### NUM BER 13-06- 0008 8-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 CORPUS CHRI ST I - 

## EDI NBURG
M ICHA EL T. JELINE K, M .D. A ND COL UM BIA

R IO GR A ND E H E AL T H C AR E , L
. P
. , D / B /A RIO GRA ND E R EGION A L HOS PITA L, A pp ellan ts,
v. FR A NC ISCO C ASAS, ETA L., A pp ellees
.

On a p p ea l f ro m th e 27 5t h D is tr ic t C o u rt of H ida lgo C ou nty , T exas . 

## ME MOR A N D U M OP I N I ON Be fo re C hie f J us tice Vald ez an d Ju stice s Ga rza an d Be na v ide s

M em o ra n d u m Op in io n b y J u st ic e Ga rza Appel lan t C olu mbia Ri o Gran d e H eal thc are, L. P., d/b/a R io Grande R eg ion al Hos pit al (t he “ Hos pit al”), appeal s from a j ur y v erdict aw ardin g $250, 000 i n damag es to appel lee s, Franci sc o Cas as and Al fredo D eLeon, Jr ., as personal represent ati v es of the est ate o f Eloi sa Cas as (c oll ect iv ely referred to a s “t h e C asas es” ). By three i ss ues, the Ho s pital asse rts that: ( 1) there w as insuf f icient evidence thatthe Hosp ital’s neglig ence prox imat ely

ca used El ois a C asas ’s i nju ry ; ( 2) there w as ins uff ic ien t ev ide nce to s uppor t t he2

jur y ’s aw ard of ment al ang uis h damag es; and (3 ) the t ri al cour t er re d by

not inc lud ing an unav oid abl e ac ci dent ins tr uct ion i n the j ur y ch arg e. Appel lan t M ic hael Jeli nek, M.D ., w ho
w as non- sui ted p ri or

to tr ial , appeals f ro m the tr ial court ’s denial of his moti on for sanc ti ons and dism issal, cl aimi ng thatthe Cas ases ’ ex per t repor t fail ed to co ntai n an adeq uate state me nt of

causa tion. W e af

f irm w ith respe ct to bo th ap pellan ts. I. B A CKGRO UND On J uly 11, 2001, El ois a C asas w as admit ted t o the Hospi tal for d iag nosi s a nd treatment of abdominal pai n and a pos si ble obs tr uct ion of the s mall intes ti ne. Cas as, w ho suffered from metast ati c c olo n canc er , had a 101- deg re e fev er and a mi ldl y

el ev ated w hit e blo od c ell co unt, w hic h i ndi cat ed a poss ibl e i nfecti on. Ac co rd in gly , her su rg eon and p rim a ry t re ati ng phy si ci an, C ar los Garci a- Can tu, M. D. , req uest ed th e as si sta nce of an infect iou s d is ease spec ial is t, Dr . J eli nek. To t re at t he uni denti fied i nfe ct io n , Dr. Jel ine k pr esc ri bed M ax ipi me, a broad- spec tr um anti bio ti c, and F lag y l, a n anti bio ti c d esi g ned t o treat a naerobi c b act er ia. Dur ing Casas ’s hos pit al sta y , her doc tors real iz ed th at t he c ancer had per forated her co lon , c ausi ng l eakag e of mater ial i nto h er abdomi nal cav ity
. The flui d and absc ess es g enerated by

the per forati on of the col on w ere det er mined t o b e the caus e of the obst ruction in Casa s’s sm all intestin e. On July 13, 200 1, Casa s und erw entmajo r surg ery to remedy

thi s p ro ble m. D r. Garci a- Can tu pe rfor med the surg er y , know n as a s ubtot al col ect omy , dur ing w hic h the per forated area of t he col on w as re attac hed to prev ent fur ther lea kag e. After surg er

y , Dr

. Garci a- Can tu presc ri bed Ma x ipi me and Fl ag y l. A cul ture of the
re mov e d a b sc e ss es w as tak en dur ing su rg er y ; t he resul ts re v eal ed th at C asas w as sufferin g from an E. c oli i nfecti on. Ma x ipi me, w hic h i s c onsi dered an eff ect iv e treatment for E. c oli , w as admini ste re d to C asas unti l Jul y

18, 2001, w hen the pres cr ipt ion s for both M ax ipi me and F lag y l ex pired automati cal ly

. How ev er , due to an ov ersi g ht by the hospi tal st aff , a re new al form for t heT he Casases’ or i gi nal pet i t i on n am ed Fr anci sco Casas, i ndi v i dual l y an d as th e pe r sonal 1 r epr esent at i v e ofE l oi sa’ s est at e, as a pl ai nt i ff , al ong wi t h DeLeon, C oncept i on Pache co, and “ Al l T hose E n ti tl e d to R e c o v e r F o r T h e W ro n g fu l D e a th o f E l o i s a C a s a s , D e c e a s e d , U n d e r t h e T e x a s W ro n g fu l D e a th A c t. ” T h e C a s a s e s ’ f ir s t a m e n d e d o r ig in a l p e tit io n , f ile d o n J u ly 2 1 , 2 0 0 4 , lis te d o n ly F r a n c is c o , in d iv id u a lly a n d a s th e p e r s o n a l r e p r e s e n ta tiv e o fE lo is a ’s e s ta te , a s a p la in tif f

. O n A u g u s t 8 , 2 0 0 5 , th e C a s a s e s f ile d th e ir second am ended or i gi nal pet i t i on, w hi ch was oper at i v e at t he t i m e oft r i al , and whi ch na m ed Fr anci sco an d D e L e o n a s p l a i n ti ff s s o l e l y i n th e i r re p re s e n ta ti v e c a p a c i ti e s o n b e h a l f o f E l o i s a ’ s e s ta te

. See T EX
. R. C IV
. P. 65. 3 m e d ica ti o n s w as not p lac ed w it h C asas ’s ch art. As a resul t, nei ther presc ri pti on w as re new ed. This ov ersi g ht w as not recog niz ed unt il Ju ly 23, 2001, w hen D r. Je li nek v is it ed Cas as and notic ed no re cord of the medic ati ons hav ing been admini ste re d. Cas as did not
re cei v e M ax ipi me or

