# IN THE SUPREME COURT O F TEX AS

4 4 4 4 4 4 4 4 4 4 4 4 

## N O



## . 15-0909

4 4 4 4 4 4 4 4 4 4 4 4


# C O L U M B IA 

# V A L L E Y 

# H E A L T H C A R E 

# S Y S T E M 

# , L

. P

. D 

# / B 

# / A 

# V A L L E Y 

# R E G IO N A L 

# M E D IC A L 

# C E N T E R 

# , P E T IT IO N E R 

# ,

v
. 

# M A R IA 

# Z A M A R R IP A 

# , A S 

# G U A R D IA N O F T H E 

# E S T A T E S O F 

# R

. F

. R

. A N D 

# R

. J

. R

. , M IN O R S 

# , R E S P O N D E N T

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4



## O N 

## P E T I T I O N F O R 

## R E V I E W F R O M T H E 

## C O U R T O F 

## A P P E A L S F O R T H E 

## T H I R T E E N T H 

## D I S T R I C T O F 

## T E X A S



### 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4



## Argued Mar ch 21, 2017

C H I E F 

## J U S T I C E 

## H E C H T 

## delivere d the opinion of the Court.

This is a health car e liability claim for the tragic d ea th of Yolanda I ris Flore s. The Texas
Medica l L iability Act (“the Act”) imposes a threshold require ment that t h e plaintiff furnish what 1



## we have descr ibed as “a st at em en t o f o p inion by an individual with expertise indicating that the
claim asser

ted

. . . has merit.” This expert repor t must addre ss, in part, “the causa l rela tionship” 2

T E X

. C IV

. P R A C

. & R E M

. C O D E § § 7 4

. 0 0 1

– . 5 0 7

. 1

S c o r e s b y v

. S a n t i l l a n , 3 4 6 S

. W

. 3 d 5 4 6 , 5 4 9 ( T e x
. 2 0 1 1 ) ; s e e T E X

. C IV

. P R A C

. & R E M

. C O D E § 7 4

. 3 5 1

. 2

## betwee n a health car e provider’ s failure to meet applicable standards of car e and the claimed injury

. 3



## The plainti ff h ere arg ues, and the court of appeals agr eed, that “an expert repor t is not require d to
addre ss ‘proximate cause ’”. We disag ree and co n c lu d e that the plaintiff’s expert repor ts do not show 4


## how the defe ndants befor e us cause d Flore s’s death. Acc ording ly , we reve rse the court of appea ls’ judgme nt and re mand the ca se to the trial cour t for fur ther proc eeding s.
I 5


## Flore s, 36, preg nant with her third child and midway throug h the third trimester, was taken by ambul an ce to the Valley Reg ional Medica l Center (“V alley Reg ional”) labor and delivery 6



## emer g ency room in Br ownsv i l l e, T ex as , ear ly on a Tuesday morning

. She had been vom iting and

was experiencing feve r, abdominal pain, and mild contra ctions. Dr. Patrick Ellis saw her and order ed

a pain relieve r, intravenous antibiotics, a sonog ram, and an MRI , as well as a biophy sical profile to

test t h e h ea lth of her baby

. The sonog ram was normal and the baby appea red to be healthy , but
Flore s’s contra ctions continued, and the MRI showed place nt a ac cre ta, an abnorma l place ntal
attachme nt to the uterine wall. Placenta acc reta is a serious condition that incre ases the risk of heavy

T E X

. C IV

. P R A C

. & R E M

. C O D E § 7 4

. 3 5 1 ( r ) ( 6 ) ( “ ‘ E x p e r t r e p o r t ’ m e a n s a w r i t t e n r e p o r t b y a n e x p e r t t h a t 3 p r o v i d e s a f

a i r s u m m a r y o f

t h e e x p e r t ’ s o p i n i o n s a s o f t h e d a t e o f

t h e r e p o r t r e g a r d i n g a p p l i c a b l e s t a n d a r d s o f c a r e , t h e m a n n e r i n w h i c h t h e c a r e r e n d e r e d b y t h e p h y s i c i a n o r h e a l t h c a r e p r o v i d e r f a i l e d t o m e e t t h e s t a n d a r d s , a n d t h e c a u s a l
r e l a t i o n s h i p b e t w e e n t h a t f a i l u r e a n d t h e i n

j u r y , h a r m , o r d a m a g e s c l a i m e d

. ” )

.

