Fourth Court of Appeals

San Antonio, Texas

OPINION

No. 04-15-00029-CV

DIAGNOSTIC RESEARCH GROUP and John R. Holcomb, M.D.,

Appellants

v.

Sushma 

Sushma VORA,

Appellee

From the 407th Judicial District Court, Bexar County, Texas

Trial Court No. 2013-CI-00357

Honorable Larry Noll, Judge Presiding

Opinion by: Jason Pulliam, Justice

Concurring and Dissenting Opinion by: Patricia O. Alvarez, Justice

Sitting: Karen Angelini, Justice

Patricia O. Alvarez, Justice

Jason Pulliam, Justice

Delivered and Filed: August 19, 2015

AFFIRMED IN PART; REVERSED AND REMANDED IN PART

This is an interlocutory appeal of the trial court’s denial of a motion to dismiss filed by 

Appellants Diagnostic Research Group (DRG) and Dr. John Holcomb. DRG and Dr. Holcomb 

contend the trial court abused its discretion in denying the motion to dismiss, finding the causes of 

action asserted against DRG are not health care liability claims under the Texas Medical Liability 

Act (TMLA). Further, DRG and Dr. Holcomb contend the trial court abused its discretion by 

denying their challenges to the expert report of Plaintiff Sushma Vora’s (Vora) expert, Dr. Amy 

Mulroy. 
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Based upon the particular record in this case, we affirm in part and reverse in part the trial 

court’s order denying DRG and Dr. Holcomb’s motion to dismiss. We remand for further 

proceedings consistent with this opinion.

BACKGROUND

This case arises from Vora’s participation in the pre-market study of a drug, linaclotide, 

anticipated to treat irritable bowel syndrome. The drug study was conducted by DRG, with Dr. 

Holcomb serving as the Principal Investigator. It is undisputed that during her participation in the 

study, Vora experienced three severe adverse events, each resulting in hospitalization. After the 

third event, Vora was removed from the pre-market drug study. Vora later suffered seizures and 

strokes, which she alleges severely disabled her. 

Vora filed suit against DRG and Dr. Holcomb asserting causes of action of negligence and 

gross negligence. In her petition, Vora asserts DRG and Dr. Holcomb departed from accepted 

standards of medical care “by conducting a study of a dangerous medication and allowing Ms. 

Vora to receive linaclotide which had serious side effects ....” Vora asserts this conduct caused 

preventable, permanent and debilitating injury. 

Although Vora maintains her negligence claims do not fall within the ambit of the TMLA, 

in the interest of caution, she timely served upon all defendants the expert report and curriculum 

vitae of Dr. Amy Mulroy, as required by Section 74.351 of the TMLA. See TEX. CIV. PRAC. &

REM. CODE ANN. § 74.351(a)(West Supp. 2014). DRG and Dr. Holcomb timely objected to Dr.

Mulroy’s report based upon her lack of qualifications to serve as an expert on causation. DRG 

and Dr. Holcomb also timely filed a motion to dismiss Vora’s negligence claims asserting the 

causes of action are health care liability claims, and as such, Vora was required to timely serve an 

expert report. Because Vora’s expert report did not meet the statutory requirements, DRG and Dr. 

Holcomb contended the suit should be dismissed. 
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Following a hearing on the motion to dismiss, the trial court overruled the objections to Dr. 

Mulroy’s expert report and denied DRG and Dr. Holcomb’s motion to dismiss. In its denial of 

their motion to dismiss, the trial court found Vora’s suit against Dr. Holcomb asserts health care 

liability claims; however, Vora’s suit against DRG does not assert health care liability claims. 

Also, the trial court found Dr. Mulroy’s expert report was “adequate as to Dr. Holcomb as it puts 

him on notice of the claims asserted by Plaintiff.” DRG and Dr. Holcomb then perfected this 

interlocutory appeal. 

