Reversed and Remanded and Opinion filed April 24, 2012.

In The

Fourteenth Court of Appeals 

___________________

NO. 14-11-00704-CV

___________________

THE UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON, 

Appellant

V.

KAI HUI QI, Appellee

On Appeal from the 212th District Court

Galveston County, Texas

Trial Court Cause No. 11-CV-0043

O P I N I O N

This case involves a Medical Liability Act claim for damages arising from allegedly 

negligent health care treatment. Appellant, The University of Texas Medical Branch at 

Galveston (―UTMBG‖), brings an interlocutory appeal from the trial court’s order denying 

appellant’s motion to dismiss based on the asserted inadequacy of appellee Kai Hui Qi’s 

expert report. We conclude that appellee’s expert report is not adequate because 
2

appellee’s expert failed to specify whether the standards of care apply to the doctor or the 

nurse; alternatively, appellee’s expert failed to specify whether there are general standards 

of care that apply to both doctors and nurses. We have also identified additional 

deficiencies which are described below. Accordingly, we reverse and remand to the trial 

court for further proceedings to include determination of whether to grant a 30-day 

extension to cure the deficiencies.

BACKGROUND

Kai Hui Qi sued UTMBG, contending certain employees were negligent in 

providing medical care, and their negligence resulted in the death of Qi’s unborn child. 

Specifically, Qi alleges that Virginia Rauth, M.D., and Julie Griffice, R.N., were negligent 

in providing medical care to Qi when they failed to diagnose preeclampsia and failed to 

admit Qi to the hospital for treatment and observation. Because the suit concerns a health 

care liability claim, Qi filed an expert report and curriculum vitae of Dr. Aaron Caughey, 

M.D., Ph.D. See Tex. Civ. Prac. & Rem. Code § 74.351. UTMBG filed its objections to 

Qi’s expert report along with a motion to dismiss with prejudice. Qi filed a response to 

UTMBG’s objections and motion to dismiss. After a hearing, the court denied UTMBG’s 

motion to dismiss. UTMBG timely filed notice regarding this interlocutory appeal.

ANALYSIS

On appeal, UTMBG argues that Qi’s expert report is inadequate because the author: 

(1) failed to identify a standard of care violated by UTMBG directly, or, alternatively, 

failed to identify standards of care violated by Dr. Rauth and Nurse Griffice that would 

give rise to vicarious liability; (2) failed to address Qi’s cause of action alleging negligent 

use of ―blood pressure cuffs/testing equipment and urine testing strips‖; (3) failed to 

identify a standard of care violated by UTMBG regarding Qi’s claim that UTMBG did not

counsel Qi on the possibility of preeclampsia and the symptoms to watch for; (4) failed to 

identify a standard of care violated by UTMBG, Rauth, or Griffice, with respect to the

failure to diagnose preeclampsia and the failure to admit Qi for elevated blood pressure;
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and (5) failed to address Qi’s ―catchall‖ claims of negligence in deviating from the 

standard of care for the treatment of high blood pressure and preeclampsia, and failing to 

refer Qi to a specialist or consult with a specialist concerning Qi’s condition. 

Section 74.351 of the Texas Civil Practice and Remedies Code requires a healthcare 

liability claimant to serve each party with one or more expert reports along with the 

curriculum vitae of each expert making the report. Tex. Civ. Prac. & Rem. Code § 

74.351(a). The expert report must provide a ―fair summary of the expert’s opinions . . . 

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 failure and the injury, harm, or damages claimed.‖ Id. § 74.351(r)(6). 

Under section 74.351(l), a trial court shall grant a motion challenging the adequacy of an 

expert report only if the report does not represent an objective, good-faith effort to comply 

with the definition of an expert report provided in section 74.351(r)(6). Id. § 74.351(l), 

(r)(6). If an expert report has not been served within the period specified by section 

74.351(a) because elements of the report are found deficient, the trial court may grant one 

30-day extension to the claimant in order to cure the deficiency. Id. § 74.351(c).