F lag y l for ov er

four day s, from Ju ly

18 t o J uly

23. D uring thi s t ime, accord ing to h e r husba nd a nd so n, Casa s suf fered a setba ck in her cond ition. Furthe r, Cas as’ s i nci si on s it e w as e m itti ng a foul odor so pote nt t hat t he hos pit al sta ff needed to br ing fans i nto C asas ’s hos pit al ro om i n an attemptto dis si pate it

. A cult ur e taken on July 21, 2001, from the si te of C asas ’s su rg ic al inc is ion sh ow ed the p re senc e of Ca ndi da, a f ung us. Di flucan, an anti -fung al dr ug , w as presc ri bed t o treat thi s i nfecti on. Anothe r cul ture of C asas ’s bl ood w as tak en on Jul y 23, w hic h s how ed th e p re s e n c e o f

a co a gu la s e -n e ga t i v e S t a p h ylo c o c c u s in fe c t io n
. Dr

. Je li n e kp re s c ri b e d two anti bio ti cs , Lev aq uin and Vanc omy ci n, to treat thi s infect ion

. Nei ther the Jul y 21 n or the Jul y 23 c ult ures show ed th e presenc e of E. col i. M oreov er , i t w as undi sput ed th at ne it her Ma x ipi me nor

F lag y l w oul d hav e effect iv ely treated the C andi da or Sta phy loc occ us infection s. Cas as died on N ov ember 12, 2001. On Ma y

30, 2003, El ois a C asas ’s hus band Franci sc o, an d her

so n, A lfre do D eLeon, Jr ., filed sui t ag ain st the H ospi tal , D r. Garci a, an d Dr . J eli nek. T h e C asas es ass erted t hat t he defendants ’ neg li g ence caus ed El ois a to

1 “s uff er g ri ev ous embar ra ss ment and humi li ati on, a s w ell a s e x c r u c i a t ing pai n the remaind er of he r li fe w hic h she w oul d not hav e suffered to suc h deg re e if proper ly di ag nosed , t re ated and c ared for

. . . .” T h e C a sa ses so ug ht da mag es for El ois a’s i nju ri es and ment alT h e C a s a s e s ’ o r ig in a l p e tit io n a ls o s o u g h t d a m a g e s f o r E lo is a ’s w r o n g f u l d e a th ; h o w e v e r , t h is c la im 2 was dr opped i n t hei r subsequ ent am ended pet i t i ons. T he onl y act i v e cl ai m at t he t i m e of t r i al was t he su r v i v al c l a i m fo r p e rs o n a l i n ju rie s to E l o i s a
. See i d.

See A c t of M ay 30 , 19 77 , 65 t h Le g., R

. S

. , c h. 81 7, 19 77 T ex
. G en
. La w s 20 39 (f orm er T EX
. R EV
. C IV
. 3 S TAT A NN . a rt. 4 5 9 0 i , § 1 3 .0 1 ), repealed b y Act of June 2, 200 3, 78t h Le g. , R

. S. , ch. 204 , § 10. 09, 2003 T ex. G e n . L a w s 8 4 7 , 8 8 4

. C h a p te r 7 4 o f th e T e x a s C i v i l P ra c ti c e a n d R e m e d i e s C o d e g o v e rn s o n l y th o s e h e a l th c a re li a b i l i ty c l a i m s c o m m e n c e d o n o r a fte r S e p te m b e r 1 , 2 0 0 3

. See O l veda v. Sepul veda , 189 S. W

. 3d 7 40, 741 n. 1 ( T ex. 200 6) ( O ’ N ei l l , J. , di ssent i ng)

. T he p ar t i es t o t hi s app eal do not di sput e t he f act t hat f or m er ar t i cl e 45 90i app l i es he r e.

Q uest i on num berone oft he j ur y char ge ask ed: “ D i d t he negl i gence, i fany , of t hose nam ed b el ow 4 pr oxi m at el y cause an i nj ur y t o E l oi sa C asas? A nswer ‘ Yes’ or‘ N o’ f or each of t he f ol l owi ng: a
. R i o G r ande R eg i on al H os pi t al [ , ] b. D r. C arl os G arc i a[, ] c
. D r. M i c ha el T

. J el i ne k , d i rec t l y , o r b y h i s a ge nt o r e m pl oy ee D r. M a ria R o m e ro .” T h e ju ry re s p o n d e d a ff i rm a ti v e l y a s to e a c h d e fe n d a n t. 4 ang uis h. 2 The Ca sas es filed an e x per t repor t w it hin 180 day s o f their or ig ina l peti ti on, p ursuant to forme r article 4590 i, section 13.0 1 of the T exas Medical L ia bility and Insuran ce Improv ement Act (“ ML IIA” ) (c ur re nt v ersi on atT EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.351 (Verno n Sup p. 20 06)). The report, au tho red by John A. Da ll e r, M.D., sta ted thatDrs. 3 Garci a- Can tu an d J eli nek w er e neg li g ent i n fail ing to re cog niz e tha t t he ant ibi oti cs w ere not bei ng g iv en to C asas , and thatthi s n eg li g ence re sul ted i n a p ro lon g ed hos pit al sta y and increase d pa in and suf fering ex perien ced b y

Casas. On M ar ch 9, 20 04, D r. Je li nek filed a “M oti on for Sanc ti ons and D is mis sal Pursuant to A rt ic le 4590i § 13 .0 1,” co ntendi ng thatD r. D all er ’s repor t “ w hol ly fail ed to ex pla in any caus al conne cti on betw een t he all eg ed dev iat ion from the a ppl ic abl e s tandard of care and [C asas ’s ] al leg ed i nju ri es. ” The tr ial co urt den ied D r. Je li nek’ s mot ion o n Nov ember 19, 2004. N ev erthel ess , on June 23, 2 005, the Cas a se s fil ed a “M oti on for Non -S uitW it h Preju dic e” as to Dr . J eli nek and Dr

