### NUM BER 13-09- 0045 6-CV 

## COURT OF A PP EA LS T H I R T E E N T H D I S T R I C T O F T E X AS C O R P U S C H R IS T I - 

## EDI NBURG
HEA LTH CA RE UNLIM ITED, INC. A ND HEA LT H CA RE UN LIM ITED -M CA LL EN, A pp ellan ts,
v . SERVA ND O VIL LA RR EA L, A pp ellee.

On ap pe al f rom th e 2 06t h Dist rict C ou rt of H ida lgo C ou nty , T exas . 

## ME MOR A N D U M OP I N I ON Be fo re Ju stice s R od rigu ez, Garza, a nd B en av ide s M emo rand um Opin ion b y Ju stice R od rigu ez Appel lan ts Hea lt h C ar e U nli mite d, I n c. a n d H eal th C ar e U nli mite d–M cAl len (c oll ect iv ely

H CU ) compl ain of the t ri al cour t' s d eni al of thei r moti on to d ismis s a ppel lee Servando Villarreal's health care liability claim for failure to se rv e an ade quat e ex pertO st eom y el i t i s i s def i ned as an " [ i ] nf l am m at i on o ft he b one m ar r ow c au s ed b y b act er i a, such as 1 s ta p h y l o c o c c i , th a t g a i n s e n try th ro u g h a w o u n d o r i n ju ry." I DA G. D OX ET AL ., A T T OR NEY ' S I L L US T RA T E D M EDI CAL D I C T I O N A R Y O 2 1 (1 9 9 7 ). F l a n k i s d e fin e d a s th e "s i d e o f t h e b o d y b e tw e e n th e rib s a n d th e p e l v i s ." I d. at F21. Vi l l ar r eal ' s expe r t r epor t r ef er s t o t he si t e of hi s i nf ect i on i nt er change abl y as hi s l ef t f l ank or hi p. 2 re por t, as re q uired by

se cti on 74. 351. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74. 351 (a)-(b) (V e rn o n S upp . 200 9). By one issue, HCU compla ins tha t the trial court abu sed its discretion by failing to dismiss Villarreal's claims beca use h is ex pert rep ort did not d e monstrate t hat t he ex per t i s q ual ified , i denti fy the a ppl ic abl e s tandard of care, or
e x p l a i n t h e c a u s a l c o n n e c t i o n b e tw e e n t h e a l l e g e d b r e a c h a n d V i l l a r r e a l ' s i n j u r y . W e aff ir m. I. B A CKGRO UND In l ate Ju ly

2005, Vi ll ar re al under w ent s pin al fusion surg er y to re pai r a frac tured lumbar v ertebra in his back

. Ov er the course of t he next y ear , Vi ll ar re a l suffered compl ic ati ons, i ncl udi ng ch ro nicrefrac tor y osteomy eli ti s— a r ecur ri ng se v er e abs ces s— on
w hat Villarreal's expert repo rt describe s as his lef t f lank. Vill arreal w as ho spitalized once

1 in Janua ry

2006 , twice i n Mar ch 2006, and onc e i n Aug ust2006, for t re atment of the absce ss; each time, the ab scess w as surgically drained , and at the March and Au gust
surg er ies , t he w ound w as fitted w it h a v acu u m as si ste d c los ur e ( VAC ) spong e dev ic e to promote he ali ng
. After dis charg e from hi s A ug ust2 0 0 6 h o sp it al sta y , Vi ll ar re al beg an receivi ng hom e he alth ca re f rom HCU, w hich continu ed th e use of the VA C sponge de v ice in its treatm ent of

Villarreal. In J une 200 7 , Vi llar re al w as ag ain admi tted to t he hos pit al becau se of conti nued dr ain ag e from t he s ame w ound i n hi s left f lan k; doct ors at the hos pit al deter mined that the
w ound w as infect ed. Dur ing surg er y to inc is e and dr ain the w ound, doct ors d is cov er ed aVi l l ar r eal al so sue d Drs. N oel O l i v ei r a an d Raul Bar r eda, D oct or s H ospi t al at R enai ssance W ound 2 C ar e C e n te r, E d i n b u rg R e g i o n a l M e d i c a l C e n te r, R e h a b C e n te r a t R e n a i s s a n c e D o c to rs H o s p i ta l , an d D oc t ors H o s p ita l, L td . H o w e v e r , n o n e o fth e f o r e g o in g a r e p a r tie s to th is a p p e a l. 3 forei g n body