We review the trial court’s determination of the adequacy of an expert report for an 

abuse of discretion. Walgreen Co. v. Hieger, 243 S.W.3d 183, 185 (Tex. App.—Houston 

[14th Dist.] 2007, pet. denied). In making its determination on whether the report 

represents a good-faith effort to comply with the statute, the trial court is limited to the 

information found within the four corners of the report. Am. Transitional Care Ctrs. of 

Tex., Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex. 2001). To constitute a good-faith effort, 

the report must provide enough information to: (1) inform the defendant of the specific 

conduct the plaintiff has called into question and (2) provide a basis for the trial court to 

conclude that the claims have merit. Scoresby v. Santillan, 346 S.W.3d 546, 556 (Tex. 

2011) (citing Palacios, 46 S.W.3d at 879). No particular words or formality are required, 

but bare conclusions will not suffice. Id. A plaintiff need not marshal all the plaintiff’s 
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proof or present evidence in the report as if it were actually litigating the merits. Palacios, 

46 S.W.3d at 878–79. However, the report must include the expert’s opinions on the three 

statutory elements—standard of care, breach, and causation. Scoresby, 346 S.W.3d at 

555–56; Walgreen, 243 S.W.3d at 185–86. A report that merely states the expert’s 

conclusions about those three elements does not constitute a good-faith effort. Palacios, 

46 S.W.3d at 879. 

Identifying the standard of care is critical. Whether the standard was violated 

cannot be determined absent specific information about what the defendant should have 

done differently. Id. at 880. Though the ―fair summary‖ of the expert’s opinions

required by the expert report is something less than a full statement of the applicable 

standard of care and how that standard was breached, the report must still set out what care 

was expected, but not given. Id.; see also Tex. Civ. Prac. & Rem. Code § 74.351(r)(6). 

UTMBG does not challenge Dr. Caughey’s qualifications. Instead, in five issues 

UTMBG contends Dr. Caughey failed to address certain of Qi’s claims and failed to 

describe a standard of care that was violated for certain claims. The relevant portion of 

Dr. Caughey’s six-page report is reproduced here:

Case Summary

Kai Hui Qi was a 33 year old . . . woman at least 26 weeks gestation 

who presented with severe preeclampsia, vaginal bleeding, and an 

intrauterine fetal demise on January 19, 2009 to the [UTMBG] labor and 

delivery unit. . . . 

Prior to January 12th, 2009, Ms. Qi had several prenatal visits. 

Notably, her blood pressure ranged from 94/60 to 118/70 and she was always 

protein negative on the urine dipstick test. On January 12th, 2009, Ms. Qi 

presented with a blood pressure of 146/83, an interval 8 pound weight gain, 

and a urine dipstick test which returned trace. The note that day signed by 

Dr. Virginia Rauth and Julie Griffice, RN makes no comment about the 

elevated blood pressure, no comment about having asked Ms. Qi about the 

symptoms of preeclampsia, or having rechecked the blood pressure.
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On January 18, 2009, Ms. Qi or her husband called into the labor and 

delivery triage at 11:19 AM to complain of painless bright red vaginal 

bleeding. In the note signed by Nancy Jahn, RN, it is noted that the patient 

had a blood pressure of 140/90 the day prior and that she was currently

feeling fetal movement. The patient was advised by Nurse Jahn to drive 

into labor and delivery. Of note, per patient report, she had checked the 

blood pressure the day before on a machine in a store not in a health care 

setting. 

On January 19, 2009, Ms. Qi presented in the afternoon with the 

complaint of vaginal bleeding, headache, and an elevated blood pressure of 

149/90. In triage, she had a blood pressure of 148/101 and was noted to 

have an intrauterine fetal demise and oligo/anhydramnios. A plan was 

made . . . to admit the patient for induction of labor. Laboratory tests on 

admission included an hematocrit of 22.4 . . . [and] urine dipstick of trace . . . 

. Her induction progressed reasonably and she delivered a stillborn infant 

on January 20, 2009.

. . . .

Standard of Care

In this case, I believe there are three potential care interactions to 

discuss: 1) the visit on January 12, 2009; 2) the triage call on January 18, 

2009; and 3) the care of Ms. Qi during her admission beginning on January 

19, 2009. 

