Patricia Pere z is the m other of Eliz abeth Shappee; Daniel Whi cker is Eliz abeth’ s husband. 1 

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

NO. 03-0 8 -00 200 -CV

P atric ia A. P ere z and Daniel Wh icker, Individ ually, an d Pat ricia P ere z as Adm inis trat or of the Estate of Elizabeth S happ ee , Appellan ts
v. Daughters of Charity Health Service s of Au stin d/ b/a S eton Me dical Center , Appellee

F ROM THE DISTRICT CO URT OF TRAVIS COUNTY , 345TH JUDICIAL DISTRICT NO. D-1- GN-08- 0001 78 , HO NORAB LE SUZ ANNE COVINGTO N , JUDGE PRESIDI NG

M E M O R

A N D U M O P I N I O N
Patricia A. Per ez and Danie l Whi cker , individually , and Patricia P er ez as t he administrator of the e state of Elizabeth Shappee (“a ppellants”) appea l the t rial court’s dismiss al of

1 a medica l neg lige nce c laim for appe llants’ failure to comply with the expert repor

t require ments of section 74.351 of t h e ci v i l prac tice and r emedies c ode. See Tex. Ci v. Prac. & Rem. Code Ann. § 74.351 (West Supp. 2008). The trial court dismiss ed appellants’ claims afte r it de termin ed t hat their expert re port did not satisfy the statutory

require ments. Be cause we c onclude that the trial cour t did not abuse its discretion in g rantingthe motion to dis miss, we aff irm the judg ment of the tr ia l c ourt
.Appellants filed a non-suit as to their claims ag ainst Seton Sout hwest, which w as g rante d 2 by the tr ia l c ourt . T hu s, on ly Se ton is a pa rt y to t his a pp e a l. 2 Tw e nty -ye ar- old

El iza be th S ha pp e e wa s dia g no se d w ithmul tip le sc le ro sis in J anuar y 2005. After diag nosis a nd treatment w ith the drug Avonex by her pr imary

car e phy sician, Eliz abeth’ s health continued to de teriorate. She soug h t t re atment for f ever , nausea , and vomiting at the Seton Southwest Medical Cente r (“ Seton Southwest”) emer g ency room on the even ing of Marc h 1 4, 20 05 , a

nd wa s tre a te d an d disc ha

rg e d. She re tur

ne d th e ne xt day

c omp la ini ngof

the same sy mptoms as well as the additional sy mptoms of head and f

acia l t wi tching . At the hospital, she suffe red a seizure. On Mar ch 16, 2005, she w as transf err ed from the Seton Southwest emerg ency room to Daug hters of Charity Hea lth Services of Austin d/b/ a Seton Medica l Center (“ Seton”) whe re she was admitted for the f irst time. Upon admission to S eton, she ha d an MRIscan a nd was evaluated by

sever al doctors. She died on Ma rch 18, 2005. I n addition to Seton, appe llants sued various doctor s and other pr oviders for medical malprac tice. B y

their seventh amende d orig inal petition, the current li ve plea ding, a ppellants named only Seton an d

B io g e nI d e c , I n c . , a

p h ar ma c e u ti c a l c o mp any

th a t s o ld an d d is tr ib u te d

th e dr ug Avonex, as defe ndants. I n addition to numerous claims ag a in st Biog en, appe llants broug ht a medica l malprac tice cla im ag ainst Seton a rising out of

Seton’s car e for

Shappee dur ing the three -day period in March 2005. 2

After filing suit, appe llants tim ely s er v ed the re port of their e x pert, Peter Be rnad, M.D., setting f

orth Seton ’s al l ege d neg lige nce a s require d under Chapte r 74 of the c ivil practice and reme dies code. Se e id
. Be rnad describe d his cre dentials, the documents he review ed, and the3

standard of

car e the h o s p i t al should have e mploy ed for a patient who “ prese nted with protrac ted
nausea , vomiting, hy

perthe rmia and new onset seizure of unknown etiology .” He conclude d that the hospital staff deviated from the sta ndard of car e as state d:

