T EX . C IV . P RAC
. & R EM . C OD E A NN . § 7 4.35 1(r)( 6) (V ern on S up p. 20 07 ). 1 

### NUM BER 13-07– 682- 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 OR P U S C H R I S T I - E D I N B U R G
ROD OLF O GU ERR ERO , M .D., A pp ellan t,
v . ROSA RIO RUIZ A ND HU SBA ND, ROB ERT O R UIZ , A pp ellees . On ap pe al f rom th e 2 75t h Dist rict C ou rt o f H ida lgo C ou nt y , T exas .



## ME MOR A N D U M OP I N I ON B efo re J u st ic es Y añ ez , R o d rig u ez , a n d V el a M emo rand um Opin ion b y Ju stice Ya ñe z Appel lan t, Rod olfo Gu er re ro , M .D ., chal len g es the tri al cour t’ s denia l of his moti on to dism iss a claim f iled by appellee s, Robe rto and Rosario Ruiz(“ the Ruiz es”), for failure to provide an ex pe rt report tha t satisf ied sect ion 74 .35 1(r)(6) of the T exas Ci v il Practice and R emedie s C ode. W e r ev erse and remand. 1Id

. § 7 4.35 1(b ). 2 25 3 S

. W

. 3d 20 4, 20 7-0 8 (T ex . 20 08 ). 3 2 Back ground The Ru iz es’ or ig ina l peti ti on, fil ed on Apr il 13, 2007, pr ov ide s t he foll ow ing factual
s u m m a ry: On t he 3r d day of Febr uar

y , 200 5, R osar io Rui zw as admit ted a t Knapp Me dic al Cen ter , a hospita l in W esl aco, Tex as, for a su rg ic al pr ocedu re to ex ci se a tumor on t he pos ter ior

tr ian g le on the left si de of the neck. Dr

. R o d olfo Gue rrero performe d the surgi cal proced ure on Rosario Rui z . In pe rfor ming the surg ic al pr ocedu re , D r. R o dol fo Guer re ro i nju re d Ros ar io Rui z ’ [si c] v ocal co rd s a nd ner v e aff ect ing the le ft side of the diap hragm. . . . Rosario Ruizhas suf fered physical pain and men tal an guish as a r esul t of thes e i nju ri es . . . . H er hus band, Rob erto R uiz , has su ff er ed los s o f conso rt ium and hou sehol d s er v ic es . . . . On A ug ust29, 2007, Guer re ro fil ed a moti on to di smi ss appel lee s’ cl a im p u rs uant to sec ti on 74. 351( b) of the c iv il pr act ic e and re medies cod e . Gu e rrer o arg ued t hat t he 2 Rui z es’ ex per

t repor t, pr epar ed by

Loui s F . Si lv er man, M .D ., faile d to sat is fy sec ti on 74. 351 in that itfail ed to (1 ) set forth the sta ndard of c ar e appl ic abl e to appel lan t; (2 ) ide nti fy how appel lan t breache d the st andard of care; an d ( 3) i denti fy and ex p la in a ny ca usal l ink bet w een any alleg ed b reach and app ellees’ com plaine d-of injuries. T he trial court denied Gue rrero’s mo tion to dism iss on Octobe r 15, 200 7. T his int er loc utor

y appeal then ens ued. Waiv er The Ru iz es ass ert t hat w e l ack ju ris dic ti on ov er

Guer re ro ’s appeal

. The jur is dic ti onal arg ument rais ed by the Rui z es, how ev er , w as ex pli ci tl y rej ect ed by

the Tex as Supr eme C our

t i n Lew is v. Funde rburk , an o pin ion i ss u e d t wo months after the Rui z es 3Am

. Transi t i onal C are Ct r

s. of Tex. , I nc. v. Pal aci os , 46 S

. W

. 3d 87 3, 87 7 (T ex . 20 01 ). 4 See Bow i e Mem ’

l H osp. v. W r

i ght , 79 S

. W

. 3d 48 , 52 (T ex . 20 02 ). 5 W alker

v. Packer , 82 7 S

. W

. 2d 83 3, 83 9-4 0 (T ex . 19 92 ). 6 See T EX . C IV . P RAC
. & R EM . C OD E A NN . § 7 4.35 1(a ). 7 S e e i d

. § 7 4.35 1(a ), (l ). 8 See Pal acios , 46 S. W

. 3d a t 878

. 9 3 f iled the ir bri ef

. A ccordingly , w e reject th e Ruiz es’ argume nt an d sha ll proceed to add ress the merits of

