United States Court of Appeals
                       For the First Circuit


No. 24-1844

 BRAD O'BRIEN, Personal Representative of the Estate of Melissa

                               Allen,

                        Plaintiff, Appellant,

                                 v.

                      UNITED STATES OF AMERICA,

                        Defendant, Appellee.


            APPEAL FROM THE UNITED STATES DISTRICT COURT
                 FOR THE DISTRICT OF MASSACHUSETTS

           [Hon. Nathaniel M. Gorton, U.S. District Judge]


                               Before

                   Gelpí, Kayatta, Circuit Judges,
                     and Smith,* District Judge.



     Adam R. Satin, with whom Andrew C. Meyer, Jr. and Lubin &
Meyer, P.C. were on brief, for appellant.

     Kevin Benjamin Soter, with whom Brett A. Shumate, Acting
Assistant Attorney General, Leah B. Foley, United States Attorney,
and Dana Kaersvang, Attorney, Appellate Staff, Civil Division,
were on brief, for appellees.




     *   Of the District of Rhode Island, sitting by designation.
September 11, 2025
           GELPÍ, Circuit Judge.        Plaintiff-Appellant Brad O'Brien

("O'Brien") filed a wrongful death medical malpractice suit as the

personal representative of the estate of Melissa Allen ("Allen"),

who died eleven days after receiving medical care at Lowell General

Hospital ("LGH" or "the Hospital").           The suit alleged that LGH and

its providers -- including Dr. Fernando Roca ("Dr. Roca") -- were

negligent in    the   care of Allen,         acts   which O'Brien contends

resulted in Allen's death.         The district court dismissed the suit

for failure to make timely presentment under the Federal Tort

Claims Act ("FTCA").       We affirm.

                                 I. BACKGROUND

           O'Brien    is   the    surviving    partner   of     Allen   and   the

personal representative of her estate.           The tragic events leading

up to Allen's death are largely undisputed.               On July 26, 2016,

Allen suffered multiple seizures at her home.            She was brought to

LGH's emergency room and later admitted to the Hospital.                Hospital

staff determined that Allen was seven months pregnant and suffering

from severe hypertension.        Dr. Roca, an obstetrician, was on call

at LGH and attended to Allen.       Dr. Roca determined it was necessary

to   perform   an   emergency    caesarian     section   and,    subsequently,

delivered Allen's baby girl.        Following the birth, an unresponsive

Allen was transferred to the intensive care unit where a brain

scan revealed "devastating neurological injury."                Allen was then

flown by helicopter to a tertiary care hospital in Boston, where


                                    - 3 -
she died eleven days later.       The cause of death was listed as

"intracranial hemorrhage and eclampsia."

            In March 2021, O'Brien sued Dr. Roca and LGH in state

court.   At the time Dr. Roca rendered care, he worked for Lowell

Community   Health   Center   ("LCHC"),   a    center   receiving   federal

grants under 42 U.S.C. § 245b.      Also at the time of the relevant

events, LCHC was a "deemed" Public Health Service ("PHS") program

for purposes of 

              Dr. Roca needed clinical

privileges at a nearby hospital as a condition of his employment;

he obtained those privileges at LGH.          To maintain privileges, Dr.

Roca was required to participate in the Hospital's on-call rotation

system and treat incoming patients under the same.

            Under the Federal Employees Liability Reform and Tort

Compensation Act ("the Westfall Act"), the government substituted

itself for Dr. Roca and removed the case to federal court.              The

Westfall Act provides:

            Upon certification by the Attorney General
            that the defendant employee was acting within
            the scope of his . . . employment at the time
            of the incident out of which the claim arose,
            any civil action . . . commenced upon such
            claim   in    a   State   court    shall   be
            removed . . . to the district court of the
            United States . . . and the United States
            shall be substituted as the party defendant.

     1 "Deeming" under the Public Health Service Act ("PHSA")
refers to the process of granting federally funded health centers
and their employees the same legal protections as employees of the
PHS. See O'Brien v. United States, 

 (1st Cir.
2022).