1) With regards to her clinic visit on January 12, 2009, I believe the 

standard of care was violated by the clinicians who saw her that day. 

Firstly, it is unclear how well the clinicians communicated the issue of an 

elevated blood pressure to Ms. Qi or whether interpretive services were 

utilized. In a woman who has previously been entirely normotensive and 

aproteinuric, a blood pressure with a systolic blood pressure of 140 or greater 

or a diastolic blood pressure of 90 or greater deserves further work-up. A 

standard work-up in that setting would have been serial blood pressures, a 

24-hour urine collection, and laboratory tests, and if any of these were 

persistently positive, a fetal ultrasound to screen for intrauterine growth 

restriction. It is difficult to determine exactly what any of these tests would 

have returned because they weren’t sent that day, but given that Ms. Qi 

continued to have elevated blood pressures when she checked them herself 

and when she presented a week later, it does seem more likely than not that 

her serial blood pressures would have been elevated.
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Further, when counseling a woman who might be developing 

preeclampsia, three symptoms, headache, abdominal pain, and visual 

changes are always discussed with the patient and they are told to return to 

the hospital with any of those symptoms. Given that Ms. Qi developed such 

symptoms on January 18, 2009, I believe it is more likely than not that she 

would have known to return on that date when those symptoms occurred. 

Given the significant language barrier that would have been recognized by 

Dr. Rauth and Nurse Girffice [sic], it would have been imperative to ensure 

that these risks/symptoms were appropriately communicated and understood 

by Ms. Qi. However, given that the majority of her labs were normal on 

January 19, 2009, I believe that these same labs would have been normal on 

January 12, 2009. The two exceptions are her hematocrit and urine protein. 

The hematocrit was quite low when she presented on January 19, 2009. I 

think the severity of this fall in hematocrit was due, at least in part, to her 

placental abruption, so I believe that the hematocrit would have been higher 

on January 12, 2009. Finally, given that the urine was trace positive, it is 

more likely than not that a 24 hour urine collection would have been 300 

mgs. or greater.

Given that it is more likely than not she would have been diagnosed 

with preeclampsia and almost certainly with gestational hypertension, a fetal 

ultrasound would have been ordered. I believe that such an ultrasound 

would have likely demonstrated the oligohydramnios and more likely than 

not would have demonstrated intrauterine growth restriction. Given these 

findings, I believe this would have prompted a hospital admission for Ms. Qi 

and a course of betamethasone. Given the fact that she eventually 

experienced a stillbirth due to placental abruption, it is likely that at some 

point during this hospitalization, the fetal heart tracing would have become 

nonreassuring prompting delivery. If such a delivery occurred it would 

have been of a 25-26 week gestational age fetus whose mortality rate would 

have been less than 50%, meaning that the fetus would have survived more 

likely than not.

2) When Ms. Qi or her husband called in to UTMB triage on January 

18, 2009 with vaginal bleeding, a recent[ly] elevated blood pressure, and 

potentially complaining of a headache, the triage nurse should have told her 

to come to labor and delivery. In the note signed the same day by Nurse 

Jahn, it clearly states that she communicated that Ms. Qi should come to 

labor and delivery immediately. I believe that due to the . . . significant 

language barrier, unfortunately, there was a failure to understand this advice 

by . . . Mr. and Mrs. Qi that led to a delay [of] 24 hours of her presentation to 

labor and delivery.
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3) When Ms. Qi presented to labor and delivery on January 19, 2009, 

it appears that she was evaluated promptly, a clear differential diagnosis was 

made, and a plan well within the standard of care was created. The care 

provided by Dr. Harirah and the team of residents and nurses appears 

exemplary.

Causality

In this case, there are competing pathways in causality – the 

pathophysiology that led to the placental abruption and stillbirth and the 

disruption of standard of care that increased the probability of this occurring. 

In terms of the natural history: 1) Ms. Qi developed preeclampsia; 2) the 

preeclampsia likely caused the placental abruption; and 3) the placental 

abruption caused the intrauterine fetal demise. However, there was at least 

one opportunity to disrupt that causal pathway.