ANALYSIS

Issue One: Whether Vora’s causes of action asserted against DRG are “Health Care 

Liability Claims”

DRG and Dr. Holcomb first contend Vora’s negligence causes of action asserted against 

DRG are health care liability claims pursuant to the TMLA because DRG is a health care provider, 

and the nature of her claims concern the care and treatment rendered to Vora during her 

participation in the drug study. DRG and Dr. Holcomb assert DRG satisfies the statutory definition 

of “health care provider” because DRG is an affiliate of a physician, Dr. Holcomb. 

Standard of Review

Ordinarily, an appellate court reviews a trial court’s determination of a motion to dismiss 

for failure to comply with Section 74.351 of the TMLA under an abuse of discretion standard. San 

Antonio Extended Med. Care, Inc. v. Vasquez, 327 S.W.3d 193, 196-97 (Tex. App.—San Antonio 

2010, no pet.). However, determination whether a petition asserts a health care liability claim

under the TMLA is a question of law, to which we apply a de novo standard of review. Id.; Inst. 

for Women’s Health, P.L.L.C. v. Imad, No. 04–05–00555–CV, 2006 WL 334013, *1 (Tex. App.—

San Antonio 2006, no pet.) (mem. op.). “[W]hen making that determination courts should consider 

the entire court record, including the pleadings, motions and responses, and relevant evidence 
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properly admitted.” Loaisiga v. Cerda, 379 S.W.3d 248, 258 (Tex. 2012). In construing a statute, 

an appellate court must give it the effect the Legislature intended as found in the plain meaning of 

the statute’s text. Bioderm Skin Care, LLC v. Sok, 426 S.W.3d 753, 757-58 (Tex. 2014); Lopez v. 

Osuna, 453 S.W.3d 60, 64 (Tex. App.—San Antonio 2014, no pet.).

Applicable Law

A “health care liability claim” is defined as:

[A] cause of action against a health care provider or physician for treatment, lack 

of treatment, or other claimed departure from accepted standards of medical care, 

or health care, or safety or professional or administrative services directly related 

to health care, which proximately results in injury to or death of a claimant, whether 

the claimant’s claim or cause of action sounds in tort or contract.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(13) (West Supp. 2014). Following this statutory 

definition, a health care liability claim under the TMLA has three elements: (1) the defendant is a 

health care provider or physician; (2) the essence of the nature of the underlying claim concerns 

treatment, lack of treatment or other departure from accepted standards of medical care, or health 

care, or safety or professional or administrative services directly related to health care; and (3) the 

defendant’s alleged act or omission was a proximate cause of the claimant’s alleged injury.1 

Loaisiga, 379 S.W.3d at 255. The party asserting application of the TMLA carries the burden to 

show the causes of action asserted are health care liability claims. Bioderm Skin Care, 426 S.W.3d

at 758; Brown v. Villegas, 202 S.W.3d 803, 806 (Tex. App.—San Antonio 2006, no pet.). 

With regard to the first definitional element, a health care provider is “any person, 

partnership, professional association, corporation, facility, or institution duly licensed, certified, 

registered, or chartered by the State of Texas to provide health care.” TEX. CIV. PRAC. & REM.

 1 The parties’ dispute in the trial court and on appeal focuses on the first two definitional elements. The parties do not 

dispute the third element: causation. Therefore, the third element is not discussed.
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CODE ANN. § 74.001(a)(12)(A) (West Supp. 2014). The term includes an officer, director, 

shareholder, member, partner, manager, owner, or affiliate of a health care provider or physician. 

See id. at § 74.001(a)(12)(B)(i). 

Following the statutory definition, the crux of classification as a “health care provider” is 

the initial requirement that the party be licensed or certified to provide health care. See id. at 

§ 74.001(a)(12)(A). As the party asserting application of the TMLA, DRG had the burden to 

present evidence to establish this licensure or certification. See Bioderm Skin Care, 426 S.W.3d

at 758; Brown v. Villegas, 202 S.W.3d at 806. DRG failed to provide any such evidence, however, 

as the record is silent as to any licensure or certification to provide health care. Without this 

evidence of licensure or certification, generally, a court cannot determine whether DRG satisfies 

the statutory definition of “health care provider.” See e.g. Shiloh Treatment Ctr., Inc. v. Ward, No. 