i n the w ound, w hic h w as ev entual ly deter mined to be a spong e from t he VA C dev ic e. The doct or

w ho per formed th e s urg er

y noted that the s pong e had been l eft in the
w ound s o l ong thatti ss ue had g ro wn in to t he s pong e. In S eptember 2007, Vi ll ar re al under w ent a nother

su rg er y to re mov e mor e s pong e mater ial from t he s ame w ound. On O cto ber

10, 2008, Vi lla rreal su ed H CU , al leg ing thati t had neg li g entl y l eft a 2 spong e from t he VA C dev ic e i n Vi ll ar re al' s w ound c ausi ng extended hospi tal iz ati on and
mu ltiple surgeries to remo v e the spon ge. Villarreal prayed for dam ages in the form o f past and futur e medic al ex pense s, pastand future los t w ag es, pas t and futur e pai n and mental
a n gu is h , d is f ig u re m e n t , l o s s o f e n jo ym e n to f

li fe , a n d a n y o t h e r d a m a ge s a ll o we d b y la w. Villarreal serv ed a n expert repo rt aut hore d by Keith Mill er, M.D. on Janua ry 29, 200 9. HCU obj ect ed to the adeq uacy of the repor

t and f il ed a moti on to di smi ss Vi ll ar re al' s c lai ms on the g roun ds tha t Dr. M iller w as u n qua lifie d as an ex pert, failed to ident if y the ap plicable sta nd a r d o f c a r e , a n d fa i l e d t o e x p l a i n t h e c a u s a l r e l a t i o n s h i p b e tw e e n H C U ' s a l l e g ed br each and Vi ll ar re al' s i nju ri es. See i d. § 74.351( a) -( b) , (r )( 6)

. On Apri l 13, 2009, the t ri al
cour t found t he repor

t defic ien t butg ra nted Vi lla rreal a t hir ty -d ay extens ion to submi t a suffici ent a mended repor t. See i d. § 74. 351( c)

. On M ay 11, 2009, Dr

. Mi ll er submi tted an
am end ed rep ort, to which HCU f iled f urt h er object ions. After a he aring on HCU's obje ctions a nd m otion to dism iss, the trial court ov erruled HC U's obje ctions to the report and denied it s motion to dis mis s. T his i nter loc utor y appeal ens ued. See i

d. § 51. 014( a) (9 ) (V er non 200 8) ( author iz ing an i nter loc utor y appeal of the d eni al of a moti on to di smi ss fil ed und er section 74.3 51(b )).4 II. S TA NDA RD OF R E V I E W A ND A PPLI C A B LE L AW W e r ev iew

a t ri al cour

t' s d eci si on on a moti on to di smi ss under se cti on 74. 351 of the ci v il pract ic e and re medies co de for abuse of dis creti on. Jer nig an v. Langley , 195 S.W .3d 91, 9 3 ( Tex . 200 6) ; Am . Tr ansiti onal Car e Ctr s. of Tex., Inc. v. Pal

aci os , 46 S.W .3d 8 73, 878 (Tex. 2001 ). T he trial court abu ses its discretion if it acts un reaso nab ly or arbitrarily
o r w i t h o u t r e fe r e n c e t o a n y g u i d i n g r u l e s o r p r i n c ipl es. W alk er v. Gut ier re z , 111 S.W .3d 56, 62 (Te x . 200 3). Und er se cti on 74. 351 of the Tex as Ci v il Pract ic e and Remedi es Cod e, a cl aimant must "ser

v e on each par

ty or the par ty 's att or ney " an e x per

t report a n d c ur ri cul um v it ae "not lat er than the 120th day

after the date the or ig ina l peti ti on w as filed ." T EX
. C IV
. P R AC
. & R EM
. C OD E A NN
. § 74.351( a)

. An ex per t re por t is "a w ri tten re por

t by an ex pert that prov ide s a fair

su mmary

of the e x per

t' s o pin ion s .
. . re gardin g appl ic abl e s tandards of
care, t he manner

i n w hic h the ca re r endered .

