In the

Court of Appeals

Second Appellate District of Texas

at Fort Worth ___________________________

No. 02-21-00217-CV

___________________________

On Appeal from the 90th District Court

Young County, Texas

Trial Court No. 34179

Before Kerr, Womack, and Wallach, JJ.

Memorandum Opinion by Justice Wallach

BRIAN NORTHCUTT, M.D., Appellant

V.

RONNIE C. STEPHENS AND RICKY STEPHENS, Appellees
2

MEMORANDUM OPINION

This case involves a healthcare-liability claim.1 Appellees Ronnie and Ricky 

Stephens, the sons of Peggy Celesta Stephens, sued appellee Dr. Brian Northcutt 

contending that his negligence in treating their mother was a proximate cause of their 

mother’s death. Dr. Northcutt answered the suit. The Stephenses then served an 

“expert report” by Seth Womack, M.D. Northcutt timely objected to the report and 

moved to dismiss the case because the report failed to address the element of 

proximate cause, a required element in a healthcare-liability claim. The Stephenses

filed no written response to the objections and motion. After a hearing, the trial court 

denied the motion. This interlocutory appeal followed. We hold that the report of Dr. 

Womack was deficient for failing to address the issue of causation; thus, we reverse 

the order of the trial court denying dismissal of the case and remand the case to the 

trial court for further proceedings.2

1

The Stephenses agree that this case is a healthcare-liability claim.

2

The Stephenses did not request a 30-day extension in the trial court to cure 

their report and have not requested one on appeal. However, Dr. Northcutt has 

requested that, in the event of reversal, we remand the matter to the trial court for 

consideration of whether a 30-day extension is appropriate under Tex. Civ. Prac. & 

Rem. Code Ann. Section 74.351(c). See Leland v. Brandal, 257 S.W.3d 204, 208 (Tex.

2008); Estorque v. Schafer, 302 S.W.3d 19, 32 (Tex. App.—Fort Worth 2009, no pet.). 

While the bar is “minimal” to qualify for the granting of an extension, the granting of 

an extension is not automatic. Scoresby v. Santillan, 346 S.W.3d 546, 549, 554 (Tex. 

2011); see Post Acute Med., LLC v. Montgomery, 514 S.W.3d 889, 894 (Tex. App.—Austin

2017, no pet.); Laredo Tex. Hosp. Co., L.P. v. Gonzalez, 363 S.W.3d 255, 259 (Tex. 

App.—San Antonio 2012, no pet.); Velandia v. Contreras, 359 S.W.3d 674, 679 (Tex. 
3

I. Background3

Ms. Stephens experienced abdominal pain and went to the emergency room at 

Graham Regional Medical Center two times on March 9, 2018. In the morning visit, 

she reported abdominal pain from the day before that was “constant, cramping, worse 

with movement, and better with rest.” Three days before this visit, she had undergone 

stenting of arteries in both legs due to peripheral vascular disease. Dr. Northcutt 

ordered labs, which revealed an elevated white blood-cell count, and a CT scan, which 

showed “dilated fluid filled small bowel loops in the right lower quadrant with some 

adjacent fluid and possible wall thickening.”

Dr. Northcutt documented that the “CT findings suggest colitis.” But the 

Stephenses’ expert, Dr. Seth Womack, reported that the treating radiologist 

interpreted the CT as “without colonic wall thickening or pericolonic inflammation.” 

Dr. Northcutt eventually discharged Ms. Stephens with an order to increase fluid 

intake and with prescriptions for nausea and vomiting. Dr. Northcutt’s diagnosis “was

gastroenteritis.” He instructed her to return “if nausea and vomiting continue[d] 

without the development of diarrhea.” Later that night, Ms. Stephens got out of bed, 

vomited, became very weak and collapsed. EMS found her on the bedroom floor. 

App.—Houston [14th Dist.] 2011, no pet.). We express no opinion on the propriety 

of an extension here.