. Garci a- Can tu, sta ti ng that they “ no l ong er

des ire[d] to prosec ute” thei r sui t ag ain st thos e defendants

. The tr ial courtentered an order di smi ss ing the c ase ag ain st Dr . J eli nek and D r. Garcia- Ca n tu w it h preju dic e on June 28, 2 005. On March 1, 20 06, Dr. Jelinek f iled a no tice of app eal, ch allenging the trial court’s den ial of his
mo tion for sanctio ns an d dism issal. Af te r a t ri a l o n t he m erits, the jury foun d tha t the neglig ence of the Hosp ital, Dr. Garci a- Can tu, and D r. Jeli nek prox imat ely caused inj ur

y to El ois a C asas
. The j ur y furth er 4T he Casases ar gued i n t hei r app el l at e br i eft hat t he Ho s pi t al ’ s m ot i on f or new t r i al and not i ce of 5 a p p e a l w e re fi l e d l a te , a n d th e re fo re th e i r i s s u e s w e re n o t p re s e rv e d fo r a p p e a l

. See T EX
. R. C IV
. P. 329 b( a) (m oti on for ne w t ri al s ha l l be fi l ed w i t hi n t hi rt y da y s aft er t he j ud gm en t i s s i g n e d ); T EX
. R. A PP
. P. 2 6 .1 ( c iv il not i ce of

app eal m ust be f i l ed wi t hi n t hi r t y day s aft er t he j udgm ent i s si gned)

. Al t hough t he Casases aband oned t hi s cont ent i on a t or al argu m en t , w e not e t hat t he Hospi t al ’ s m ot i on f or new t r i al and not i ce of appea l wer e i ndeed t i m el y f i l ed, beca use i n com put i ng t he t hi r t y - day t i m e per i od, t he day oft he si gni ng oft he ju d g m e n t i s n o t i n c l u d e d

. See T EX
. R. C IV
. P. 4. 5 foun d tha t t h e n e gl igen ce w as att ributa ble as follows: 90% to the Hosp ital; 5% to Dr. Garcia-Cant u; an d 5% to Dr. Jelinek. Finally , the jury conclud ed th at $2 50, 000 w ould fairly and reason abl y

co mpensat e El ois a C asas for “ pai n and mental ang uis h” ca used by the neg li g ence of the H ospi tal and of Drs. Garci a- Can tu and Je li nek. F ina l jud g ment w as re ndered on the ju ry

v erdict on Febr uar

y 1, 2006. The H ospi tal fil ed a “M oti on for New Tri al, or i n the Al ter nati v e, Mo ti on for Remi tti tur and/or to Mo dify Ju dg ment” and a moti on for j udg ment notw it hst andi ng the v erdict on Ma rc h 3, 2006, both of w hic h w ere ov er ru led by operati on of l aw
. See T EX
. R. C IV
. P. 329b( c)

. The Hos pit al filed i ts noti ce of appeal on Ma rc h 3, 2006, and t his appeal ens ued. 5 II. D I S CUS S I ON A
. Suf fi cien cy o f Cau sat io n Ev id ence By i ts firs t i ss ue, t he Hos pit al cl aims that there w as leg all y and factual ly

i nsuffici ent evidence to supp ort t h e j u ry’s find ing that its neglig ence proxi ma tely cause d Casas’s injuries. 1. St and ard o f Rev iew W e w ill susta in a challen ge to the legal suf f iciency of

ev iden ce on ly if : (1) there is
a c omplet e abs ence of ev ide nce of a v it al fact; (2) the cour t is bar re d by

r ule s o f law

or of
ev ide nce from g iv in g wei g ht t o the onl y ev ide nce off ered to prov e a v it al fact; ( 3) the evidence o f

fered to prove a v ital fact i s no more th an a mere scintilla; or (4) the ev iden ce est abl is hes conc lus iv ely the oppos it e of a v it al fact. City of Kel ler v. Wils on , 168 S.W .3d 802 , 810 (Tex. 2005 ). More than a scintilla of ev iden ce exists, and th e evidence is l egally suffici ent, if the ev ide nce furni shes so me reason abl e bas is f o r d if feri ng co ncl usi ons by
re asona ble min ds about a v it al fact’ s e x is tenc e. Lee Lewi s Constr . C o. v . Har ri son , 706

S.W .3d 7 78, 7 82- 83 ( Tex . 20 0 1 ). How ev er , “ w hen t he ev ide nce off ered to prov e a v it al fact i s s o w eak as to do no more tha n c re ate a mere sur mis e or su spi ci on of i ts ex is tenc e, the ev iden ce is no mo re than a scintilla and , in legal ef fect, is no e vid ence .” For d Motor Co. v. Ridg way , 1 3 5 S. W .3 d 59 8 , 6 0 1 (T e x. 20 0 4 ) (ci ti n g Kindred v. Con/Ch em , Inc. , 650 S.W .2d 61, 63 (Tex. 1983 )). In c onduc ti ng a leg al suffici ency rev iew , w e c re ditev ide nce suppo rt ing the jud g ment if reason able jurors could, and disregard contrary evidence u nless reaso nab le jurors could not. City of K

ell er , 168 S.W .3d a t 827 ; Villago m ez v. Ro ckwo od Sp ecialties, Inc. , 210 S.W .3d 720 , 748 (Tex. App. –Corpu s Christi 200 6, pe t. de nied ). In condu cti ng a factual suffici ency re v iew , w e do not s ubst it ute o ur j udg ment for that of the j ur

y ; rather , w e v iew

al l the e v ide nce in a ne u tral l ig ht t o det er mine w hether the cont est ed findi ng i s s o c ontrar y to the g re at w eig ht and preponderance of the ev ide nce as to be manifest ly

unj ust , s hock

the cons ci ence, or

cl ear ly demons trate b ias

. See G olden Eagle Ar cher y, Inc . v . Jack son , 116 S.W .3d 7 57, 7 61 ( Tex . 200 3) ; Pool v. F or d Motor C o. , 715 S. W .2d 6 29, 6 35 ( Tex . 198 6) ; Vi ll agom ez , 210 S.W .3d a t 749