If Ms. Qi had been diagnosed appropriately with gestational 

hypertension and preeclampsia on January 12, 2009, then as delineated 

above, the intrauterine fetal demise could have been prevented by earlier 

delivery and, if delivered, the infant would have survived, more likely than 

not. Further, if Ms. Qi had been diagnosed, she would have been treated 

with bedrest and with antihypertensive agents if her blood pressures were 

severely elevated. There is evidence to suggest that bedrest in the setting of 

preeclampsia is associated with a prolongation of the pregnancy. The same 

is true with controlling blood pressures in the setting of preeclampsia.

Conclusion

Thus, the clinicians who saw Ms. Qi on January 12, 2009 violated the 

standard of care by not further evaluating her for gestational hypertension / 

preeclampsia [or] communicating the importance of preeclampsia signs and 

symptoms to a woman with elevated blood pressure. Because of this, Ms. 

Qi lost an opportunity to prevent the subsequent intrauterine fetal demise.

I. Alleged failure to address liability

In its first issue, UTMBG argues that Dr. Caughey identifies UTMBG by name only

twice, does not state a hospital standard of care that was applicable to UTMBG, and does 

not state facts sufficient to demonstrate that UTMBG would be vicariously liable for 

violations of the standards of care by Dr. Rauth or Nurse Griffice. UTMBG further 

contends that, even presuming that UTMBG’s liability is based upon vicarious liability for 
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the conduct of Dr. Rauth or Nurse Griffice, the report still fails to identify a physician’s 

standard of care violated by Dr. Rauth or a nurse’s standard of care violated by Nurse 

Griffice. 

A. Vicarious liability alleged against UTMBG

Dr. Caughey’s expert report was not required to name UTMBG specifically or 

identify a hospital standard of care breached by UTMBG, so long as UTMBG’s liability is 

based entirely upon the actions of its resident physicians and nurses.1 See Univ. of Tex. 

Sw. Med. Ctr. v. Dale, 188 S.W.3d 877, 879 (Tex. App.—Dallas 2006, no pet.) (holding 

that expert report did not need to name UT Southwestern because the claims against UT 

Southwestern were based entirely upon the actions of its physicians, and there was no 

allegation that UT Southwestern was directly negligent); Gardner v. U.S. Imaging, Inc., 

274 S.W.3d 669, 671–72 (Tex. 2008) (―When a party’s alleged health care liability is 

purely vicarious, a report that adequately implicates the actions of that party’s agents or 

employees is sufficient.‖). Because Qi is not alleging that UTMBG is directly liable, Dr. 

Caughey’s expert report was not required to mention UTMBG by name. See Dale, 188 

S.W.3d at 879. 

B. Standard of care for each defendant

UTMBG argues that Dr. Caughey was required to either affirmatively state that the

same standard of care applied to both Dr. Rauth and Nurse Griffice, or was required to 

describe the respective standards of care for a nurse and a doctor in the same situation.2 

 

1

Plaintiff’s Original Petition states that both individual defendants were employees of UTMBG.

2

See Hayes v. Carroll, 314 S.W.3d 494, 506 (Tex. App.—Austin 2010, no pet.) (―Because the 

report affirmatively states that a uniform standard of care applies to each physician and nurse, and identifies 

what the standard of care is, [the] report is sufficient to provide a fair summary to each physician and nurse 

of his opinion regarding the standard of care applicable to each.‖); Polone v. Shearer, 287 S.W.3d 229, 235 

(Tex. App.—Fort Worth 2009, no pet.) (―Because the report does not delineate between the standard of care 

applicable to a physician’s assistant and the standard of care applicable to a physician, the report sets forth 

but one standard of care . . . [and] [b]ecause the report does not articulate that the standards of care are the 

same, the report required the trial court to impermissibly infer that [the physician’s assistant and doctor] 

shared identical standards of care . . . which may or may not be correct . . . .‖); Rittger v. Danos, 332 S.W.3d 
9

Dr. Caughey’s expert report stated that ―[Caughey] believe[d] the standard of care was 

violated by the clinicians who saw [Qi] that day.‖ (Emphasis added). We hold Dr. 