                                 - 4 -


(d)(2).            The district court upheld substitution

and    dismissed    the    case,    holding   that   O'Brien's      claims     were

time-barred by the two-year limitations period under the FTCA.

O'Brien appealed.

            On appeal, the government acknowledged its argument

incorrectly relied on the Westfall Act, which applies to government

employees, instead of the PHSA, which applies to health centers.2

The government argued that substitution was still proper, although

for different reasons than would have applied under the Westfall

Act.    We vacated the substitution order and remanded given the

error    "brought    new    issues    into    play   and   left    gaps   in    the

evidentiary record."        O'Brien, 

.             On remand, the

government again moved for substitution, this time based on the

PHSA.     On September 6, 2024, the district court granted the

government's motion and dismissed O'Brien's complaint.                    O'Brien

again appeals.

                            A. STANDARD OF REVIEW

            We "review the grant of a motion to dismiss de novo,

accepting well-pled facts as true and drawing all inferences in

favor of the non-moving party."          3137, LLC v. Town of Harwich, 126



       2 "The Westfall Act amended the FTCA to make its remedy against

the United States the exclusive remedy for most claims against
Government employees arising out of their official conduct." Hui
v. Castaneda, 

 (2010).


                                      - 5 -
F.4th 1, 8 (1st Cir. 2025) (quoting Rivera-Rosario v. LSREF2 Island

Holdings, Ltd., 

 (1st Cir. 2023)).             "So, too, we

review de novo a district court's grant of a motion to substitute

the United States in lieu of a named defendant."      O'Brien, 

.

          We also review scope of employment determinations under

the same de novo standard.    McIntyre ex rel. Estate of McIntyre v.

United States, 

 (1st Cir. 2008) (citing Aversa v.

United States, 

 (1st Cir. 1996)).3

                       B. STATUTORY BACKGROUND

          The PHSA, 

, "protects PHS employees from

personal liability for injuries resulting from the performance of

medical services rendered within the scope of their employment."

O'Brien   v.   Roca,   

,   161   (D.   Mass.),

reconsideration denied sub nom., O'Brien v. Lowell Gen. Hosp., 

 (D. Mass. 2024) (citing 

(a)).

Pursuant to the PHSA, suits brought against employees of public

health centers receiving federal funds are governed under the FTCA,

.      Thus, when an action is filed against a PHS

employee in state court, the PHSA requires the government to be


     3 We have held that "motions to dismiss based on the FTCA's
statute of limitations should now be brought under Federal Rule of
Civil Procedure 12(b)(6) (failure to state a claim upon which
relief can be granted), or considered pursuant to Rule 56 (summary
judgment)." Morales-Melecio v. United States (Dep't of Health &
Hum. Servs.), 

 (1st Cir. 2018).


                                  - 6 -
substituted as the defendant and the case to be removed to federal

court upon the Attorney General's certification that the PHS

employee acted within the scope of his or her employment.                     See 

(c).           In other words, "[w]hen federal employees are

sued       for   damages    for   harms    caused    in   the   course   of   their

employment, the [FTCA] generally authorizes substitution of the

United States as the defendant."                  Hui, 

.       As we

explained in Morales-Melecio v. United States (Dep't of Health &

Hum. Servs.):

                 The FTCA constitutes a limited waiver of [the
                 United States'] sovereign immunity, allowing,
                 in relevant part, for damages claims to be
                 brought against the United States for any
                 "injury or loss of property, or personal
                 injury or death caused by the negligent or
                 wrongful act or omission of any employee of
                 the Government while acting within the scope
                 of his office or employment."