. 2. A nal ysis A pl ain ti ff

mustes tabl is h tw o c ausal nex uses i n order to be ent it led to re cov er y : (1 ) the p lai nti ff

mustshow

that the defendant’ s c onduc t c aused the ev ent s ued upo n; an d ( 2) the plai n t iff

m u s te stab lish thatthis event cause d the plaintif f to suf fer injuries for w hich compens ati on i n damag es shoul d be pai d. See Mor gan v . C om pugr aphic C or

p. , 675 S.W .2d 729, 731 (Tex . 198 4) ; Ki rk patr ick v . Mem ’ l Hos p. of Gar lan d , 862 S.W .2d 762, 772 (Tex . Ap p.–D all as 1994, pet. deni ed) ; see als o Gue var a v . F er re r , 247 S.W .3d 6 62, 6 66 (Tex . 2007). The H ospi tal co ncede s t hat i ts employ ees’ neg li g ence caus ed th e ev ent s ued upon—that is , the f ail ure of Casas to re cei v e Max ipi me and Fl ag y l from Ju ly 18, 2001 t o J u l y 2 3 , 2 0 0 1

. H o w e v e r , t h e H o s p i t a l c o n t e n d s t h a t t h e r e w a s i n s u ffi c i e n t ev ide nce to est abl is h tha t t his ev ent c aused C asas ’s i nju ri es. W e di sag re e.7

Cas as’ s h usban d and son tes ti fied th at s he s uff ered a dramatic se tb a ck i n her condi ti on beg inn ing on the day that she w as infor med of t he Hos pit al’ s ov ersi g ht, and t hat thi s d eter iorated condi ti on c onti nued unti l the t ime of her death. The record al so re flect s that Cas as suffered from depress ion and anx iety after the Ho spi tal fail ed to prov ide her
w ith the prescribed ant ibiotics. A certain am oun t of dep ression an d an x iety can ce rtainly be e xp e cted in a patie nt w ho su f fers f rom m eta static colo n can cer and has recen tly underg one i nv asive su rg er y
. How ev er , C asas ’s hus band an d s on te sti fied th at s he suffered addit io n a l pai n and mental ang uis h foll ow ing the Hos pit al’ s o v ersi g ht. Lay tes ti mony

i s adeq uate to prov e causat ion in those c ases i n w hic h g eneral ex per ien ce and
common s ense w il l enabl e a lay man to deter mine, w it h re asona ble probabi li ty , t he c ausal
re lat ion shi p betw een t he e v ent a nd th e c ondi ti on. Mo rg an , 675 S.W .2d a t 733 ( ci ti ng Len ger v. Physician ’

s Gen. Hosp., In c. , 455 S.W .2d 703, 706 (Tex . 1970)) (hol din g that l ay tes ti mony

co uld es tabl is h causal connect ion betw een c hemic al lea k a nd pl ain ti ff ’s i nju ri es
w he n pl a i n t i ff , w h o h a d p r e v i o u s l y b e e n i n g o o d h e a l t h , b e g a n e x p e r i e n c i n g s y m p t om s suc h as w ater

y ey es, b lu rre d vi si on, h eadac hes and s w ell ing of the b re athi ng pas sag es four day s a fter ty peset ti ng machi ne th at s at tw o i n ch e s f ro m h e r face w as found to be lea ki ng ch emic al fumes); Ins . Co

. o f N. Am . v . Kn eten , 440 S.W .2d 5 2 ( Tex . 196 9)

. In l i mi ted ci rc ums t a n c e s , t h e e x i s t e n c e a n d n a t u r e o f c e rt a i n b a s i cc o n d i t i o n s , p ro o f o f a log ic al seq uence o f

ev ents , and temporal prox imi ty betw een an occ ur re nce and t he condi ti ons can be s uff ic ien t to suppor t a jur y f ind ing of

causat ion w it hout ex per t ev ide nce. Gue vara , 247 S.W .3d a t 667

. In the inst ant cas e, the jur y could hav e found, ba sed on th e lay t e s t im ony of

Casas’s husb and and son, th at he r condition dete riorated prom ptly followi ng the Hospita l’s fa ilure to provide her w ith Maxi pim e an d Flagy l fo r fo ur and a half day s. The ev ide nce thus prov ide d a reason abl e bas is fo r th e j u ry ’s findi ng thatC asas suffered addi ti onal pai n and mental ang uis h becau se of that fai lure. Se e id. ; Mo rg an , 675 S.W .2d a t 733 ; Kneten , 440 S.W .2d a t 54. Mo re ov er , D r. D all er

tes ti fied attr ial that addi ti onal , undetected bact er ial i nfecti ons8

coul d hav e been presentin Casas ’s inci si on sit e w hic h could hav e been treatabl e by the pr esc ri bed ant ibi oti cs
. Dr . D all er note d speci fical ly

that anaerobi c b act er ia, w hic h c annot
sur v iv e w it hout oxy g en, w oul d not hav e been detec tabl e by tak ing a c ult ure of the inc is ion
area , and so a negative fin ding wi t h r espe ct to such a culture would notbe m edica lly si g nific ant. D r. D all er

al so tes ti fied th at t he put ri d odor ema n a ti ng from t he i nci si on s it e
w as ind ic ati v e of suc h an anaerobi c i nfecti on. V iew ing each p ie ce of ci rc umstan ti al
ev ide nce not in is ola ti on, but i n l ig ht of al l the k now n c ircums tanc es, see City of K eller , 168 S.W .3d a t 8 13- 14, w e find that itw as re asona ble for t he j ur y to hav e c oncl uded t hat a n anaerobi c inf e ct io n w as presentand caus ed C asas to suffer addi ti onal pai n and mental ang uis h. The Ho spi tal furth er

co ntends thatD r. D a lle r’ s t est imony ca nnot be c onsi dered becau se: ( 1) D r. D all er w as not c ompetentto re nder an o pin ion on the i ss ue of cau sat ion ; and (2) his testim ony a mo unt ed to no more than mere specu lation . Th e Hospita l is correct that inc o m p e te n t e vi dence i s l eg all y i nsuffici ent t o s uppor

t a jud g ment, ev en i f admitt ed
w it h o u t o bje ct ion

. See i d. at 820. To prov ide opi nio n tes ti mony , an ex per t mus t be q ual if ie d by

kn ow led g e, s ki ll , ex per ien ce, train ing , or educ ati on. See T EX
. R. E V ID . 702