. . fail ed to meet th e s ta n d a rd s, and t he
caus al re lat ion shi p betw een t hat fai lure and the i nju ry , har m, or damag es cl aimed. " Id. § 74. 351 (r) (6). In ou r review

of the expert repo rt, w e are limited t o the f our corne rs of the rep ort in det e rm in in g w het her the report m anif ests a good faith e f fort to com ply w ith the statu tory defini ti on of an ex per

t repor t. Pal aci os , 46 S.W .3d a t 878 ; see T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 7 4 .351( l ) (req uir ing thatthe tr ial co urt "g ra nt a moti on c hal len g ing the ade quacy of

the expert repo rt only if app ears to th e cou rt, af ter hea ring, that the report doe s not rep resen t an objective g ood faith e f fort to com ply" w ith the statu tory def inition). The r epor

t "nee d notm a rsh a l all the pla int iff's proof." Pal aci os , 46 S.W .3d a t 878 ;I t i s und i sput ed t hat H C U i s a heal t h car e pr ov i der subj ect t o cha pt er 7 4 of t he c i v i l pr act i ce an d 3 re m e d i e s c o d e
. See T EX
. C IV
. P RAC
. & R EM
. C OD E A NN
. § 7 4.00 1(1 2)(A ) ( V ern on 20 05 ). 5 Jer nig an , 195 S.W .3d a t 93. I f the ex per t repor t put s t he defendant on not ic e of the spec ificco nductco mplai ned of and prov ide s t he tr ial co urt a basi s on w hic h to c oncl ude the c lai ms hav e mer it , t he repor t repr esent s a g ood- faith e ff ort t o c omply w it h the st atute

. Pal aci os , 46 S.W .3d a t 879

. III . D I S CUS S I ON By i ts sol e i ss ue, H CU argu e s that the t ri al cour t er re d i n deny ing i ts moti on to dis mis s V il lar re al' s c lai ms bec ause his ex per t repor t w as inad eq uate under secti on 74. 351. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74. 351 (a)-(b). A . Qu alif icat io ns of

D r. Mi ller Fi rs t, HC U compl ain s t hat Dr . Mi ll er 's amended re por t f ail s to demons tr ate t hat h e is q ualif ied to be an expert in V illarreal's case

. HCU co nte nds, in particular, th at Dr. Mil ler's certif ication in fa mily me dicine d oes n ot qualif y him to rende r an opin ion regarding chronic
w ound c ar e manag ement, the t y pe of care H CU prov ide d to Vi ll ar re al. In a sui t al leg ing heal th c ar e l iab il it y ag ain st a heal th c ar e prov ide r, a pe rs on 3 q ual ifies as an e x per

t w it ness i f the person: ( 1) i s pr actic i ng he al th c are i n a fi el d of prac ti c e th at i nv ol v es th e s am e ty pe of care or

treatment as that del iv er ed by the d e f e ndant heal th care prov ide r, if the d efendant heal th c ar e prov ide r is an i ndi v idu al, at the t ime the t est imony

i s g iv en or

w as pr act ic ing t h a t type of heal th care at the t ime the c lai m arose; ( 2) ha s k no w l ed g e of ac c ep ted stand ards of care f or hea lth care prov ide rs for t he diag nosi s, care, or tr eatment of the i ll ness , i nju ry , or condi ti on i nv olv ed i n the cl aim; and6

(3) is qualif ied on the basis of training or expe ri e n c e to of fer an e x pert opi nio n r eg ar din g thos e ac cept ed s tandards of healt h c ar e. Id. § 74.402( b) (1 )- (3 ) ( Ver non 2005). In deter mini ng w hether a w it ness i s q ual ified on t he basi s o f trai nin g or ex per ien ce, w e cons ide r w hether , at the ti me the cl aim arose or at the ti me the tes ti mony

i s g iv en, t he w it ness : (1 ) is cer

ti fied by a li cens ing ag ency of on e or more sta tes of t he U nit ed St a t e s o r

a n a t i o n a l p ro fe s s i o n a l c e rt i fy i n g a g e n c y , o r h a s othe r subs tanti al tr ain ing or ex per ien ce, in the a re a of heal th c ar e rele v ant to t he c lai m; and ( 2 ) is act i v e l y

p r a c t i c i n g h e a l t h c a r e i n r e n d e r i n g h e a l t h c a re serv ic es re lev ant t o the cl aim. Id. § 74 .402( c) (1 )- (2 ); see als o Polone v. Shear er , 287 S.W .3d 229 , 238 (Tex. App. –Fort W orth 20 09, n o pet .)