01-14-00626-CV, 2015 WL 1825757, at *4 (Tex. App.—Houston [1st Dist.] 2015, no pet.); 

Doctors Data, Inc. v. Stemp, No. 03-12-00079-CV, 2014 WL 3809742, at *3 (Tex. App.—Austin 

2014, pet. denied) (mem. op.); Brown v. Villegas, 202 S.W.3d at 806. However, in this factual 

situation, the analysis need not end with this omission of important evidence because the statutory 

definition of health care provider goes on to encompass any affiliate of a physician. See Bioderm 

Skin Care, 426 S.W.3d at 758.

The TMLA defines a health care provider to include, inter alia, an affiliate of a physician.

See TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(12)(B)(i); Bioderm Skin Care, 426 S.W.3d 

at 758. The TMLA then defines “affiliate” as “a person who, directly or indirectly, through one 

or more intermediaries, controls, is controlled by, or is under common control with a specified 

person, including any direct or indirect parent or subsidiary.” TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.001(a)(1). Further, the statute defines “control” as “the possession, directly or indirectly, of 

the power to direct or cause the direction of the management and policies of the person, whether 
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through ownership of equity or securities, by contract, or otherwise.” Id. at § 74.001(a)(3). 

Therefore, if DRG is an affiliate of Dr. Holcomb, then it is a health care provider under the first 

element of the three-prong test to determine whether the claim against it is a health care liability 

claim. Id. at §§ 74.001(a)(1), 74.001(a)(12)(B)(i); see Bioderm Skin Care, 426 S.W.3d at 758-59; 

Doctors Data, Inc., 2014 WL 3809742, at *3. 

DRG attached no evidence to its motion to dismiss and presented no evidence during the 

hearing on the motion to dismiss.2

 Due to this sparse record, the only facts upon which this court 

may rely to make any determination regarding whether DRG is an affiliate of Dr. Holcomb are the 

undisputed facts derived from Vora’s petition and the appellate briefs. As stated, no party disputes 

that Dr. Holcomb is a physician duly licensed in Texas to practice medical care and is employed 

by DRG. The trial court found Dr. Holcomb to be a physician and found Vora’s negligence claims 

against Dr. Holcomb to be health care liability claims as defined by the TMLA. This holding is 

not challenged on appeal, and therefore, will be accepted as a given fact. It is also undisputed that 

Dr. Holcomb, as DRG’s employee, was the Principal Investigator of the subject drug study in 

which Vora participated. Vora’s petition states DRG is a Texas Limited Liability Corporation and 

may be served with process through its registered agent, Charles Andrews. 

This limited record contains no evidence that Dr. Holcomb held any ownership of DRG or 

exercised any control over DRG’s management and policies. The limited record contains no 

evidence of Dr. Holcomb’s scope of employment or job description. The undisputed facts provide 

no basis from which this court could determine whether DRG satisfies the statutory definition of 

 2 Although DRG and Dr. Holcomb attach evidence to their appellate brief, this evidence was not presented to the trial 

court in its determination of the motion to dismiss and objections to Vora’s expert report. For this reason this court 

may not consider the evidence. See e.g. Crutcher v. Dallas Indep. Sch. Dist., 410 S.W.3d 487, 492 (Tex. App.—

Dallas 2013, no pet.); Hendee v. Dewhurst, 228 S.W.3d 354, 376 (Tex. App.—Austin 2007, pet. denied) (citing 

Cincinnati Life Ins. Co. v. Cates, 927 S.W.2d 623, 626 (Tex. 1996)) (in summary judgment context).
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“affiliate” or “control” to determine whether DRG is an affiliate of Dr. Holcomb. TEX. CIV. PRAC.

& REM. CODE ANN. § 74.001(a)(3); but see Bioderm Skin Care, 426 S.W.3d at 758-59 (record 

contained evidence Dr. Nguyen was the sole owner of the clinic, possessed power to direct its 

management and policies and was responsible for its operations.). 