 (1st Cir. 2018) (quoting 28 U.S.C.§ 1346(b)(1)).4

       The Federally Supported Health Centers Assistance Act of 1995

("FSHCAA") amended the PHSA to allow for certain health care

entities to apply for federal funds and to extend, to health

centers, the "same PHSA and FTCA protections as are enjoyed by PHS




       "In lieu of personal liability, the statute makes available
       4

a tort action against the United States under the FTCA as the
'exclusive' remedy for certain 'act[s] or omission[s]' on the part
of PHS employees resulting in personal injury or death." O'Brien,

 (alterations in original) (quoting 

(a)).



                                          - 7 -
employees."   See O'Brien, 

 (citing 

(g)(1)(A)).   "[A] federally funded health center or any

particular individual associated with it must be 'deemed to be an

employee' of the PHS" in order for the protections to apply.     

These deeming determinations are made by the Secretary of the

Department of Health and Human Services ("Secretary").    If deemed,

a health center is generally covered under the FTCA when treating

its own patients; however, deeming does not conclusively establish

liability protection for services rendered to someone who was not

a patient of the health center.5      

.   Covered entities

have to "comport with specific requirements laid out in 233(g) and

accompanying [HHS] regulations." Bray v. Bon Secours Mercy Health,

Inc., 

 (6th Cir. 2024)(citing 

).6

          Further, an "act or omission [giving] rise to the claim"

must also have occurred while the defendant was "acting within the

scope of his office or employment."       

(a).    The



     5 "[T]he Secretary's annual 'deeming' determination does not
conclusively establish PHSA and FTCA coverage with respect to a
particular lawsuit when -- as in this case -- an action is brought
against a physician affiliated with a federally funded health
center." In such a case, "coverage hinges on the circumstances in
which care has been provided." O'Brien, 

.
     6 "These requirements include that the entity be a covered
entity; that the individual be a covered employee, contractor, or
officer of that entity; and that the individual act within the
scope of his or her employment. Additionally, coverage applies
only to services related to grant-supported activities." Bray, 

 (citing 

).


                              - 8 -
Attorney General determines whether to certify "that the defendant

was acting in the scope of his employment at the time of the

incident out of which the suit arose."          

 § 233(c).   "If the

Attorney General advises [a] court that the defendant has been

'deemed' a PHS employee 'with respect to the actions or omissions'

giving rise to the plaintiff's claims, removal is in order."

O'Brien, 

 (citing § 233(l)(1)).

            If   the   covered   individual   provided   services   to   a

non-patient of the covered entity, however, malpractice liability

protection requires either: (1) a specific determination by the

Secretary as to the specific arrangement at issue pursuant to 

(d)7 or (2) that the services provided "fall squarely


     7   The regulation provides:
            Acts and omissions related to services
            provided to individuals who are not patients
            of a covered entity will be covered only if
            the Secretary determines that:
            (1) The provision of the services to such
            individuals benefits patients of the entity
            and general populations that could be served
            by   the   entity    through  community-wide
            intervention efforts within the communities
            served by such entity;
            (2) The provision of the services to such
            individuals facilitates the provision of
            services to patients of the entity; or
            (3) Such services are otherwise required to be
            provided   to   such  individuals   under   an
            employment contract or similar arrangement
            between the entity and the covered individual.
     

(d).


                                   - 9 -
within" one of the listed scenarios the Secretary has already

categorically deemed covered under 

(e)(4).                    Bray,

.

                                  II. DISCUSSION

             O'Brien     makes    four    principal    arguments    on      appeal.

First, he contends that the district court erred in holding that

the regulation promulgated by the Secretary did not violate the

PHSA's statutory scheme.          Second, O'Brien argues that the district

court     erred   in    finding   that    deeming   extended   to     Dr.    Roca's

treatment of Allen.         Third, O'Brien believes his time to file a

claim did not begin accruing until he first spoke to his lawyer in

September 2017.         Lastly, O'Brien contends that, even if his claim

accrued before he spoke with his lawyer, the FTCA's Savings Clause

saves his claim.         We analyze each argument seriatim, concluding

that the district court correctly allowed the substitution of the

United States as the defendant and properly dismissed the case.

We, thus, affirm.