. Cha pter 74 d oes not req uire tha t t he ex per t be a s peci ali st in the
ex actsame field as the heal th car e prov ide r. See R ober ts v. W il li am son , 111 S.W .3d 1 13, 121 (Tex. 2003 ). Our analysi s of the qualif ication s of

an e xp e rt unde r section 74 .35 1 is li mite d to the four

co rn ers o f the e xpe rt's r epor t and cu rr ic ulu m v it ae. Sa n Jaci nto Me thodi st Ho sp. v. Benn ett , 256 S.W .3d 806, 813 (Tex

. App.–H oust on [14th Di st. ] 200 8, no p et.). Our rev iew

of Dr. Mill er's ex pert rep ort and curriculu m vi tae rev eals th at he is a medic al doct or

l ic ensed i n the Sta te of Tex as and board- cer ti fied in family

medi ci ne w ho has been pract ic ing for o v er tw enty y ears. D r. M il ler

se rv ed as a c ommis si oner on t he Tex as Stat e Board of M edi cal Ex aminers for near ly four y ears and as a facult y member at both the U niv ersi ty

of Tex as Hea lt h Sci ence Cen ter Fami ly Pract ic e R esi dency

Prog ra m and the Pan ola College S choo l of License d Voca tiona l and Registered Nursing. He also
w orked for tw o y ears as th e chief of staf f and f o r ten y ears as th e directo r of eme rg ency
serv ices at the Shelb y

Regi ona l Medical Cente r in Cente r, T exas. Dr. M iller's expert report7

provides the f o ll o win g w ith regard to his qualif ication s that is specif ically relev ant to this
cas e: I am a medi cal doc tor cu rrentl y

l ic ensed to pr act ic e i n the st ate o f Tex as. I hav e been a l ic ensed m e dic al doct or si nce 1985, hav e been practicing me dicine co ntinu ously since then , includin g during the tim e of this claim, and as part of

my practice , have bee n, an d am currently involv ed in the dia g nosi s, care, and tr eatment of many pati ents si mil ar to Mr . Se rv ando Vi ll ar re al. I am famil iar w it h the di ag nosi s a nd treatment of pati ents w it h cond itions an d the ir com p li cation s similar to tho se experience d by M r. Ser v ando V il lar re al. I am famil iar w it h the st andards of car e a p p li cabl e to physicians, nu rses, hosp itals, em ergency dep artm ent s, w oun d care cen ters, and home heal th car e agenc ies , w hic h treatpatient s w it h c ondi ti ons si mil ar to M r. Ser

v ando V il lar re al.

. . . I n addi ti on, I i nteractw it h nursi ng and other s ta ff ath os pi ta l s , c l i ni c s , em erg en c y roo ms , w ou nd c are c en te rs , an d ho me hea lth care ag en c i es , on a d ai l y b as i s , an d I am fam i l i ar w i th t he s ta nd ar d proce dure s for physicians and nurses ta king care of patie nts like Mr. Ser van d o V ill ar re al. I am famil iar w it h the se sta ndard procedu re s .
. . beca use I ha v e treat ed m any patien ts w ith the se con dition s. Afte r s um ma r i z i ng th e fac ts of Vi l l ar r ea l ' s trea tm en t, D r
. M i l l er fur th er de s c r i bed his qualif ication s as follows:

I am fam iliar w ith the a ccept ed me dical stan dard s o f care app licable to t he as ses sment, di ag nosi s, and t reatment of pati ents w it h w ound inf ection s, and their cause s, as w ell as their com plication s .
. . . I know this on th e bas is of myeduc ati on, k now led g e, t ra ini ng , and di re ct ex per ien ce. I acquired this edu cation , knowledge, training, and direct experience throug h: 1) myatt endi ng , a n d su cc ess fully co mplet ing , medi cal sc hool classes, a nd reside ncy, that tea ch the ev alua tion, diagnosis, care an d treat me nt of

patie nts w ith . . . w oun d inf ection s; 2) pr act ic al ex per ien ce of dia g nosi ng and treati ng pati ents w it h .

