Affirmed and Memorandum Opinion filed January 13 , 202 2.

In The 

## Fourteenth Court of Appeals

NO. 14
- 20
- 00004
- CV
NORTH CYPRESS MEDICAL CENTER OPERATING COMPANY, LTD., D/B/A NORTH CYPRESS MEDICAL CENTER AND DR. OZOCHUKWU ODILI , Appella nt s V. RANDY WHI T E , Appellee
On Appeal from the 189th District Court

Harris County, Texas Trial Court Cause No. 2019
- 14054

MEMORANDUM OPINION In this interlocutory appeal , appellants Ozochukwu Odili, M.D., ( “ Dr. Odili ” ) and North Cypress Medical Center Operating Compan y , Ltd. D/B/A North Cypress Medical Center ( “ Hospital ” ) appeal the deni al of their motion s to di smiss the health

- care liability claims of ap pellee Randy White. In three issues, Dr. Odili argues the trial court erred when it allowed White to amend his e x pert rep ort and denied his motion to dismiss

. In two issu es , the Hospital ar gues that the trial court2

erred w hen it overruled its objections to White ’ s e xpert repo rt and denied its motion to dismiss and that t he appropriate remedy , after White was permitted to amend his expert report once, i s rendition of judgment and remand for th e
assess ment of attorney ’ s fees and costs

. We affirm.
I. B ACK GROUND On Mar c h 11, 2017 , White was admitted to the emergency department of the Hospital after a toolb ox f ell on hi s hand

. W hite was diagno sed with a six

centimeter laceration to his t hum b and an open intra

- articular distal phalanx fr acture with extension in t o the prox i mal phalanx of the thumb. Dr . Odili , an emergency room physician , treated White f or hi s inju r y at the Ho spita l and, on that same day, referred White for an orthopedic consultation on March 13, 2017

. On March 13, 2017, White sought treatment with a different orthopedic surgeon and was scheduled for surgery on Mar ch 16, 2017. During s urgery, i t was d iscovered that White ’ s wou nd was infected

. T he surgery was aborted , and a n incision and drai nage procedure was performed

. White underwent t wo subsequent in cision and drai nage proce dures on March 30 , 2017, and April 2, 2017.
On Fe bruary 2 5, 2019, Whit e s u ed D r. Odili and the H os pital for negligence in the treatment of his injury

. In his live petition , White alleges that the proper st andard of care for his injury required Dr. Odi li to im me di ately send Whi te for

e xamination and care by a sp e cialist in ha nd i n jur ies , and tha t White should have been rushed to surgery
. White alleged that as a result of the de lay in treatment , he suffered multiple complica tions and expenses , permanent injury to his thumb , and

an impa ir ment ra ting of nine percent

. W hite alleged t h at Dr. Odili and the Hospital

were negligent b y failing to refer White to a hand specialist immediately for

ex ami n ation an d care of White ’ s hand ; by failing to refer White to emergency

sur gery im mediately or within twe nty

- four hours ; a nd i n Whit e ’ s follo w up care
.3

White f urther all eged that Dr. Odil i an d the Hospital were grossly negligent , and t hat the H ospital was , under v arious theories, vicariously liable for Dr. Odili ’ s neglige nce
. On Mar ch 21, 201 9 , White serve d Dr . Odili with an exper t report a uth or ed by Ramesh Sri nivasan, M.D. , ( “ Dr. Srinivasan ” ) , a board

- c erti fied orthopedic surgeon. On May 6, 2019, White served the Hospital with Dr. Srinivasan ’ s expert report

. 1
Dr. Odili a nd the Hos pital ea ch filed timely objecti ons to Dr. Srinivasan ’s exper t re port on April 8, 2 019, and May 2 4, 2019, re spectively

. Se e Tex. Civ. P rac
. & Rem. Code Ann. § 74.351(a) ( providing that a part y must object to a plaintiff ’ s expert repor t wi thin twe nty

- one days)

. D r. Odili objected to the report on the bas is tha t Dr. Srini v asan was not qual ified to opin e on Dr. Odi li ’ s standard of care or breach of the standard of care because Dr. Srin ivasan ’ s letter and CV do not re flect

e d ucation, training , or experience as an emergency room p hysi cian , and that Dr. S rinivasan ’ s experienc e as an orthopedic surgeon does not “ over lap ” with the dis cipline of em ergency medicine. Dr. O dili further object ed to the report , averring that the report did not meet th e statutory requi rements regarding t he sta ndard of care, breach of the standard of ca re, and causat ion

. Dr . Odili further argued that the report advanced by Whi te was not a deficien t report under the statute , but r ather it

was n o t an expert rep or t at all under the statute

. The Hospital o bj e cted to the expert report on the basi s that it did not a ddress the st andard of care applicable to nursing staff or the H ospital , brea ch of the standard of care by the H ospital , and ca u s ation as to the H ospital.

