### TEXA S C OU R T OF A PPEAL S, THIR D DIST R ICT , AT AU STIN

NO. 03-0 6 -00 583 -CV

P if i Constancio, In divid ually an d on b ehalf of T he Estate of Rub e n Co nst anc io, De c e as e d , A ppe lla nt

v. Jam es Bray, M.D . , Appellee

F ROM THE DISTRICT CO URT OF TOM GREEN COUNTY , 119TH JUDICIAL DISTRICT NO. B -06 -01 57- C-1 , HO NORAB LE THO MAS J. GO SSETT , JUDGE PRESIDI NG

D I S S E N T I N GO P I N I O N
The e x pert re port requir ement for health-c are liability

claims serve s a g atekeep i ng function desig ned to pr omptly identify frivolous lawsuits while prese rving meritorious claims. At this ear ly stag e in the proceeding s, the key conce rns ar e identify ing the specific conduct at issue and demonstrating the expert’s opinions have a sound basis. The standards are “objective good fa ith” and “f air summary

of the e x pert’s opinions.” Tex. Civ. Prac. & Rem. Code Ann. § 74.351( l ), (r )(6) (We st Su pp . 2 00 8) . Be c a

us e the se c on d expe rt re po rt se rv e d by a pp e lla nt in this c a se me e ts tho se sta nd ard s, Iwo uld re ve rs e the tr ia l c ourt ’s or de r g ra nti ngDr . B ra

y ’s mot ion

to d ism iss . F or

thi s
re a so n, Ire sp e c tf

ull y dis se nt.I n her f irst-amende d petition, a

ppellant contends that these three drug s cause respiratory 1 de pr e ssi on to so me deg re e and “ in c omb inatio n th e y

c an s y ne rg ist ic a lly

sig nif ic antl y inc re a se respiratory

depre ssion.” 2

F ACTUAL AND P ROCEDURAL BACK GR OUND On Fe bruar

y 3, 2006, appellant f

iled suit ag ainst Shannon West T ex as Memorial Hospital and Dr. James B ray , alleg ing that they neg lige ntly

cause d the death o f h er husband, Ruben Constancio. Acc ording to appellant’s pe tition, M r. Constancio suffe red a car diorespiratory
arr est on Dec em b er 1 , 2003; he was r esuscitated a nd his vital signs wer e re stored, but he ne ver
rec overe d and wa s pronounce d dead on D ece mber 1 3 , 2 0 0 3
. Only the claims ag ainst Dr. B ray
are curr ently

befor e this Court. Appellant alleg ed that Dr . Br ay , who treated M r. Constancio on November

30, 2003 and De cembe r 1, 2003 , wa s n eg lige nt in (i) order ing A tivan, morphine and Phenerg an to be administered to Mr
. Constancio in the fac e of respiratory distress; ( ii) not coming

1 in to e v a lu a te th e p a ti e n t i nth e f a c e o f r e s p ir a to r

y d is tr e s s an d

d e te r io r a ti o n ; a

n d ( ii i) d e c r e a s ing the fr e qu e nc y

of nurs inga sse ssm e nts and vit al si gn c he c ks in t

he fa c e of

re sp ir a tor

y dis tr e ss and dete rioration.

On the same d at e appellant filed suit, she serve d the expert repor t and cur riculum vitae of Dr. J . Steven Hata , a triple boa rd-c ertified phy sician who ser ves as dire ctor of the Surg ical I ntensive C are Unit at t he Univer sity of I owa Colleg e of Me dicine. See id. § 74.351(a) (re quiring claimant in hea lth care liability case to file expert repor

t and cur riculum vitae with i n 1 2 0 d ay s of filing suit). Dr. Bra

y filed a motion objecting to the a dequac y of the e x pert re port on Fe bruar y 22 (19 day s after