. . w ound i nfecti ons; 3) discu s s i on s w i th c ol l ea g ue s at y ea r l y c on fer en c es , sem inars and mee tings; 4) stud yof

techn ical w orks routinelypub lished in textboo ks, journa ls and literat ure con cerning the e v alua tion, diagno s is, care an d treat me nt of

patie nts w ith . . . w oun d inf ection s;8 5) myrouti ne disc uss ion s and consul tati ons w it h other phy si ci ans w ho al so tr eat p ati ents w it h the sa me or si mil ar co ndi ti ons as Mr. Serv and o Villarreal and w oun d inf ection s; 6) myrouti ne and re g ula r cont actw it h hos pit al nurses , staff and re side n ts w ho ta ke care of pati ents w it h the sa me or si mil ar cond itions as Mr. Serv and o Villarreal and w oun d inf ection s; 7) my knowl e d ge a n d experience giv ing lecture s and in-serv ice c o n fe r e n c e s t o n u rs e s a n d s t a ff; 8) my ex perien ce servi ng on num erou s hosp ital com mitt ees; 9 ) myobs erv ati on of nur ses and nur s e c o n duct , super v is ing re si dents , and i nst ru cti n g nurses and re si dents i n the ev al ua ti on , di ag no s i s , c are an d trea tm en t of p at i en ts t he s am e as, or similar to, Mr. Servando Villarreal an d w oun d inf ection s; and 10) mypas t us e of w ound VAC sp ong e dev ic es on pati ents si mil ar to M r. Ser

v ando V il lar re al

. . . .

. . . . I hav e had tr ain ing and ex per ien ce conc er nin g prov idi ng home he alt h care for pati ents r ecei v ing w ound t re atm e n t, general ly , and w ound VAC therapy sp eci fical ly , t o pat ien ts suc h as M r. Vi ll ar re al

. . . . HCU argues tha t Dr. Mill er's state me nts regarding his qualif ication s are con clusory and unsu ppo rted by the facts. W e disagree. T he inf orma tion p rov ided in Dr

. Mill er's report show s t hat h e h as been c onti nuous ly pract ic ing i n a "fie ld of prac ti ce that inv olv es the same t y pe of care or trea tment as that del iv er ed" by H CU , w ound t re atment and maint enanc e. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.402( b) (1 ); Rob er ts , 111 S.W .3d at 12 1 (h old ing that an ex per t nee d notbe a sp eci ali st in the e x actfiel d s o l ong as he h as knowledge, skills, ex pertise , and training regarding t he specif ic issue in the case ); see also Polone , 287 S.W .3d at 238-39 ( hol din g that a doct or i s q ual ified w her e r epor t s tates that he h as experience treating oth er patie nts w ith cond itions similar to tho se of the pla intif

f ).9

Furthe rmore , Dr. M iller states in his report th at, th rough his edu cation a n d direct experience , he ha s knowle d ge o f t he sta nda rds of

care app licable to HCU in their tr eatment of pati ents w it h w ounds lik e Vi ll ar re al. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN
. § 74. 402( b) (2 ); see als o Benn ett , 256 S.W .3d at 814 ( af f irming the den ial of a he alth ca re provider's motio n to dism iss becau se, in pa rt, the d octo r w as qualif ied to auth or the rep ort based on h is ex per ien ce w or ki ng w it h and ins tr uct ing nurses and other st aff w ho c ar e for pati ents w it h bed sores)