1 The Ho spital states in i ts brief that it was se r ved with the orig inal expert report on July 10, 2019 ; however, this date is incorrect because the Hos p ital filed its objections t o the ori ginal expe rt r e port on May 24, 2019. In its obj e ctions filed in th e trial co urt, the Hospital states that it was serv e d with the expert re port on May 6, 2019

.4

On July 30, 201 9, Dr. Odili filed a motion to dismiss Wh ite ’ s c laims on the ba sis that Dr. Sr i nivasan ’ s repo rt wa s not a n expert report un der the sta tu te and was in capable of cur e
. See id. § 74.351(b ) (2) ( pr o viding that i f an expert re port has n ot been served within the statutory 120

- day period as t o a defendant p hysician or health care provide r , t he court then , on t he motion of the affected physicia n or healthcare provi d er, shall enter an order that dismis se s the claim with p rejudice

w ith respect to the physi cian or health care provider ) ; see also id

. § 74.351(a) (providing that claim ant in health care liability clai m must serve on the defendant

on e or more expert reports within 120 days afte r the date each d e fendant ’ s answer is filed)

. On September 23 , 2019, the trial court sustained Dr. Odili ’ s objectio ns in part , granted White thirty da ys to file an ame nded expert report , and i nformed Dr. Od ili that it would con sider his motion to dismiss after an amended r e port was filed

. See id. § 74.351(c) ( “ If an expert report has n ot been served within the peri od specified by [§ 74.351(a)] because el ements of the r eport are fou nd def icient, the court may grant one 30

- day ex tension to the claimant in order t o cure the deficie ncy. ” ).
O n O ctober 22, 2019 , Whit e served appellants w ith Dr. Sri nivasan ’ s
amen ded expert report. O n November 1, 2 019, the Hospital objec ted to Dr. Srini vas an ’ s amended report and fi led it s own mo tion to dismiss

. Specifi cally, t h e Hospital argued that the amended expert report failed to address the standard of care, brea ch of the standard of care , and cau sation as to the Hospital and failed to provide any fac tual basis f or Dr. Sriniv asan ’ s conclusion that the Hos p ital did not have han d

- fell owship trained sur g eons on staff. On November 6, 2019, Dr. Odili filed his objections to the a mended expert report and a second motion t o dismiss. Dr. Od ili objected to the amended report on the grounds t h at (1) Dr. Sriniv asan was n ot qualified to opin e on Dr. Odili ’ s5

standard of care or breach of the standard of care , and (2) t he amen ded r e port had

“ no opinions on proximate c ause other than the statement that there was
cau s ation. ” Dr. Odili also argued that Dr . S rinivasan ’ s “ amended ‘ report ’ does not qualify as an expert report ” and that White ’ s suit should be dismissed for failing to comply with the stat utory requir ements. O n December 16, 2019, following a hearing, the tri al court sign e d an o rder denyin g Dr. Odil i and the H ospital ’ s obj ections to Dr. Srinivasan ’ s expert report and their motion s to dismiss

. This interlocutory appeal followed. See i d. § 51.014(a) (9) ( authorizing interlocutory appeal of the denial of a motion to d ismiss filed purs ua nt to Texas Ci vil Practice and Reme die s Code § 74.351 (b) ).
II. D ISCUSSION A. A PPLICABLE L AW The Texas Medical L i abili ty A ct ( “ TMLA ” ) is codi fied in Chapter 74 of the Tex as Civi l Practice and Remedies Code

. See Tex. Civ. Pr ac. & Rem. Co de Ann. § § 74.001

– 74. 50 7. S e ction 74 .3 51 provides that a pla intiff in a he alth care liability suit must serve the medical defendant with a sta tutori ly

- compliant expert r eport accompan ied by the exp ert ’ s curriculum vi tae ( “ CV ” )

. See Tex. Civ. P rac. & Rem

. C ode Ann. § 74.351

. If a pla i ntiff fa ils to do so within 120 days after the defenda nt ’ s original answer is filed , the n the trial court must dismiss the c laim with prejudice on the defe ndant ’ s motion. Baty v. Futrell , 543 S.W.3d 68 9, 692 n.1 (Te x. 2018); s ee Tex. Civ

. Prac. & Rem . Cod e Ann. § 74.351(a), (b)(2). The goal is “ to deter frivolous lawsuits by requiring a cla im ant early in litigation to produce the opinion of a suitable exper t that his claim has merit. ” Columbia Valley Healt hcare Sys. , L.P. v. Zam ar ripa , 5 2 6 S.W.3d 453, 460 (Tex. 20 17) (citing Scoresby v. Sant illan , 346 S.W.3d 546, 552 (Tex. 2011)) ; see also6