Dr. Hata’s re p o rt was ser ved). See id. (r e qu ir ingde fe nd ant w ho se c on du c t is implicated in repor

t to file and ser

ve any objections to repor t’s sufficie ncy within 21 day s after repor t3

was ser ved). In response , appellant asser ted that the expert repor

t was ade quate a

nd that the motion should be denied, but r equeste d, in the alternative, that the cour t gr ant a 30- day

extension i n which t o c u r e an y d e f

e c t s i nt h e r e p o rt
. T h e c o u rt h e l d a h e ar i n g o n D r . B r ay’ s m o t i o no nM ay 5 ( 9 6 d a ys
a ft e r t h e o r i g i n a l r e p o rtw a s s e r v e d ) an d f o u n d t h a tD r . H a t a ’ s e xp e rtr e p o rtd i d n o ts u f f i c i e ntl y addre ss the standard of

car e applica

ble t o Dr
. Br ay

or ca usation. The cour

t theref ore g rante d Dr. B ray ’s motion, but also g rante d appellant’ s reque st for a 30- day extension, wit h the extension to run from that date, May 5. On May 30 (day 1 1 6 ), ap p el l ant fil ed an a mended r eport fr om Dr. Hata. Dr. B ray filed a motion to dismis s assertingthat this second re port also was ina dequate
. See id. § 74.351(b)- (c) (mandating dis m i s s al wi th prejudice for f ailing to se rve e x pert re port within 120-day period unless court g rants one- time, 30-day extension). Appellant fi l ed a re sponse and a g ain re quested an extension. The trial co u rt fo und that the sec ond repor t failed to ade quately

addre ss causation and ther efor e g rante d Dr. B ray ’s motion to dis miss. The court also de nied appe llant’s reque st for an extension.
The e xp e rt re po rt re qui

re ment I n a hea lth-car e liability

claim, th e claimant must provide eac h defe ndant with one
o r mo r e e xp e rt r e p o rts , in c lu d in g a c u r r ic u lum v it a e f

o r e a c h e xp e rt, w it

h in 1 2 0 d ay s o f filing the orig inal petition. Id. § 7 4. 35 1( a ). An “ e xpe rt re po rt ” is:

a wr itten report by

an expert t hat provides a fair s ummary of t he ex pert’s opinions as of the date of the repor

t reg ardingapplicable standards of car e, the manne r in which the ca re r ender ed by

the phy sician or he alth car e provide r fa iled to m ee t the4

st an d ar d s , and the c ausal re lationship between the failure and the injury , harm, or damag es cla imed.
Id. § 74.351(r) (6)
. A re p ort nee d not marshal all of the plaintiff’s proof , but it mus t include the expert’s opinion on eac h of t he elements identified in the statute. Am e ric an Tra ns iti on al C ar e Ctr s. of Tex., Inc . v. Palacios , 46 S.W .3d 873, 878 (Tex. 2001). To constitute a g ood faith ef fort, the
re po rt must in fo rm

the de fe nd ant o f t

he sp e c if ic c on du c t c a lle d in to q

ue sti on and pr ov ide a

ba sis for the trial court to determine that the cla ims have merit. Id. a t 87 9. A r e po rt do e s n ot f

ulf ill the se tw o p ur po se s if it f a ils to a dd

re ss the stan da

rd of c are , b re a c h o f t

he sta nd ard , a nd c a us a tio n, or

if it mere ly states t he ex pert’s c onclusions reg ardingthese e lements. Id. The expert must ex plain the basis of his statements t o link his conclusions to t he fa cts. Bowie Mem ’l Hosp. v. W right , 79 S.W .3d 4 8 , 5 2 (T ex . 2 0 0 2 ) ( qu o t i n g Ea rlev . R atl iff , 998 S.W .2d 882, 890 (Tex. 1999)).
Dr . Ha ta’ s se c ond re po rt Appellant filed thre e re ports from Dr . Hata. A t issue on appea l is the adequa cy of the s eco n d

r e p o rt, w h ic h w a s f

il e d o nM ay 3 0 , 2 0 0 6
. T h a t r e p o rt b e g in s w it h a s u mm a r y of Dr. Hata’s qualific ations and then rec ounts the medical car e Mr. Constancio rec eived a fter he was
a dmi tte d t o t h e h o s p i t a l o nN o v e mb e r 2 9 , 2 0 0 3 , w i t h “ c o mp l a i n t s o f c o u g h , c o l d

s y mpto ms, abdominal pain, and de lirium”:
On 11/30/03 Dr. Bra

y repor ted t hat t he patient was mi ldly ag itated. . . . He stated that ag itation might be sec ondary to pain. At 0100 he orde red w rist restra ints. At 0145A pulse oxi meter is a d ev i ce t h at measur es the oxy g en saturation of arter ial blood. 2 Do rla nd ’s Il lus tra te d M