3

The Stephenses and Dr. Northcutt agree that Dr. Northcutt’s summary of the 

facts taken from Dr. Womack’s report and the proceedings in the trial court are 

accurate and we will utilize his recitations.
4

“She was very pale, diaphoretic, and slow to respond.” She had an elevated heart rate

and blood-glucose level. EMS took her back to Graham Regional Medical Center 

where Dr. Northcutt again evaluated her.

Dr. Northcutt documented that she passed out (“a syncopal event”) after 

nausea and vomiting. His diagnosis was syncope and gastroenteritis and he 

recommended her admission to the hospital. A nurse practitioner admitted Ms. 

Stephens from the emergency room. The nurse practitioner noted, “Ms. Stephens had 

diffuse abdominal pain with nausea, vomiting, and dry heaving.” The nurse 

practitioner’s physical exam found that “Ms. Stephens’[s] abdomen was soft but 

diffusely tender,” and Ms. Stephens’s discomfort prevented the nurse practitioner 

from feeling the liver.

The next day, Ms. Stephens vomited “dark brown” material, which could be a 

sign of gastrointestinal bleeding and bowel ischemia. Her hemoglobin had dropped 

and her white blood cell count had risen. A different doctor (Gerald Mitchell) 

transferred Ms. Stephens to the emergency room of Huguley Medical Center where 

Dr. Mehboob Qassam examined her. He found her “alert, ill appearing, and in mild 

distress.” She had an elevated heart rate and “abdominal tenderness with voluntary 

guarding.” He ordered a CT scan, “which showed a medium to high grade small 

bowel obstruction with a possible transition point at the center of the lower 

abdomen.” Considering Ms. Stephens’s atherosclerotic disease and recent stenting, the 

radiologist who interpreted this CT scan said that an “ischemic etiology should be 
5

considered.” Dr. Qassam diagnosed her with mesenteric ischemia and small bowel 

obstruction. He consulted with a surgeon, Dr. Wesley Marquart.

Dr. Marquart took Ms. Stephens for emergency surgery that afternoon. He 

“found an ischemic segment of bowel associated with a strangulated internal hernia.”

He also “found other patchy areas of ischemic small bowel globally,” that he thought 

“was from a thromboembolic event from her recent [arterial stenting].” Ms. Stephens

“developed septic shock due to small bowel ischemia and died the next day.”

The Stephenses’ petition alleged that Dr. Northcutt was negligent by:

• not properly diagnosing Ms. Stephens’s small bowel obstruction;

• discharging her with the wrong diagnosis;

• failing to properly treat her mechanical bowel obstruction;

• failing to order appropriate tests;

• failing to properly evaluate diagnostic studies and order indicated

treatments;

• failing to prescribe appropriate medications; and

• failing to order timely diagnostic studies.

The Stephenses claimed that Dr. Northcutt’s conduct was the proximate cause of Ms. 

Stephens’s death. Further, the Stephenses alleged that Dr. Northcutt’s acts and 

omissions “constitute[d] a direct and proximate cause of [Ms. Stephens’s] untimely 

death and the damages” described in the petition.
6

Dr. Womack’s “expert report” is six pages long with his signature on the 

seventh page.4 The first page of his report addresses his qualifications and the 

materials he reviewed. Pages 2 and 3 summarize the pertinent facts he gleaned from 

the records he reviewed. Pages 4–6 set out his opinions about the case. Dr. Womack 

identified six areas where Dr. Northcutt breached the standard of care and the 

reasons why. The asserted breaches of the standard of care were: 1) the failure to 

consult a surgeon on both emergency room visits; 2) the failure to properly interpret 

the radiologist’s reading of Ms. Stephens’s CT scan; 3) the failure to obtain a repeat 

CT scan on the second emergency room visit; 4) the failure to obtain repeat labs 

during the second emergency room visit; 5) the failure to obtain and monitor vital 

signs during both emergency room visits; and 6) the failure to obtain an EKG during 

both of her emergency room visits. Dr. Womack’s report is devoid of any opinions on 

how any of the alleged departures from the standard of care caused Ms. Stephens’s 

injury or death or how the outcome would have been altered if the standards had 

been met.