A bshire v. Christus Health Se. Tex. , 563 S.W. 3d 219, 223 (Tex. 2018) (per curiam)

. Therefore, an expert report is a low threshold a person bri nging a c l aim

a gainst a h ea lth care provider must c ross mere ly t o show th at his claim is not frivolous. Loaisiga v. Cerda , 379 S .W.3d 248, 264 (Tex. 2012 ).
An “ expe rt report ” under t he TMLA means : a written report by an expert that provides a fair summar y of the e xpert's opinions as of the date of the report rega rdin g applicable standards of care, the manner in which the care rendered by the physician or he alth care provider failed t o meet the stand ards, and the causal relationship between th at failure an d the inj u ry, harm, or dama ges claim e d

. Id. § 74.351(r)(6).

“ A trial court must sustain a challenge to a report ’ s adequacy if the report does not represent an objective good faith ef fort to provide a fair summary of the appl icable standard of care, the de fendant ’ s breach of that st andard, a nd how that breach cause d the pati ent ’ s harm. ” Miller v. JSC Lake Highland Operations , L P , 536 S.W .3d 510, 513 (Tex. 2017) (per curiam) (interna l q uotation marks omitted);

see Tex. Civ . Prac . & Rem. Code Ann . § 74.351( l ) , (r)(6). “ A good

- faith eff ort must ‘ provide enough informat ion to fulfill two p urposes: (1) it mus t inform the defen dant of the specific conduct the plaintiff has cal led into questio n, and (2) it must provide the basis for t he tria l court to conclude t hat the clai m s have merit. ” Mi ller , 536 S.W.3d at 513 (quoting Bowie Mem ’ l Hosp. v

. Wright , 79 S.W.3d 48, 52 (Tex. 2002) (per curiam)). All information needed for this in quir y is fo und

w ithin the four co rn ers of the expert report, which ne ed not marshal all o f the pla i ntiff ’ s proof. Je linek v. Casas , 328 S. W.3d 52 6, 5 39 (Tex. 2010) (citing Am. Transitional Ctr

s. o f Tex., Inc v. Palacios , 46 S.W.3d 873 , 879 (Tex. 2001)). A report that mere ly stat es the expert ’s conclusions about the standard of car e, brea ch, an d causati o n does not fulfil l these two p urposes
. Palacios , 4 6 S.W .3d at7

879; New Med. Horizons , II, L td . v. Milner , 575 S.W.3d 53, 60 (Tex. App.

— Houston [1st Dist.] 2019, no pet. ) ; se e Score sby , 346 S.W.3d at 556 ( “ No particular words or forma lity are requ i red, but bare c onclusions will not suffice

. ” )

. A plaintiff is required to timely file an adequate expert report as to each defendant in a he alth care liability claim, but the plaint iff is not required to file an expert report as to each liab ility theory alleged a g ai nst that defend ant. See TTHR Ltd. P ’ ship v. More no , 40 1 S.W.3d 41, 44 (Tex . 2013) ; Cert ified EMS, Inc. v. Potts , 392 S.W.3d 625, 6 32 (Tex. 201 3)

. B. S TANDARD OF R EVIEW We review a trial c ourt ’ s ruling on the sufficiency of an expe r t ’ s report a nd

on a m o tion to d ismiss u nder the expert

- report rule for a n abuse of discretion. Jelinek , 328 S. W .3d at 5 39 ; see Tex. Civ. Prac. & R em. Code Ann. § 74.351 ; Miller , 536 S.W.3d at 512

. Likewise, w e review a trial court ’s determination that

an expert is qua lifi ed un d er an abuse of di scretion standard. Rosemond v. Al

- Lahi q , 362 S.W.3d 830, 833 (Te x. App.

— Houston [14th Dist.] 2012, pet. den ied ) ; see Larson v. Downing , 197 S.W .3d 303, 304

– 05 (Tex. 2006) (per curiam)

. A cour t abuses its disc retion i f it acts in an arbitr a r y or unre asonabl e manner and without reference to any guiding rules or prin ciples. Crawford v. X TO Energ y, Inc. , 509 S.W.3d 906 , 911 (Tex. 2017). C. D R . O DILI ’ S A PPEAL 1
. Dr. Sri nivasan ’ s Origi nal Ex pert Repo rt
In his first issue , Dr. Odili a rgues tha t Dr. Sr i nivasan ’ s original report was not an “ expe rt report ” as required by the TMLA. Specifica lly , Dr. O dili argues that Dr. Srinivas an was not qualified to opin e on the re levant stan dard of care and that the original report did not set out the standard o f care , the breac h of the standard of8

care , or ca u sation . As a result , Dr. Odili argues, Dr. Sr inivasan ’ s original report

was “ no report ”

—

i.e., not a deficient re por t

— and Wh ite failed to comply with the sta tutory requirement that an expert

- report be ser ve d on the medical d efendant within 120 days of their answer
. 2 See Tex. Civ. Prac. & Rem . Code Ann. § 74.351 (a), (b)(2). Thus, Dr. O dili argues, the tria l court w as required to dismiss White ’ s claims for failure to comply with the TMLA ’ s expert

- repo rt requir e me nt

. See Tex. Ci v. Prac. & Rem. Code Ann. § 74.35 1 ( a) , (b ) (2 ), (r)(6 ) ; see also CHCA Clear Lak e, L.P . v . Stewart , No. 01

- 19

- 00874

- CV, 2021 WL 3412461, at *13 (Tex. App.