• Nursing staff failed to assess Ms. Shappee’ s clinical condition and monitor vital signs at lea st every

4 hours

• Nurs ingsta ff

fa ile d to ma int a in a

nd mon ito r l a

b r e su lts

• Nursing staff f

ailed to obtain complete history and phy sical

• Nursing staff f

ailed to formulate a plan of car e
• Nu rs i n g s t af

f fa i l ed re p o rt ch an ge in co n d i t i o n t i m el y t o p h y s i ci an , i n cl u d i n g, bu t no t li mit e d to , o n M arc h 1 8, 20 05 du ri ng15 00 -2300 shif

t, f a ili ngto repor t new onset of ny stag mus and visual disturbance s, on Marc h 17, 2005 at 2230, the onset o f “gar bled spee ch . . . moder ate f acia l twitching a

nd repor ts of inability

to control tong ue”.
• Fa iled to properly and timely

as s ess patient, including , but not lim ited to, Mishandling the a

utopsy by delay ing the exam a

nd having it perfor

med at an aff iliate hospital, Bra ckenr idge Hospital, rather than the County

Medica l Ex aminer in c ompliance with state statute.

• Fa iled to follow phy sician’s orde rs, including , but not limit ed to: obtaining pr e vio us MRI

fo r c omp ari so n, fa ili ngto o bta in C B C on Ma rc h 1 7, 20 05 in the a.m. as or dere d.

• Fa iling to kee p complete r ecor ds by failing to r ecor d dates, times, a nd names of per sonnel leadingto dis-continuity of ca re.
• Fa ilure to perf

orm Neur ol o gi cal Status Assessment eve ry two hours as order ed on Mar ch 16, 17, 18 of 2005.
I n concludingthat the hos pital did not use the car e of a rea sonably

prudent he alth car e provider a

nd that this contributed to Eliz abeth’ s death, B erna d stated:
Fa ilingto d is c o v e r

d e c li n in g n e u r o lo g ic a l s tatu s ti me ly an d f a il u r e to r e p o rt a

ny de c lin e in ne ur olo g ic a l sta tus de lay e d tre a tme nt ult imate ly c a us ing de a th. F a ili ngto a sc e rt a in a

c omp le te his tor

y and ph y sic a l and

fo rm ulate a pla n o f c are le d to substandard c are contributing to the death of Ms. Shappee.4

Appellants re ly

upon t h es e two sente nces to satisfy their burde n of addr essing causation in the
e xpe rt re po rt
. Seton moved to dismiss the claims asser ted aga inst it pursuant to section 74.351(b) on the g rounds that (i) Dr . Be rnad is not qualified to rende r an ex pert re port in the ca se; and (ii) the
e x p e rtr e p o rti s w h o l l y i n a d e qu a t e an d f a i l s t o a d dr e s s t h e s t a tu t o r y e l e m e n t s an d , s p e c i f

i c a l l y, the ca usation element. Se e id . § 74 .3 51 (b ). Se ton ur g e d th a t th e e xpe rt

re po rt is n ot a g oo d f a ith eff ort to comply

with the require ments of setting forth the a pplicable standard of c are , the manner in which the ca

re f ailed to m ee t t he standa

rds, and the c ausal re lationship between the failure and the injury suffe red by

the plaintiff. There fore , Seton a rg ued, the repor

t doe s not satisfy

the statutory require ments. After

a hea ring on the ade quacy

of the e x pert re port, the dist ri ct cour t sustained Seton’s objections to the qualifications of the expert and t o the adequacy of the re port and g rante d Se ton ’s mot ion

to d ism iss
. I n a hea lth care liability

claim, the cla ima n t m u s t provide e ach de fenda nt with one
or more e x pert re ports, including a curr iculum vitae for eac h ex p er t , within 120 day s of filing the orig inal petition. Id . § 74 .3 51 (a ). An “ e xpe rt re po rt ” is:

a wr itten report by an expert that provides a fa ir summary of the e x pert’s opinions as of the date of the repor