Given the sparse record evidence, DRG has failed to show it “was duly licensed, certified, 

registered, or chartered by the State of Texas to provide health care.” See Shiloh Treatment Ctr., 

Inc., 2015 WL 1825757, at *4; TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(12)(A). Further, 

given the sparse record evidence, DRG has failed to show that DRG is an affiliate of a physician 

to otherwise meet the statutory definition of health care provider. See TEX. CIV. PRAC. & REM.

CODE ANN. § 74.001(a)(12)(B)(i); Bioderm Skin Care, 426 S.W.3d at 758. Because there is no 

evidence, based upon the limited undisputed facts before this court, this court cannot conclude 

DRG is a health care provider as defined by the TMLA. Because DRG failed to show it is a health 

care provider, it also cannot show Vora’s claims against it are health care liability claims. See

Loaisiga, 379 S.W.3d at 255. 3

Based upon this particular record, DRG’s first issue is overruled, and we affirm the trial 

court’s order concluding Vora’s causes of action asserted against DRG are not health care liability 

claims under the TMLA. 

Issue Two: Dr. Mulroy’s Qualifications to Opine on the Issue of Causation

DRG and Dr. Holcomb4 assert the trial court abused its discretion by denying their motion 

to dismiss because Dr. Mulroy is not qualified to opine on causation. Without expert opinion on 

 3 Because we make this determination, the court will not reach the second prong of the analysis whether Vora’s 

asserted causes of action are health care liability claims: the essence of the nature of the asserted claims. 4 DRG makes these assertions assuming this court concluded the claims asserted against it are health care liability 

claims, and therefore, the suit against it falls within the purview of the TMLA. Because we do not conclude the claims 

asserted against DRG are health care liability claims under the facts and evidence before the court, we address this 

issue only as it applies to Dr. Holcomb.
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causation, Dr. Holcomb contends Vora fails to meet the requirements of the TMLA, and therefore, 

her claims against him should be dismissed. Specifically, Dr. Holcomb argues Dr. Moyer’s report 

fails to establish she is qualified to testify on the issue of the causal relationship between Dr. 

Holcomb’s decision to prescribe linaclotide and the claimed side effects. Dr. Holcomb argues Dr. 

Mulroy’s report does not “state that she has any experience or training regarding linaclotide or 

gastrointestinal conditions” and fails to indicate whether Dr. Mulroy has any specific knowledge 

or experience in assessing the causal relationship between the prolonged use of linaclotide and the 

alleged side effects and injuries. 

Standard of Review

We review a trial court’s determination with regard to an expert’s qualifications to assert 

an opinion pursuant to Section 74.351 for an abuse of discretion. See Am. Transitional Care Ctrs. 

of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001). A trial court abuses its discretion if its 

decision is arbitrary, unreasonable, and without reference to any guiding principles and rules. 

Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002) (per curiam). Under this standard, 

when reviewing factual matters committed to a trial court’s discretion, an appellate court may not 

substitute its own judgment for the trial court’s judgment. Gray v. CHCA Bayshore L.P., 189 

S.W.3d 855, 858 (Tex. App.—Houston [1st Dist.] 2006, no pet.). Merely because a trial court 

may decide a matter within its discretion in a different manner than an appellate court would in a 

similar circumstance does not demonstrate that an abuse of discretion has occurred. Davisson v. 

Nicholson, 310 S.W.3d 543, 548 (Tex. App.—Fort Worth 2010, no pet.). A trial court does not 

abuse its discretion if it commits a mere error in judgment. See E.I. du Pont de Nemours & Co. v. 

Robinson, 923 S.W.2d 549, 558 (Tex. 1995).
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Applicable Law

In determining whether the report constitutes a good faith effort to comply with the 

statutory requirements, the trial court’s inquiry is limited to “the four corners” of the report.

Palacios, 46 S.W.3d at 878; Mem’l Hermann Healthcare Sys. v. Burrell, 230 S.W.3d 755, 758

(Tex. App.—Houston [14th Dist.] 2007, no pet.); Gray, 189 S.W.3d at 859. Thus, an expert’s 

qualifications cannot be inferred, but must be present in the expert report and the curriculum vitae.