e dic al D ic tio na ry

1343 (Doug las M. Ander son chief le x icog raphe r, 30th ed. 2003) [hereina fter Dorland’s ]. Ap p el l an t ’s fi rs tam en d ed p et i t i o n s t at es t h at M r. C o n s t an ci o wa s a p at i en t o f D r. C h an g, 3 but that Dr. B ray

was Dr . C h ang’s “ cover ing pa rtner” on November

30, 2003, and De cembe r 1, 2003. An oxic e nc e ph a lop a thy is s y no ny mou s w ith hy

po xic e nc e ph a lop a thy , w hic h is a 4 deg ener ative disea se of the br ain ca used by hy pox ia from e ither dec rea sed rate of blood flow or decr ease d ox y g en conte nt of arte rial blood. Dorland’s , supra note 2, at 610-11. 5 Mr. Constancio showed a pulse ox imetry rea ding of 84-85% on r oom air. At 0405 2 h o u r s D r . B r ay o r d e r e d n e b u l i z e d b r o n c h o d i l a t o r s . N u r s i n g n o t e s r e p or t c oa rs e respiratory

sounds. At 0503 hours Dr. B ray decr ease d vital s i gn monitoring fr om ever y one hour to ever

y 4 hours. At 0830 hours he order ed P hener g an, Ativan, a nd morphine ora lly

or intrave nously

on an as ne cessa

ry basis. At 1400 hours Dr. B ray order ed Ha ldol 10 mil ligr ams I V. Nursingnotes at 2000 hours re port that the patient w a s i na s u p i n e p o s i t i o n , “ t h r a s h i n g ar o u n d a g i t a t e d ” , w i t h c o ar s e b r e a t h s b i l a t e r a l l y. Mr . Co ns tanc io’ s G la sg owsc or e de c re a se d f ro m 15 to 1 2 b y

23 00 ho ur s. On 12/1/03 at 0040 Mr. Constancio showed ta chy pnea w ith a respiratory

rate of 32 wi th b ilate ra l w he e zes wi th a he art rate of 10 2. No pu lse oxime tr

y wa s re po rt e d. Hi s nurse r eports that he was ag itated at 0145 hours. The re w as no re port of pain, na usea, or anxiety . The nurse . . . injected lorazepam 0.5 mg I V, morphine 2.0 mg IV, and Phenerg an 25 mg I V, all at 0145 hours i nto Mr. C onstancio. There are no vital signs wr itt e n at th is t ime or

pu lse oxime tr

y . A t 02 30 ho ur s, Mr . Co ns tanc io w a s r e po rt e dly aslee p. Mr. Constancio code d at 0340 hours. He require d intubation and mecha nical ventilation. He wa s t hen admitted to the I CU and treated with broad- spectrum antibiotics. Blo od cultures we re positive for methicillin resistant St aphylococc us aure us. Chest x -ra

y showed c hest infiltrates sug g estive of pulmonar y edema
. The patient s h o we d no responsivene ss after the eve nt. Dr. Chang stated that 3 f i n d i n g s w e r e c o n s i s t e n t[ w i t h ] an o x i c e n c e p h a l o p a t h y. The patient died on 4 12/13/03.
The re port next l ists si x actions the standa rd of c are applicable to Dr. B ray alleg edly require d:
Ba sed upon the m edica l condition of Mr. Constancio [and] based upon the medical rec ord, the standa

rd of c are for Dr . Br ay

would have r equire d:Hy pox emia is defic ient ox y g enation of the blood. Dorland’s , supra note 2, at 900. 5 Hy po xi a is a reduct ion

of oxy g e n s up ply

to t iss ue be low

ph y sio log ic a l le ve ls d e sp ite 6 adequate per fusion of the tissue by blood. Id. 6 (1) Re-eva luation of the incre asing ly disoriented patient on 11 /3 0 /0 3 and 12/1/03 by g oing to the patient’s be dside, listen[ ing] to the lung s with a stethoscope and per forming a neur ologic examination; (2 ) ob ta in c ur

re nt b lood st ud ies o f h is g luc os e le ve l to mon ito r f or dia be tic ke toa c ido sis wi th b loo d te sts ; (3) monitor continuous ox y g en saturation levels with the use of pulse oximetry re c or de d at le a st e ve ry

