Opinion issued August 5, 2021

In The 

## Court of Appeals For The 

## First District of Texas

———————————— NO. 01
- 19
- 00 874
- CV

——————————— CHCA CLEAR LAKE, L.P. D/B/A CLEAR LAKE REGIONAL MEDICAL CENTER, WILLIAM UZELMEI E R, M.D., MICHAEL NORMAN, M.D., DARRELL L. MOULTON, JR., M.D., SAFI MADA I N, M.D., AND CHERYL BREAUX, FNP , Appella nt s

V. JON K. STEWART , Appell e e
On Appeal from the 152nd District Court

Harris County, Texas Trial Court Ca se No. 2018
- 76280

MEMORANDUM OPINION2

In this interlocutory appeal, 1 appellant s , CHCA Clear Lake, L.P., doing business as Clear Lake Regional Medical Center (“Clear Lake Regional”), William Uzelmeier, M.D., Michael Norman, M.D., Darrell L. Moulton, Jr., M.D., Safi Madain, M.D., and Cheryl Breaux, FNP (collectively, “appellants”) , challenge the trial court ’ s order s overruling their objections and denying their motions to dismiss the health care liability claim s 2 brought against them by appellee, Jon K. Stewart, in
h is suit for negligence. In multiple issues , appellants contend that the trial court erred in overruling their objections and denying their motions to dismiss Stewart ’ s claims against them

. 3
We reverse and remand. Background In h is first amended petition, Stewart alleges that on October 22, 2016, he was involved in a “bicycle incident.” He was admitted to Clear Lake Regional as a trauma patient. Dr s . Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux provided Stewart with medical care. While at Clear Lake Regional, it wa s “noted” that Stewart had “a compromised spine with extensive

1 See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 51.014(a)(9).
2 See id. § 74.001(a)(13) (defining “[h]ealth care liability claim” (internal quotations omitted) ). 3 See id. § 74.351 (governing expert reports).3

cervical disc disease [ 4 ] that made him susceptible to be[ing] easily injured.” Yet none of the physicians nor nurse practitioner Breaux “took [any] affirmative action to inform

. . . Stewart [that] he should take precautions to guard his neck or [that he should] seek additional medical treatment” related to his cervical disc disease. After Stewart was discharged from Clear Lake Regional, he had surge ry to repair his injuries from the bicycle incident. Another physician from another hospital performed that surgery. Stewart alleges that s ometime later , after his surgery, he was rendered a quadriplegic. Stewart brings health care liability claims again st appellants, alleging that they failed to exercise the requisite degree of skill and care ordinarily exercised by any careful, prudent physician, resident, intern, representative, employee , or agent in the same or similar circumstances. According to Ste wart , appellants were negligent in failing to inform him of “a dangerous medical condition” and failing to adequately
document that condition. Appellants ’ negligence “proximately caused [Stewart ’ s] resulting injuries and damages.” Stewart also alleges th at Clear Lake Regional is vicariously liable for the negligent acts and omissions of its “agents, servants, and/or employees.”

4 See Rumz ek v. Lucchesi , 543 S.W.3d 327, 334 n.5 (Tex. App.

— El Paso 2017, pet. denied) (“Cervical degenerative disc disease develops when one or more of the cushioning discs in the cervical spine starts to break down due to ‘wear and tear’ over the course of the patient’s lifetime.”).4

Stewart requests damages for the reasonable costs of necessary medical treatment in the past, the reasonable costs for any necess ary medical treatment in the future, the physical pain and mental anguish Stewart suffered in the past and will suffer in the future, the physical impairment and disfigurement Stewart suffered in the past and will suffer in the future, and the loss of earn ing capacity Stewar t suffered in the past and will suffer in the future. Stewart also seeks punitive damages. To support h is claim s , Stewart timely served appellants with two medical expert reports. The first expert report was authored by Thomas M. DeB erardino,
M.D. 5 The second report was authored by Julie Lindenberg, DNP. 6 Appellants objected to the expert reports on multiple grounds and moved to dismiss Stewart ’ s claims against them. In response to appellants ’ objections and motions to dismiss,
Stewar t sought an extension under Texas Civil Practice and Remedies Code section 74.351(c) to cure any deficiencies in his expert reports. 7 After a hearing, the trial court granted Stewart ’ s motion for extension, allow ing him thirty days “to cure any deficiencies in his expert reports.”

5 Dr. DeBerardino attached his curriculum vitae (“CV”) to his expert report.
6 Lindenberg attached her CV to her expert report.
7 See id. § 74.351(c).5

Stewart then served on appellants an amended expert report authored by Dr. DeBerardino. 8 In his amended expert report, Dr. DeBerardino states that he is a licensed physician and is boa rd certified in orthopedic surgery. He also holds a certificate of additional qualification in sports medicine. He primarily practices in the area s of orthopedic surgery and sports medicine

. H e is a practicing orthopedic
surgeon. Additionally, Dr. DeBe rardino notes that he is the clinical professor of orthopedic surgery at Baylor College of Medicine at t he San Antonio Orthopedic Group, the co

- director of the Baylor College of Medicine

– San Antonio Combined Texas Sports Medicine Fellowship, the Gold Cup International Soccer s ports

m edicine c onsultant, the medical director for the Burkhart Research Institute of Orthopedics of t he San Antonio Orthopedic Group, a practicing orthopedic surgeon
at t he San Antonio Orthopedic Group, and a member of the Physicia n Leadership Counsel for the Baptist North Central Hospital in San Antonio, Texas. His medical experience includes a military medical background and assignments including an orthopedic residency at the Tripler Army Medical Center, a joint and soft tissue t rauma fellowship at the U.S. Army Institute of Surgical Research, a joint and soft tissue trauma fellowship at the West Point MEDDAC, a member of the orthopedic staff on the orthopedic surgery service at the Brooke Army

8 Dr. DeBerardino attached his CV to his amended expert report. The amended e xpert report superseded Dr. DeBerardino ’ s initial expert report. See Cornejo v. Hilgers , 446 S.W.3d 113, 124 n.11 (Tex. App.

— Houston [1st Dist.] 2014, pet. denied).6

Medical Center, the chief of the spo rts medicine section of the orthopedic surgery service at the Brooke Army Medical Center, the chief of the orthopedic surgery service at the 801st Combat Support Hospital in support of Operation Iraqi Freedom , and the chief of the orthopedic surgery service at Keller Army Hospital

. Dr. DeBerardino also explains that as a military physician he was trained in

an d practiced in trauma and emergency care. And he has directed hospital staff regularly . Dr. DeBerardino states that he often treats patients , like Stewart, who ha ve extensive mid to low cervical degenerative disc disease . He is familiar with the standar d of care for sports and traumatic cervical spine injuries. In his report, Dr. DeBerardino states that on October 22, 2016, Stewart was involved in a “ bicycle incident ” and was admitted to Clear Lake Regional as a trauma patient. Drs. Uzelmeier, Norman, M oulton, and Madain and nurse practitioner Breaux provided Stewart with medical care. While at Clear Lake Regional, it was “noted” that Stewart had “a compromised spine with extensive cervical disc disease that made him susceptible to be[ing] easily injure d.” Yet n one of the physicians nor nurse practitioner Breaux “took [any] affirmative action to inform

. . . Stewart [that] he should take precautions to guard his neck or [ that he should ] seek additional medical treatment.” After being discharged from Cl ear Lake Regional, another physician from another hospital performed surgery to repair Stewart’s bicycle

- incident injuries. Later, Stewar t broke his neck and injured his7

spinal cord in the same location of an “undisclosed stenosis.” 9 He is now a quadriplegic. As to the standard of care and breach of the standard of care for Dr. Uzelmeier, a radiologist, Dr. DeBerardino states that on October 22, 2016, Dr. Uzelmeier made a radiology report to Dr. Madain about Stewart that s aid : “Post erior osteophytes at
C5

- 6 and C6

- 7 result in mild acquire [d] spinal stenosis” and “ [m] id to lower cervical degenerative disc disease with reversal of cervical curvature.” (Internal quotations omitted.) According to Dr. DeBerardino, when a radiologist ’ s findings show that a patient has extensive mid to lower cervical degenerative disc disease, the radiologist must inform the patient of the condition and its risks , so that the patient can take the necessary steps to avoid any known risks and complications such as spinal fractures. 10 Dr. Uzelmei e r breached the standard of care by: (1) failing to inform Stewart that he had extensive mid and lower cervical degenerative disc disease and

9 See Pacheco

- Serrant v. Munoz , 555 S.W.3d 782, 786 n.4 (Tex. App.