t r eg arding applicable standards of ca re, the manner

in which the ca re r ender ed b y the phy sician or he alth car e provide r fa iled to meet the standards, a

nd the ca usal relationship between t h at fa ilure and the injury , harm, or damag es cla imed.
Id . § 74 .3 51 (r )( 6)
. A re po rt ne e d not m ars ha l a ll o f t he pla int if

f’ s p ro of , b ut i t mu st i nc lud e “ a

fa ir summary ” of the expert’s opinion on eac h of t he elements identified i n the s tatute—the st andar d of5

car e, t h e breac h or deviation from the standar d of ca re, a nd the ca usal relationship between the brea ch and the i n

j u ry . Id .; American Transitional C are Ctrs. of T

ex., I nc. v. Palacios , 46 S.W .3d 873, 878 (Tex. 2001). To constitute a g ood faith eff ort, the re port must (i) inform the def endant of the spec ific conduc t called into question; and (ii) provide a basis for the tr ial court to dete rmine that the claims have merit. Palacios , 46 S.W.3 d at 879
. A re po rt do e s n ot f ulf ill the se tw o p ur

po se s if it fails to a ddress the standard of car e, brea ch of the standard, a nd causation. Nor is it sufficient for the report to mere ly state t he ex pert’s conclusions reg arding these elements. Id .; Cas til lo v . A ugus t , 248 S.W .3d 874, 880 (Tex. App.—El Pas o 2 0 0 8 , n o pet.) (r eport c annot mere ly state expert’s conclusions about statutorily require d elements). The expert must ex plain the basis of the e x pert’s statements to link the e x pert’s c onclusions to the fac ts. 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 rle v . R atl iff , 9 98 S.W. 2d

88 2, 89 0 ( Te x. 19 99 )) . I f a pla int if f t ime ly files an e x pert re port and the de fenda nt moves to dismi ss beca us e o f t h e re p o rt’s inade quacy , the trial court must g rant the motion “only if it a ppear s to the court, a fter he aring , that the re port does
no t r e pr e se nt a

n o bje c tiv e g oo d f

a ithe ff or t to c ompl y wi th the de fi nit ion of an e xpe rt

re po rt in Subsection (r)( 6).” Tex. Ci v. Prac. & Rem. Code Ann. § 74.351( l ). To per form its re view, the trial court should look no further than the report i tself, bec ause a ll the information rele vant to the inquiry is contained within the docume nt’s four c orner s. Palacios , 46 S.W .3d at 878.

We r e vie w a

tr ia l c ourt ’s or de r d ism iss inga c la im f or fa ilure to comply

wi th the expert repor

t require ments under a

n abuse- of-discr etion standard. Id . Atr ia l c ourt a buses its discretion if it ac ts in an arbitra ry or unre asonable manner

without refe renc e to any g u i ding r ules and princ iples. Downer v. Aquam arine Operator s , Inc. , 701 S.W .2d 238, 241-42 (Te x . 1985).6

Whe n r e vie wi ngmatters com mi tt e d to the tr ia l c ourt ’s dis c re tio n, thi s c ourt may no t su bs tit ute its own judgment for

the t ri al co urt’s judg ment. See W alker v . Gutierrez , 111 S.W .3d 56, 63 (T ex . 2 0 0 3 ) ( ci t i n g Flores v . F ou rth Ct. of A

pp e als , 777 S.W .2d 38, 41-42 (Te x . 1989)). Her e, the pa

rties dispute whethe r the e x pert re port fair ly summarizes the alleg ed sta nd ard of c are , h owSe ton

a lle g e dly br e a c he d th e sta

nd ard of c are , a nd the c a us a l r e latio ns hip betwee n any

brea ch and the injury
. Be cause we conclude that the trial court did not err in finding the expert repor

t inadequate with respec t to the element of causation and that thi s case is gove rned b y Bowie Mem orial Hospital v. W right , we will limit our d i s cu s s i o n to the element of causation. Under the Pa lac ios two-prongtest, as applied in Bo wie , we must de termine whe ther the tria l court
a c te d unr e a so na

bly and wi tho ut r e fe re nc e to guid ingpr inc ipl e s w he n it dis mis se d th e c la ims a g a ins t Seton. Bo wie , 79 S.W .3d at 52 ; see D owner , 701 S.W .2d at 241-42.