. Fi nal ly , Dr . Mi ll er is li cens ed to pract ic e in the state of Tex as and has b een activ ely practici n g me dicine th at is relev ant to Villarreal's claim, w hich dem onst rates th at he is "qualif ied on the ba sis of training or ex perien ce to of fer an expert opi nio n re g ar din g " the s tandard of care appl ic abl e to thi s c ase. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN
. § 74. 402( b) (3 ), ( c) (1 )- (2 ). W e therefor e concl ude that Dr . Mi ll er i s q ual ified to prov ide an e x per

t repor t i n Vi ll ar re al' s c ase. B. St and ard o f Care an d Breach Se co n d , H CU co mplai ns that Dr . M il ler 's amended re por t fail s t o s et forth t he appl ic abl e s tandard of car e. Spec ific all y , H CU co ntends that"D r. M il ler w hol ly fail s t o p ro vid e a fa ir s u m m a ry of t h e c a re wh ic h wa s e xp e c t e d o r s p e c ify wh a t[ HC U] sh o u ld h a ve done or i n d i c a t e w h a t a c t i o n s t a k e n b y [ H C U ] d e v i a t e d fro m t h e a p p l i c a b l e s t a n d a rd of
care." See i

d. § 74 .351( r) (6 ). In hi s a mended repor

t, Dr . M il ler opi nes that the a ppl ic abl e s tandard of care r eq uires that HC U "do w hat a r eason abl e home h eal th c ar e ag ency w oul d hav e done under the
sam e or similar circumsta n c e s , or not do w hat a reason able hom e he alth ca re agency
w oul d not hav e done under the same or si mil ar ci rc umstan ces ." Dr . M il ler emphas iz es that the staf f of HCU "w ere respo nsible for a ssessing, remo v ing, and/ or chan ging this patie nt's10

w ound VAC spong e dev ic e." The amended ex per t re por t t hen s ets forth the sta ndard of care as follows:

T he a ccept ed sta nda rd s o f m edica l care app licable to . . . [HCU ] in [i ts] ca re of Mr . Se rv ando V ill a rre a l

. . . inc lud e, bu t are notl imi ted t o, t he followi ng stand ards: 1) This is a device w hich is p laced routine ly and as a ma tter of

course by the n urses and st af

f o f f acilities such as . . . [HCU], and th is same device shou ld have bee n rem oved and /or chan ged by . . . the nu rses and staf fs.

. . . . 3) The stand ard of

care required that , during th e t im e t h ey w ere c a ri n g fo r M r. S e rva n d o V il la rr e a l in 2 0 0 6 a n d 2 0 0 7 , [ HC U]

. . . sh o u ld h a ve discovered the p re sence of a foreign bod y

in the left f lank w oun d of this pat ient and alerted physici ans for app ropriate treatm ent . Th e staf f of [HCU] . . . shou ld have assesse d Mr. Villarreal on a daily basis an d ma ke [sic] sure t h a tn o wo u n d VA C d e vic e re m a in [ s ic ] in t h is p a t ie n t ' s h ip fo r m o re t h a n two day s. Si nce itw as the s taff of thi s facil it y that w as tr eati ng M r. Vi ll ar re al for h is wo u n d , i twa s t h e ir o b li ga t io n t o a s s e s s t h e wo u n d a tle a s te ve ry two days. 4) The sta ndard of care req uired th at du ri ng the ti me they w er e c ar ing fo r M r. S e rva n d o V il la rr e a l i n 2 0 0 6 a n d 2 0 0 7

. . . [ H C U ]

. . . sh o u ld h a ve proper ly cl eaned t he w ound in Mr

. Vi ll ar re al' s l eft flank and proper ly r emov ed and /or replace d t h e wo u nd VA C sponge de v ice at least ev erytw o da y s. Pr o p e r te ch n iqu e in rem o ving a n d /o r re p la cin g th e w o u n d VA C sp o n ge dev ic e, [ si c] w ould hav e i nv olv ed th oroug hly ex plo ri ng the full extent of the w oun d at ea ch rem oval and /or replace me nt. T his w ould ensu re that any old spong e dev ic es or

por ti ons of the s ame w oul d al w ay s b e found and remov ed and no forei g n bodi es w oul d be left i n thi s p ati ent' s w ound. The nurses and staf fs of . . . [HCU ] shou ld have docu me nte d in the med ical record tha t this wou n d ha d in d e e d be e n th o ro u ghl y explo re d , c le a n e d , a n d an y old sp o n ge dev ic e of [s ic] p a rts thereof, [s ic ] had been compl etel y r emov ed pr ior

to re pla ci ng any

new sp ong e dev ic es int o the w ound.