See Olveda v. Supulveda, 141 S.W.3d 679, 683 (Tex. App.—San Antonio 2004, pet. denied). 

Should a plaintiff fail to establish the purported expert’s qualifications to submit the report, it is 

deficient and does not comply with Section 74.351. Collini v. Pustejovsky, 280 S.W.3d 456, 464-

66 (Tex. App.—Fort Worth 2009, no pet.); see TEX. CIV. PRAC. & REM. CODE ANN. §§ 74.351(l), 

(r)(5)-(6) (West Supp. 2014). 

A person is qualified to give opinion testimony concerning the causal relationship between 

the alleged injury and the alleged departure from the applicable standard of care only if the person 

is a physician and is otherwise qualified to render opinions on that causal relationship under the 

Texas Rules of Evidence. See TEX.CIV. PRAC.&REM.CODE ANN. §§ 74.351(r)(5)(C) (West Supp. 

2014), 74.403(a) (West 2011). To be so qualified under the Texas Rules of Evidence, an expert 

must have “knowledge, skill, experience, training, or education” regarding the specific issue before 

the court. TEX. R. EVID. 702 (West 2014); Broders v. Heise, 924 S.W.2d 148, 153 (Tex. 1996). 

Sections 74.351 and 74.403(a) do not require that the physician serving as an expert be a 

practitioner in the same medical specialty as the defendant. Accordingly, the proper inquiry 

concerning whether a doctor is qualified to testify regarding causation is not the doctor’s area of 

practice or expertise, but rather the doctor’s familiarity with the issues involved in the factual claim 

before the court. Roberts v. Williamson, 111 S.W.3d 113, 121 (Tex. 2003); Collini, 280 S.W.3d 

at 464; Blan v. Ali, 7 S.W.3d 741, 745 (Tex. App.—Houston [14th Dist.] 1999, no pet.). “A 
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physician who is not of the same school of medicine may be competent [to testify as to causation] 

if he has practical knowledge of what is usually and customarily done by a practitioner under 

circumstances similar to those confronting the defendant.” Estorque v. Schafer, 302 S.W.3d 19, 

26 (Tex. App.—Fort Worth 2009, no pet.); see also Ehrlich v. Miles, 144 S.W.3d 620, 625 (Tex. 

App.—Fort Worth 2004, pet. denied).

Analysis

Following these guidelines, to establish Dr. Mulroy’s qualifications to opine on causation, 

Vora was required to demonstrate Dr. Mulroy’s knowledge, skill, experience, training, or 

education that would qualify her to opine regarding the specific issues raised in Vora’s petition.

See Roberts, 111 S.W.3d at 120-21; Ehrlich, 144 S.W.3d at 625. Vora’s original petition states 

Dr. Holcomb was “negligent in conducting a study of a dangerous medication and allowing Ms. 

Vora to receive Linaclotide which had serious side effects including, but not limited to, bowel 

obstructions, seizure and stroke.” Vora contends Dr. Holcomb’s acts and omissions caused her 

asserted injuries.

Thus, the issues involved in the factual claim before the court are Dr. Holcomb’s conduct 

in facilitating a drug study and Dr. Holcomb’s continued prescription of linaclotide to Vora after 

she exhibited side-effect symptoms while participating in the study. Based upon the allegation in 

the petition, the specialized branches of internal medicine or gastroenterology are not implicated 

by Dr. Holcomb’s alleged negligence in conducting the drug study or continuing to prescribe 

linaclotide, nor is experience with linaclotide or knowledge of its side effects implicated. Rather, 

the factual issues raised in Vora’s petition pertain to a doctor’s standard of care in conducting a 

study of an experimental drug and in continuing a person in a drug study after exhibition of 

potential side effects. Thus, Vora must demonstrate Dr. Mulroy’s knowledge, skill, experience, 
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training, or education in the field of conducting a drug study of an experimental drug and in 

treatment of a participant should potential side-effect symptoms arise.5

 

Dr. Mulroy’s curriculum vitae shows she has been a licensed physician in the State of 