15 min ute s; (4) incre ase, r ather

than dec rea se, the fr equenc y of monitoring vital sig ns (blood pressure ; pulse; respirations; and blood oxy g en saturation); (5 ) ad m i tM r. C o n s t an ci o t o I C U f o r i n t en s i v e m o n i t o ri n g; (6) place Mr. Constancio on supplemental oxy g en.
The re port then states that Dr. B ray deviated f

rom the standar d of ca

re be cause he fa iled to take ea ch of the six actions li sted. The r eport e nds with a two-par ag raph discussion titled “Causation”:
Had Dr . Br ay

com p l i ed with the standa rd of c are , within reasona ble medica l probability , Mr. Constancio would not ha ve died when he did. Closer evaluation on 11/30/03 and 12/1/03 would have led Dr
. Br ay to rec og nize that Mr. Constancio’s ag itation was n o t a re s p onse to pain, but a sy mptom of hy

pox emia. Hy

po xia 5 6 pr ob a bly c a us e d th is p a tie nt t o b e c ome a g itate d. Th is i s c on fi rm e d w itha pu lse oxime tr y re a din g of

84 -8 5% . Pu lse ox im e tr y a t th is l e ve l in

thi s p a tie nt i s signific antly

abnorma l and indicates hy pox emia. I n the fa ce of

these c hang es, Dr. B ray

reduc ed Mr. Constancio’ s mo nitoring sc hedule. Ha d D r. B ra

y a dmi tte d M r. Con sta

nc io t o th e I nte ns ive Care Un it, Mr . Con sta nc io would have r eceived consta nt monitoring and his hy pox ic condition would have been, in r easona

ble medica l pr obability , rec og nized by the nursing staff a nd aler ted Dr. B ray . The standa

rd of c are at that point in tim e wo uld be for D r. B ray to put Mr . Co ns tan cio o n s up ple me nta l oxyg e n o r a ve nti la tor ; tr e a t th e dia be tic7

keto a c id o s is b y lo w e r in g h is b lo o d g lu c o s e , an d h e w o u ld h a v e r e c o g n iz e d the combination eff

ects of the medications g iven and r ever sed those with medica l support in the I ntensive Care Unit. Had this been done , Mr. Constancio would not have , in re a so na ble me dic a l pro ba

bil ity , die d dur ing that hosp ita lizatio n, and wo uld have , in re a so na ble me dic a l pr ob a

bil ity , r e c ov e re d a

nd be e n dis c ha

rg e d. Di a g no sis would be community

acquir ed pneumonia and diabetic ketoac idosis, the major ity of patients with this diagnosis survive if r easona ble ca re is provide d.
AN AL YSI S On ap p ea l , ap pellant contends that (1) the tria l court er red in g ranting Dr. B ray ’s mot ion to di sm is s because Dr . H a ta ’s se c on d r e po rt wa s su ff ic ie nt, and

(2 ) t he tr ia l c ourt

e rr e d in g ranting an extension of time that was not in confor m an ce with the statutory 30-day extension provided by

section 74.351(c ). See Tex. Ci v. Prac. & Rem. Code Ann. § 74.351(c ).
Stan dard of rev iew

We reviewa trial c ourt’s ruling on a motion to di smiss under section 74.351(b) for an abu s e o f d i s cr et i on. See P alacios , 46 S.W .3d at 877-78. We also re view a tr ial court’s or der g ranting or deny

ing a 30-day extension t o cure an expert re port using an abuse of discretion standa

rd. Og le tre e v . M

att he ws , No. 06-0502, 2007 Tex. L EXI S 1028, at *10 (Tex. 2007). A trial cour t abuses its discretion if it acts in an ar bitrary or unre asonable manner

or without ref

ere n ce to any

g uiding rules and pr inciples. Downer v. Aquam arine Operators, Inc

. , 701 S.W .2d 238, 241-42 (Te x . 1985). When review ing matters committed to th e t rial cour t’s discretion, we may

not substit ute our own judgme nt for that of the trial court. W alker v . Gutierrez , 111 S.W .3d 56, 63 (Tex. 2003).8