Guerrero’s ap pea l. St and ard o f Rev iew W e revi ew a trial court’s ruling regarding the ad equacy of an expert repo rt fo r abuse of dis cr eti on. A tr ial co urt c ommit s a n abuse of di sc re ti on i f it act s i n an ar bit ra ry or 4
unr eason abl e manner

w it hout re ferenc e to g uid ing r ule s o r pr inc ipl es. W e may not 5 subs ti tute our

j udg ment for that of t he tr ial co urt w hen rev iew ing matte rs co mmitt ed to the tr ial co urt’ s d is creti on. 6 Unde r section 74 .35 1 of the T exas Ci v il Practice and Rem edie s Code , hea lth care li a b il it y cl a im a n t s m u s tp ro vid e a n e xp e rt re p o rt t o t h e d e fe n d a n tn o la t e r t h a n 1 2 0 d a ys af ter f iling the origi nal petition

. A def end ant may file a m otion challen ging the ad equacy 7 of the rep ort, an d the trial court “shall g rant” the mot ion on ly if it a p p e a rs that th e repo rt doe s not rep resen t a good f aith e f fort to com ply w ith th e statu tory def inition o f an expert repo rt. In d e t e rmining w het her the report represe nts a good faith e f fort, the trial court’s 8 inq uir y i s l imi ted t o the four cor ners o f the r epor t, and no infer ences m a y b e d ra wn from infor mati on out si de th e r epor t. 9 An expert repo rt is def ined as a w ritte n r e p o rt byan expert tha t provides a fairSee T EX . C IV . P RAC
. & R EM . C OD E A NN . § 7 4 .3 5 1 (r )( 6 ); Pal aci os , 46 S. W

. 3d a t 878
- 79. 10 Pal aci os , 46 S. W

. 3d a t 879

. 11 I d. 12 W r i ght , 79 S. W

. 3d a t 52. 13 Pal aci os , 46 S. W

. 3d a t 879

. 14 I d. 15 W r i ght , 79 S. W

. 3d a t 53. 16 4 summar y of the e x per

t’ s o pin ion s reg ar din g : (1 ) th e a p pli cabl e s tandard of care; ( 2) the
manner i n w hic h the ca re prov ide d fail ed to meet th a t sta ndard; an d ( 3) the caus al
re lat ion shi p betw een t hat fai lure and the i nju ry , harm, or damag es cl aimed. I n 10 compl ian ce w it h the se sta ndards, the ex per t re por t mus t i ncor por ate e noug h i nformati on to fulfil l tw o purpos es: (1 ) the repor t mus t i nform the defendant of the s peci fic c onduc t t he plaint if f has called into question ; and (2) the report m ust provide a ba sis fo r the trial court to con clude the claim s are me ritorious. A repo rt m e rely ex pressing the e x pert’s 11 conclu sions ab out the sta nda rd of care, brea ch, a n d ca usat ion f ails to f ulf ill the se purp oses. The ex pert m ust explain the basis for his state me nts an d mu st link his

12
conc lus ion s t o the f act s. H ow ev er , t o av oid di smi ss al, a pl ain ti ff need not p re sental l the 13
ev ide nce neces sar

y to li ti g ate t he mer it s o f her cas e. The re por t may be i nformal i n tha t 14 the i n f o rm ati on need not fulfill the same req uirements as the ev ide nce off er ed i n a sum ma ry -judgmen t procee ding or at trial. M oreo v er, the e x pert is n ot required to e x press 15 the causa l relationsh ip in terms o f any “ ma gical” w ords. 16 Th e Exp ertR epo rt The Rui z es’ ex per

t re por t, w ri tten by Dr

. Si lv er man, sta ted, in re lev ant part, the5

fo llo wing: I am q ual ified by

educ ati on, t ra ini ng , and ex per ien ce to as ses s the qua li ty of such su rg ical proced ures as th at pe rforme d by D r. Guerro [sic] upo n Ms. Rui z , and to re nder

an e x per

t opi nio n r eg ar din g the q ual it y of suc h c ar e.

. . . . W hen a surgeon pe rforms a n op eratio n on the ne ck, the stand ard of care m a n d a te s that v it al str uct ur es suc h as the phr eni c n er v e w hic h i nner

v ates the diaph ragm be pre serv ed unless directly i nvolv ed in a m alignant p rocess. Dam age to the phre nic nerve cause s para ly sis of the dia phra gm. Ms. R uiz h a d a n o r ma l p r e o p e ra t i v e c h e s tx - r a y a n d n o h o a rs e n e ss pri or to t h e l e ft neck su rg eryperforme d by D r. Guerro [sic] on Febru ary13, 20 05. The se f in d in gs we re n o t e d fo ll o win g t h a tsu rg e ry. Mo re l ik ely

than not, thi s fin din g w as the resul ts [si c] of damag e to the p h re n ic n e rve d u ri n g Ms