— El Paso 2018, no pet.) (“According to medical literature, stenosis means the abnormal narrowing of a body channel. When combined with the word spinal, it defines a narrowing of the bone channel occupied by the spinal nerves or the spinal cord.” (internal quotations omitted)). 10 Dr. DeBerardino states that , as an orthopedic surgeon, he is qualified to opine on the standard of care for a radiologist because orthopedic surgeon s work closely with radiologists and the specialties are intertwined. Both specialties review and interp ret imaging tools such as x

- rays, computed tomography (“CT”) scans, and magnetic resonance imaging (“MRI”) results and are responsible for correctly and accurately informing patients of their diagnoses and risk factors.8

(2) failing to be a patient advocate and inform Stewart of the serious co nsequences of that condition. As to causation for Dr. Uzelmei e r, Dr. DeBerardino states that Dr. Uzelmeier had a discussion with Dr. Madain and Dr. Norman about th e care that Stewart was receiving. But Dr. Uzelmeier did not inform Stewart of the extensive mid to lower cervical degenerative disc disease and the possibility of serious injury or death as a consequence of the condition. Because Dr. Uzelmeier violated the standard of care for a radiologist, Stewart suffered a spinal cord injury in the same loc ation as an “undisclosed stenosis.” If Dr. Uzelmeier had followed th e standard of care, within a reasonable medical probability, Stewart ’ s neurologic condition would have remained stable and would not have progressed. He would have had the option of

rece iving neurosurgical consultation and care, which could have include d further neurological testing, like e lectromyography (“EMG”), detailed cervical spine care and activity limitations, physical therapy/rehabilitation, and/or surgical intervention.
Stewart would have had surgery to correct his condition, or he would have been prohibited from engaging in the activities that led to his broken neck. Instead, profound neurologic compromise occurred. Because Stewart was not informed of his fragile condition an d the need to take immediate protective measures until his condition could be corrected, he continued to engage in his normal athletic activities, risking and injuring his spinal cord, which led to a neurological injury. Had Stewart9

been properly advised of his condition, based on his medical records showing patient compliance with physician instruction, it is likely that he would have obeyed a physician’s instructions to restrict his activity until further evaluation and treatment of his condition could b e undertaken and he would not have suffered a broken neck and a neurological deficit. As to the standard of care and breach of the standard of care for Dr. Madain, Dr. DeBerardino states that on October 22, 2 01 6, Dr. Madain , an emergency room physician, re ceived a radiology report from Dr. Uzelmeier about Stewart . The radiology report s aid : “Posterior osteophytes at C5

- 6 and C6

- 7 result in mild acquire [ d ] spinal stenosis” and “ [m] id to lower cervical degenerative disc disease with reversal of cervical curvature.” (Internal quotations omitted.) According to Dr. DeBerardino, when a patient ’ s records show a finding of extensive mid to lower cervical degenerative disc disease, an emergency room physician must inform the patient of this condition and its risks, so that the patient can take the necessary steps to avoid any known risks and complications, such as spinal fractures. 11 Dr. Madain breached the standard of care by: (1) failing to inform Stewart that he had extensive

11 Dr. DeBerardino states that , as a n orthopedic surgeon, he is qualified to opine on the standard of care for an emergency room physician because orthopedic surgeon s work closely with emergency medicine physicians and the specialties are intertwined. Also, as a military physician , Dr. DeBe rardino was trained in and practiced in trauma and emergency care.10

mid and lower cervica l degenerative disc disease and (2) failing to be a patient advocate and inform Stewart of the serious consequences of that condition. As to the standard of care and breach of the standard of care for Dr. Norman, a trauma physician, Dr. DeBerardino states that when a patient ’ s records show a finding of extensive mid to lower cervical degenerative disc disease, a trauma physician must inform the patient of this condition and its risks, so that the patient can take the necessary steps to avoid any known risks and complications, such as spinal fractures. 12 Dr. Norman breached the standard of care by: (1) failing to inform Stewart that he had extensive mid and lower cervical degenerative disc disease and (2) failing to be a patient advocate and inform Stewart of the serious consequences of that condition. As to causation for Drs. Madain and Norman, Dr. DeBerardino states that the physicians did not inform Stewart of the extensive mid to lower cervical degenerative disc disease and the possibility of serious inj ury or death as a consequence of the condition. Because Dr s. Madain and Norman violated the applicable standard s of care for an emergency room physician and a trauma physician , respectively, Stewart suffered a spinal cord injury in the same location as

12 Dr. DeBerardino states that, as an orthopedic surgeon, he is qualified to opine on the standard of care for a trauma physician because orthopedic surgeon s work closely with trauma physician s and the specialties are intertwined. Also, as a military physician , Dr. DeBerardino was trained in and practiced in trauma and emergency care.11

an “undisclosed stenosis.” If Drs. Madain and Norman had followed th e standard s of care, within a reasonable medical probability, Stewart ’ s neurologic condition would have remained stable and would not have progressed. He would have had the option of recei ving neurosurgical consultation and care, which could have include d further neurological testing, like EMG, detailed cervical spine care and activity limitations, physical therapy/rehabilitation, and/or surgical intervention. Stewart would have had surger y to correct his condition, or he would have been prohibited from engaging in the activities that led to his broken neck. Instead, profound neurologic compromise occurred. Because Stewart was not informed of his fragile condition and the need to take immediate protective measures until his condition could be corrected, he continued to engage in his normal athletic activities, risking and injuring his spinal cord, which led to a neurological injury. Had Stewart been properly advised of his condition, based on his medical records sh owing patient compliance with physician instruction, it is likely that he would have obeyed a physician’s instructions to restrict his activity until further evaluation and treatment of his condition could be undertaken , and he would not have suffered a br oken neck and a neurological deficit. As to the standard of care and breach of the standard of care for Dr. Moulton, an orthopedic surgeon , Dr. DeBerardino states that when a patient ’ s records show a finding of extensive mid to lower cervical degenerative disc disease, an orthopedic12

surgeon must inform the patient of this condition and its risks, so that the patient can take the necessary steps to avoid any known risks and complications, such as spinal fractures. 13 Dr. Moulton breached the standard of care by: (1) failing to inform Stewart that he had extensive mid and lower cervical degenerative disc disease and (2) failing to be a patient advocate and inform Stewart of the serious consequences of that condition. As to causation for Dr. Moulton, Dr. DeBer ardino states that Dr. Moulton did not inform Stewart of the extensive mid to lower cervical degenerative disc disease and the possibility of serious injury or death as a consequence of the condition. Because Dr. Moulton violated the standard of care for an orthopedic surgeon, Stewart suffered a spinal cord injury in the same location as an “undisclosed stenosis.” If Dr. Moulton had followed th e applicable standard of care, within a reasonable medical probability, Stewart ’ s neurologic condition would have remained stable and would not have progressed. He would have had the option of receiving neurosurgical consultation and care, which could have include d further neurological testing, like EMG, detailed cervical spine care and activity limitations, physica l therapy/rehabilitation, and/or surgical intervention. Stewart would have had surgery to correct his condition, or he would have been prohibited from engaging

13 Dr. DeBerardino states that, as a practicing orthopedic surgeon, he is q ualified to opine on the standard of care for an orthopedic surgeon because he is board certified in orthopedic surgery.13

in the activities that led to his broken neck. Instead, profound neurologic compromise occurre d. Because Stewart was not informed of his fragile condition and the need to take immediate protective measures until his condition could be corrected, he continued to engage in his normal athletic activities, risking and injuring his spinal cord, which l ed to a neurological injury. Had Stewart been properly advised of his condition, based on his medical records showing patient compliance with physician instruction, it is likely that he would have obeyed a physician’s instructions to restrict his activity until further evaluation and treatment of his condition could be undertaken , and he would not have suffered a broken neck and a neurological deficit. As to the standard of care and breach of the standard of care for Clear Lake Regional, Dr. DeBerardino st ates that when a patient ’ s records show a finding of extensive mid to lower cervical degenerative disc disease, a hospital ’ s representatives, either its nurses or physicians, must inform the patient of th e condition and its risks, so that the patient can t ake the necessary steps to avoid any known risks and complications, such as spinal fractures. 14 Clear Lake Regional breached the standard of care by: (1) failing to have hospital employees and

14 Dr. DeBerardino states that , as an orthopedic surgeon, he is qualified to opine on the standard of care for a hospital because he wa s the chief of the sports medicine section of the orthopedic surgery service at Brooke Army Medical Center, the chief of orthopedic surgery at the 801st Combat Support Hospital, and the chief of the orthopedic surgery service at Keller Army Hospital.14

representatives, either its nurses or physicians, inform Stew art that he had extensive mid and lower cervical degenerative disc disease and (2) failing to have hospital employees or representatives be patient advocate s and inform Stewart of the serious consequences of that condition. As to causation for Clear Lake Regional, Dr. DeBerardino states that b ecause Clear Lake Regional violated the applicable standard of care, Stewart suffered a spinal cord injury in the same location as an “undisclosed stenosis.” If Clear Lake had followed th e standard of care, within a reasonable medical probability, Stewart ’ s neurologic condition would have remained stable and would not have progressed. He would have had the option of rece iving neurosurgical consultation and care, which could have include d further neurological testing, like EMG, detailed cervical spine care and activity limitations, physical therapy/rehabilitation, and/or surgical intervention. Stewart would have had surge ry to correct his condition, or he would have been prohibited from engaging in the activities that led to his broken neck. Instead, profound neurologic compromise occurred. Because Stewart was not informed of his fragile condition and the need to take im mediate protective measures until his condition could be corrected, he continued to engage in his normal athletic activities, risking and injuring his spinal cord, which led to a neurological injury. Had Stewart been properly advised of his condition, bas ed on his medical records showing patient compliance with physician instruction, it is likely that he would15

have obeyed a physician’s instructions to restrict his activity until further evaluation and treatment of his condition could be undertaken , and he would not have suffered a broken neck and a neurological deficit. As to the standard of care and breach of the standard of care for nurse practitioner Breaux, Dr. DeBerardino states that a nurse practitioner must make accurate and complete documentation of the assessment of the radiologically present cervical spine condition upon discharge, must notify a patient of the radiologically present cervical spine condition, including the potential course of the disease, sequelae, and neurological warning signs and symptoms, and must provide comprehensive patient discharge education on follow up cervical spine care, precautions, activity limitations, and follow up treatment. 15 Nurse practitioner Breaux breached the standard of care by: (1) failing to document Stew art ’ s extensive cervical disc disease and compromised spine upon discharge, (2) neglecting to notify Stewart of that dangerous medical condition and potential neurologic sequelae at the time of discharge, and ( 3 ) failing to educate Stewart on the care and follow up for his unstable cervical spine at the time of discharge.