Texas since 1994 and has been board certified in psychiatry and neurology since 1998. Dr. Mulroy 

is a practicing adult psychiatrist, and outside of her private practice, Dr. Mulroy served as a 

Principle Investigator for at least 45 pre-market drug studies from 2003 to 2012. These pre-market 

studies included “open label studies”, as in this case, as well as “double blind studies.” The 

majority of these drug studies in which Dr. Mulroy served as the Principal Investigator involved 

medication used primarily in the practice of psychiatry; however, many involved medication 

relevant to other medical fields. Through this experience as a Principal Investigator, Dr. Mulroy 

states she has an understanding of, and is qualified to testify to, the responsibilities and standards 

required of a physician conducting a study of an experimental drug. Dr. Mulroy states these 

responsibilities and standards in conducting a drug study are the same regardless of the condition 

and/or symptoms the experimental medication is used to treat. 

Based upon independent review of Dr. Mulroy’s curriculum vitae and expert report, we 

conclude the trial court did not abuse its discretion in finding Dr. Mulroy’s credentials and 

experience provide adequate qualifications to express an expert opinion on causation under these 

facts. The relevant inquiry under these facts is whether Dr. Mulroy’s experience in conducting 

pre-market drug studies provides sufficient familiarity with the presented issues whether Dr. 

Holcomb acted pursuant to the standard of care in conducting the subject drug study and whether 

 5 Although Dr. Holcomb asserts the factual issues before the court are “the causal relationship between the prolonged 

use of linaclotide and the alleged side effects and injuries”, this is a mischaracterization of the allegations in the 

original petition against Dr. Holcomb. This characterization pertains to the strict product liability claim asserted 

against the drug manufacturer. Dr. Holcomb also argues Dr. Mulroy’s report does not “state that she has any 

experience or training regarding linaclotide or gastrointestinal conditions” and fails to indicate whether Dr. Mulroy 

has any specific knowledge or experience in assessing the causal relationship between the prolonged use of linaclotide 

and the alleged side effects and injuries; however, this is a mischaracterization of the required specialization. 
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Vora’s continuation in the study after her hospitalizations caused her alleged injuries. Dr. Mulroy 

exhibits extensive experience as a Principal Investigator in these numerous studies of experimental 

medication, the same position held by Dr. Holcomb. Dr. Mulroy’s practice as a Principal 

Investigator in a drug study provides sufficient knowledge, experience and training for the trial 

court to conclude she possesses sufficient qualifications to opine on the causal link between Vora’s 

alleged injuries and Dr. Holcomb’s alleged acts or omissions in allowing Vora to continue

participating in the drug study following two hospitalizations. Based upon this review of Dr. 

Mulroys curriculum vitae and report, the trial court’s conclusion is not arbitrary, unreasonable, 

and without reference to any guiding principles and rules.

For this reason, we conclude the trial court did not abuse its discretion in finding Dr. 

Mulroy qualified to opine on causation, and thus, overruling Dr. Holcomb’s objections to Dr. 

Mulroy’s expert report. Dr. Holcomb’s second issue is overruled, and the trial court’s order is 

affirmed in part in this respect. 

Issue Three: Sufficiency of Dr. Mulroy’s Expert Report on Causation 

Dr. Holcomb argues the trial court abused its discretion in denying his motion to dismiss 

because Dr. Mulroy’s expert report is merely conclusory on the issue of causation, and therefore, 

does not constitute a good faith effort to comply with the statutory expert report requirement of 

Section 74.351. Dr. Holcomb contends Dr. Mulroy’s report contains only a series of repetitious, 

conclusory statements regarding causation and does not provide the necessary medical detail and 

explanation of the causal relationship between Dr. Holcomb’s prescription of linaclotide and 

Vora’s alleged injury. 

Standard of Review

Again, we review a trial court’s denial of a motion to dismiss pertaining to an expert’s 

report served pursuant to Section 74.351 for an abuse of discretion. See Palacios, 46 S.W.3d at 
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875. A trial court abuses its discretion if its decision is arbitrary, unreasonable, and without 

reference to any guiding principles and rules. Bowie Mem’l Hosp., 79 S.W.3d at 52.