                         A. The Regulation's Validity

             As noted, by statute, health centers and their employees

are   generally        deemed   federal    employees    only   when      providing

services to individuals who are health center patients.8                        The


      8The statute provides:     "The deeming of any entity or
officer . . . of  the   entity   to  be   an   employee of   the
[PHS] . . . shall    apply     with    respect     to   services



                                      - 10 -
Secretary's      regulation     includes   two    methods   for     determining

whether FTCA coverage extends to non-patient services:

               The first method allows a health center or
               affiliated    individual   to    submit    an
               "application . . . seek[ing] a particularized
               determination" that coverage extends to the
               care at issue. The second method involves a
               predetermination by the Secretary that FTCA
               coverage extends in certain circumstances
               without any need for a "specific application"
               on the part of the entity or affiliated
               individual. To qualify for this predetermined
               coverage, the care rendered or the "activity
               or arrangement in question" must "fit[ ]
               squarely" into one of a number of scenarios
               described in the regulation.

O'Brien, 

 (alterations in original) (citations

omitted) (citing 

(e)(4)).             Where the activity or

arrangement does not fit squarely into one of the scenarios, an

additional "particularized determination of coverage" application

is required.         

(e)(4).

               When reviewing an application, the Secretary determines

whether provision of services to the relevant non-patient meets at

least    one    of    the   three   statutory    criteria   under    

(d).9      Those criteria are that the treatment must, in the view

of the Secretary, "benefit[] patients of the entity and general


provided . . . (i) to all patients of the entity, and (ii) subject
to subparagraph (C), to individuals who are not patients of the
entity." 

(g)(1)(B).
     9 The regulation goes on to list examples of specific
scenarios that fall within the scope of paragraph (d). See 

(e)(4)(i)-(iv).


                                      - 11 -
populations that could be served by the entity," "facilitate[] the

provision of services to patients of the entity," or be "otherwise

required under an employment contract (or similar arrangement)."

(g)(1)(C).           For    coverage     of   medical        services

provided to a non-patient, the federally funded health center

(generally)       must   submit      an     application       to     HHS.         See   

§ 233(g)(1)(D).

               The government tells us that the care provided in the

underlying       facts      of     this        case   falls    under         

(e)(4)(ii),         "Hospital-Related            Activities."                 O'Brien

challenges the legality of this provision, arguing that the issuing

of automatic or "blanket" pre-deeming -- without the required

documents      supporting        individualized       extension      of     coverage    or

pre-requisite review -- violates the PHSA and is beyond the powers

afforded to the Secretary.               In making this argument, O'Brien says

deeming of non-clinic patients is inappropriate until after the

Secretary has reviewed a particularized application for the care

in question. Thus, on this reading of the statute, O'Brien insists

the    district     court        erred    in     upholding     the     regulation       as

permissible.

               By contrast, the government contends that the district

court correctly concluded predeterminations are consistent with

the PHSA.        The government argues the statute does not require

health centers to submit "additional, unnecessary applications and


                                          - 12 -
information" for particularized determinations of coverage for

treatment    of    non-patients    during     certain    commonly     recurring

situations.       It counsels that a periodic hospital call required

for hospital admitting privileges, like Dr. Roca's treatment of

Allen, is covered.      Anything more would be too "impractical" and

"burdensome" for hospitals and health centers where they would

need to try to foresee and capture all possible future incidents.

The Secretary is given discretion to determine the form and manner

of deeming applications and, the government reasons, the decision

to pre-deem certain scenarios involving non-patients falls within

that discretion.

            We agree with the government that the regulation is

consistent    with     the   PHSA.       Relevant       here   is    

(g)(1)(C)(iii), under which the care by a health center

employee (like Dr. Roca) to a non-health center patient (like

Allen) meets the deeming criteria since such services "[were]

otherwise    required    under    an   employment   contract        (or   similar

arrangement) between the entity and an . . . employee . . . ."                 As

particularly relevant here, the implementing regulation reads:

"Periodic hospital call or hospital emergency room coverage is

required by the hospital as a condition for obtaining hospital

admitting privileges.        There must also be documentation for the

particular health care provider that this coverage is a condition

of employment at the health center."           