The motio n to dis miss

A re port may

be held inade quate a s to causation only if i t d oes not constitute an objective g ood faith ef

fort to provide a fair s ummary of the e x pert’s c ausation opinions. Tex. C iv. Prac. & Rem. Code Ann. § 74.351( l ), (r )(6) . The supre me co u rt addre ssed the ade quacy of an
e xp e rt r e p o rt’ s d is c u s s io no f c a u s a ti o nu n d e r

th e f o r me r e xp e rt r e p o rt s tatute in B o w i e Memorial Hospital , 79 S.W .3d at 48. I n t h at ca s e, the cour t upheld a trial c ourt’s dete rmination that an expert re p o rt failed to a dequate ly addre ss causation. Id. at 53. The r eport include d only one state me nt a dd

re ssi ngc a us a tio n: “ Ido be lie ve that it is r e a so na

ble to be lie ve that if the x-r ay s w ou ld have be en cor

rec tly rea d and the appropr iate medical personne l acte d upon those finding s then [the plaintiff] would have had the possibili ty of a be tter outcome.” Id. a t 51 . T he c ourt c on c lud e d th a t, be c a us e the re po rt

la c ke d “ inf

or ma tio n li nk ingthe e xpe rt ’s c on c lus ion (t hat [ th e pl a int if

f] w ou ld have ha d ‘the possibility

of a be tter o u t come’) to [t he def endant’ s] allege d brea ch (that it did not
corr ectly rea d and ac t upon the x -ra y s), the trial c ourt cou l d h av e re asonably deter mined that the repor t was conc lusory .” Id. a t 53. Th e c ourt state d th a t, “ wh ile the e xpe rt re po rt do e s n ot n e e d to
mars ha l a ll the e vid e nc e ne c e ssa ry to e sta bli shc a us a tio n at tr ia l, i t must co nta in s uf fi c ie ntl y sp e c if ic information to demonstrate c ausation beyond mere conjec ture.” Id. at 52.

Rely ing on Bowie Mem orial Hospital , 79 S.W .3d at 51, the majority conclude s t h at Dr. Hata’s sec ond repor t did not adequately

“indicate ” and state what “ ultimately ” ca used Mr. C o n s t an ci o ’s death. Idisag ree . The stateme nts in Dr. Hata’ s repor t are distinguishable f

rom the conc lusory

statements at issue in those case s cited by the majority
. Whil e the initial statement alone in D r. Hata’ s repor

t addre ssing c ausation—“H ad Dr . Br ay complied with the standar d of ca re,9

wi thi n r e a so na

ble me dica l pr ob a

bil ity , M r. Con sta

nc io w ou ld n ot h a ve die d w he n h e did ” —is conclusory , Dr. Hata’s re port g oes fur ther. As the majority

rec og nizes, the report c lear ly ties Dr. B ray ’s fa ilure to re- evaluate or more closely evaluate Mr. Constancio on N o v ember 30 and Dec ember

1 to Dr. B ray ’s fa ilure to diag nose hy pox emia. The rep o rt s t at es that such eva luation

“ wo uld have le d D r. B ray to re c og nize that Mr . Co ns tanc io’ s a g itatio n w a s n ot a re sp on se to pain, but a sy

mptom of hy

pox emia.” T his conclusion is tied t o t h e fa ct s b y the statements that (1 ) “ [h]y po xia p ro ba

bly c a us e d th is p a tie nt t o b e c ome a g itate d;” (2 ) “ [t]his is c on fi rm e d w itha pu lse oxime tr y re a din g of

84 -8 5% ;” and

(3 ) “[p ]uls e oxime tr

y a t th is l e ve l in

thi s p a tie nt i s si g nif

ic a ntl y abnorma l and indicates hy pox emia.” Simi la rl y , th e re po rt

tie s th e de c re a se in monit or ingvit a l si g ns and the fa ilure to admit Mr. Constancio to the I CU for intensive monitoring to the failure to dia g nose hy pox emia. The repor t states that, “[i] n the fa ce of these c hang es [ i
. e. s ignif icantly abnorma l pulse ox imetry and ag itation likely

due to hy pox ia], Dr. Br ay

reduc ed Mr. Constancio’ s monitoring sche dule. Had Dr. B ray admitted Mr. Constancio to the I ntensive Care Unit, Mr. Constancio would have r ece ived
c o n s t an tm o n i t o r i n g an d