. In a m e d ica l n e glige n ce ca se , a n e xpe rtm u stha ve kn o wled ge, ski ll, exp e rie n ce , t ra in in g, or edu cation regarding the specif ic issue before the court w hich w ould q ualif y the expert to gi v e an opi nio n on that par ti cul ar su bje ct. See R ober

ts v. W il li am son , 111 S.W .3d 1 13, 1 2 1 (T e x. 20 0 3 ) (qu o ti n g Brode rs v. Heise , 924 S .W .2d 1 48, 153 (Tex. 1996 )). How ever, thi s does not mean, for ex ample, thatonl y a ne urosurg eon c an te sti fy about the c ause of deat h from an i nj ur

y to th e brai n, or th at an em erg en c y roo m ph y s i c i an c ou l d ne v er so tes ti fy. See Brode rs , 924 S.W .2 d a t 153

. Dr . D all er tes ti fied th at he i s a n ex per ien ced transpl ant s urg eon and that he has a doctorate in phar macol og y , a field thati ncl udes the stu dy of dr ug int eract ion s w it hin the body

. He tes ti fied th at he has treated in ex ces s o f one hu nd r ed p at i en ts w i th i nt r a- ab dom inal i nfe c ti on s s uc h as t he o ne C as as s uffered from
. A lt h o u gh Dr

. Da ll e r d o e s n o tsp e c ia li ze a n d is n o tce rt if ie d in in fe c t io u s d is e a s e , we9

conc lud e that his ex per ien ce and trai nin g qual ified him as an ex per t t o tes ti fy re g ardin g the
cause of Casas’s injuries. T he Hosp ital also claim s that , even if Dr. Daller w as com pet e nt to g iv e expert testim ony, the jury could nothave based its causatio n f inding on his hypoth esis beca use to do so, “it w ould have had to i nfer (1) other ba cteria w ere in fact prese nt; (2) tha t w ould
cause pain an d (3) w ould have been ef f e c t ive ly treated byMax ipime and Flagy l.” See Schlum ber

ger W ell Sur vey ing C or p. v . Nor tex Oi l & Ga s C or

p. , 4 3 5 S

. W

. 2 d 8 5 4 , 8 5 8 (T e x. 1 9 6 8 ) ( “ Av i t a l fa c tm a y n o tb e e s t a b l i s h e d b yp i l i n g i n fe r e n c e u p o n i n fe r e n c e
. ” )

. W e dis ag re e tha t t he j ur

y eng ag ed i n i mpermi ss ibl e inf e re n ce s tac ki ng here. Dr . D all er p ro vid e d co m p e t e n tt e s t im o n y t h a tt h e o d o r e m a n a t in g f ro m t h e in c is io n s it e wa s in d ic a t ive of an anaerobi c i nfectio n, an d tha t s uch an i nfecti on w oul d hav e been treatabl e by Ma x ipi me and F lag y l. D r. D a lle r als o tes ti fied th at t he i ncreased hear t rate a nd fev er ex per ien ced by

C asas after

the Hos pit al’ s fai lure to p ro v ide her w it h tho se medic ati ons i n d i c a t e d a n i n c r e a s e d p a i n l e v e l

. T h e j u r y m a y n o tp i l e i n fe r e n c e u p o n i n fe r e nce, see Schlum ber

ger , 4 3 5 S

. W

. 2 d a t 8 5 8 , b u t t h e y a re f re e t o b e li e ve o n e wit n e s s a n d d is b e li e ve another

. City of K

ell er , 1 6 8 S

. W

. 3 d a t8 0 7

. He re , t h e ju ry b e li e ve d Dr

. Da ll e r’ s t e s t im o n y, and w e c annot impos e our ow n opi nio n to the c ontrar y
. See i d. W e find that the e v ide nce furni shed a re asona ble basi s for the jur y to find th at t he Hos pit al’ s a cti ons prox imat ely ca used inj ur

y to Cas as; therefore, more th a n a sci nti ll a of
ev ide nce ex is ts. See Le e Lewi s C onst r. C o. , 70 S. W .3d a t 782 -8 3. Fur ther , v iew ing al l the
ev ide nce in a neut ra l li g ht, w e canno t say that the jur y ’s findi ng i s s o c ontrar y to the g re at
w eig ht an d preponderance of the ev ide nce as to be mani festly u n just, sh ock the
cons ci ence, or

cl ear ly demons trate b ias

. See Golde n Eag le Archery, In c. , 116 S.W .3d a t 761. Ac cordin g ly , w e c oncl ude t h a t the ev ide nce w as leg all y and factual ly

su ff ic ien t t o suppo rtthe jur

y ’s f ind ing w it h resp ectto caus ati on. The Ho spi tal ’s first is sue is ov er ru led

.10 B. Su ff icien cy

o f Dam ages Ev id ence By i ts s ec on d i s s ue , th e H os pi ta l c on te nd s t ha t th ere w as l eg al l y a nd fac tu al ly ins uff ic ien t ev ide nce to s uppor t t he j ur y ’s findi ng of mental pai n and distre ss r is ing to a leg all y co mpensabl e l ev el. The Tex as Supreme C our t has st ated: T he t e rm “men tal an guish” implies a relatively high degree of

men tal pa in and dis tress
. It is more than mere dis appoi ntment, ang er , re sentm e n t or embar ra ss ment, alt houg h it m a y inc lud e al l of these. I t i ncl udes a mental sensa tion o f

p a in r e s u lting from such pa inf ul em otion s as gr ief , severe disap p o intm ent , indignatio n, w oun ded pride, sha me , desp air and/ or pub lic humil iat ion

. Par kway Co . v. Woodruf

f , 90 1 S. W .2 d 4 3 4 , 44 4 (T e x. 1 9 9 5 ) (qu o ti n g Trevino v. Sw. Bell Tel. C o. , 582 S.W .2d 582, 584 ( Tex . C iv . Ap p.–C or pus Chr is ti 1979, no w ri t) ). I n Par kway Co. , t he pl ain ti ff

so ug ht ment al ang uis h damag es ar isin g from floo din g ca used by the defendant’ s n eg li g ence. The s upreme co urt found ins uff ic ien t ev ide nce of mental ang uis h, ci ti ng “ [no] directev ide nce of the nature, du ra ti on, o r sev er ity of the [ pla int iff’s] mental anguish, [and ] no circum stan tial evi den ce oth er than t he fact of the f lood ing i tself