15 Dr . DeBerardino states that, as an orthopedic surgeon, he is qualified to opine on the standard of care for a nurse practitioner because he was the chief of the sports medicine section of the orthopedic surgery service at Brooke Army Medical Center, the chie f of orthopedic surgery at the 801st Combat Support Hospital, and the chief of the orthopedic surgery service at Keller Army Hospital, and , as such, he directed hospital staff regularly

.16

As to causation for nurse practi ti oner Breaux, Dr. DeBerardino states that b ecause nurse practitioner Breaux violated the applicable standard of care, Stewart suffered a spinal cord injury in the same location as an “undisclosed stenosis.” If nurse practitioner Breaux had followed this standard of care, within a reasonable medical probability, Stewart ’ s neurologic condition would have remained stable and would not have progressed. Stewart would have had the option of receiving neurosurgical consultation and care, which could have include d further neurological testing, like EMG, detailed cervical spine care and activity limitations, physical therapy/rehabilitation, and/or surgical intervention. He would have had surgery to correct his condition, or he would have been prohibited from engaging in the activities that led to his broken neck. Instead, profo und neurologic compromise occurred. Because Stewart was not informed of his fragile condition and the need to take immediate protective measures until his condition could be corrected, he continued to engage in his normal athletic activities, risking and injuring his spinal cord, which led to a neurological injury. Had Stewart been properly advised of his condition, based on his medical records showing patient compliance with physician instruction, it is likely that he would have obeyed a physician’s inst ructions to restrict his activity until further evaluation and treatment of his condition could be undertaken , and he would not have suffered a broken neck and a neurological deficit. The failure to notify Stewart of his extensive mid to lower cervical sp ine disc disease17

as it related to his discharge care and follow up was, in Dr. DeBerardino ’ s opinion, a causative factor in Stewart ’ s “ suffering a subsequent life [

- ] altering neurologic [ al ] injury. ” Finally, Dr. DeBerardino concludes that Stewart ’ s injuries were foreseeable and could have been reasonabl y anticipated as a result of appellants ’ breaches of the applicable standard s of care. Appellants ’ breaches of the relevant standard s of care were substantial factor s in bringing about Stewart ’ s harm , and wit hout such conduct , Stewart’s injuries would not have occurred. Stewart never served appellants with an amended expert report authored by Lindenberg. In her original expert report, Lindenberg states that she has a Clinical Doctor of Nursing Practice and sh e is a board

- certified family nurse practitioner. She is also a certified professional in health care quality by the National Association of Health Care Quality, a diplomat e of the American Board of Comprehensive Care (“ABCC”) , a member o f the board of directors for ABCC, the director of
p erformance i mprovement at Parkland Health and Hospital System, and a consultant reviewer for se vera l nursing and nurse practitioner journal s. As to her medical experience, Lindenberg states that she often treats patients, like Stewart, who present with various types of cervical spine abnormalities, which are evident radiologically, both as a chief complaint or as incidental radiologic finding s. She is familiar with the standard of care for a family nurse practitioner18

who is treating a patient with Stewart’s condition. Lindenberg ha s formulated and written discharge instructions for cervical spine conditions. In her report, Lindenberg states that on October 22, 2016, Stewart was in a

“ bicycle accident” while wearing a helmet. He was transported to Clear Lake Regional by ambulance in “critical condition,” with a chief complaint of “neck pain.” (Internal quotations omitted.) He was admitted t o the hospital. CT scans of
Stewart ’ s pelvis, chest, and spine revealed certain findings:

• “A 40% right anterior apical pneumothorax of the lung”;

• “Bilateral clavicular fractures”;

• “Multiple right rib fractures (1st, 2nd, 4th, 5th, and 7th)”;

• “Lumbar 5

- Sacral 1 degenerative disc disease”; and

• “Cervical 4

- 7 disc narrowing, cervical 5

- 7 osteoarthritis and spinal stenosis.” Stewart was discharged from Clear Lake Regional on October 25, 2016 by nurse practitioner Breaux. At the time of discharge , Stewart had an outpatient clavicular surgery scheduled. Nurse practitioner Breaux wrote the following discharge assessment: “Medically stable for discharge home with outpatient follow up” and “ [t] ertiary trauma survey was negative for missed or occult trauma.” (Internal quotations omitted.) Nurse practitioner Breaux ’ s discharge instructions to Stewart included: “Follow up with orthopedist as scheduled,” “ [f] ollow up in clinic19

in two weeks

– call for appointment,” “ [p] resent to [emergency department] /911

. . . with worsening symptoms,” and “ [a] ctivity as tolerated, nonstrenuous.” (Internal quotations omitted.) On October 27, 2016, Stewart had outpatient open reduction and internal fixation (“ORIF”) surgery on his right clavicle. He attended follow u p orthopedic visits on November 16, 2016, December 14, 2016, and January 25, 2017. At the January 25, 2017 follow up visit, Stewart had continuing upper extremity weakness, was prescribed strengthening physical therapy, and was given “a full activity
rele ase” and “orthopedic surgery clearance.” Sometime after the January 25, 2017 orthopedic visit, Stewart was involved in a skiing accident that rendered him a quadriplegic. As to the standard of care and breach of the standard of care for nurse practitioner Breaux, Lindenberg s t ates that a nurse practitioner must make accurate and complete documentation of the assessment of the radiologically present cervical spine condition upon discharge, must notify the patient of the radiologically present

ce rvical spine condition, including potential course of the disease, sequ e lae, and neurological warning signs and symptoms, and must provide comprehensive patient discharge education about follow up cervical spine care, precautions, activity limitations, and follow up treatment. According to Lindenberg, nurse practitioner Breaux breached the standard of care by failing to document Stewart ’ s extensive20

cervical disc disease and compromised spine upon discharge, neglecting to notify Stewart of his medical condi tion and potential neurological sequ e lae at the time of discharge , and failing to educate Stewart on the care and follow up for his unstable cervical spine at the time of discharge. As to the standard of care for Clear Lake Regional, Lindenberg states that the hospital had to provide contractual expectations and orientation/training for providers about the required elements of discharge planning, discharge summary documentation, and patient discharge education , and it had to provide an electronic medical re cord template for discharge summary instructions comprised of a standard set of elements to include patient discharge education and follow up. 16 Dr. Uzelmeier objected to Dr. DeBerardino ’ s amended expert report and requested that Stewart ’ s health care liab ility claim against him be dismissed. Dr. Uzelmeier asserted that the amended expert report does not provide a fair summary of the applicable standard of care and how Dr. Uze l meier breached the standard of care. The report also does not establish a causa l connection between Dr. Uzelmeier ’ s alleged breach of the standard of care and Stewart ’ s injuries

. Dr. DeBerardino ’ s opinion on causation is conclusory and speculative. Dr. DeBerardino i s not qualified to offer an opinion on the standard of care as to D r. Uzelmeier.

16 Lindenberg ’ s expert report does not provide opinions as to Drs. Uzelmeier, Madain, Norman, and Moulton.21

Drs. Norman and Moulton objected to Dr. DeBerardino ’ s amended expert report and requested that Stewart ’ s health care liability claim against them be dismissed. Drs. Norman and Moulton asserted that the amended expert report does not provide a fair summary of the causal relationship between the alleged breaches of the applicable standard s of care by Drs. Norman and Moulton and Stewart ’ s injuries , and Dr. DeBerardino ’ s opinion on causation is conclusory and contains analytical gaps. Dr. DeBera rdino is not qualified to offer an opinion on causation as
to Drs. Norman and Moulton. Dr. Madain objected to Dr. DeBerardino ’ s amend e d expert report and requested that Stewart ’ s health care liability claim against him be dismissed. Dr. Madain asserted that the amended expert report does not provide a fair summary of the applicable standard of care and how Dr. Madain breached the standard of care. The report also does not expla in “how and why” Dr. Madain ’ s alleged breach of the standard of care caused Stewart ’ s injuries, and Dr. DeBerardino ’ s opinion on causation is conclusory. (Internal quotations omitted.) Dr. DeBerardino is not qualified to offer an opinion on the standard of care as to Dr. Madain. Clear Lake Regional objected to Dr. DeBerardino ’ s amended expert report and requested that Stewart ’ s health care liability claim against it be dismissed. Clear Lake Regional asserted that the amended expert report does not provid e a fair summary of the applicable standard of care and how Clear Lake Regional breached22

the standard of care. The report also does not explain how Clear Lake ’ s alleged breach of the standard of care proximately caused Stewart ’ s injuries , and Dr. DeBerard ino ’ s opinion on causation is conclusory . Clear Lake Regional asserted that Dr. De Berardino is not qualified to offer an opinion on the standard of care as to Clear Lake Regional.
C lear Lake Regional objected to Lindenberg ’ s report and requested that
Stew art ’ s health care liability claim against it be dismissed. Clear Lake asserted that Lindenberg ’ s report does not provide a fair summary of the applicable standard of care and how Clear Lake Regional breached the standard of care. Clear Lake Regional asse rted that Lindenberg ’ s expert report only pertained to nurse practi ti oner Breaux and the report constitutes no report as to Clear Lake Regional. Additionally, Lindenberg, as a nurse practitioner, is not qualified to offer an opinion

on causation

. Nurse pr actitioner Breaux objected to Dr. DeBera rd ino ’ s amended expert report and requested that Stewart ’ s health care liability claim against her be dismissed. Nurse practitioner Breaux asserted that the amended expert report does not provide a fair summary of t he causal relationship between nurse practitioner
Breaux ’ s alleged breach of the standard of care and Stewart ’ s injuries and Dr. DeBerardino ’ s opinion on causation is conclusory. Dr. DeBerardino is not qualified to offer an opinion on causation as to nurse practitioner Breaux.23

Nurse practitioner Breaux objected to Lindenberg ’ s report and requested that
Stewart ’ s health care liability claim against her be dismissed because Lindenberg, as a nurse practitioner, is not qualified to offer an opinion on causation. After Stewart responded 17 to appellants ’ objections and motions to dismiss , the trial court, in multiple orders, overruled appellants ’ objections to Dr. DeBerardino ’ s amended expert report and Lindenberg ’ s expert report and denied appellants ’ motions to dismiss the health care liability claims against them. Standard of Review We review a trial court ’ s decision on a motion to dismiss a health care liability claim for an abuse of discretion. See Am. Transitional Care Ctrs. of Tex., I nc. v. Palacios , 46 S.W.3d 873, 875 (Tex. 2001); Gray v. CHCA Bayshore L.P. , 189 S.W.3d 855, 858 (Tex. App.