Appellants urg e that, in his repor t, Dr. Berna d repr esents “how the spec ific ac ts and omissions of Appe llee proximately cause d Eliz abe t h ’s death,” that Dr. B erna d “make s a positive statement of f

act r eg ardinghis opinion and the u n d er l ying f acts a llowing this Court to believe Pla int if fs have a me ri tor iou s c la im, ” and

that a lin k is c le arl y

se t f or th by the fo llo wi ngstate me nt: “F ailing to a scer

tain a complete history and phy sical and formulate a plan of c are led to substandard
car e contributing to the death of Ms. Shappe e.” Parsing this sing le sentenc e, ap p el l an t s contend that the phra se the fa ilure “to a scer tain a complete history

and phy sical and formulate a pl an of care ” constitutes an ade quate state ment of bre ach, the phrase this conduct led to “substanda rd ca re”
c on sti tut e s a de qu a te lin ka g e , a nd the ph ra se it “ c on tr ibute d” to E lizabet h’s de a th a de qu a te ly ide nti fi e s th e ha

rm .7 Seton r esponds that the repor t’s single statement about causation is “ s p eculative and conc lusory ”: “Nowhere in his report
. . . does Dr. B erna d state what cause d Shappee’ s death or descr ibe her

manner of death.” Seton contends that Dr. Be rnad fails to expl ain the ca use of de ath, how Seton’s conduc t or any specific injury

contributed to her unide ntified ca use of de ath, or what ste ps Se ton

c ou ld h a ve take n to pr e ve nt a de a th f ro m unkn ow n c a

us e s. The supre me cour

t’s opinion in B owie is instructive. I n that case , the plaintiff
s i m i l ar l y r e l i e d o na s i n g l e s t a t e m e n t i nt h e r e p o rtt o e s t a b l i s h c a u s a t i o n . 7 9 S
. W
. 3 d

a t5 2
- 5 3
. In Bo wie , the plaintiff sustained injuries in a c ar a ccide nt. Id . at 50. While at the hospital her rig ht kn e e an d f

o o t w e r e x- r ay e d an d s h e w a s d ia g n o s e d w it h a f r a c tu r e d p a tella. Id
. The phy sician’s assistant did not discover that the pl aintiff had also fra cture d her right foot in the accident. Id . The plaintiff’s orthope dic surg eon discove red the fra cture d foot only afte r he ha d alr ea d y o p er ated on the knee
. Id . A s th e ba sis fo r t he ir ma lpr a c tic e c la im, the pla int if f a lle g e d th e fa ilure to d ia g no se the foot fr actur e and failure to proper ly revie w di agnostic tests. Id . To comply with the causation
e le me nt, the re po rt

state d: “ [I ]f the x-r ay s w ou ld h a ve be e n c or re c tly re a d a nd the a pp ro pr iate medical personne l a cted upon those f indings then [the plaintiff] would have ha d the possibilit y of a better outcome.” Id
. a t 52 -5 3. Th e ho sp ita l de fe nd ant a sse rt e d that th e re po rt fa ile d to a de qu a te ly addre ss the causation e lement betwee n the alleg ed brea ch and the injury , and the trial court dismissed plaintiff’s cla ims. Id . at 51.