to supp ort any aw ard of

men tal an guish.” Id. at 445. The Ho spi tal co ntends thatthe same resul t s houl d obt ain here, and i n s uppor t of i ts
arg ument po int s t o D r. Je li nek’ s d eposi ti on te sti mony , w herein he s tated thatC asas , upo n bei ng i nformed t hat s he di d notrecei v e ant ibi oti cs for four and a hal f day s, did not cr y or express anger or fe ar. How ever, Casas’s son and husb and g ave conf licting tes t im o n y. DeLe on te stif ied th at “s h e w as v isibly upse t, ma d, th at th e me dicatio n, th e an tibiotics
w er en’ t bei ng g iv en to her .” DeL eon tes ti fied that the d epress ion hi s mot her su ff ered from
w as unusu al and out of chara cte r for her. Franci sc o Casas tes ti fied th at, w hen D r. Je li nek
re mov ed th e s tapl es from hi s w ife’s i nci si on to deter mine the e xtent of the i nfecti on, s he
cr ied out in pai n. Franci sc o al so sta ted t hat t he odor and th e d ra in a ge o f

pus from t he incision site cau sed h is w ife to w orry a nd feel em barrasse d as to the way she looke d. He tes ti fied th at his w ife “w oul d be in tears, and s he w oul d al w ay s t ell me [s ic ] w hen w as I ev erI n r esponse t o t he Hospi t al ’ s t hi r d i ssue, C asas a r gues t hat , i ft he t ri al c ou rt h ad i ncl uded an 6 unav oi dabl e acci dent i nst r uct i on, i t woul d ha v e be en a n i m per m i ssi bl e com m ent on t he wei ght of t he e v i dence. See T EX
. R. C IV
. P. 2 7 7 ; W al

- M art St ores, I nc. v. John son , 1 06 S. W

. 3d 7 18 , 7 23

- 24 ( T ex
. 2 00 3)

. As di scussed her ei n, howev er , we ne ed n ot add r ess t hi s ar gum ent a s t he h ospi t al has f ai l ed t o sho w t he po s s i bi l i t y of reve rsi bl e e rr or. 11 g oin g to g et w ell from t his cu t.

. . . She feltdi sg ust ed, mad, becau se they had forg otten to g iv e her anti bio ti cs
. She w asn’ t t he s ame any more. She did n’t tr ust the n urses or doc tors.” Cas as’ s h usban d and son tes ti fied that the putr id odor emanati ng from the inc is ion si te w as so strong thatit pers is ted ev en af ter the nursi ng st aff

had broug ht i n fans t o c ircul ate t he ai r i n th e ho s pi ta l roo m. J u ro rs a re t h e s o le ju d ge s o f t h e c re d ib il it y o f t h e wit n e s s e s a n d t h e we ig h t t o gi ve thei r tes ti mony
. Ci

ty of K eller , 168 S.W .3d a t 807

. Here, un li ke in Par kway Co. , the record cont ains com pet entev iden ce indicat ing tha t Casas’s me nta l anguish w as “more than mere disap poin tm ent , anger, resen tm entor emb arrassm ent .” S e e Pa r k wa y C o. , 901 S. W .2d at 44 4. Gi v ing credi t t o ev ide nce suppo rt ing the jud g ment, and v iew ing the ev ide nce in a neutral li g ht, w e find lega lly a n d f act ual ly su ff ic ien t ev ide nce to s uppor t t he j ur y ’s findi ng of compens abl e mental ang uis h damag es. See City of K eller , 1 6 8 S

. W .3d a t 827 ; Villa g o m ez

, 210 S. W .3d a t 748 ; Golde n Eag le Archery, In c. , 116 S.W .3d a t 761

. Acc ordin g ly , t he H ospi tal ’s se cond is sue is ov er ru led

. C. Un av oidable Acci dent Instruction By i ts thi rd i ss ue, t he H ospi tal cl aims thatthe tr ial co urt er re d i n noti ncl udi ng i n the jury charge an instruct ion regarding the ho spital’s de fense thatCasas’s in ju ri e s w ere caus ed by

an u nav oid abl e ac ci dent. 6 1. St and ard o f Rev iew Tex as Rul e of Ci v il Procedu re 277 re q uires the tr ial cour t to submi t ins tr uct ion s a nd defini ti ons to the jur

y as are necess ar

y to enabl e the j ur

y to re nder

a v erdict. T EX
. R. C IV
. P. 277. A tr ial courthas greater disc re ti on in submitti ng i nst ru cti ons and defin it ion s t o the jur y than it does i n s ubmit ti ng q uest ion s. W al- Ma rt Sto re s, Inc . v

. M idd leton , 982 S.W .2d12

468, 470 ( Tex . Ap p.–San An to n io 1 998, pet. deni ed) ; see Steak & Ale of Tex., In c. v. Bor nem an , 62 S. W .3d 898 , 904 (Tex. App. –Fort W orth 20 01, no pe t.). W hen a tr ial co urt refuses to submi t a re q uest ed i nst ru cti on, t he q uest ion on a ppeal is w hether

the re q uestw as re asona bly n e ce ss ar y to enabl e the j ur

y to re nder

a proper
v erdic t. See T EX
. R. C IV
. P. 277; Tex. Work er s’ C om p. Ins. Fund v

. M andl bauer , 34 S.W .3d 9 0 9 , 9 1 2 (T e x. 2 0 0 0 ). Fu rt h e r, fo r a n in s t ru c t io n t o b e p ro p e r, itm u s t : (1 ) a s s is tt h e ju ry; (2 ) acc uratel y

state the law ; and ( 3) find s uppor t i n the pl eadi ng s a nd th e ev ide nce. See T EX
. R. C IV
. P. 2 7 8; Ma ndl bauer , 34 S. W .3d at 912 . As long as the cha rg e is legally correct, trial courts are a f for d e d b road discretion, subjectto rev ersal only on a court’s abuse of t hat dis creti on. Tex. D ep’ t of H um an Ser

vs . v . E. B. , 8 0 2 S

. W

. 2 d 6 4 7 , 6 4 9 (T e x. 1990) ; Hagins v. E-Z Mart Stores, Inc. , 128 S.W .3d 3 83, 3 87 ( Tex . Ap p.–Tex ar kana 2004, no p et.). Ev en i f t he tr ial cour

t abuse d it s dis creti on, w e re v erse onl y w here the er ro r in the jur y ch arg e i s s how n to be har mf ul. Boatl and of Houston, Inc. v. Bai ley, 609 S.W .2d 7 43, 749- 50 (Tex . 1980). That is, a jur y charg e error

is rev ersi ble onl y

i f it probabl y

ca used the rend itio n o f

a n imp rope r judgmen t or proba bly prevente d the app ellantf rom p rope rly pr esent ing the cas e on appeal