— Houston [1st Dist.] 2006, no pet.). We apply the same standard to a trial court ’ s determination that an expert is qualified. See Broders v.
Heise , 924 S.W.2d 148, 151

– 52 (Tex. 1996); San Jacinto Methodist Hosp. v.
Bennett , 256 S.W.3d 806, 811 (Tex. App.

— Houston [14th Dist.] 2008, no pet.). A trial court abuses its discretion if it acts in an arbitrary or unreasonable manner without reference to gui ding rules or principles. Jelinek v. Casas , 328 S.W.3d 526, 539 (Tex. 2010). When reviewing matters committed to a trial court ’ s discretion, we may not substitute our own judgment for that of the trial court. Bowie Mem ’ l

17 Certain replies and sur

- replies were also filed by the parties.24

Hosp. v. Wright , 79 S.W.3d 48, 52 (Tex. 2002). A trial court does not abuse its discretion merely because it decides a discretionary matter differently than an appellate court would in a similar circumstance. Harris Cty. Hosp. Dist. v. Garrett , 232 S.W.3d 170, 176 (Tex. App.

— Houst on [1st Dist.] 2007, no pet.). But a trial court has no discretion in determining what the law is or in applying the law to the facts. See Walker v. Packer , 827 S.W.2d 833, 840 (Tex. 1992). In conducting our review, we always consider that the Legislatu re ’ s goal in requiring expert reports i s to deter baseless claims, not block earnest ones. Jackson v. Kindred Hosps. Ltd.
P ’ ship , 565 S.W.3d 75, 81 (Tex. App.

— Fort Worth 2018, pet. denied); Gonzalez v. Padilla , 485 S.W.3d 236, 242 (Tex. App.

— El Paso 2016, no pet.); see also Scoresby v. Santillan , 346 S.W.3d 546, 554 (Tex. 2011). Under the Texas Medical Liability Act (“TMLA”) , a plaintiff asserting a health care liability claim must timely serve each defendant physician and health care provider 18 with at le ast one expert report , with a CV for the expert whose opinion is offered , to substantiate the merits of the plaintiff’s claim. T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 7 4.351(a), (i); see also Mangin v. Wendt , 480 S.W.3d 701, 705

18 See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.001(a)(12)(A) (“ [h] ealth care provider” means “any person, partnership, professional association, c orporation, facility, or institution duly licensed, certified, registered, or chartered by the State of Texas to provide health care, including:

. . . a registered nurse

. . . [and] a health care institution” (internal quotations omitted)); see also id. § 74.001(a)(11)(G) (“ [h] ealth care institution” includes “a hospital” (internal quotations omitted)).25

(Tex. App.

— Houston [1st Dist.] 2015, no pet.). The expert report must provide a “fair summary” of the expert ’s opinions on (1) the applicable standard of care, (2) the manner in which the care rendered by the defendant physician or health care provider fa iled to meet the standard of care , and (3) the causal relationship between that failure and the injury, harm, or damages claimed. T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 7 4.351(r)(6) ; see also Certified EMS, Inc. v. Potts , 392 S.W.3d 625, 630 (Tex. 2013)

. A “ fair summary ” of the expert ’ s opinions means that, at the least, the report must state more than the expert’s mere conclusions on the standard of care, breach, and causation; it must instead explain the basis of the expert ’ s opinion so as to link the concl usions to the facts of the case. See Jelinek , 328 S.W.3d at 539 ; Wright , 79 S.W.3d at 52. If a plaintiff fails to timely serve an expert report, then, on the motion of a defendant physician or health care provider, the trial court must dismiss the pertine nt health care liability claim with prejudice and award attorney’s fees. T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(b); Baty v. Futrell , 543 S.W.3d 689, 692 (Tex. 2018). But if a plaintiff timely serves an expert report and a defendant physician or health care provider files a motion challenging the adequacy of that report, then the trial court may only grant the motion “if it appears to the court, after [a] hearing, that the report does not represent an objective good faith effort to comply with the [TMLA ’s] definition of an expert report.” T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(l);26

Baty , 543 S.W.3d at 692

– 93 ; see also T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(r)(6) (“ [e] xpert report” means “a written report by an expert that provides a fair summary of the expert ’ s opinions as of the date of the report regarding applicable standards of care, the manner in which the care rendered by the physician

or health care provider failed to meet the standards, and the causal relationship between that fail ure and the injury, harm, or damages claimed ” (internal quotations omitted)). An expert report qualifies as an “objective good faith effort” to avoid dismissal if it discusses each element with sufficient specificity so that it (1) informs the defendant ph ysician or health care provider of the specific conduct that the plaintiff questions or about which the plaintiff complains and (2) provides a basis for the trial court to conclude that the plaintiff’s health care liability claim has merit. Miller v. JSC Lake Highlands Operations, LP , 536 S.W.3d 510, 513 (Tex. 2017); see also Baty , 543 S.W.3d at 693

– 94. The expert report need not use any particular words, and it may be informal, “but bare conclusions will not suffice.” Scoresby , 346 S.W.3d at 555

– 56.
In determining whether an expert report constitutes an “objective good faith effort” to address each element, “a trial court may not draw inferences; instead, it must exclusively rely upon the information contained within the four corners of the report.” Pup

pala v. Perry , 564 S.W.3d 190, 197 (Tex. App.

— Houston [1st Dist.]27

2018, no pet.) (internal quotations omitted). And when the issue of adequacy hinges on an expert’s qualifications, the trial court may also consider the “four corners” of the expert’s CV. Id. ; Mangin , 480 S.W.3d at 706 . C ourts must view the report in its entirety, rather than isolating specific portions or sections, to determine whether it is sufficient

. See Baty , 543 S.W.3d at 694; see, e.g. , Van Ness v. ETMC First Physicians , 461 S.W.3d 140, 144 (Tex. 2015); see also Austin Heart, P.A. v. Webb , 228 S.W.3d 276, 282 (Tex. App.

— Austin 2007, no pet.) (“The form of the report and the location of the information in the report are not dispositive.”). In reviewing the adequacy of an expert repo rt, a trial court may not consider an expert ’ s credibility, the data relied on by the expert, or the documents that the expert failed to consider at this pre

- discovery stage of the litigation. See Mettauer v. Noble , 326 S.W.3d 685, 691

– 92 (Tex. App.

— Houston [1st Dist.] 2010, no pet.); Gonzalez , 485 S.W.3d at 245. Multiple expert reports may be considered together in determining whether a plaintiff has provided a report meeting the statutory requirements. See T EX
. C IV
. P RAC
. & R EM
. C ODE A N N
. § 74.351(i); Salias v. Tex. Dep ’ t of Aging & Disability
Servs. , 323 S.W.3d 527, 534 (Tex. App.

— Waco 2010, pet. denied); Walgreen Co. v. Hieger , 243 S.W.3d 183, 186 n.2 (Tex. App.

— Houston [14th Dist.] 2007, pet. denied). A single report addressing both liability and causation issues related to a defendant physician or health care provider is not required. See T EX
. C IV
. P RAC
. &28

R EM
. C ODE A NN
. § 74.351(i); Gannon v. Wyche , 321 S.W.3d 881, 896 (Tex. App.

— Houston [14th Dist.] 2010, pet. denied). But the mu ltiple expert reports , when read together, must provide a “fair summary” of the expert ’s opinions on (1) the applicable standard of care, (2) the manner in which the care rendered by the defendant physician or health care provider failed to meet the standa rd of care , and (3) the causal relationship between that failure and the injury, harm, or damages claimed. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(i), (r)(6); see also
Gannon , 321 S.W.3d at 896.

Drs. Uzelmeier , Madain, Norman, and Moulton In a porti on of his first issue, Dr. Uzelmeier argues that the trial court erred in overruling his objections to Dr. DeBerardino ’ s amended expert report and denying his motion to dismiss Stewart ’ s health care liability claim against him because Dr. DeBerardino ’ s report does not adequate ly address causation related to Dr. Uzelmeier. T he amended expert report fails to establish how Dr. Uzelmeier ’s alleged ly negligent acts or omissions proximately caused , or were a substantial factor in causing , Stewar t ’ s injuries . The amended expert report contains analytical gaps between Dr. DeBerardino ’ s assertion that Dr. Uzelmeier breached the standard of care and Stewart ’ s injuries, and it does not provide an opinion on how Stewart ’ s injuries were foreseeable.29

In a portion of his sole issue, Dr. Madain argues that the trial court erred in overruling his objections to Dr. DeBerardino ’ s amended expert report and denying his motion to dismiss Stewart ’ s health care liability claim against him because Dr. DeBerardino ’ s report does not adequate ly address causation related to Dr. Madain.
T he amended expert report does not establish a causal link between Dr. Madain ’ s alleged ly neglige nt acts or omissions and Stewart ’ s injur ies. Still yet, Stewart’s injuries were too far attenuated , and the amended expert report does not explain how Dr. Madain ’ s alleged negligence in not informing Stewart of his mid and lower cervical degenerative disc disease and in not being a patient advocate more likely than not resulted in the injurie s Stewar t sustained in a skiing accident more than three months after he received the medical care provided by Dr. Madain. In their first issue, Drs. Norman and Moulton argue that the trial court erred in overruling their objections to DeBerardino ’ s amende d expert report and denying their motion s to dismiss Stewart ’ s health care liability claim against them because Dr. DeBerardino ’ s report does not adequate ly address causation related to Drs. Norman and Moulton. T he amended expert report fails to set forth how their allege d ly negligent acts or omissions proximately caused , or were a substantial factor in causing , Stewart ’ s injuries, does not discuss how Stewart ’ s alleged skiing accident and injuries occurred, and contains analytical gaps.30

A n expert rep ort must provide a “fair summary” of the expert ’ s opinion on the causal relationship between the failure of a defendant physician to provide care in accord with the applicable standard of care and the plaintiff’s claimed injury, harm, or damages. T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(r)(6); see also Potts , 392 S.W.3d at 630. T he expert report must explain how and why the defendant physician ’ s breach of the standard of care proximately caused the plaintiff ’ s injury. Columbia Valley Healthcare Sys., L. P. v. Zamarripa , 526 S.W.3d 453, 459

– 60 (Tex. 2017). An expert report need not marshal all the plaintiff ’ s proof necessary to establish causation at trial, and it need not anticipate or rebut all possible defensive theories that may ultimately be presente d to the trial court. Wright , 79 S.W.3d at 52; Cornejo v. Hilgers , 446 S.W.3d 113, 12 3 (Tex. App.