— H ouston [1st Dist.] Aug. 5, 2021, no pet. ) (mem . op. ) ( “ An e xp ert report by a perso n not qualified to testify does not constitute a go od

- faith effort to c omply with the TMLA ’ s definition of an expert report and warrants dismiss al. ” )

. A n expert report must at a minimum (1) be timely served, (2) contain the opinion o f a qu alified expert, and (3) implicate th e defendant ’ s conduct. S cores b y , 346 S.W.3d at 557. Here, Dr. Odili filed his answe r to White ’ s suit on March 12, 2019 , and White timely served Dr. Srin i vsan ’ s original expert re port on Dr. Odili within 120 days of Dr . Odili ’ s answer o n Mar ch 21, 2019

. H owever, Dr. Odili

a rgues that Dr. Srinivisan , an orthopedic surgeon, was not qualified to opine on the standard of care owed by Dr. Odil i, an emergency room physician

. See id.
In a health

- care liability suit, a pers on may q u alif y as an e xper t witness on the issue of whether the physician departed from the accept ed standards of medi cal care only if the person is a physician who : (1) is practicin g medi cine at the time testimony was given or when the cla im arose; (2) ha s knowle d ge o f the accepte d standards of medical care for t he d iagnosis , care, or treatment of the il lness, injury,

or condition in volved in the claim; and (3) is qualified on the ba sis of training or

2 Dr. Odili filed his answer to White ’s suit on Marc h 12, 2019. White served app ellants w ith Dr. Sr i nivasan ’ s amen ded expert report over 120 days later on O c t ober 22, 2019

. S ee Tex. Civ. Prac. & Rem . Code Ann. § 74.351(a), (b)(2).9

expe rience to offer a n expe rt opinion regardi ng those a ccepted s tand ards of medic al care. R osemond , 362 S.W.3d at 834 (citing Tex. Civ. Prac. & Rem. Code Ann. § § 74.401(a), 74.351(r )(5)(A) )

. Dr. Odili contends that Dr. Srinivasan is not qualified to render an expert opinion regarding the claims against Dr. Odi li becau s e Dr . Sriniva san was not actively p racticin g emerg ency medic ine at the time the

c laim aro se or at the time of hi s r e port.

“ T o cla rify the required qualifications, an expert must show the ‘ accepted standards of medical care for the diagnosis, care , or tre a tmen t of the i lln ess, injury,

or condition involve d in the claim. ’ ” Mem ’l Hermann Health S y s. v. Heinzen , 584 S.W.3d 902, 916 (Tex. App.

— Houston [14th Dist.] 2019, no pet.) (quoting Tex. Civ. Prac

. & Rem. Code Ann. § 74.401(a) (2) ) (emphasis in ori ginal)

. “ By i ts plain l ang uage, the statute does not focus o n the defendant docto r ’ s area of expertise , but on the condition involved in the claim. ” Id. ; see Blan v. Ali , 7 S.W.3d 74 1, 746 (Tex. App.

— Houston [14th Dist.] 1999, no pet. )

. The “ illness, injur y , or co n diti on ” involved in Wh ite ’ s claim is an open intra

- articular distal p halanx fr acture with extension in t o the prox i mal phalanx of the thumb

. Thus, to offer an exper t opinion, Dr. Srinivasan must b e qualifie d on the basis of training and experienc e to offer an e xpe rt opinion regarding the accep ted standards of medic al care and diagnosis , care , or treatment of an open intra

- articular distal phalanx fr acture with extens ion in t o the prox i mal phalanx of the thumb

. See Tex. Civ. Prac

. & Rem. Code Ann. § 7 4.401(a) (2) ; Hei nzen , 584 S.W.3d at 916

– 17. And t o determine whether Dr. Srinivasan is q ualified on the basis of training or exp erience to offer an expert opinion on the st andards of care for the diagnosis, care, o r t reatment of White ’ s injury , t he trial c ourt was requ ire d to considered whether, at the t ime the claim a rose or at the time he author ed the report , Dr. Srinivasan had substantial training and experience in “ an ar ea of10

medical practice relevant to the claim ” and was ac tively practi cing medicine i n rende ring m edi cal services “ rele v ant to the cla im. ” Dr. Srinivasa n is a board