. T EX
. R. A PP
. P. 4 4.1( a)

. Mo re ov er , fail ure to submi t an instructio n sha ll not be d eem ed a g roun d for rev ersal of the judgme nt unless a sub stan tially
cor re ct ins tr uct ion has been re q uest ed i n w ri ti ng and tendered by the par ty co mplai nin g of the j udg ment. T EX
. R. C IV
. P. 2 78. 2. A nal ysis The pur pose of an unavo id a b le acci dent ins tr uct ion i s t o i nform the j ur y that , al th ou g h th e de fen da nt ’ s c on du c t ma y ha v e be en ne g l i g en t, i t mu s t prod uc e th e ou tc om e compl ain ed of i f t he pla int iff i s to re cov er
. See Wil li am s v . Vi swanath an , 64 S.W .3d 6 24, 629 ( Tex . Ap p.–Amar il lo 2 0 0 1 , n o pet .) ; Cr awfor d v . Hope , 8 9 8 S

. W

. 2 d 9 3 7 , 9 4 1 (T e x. App.–A mari ll o 1995, w ri t den ied ). T h e i n str uct ion has been his tor ic all y us ed i n medi cal13

malpract ic e c ases i f there is some ev ide nce firs t pres ented that the ev ent w as caus ed by
some c ondi ti on ot her

than the neg li g ence of the par ti es. W il lia ms , 64 S.W .3d a t 629 ; see Hill v. W inn Dixie Tex., Inc. , 849 S.W .2d 802, 803 (Tex . 199 2) ; Crawf ord , 898 S.W .2d a t 941; W isenb arge r v. Gonzales W armSprings Reh abilitat ion Hosp ., Inc. , 789 S.W .2d 6 88, 692 ( Tex . Ap p.–C or pus Chr is ti 1990, w ri t den ied ). Ho wever, a defendant i s n ot aut om atically ent itled to an instruct ion explaining u navoidab le accide nt; rath er, evidence must firs t be present ed that t he ev ent w as caus ed by so me con dit ion othe r than the neg li g ence of the par

ti es. Crawf

ord , 898 S.W .2d a t 941

. In the i nst ant c ase, the Hos pit al cont ends that itreq uest ed an unav oid abl e ac ci dent ins tr uct ion to follo w

the jur y ins tr uct ion on prox imat e caus e. H ow ev er , t he H ospi tal poi nts to nothin g in the record tha t can be conside red a “subst ant ially correct” rendition of

such an i nst ru cti on. See T EX
. R. C IV
. P. 2 78. At t ri al, there w as a di sc uss ion outs ide the pr esenc e of the jur

y reg ardin g the charg e, du ri ng w hic h c ounse l for bot h par ti es ex press ed obj ect ion s t o the tr ial co urt’ s p ro posed ch arg e. At t hat time, the follo w ing ex chang e too k place between th e trial court an d cou nsel for the Hosp ital: [Hospita l’s coun sel]: Yo u r H o n o r, a ls o f o rt h e re c o rd we h a ve propose d i n w ri ti ng – the D efendant H ospi tal has re q uest ed i nst ru ctions and spec ial i ss ues. The f irst of w hich w e believe is the ultim ate is s u e in this case thatshou ld b e d e c id ed a nd th at w as: W het her by a prepon dera nc e of the evidence the Plaintif

f has pr o ve d thatthere was an injury to M s. Cas as in the c ase. Also, they requeste d instructio ns on una v oida ble accide nt. And as w e have share d w ith the Court as it is used in me dical ma lpractice case s, and is understood i n s uch as the d eci si on of [ W is enbar ger ], in a me dical ne gli gence case w here ex per

t t est imony

es tabl is hes that another phy si cal co ndi ti on or

ci rc umstan ce w as the probabl e c ause of the i nju ry , t he defini ti on of un av oi da bl e ac c i de ntmu s t fol l ow t he j ury ins tr uct ion on p ro x imat e c ause. W e hav e als o proferred new and i ndependen t14 caus e and sol e prox imat e cause to t he C our t for cons ide ra ti on and submi ss ion of the C harg e. I bel iev e the sa me hav e b e en rais ed by the ev ide nce o f

other suc h ev ents , c ircums tanc es and person s w ho are notDefend ant s in the case as the p ro x imat e c a u se of the i nju ry to the Pl ain ti ff , and they ’re present ly not i n the C harg e, and I just respectf ully

request the Court to m ake a r uli ng on t he record. TH E C O U R T: Y es, si r. Thos e w er e the sa me re q uest ed ins tr uct ion s a nd q uest ion s t h a t – or defini ti ons that y ou re q uest ed ear li er i n c hambers o ff

the re cord, r ig ht? [H ospi tal ’s co unsel ]: That’s co rrect

. THE CO UR T: Al l of thos e that w ere show n to me and that y ou made a req uestfor a re deni ed. Al thoug h the H ospi tal al lud es to t he presence of a w ri tten unav oid abl e ac ci dent ins tr uct ion tendere d to the tr ial court , it does not a ppear i n the record. Beca use th e record does not re flect that a “s ubst anti all y cor re ct” ins tr uct ion has been “ re q uest ed i n w ri ti ng and tendered” by

the Ho spi tal , w e concl ude that anyerror that may

hav e been commi tted by the tr ial cour

t in re fusing to submi t an av oid abl e ac ci dent ins tr uct ion i s n ot rev ersi ble

. See T EX
. R. C IV
. P. 278; see a lsoT EX
. R. A PP
. P. 33.1( a)