— Houston [1st Dist.] 2014, pet. denied)

. But an expert cannot simply opine that the breach caused the injury. Jelinek , 328 S.W.3d at 539. Causation consists of two components: (1) cause - in

- fact and (2) foreseeability. Gunn v. McCoy , 554 S.W.3d 645, 658 (Tex. 2018). A defendant physician ’ s breach was a cause

- in

- fact of the plaintiff ’ s injury if the breach was a substantial factor in bringing about the harm, and absent the breach the harm would not have occurred. Id. Even if the harm would not have occurred absent the defendant physician ’ s breach, “the connection between the defendan t and the plaintiff ’ s injuries simply may be too attenuated” for the breach to qualify as a31

substantial factor. Allways Auto Grp., Ltd. v. Walters , 530 S.W.3d 147, 149 (Tex. 2017) (internal quotations omitted). A breach is not a substantial factor if it “does no more than furnish the condition that makes the plaintiff ’ s injury possible.” Id. A defendant physician ’ s breach is a foreseeable cause of the plaintiff ’ s injury if physician of ordinary intelligence would have anticipated the danger caused by th e negligent act or omission. Puppala , 564 S.W.3d at 197.
In his amended expert report, Dr. DeBerardino states that Stewart was involved in a “ bicycle incident ” and admitted to Clear Lake Regional. He was provided medical care by Drs. Uzelmeier , Madain, N orman, and Moulton, among others. After Stewart was discharged from Clear Lake Regional, another physician from another hospital , who is not a party to this appe al , performed surgery on Stewart to repair Stewart’s bicycle

- incident injuries . Stewart then resumed his normal athletic activities

. Later, Stewart broke his neck and injured his spinal cord , rendering him a quadriplegic. Lindenberg ’ s report, which Dr. DeBera r dino incorporates in his amended expert report, provides slightly more i nformation about Stewart ’ s eventual injuries. Lindenberg states that Stewart was involved in a “ bicycle accident ” and was taken to the emergency room at Clear Lake Regional. Five days after the bicycle accident, and two days after being discharged from C lear Lake Regional, Stewart had outpatient ORIF surgery on his right clavicle . A nother physician from another32

hospital , who is not a party to this appeal , performed that surgery. Stewart attended follow up orthopedic visits after his surgery on November 16, 2016, December 14, 2016, and January 25, 2017. On January 25, 2017, Stewart ’ s other physician gave him “ a full activity release ” and “orthopedic surgery clearance

. ” Sometime later, Stewart was involved in a skiing accident that rendered him a quadrip legic. According to Dr. DeBerardino, Drs. Uzelmeier , Madain, Norman, and Moulton all breached the purported ly applicable standard s of care in the same

manner

— by failing to infor m Stewart , while he was at Clear Lake Regional being treated for injuries related to the bicycle incident, that he had extensive mid and lower cervical degenerative disc disease and by failing to be patient advocate s and inform Stewart of the serious consequences of that condition

— a condition unrelated to the injuries S tewart sustained in the bicycle incident

. The amended expert report also states that the alleged breaches of the standard of care by Drs. Uzelmeier , Madain, Norman, and Moulton ca u sed Stewart ’ s subsequent neck and spinal injuries , but Dr. DeBerardino does not provide many facts about how Stewart allegedly sustained his skiing

- related injur ies or how those skiing

- related injuries relate to Stewart ’ s mid and lower cervical degenerative disc disease

. Dr. DeBerardino simply states that Stewart ’ s neck and spinal cord injuries were in the same location as his “stenosis,” but Dr. DeBerardino does not link the33

purported stenosis to the allegedly undisclosed extensive mid and lower cervical degenerative di sc disease about which Stewart complains. 19 Instead, Dr. DeBerardino generally opines that if the physicians had not breached the purported standard s of care

— by failing to inform Stewart , while he was at Clear Lake Regional, that he had extensive mid and l ower cervical degenerative disc disease and by failing to be patient advocate s and inform Stewart of the serious consequences of that condition

— Stewart ’ s extensive mid and lower cervical degenerative disc disease would have remained stable and not progress ed. Stewart would have had the option of receiving neurosurgical consultation and care, which could have included further neurological testing, detailed cervical spine care, activity limitations, physical therapy/rehabilitation, and surgical intervention. Further, Stewart would have had surgery to correct his condition or would have been prohibit ed from engaging in the unspecified activities that led to his broken neck

. According to Dr. DeBerardino, Stewart would have obeyed any physician ’ s instructions to restrict his activity. Yet, because Drs. Uzelmeier , Madain, Norman, and Moulton breached the purported standard s of care , Stewart continued to engage in his normal athletic activities and later suffered a broken neck and spinal co rd injury during a skiing accident more than three months later

. Cf. Jelinek , 328 S.W.3d

19 Dr. DeBerardino does not state, and Stewart does not allege, that Drs. Uzelmeier, Madain, Norman, and Moulton were required to inform Stewart of his ste nosis or that they breached the applicable standards of care by allegedly failing to do so

.34

at 533 (“Care must be taken to avoid the post hoc ergo propter hoc fallacy, that is, finding an earlier event caused a later event merely because it occurred first.”); Curnel v. Hou ston Methodist Hosp.

- Willowbrook , 562 S.W.3d 553, 565 (Tex. App.

— Houston [1st Dist.] 2018, no pet.) (“It is not enough that one event occurred before the other . . . .”). An expert cannot simply opine that a breach of the standard of care caused the plaintiff ’ s injury. Jelinek , 328 S.W.3d at 539 ; Nw. EMS Consultants, P.A. v. Guillory , No. 01

- 19

- 00668

- CV , 2020 WL 4516872, at *12 (Tex. App.

— Houston [1st Dist.] Aug. 6 , 2020, pet. denied ) ; see also Abshire v. Christus Health Se. Tex. , 563 S.W.3d 219, 224 (Tex. 2008) (“A conclusory statement of causation is inadequate

. . . .”). And an expert ’ s conclusion that “in medical probability” one event caused another is no more than an expert ’ s simple ipse dixit , which is insufficient to establish causation. Jeli nek , 328 S.W.3d at 539

– 40 (internal quotations omitted) ; see also City of San Antonio v. Pollock , 284 S.W.3d 809, 818 (Tex. 2009). Here, Dr. DeBerardino ’ s amended expert report offers no more than a bare assertion that the purported breaches by Drs. Uzelm eier , Madain, Norman, and Moulton resulted in the later injuries Stewart sustained while skiing. See Jelinek , 328 S.W.3d at 5 39

– 40 (bare assertion that breach resulted in increased pain , suffering , and prolonged hospital stay was inadequate); Guillory , 20 20 WL 4516872, at *12. Dr. DeBerardino does not explain how the named

- defendant35

physicians’ purported breaches caused Stewart ’ s skiing

- related injuries. See Jelinek , 328 S.W.3d at 540; see also THN Physicians Ass ’ n v. Tiscareno , 495 S.W.3d 599, 614 (Tex. App.

— El Paso 2016, no pet.) (“[T]he expert must at a minimum explain the connection between [the physician’s ] conduct and the injury to the [plaintiff].”)

. “A report that merely states [an] expert ’ s conclusions about

. . . caus ation” does not fulfill the purposes of requiring a good

- faith effort. Palacios , 46 S.W.3d at 879. Further, a n event that starts a chain of events can be too attenuated from an injury to cause it

. See Providence Health Ctr. v. Dowell , 262 S.W.3d 324, 3 29

– 30 (Tex. 2008) (holding medical providers ’ “negligence was too attenuated from the [harm] to have been a substantial factor in bringing it about”); Curnel , 562 S.W.3d
at 565; Shenoy v. Jean , No. 01

- 10

- 01116

- CV, 2011 WL 6938538, at *9 (Tex. App.

— Houston [1 st Dist.] Dec. 29, 2011, pet. denied) (mem. op.) (“A causal link can be too attenuated to satisfy the causation requirement for an expert report.”). It is not enough that one event occurred before the other. Curnel , 562 S.W.3d at 565; Shenoy , 2011 WL 693 8538, at *9; see Jelinek , 328 S.W.3d at 533 (“Care must be taken to
avoid the post hoc ergo propter hoc fallacy, that is, finding an earlier event caused a later event merely because it occurred first.”). A n event is not a substantial factor in bringing about the harm if it is “too attenuated” from the harm or “does no more than furnish the condition that makes the plaintiff ’ s injury possible.” Walters , 530 S.W.3d at 149 ; see also Curnel , 562 S.W.3d at 565

.36

Here, t he named

- defendant physicians’ purported breaches of the standard s of

care

— that were committed when Stewart was admitted to Clear Lake Regional for injuries related to a “ bicycle incident ”

— are too attenuated from Stewart ’ s later neck and spinal injuries sustained while skiin g to be considered a substantial factor in bringing about those skiing

- related injuries. See Curnel , 562 S.W.3d at 565

– 66

. The purported breaches by Drs. Uzelmeier , Madain, Norman, and Moulton in failing to inform Stewart that he had extensive mid and lo wer cervical degenerative disc disease and failing to be patient advocate s and inform Stewart of the serious consequences of that condition when Stewart was admitted to Clear Lake Regional for injuries related to his bicycle incident, at most, did “no more than furnish the condition” that made Stewart ’ s later injur ies while skiing possible. Cf. Curnel , 562 S.W.3d at 565