h i s h yp o x i c c o n d i t i o n w o u l d h a v e b e e n , i nr e a s o n a b l e m e d i c a l p r o b a

b i l i t y,
rec og nized by

the nursing staff a

nd aler ted Dr. B ray .” The re p o rt ’s nex t statement lists t he ac tions that should have been taken af ter
rec og nizi ng hy

pox emia—putting Mr. Constancio on supplemental ox y g en or a ventilator, lower ing his blood glucose to treat his diabetic ketoacidosis, and recog nizi ng and reversingthe combinationDr. Hata’s orig inal repor t included an e x p lanation of the “ combination eff ects” of the 7 medications. In that repor t, he stated that “[i] t is well understood in medicine that the use of Ativan, Phenerg an an d morphine whe n injected in close proxi mity of time raise s unrea sonable risk of sy nerg istic reac tion gr eatly

exacer bating eac h of

th e d r u g ’ s individual abiliti es to provoke r espirator y depre ssion and/or respiratory arr est.” In that repor

t Dr. Hata also expressly

stated hi s opinion of what ca used Mr. Constancio’s de ath: “The injections of these thre e drug s increa sed t h e risk of somnolence a

nd respiratory

failure in this pati en t . I t is my opinion that these medications given cause d the patient’s death due to the depre ssion of his respirator

y function.” The se statements we re no t in c lud e d in

Dr . H a ta ’s se c on d r e po rt
. 10 e ff e c ts of the me dic a tio ns g ive n. Th e re po rt the n state s that “ [h]a d th is b e e n d on e , M r. Con sta nc io 7
wo uld no t ha ve , in re a so na ble me dic a l pr ob a

bil ity , d ie d d

ur ingthat ho sp ita lizatio n, and wo uld have , in re a so na ble me dic a l pr ob a

bil ity , r e c ov e re d and be e n dis c ha rg e d. ” Vi e we d in iso la tio n, thi s sentenc e would see m conclusory . Howeve r, this statement is tied to the previously mentioned three actions Dr. Hata states should have occ urre d afte r re cog nizi ng hy pox emia. I t is also linked to the
su bs e qu e nt s e nte nc e , w hic h s ta te s th a t th e “ [d]ia g no sis wo uld be c omm un ity a c qu ir e d p ne umo nia and diabe tic ketoac idosis, [ and] the majority of patients with this diag nosis survive if rea sonable c are is p ro vid e d. ” Dr . H a ta ’s f ina l se nte nc e c lari fi e s th a t he be lie ve s Mr . Co ns tanc io h a d c omm un ity acquir ed pneumonia a

nd diabetic ke toacidosis, but that Mr. Constancio would not have die d from those conditions had he r ece ived re asonable car e.

The majority

faults the re port for f

ailing to make an additional link t h at ties the f a i l u r e t o d i a g n o s e M r . C o n s t an c i o ’ s h yp o x e m i a t o h i s u l t i m a t e d e a t h
. A c c o r d i n g t o t h e m a j o r i t y, Dr. Hata’s re port fails to make this final link b ec au s e h e mentions severa l medical conditions but never expressly states from what Mr. Constancio died. Dr. Hata’ s repor t, however , states that Mr. Constancio “showe d no responsivene ss” af ter he coded and t hat “Dr . Chang stated that the fi nd ing s w e re c on sis te nt [w ith ] an oxic e nc e ph a lop a thy ,” wh ic h is a de g e ne rativ e dis e a se of the br a inAn e xpe rt re po rt wi ll n e c e ssa

rily inc lud e the c on c lus ion s o f a n e xpe rt . Pr ob le ms w ith 8 a de qu a c y ari se wh e n th e re po rt

state s me re conclusions, s uch as a single statement that the bre ach of the standa

rd of c are caus ed the injury . These ty pes of c onclusory

statements do not inform the defe ndant of the specific conduct called into que stion a nd do not provide a ba sis for the trial c ourt to determine that the claims have merit. See A merican Transitional C are Ctrs

. o

f T ex., I nc. v. Palacios , 46 S.W .3d 873, 878 (Tex. 2001). 11 cause d by hy pox ia. Se e su

pra note 4. The ne x t sentence states that “[t] he patient died on 12/13/03.” At a minimum , Dr. Hata’s re port ties the fa ilure to diag nose hy pox emia to Mr. Constancio coding and showing no responsivene ss afte r he coded. The majority conclude s that this li nk is not sufficient to sustain appellant’s cla im. I disag ree .