. Ru iz' s o p e ra t io n . F a il u re t o p ro t e c tt h is n e rve dur ing nec k s u rge ry

i s c lea rl y

bel ow st andard. In al l re asona ble medi cal pr obabi li ty , D r. Guer ro 's [s ic ] fail ur e to pr otec t M s. Rui z 's phr eni c n er v e w as t h e p ro xim a t e ca u s e o f Ms

. Ru iz' s in ju ry. Discus sion T h e Ru izes c o n t e n d th a t t h e ir e xpe rtrep o rtse ts ou t t h e st a n d a rd of ca re th ro u gh the followi ng ex cerpt: “ W hen a surgeon performs an ope ration on the neck, th e stan dard of car e mandat e s th at v it al str uct ur es suc h as the phr eni c n er v e w hic h i nner

v ates the dia phr ag m be preser

ved u n les s d irect ly

i nv olv ed i n a mal ig nant pr oces s.” They furth er cont end that breac h and caus ati on are estab li shed throug h D r. Si lv er man’s co ntent ion that “[ d]amag e to the p hr eni c n er v e c auses par aly si s o f the di aphr ag m,” in conj unct ion w it h the follo w ing st atements : “F ail ur e to pr otec t th is ner v e dur ing nec k s urg er

y i s c lea rl y

bel ow stan dard . In all reason able m e d ic a l prob ability, D r. Guerro's [sic] failure to p rotect Ms. Rui z 's phr eni c n er

v e w as the p ro x imat e c ause of Ms . R uiz 's i nju ry .” W e f ind th at th e expert report do es no t suf f ici e n t ly dem onst rate th at Gu errero br eache d the st andard of care s et ou t i n Dr . Sil v er man’s repor t. T houg h the repor

t s tatesSee Pal aci os , 46 S. W

. 3d a t 878

. 17 See Hut chinson v. Mont em ayor , 1 4 4 S .W .3 d 6 1 4 , 6 1 8 (T e x . A p p .– S a n A n to n i o , n o p e t.); see a l so 18 C ooper v. Ar i zpe , N o. 0 4-0 7-0 07 33 4-C V , 2 00 8 T ex . A pp . L E X I S 2 50 6, a t *9-1 1 (T ex . A pp . –S an A nton i o A pr. 9, 200 8, pet

. f i l ed) ( hol di ng t hat an exper t r epor t f ai l ed t o est abl i sh t hat def endan t s br eached t he st andar d of car e be cause f i ndi ng t hat t he d ef endan t s br eached r equi r ed t he co ur t t o m ak e an assum pt i on o ut si de t he rep ort ’ s fou r co rne rs).

Pal aci os , 46 S. W

. 3d a t 880 ( quot i ng Pal aci os v. Am

. Transi t i onal C are Ct r

s. of Tex. , I nc. , 4 S. W

. 3d 19 85 7, 86 5 (T ex . A pp . –H ou s t on [ 1s t D i s t

. ] 19 99 ) ( T aft , J. di s s en t i ng ))

.

Id

. at 876

. 20 6 tha t Gue rrero fa iled “to prote ct Ms. Ruiz’s phre nic nerve,” the repo rt also seem s to imp ly that the n e rve n e e d notbe p ro tec ted i f it is “ direct ly i nv olv ed i n a mal ig nant pr oces s.” There is noth ing i n D r. Si lv er man’s re p ort es tabl is hin g thatthe phr eni c n er v e w as not directly involv ed in a malignant proce ss. And b ecau se w e are limite d to th e four corne rs o f t h e re p o rt a n d in fe re n c e s m a y n o tb e d ra wn f ro m in fo rm a t io n o u t s id e t h e re p o rt , we 17 maynot si mply

as sume t hat i t w as not d irec tl y i nv olv ed. Ac cordin g ly , w e find that the

18 Ruiz es’ expert report is def icient in f ailing to estab lish that Guerrero brea ched the sta nda rd of car e. W e furt her

find that the R uiz es’ ex per t repor t doe s n ot s uff ic ien tl y

se t outthe sta ndard of care appl ic abl e to Guer re ro . In Pal aci os , the Tex as Supr eme C our t obs er v ed th a t id e n ti f

ying t h e st a n d a rd of

ca re is cr it ica l, st a ti n g: W hether a defendant br eache s h is or her duty to a pat ien t c annot be det ermin ed a bsen t specif ic informa tion a b o ut w hat the de fend ant shou ld have don e dif

feren tly

. “W hile a ‘fair summ ary ’ is som eth ing l ess tha n a f ull sta tement of the appli cabl e standard of care and how

i t w as br eache d, ev en a fair su mmary

mustse t outw hat c ar e w as ex pect ed, b ut no t g iv en.” 19 In that cas e, Pal aci os w as a pati ent w ho s uff er ed i nju ri es after falli ng from hi s h ospi tal bed; Pal aci os and hi s family then br oug ht s uitag ain st the h ospi tal , s eeki ng co mpensat ion for the i nju ri es Pal aci os sus tai ned f ro m his fall