– 66 (internal quotations omitted) ; see also IHS Cedars Treatment Ctr. of DeSoto, Tex., Inc. v. Mason , 143 S.W.3d 794, 800 (Tex. 2004) ( “ Our precedents establish that merely creating the condition that makes harm possible falls short as a matter of law of satisfying the substantial factor test .”).
We conclude that Dr. DeBerardino ’ s amended expert report does not adequately inform Drs. Uzel meier , Madain, Norman, and Moulton of the causal relationship between their purported failures to provide care in accord with the appli c able standard s of care and the claimed injury, harm, or damages. Thus, we37

hold that the trial court erred in overruling the objections and denying the motions to dismiss of Drs. Uzelmeier , Madain, Norman, and Moulton. 20 We sustain this portion of Dr. Uzelmeier ’ s first issue, this portion of Dr. Madain ’ s sole issue, and Drs. Norman and Moulton ’ s first issue. Nurse Practitio ner Breaux In her second issue, nurse practitioner Breaux argues that the trial court erred in overruling her objections to Dr. DeBerardino ’ s amended expert report and denying her motion to dismiss Stewart ’ s health care liability claim against her because Dr. DeBerardino is not qualified to render an expert opinion on causation related to nurse practitioner Breaux

. An expert report by a person not qualified to testify does not constitute a good

- faith effort to comply with the TMLA ’ s definition of an expert report and warrants dismissal. See Mettauer , 326 S.W.3d at 693; Hendrick Med. Ctr. v. Conger , 298 S.W.3d 784, 78 9 (Tex. App.

— Eastland 2009, no pet. ) (where expert

20 Stewart cannot rely on Lindenberg ’ s expert report to address the causal relationship between the purported failures to provide care in accord with the appli c able standards of care by Drs. Uzelmeier, Madain, Norman, and Moulton and the claimed injury, harm, or damages. Lindenberg ’ s expert report does not discuss the named

- defendant physicians, and under Texas Civil Practice and Remedies Code section 74.403 , only physicians are qualified to render causation opinions in suits involving health care liability claims. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a); Walgreen Co. v. Hieger , 243 S.W.3d 183, 186 n.2 (Tex. App.

— Houston [14th Dist.] 2007, pet. denie d). Lindenberg , a nurse practitioner, is not a physician. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.001(a)(23) (defining “[p]hysician” (internal quotations omitted)). In his briefing, Stewart states that Lindenberg’s report “is not offered for purposes of establishing causation.”38

not qualified to render opinion, expert report is rendered deficie nt); see also T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(l), (r)(6). Whether an expert witness is qualified to offer an expert opinion lies within the sound discretion of the trial court. Cornejo , 446 S.W.3d at 121. The expert ’ s qualifications must appea r in the four corners of the expert report or in the expert ’ s accompanying CV. Puppala , 564 S.W.3d at 197, 202; see also Cornejo , 446 S.W.3d at 121. To be qualified to opine on the causal relationship between a defendant health care provider ’ s alleged fai lure to meet an applicable standard of care and the plaintiff ’ s claimed injury, harm, or damages, the author of an expert report must be a physician who is qualified to render opinions on such causal relationships under the Texas Rules of Evidence. See T E X
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a); see id. § 74.351(r)(5)(C) (“ [e] xpert” means “with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or damages claimed and the alleged departure from the applicable standard of care in any health care liability claim, a physician who is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence” (internal quotations omitted)); Cornejo , 446 S.W.3d at 120. An expert witness may be qualified on the basis of knowledge, skill, experience, training, or education to testify on scientific, technical, or other specialized subjects if the testimony would “assist the trier of fact” in understanding39

the evidence or determining a fact issue. Cornejo , 446 S.W.3d at 121 (internal quotations omitted); see T EX
. R

. E VID
. 702

. Thus, a plaintiff must show that h is expert has “knowledge, skill, experience, training, or education” about the specific issue before the court that would qualify the expert to give an opinion on that particular subject. Broders , 924 S.W.2d at 153

– 54 (internal quotations omitted); see also Cornejo , 446 S.W.3d at 121. Not every licensed physician is qualified to testify on every medical question. See Broders , 942 S.W.2d at 152

– 53; Cornejo , 446 S.W.3d at 121. Yet , a physician need not practi ce in the particular field about which he is testifying so long as he can demonstrate that he has knowledge, skill, experience, training, or education about the specific issue before the court that would qualify him to give an opinion on that subject. Cor

nejo , 446 S.W.3d at 121. Simply put , what is required is that the physician demonstrate that he is qualified to opine on the specific issue before the
court. Puppala , 564 S.W.3d at 202. Nurse practitioner Breaux argues that Dr. DeBerardino is not qualifi ed to render an expert opinion on causation because he is an orthopedic surgeon and his primary practice is orthopedic surgery and sports medicine. Dr. DeBerardino is a licensed physician and a board

- certified orthopedic surgeon. He also holds a certifica te of additional qualification in sports medicine. He primarily practices in the area s of orthopedic surgery and sports medicine

.40

C urrently, he is a practicing orthopedic surgeon. Dr. DeBerardino is the clinical professor of orthopedic surgery at Baylor College of Medicine at t he San Antonio Orthopedic Group, the co

- director of the Baylor College of Medicine

– San Antonio Combined Te xas Sports Medicine Fellowship, the Gold Cup International Soccer

s ports m edicine c onsultant, the medical director for the Burkhart Research Institute of Orthopedics of t he San Antonio Orthopedic Group, a practicing orthopedic surgeon at t he San Antonio Or thopedic Group, and a member of the Physician Leadership Counsel for the Baptist North Central Hospital in San Antonio. Dr. DeBerardino ’ s medical experience also includes a military medical background. As a military physician , Dr. DeBerardino was trained in and practiced in trauma and emergency care. As to nurse practitioner Breaux, Dr. DeBerardino states that he, an orthopedic surgeon, is qualified to opine on the standard of care for a nurse practitioner because he was the chief of the sports medicine se ction of the orthopedic surgery service at Brooke Army Medical Center, the chief of orthopedic surgery at the 801st Combat Support Hospital, and the chief of the orthopedic surgery service at Keller Army Hospital, and as such, he directed hospital staff re gularly

. 21 But Dr. DeBerardino

21 We express no opinion on whether Dr. DeBerardino is qualified to opine on the standard of care for a nurse practitioner.41

does not specifically set forth why he is qualified to opine on causation as it relates to nurse practitioner Breaux. In his first amended petition, Stewart alleges that appellants, including nurse practitioner Breaux, were negligent in failing to inform Stewart of his cervical disc disease and failing to adequately document that condition. Stewart thus had the burden of establish ing that Dr. DeBerardino had “knowledge, skill, experience, training, or education” about whethe r those allegedly negligent acts or omissions caused Stewart ’ s claimed injury, harm, or damages resulting from his subsequent skiing accident. See Matagorda v. Nursing & Rehab. Ctr., L.L.C. v. Brooks , No. 13

- 16

- 00266

- CV, 2017 WL 127867, at *6 (Tex. App.

— Corpus Christi

– Edinburg Jan. 12, 2017, no pet.) (mem. op.) (internal quotations omitted) ; Diagnostic Research Grp. v. Vora , 473 S.W.3d 861, 869

– 70 (Tex. App.

— San Antonio 2015, no pet.); see also Cornejo , 446 S.W.3d at 121 (plaintiffs required to estab lish expert qualified on basis of knowledge, skill, experience, training, or education to offer opinion on causal link between alleged breaches of standard of care and injuries suffered); Mem ’ l Hermann Healthcare Sys. v. Burrell , 230 S.W.3d 755, 762 (Tex. App.

— Houston [14th Dist.] 2007, no pet.) (party offering witness as expert must establish witness is qualified). In his amended expert report, Dr. DeBerardino states that Stewart, after a skiing accident, broke his neck and injured his spinal cord , renderi ng him a42

quadriplegic. But nothing in his expert report or CV addresses whether, or how, his knowledge, skill, experience, training, or education in o rthopedic surg ery, sports medicine, and trauma and emergency care, qualif y him to opine on whether nurse practitioner Breaux ’ s alleged breach of the standard of care

— by failing to inform Stewart of his cervical disc disease and failing to adequately document that condition while he was admitted to Clear Lake Regional more than three months before his skiing a ccident

— caused Stewart ’ s skiing

- related injuries. See Broders , 924 S.W.2d at 153 (“[W]e [focus] on whether the expert ’ s expertise goes to the very matter on which he or she is to give an opinion.”) ; Estorque v. Schafer , 302 S.W.3d 19, 26 (Tex. App.

— Fort W orth 2009, no pet.) (“Qualifications must appear in the expert report [and CV] and cannot be inferred.”); Palafox v. Silvey , 247 S.W.3d 310, 316 (Tex. App.

— El Paso 2007, no pet.) (“In deciding whether an expert is qualified, the
trial court must ensure tho se who purport to be experts truly have expertise concerning the actual subject about which they are offering an opinion.” (internal quotations omitted)); see also T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a) (expert must be qualified to opine on causal re lationship between defendant health care provider ’ s alleged failure to meet applicable standard of care and plaintiff ’ s claimed injury, harm, or damages). We may not fill in gaps in Dr. DeBerardino ’ s report and CV where he fails to detail why or how he is qualified to offer an opinion on causation as it relates to nurse practitioner Breau x. See Concentra Health Servs.,43

Inc. v. Everly , No. 2

- 08

- 455

- CV , 2010 WL 1267775, at *6 (Tex. App.