The re port satisfies the standa rds re quired by

the statute—“f

air summary

of the
e xpe rt’s op ini on s” and

“ ob je c tiv e g oo d f

a ith .” Dr . H a ta ’s re po rt

a dd re sse s a ll thr e e statut or ily
r e qu i r e d e l e m e n t s a

n d s t a t e s m o r e t h anm e r e c o n c l u s i o n s a s t o e a c h e l e me nt. S ee Palacios , 8 46 S.W .3d at 878. I t a lso e x plains the fa ctual basis for Dr. Hata’s stateme nts, links hi s conclusions to the fac ts, and contains “suf ficiently specific information to demonstrate c ausation beyond mere conjec ture.” See B owie Mem’ l Hosp. , 79 S.W .3d at 52. T h e report links the alleg ed bre ache s of the sta nd ard of c are to Dr. B ra

y ’s fa ilure to d ia g no se hy po xemi a and fu rt he r l ink s th e fa ilure to diag nose hy

pox emia to Mr. Constancio’s c oding a nd showing no responsivene ss after coding . The repor t theref ore r epre sents a fair s ummary of Dr. Hata’ s opinions. See Tex. Ci v. Prac. & Rem. Code Ann. § 74 .3 51(r )( 6) . In a dd iti on , th e re po rt inf or ms D r. B ra

y of the sp e c if

ic c on du c t c a lle d in to question and provides a

sufficie nt basis to deter

mine whether

the claims have merit. See P alacios , 46 S.W. 3d a t 879. Th e re po rt the re fo re a lso re pr e se nts “ an o bje c tiv e g oo d f a ithe ff or t to c omp ly

wi th the def inition of an expert report.” See Tex. Ci v. Prac. & Rem. Code Ann. § 74.351( l ), (r )( 6 ).12

Be cause the report provides a fair summary of Dr. H ata’ s opinions and repre sents an objec tive g ood fa ithe ff or t to c omp ly

wi th t he de fi nit ion

of an e xpe rt re po rt , th e tr ia l court a

bu se d it s d isc re tio n in g ranting Dr. B ray ’s motion to dis miss. I would reve rse the tr ial court’s or der.
E x t e n s i o n o f t i me Wit h reg ard to the se cond issue, I ag ree with the majo ri t y t h at t he trial c ourt improperly

calc ulated the period of time to cure the def iciencie s of the first amended r eport, re sulting in only a 7-da y extension of the 120-day

deadline f

or ser ving r eports. Having exercised its discretion to g ra nt a n e xten sio n to c ur e a

re po rt it f ound de fi c ie nt, the tr ia l c ourt do e s not have dis c re tio n as t o the leng th of the ex tension. Section 74.351’s plain lang uag e per mits t he cour

t to gr ant “one 30-day extension t o the claimant in orde r t o cure the def iciency .” Id. § 7 4. 35 1( c ); Leland v. Brandal , No. 06-1028, 2008 Te x . L EXI S 574, at *6-10 (Tex. J une 13, 2008) (discussing 30-da y extension); Ogletree , 2008 Tex. L EXI S 1028, at *7 (same) . Ithere fore disag ree wi t h the majority ’s g ener al
re mand . B e c a

us e the tr ia l c ourt

ha s e xer c ise d it s d isc re tio n to gr ant an e xten sio n, bu t er re d as t o it s leng th as the majority

also seems to conc lude, I

would rema

nd with instructions to gra nt “one 30- day extension.”
CO NC LU SION

Be cause the s ec o nd expert repor t proffe red by

Constancio satisfies the statutory require ments for a

n expert repor

t and the trial c ourt there fore ab u s ed i t s discretion in g ranting Dr. B ray ’s motion to dis miss, I would reve rse the trial court’s order
. Alternatively , Iwould rema nd with instructions to gra

nt the statutory

extension.13 J an P. Patterson, J ustice Be fore J ustices Patterson, Pember ton and Waldrop Filed: September

5, 2008