II. Standards of Review and Applicable Law

We review a trial court’s decision on a motion to dismiss a health care liability 

claim for an abuse of discretion. See Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 

46 S.W.3d 873, 875 (Tex. 2001); CHCA Clear Lake, L.P. v. Stewart, No. 01-19-00874-

4

Dr. Womack claims to be a physician, board certified in emergency medicine. 

His qualifications are not at issue here.
7

CV, 2021 WL 3412461, at *8 (Tex. App.—Houston [1st Dist.] Aug. 5, 2021, no pet.) 

(mem. op.). A trial court abuses its discretion when its decision is arbitrary, 

unreasonable, or without reference to any guiding rules or legal principles. K-Mart 

Corp. v. Honeycutt, 24 S.W.3d 357, 360 (Tex. 2000). In reviewing the adequacy of an 

expert report, the expert report must provide a “fair summary” of the expert’s 

opinions on (1) the applicable standard of care, (2) how the care rendered by the 

defendant physician or health-care provider failed to meet the standard of care, and 

(3) the causal relationship between that failure and the injury, harm, or damages 

claimed. Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6); see also Certified EMS, Inc. v. 

Potts, 392 S.W.3d 625, 630 (Tex. 2013); CHCA Clear Lake, L.P., 2021 WL 3412461, at 

*8. A “fair summary” of the expert’s opinions means that, at the least, the report must 

state more than the expert’s mere conclusions on the standard of care, breach, and 

causation; it must instead explain the basis of the expert’s opinion to link the 

conclusions to the facts of the case. CHCA Clear Lake, L.P. 2021 WL 3412461, * 8; see 

also Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010); Bowie Mem’l Hosp. v. Wright, 

79 S.W.3d 48, 52 (Tex. 2002).

An expert report qualifies as an “objective good faith effort” to avoid dismissal 

if it discusses each element of the health care liability claim with sufficient specificity 

so that it (1) informs the defendant physician or health-care provider of the specific 

conduct that the plaintiff questions or about which the plaintiff complains and 

(2) provides a basis for the trial court to conclude that the plaintiff’s health care 
8

liability claim has merit. Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d 510, 

513 (Tex. 2017). The expert report need not use any particular words, and it may be 

informal, “but bare conclusions will not suffice.” Scoresby, 346 S.W.3d at 555–56. In 

determining whether an expert report constitutes an “objective good faith effort” to 

address each element, “a trial court may not draw inferences; instead, it must 

exclusively rely upon the information contained within the four corners of the 

report.” CHCA Clear Lake, L.P., 2021 WL 3412461 at *9 (quoting Puppala v. Perry, 

564 S.W.3d 190, 197 (Tex. App.—Houston [1st Dist.] 2018, no pet.)). As noted by the 

San Antonio Court of Appeals,

The report need not use any particular “magical words” such as 

“proximate cause,” “foreseeability,” or “cause in fact.” [Columbia Valley 

Healthcare Sys. v. Zamarripa, 526 S.W.3d 453, 460 (Tex. 2017).] On the 

other hand, “merely incanting words does not suffice.” Id. Also, “merely 

providing some insight into the plaintiff’s claims does not adequately 

address causation.” Tenet Hosps. Ltd. v. Love, 347 S.W.3d 743, 755 (Tex. 

App.—El Paso 2011, no pet.). When a report fails to outline how a 

suggested action “would have resulted in different care and treatment, or 

a different outcome” then there is “a broad analytical gap between the 

alleged breach and the ultimate harm” and thus, the report is 

“insufficient to establish causation.” Id.

Thilo Burzlaff, M.D., P.A., v. Weber, 582 S.W.3d 314, 325 (Tex. App.—San Antonio 

2018, no pet.) (holding conclusory expert report on causation deficient); see also 

Zamarripa, 526 S.W.3d at 460. An expert report that does not address causation is 

deficient. Mitchell v. Swanson, No. 02-19-00460-CV, 2020 WL 6065986, at *4–5 (Tex. 