Caughey did not sufficiently describe the standard of care applicable to, and breached by, 

each defendant.3 Nor did Dr. Caughey explicitly state that the same standard of care 

applies to both Dr. Rauth and Nurse Griffice. Accordingly, we sustain UTMBG’s first 

issue.

II. Alleged failure to identify standard of care as to specific criticisms

In its third and fourth issues, UTMBG argues that Dr. Caughey’s expert report 

failed to identify a standard of care that was violated with regard to specific theories of 

liability, including allegedly failing to communicate with and diagnose Qi. 

Specifically, in its third issue, UTMBG argues that Dr. Caughey’s expert report 

failed to identify a standard of care that was violated by Dr. Rauth and Nurse Griffice in 

failing to communicate to Qi the ―possibility of developing preeclampsia and the 

symptoms to watch for.‖ Dr. Caughey’s expert report states that: 

[I]t is unclear how well the clinicians communicated the issue of an elevated 

blood pressure to Ms. Qi or whether interpretive services were utilized. . . . 

[W]hen counseling a woman who might be developing preeclampsia, three 

symptoms[—]headache, abdominal pain, and visual changes[—]are always 

discussed with the patient and they are told to return to the hospital with any 

of those symptoms. . . . Given the significant language barrier that would 

have been recognized by Dr. Rauth and Nurse Girffice [sic], it would have 

been imperative to ensure that these risks/symptoms were appropriately 

communicated and understood by Ms. Qi.

Dr. Caughey’s report further reveals that ―[t]he note . . . signed by Dr. Virginia 

Rauth and Julie Griffice, RN makes . . . no comment about having asked Ms. Qi about the 

 

550, 556 (Tex. App.—Houston [1st Dist.] 2009, no pet.) (―Appellees are not required to specifically state 

the same standard of care for each individual physician practicing on the same patient when each physician 

owes the same duties to the patient.‖).

3

See Polone, 287 S.W.3d at 234 (―Just as an expert report must provide an explanation of how 

each defendant specifically breached the standard of care, the expert report must set forth the applicable 

standard of care for each defendant.‖).
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symptoms of preeclampsia . . . .‖ The report notes that the standard of care was to ensure 

that the risks and symptoms of preeclampsia were communicated to Qi, especially where 

there was a significant language barrier. The report states that the medical records fail to 

note such counseling. 

In his report, Dr. Caughey describes a standard of care for communication of the 

risks and symptoms to the patient.4 However, Dr. Caughey failed to specify whether the 

standard of care applied to Dr. Rauth, Nurse Griffice, or both. Accordingly, we sustain 

UTMBG’s third issue. 

In its fourth issue, UTMBG argues that Dr. Caughey failed to identify a standard of 

care that was violated with regard to the theories of liability that Dr. Rauth and Nurse 

Griffice were negligent in failing to diagnose preeclampsia and failing to admit Qi to the 

hospital for elevated blood pressure. We again conclude that Dr. Caughey did not 

sufficiently identify whether the standard of care applies to Dr. Rauth or Nurse Griffice, or 

whether it was a general standard that applied to both. 

In addition, UTMBG argues that the relevant statements and opinions in Dr. 

Caughey’s report were ―all speculation and unsubstantiated conclusions.‖ In his report, Dr. 

Caughey notes that when Qi visited the hospital on January 12, 2009, her blood pressure 

was 146/83, she had an 8 pound weight gain since her previous visit, and a urine dipstick 

test ―returned trace.‖ Over the course of previous prenatal visits, Qi’s blood pressure 

ranged from 94/60 to 118/70. As noted previously, Dr. Caughey stated that either a 

systolic blood pressure of 140 or greater or a diastolic blood pressure of 90 or greater 

―deserves further work-up.‖ Dr. Caughey described what a further work-up would entail, 

and opined: ―given that Ms. Qi continued to have elevated blood pressures when she 

checked them herself and when she presented a week later, it does seem more likely than 