- c erti fied orthopedic surgeon , and Dr. Odili does not dispute that Dr . Srinivasan is qualified to address the accepted standards of medical care for the diagnosis , care, and t r eatment , of t he i njury suffered by White ; instead , Dr. Odi li conten ds that Dr. Srinivasan failed to show any experience, training, or ed ucation in emergency medicine. Dr. Sriniva san ’ s original expert report did not pro vi de any c omme n tary on his qu ali ficat ions, but his attached C V provided that : (1) h e has been working for the preceding seven years as a staff hand, upper extremi ty, and microvascular surgeon and as the associate fel lowship director for the hand and up per extre mity fell o wship at The H a nd Cent er of San An t onio ; (2) before his mos t recent employment, he taught for six years at the Department of Orthopedic Surgery at the University of Texas in San Antonio; (3) he is boar d certified by the American Board of Orthopedic Sur ger y and has Hand Cer tific ate of Added Qualification ; and (4) h e complet ed hi s medical residency in ortho pedic surgery followed by a hand, upper extremity, and mi crovascular surgery fellowship

. See Me m ’ l Hermann He althcare S

ys. v . Burrell , 230 S.W

. 3d 755, 75 8 (Tex. App.

— Houston [14 th Dist.] 200 7, no pet.) ( “ [O ]ur a nalysis of the qualifications of an expert report under section 74.351 is limited to the four corners of the expert ’ s report and curr icul um vitae. ” ). Given Dr . Srinivasan ’ s CV , we cannot c onclude that the trial court abuse d its discret ion in fi nding Dr. Sr inivasan qualified to render an expert opinion concerning White ’ s claims again st Dr. Odili. See Tex. Civ. Prac

. & Rem. Code Ann. § 74 .401(a) (2) ; Heinzen , 584 S.W.3d at 916

– 17 (concluding t hat board certifi ed ophthalmologis t was qua lifi ed to render an exper t opinion c oncerning11

emergency room ph ysician ’ s treatment of acute angle

- cl osu re glaucoma ) ; see also Robert s v. Will iamson , 111 S .W.3 d 113, 121

– 22 (Tex. 200 3) ( concluding that pediatri cia n had e xperience a nd experti se rega rding the spe cific causes and effe cts of plaintiff ’ s injuries and could therefore provide expert testimony in suit against

neuro logist )

. Fu rthermore, we conclude that Dr. Sriniva san ’ s original expert report implicate d Dr. Odili ’ s conduct

. See Scoresby , 346 S.W.3d at 55 7 . Speci fically, Dr. Srinivasan ’ s original expert report provided tha t “ Whit e was see n in the Emergency Department a t North Cypress Medica l Records [sic] ” and “ was
e va luated by Dr. Odil i, ” a nd the report is d i rected at the “ in itial care ” White received at the Ho spital

. Thus, we conclude that Dr. Srinivasan ’ s original report

was an expert report under the TMLA

. See i d.
To the exten t that Dr. Odili a rgues that inadequacies in the standard of care, breac h of the s tandard of care, and causation in the original expert repor t rendered it “ no report , ” we note that these objections go to the adequacy of an expert r eport under the statute. See Ogletr ee v . Ma tthews , 26 2 S.W.3d 316, 32 2 (Tex. 2007 ). Here, Dr. Sri n ivas an ’ s original report was timely served, contained th e opini on s of a quali fied expert, and implicated Dr. Odili ’s conduct. See Scoresby , 346 S.W.3d at 557

. Thus, we reject Dr . Odili ’s argumen t t hat the ori ginal report was not a report under the TMLA an d overrule his fir st issue. 2. Opportunity to Amend Dr. Sriniv asan ’ s Original Expert Report
In its second issue, Dr. Odili argues that the trial c ou r t a bused its disc retion when it granted White an extensio n to cure any deficiencies in Dr. Srinivasan ’ s
o riginal ex pert re port. See Tex. Civ . Prac. & Rem. Code A nn. § 7 4. 351( c).
T he TMLA does not require dismissal of deficient but curable reports. Ogletr ee , 26 2 S.W.3d at 32 0

. “ [A] 30

- day ex tension to cure defic iencies in an expert report may be granted if t h e report is serve d by the statutory d eadlin e, if it12

cont ains th e opinion of an individual with expertise that the claim has meri t, and if the defendan t ’ s conduct is implicated. ” Scoresby , 346 S.W.3 d at 557 ; s ee Tex. Civ. Prac. & Rem . Code Ann. § 74.351 (c)