. . . . T he b reach es an d v iolation s of the sta nda rds of

care are as follows:

. . . . 2) [HCU ] . . . fa iled the stand ard of care w hich required tha t . . . [HCU] shoul d hav e di sc ov er ed th e presenc e o f a forei g n body i n the l eft flank11

w ound of thi s p ati ent a nd al erted h is phy si ci ans for appropr iat e treatment. T he sta f f . . . fa iled to asse ss Mr . Villarreal on a da ily basis and make sure t h a tn o wo u n d VA C d e vic e re m a in e d in t h is p a t ie n t ' s h ip fo r m o re t h a n two day s .
. . . A "fair summar

y " of t he appl ic abl e s tandard of care and br each ide nti fies the t y pe of care ex pect ed but not rend ered and tha t is precisely the informa tion that Dr . Mi ll e r's amended repor

t prov ide s. See Pala ci

os , 46 S.W .3d a t 880

. He ex plains th e spe cif ic tasks and respon si bil it ies r eq uired of H CU and notes thatH CU faile d to per form thos e tas ks and
re spons ibi li ti es. W e conc lud e that Dr

. Mi ll er 's re por t suffici entl y

se ts forth the s tandard of
care and br each el ements req uired of ex per t repor ts under se cti on 74. 351. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.351( r) (6 ). C. Causation Th i r d , H C U co mp l a i n s th a tD r
. M i l l e r ' s am e n d e d r e p o rtd i d n o ta d e q u a t e l y i d e n t i fy the caus al conne cti on betw een HC U' s all eg ed br each and Vi ll ar re al' s i nju ri es. H CU note s that Vi ll ar re al w as hospi tal iz ed four ti mes i n 2006 for t re atment of the abs ces s p ri or to the ti me H CU beg an c ar ing for V il lar re al in Aug ust2006. Empha si z ing thi s fact , H CU arg ues that Dr . M il ler 's st atements r eg ar din g ca usat ion are c oncl usor y , fail to ru le out c ondi ti ons
ex is ti ng before HC U' s t re atment of Vil lar re al, and fail to di ff er enti ate b etw een t he al leg ed neg li g e n c e o f H C U a n d t h e p o t e n t i a l l y n e g l i g e n t a c t s o f o t h e r h e a l t h c a r e p ro v i der s w ho tr eated Vi ll ar re al before A ug ust 2006. Our re v iew of Dr . M il ler 's r epor t i ndi cat es other

w is e. In hi s repor

t, Dr . M il ler

descr ibe s Vil lar re al' s inj ur ies as theyappeared in June 2007: Mr . Vi ll ar re al w a s a d m it ted .

. . . from 6- 18- 07 th ro ug h 6- 26- 07 for cont inu ed drain ag e from t he s ame w ound fro m hi s left flank from w hic h he had ex per ien ced troubl e .
. . . U pon admi ss ion , t his pati ent w as dia g nosed w ith oste om y elitis of

his lum bar spine w ith infection f rom multiple organisms. Mr . Vi ll ar re al w as tak en to surg er y for i nci si on and dr ain ag e of the thi s w ound

. . . . [The s urgeo n ] immedi atel y di sc ov er ed a forei g n body i n thi s w ound w hic h w as deter mined to be an o ld w ound VAC sp o n g e l eft in pla ce. [ The12

surg eon] noted that the s pong e had been i n pl ace for s o l ong thati t ".

. . appeared to hav e ti ss ue g ro w n i nto i t". [T he su rg eon ] sentthe rem oved spon ge to path ology for ana ly sis w hi c h c o n fi r me d t h a t t h e o b j e c t w a s a "

. . . w o u n d v a c s p o n g e sh ow ing re act iv e fibrosi s a nd g ra nul ati on ti ss ue w it h forei g n body g ian t cel l re act ion

. . . neg ati v e for si g nific ant a cut e i nflammati on". On 9-2 5 -0 7 , Mr. Vil la rre a l was a d m it te d

. . . wit h co n ti n u e d dra in a ge from hi s l eft flank w ound. At thi s a dmis si on, h e w as tak en to s u rg er y . . . [w hic h unc ov er ed] more s pong e mater ial i n the w ound.