— Fort Worth Apr. 1, 2010, no pet. ) (mem. op.). In his briefing, Stewart generally asserts that Dr. DeBerardino is qualified to offer opinions about causation because as an orthopedic surgeon he “sees patients suffering fr om the condition at issue in this case” and he “often treat[s] patients such

as . . . Stewart who have extensive mid to lower cervical degenerative disc disease.” (First alteration in original.) (Internal quotations omitted.) But, h ere, Dr. DeBerardino ’ s amended expert report and CV do not demonstrate that he has expertise on the actual subject about which Stewart is offering Dr. DeBarardino’s opinion. See Burrell , 230 S.W.3d at 762; see also Guillory , 2020 WL 4516872, at *10. And even though Dr. DeBerar dino may have training and experience in the area of orthopedic surgery, nothing indicates that he has the knowledge, skill, experience, training, or education in determining whether the purportedly negligent acts or omissions of nurse practitioner Breaux

— failing to inform Stewart of his cervical disc disease and failing to adequately document that condition while he was admitted to Clear Lake Regional more than three months before his complained

- of skiing

- related injuries

— can ca u se the broken neck and spin al injury seen in Stewart after his skiing accident. See Guillory , 2020 WL 4516872, at *10; Puppala , 564 S.W.3d at 202 (physician must be able to demonstrate that he is qualified to opine on the specific issue before court); see also44

Broders , 924 S.W.2d a t 152

– 53 (“[T]here is no validity, if there ever was, to the notion that every licensed medical doctor should be automatically qualified to testify as an expert on every medical question.”)

. We conclude that Dr. DeBerardino ’ s expert report and CV do not es tablish that he is qualified to opine on causation as it relates to nurse practitioner Breaux.
See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a) ; see also Conger , 298 S.W.3d
78 9 (where expert not qualified to render opinion, expert report is deficient)

. We note that Stewart cannot rely on the expert report of Lindenberg, a

non - physician, to address the causal relationship between the purported failure of nurse practi ti oner Breaux to provide care in accord with the applicable standard of care and Stewart ’ s claimed injury, harm, or damages. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a); Hieger , 243 S.W.3d at 186 n.2. Under Texas Civil Practice and Remedies Code section 74.403 , only physicians are qualified to render causation opinions in suits involving health care liability claims. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a); Hieger , 243 S.W.3d at 186 n.2. Lindenberg , a nurse practitioner, is not qualified to render an o pinion on causation. 22 See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.001(a)(23) (defining “[p]hysician” (internal quotations omitted)).

22 In his briefing, Stewart states that Lindenberg ’ s report “is not offered for purposes of establishing causation and any references to causation in the report are mere surplusage.”45

Thus, we hold that the trial court erred in overruling nurse practitioner
Breaux ’ s objections and denying her motion to dis miss Stewart ’ s health care liability claim against her.
We sust ain nurse practitioner Breaux ’ s second issue.

Clear Lake Regional In its sole issue, Clear Lake Regional argues that the trial court erred in overruling its objections to Dr. DeBerardino ’ s amended expert report and denying its motion to dismiss Stewart ’ s health care liability claim against it because Stewart did not allege that Clear Lake Regional was vicariously liable for the negligent acts or omissions of Drs. Uzelmeier, Nor man, Moulton, and Madain and nurse practitioner Breaux , Dr. DeBerardino ’ s report does not adequately address the standard of care, breach of the standard of care, or causation related to the direct liability of Clear Lake Regional, and Dr. DeBerardino is n ot qualified to offer an opinion on the standard of care and breach of the standard of care related to Clear Lake Regional. Clear Lake Regional also argues that the trial court erred in overruling its objections to Lindenberg’s expert report and denying i ts motion to dismiss Stewart’s health care liability claim against it because Lindenberg, as a nurse practitioner, is not qualified to offer an opinion on causation.46

A. Vicarious Liability In a portion of its sole issue, Clear Lake Regional argues that the trial court erred in overruling its objections to Dr. DeBerardino ’ s amended expert report and denying its motion to dismiss Stewart ’ s health care liability claim against it because
Stewart did not allege in his first amended petition that the hospital was vicariously liable for the purportedly negligent acts and omissions of Drs. Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux. Instead, Stewart only alleged “a vague vicarious liability allegation” that did not inform Clear Lake Regiona l that Stewart sought to hold it vicariously liable for the alleged ly negligent conduct of Drs. Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux. And , as such, the vague vicarious liability health care claim is insufficient to impute D r. DeBera r dino ’ s expert opinions against the named

- defendant physicians and nurse practitioner Breaux to Clear Lake Regional.
In his briefing , Stewart asserts that his first amended petition alleges that Clear Lake Regional is vicariously liable for the al leged ly negligent acts or o missions of Drs. Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux. Stewart does not assert that his pleadings allege that Clear Lake Regional is vicariously liable for the acts and omissions of anyone other t han the named

- defendant physicians and nurse practitioner Breaux. Thus , Stewart argues that b ecause Dr. DeBerardino ’ s amended expert report adequately addresses the47

standard s of care, breach es of the standard of care, and causation as to Drs. Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux , the trial court did not err in overruling Clear Lake Regional ’ s objections to Dr. DeBerardino ’ s amended expert report and denying Clear Lake Regional ’ s motion to dismiss. Generally, when a plaintiff brings health care liability claims against more than one defendant physician or health care provider , the expert report must set forth the standard of care and breach of the standard of care as to each defendant and explain the causal relatio nship between each defendant ’ s individual acts or omissions and the claimed injury. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(a), (r)(6); Seton Family of Hosps. v . White , 593 S.W.3d 787, 793 (Tex. App.

— Austin 2019, pet. denied ); Pharmacy Healthcare So ls., Ltd. v. Pena , 530 S.W.3d 169, 175 (Tex. App.

— Eastland 2015, pet. denied). Yet , when a plaintiff brings a health care liability claim based on a vicarious l iability theory against a defendant health care provider , an expert report that adequately impl icates the actions of that party ’ s agent or employee is sufficient. Gardner v. U.S. Imaging,
Inc. , 274 S.W.3d 669, 671

– 72 (Tex. 2008) ; Seton Family , 593 S.W.3d at 792 ; see also Owens v. Handyside , 478 S.W.3d 172, 191 (Tex. App.

— Houston [1st Dist.] 2015, pet. denied) ( “[W]hen a health care liability claim involves a vicarious liability theory, either alone or in combination with other theories, an expert report that meets48

the statutory standards as to the employee is s ufficient to implicate the employer ’ s conduct under the vicarious theory .” (alteration in original) (internal quotations omitted)) . In other words, when a health care liability claim against a defendant health care provider is based on vicarious liability , an expert report that meets the statutory standards as to an agent or employee is sufficient to implicate the health care provider’s conduct. Potts , 392 S.W.3d at 632; Seton Family , 593 S.W.3d at 792. Here, we presume, as Stewart asserts, that his first amended petition is sufficient to allege that Clear Lake Regional is vicariously liable for the alleged ly negligent conduct of Drs. Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux. 23 Ye t , as discussed above, we have concluded that Dr

. DeBerardino ’ s amended expert report is deficient as to Drs. Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux for various reasons . Thus , because Dr. DeBerardino ’ s amended expert report does not meet the statutory

23 We note that if Stewart ’ s pleadings were insufficient as to the legal nexus establishing Clear Lake Regional ’ s vicarious liability for the alleged ly negligent acts or omissio ns of Drs. Uzelmeier, Norman, Moulton, and Madain and nurse practitioner Breaux, the appropriate remedy would have been for Clear Lake Regional to challenge Stewart ’ s pleadings, not Dr. DeBerardino ’ s expert report. See Seton Family of Hosps. v. White , 593 S.W.3d 787, 794 (Tex. App.

— Austin 2019, pet. denied ); see also T EX
. R. C IV
. P. 91 (providing for special exceptions to pleadings), 91a (providing for dismissal of cause of action that has no basis in law or fact). Clear Lake Regional did not challenge Stewart’s pleadings in this case

. See Seton Family , 593 S.W.3d at 794.49

standards as to the n amed

- defendant physicians and nurse practi ti oner Breaux

— the individuals whose purportedly negligent acts or omissions serve as the basis for
Stewart ’ s vicarious liability health care liability claim against Clear Lake Regional

— we conclude that Dr. DeBerardino ’ s amended expert report is also deficient as to Clear Lake Regional on Stewart ’ s vicarious liability health care liability claim. 24
We must now consider whether Dr. DeBerardino ’ s amended expert report is sufficient as to St ewart ’ s direct liability claim against Clear Lake Regional. See
Potts , 392 S.W.3d at 630 (“A report that satisfies the [] requirements, even if as to one theory only, entitles the claimant to proceed with a suit against the [defendant] physician or health care provider.”) ; Whitmire v. Feathers , No. 01

- 19

- 00094

- CV , 2020 WL 4983321, at *21 (Tex. App.

— Houston [1st Dist.] Aug. 25, 2020, no pet.)