Applicable Law

Pursuant to Section 74.351, a plaintiff who brings a health care liability claim must serve 

on the defendant an expert report that addresses standard of care, liability and causation no later 

than the 120th day after the claim is filed. See TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(r)(6) (West Supp. 2014); HEB Grocery Co., L.L.P. v. Farenik, 243 S.W.3d 171, 173 

(Tex. App.—San Antonio 2007, no pet.). If an expert report has not been served on a defendant 

within the 120–day period, then on the motion of the affected defendant, the trial court must 

dismiss the claim with prejudice and award the defendant reasonable attorney’s fees and costs.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(b); Barber, 303 S.W.3d at 790-91. A report has not 

been served under the statute if it is found to be deficient. Lewis v. Funderburk, 253 S.W.3d 204, 

207-08 (Tex. 2008); Barber, 303 S.W.3d at 790-91. In such instance, the trial court has discretion 

to grant one thirty-day extension to allow the plaintiff the opportunity to cure the deficiency. See

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c); Barber, 303 S.W.3d at 790-91. If the deficiency 

is not cured or cannot be cured, the case must be dismissed. Id. § 74.351(b)(2). 

A report is deficient if it does not represent an objective good faith effort to comply with 

the definition of an expert report. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(l); Barber, 303 

S.W.3d at 791. To qualify as a good faith effort, the report must “discuss the standard of care, 

breach, and causation with sufficient specificity to inform the defendant of the conduct the plaintiff 

has called into question and to provide a basis for the trial court to conclude that the claims have 

merit.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6); Palacios, 46 S.W.3d at 878; Barber,

303 S.W.3d at 791. A report does not fulfill this requirement if it merely states the expert’s 
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conclusions or if it omits any of the statutory requirements. Palacios, 46 S.W.3d at 879; Barber,

303 S.W.3d at 790-91. 

When reviewing the adequacy of a report, the only information relevant to the inquiry is 

the information contained within the four corners of the document alone. Palacios, 46 S.W.3d at 

878; Barber, 303 S.W.3d at 790-91. This requirement precludes a court from filling gaps in a 

report by drawing inferences or guessing as to what the expert likely meant or intended. Barber,

303 S.W.3d at 790-91; see Austin Heart, P.A. v. Webb, 228 S.W.3d 276, 279 (Tex. App.—Austin 

2007, no pet.) (citing Bowie Mem’l Hosp., 79 S.W.3d at 53). 

Although the report need not marshal all of a plaintiff’s proof, it must do more than merely 

state conclusions; rather, it must explain the basis for the expert’s causation opinions by linking 

the expert’s conclusions to the relevant facts. Palacios, 46 S.W.3d at 878-79; Bogar v. Esparza, 

257 S.W.3d 354, 364 (Tex. App.—Austin 2008, no pet.). Thus, to satisfy the statutory purpose 

with regard to causation, an expert report must provide a fair summary of the expert’s opinions on 

the causal relationship between a breach in the standard of care and the alleged harm with enough 

specificity to allow the trial court to conclude the plaintiff’s claims have merit. Palacios, 46 

S.W.3d at 878-79; TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6). The report must explain 

how any breach in the standard of care caused the alleged injury. Jones v. King, 255 S.W.3d 156, 

160 (Tex. App.—San Antonio 2008, no pet.). 

Application

Dr. Mulroy states in her report that Dr. Holcomb “breached the standard of care and that 

as a result of this breach Ms. Vora was hospitalized for a third time while participating in the study. 