. Furthermore , the decision to grant a thirt y day extensi on is n ot appealable. Og letree , 2 62 S .W.3d at 319 ; see Tex. Civ. P rac. & Re m. Code Ann. § 51.014(a)( 9) (providing that an app eal may not be t aken from

a n order granting an ex tension under § 74.351 )

. T herefore, we c onc lude that we lack jurisdic tion to revie w the t rial cour t ’ s order granting White thir t y days t o
a mend any deficienc ies in Dr. Srinivasan ’ s original expert repot. We overrule Dr. Odi li ’ s second issue. 3. Dr. Sriniv asan ’ s Amended E xpert Re p ort In his third issue, D r. Odili argues t hat the trial court a bused i ts discretion when it d enied his motion to dismiss Whi te ’ s lawsuit following Dr. Sr iniv asan ’ s amended e xpert report because th e amended r eport fails to me et the stat utory requ irements. 3 S p ecifically, Dr . Odili argues the trial c ourt should h a ve gra nted his motion because the amended expert report fails to establish causation. D r. Odili concedes that the amended report prov ides t h e applicabl e standard of care and the breach of that stand a

rd of care.

a. Proximate Causation
The causal re lationship requir ed in a healthcare

- liability claim is proximate

caus ation

. See Tex. Civ. Prac. & Rem. Code Ann. § 74.001 (a)(13) (defi n ing “healt h care liability claim ” a s a cause of action fo r physician ’s or h ealthcare provider ’s breach of the standard of care “ whi ch proximat ely results in injury to or death of a claimant ”). Proximate cause has two components: (1) foreseeability and

3 Dr. Odili also argues that his motion to dismiss based on the amended report should have bee n granted be cause Dr. Srinivasan was not qualif i ed to opine on the s tandard of care and b reach of the st andard of car e . B ecause w e have previously concluded that the trial cour t did not abuse it s discretion in finding Dr. Sri nivasan qualified , we reject th is argumen t

.13

(2) cause
- in

- f

act. Id. Accordingly, an exper t report under th e TMLA must e xplai n both foreseeability and cause

- in

- fact. Se e M iller , 536 S.W.3d at 515 (citing Zam arripa , 526 S.W.3d at 460 ). A healthcare provider ’ s brea ch was a foreseeable cause of the plaintif

f ’ s injury if a healthcare provider of ordina ry intelligen c e would have anti cipated the danger caused by the negligent act or omissi on. See Price v. Divita , 2 24 S.W.3d 331, 336 (Tex. App.

— Houston [1st Dist.] 2006, pet. denied) ( citing Doe v. Boys Clubs of Greater Dal l. , Inc. , 907 S.W.2d 472, 478 (Tex . 199 5)). For a ne gligent act o r omission to have been a cause

- i n
- fact of the harm, t he act or omission must have been a substantial factor in bringing a bout the harm, a nd absent the act or omission

— i .e., but fo r the act o r omission

— the harm would not have occurred. Za m arripa , 526 S.W.3 d at 460. Although the report need not use “pr oximate ca u se, ” “foreseeability, ” or “cause in fact ” to satisfy the TMLA ’ s requirem ents and show how and why a breach of the standa rd of care cau sed injury, the expert re port m ust make a good

f aith effort t o e x plain, factually, how proximate c ause will be proven. Id

. Without factual explanations, a report amount s to “nothing more than the ipse dixit of the experts ” and is “clearly insuff icient.” Id

. at 461 ; see , e.g. , Jelin ek , 328 S.W.3d at 540

. An expert report may not have an analytical gap or missing lin k between the expert ’ s allegation that the healthcare provider defendant breached the s tandard of care and the plaintiff ’ s injuries. S ee Wri ght , 79 S.W .3d at 53 ; see, e. g. , H umble Surgi cal Hosp. , L

LC v. Davis , 5 42 S.W.3d 1 2, 23

– 26 (Tex. Ap p.

— Houston [14 th Dist.] 201 7, pet . denied) ( c o ncluding that expert ’ s “ o pi nion on causation contains analytical gaps and missing links which render his opinion c onclu sory ” )

. To determine whether the expert ’ s ca u sati on conclusion is detailed enough, we re ad the expert ’ s c onc lusion on causation in the c ontext of the entire report, not piecem eal or in a vacuum
. Harvey v. Kindred Health care O perating, Inc. , 5 7814

S.W.3d 6 38, 653 (Tex. App.