 

4 Though not clearly challenged by UTMBG, the causation element of this claim is not specifically 

addressed under the ―Causality‖ section of Dr. Caughey’s report. It is not clear that Qi developed any of 

the symptoms—a headache, abdominal pain, or visual changes—and failed to return to the hospital once 

those symptoms manifested.
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not that her serial blood pressures would have been elevated.‖ Dr. Caughey further notes

that ―[g]iven that it is more likely than not [Qi] would have been diagnosed with 

preeclampsia and almost certainly with gestational hypertension, a fetal ultrasound would 

have been ordered.‖ Dr. Caughey also opines that the ultrasound would have 

demonstrated intrauterine growth restriction, which would have ―prompted a hospital 

admission for Ms. Qi.‖ Dr. Caughey concludes this portion of the report by stating that if 

Qi had been diagnosed with preeclampsia and hospitalized, it is likely that delivery would 

have been induced and the ―fetus would have survived more likely than not.‖ We 

conclude that the relevant statements and opinions in Dr. Caughey’s report are not all 

speculation and unsubstantiated conclusions.

Accordingly, we sustain UTMBG’s fourth issue only as to Dr. Caughey’s failure to 

describe the standard of care respectively for doctors and nurses and overrule the 

remainder of this issue.

III. Alleged failure to address specific acts of negligence raised in pleadings

UTMBG’s second and fifth issues concern the alleged failure of Dr. Caughey’s 

expert report to address certain claims raised in Qi’s pleadings. 

In its second issue, UTMBG argues that Dr. Caughey’s expert report wholly fails to 

identify the standard of care, breach, and causality related to Qi’s claim that Dr. Rauth and 

Nurse Griffice negligently used ―blood pressure cuffs/testing equipment and urine testing 

strips.‖ In its fifth issue, UTMBG argues that Dr. Caughey’s expert report wholly fails to 

address the claims raised in Qi’s pleadings that Dr. Rauth and Nurse Griffice were 

negligent and proximately caused Qi’s injuries by: (1) deviating from the standard of care 

for the treatment of high blood pressure and preeclampsia, and (2) failing to refer Qi to a 

specialist or a physician qualified to confirm diagnosis and treat Qi, or failing to consult 

with such a specialist regarding Qi’s condition. 
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We agree with UTMBG, and conclude that Dr. Caughey failed to address the 

applicable standards of care, breach, and causality related to these claims. However, we 

note that all of the claims asserted by Qi fall within the same cause of action. See Certified 

EMS, Inc. v. Potts, 355 S.W.3d 683, 691–92 (Tex. App.—Houston [1st Dist.] 2011, pet. 

granted) (noting that the expert report is required to address each ―cause of action,‖ which 

refers not to a specific claim, but rather a ―group of operative facts giving rise to one or 

more bases for suing.‖). An expert is not required to address each and every act or 

omission mentioned in the pleadings, so long as at least one liability theory within each 

cause of action is sufficiently addressed. Lopez v. Brown, 356 S.W.3d 599, 604–05 (Tex. 

App.—Houston [14th Dist.] 2011, no pet.); Potts, 355 S.W.3d at 691–94, 700. Therefore,

Dr. Caughey’s failure to address all the acts or omissions alleged in the petition is not by 

itself a failure to comply with section 74.351 that would justify a dismissal of Qi’s health 

care liability claim. See Lopez, 356 S.W.3d at 604–05. Accordingly, we overrule 

UTMBG’s second and fifth issues.

CONCLUSION

Because Dr. Caughey did not sufficiently describe or specify whether the standards 

of care breached by the ―clinicians‖ applied to Dr. Rauth, Nurse Griffice, or both, and 

because we may not infer an answer, we hold Dr. Caughey’s report is inadequate. We 

remand to the trial court for further proceedings, including determination of whether to 

grant Qi a thirty-day extension to cure the deficiencies in the expert report. See Tex. Civ. 

Prac. & Rem. Code § 74.351(c).

/s/ Martha Hill Jamison

Justice

Panel consists of Justices Frost, Seymore, and Jamison.