Ms. Vora’s third hospitalization and the pain and suffering related thereto would have been wholly 

prevented if Dr. Holcomb ... had withdrawn Ms. Vora from the study after her first two 

hospitalizations ....” To reach this conclusion, Dr. Mulroy began by explaining the standard of 
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care of a Principal Investigator of a drug study. The first responsibility is to monitor a participant 

for “severe adverse events.” If one occurs, the second responsibility is to re-assess the safety of 

the participant, the appropriateness of the participant’s continued involvement in the study and the 

integrity of the study. Dr. Mulroy explained that upon the occurrence of more than one severe 

adverse event, such as hospitalization, the Principal Investigator must “highly question the 

appropriateness of that patient in the study” and “hospitalization for a potential side effect ... is 

enough to warrant a decision to remove the patient from the study.” Finally, Dr. Mulroy opines 

that after the first hospitalization, Dr. Holcomb had a duty to closely monitor and communicate 

with Vora; however, Dr. Holcomb failed to do so, and therefore, was not aware of Vora’s second 

hospitalization. Dr. Mulroy opines, then, under the standard of care of a doctor conducting a drug 

study, discovery of the second hospitalization would have required Dr. Holcomb to remove Vora 

from the study. Because Dr. Holcomb did not discover the second hospitalization, and therefore, 

did not remove Vora from the study, Dr. Mulroy opines Vora continued to ingest a drug that 

presented dangerous side effects to her. Dr. Mulroy concludes that if Dr. Holcomb had removed 

Vora from the study, she would not have continued this use of linaclotide. Based upon this 

premise, Dr. Mulroy concluded “the proximate cause of the third hospitalization was the continued 

use of linaclotide. The third hospitalization was for a distended abdomen and vomiting, which 

was a known risk of the drug. Therefore, it was foreseeable that the continued use of the drug 

could cause distended abdomen and vomiting. Ms. Vora had already been hospitalized twice for 

similar injuries while taking the drug, making it foreseeable that continued use of the drug would 

result in distended abdomen and vomiting.” 

Upon review of Dr. Mulroy’s expert report, we conclude the report is conclusory with 

regard to causation. Dr. Mulroy adequately explained the standard of care of a Principal 

Investigator of an experimental drug study, explained how Dr. Holcomb breached the standard of 
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care and explained how Dr. Holcomb should have acted under these facts. However, Dr. Mulroy 

failed to provide sufficient facts to support her opinion that Dr. Holcomb’s failure to comply with 

the standard of care, i.e. failing to monitor Vora closely after the first hospitalization and failing to 

remove Vora from participation in the study following the second hospitalization, caused Vora’s 

third hospitalization and other alleged resulting injuries. The report fails to set forth a specific link 

between Dr. Holcomb’s alleged omissions with Vora’s alleged injuries and fails to discuss the 

factual basis of her opinion that Vora’s continued ingestion of linaclotide caused Vora’s third 

hospitalization. Particularly, Dr. Mulroy fails to state she reviewed Vora’s medical records 

pertaining to her hospitalizations. Dr. Mulroy’s report does not provide a fair summary of her 

opinions on the causal relationship between the asserted breach in the standard of care and the 

alleged harm with enough specificity to allow the trial court to conclude Vora’s claims have merit 

and to adequately inform Dr. Holcomb of the specific conduct that Vora calls into question. For 

these reasons, Dr. Mulroy’s expert report is deficient. 

Accordingly, we conclude the trial court abused its discretion by denying Dr. Holcomb’s 

motion to dismiss based upon insufficiency of Dr. Mulroy’s expert report on the element of 

causation. Dr. Holcomb’s third issue is sustained. 

Although Dr. Holcomb contends the proper resolution is to render a judgment dismissing 

Vora’s claims against him, the Texas Supreme Court has held that should a court of appeals 

conclude an expert report is deficient in a manner that can be cured, Section 74.351 permits one 

thirty-day extension to cure the specified deficiency. Leland v. Brandal, 257 S.W.3d 204, 207 

(Tex. 2008); Collini, 280 S.W.3d at 468. Accordingly, the trial court should have an opportunity 

to consider granting Vora an extension to cure the deficiencies detailed in this opinion. 
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CONCLUSION

Based upon the foregoing reasons and based upon the limited appellate record, we affirm 

in part and reverse in part the trial court’s order denying DRG and Dr. Holcomb’s motion to 

dismiss. We remand for further proceedings consistent with this opinion. 

Jason Pulliam, Justice