— Housto n [14th Dist.] 2019, n o pet.). Here, Dr

. Srinivasan stated in his amended report t hat he revie w ed D r. Odili ’ s preoperative notes and t he ope rative and postoperative reports by Mar k Ciagla, M.D., from the surgery perform e d on White ’ s hand

. He f urther state d: On March [ ] 11 [,] 2017, Mr. Randy White was seen in the Emergency departm ent at N orth Cypress . According to the medical records, he was e valuated by Dr. Uzochukw u [Odili] , an Eme rgency Medicine Physician. Ph ysical e xam ination was not able for 6cm skin laceration, no r mal function ing t endo ns, normal v ascularity and x - rays indicati ve of a n open intra

- articular di stal phalanx f racture with extension into the proximal phalanx of the thumb. Medical records state tha t Dr. [Odil i] treated Mr. White ’ s injuries with irrigation , s uturing [,] and scheduled fol low

- up with Dr. T anous (an orthop edic s u r geon) on Mon day, 3/ 1 3/2017

. M r
. White saw Dr

. Ciagla ( an Orthopedic surgeon ) on 3 / 13 / 2017 who recommended surgery including OR IF

. Surgery was performed March 16 , 2017 ( 5 days after in i tial in jury )

. Int r aoperative fi ndings were notable for copious p us whi ch caused Dr

. Ciagla to abort the case after i ncision and drainage

. Picc line was place d and IV antibiotics were started

. On 3 / 3 0 / 2017 , rep eat l + D was per formed by Dr

. Ciagla

. Minimal p u rulence was noted but no fixati on was placed

. On 4 / 2 / 2017 , Dr

. C iagla performed the 3 rd incision and drainage without fixation placed

. On 4 / 17 / 2017 , Dr

. Cia gla saw Mr

. White , 18 days postop

. Plan w as for CT s can at 8 weeks postop

. No other relevant record s are a vailable fo r my review s uch as copy of xrays or CT scan o r OT n o tes indicatin g the patient ' s final range of motion , stability , or strength

. However , h e did receive an impairment rating of 9 %

. The stand ard of care in an ER setting for an injury such as Mr

. White ' s (g r ade 2 open i ntraarticular thumb fracture invo lving t he distal and proximal phalanx) is immediate consultation with a hand

- fellowship train ed surgeon

. There was a breach in the sta ndard of ca re by Dr

. [Odil i] for not immediately consultin g a hand

- fellowshi p trained15

sur geon o r North Cypress for not hav ing ha n d [

- ] fellowshi p trained surgeo ns ava ilable to Dr. [Odili] for cons ultation. Open fractu res of this type are taken to the operati ng room wit hin 24 hours of initial evaluation for treatmen t to avoid risk of infection and subsequent nonunion , malunion , hardwa r e failure , st iffness pain , arthritis , and loss of strength

. Alternatively , if the woun d is grossly clean and irrigated with 1L of Norm al S aline it can be referred in delayed fashi on to a hand fellowship t rained surgeon after consultation

. [] The medi cal re a sons I have r eviewed do not indicate a medical reason that Mr

. White ’ s case could not have been reviewed with a hand fellowship traine d su rgeon
. Instead , Mr

. White was referred to a non hand fellowship

- t r ained surgeon
. In all medical probability , Mr

. Whit e would not ha ve ended up with an infection and subsequent impairment if Dr

. [Odili] ha d obtained a grossly clea n wound or provi ded imm edia te referral for surgery to a hand

fellowship tr a ined surgeon
. Concerning foreseeability, Dr. Srin i vasan ’ s report prov ides that pa t ients with White ’ s injury are taken to the operating room within twe n ty

- four ho urs of initial evaluati on for trea tment to avoid inf ection and other complication s
. See Abshire , 56 3 S.W. 3d at 223

– 25 ; Miller , 536 S.W.3d at 515. A s to cause

- in

- fac t , Dr. Sriniv asan opined that White would not have ended up with an i nfection and subsequent impair ment if White ha d been imme diate ly referr ed for sur gery to a hand

- fello wsh i p trained surge on
. See Zamarripa , 526 S.W.3d at 460

. Dr. Srini vasan ’ s am ended repo rt provides h ow and why the alleged negligence

—

i.e., Dr. Odili ’ s failure to immediately refer White for sur gery to a han d

- fell owship trained surgeon

— ca used White ’ s complain e d of inj ury
. See A b shire , 563 S.W

. 3d at 223

– 25 ; Zamarripa , 526 S.W.3d at 460

. Dr. S rinivasan ’ s
r eport ex plains the basis of his conclusion , li nks his conclusion to the facts , and provides eno ugh inf

ormation t o inform Dr. Odili of the specific conduct White has called into q u estion and for the t rial court to conclude t hat the claims have merit. See Ab shire , 563 S.W.3d at 223

– 25 ; Bowi e Mem ’l Hosp. , 79 S.W .3d at 52 ;16

Palacios , 46 S .W.3d at 897

. After rev iewing Dr. Srinivasan ’ s amended report , we conclude that t h e tr i al co urt cou l d have reasonably dete rmine d that the amende d expert report repr esent ed a goo d

- faith effort to summarize th e causal relati onship between Dr. Odi li ’ s failure to meet the applicabl e standard o f care and White ’ s injury. See Abshire , 563 S.W

. 3d at 223

– 25 ; Har v ey , 578 S.W.3d at 653

– 54; see als o Gonz alez v. Padilla , 485 S.W. 3d 236, 252

– 5 3 (Tex. App.