24 We have already explained why Stewart cannot rely on the expert report of Lindenberg, a non

- physician, to support his claims against Drs. Uzelmeier, Madain, Norman, and Moulton and nurse practitioner Breaux. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a); Hieger , 243 S.W.3d at 186 n.2 ; see also T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.001(a)(23) (defining “[p]hysician” (internal quotations omitted))

. H e also cannot rely on Lindenbe rg ’ s expert report to support his vicarious liability health care liability claim against Clear Lake Regional that is based on the purportedly negligent acts and omissions of the named

- defendant physicians and nurse practitioner Breaux. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a); Hieger , 243 S.W.3d at 186 n.2 (only physicians are qualified to render causation opinion in suits involving hea l th care liability claims). In his briefing, Stewart states that Lindenberg’s report “is not offered for pur poses of establishing causation and any references to causation in the report are mere surplusage.”50

(mem. op.) (“An expert report that adequately addresses at least one pleaded liability theory against a defendant hea lth care provider is enough to defeat that defendant ’ s motion to dismiss challenging the adequacy of the report.”).
B. Direct Liability In another portion of its sole issue, Clear Lake Regional argues that the trial court erred in overruling its objections to Dr. DeBerardino ’ s amended expert report and denying its motion to dismiss Stewart ’ s health care liability claim against it because Dr. DeBerardino ’ s report does not adequately address the standard of care, breach of the standard of care, and causation rel ated to the direct liability of Clear Lake Regional.
A n expert report must provide a “fair summary” of the expert ’ s opinion on the causal relationship between the failure of a defendant health care provider to provide care in accord with the applicable standard of care and the plaintiff’s claimed injury, harm, or damages. T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(r)(6); see also
Potts , 392 S.W.3d at 630. The expert report must explain how and why the defendant health care provider ’ s breach of the standard of care proximately caused the plaintiff ’ s injury. Zamarripa , 526 S.W.3d at 459

– 60. A n expert cannot simply opine that the b reach caused the injury. Jelinek , 328 S.W.3d at 539. In the amended expert report, Dr. DeBerardino states that Stewart was involved in a “ bicycle incident ” and admitted to Clear Lake Regional. He was51

provided medical care by Drs. Uzelmeier, Madain, Norma n, and Moulton and nurse practitioner Breaux . After Stewart was discharged from Clear Lake Regional, another physician from another hospital , who is not a party to this appeal, performed surgery on Stewart to repair his bicycle

- incident injuries. Stewart then resumed his normal athletic activities. Later, Stewart broke his neck and injured his spinal cord , rendering him a quadriplegic. Lindenberg ’ s report, which Dr. DeBerardino incorporates in his amended expert report, states that Stewart was involved in a “ bicycle accident ” and was taken to the emergency room at Clear Lake Regional. Five days after the bicycle accident, and two days after being discharged from Clear Lake Regional, Stewart had outpatient ORIF surgery on his right clavicle

. Another p hysician from another hospital , who is not a party to this appeal , performed that surgery. Stewart attended follow up orthopedic visits after his sur gery on November 16, 2016, December 14, 2016, and January 25, 2017. On January 25, 2017, Stewart ’ s other physician gave him “ a full activity release ” and “orthopedic surgery clearance

. ” Sometime later, Stewart was involved in a skiing accident that r ende red him a quadriplegic. According to Dr. DeBerardino, Clear Lake Regional breached the purported standard of care by failing to have hospital employees and representatives, either its nurses or physicians, inform Stewart that he had extensive mid and lower cervical degenerative disc disease and failing to have hospital employees or representatives52

be patient advocate s and inform Stewart of the serious consequences of that condition. And Clear Lake Regional ’ s alleged breaches of the standard of care caused Stewart ’ s subsequent neck and spinal injuries. But Dr. DeBerardino does not provide many facts about how Stewart sustained his later skiing

- related injur ies or how those injuries relate to his mid and lower cervical degenerative disc disease.
Dr. DeBerar dino simply states that Stewart ’ s neck and spinal cord injuries were in the same location as his “stenosis

. ” Yet, Dr. DeBerardino does not link the purported stenosis to the undisclosed extensive mid and lower cervical degenerative disc disease

. 25
As with the named

- defendant physicians, Dr. DeBerardino only generally opines that if Clear Lake had not breached the purported standard of care

— by failing to have hospital employees and representatives inform Stewart that he had extensive mid and lower cervi cal degenerative disc disease and by failing to have hospital employees or representatives be patient advocate s and inform Stewart of the serious consequences of that condition

— Stewart ’ s extensive mid and lower cervical degenerative disc disease would have remained stable and not progressed. Stewart would have had the option of receiving neurosurgical consultation and care, which

25 Dr. DeBerardino does not assert , and Stewart does not allege, that Clear Lake Regional failed to have hospital employees and representatives, either its nurses or physicians, inform Stewart of his stenosis or failed to have hospital employees or representatives be patient advocates and inform Stewart of the serious consequences of his stenosis.53

could have included further neurological testing, detailed cervical spine care, activity limitations, physical therapy/rehabilit ation, and surgical intervention. Further, Stewart would have had surgery to correct his condition or would have been prohibited from engaging in the unspecified activities that led to his broken neck. Dr. DeBerardino assumes that Stewart would have obey ed any physician ’ s instructions to restrict his activity. Yet because Clear Lake Regional breached the purported standard of care, Stewart continued to engage in his normal athletic activities and later suffered a broken neck and spinal co rd injury during a skiing accident more than three months later. Cf. Jelinek , 328 S.W.3d at 533 (“Care must
be taken to avoid the post hoc ergo propter hoc fallacy, that is, finding an earlier event caused a later event merely because it occurred first.”); Curnel , 562 S.W.3d at 565 (“It is not enough that one event occurred before the other . . . .”). As discussed above, an expert cannot simply opine that a breach of the standard of care caused the plaintiff ’ s injury. Jelinek , 328 S.W.3d at 539; Guillory , 2020 WL 45168 72, at *12; see also Abshire , 563 S.W.3d at 224 (“A conclusory statement of causation is inadequate

. . . .”). And an expert ’ s conclusion that “in medical probability” one event caused another is no more than an expert ’ s simple ipse dixit , which is insuff icient to establish causation. Jelinek , 328 S.W.3d at 539

– 40 (internal quotations omitted) ; see also Pollock , 284 S.W.3d at 818. Here, Dr. DeBerardino ’ s amended expert report offers no more than a bare assertion that Clear54

Lake Regional ’ s purported breac h es resulted in the later injuries Stewart sustained while skiing. See Jelinek , 328 S.W.3d at 5 39

– 40 (bare assertion that breach resulted in increased pain , suffering , and prolonged hospital stay inadequate); Guillory , 2020 WL 4516872, at *12. There is n o explanation as to how Clear Lake Regional’s purported breaches caused Stewart ’ s skiing

- related injuries. See Jelinek , 328 S.W.3d at 540; see also Tiscareno , 495 S.W.3d at 614 (“[T]he expert must at a minimum explain the connection between [the health care provider ’ s] conduct and the injury to the [plaintiff].”)

. “A report that merely states the expert ’ s conclusions about

. . . causation” does not fulfill the purposes of r equiring a good

- faith effort. Palacios , 46 S.W.3d at 879. Further, a n event is not a substantial factor in bringing about the harm if it is “too attenuated” from the harm or “does no more than furnish the condition that makes the plaintiff ’ s injury possib le.” Walters , 530 S.W.3d at 149 ; see also Curnel , 562 S.W.3d at 565

. H ere, Clear Lake Regional’s purported breach es of the standard of care

— that were committed while Stewart was admitted to Clear Lake Regional for injuries related to his bicycle incident

— are too attenuated from Stewart ’ s later neck and spinal injuries sustained while skiing to be considered a substantial factor in bringing those injuries about. See Dowell , 262 S.W.3d at 3 29

– 30 (holding medical providers ’ “negligence was too attenuated fr om the [harm] to have been a substantial factor in bringing it about”); Curnel , 562 S.W.3d at 565

– 66 ; Shenoy ,55

2011 WL 6938538, at *9 (“A causal link can be too attenuated to satisfy the causation requirement for an expert report.”)

. It is not enough that one event occurred before the other. Curnel , 562 S.W.3d at 565; Shenoy , 2011 WL 6938538, at *9; see Jelinek , 328 S.W.3d at 533 (“Care must be taken to avoid the post hoc ergo propter hoc fallacy, that is, finding an earlier event caused a later event merely because it occurred first.”). At most, Clear Lake Regional ’ s purported breach es

— by failing to have hospital employees and representatives inform Stewart that he had extensive mid and l ower cervical degenerative disc disease and by failing to have hospital employees or representatives be patient advocate s and inform Stewart of the serious consequences of that condition

— did “no more than furnish the condition” that made
Stewart ’ s later in

jury while skiing possible. Cf. Curnel , 562 S.W.3d at 565

– 66 (internal quotations omitted) ; see also Mason , 143 S.W.3d at 800 (“Our precedents establish that merely creating the condition that makes harm possible falls short as a matter of law of satisfyi ng the substantial factor test.”).
As to Stewart ’ s direct liability claim against Clear Lake Regional, we conclude that Dr. DeBerardino ’ s amended expert report does not adequately inform Clear Lake Regional of the causal relationship between its purported failure to56

provide care in accord with the applicable standard of care and the claimed injury, harm, or damages. 26
Because Dr. DeBerardino ’ s amended expert report is inadequate on Stewart ’ s direct liability and vicarious liability health care liability claims against Clear Lake Regional and Stewart cannot rely on Lindenberg’s expert report to support his direct liability and vicarious liability health care liability claims against Clear Lake Regional , we hold that the trial court e rred in overruling Clear Lake Regional’s objections and denying its motion to dismiss. See Potts , 392 S.W.3d at 630; Whitmire , 2020 WL 4983321, at *21. We sustain Clear Lake Regional ’ s sole issue. 27

26 We note that Stewart, as to his direct liability claim aga inst Clear Lake Regional, cannot rely on the expert report of Lindenberg, a non

- physician, to address the causal relationship between Clear Lake Regional ’ s purported failure to provide care in accord with the applicable standard of care and Stewart ’ s claim ed injury, harm, or damages. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.403(a) (only physicians are qualified to render causation opinions in suits involving health care liability claims); Hieger , 243 S.W.3d at 186 n.2 ; see also T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.001(a)(23) (defining “[p]hysician” (internal quotations omitted))

. Further, i n his briefing, Stewart states that Lindenberg ’ s report “is not offered for purposes of establishing causation and any references to causation in the report are me re surplusage.”
27 To dispose of this appeal, w e need not resolve any remaining portions of appellants ’ issues not already addressed in th is memorandum opinion. See T EX
. R. A PP
. P. 47.1.57 Conclusion We reverse the trial court ’ s order s overruling appellants ’ objections and denying appellants ’ motion s to dismiss the health care liability claims made against them . We remand this case to the trial court with instructions to assess and award appellants their reasonable attorney ’ s fees and c osts of court and to dismiss Stewart’s claims against appellants with prejudice. See T EX
. C IV
. P RAC
. & R EM
. C ODE A NN
. § 74.351(b).

Julie Countiss Justice Panel consists of Justices Countiss, Rivas

- Molloy, and Guerra

.