. Acc ordin g ly , t he H ospi tal ’s thi rd i ss ue is ov er ru led

. D. D eni al o f Jelin ek’s Mo ti on t o Di smis s By his sol e is sue, Dr

. Jel ine k ass erts that the tr ial cour t er re d by deny ing his moti on for s anct ion s a nd d ism is sal under former ar ti cl e 4590i , s ect ion 13.0 1 of the ML IIA. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.351. W e di sag re e. Me di c a l ma l p r a c t i c e p l a i n t i ffs mu s t p ro v i d e e a c h d e fe n d a n t p h y s i c i a n and hea lth-care provider an expert repo rt co nta ining th e expert’s cu rriculum vi tae , and “a fa ir
sum ma ry

of the expert’s opin ions as o f the da te of

the rep ort regarding applicab le stan dard s o f

ca re, the m ann er in w hich th e care rend ered bythe ph y sician or hea lth care prov ide r faile d to meet the standards, and the caus al rela ti onshi p betw een t hat fai lure and15

the injury , harm , or dam ages claime d.” Bowie Me m 'l Hosp. v. Wrigh t , 79 S.W .3d 4 8, 51 (Tex . 200 2) ; see Am . Tr ansiti onal Car e C tr s. of T ex. , Inc. v. Pal

aci os , 46 S. W .3d 8 73, 8 77 (Tex . 200 1)

. The ex per t repor t mus t prov ide “a fair summar y of the e x per

t’ s o pin ion s a s of t he date of t he re por t reg ardin g appl ic abl e s tandards of care, t he manner i n w hic h the
care rendered by the phy si ci an or heal th care prov ide r faile d to meet the s tandards, and the c ausal rela ti onshi p betw een t hat fai lure and the i nju ry , har m, or damag es cl aimed. ” Bo w ie M em ’ l Hos p. , 7 9 S

. W

. 3 d a t5 1

. I f a p l a i n t i ff t i me l y fi l e s a n e x p e rtre p o rta n d the defendant mov es to dis mis s becau se of t he re por t’ s ina deq uacy , the tr ial co urt mus t g ra nt the moti on “o nly if it appears to the cour t, after hear ing , that the re por t doe s n ot represent a good faith e f

fort to com ply w ith the d ef inition of a n expert re port in [th e MLIIA ].” See i d. at 51 -5 2; Pal

aci os , 46 S.W .3d at 878. T o const itute a “g ood faith ef fort,” the report m ust prov ide enoug h i nformati on to fulfil l tw o pur poses : (1 ) itmust infor m the d efendant of the spec ific condu ct the pla int iff has cal led int o q uest ion , and (2 ) it mustprov ide a ba si s for the tr ial co urt t o c o n clu d e t hat t he c lai ms hav e mer it

. Bowie Me m ’ l Hos p. , 79 S.W .3d a t 52;
see Pal aci os , 46 S.W .3d at 879. The re por t need not mars hal all the pla int iff’s p ro of, but it mu st include the expert’s opin ion on each of the th ree elem ent s thatthe MLII A iden tif ies: sta ndard of

care, breac h, and ca usal rela ti onshi p. Bowie Me m ’ l Hos p. , 79 S.W .3d a t 52. That i s, a pl ain ti ff

need not p re sentev ide nce in the repor t as i f it w ere ac tual ly

l it ig ati ng the meri ts. Pal

aci os , 46 S. W .3d at 879

. T he report can be informa l in that th e informa tion in the repor

t doe s n ot ha ve to m eet t he s ame req uirements as the ev ide nce off ered i n a summar y -j udg ment proceed ing or at tr ial

. Id. W e r ev ie w a t r i a l c o u rt ’ s o rd e r d i s mi s s i n g a c l a i m fo r fa i l u r e t o c o mp l y w it h the
ex per t repor t req uirement un der

an abuse of dis creti on s tandard. Bowie Me m ’ l Hos p. , 79 S.W .3d a t 52; Pal

aci os , 46 S.W .3d a t 878. A tr ial cour t abuse s it s d is creti on i f it act s i n an arbitrary or unrea sona ble m ann er w ithou t referen ce to an y g uiding rules or principles. Dow ner v. Aqu am arine Op erato rs, Inc. , 701 S.W .2d 238 , 241 -42 (Te x . 198 5).16

Dr. Daller’ s orig inal expert report da ted Octob er 30, 2 003 , state d as follows: The st andard of ca re wh e n manag ing a pa ti ent req uires v ig il ance tow ards the t re atments the pati ent i s recei v ing and confir ming thatorders s peci f ied in the physici an order shee ts are carried ou t. Both Dr. Carlos Garcia and Dr. Mi chael Jel ine k by thei r failu re to re cog niz e that the anti bio ti cs w ere not bei ng admi nis tered as ordered c ommitt ed a breach in the sta ndard of care. T his breach in t h e stan dard of care represe nts ne gli gence an d, w ithin re asona ble medi cal probabi li ty , res ult ed in a prolo ng ed hospi tal co urse and increase d pa in and suf fering being ex perien ced b y Ms. C asas. T he report the reby informe d Dr. Jelinek of the spe cif ic condu ct bein g challen ged—i.e., his “fai lure to re cog niz e tha t t he ant ibi oti cs w ere no t b e ing admi nis tered” —and itprov ide d a basi s for the tr ial co urt t o c oncl ude t hat t he c lai ms had mer it

. See Pala ci os , 46 S.W .3d a t 879. M oreov er , the re por t inc lud ed Dr

. Dal ler ’s opi nio n that Dr

. Jel ine k’ s n eg li g ence w as causa lly related to the “increased pain an d suf fering” experience d by C asas. Dr . D all er ’s repor

t i ncl uded hi s o pin ion on the three ele ments re q uired by the ML IIA: sta ndard of c are, breach, and caus ati on. See i d. at 878. Therefore, w e c oncl ude t hat t he
re por t c onst it uted a g ood fait h ef fort to comply

w it h the ex per

t repor t req uirements of the MLIIA. Accordingly , the trial court did notabu se its discretion in ref using to grantDr. Jel ine k’ s motion for

sa nct ion s a nd di smi ss al. See B owie Me m ’ l Hos p. , 79 S. W .3d a t 51- 52. Dr . J eli nek’ s i ss ue i s o v er ru led

. III
. C ONCL US I ON W e af f irm the judgmen t of

the trial court as to both app ellant s.

_________

_________

_________

___ DO RI C ON TRERAS G AR ZA, J u s t i c e Me moran dum Opi nio n del iv ered and filed thi s t he 29t h day

of Jul y , 200 8.