— El Paso 2016 , no pet.) (holding expert report w as adequate when e xpert opined that “ the f ailure to timely e stablish an appropriate treatment plan w h ich provided for i nfection prevention ” cause d patient to devel op infection resulti n g in amputat ion of his leg )

. We over rul e Dr. Odili ’s thir d issue.
D. T HE H OSPITAL ’ S A PPEAL In its first issue, the Hosp it al argues that the trial court abused its discr e tion in denying i t s objections to Dr. Srinivasan ’ s amended exp ert report and its mo tion to dismi ss . Spe cifically, the Ho spital a rgues that the amended report failed to address the sta ndard of care , breac h o f standard of care , and causation regarding White ’ s direct liabilit y claims against t he Hos pital

. Her e, White assert ed direct and v icarious liab ility claims against the Hospit al. We note th at t he TMLA does not re quire an e xpert report as to ea ch liabil ity the ory alleged against the defendant

. See , e.g. , TTHR Lt d. P ’ ship , 401 S.W.3d at 44 ( “ [B]ecause the trial court d id not abuse its d iscretion in f inding Moreno ’ s reports adeq uate as t o he r theory that [the hospital ] is vi cariously liable fo r th e doctor ’ s actions, her suit against [the hospita l ]

— including her c la ims that the hospital has direct liabil ity and vicarious liability for acti o ns of the nu r ses

— may proceed. ” ); Certifie d EMS, Inc. , 392 S .W.3d at 632 ( “ [W]hen a healthcare liability claim i nvolves a vicarious liability theory, either alon e or in combinatio n with othe r theories, an expert rep ort t hat meets the statutory standards a s to the17

emplo yee is sufficient to implicat e th e employer ’ s conduct under the vicarious theory. And if any liabil ity theor y has been adequately covered, t he entir e case may proceed

. ” )

. F o r vicarious liability claims , a r eport tha t adequately implica tes the

a ctions of th at party ’ s agents or em ployees is suf ficient. See Gardner v. U .S. Imaging, Inc. , 274 S.W.3d 6 69, 671

– 7 2 (Tex. 2 008) ( per curiam ) ; see also Methodist Hosp. v. Addison , 574 S.W.3d 49 0, 502 (T ex. App.

— Houston [14th Dist.] 2018, no p e t. ) ( “ Because we ha ve dete rm ined that Dr. Cohen ’ s report

a dequatel y addressed o ne theory of liability against Meth odist, we need not address Methodist ’ s remaining argum ents

. . . that the trial cou rt abused its disc retion when it denied Metho dist ’ s motion to dismiss. ” ) ; Ho us . Metho dist Hosp. v. Nguyen , 470 S.W .3d 127, 130 (Tex. App.

— Houston [14th Dist.] 2015, pet

. denied) (concluding that expert report containing expert opinion as to claims against defend ant physicians implicated the Hospital ’ s conduct und e r plai ntiff ’ s ple ad ed theo ry of v ica rious liability ) ; McAllen Hosps. , L .P. v. Gonzalez , 566 S.W.3 d 451, 458 (Tex. App.

— Corpus Christi

– Edinburg 2018, no pet .) ( “ When a health care liability claim involves a vicarious liability theory , either alon e or in

c o m bination wi th oth er theor i es, and there is an expert report suffici ent to support tha t vicarious liability theory, the e ntire case may proceed past a motion to dismiss based on the expert report rul e
. ” )

. As previously concl uded, Dr. Srinivasan ’ s amended r e port adequate ly i mp licate s t he actions of Dr. Odili, a physici an at the Hospital. Therefore, we c annot conclude that the trial court abused its discretion when it d enied the Hospital ’ s motion to dismiss. 4 See TTHR Ltd. P ’ ship , 401 S.W.3d at 44 ; Certified E MS, Inc. , 392 S .W .3 d at 6 3 2

. B ecaus e we conclude that the trial cour t did not err when it denied the H ospital ’ s motion to dismiss, we need not address its argument regarding its

4 At oral argument before this co u rt, the Hospital c on ceded that if the ame nded report was sufficient a s to Dr. Odili, then it w as sufficient as to the Hospit al.18

objections or its secon d issue

. See Tex. R. App. 47. 1. We overrule the Hosp i tal ’ s t wo iss ues. III. C ONCLUSI ON Having ove rruled all of the issues on appeal, we a ffirm t he trial cour t ’s order

.

/s/ Margar et “ Meg ” Poi ssan t J ustic e
Pa nel consi sts of Chief J ustice Christ opher and Justices J e well a nd Pois sant.