable a qualified disabled pupil to remain in school, it must be provided as long as it is not a purely “medical” service.  And “medical” is provider controlled, that is, if the service can only be provided by a licensed physician, it is an exempt “medical” service unless it is needed for diagnostic or evaluative purposes.  If, however, the service is capable of being delivered by a non-physician, it must be provided by school districts regardless of any financial or staffing burdens the act of providing the services might impose.  The Supreme Court has again – and quite predictably in light of the Honig case on expulsion – read the Act for its plain, simple meaning and has again declined to “read in” exceptions that are not present.