(e)(4)(ii).


                                     - 13 -
          The    HHS   mandates    that     any    services    described    in

subsection (e)(4) are already covered -- or "pre-deemed" -- under

(d) "without the need for specific application for

an additional coverage determination."              

(e)(4).

The statute provides that "[t]he Secretary may not" deem an entity

or its employee "and may not apply such deeming to services" to

non-patients "unless the entity has submitted an application for

such deeming to the Secretary in such form and such manner as the

Secretary shall prescribe."         

(g)(1)(D).              The

district court correctly observed that "[t]he statute refers to

the term 'application' in the singular, indicating that at least,

but not necessarily more than, one application is required."               The

statute, as written, does not require or specify the information

required for verification of coverage.            

(g)(1)(D).

We, thus, hold that the Secretary acted within his discretion in

implementing the regulation at issue.

                  B. Dr. Roca's Treatment of Allen

          As    relevant   to   O'Brien's    next    argument,    "

(d) provides that '[a]cts and omissions related to services

provided to individuals who are not patients of a covered entity

will be covered only if the Secretary' makes a particularized

determination that the arrangement satisfies certain enumerated

objectives of the FSHCAA."      Bray, 

.        "Absent a prior

particularized determination as to the coverage of the arrangement


                                  - 14 -
by the Secretary, treatment of non-entity patients falls outside

the    scope    of    coverage   unless      it     fits    within       one    of   the

circumstances enumerated by § 6.6(e)(4)."                  Id.    Section 6.6(e)(4)

lists four such circumstances.           The relevant circumstance here is

described in Section 6.6(e)(4)(ii), which provides that "[t]here

must . . . be        documentation     for    the       particular       health      care

provider that [the relevant] coverage is a condition of employment

at the health center."        

(e)(4)(ii).

              The district court found that Dr. Roca's treatment of

Allen met those conditions.            In so holding, it stated that "Dr.

Roca's employment contract with [LCHC] required that he provide

on-call coverage at [the Hospital]."                    It, thus, found that Dr.

Roca's treatment of Allen was covered by the regulation because it

was (1) periodic and (2) "required by the hospital as a condition

for obtaining hospital admitting privileges."

              On appeal, O'Brien argues that Dr. Roca's treatment of

Allen does not fit within the (e)(4) exception.                   He tells us that

Dr. Roca's employment contract only required that Dr. Roca obtain

admitting privileges at a hospital in the vicinity of LCHC and

that there is no mention of emergency room coverage.                       Therefore,

the argument goes, Dr. Roca was not contractually obligated to

care    for    non-health     center     patients         under    his     employment

agreement,      so    his   deeming    (and       its    accompanying          liability

protection) did not extend to his treatment of Allen, a non-health


                                      - 15 -
center patient.         Without a contractual obligation to provide the

care in question, O'Brien argues that the statute required a

particularized         deeming      application -- in      addition      to    LCHC's

initial deeming application -- to extend coverage of services

provided by Dr. Roca to a non-patient such as Allen.

            Furthermore,         O'Brien     contends     that     the   regulation

"explicitly    requires        there    be   documentation       that    Dr.   Roca's

treatment    of    Ms.    Allen . . . was        a   condition     of    Dr.   Roca's

employment at the health center."10                  O'Brien contends no such

documentation was ever submitted or approved.                  Given Dr. Roca was

not contractually obligated to care for Allen and no particularized

deeming    application        was    submitted,      O'Brien   submits     that   the

district court erred in ruling that the United States was properly

substituted as the defendant under the Health Centers Act.

            In response, the government argues no further deeming

application was needed to cover Dr. Roca's treatment of Allen.