. The s upr eme co urt s tated thatthe sta tement 20I d. at 880

. 21 7 the Pal aci oses re li ed on in thei r ex per t re por t to est abl is h the sta ndard of ca re —“ that p r e c a u t i o n s t o p r e v e n tP a l a c i o s ’ fa l l w e r e n o tp r o p e r l y u s e d ” —w as no ta s t a t e me n to f a sta ndard of care , stati ng : “ Nei ther the tr ial co urt nor

[t he hos pit al] w oul d be abl e to det ermin e f rom th is co ncluso ry st ate me nt if

[ the e x pert] believes that th e stan dard of care required [the hosp ital] to ha ve m onito red Pa lacios mo re closely, restraine d him more secure ly , or don e som eth ing else entirely.” W ith this stat em e n t c o me s the im plicit 21 cont enti on th at t he Pal aci oses ’ ex per t repor t c oul d nothav e adequ a tely es tabl is hed t he sta ndard of care throug h a b ar e ass erti on that the s tandard of care mandat ed th at pa ti ents be s afeguarded from falli ng out of bed—for thi s a ss erti on w oul d notprov ide any ins ig ht as to w hat e x act ly

the hospi tal shoul d hav e done, but faile d to do, to uphol d the s tandard of
care. Such a ba re as ser ti on i s s imi lar

to that pr off er ed by

the Rui z es’ ex per

t repor t. The Ru iz es’ ex per

t re por t sta tes that Guer re ro faile d to pr otec t t he phreni c n er v e, w hich goes against a stand ard of care mand ating tha t the nerve be preserved. It is entirely
u n clear from t he r epor t, how ev er , w hat s peci fic a cti ons w er e r eq uired by Guer re ro to pr eser v e the phr eni c n er

v e ( e .g., i sol ate t he phreni c n er v e throug h the us e of a medi cal app aratu s, or perha ps simp ly posse ss a stead ier hand ). Ext ensi on o f Ti me The par ti es dis ag re e as to w hat c ourse of acti on th is C our t s houl d tak e upon findi ng the Ruiz es’ expert re port def icient. T he Ruiz es con ten d tha t w e sho uld rem and their cause to t he tr ial co urt s o i t c an c onsi der thei r ear li er re q uest for a 30- day extens ion to cure anySee T EX . C IV . P RAC
. & R EM . C OD E A NN . § 7 4.35 1(c ). 22 See ge ner

al l y Mi r anda v. Mar t inez , N o. 13- 06- 386- C V, 200 7 T ex. App. LEX I S 1802, at * 13- 15 ( T ex. 23 A pp . –C orp us C hri s t i M ar. 8, 20 07 , pe t

. de ni ed ) ( m em . op . ).

Leland v. Br

andal , N o. 06 -10 28 , 20 08 T ex . LE X I S 57 4, at *8 (T ex . Ju ne 13 , 20 08 ). 24 I n hi s br i ef , G uer r er o see k s an awar d of cost s. Because we ar e r em andi ng t he ca se t o t he t r i al 25 cour t so t hat t he cour t m ay exer ci se i t s di scr et i on i n de t er m i ni ng whet her or not t o aff or d t he Rui z es a 30- day ext ensi on, a det er m i nat i on o fent i t l em ent t o cost s i s pr em at ur e. 8 and all def iciencies w ith the ir repo rt. Guerrero cont end s that this course of action , w hich 22 this Court ha s tradition ally taken , is w ron g. S u b s e que nt to the f iling of Guerrero’s 23 app ellate b rief , howev er, the Te x as Sup reme Court held that “section 74 .35 1’s plain lan g uag e per mits one thi rt y -day extens ion w hen t he c our t of appeal s fin ds defici ent a repo rt that th e trial court con sidered ade quate, ” thus af f irming the prop rietyof

this Court’s 24 policy of rema ndin g. Accordin gly , w e f ind tha t the t rial cou rt still has discretion to ent ertain the R uiz es’ r eq uestfor a 30- day extens ion to cure defic ien ci es in thei r re por t. Conclusion W e r ev erse the t ri al cour t’ s o rd er deny ing Guerrer o’s moti on to di smi ss and re mand for furt her

proceed ing s c onsi ste nt w it h thi s o pin ion

. 25

LINDA REYNA Y

AÑEZ, J u s t i c e

Me moran dum Opi nio n del iv er ed and filed thi s t he 29t h day

of Aug ust , 200 8.