App.—Fort Worth Oct. 15, 2020, no pet.) (mem. op.); Nexion Health at Southwood, Inc. 
9

v. Judalet, No. 12-08-00464-CV, 2009 WL 3019717, at *3 (Tex. App.—Tyler Sept. 23, 

2009, no pet.) (mem. op.).

III. Analysis

The analysis of this matter is very straightforward. The only expert report

proffered by the Stephenses to meet their statutory obligation was Dr. Womack’s 

report. Although Dr. Womack described in significant detail his opinions about Dr. 

Northcutt’s breaches of the standards of care, he never offered any opinions or 

explanations, using magic words, conclusions or otherwise, about how those breaches 

caused injury or death to Ms. Stephens. The need to explain the causal connection 

between breaches of the standards of care and the claimed injury or death is 

particularly acute in cases where the allegations are that a patient, who had a preexisting condition, would have experienced a better outcome had earlier diagnosis or 

treatment been undertaken. THN Physicians Ass’n v. Tiscareno, 495 S.W.3d 914, 

923 (Tex. App.—El Paso 2016, no pet.) (holding report inadequate because expert 

merely offered conclusory opinion that failure to recognize and treat a pre-existing

infection was substantial cause of harm to the plaintiff); Jones v. King, 255 S.W.3d 156, 

160 (Tex. App.—San Antonio 2008, pet. denied) (concluding expert report inadequate 

because it failed to explain how a 48-hour delay in diagnosis caused the patient’s

alleged injuries); Costello v. Christus Santa Rosa Health Care Corp., 141 S.W.3d 245, 

249 (Tex. App.—San Antonio 2004, no pet.) (holding expert report claiming that 

patient would have survived but for the delays in diagnosing and treating her was 
10

insufficient because it failed to describe “what treatment would have or could have 

been available, that the patient was a candidate for the unknown treatment, or that the 

unknown treatment could have or would have been effective”).

In this case, the record reviewed by Dr. Womack reflects that three days before 

Ms. Stephens’s first emergency visit to Dr. Northcutt on March 9, she had arterial 

stents placed in both legs because of atheroslerotic disease. At surgery on March 10, 

her surgeon found a segment of ischemic bowel associated with a strangulated hernia 

along with other patchy areas of ischemic small bowel globally, which he believed was 

from a thromboembolic event from her recent endovascular procedure. Dr. Womack 

footnoted this finding as follows: “[D]uring endovascular procedures, the internal 

walls of blood vessels can be disrupted causing plaques/clots to dislodge where they 

proceed to obstruct a smaller blood vessel, distally; and cause ischemia.” It was 

incumbent on Dr. Womack to explain how Ms. Stephens was injured, or how her 

death was caused, by the breaches of the standard of care which he outlined in his

report, especially since he noted her pre-existing condition that appears to have 

precipitated her deterioration and contributed to her demise.

The Stephenses argue that we should infer that Dr. Northcutt’s alleged 

negligent conduct was a cause of Ms. Stephens’s death. However, we are limited to 

the four corners of Dr. Womack’s report and we cannot infer or make educated 

guesses about causation. Methodist Hosp. v. Addison, 574 S.W.3d 490, 505 (Tex. App.—

Houston [14th Dist.] 2018, no pet.) (“Our review is limited to the four corners of the 
11

report, and we cannot make inferences to establish the causal connection” (quoting 

Rice v. McLaren, 554 S.W.3d 195, 201 (Tex. App.—Houston [14th Dist.] 2018, no. 

pet.)); Austin Heart, P.A. v. Webb, 228 S.W.3d 276, 281 (Tex. App.—Austin 2007, no 

pet.) (concluding expert report that required reader to infer or make educated guess as 

to which of two doctors breached standard of care and caused injury was not 

adequate).

Because Dr. Womack’s report was inadequate regarding the element of 

causation, the trial court abused its discretion in overruling Dr. Northcutt’s Motion to 

Dismiss. We reverse the trial court’s order denying Dr. Northcutt’s Motion to Dismiss 

and remand the case to the trial court for further proceedings consistent with this 

opinion.

/s/ Mike Wallach

Mike Wallach

Justice

Delivered: January 6, 2022