The government reasons that Dr. Roca's contract required him to

participate       in    LCHC's      "departmental      call      schedule,"    which

consisted of caring for LCHC patients admitted to one of the

approved hospitals within the center's vicinity -- a radius which

included    LGH.        For   access    to   the     hospital's    facilities     and


     10Documentation that hospital emergency room coverage was a
condition of Dr. Roca's employment at the health center is a
factual pre-requisite for application of the on-call exception.

(e)(4)(ii).


                                        - 16 -
authorization to admit LCHC patients, Dr. Roca needed to "maintain

[clinical]    privileges"         by   "conform[ing]     with . . . all      rules,

regulations and by-laws promulgated by" the hospital.                Indeed, one

of the hospital's regulations required that Dr. Roca participate

in LGH's hospital call rotation, which included treating non LCHC

patients.    Therefore, the government argues, Dr. Roca's employment

at LCHC was contingent on his participation in LGH's hospital call

rotation, which required him to treat non-health center patients

such as Allen.        Accordingly, the government reasons, Dr. Roca's

deeming extended to his care of Allen and was covered under 

(g)(1)(C).

             We    agree   with    the    government's      understanding.      Dr.

Roca's employment contract with LCHC required he "participate in

the departmental call schedule" and, as such, stated that he "may

be asked to be on primary call wherein [he] will be responsible

for addressing all [LCHC] patient care responsibilities when such

patients seek services either by the telephone or when they present

at [LGH]."        It also stated that the "[p]hysician shall maintain

privileges at a hospital within a reasonable vicinity of [LCHC]

throughout        duration   of        this    Agreement,    including     [LGH]."

Furthermore,         Dr.      Roca            needed   to       "conform       with

all . . . regulations and by-laws promulgated by [LCHC] and such

other hospitals at which Physician has clinical privileges."




                                         - 17 -
            Thus, Dr. Roca was contractually obligated to maintain

admitting privileges at LGH, and, to do that, Dr. Roca needed to

treat non health center patients, like Allen, during required LGH

on-call rotations.

            Bray v. Bon Secours Mercy Health, Inc. reached a similar

conclusion, with the Sixth Circuit holding that a physician's

conduct fell under the regulation where that conduct furthered

"grant objectives and the provision of care" to patients. 

.     That suit also involved a non-patient pregnant woman,

treated by a physician who was required by his contract to "obtain

and maintain hospital privileges as a part of [his] practice."

 (alteration in original).      The Bray physician was also

required to "provide call coverage overnight and on weekends."

    Like the Bray record, the record here supports the conclusion

that LCHC required Dr. Roca to obtain and maintain admitting

privileges for on-call shifts -- like the one in which Dr. Roca

encountered Allen.    

.

            The government has provided the necessary documentation

to show that LGH conditioned admitting privileges on satisfaction

of on-call coverage and that Dr. Roca acted in accordance with

that    condition   when   treating   Allen.   Thus,   the   necessary

requirements under the § 6.6(e)(4)(ii) exception were met.




                                 - 18 -
                        C. Timeliness of FTCA Claim

            We   have    held    that    legal   questions       regarding    the

timeliness of an FTCA claim are reviewed de novo.            Skwira v. United

States, 

 (1st Cir. 2003).             We also review de novo

appeals   involving      "only   the    objective    reasonableness      of   [a]

plaintiff['s] failure to discern at an earlier time both their

injury and its likely cause."           Donahue v. United States, 

 (1st Cir. 2011); see Skwira, 

.

            The FTCA's statute of limitations provides that "[a]

tort claim against the United States shall be forever barred unless

it is presented in writing to the appropriate Federal agency within

two years after such claim accrues."          

(b).        A tort

claim   under    the    FTCA   generally   accrues    at   the    time   of   the

plaintiff's injury.       Donahue, 

; see also Gonzalez

v. United States, 

 (1st Cir. 2002).               However, the

Supreme Court has held that a "discovery rule" exception may toll

the commencement of accrual in medical malpractice cases.                Skwira,

 (citing United States v. Kubrick, 

(1979)); see also McIntyre v. United States, 

 (1st

Cir. 2004) (the discovery rule also applies to wrongful death

actions).    The exception delays the commencement of the clock to

when "plaintiff discovers, or in the exercise of due diligence

should have discovered, the factual basis for the cause of action."