. . . Dr. M iller opines th at du ring the time it w as caring fo r Vill arreal in 200 6 an d 20 07, HCU "shoul d hav e disc ov er ed the prese nce of a for eig n body " in Vi ll ar re al' s w ound an d al erted his doct ors for treat me nt. Dr. Mill er f urthe r not es tha t it w as HCU's obligation to "a ssess the w oun d on a daily basis" and "cha nge or remo v e any w oun d VAC device at l east ev ery tw o day s." H e the n s tates thatH CU st aff fail ed to p e rf o rm thes e obl ig ati ons and spec ific all y

co ncl udes that: Beca use th is fo reign body w as lef t in Mr. Villarreal's hip too long, it caus ed s ev er e i nfecti on w hic h s pr ead al l the wa y into thi s p ati ent' s b ones and s pin e, resul ti ng i n a s ev er e bone inf ect ion or os teomy eli ti s, nei ther

of w hich w ould have occurred ha d the w oun d VAC de v ice b e e n time ly dis cov er ed and re mov ed. Had [HC U]

. . . cared for Mr . Se rv ando V il lar re al acc or din g to the a cc eptabl e standards of care, then more l ik ely than not and to a rea sona ble de gree of me dical certain ty, the foreign bod y in this pat ient's f lank w ould have b e e n f o u n d an d rem oved in a time ly man ner an d Mr. Villarreal w ould not have und ergone prolonged pa in and suf fering, multip le hosp italiz ation s a nd surgical proce dure s, as w ell a s o v erall worsening of his c o n d it io n , p a in m e n t a l a n gu is h , a n d lo s s o f d ig n it y. To compl y

w it h s ect ion 74.3 51's r eq uirements , an ex per t repor t mus t i n clu d e an
e xp la n a t io n o f

t h e ca u s a l c o n n e c t io n b e twe e n a d e fe n d a n th e a lt h ca re p ro vid e r' s d e p a rt ure fro m t h e s t a n d a r d o f c a r e and the inj ur y , h a r m, a n d / o r

d a ma g e s c l a i me d b y

t h e p l a i n t i ff. T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74. 351 (r) (6). This require m e n t i s m e t if the rep ort explains the basis of

the ex pert's statem ent s and links his conclusion s to the facts. Se e13

Bowie Me m 'l Hos

p. v. W right , 79 S.W .3d 4 8, 52 ( Tex . 200 2)

. By ex pla ini ng how

the spong e neg li g entl y

l eft in Vi ll ar re al' s w ound byHCU caused a s ev er e i nfecti on th at s pr ead all the w ay to hi s b ones and s pin e nec ess it ati ng mul ti ple pai nful s urg er ies , D r. M il ler has don e just tha t. In oth er w ords, th e expert report de mo ns t ra t e d t h e b asis of Dr. Mill er's sta tement li nki ng H CU 's b re a ch to V il lar re al' s i nfected a bsc ess , resul ti ng 2007 hospi tal iz ati ons, and pai nful recov er y . See i d. Base d on the for eg oin g , w e c annot conc lud e tha t t he tr ial co urt abu sed it s d is creti on in deny ing H CU 's moti on to di smi ss
. See Jer nig an , 195 S.W .3d a t 93; Pal aci os , 46 S. W .3d at 87 8. Looki ng onl y

w it hin the four c or ners o f Dr . M il ler 's amended re por t, w e hol d tha t the repor

t ade q uatel y

i denti fied Dr. Mill er 's q ual ific ati ons and t he appl ic abl e s tandard of
care and HC U' s b re ach and ex pla ine d how , i n D r. M il ler's opi nio n, t he breach caus ed Vi ll ar re al' s i nju ri es. See Pala ci os , 4 6 S

. W

. 3d a t 878 . Th e repo rt w as a good f aith e f fort to c omply

w it h the st atute bec ause itput HC U on notic e of the spec ificco nductco mplai ned of and prov ide d the tr ial cour t a basi s on w hic h to conc lud e the cl aims hav e mer it

. See i d. at 87 9; T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.351( l ). H CU 's so le is sue is ov er ru led

. IV. C ONCL US I ON The order

of the t ri al cour

t i s a ff ir med.
NE LDA V. RO DR IGU EZ J u s t i c e Del iv er ed and filed the 11th day of Febr uar

y , 201 0.