Ac kn o w l e d g i n g t h a t e xp e rt s n e e d n o t i n v o k e an y p art i c u l ar “ m a g i c a l w or ds ” to demonstrate that the repor t met the g ood faith ef

fort test as to the e lements, the supre me cour t iterate d the applica

ble standar d of re view, which is c ritical to our ana ly sis in thi s case :8

We h ave hel d th a t th e on ly inf or matio n r e le va

nt t o w he the r a

re po rt re pr e se nts a g ood-fa ith effor

t to comply

with the statutory

require ments is the report itself. . . . And, we ha

ve held that we revie w a tria l court’s de cision abou t whether a re port constitutes a g ood-fa ith effor t to c omply with the Act under an abuse -of- discretion standard.
Id . at 53 (c itations omi tted). B ased upon the standard of revie w, t he supreme court then conclude d that the tri al co u rt could have rea sonably deter mined that the re port was c onclusory and did not
a bu se its dis c re tio n in

dis mis sin g the c la ims :
Af te r r e vie wi ngthi s r e po rt , we c on c lud e that th e tr ia l c ourt c ou ld h a ve re a so na

bly deter mined that the repor

t doe s not r epre sent a g ood-fa ith e ffor t to su m m ar i z e t he causa l relationship betwee n [t he hospital] ’s failure to meet the applica ble standar ds of ca re a nd [t he cla imant] ’s injury
. . . . That is beca use the re port simply

opines that [t he cla imant] might have had “the possibili ty of a be tter outcome” without explaining how [the hospital] ’s conduct c aused injury to [ the claimant]. We cannot infer f rom this statement, as [the claimant] ask[ s] us to, that [ the hospital]’s allege d brea ch pre cluded [the claimant] from obtaining a quicker di ag nosis and tre atment for her f oot. Rather, the r eport must include the r equire d information within its four c or ne rs . Id . (citations omitted).

Assuming without dec iding that Dr . Be rnad’ s repor t adequately

cover s the standar d of c are and ho w i t w a s b re a c he d, we fi nd the tw o s e nte nc e s o n th e c a us a tio n e le me nt i ns uf

fi c ie nt. The repor t doe s not link the hospital’s actions to Shappe e’s death or any cause of death. Nor does it identify any specific i n

j u ry that would have be en pre vented ha d the hospital complied with the standard of

car e. See, e .g. , Constancio v. Bray , No. 03-06-00583- CV, 2008 Tex. App. L EXI S 6652, at *19 (Tex. A

pp.—Sept. 5, 2008, no pet. h.); CH CA Ma inl an d, L.P . v . D ic k

ie , No. 14-07-00831- CV, 2008 Tex. App. L EXI S 6787, at *28-29 (Te x . App.—Houston [14th Dis t.] Aug. 21, 2008,9

no pet. h.) ; W

ooten v. Samlowski , No. 10-07-00305- CV, 2008 Tex. App. L EXI S 3709, at *18-19 (Tex. App.—Waco May

21, 2 0 0 8, pet. filed). Whil e a c la ima nt i s n ot r e qu ir e d to c on c lus ive ly prove he r ca se throug h a pre liminary expert repor

t, the repor

t may not me rely state conclusions about any of the e lements. Se e Bo wie , 79 S.W .3d at 53. I mportantly , Dr. B erna d’s expert repor t require s
us to inf er causation, whic h, under the “four corne rs” rule, we are not pe rmitted to do. See, e .g. , Con sta nc io , 2008 Tex. App. L EXI S 6652, at *9; Cas til lo , 248 S.W .3d at 883 (c i t i n g P a l a cios , 46 S.W .3d at 878). As t h e ex p er t repor t was def icient as to ca

usation, it cannot repr esent a g ood fa ithe ff or t to c omp ly

wi th t he statut or

y re qu ir e me nts . T he tr ia l c ourt the n h a d n o d isc re tio n b ut t o dismiss appellants’ c laims ag ainst Seton. See Palacios , 46 S.W .3d at 880.

For the same r easons a s in B o wie and base d on the re cord be fore us, we c annot conclude that the t rial court abused its discretion when it deter mined that the re port did not repre sent
a g oo d f a ithe ff or t to me e t th e e xpe rt

re po rt re qu ir e me nts . A c cord in gly , we ove rr ule a pp e lla nts ’ iss ue s and

a ff ir m th e jud g me nt o f t

he tr ia l c ourt
.

__________________________________________ J an P. Patterson, J ustice Be fore J ustices Patterson, Waldrop and H enson Affir med Filed: Oc tober 10, 2008