McIntyre, 

 (citation omitted); see also Donahue, 634


                                    - 19 -
F.3d at 624 (finding accrual begins once the generally available

information   or     the   likely   outcome   of    a    reasonably   diligent

investigation is sufficient for the plaintiff to reasonably know

they were injured).

            This does not mean a plaintiff must know the "full extent

of the injury."        Morales-Melecio, 

     (citation

omitted). In clarifying the knowledge prong of the discovery rule,

this court has held that a plaintiff does not need actual or even

suspected knowledge that the injury was negligently inflicted,

Donahue, 

, nor that the acts might constitute

medical malpractice, Kubrick, 

. Instead, plaintiffs

need only be reasonably diligent when, once they know of the injury

and   its   cause,    they   inquire   within      the   medical    and   legal

communities as to whether the treatment was proper and conformed

to the generally applicable standard of care.             Gonzalez, 

 (citations omitted).11

            We have held that the FTCA's statute of limitations is

triggered by "the discovery of sufficient facts about the injury

and its cause to prompt a reasonable person to inquire and seek

advice preliminary to deciding if there is a basis for filing an



       Once a potential claimant is aware of the injury and the
      11

identity of the parties who caused it, he is no longer "at the
mercy of" the government and can seek counsel from doctors or
lawyers regarding the injury and the care received. See Kubrick,

.


                                    - 20 -
administrative claim against the government."                Skwira, 

.12    In order for a plaintiff to take advantage of this discovery

rule, he or she must demonstrate that the "factual basis for the

cause of action [was] inherently unknowable at the time of the

injury" for his or her claim to be found timely.                  Gonzalez, 

.   Anything       less     countervails   the   statute   of

limitations'       purpose   in    "requir[ing]      the   reasonably   diligent

presentation of tort claims against the Government."                  

 (citing

Kubrick, 

); see Skwira, 

 (finding the

factual basis of a claim is "inherently unknowable" when there are

no facts discoverable through the exercise of reasonable diligence

for a plaintiff to reasonably believe there may be a connection).

               O'Brien argues his cause of action did not begin accruing

until September 6, 2017, when he                 first met with his lawyer.

Importantly,       according      to   O'Brien,    Allen's   death    certificate

listed "eclampsia as a consequence of pregnancy" as the cause of

death.        O'Brien argues that because these were natural causes,

there was no indication that any errors in care caused Allen's

death.        It was not until O'Brien met with his lawyer, he claims,

that he learned Dr. Roca's possible failure to properly treat the



        In Skwira, where the family was told the victim died of
        12

natural causes, the question was when, as a factual matter, was
there sufficient information available to the plaintiffs to reveal
a causal connection between the injury and the government. Skwira,

.


                                        - 21 -
eclampsia within the required standards of care could have caused

the death of Allen. O'Brien contends that the district court erred

in holding that "accrual of the plaintiff's claim was not tolled

by the federal discovery rule."          He also argues that absent

specialized medical expertise, it was reasonable to believe Allen

inevitably died naturally from the medical emergency that began

before being treated by Dr. Roca, not from any negligence in

treatment.   Therefore, O'Brien reasons, time began to accrue when

he first learned, on September 6, 2017, that the doctor's actions

could be a probable cause of Allen's death.      Since O'Brien had two

years to file, he argues his filing in June of 2019 was timely.

          The government argues the accrual began at the time of

Allen's death on August 6, 2016, and the district court correctly

ruled that the discovery rule did not pause accrual of O'Brien's

claims until he spoke with an attorney.         The government argues

that even if O'Brien could not have reasonably known about the

negligence, he failed to show reasonable diligence in inquiring

about the factual basis for a cause of action.          The government

argues that O'Brien had two years to investigate the death of Allen

and file a claim.   However, he waited over a year after Allen's

death to first speak with a lawyer.      After meeting with his lawyer,

O'Brien still had eleven months to timely file his claim and

nevertheless failed to do so.     Therefore, the government argues,




                                - 22 -
O'Brien's claims expired in August 2018 and the filing in June

2019 was untimely.

             In Sanchez v. United States, we stated: "[t]he death of

a generally healthy woman in childbirth is sufficiently rare in

this country today so as to make most reasonable people ask why it

happened."         

    (1st     Cir.    2014).         Furthermore,

retaining counsel following such a death "is a telling sign that

a     reasonable     person       would        have    concluded        that    'reasonable

diligence' was called for in order to determine whether there was

negligence."        

    So, too, in Morales-Melecio v. United States.

There, we held that appellant's claim was time-barred and rejected

the    argument     that    the    cause        of    death     for    the     decedent -- a

thirty-six-year old man weighing over 370 pounds with a history of

hypertension -- was           unclear          because     he     was     not    "generally

healthy."    

.             Moreover, we also held appellants had

sufficient facts about decedent's condition and care before their

receipt of the death certificate to alarm a reasonable person the

probable cause of death was connected to the defendant's treatment,

or lack thereof.          Id.; cf. Cascone v. United States, 

    (1st   Cir.    2004)       (finding        there     "was       nothing    inherently

suspicious in [decedent's] reported death of an apparent heart

attack," where the death certificate listed the cause of death as

"chronic atrial fibrillation" (emphasis omitted)); K.B. v. United

States, No. 23-CV-12030-ADB, 

, *4 (D. Mass. May 24,


                                           - 23 -
2024) (the transfer of a patient to Tufts Children's Hospital, a

tertiary hospital, created a reasonable basis to know an injury

related to the care had occurred, even without access to the full

medical records).13

           O'Brien argues this reasoning does not apply as Allen

was not "generally healthy" because the medical emergency began

before she was admitted and treated by Dr. Roca.           This argument

misses the mark.    One medical emergency does not conclusively mean

Allen was not "generally healthy."        There is no indication in the

record    Allen   previously   suffered    a   difficult   or   high-risk

pregnancy, nor that she had a history of illness. O'Brien provides

no other basis for his argument and, so, is not entitled to tolling

of the statute of limitations.

                          D. Savings Clause

           "The Savings Provision of the FTCA cannot resurrect the

plaintiff's claim[ but may] excuse[] a plaintiff's failure to

exhaust administrative remedies where" two circumstances are met.

Gonzalez, 

 n.11.     Those two circumstances are that

"(1) the tort claim accrued within two years of the filing of the


     13 In Cascone, the fact that the decedent was admitted for
treatment of a different illness, rather than a cardiac condition,
did not undermine the inference that he died of natural causes.
The court held, "[i]t was perfectly reasonable for [the family of
the decedent] to believe . . . that the [new illness] exacerbated
his preexisting heart conditions or that his heart problems simply
happened to flare up at that point, independently of his other
illness." Cascone, 

 n.12.


                                 - 24 -
state court action and (2) the plaintiff presents the claim to the

appropriate federal agency within sixty days after the dismissal

of the action."     Id.; see also 

(d)(5).14   Here,

O'Brien fails at the first step: As explained above, he did not

file in state court within two years of accrual of his claims.

                           III. Conclusion

            For the foregoing reasons, we affirm.




14   The clause reads:

            (5) Whenever an action or proceeding in which
            the United States is substituted as the party
            defendant under this subsection is dismissed
            for failure first to present a claim pursuant
            to section 2675(a) of this title, such a claim
            shall be deemed to be timely presented under
            section 2401(b) of this title if—
            (A) the claim would have been timely had it
            been filed on the date the underlying civil
            action was commenced, and
            (B) the claim is presented to the appropriate
            Federal agency within 60 days after dismissal
            of the civil action.
       

(d)(5).


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