_ _ _ S

. W

. 3 d

_ _ _ ,

_ _ _ ( T e x
. A p p
. — C o r p u s C h r i s t i

- E d i n b u r g 2 0 1 5 ) ( m e m
. o p
. )

. 4

T h i s f a c t u a l b a c k g r o u n d i s t a k e n f r o m t h e p l a i n t i f

f ’ s p l e a d i n g s a n d e x p e r t r e p o r t s
. 5

V a l l e y R e g i o n a l i s o w n e d b y p e t i t i o n e r C o l u m b i a V a l l e y H e a l t h c a r e S y s t e m , L

. P

. , a n d i s a n H C A H e a l t h c a r e 6

a f f i l i a t e
. W e u s e “ V a l l e y R e g i o n a l ” b o t h t o r e f e r t o t h e h o s p i t a l a n d t o i d e n t i f y p e t i t i o n e r
. 

### 2

## bleeding during delivery

. The MRI did not show a place ntal abruption—a detac hment o f t he 7 

## place nta fro m t h e uterus which can deprive the baby of ox y g en and nutrients and cause heavy bleeding in the mother. 8

A n u l t r a s o u n d s e v e r a l w e e k s e a r l i e r , w h e n F l o r e s h a d g o n e t o t h e e m e r g e n c y r o o m f o l l o w i n g a n a u t o m o b i l e 7

a c c i d e n t , s h o w e d a c o m p l e t e p l a c e n t a p r e v i a
. A c c o r d i n g t o t h e M a y o C l i n i c w e b s i t e :

T h e p l a c e n t a i s a s t r u c t u r e t h a t d e v e l o p s i n s i d e y o u r u t e r u s d u r i n g p r e g n a n c y , p r o v i d i n g o x y g e n a n d
n u t r i t i o n t o a n d r e m o v i n g w a s t e s f r o m y o u r b a b y
. T h e p l a c e n t a c o n n e c t s t o y o u r b a b y t h r o u g h t h e u m b i l i c a l c o r d

. I n m o s t p r e g n a n c i e s , t h e p l a c e n t a a t t a c h e s a t t h e t o p o r s i d e o f t h e u t e r u s
. P l a c e n t a p r e v i a
. . . o c c u r s w h e n a b a b y ’ s p l a c e n t a p a r t i a l l y o r t o t a l l y c o v e r s t h e m o t h e r ’ s c e r v i x

— t h e o u t l e t f o r t h e u t e r u s
. P l a c e n t a p r e v i a c a n c a u s e s e v e r e b l e e d i n g d u r i n g p r e g n a n c y a n d d e l i v e r y
.
P l a c e n t a p r e v i a , O v e r v i e w , M A Y O C L IN IC ( M a y 1 7 , 2 0 1 7 ) , h t t p : / / w w w
. m a y o c l i n i c
. o r g / d i s e a s e s - c o n d i t i o n s / p l a c e n t a p r e v i a / h o m e / o v c - 2 0 3 1 9 6 2 3 ( l a s t v i s i t e d J u n e 2 , 2 0 1 7 , c o p y i n c a s e f i l e )

.
P l a c e n t a a c c r e t a i s a s e r i o u s p r e g n a n c y c o n d i t i o n t h a t o c c u r s w h e n b l o o d v e s s e l s a n d o t h e r p a r t s o f t h e p l a c e n t a g r o w t o o d e e p l y i n t o t h e u t e r i n e w a l l

. T y p i c a l l y , t h e p l a c e n t a d e t a c h e s f r o m t h e u t e r i n e w a l l a f t e r c h i l d b i r t h

. W i t h p l a c e n t a a c c r e t a , p a r t o r a l l o f t h e p l a c e n t a r e m a i n s f i r m l y a t t a c h e d

. T h i s c a n c a u s e s e v e r e b l o o d l o s s a f t e r d e l i v e r y
. . . . P l a c e n t a a c c r e t a i s c o n s i d e r e d a h i g h

- r i s k p r e g n a n c y c o m p l i c a t i o n
. I f p l a c e n t a a c c r e t a i s s u s p e c t e d d u r i n g p r e g n a n c y , y o u ’ l l l i k e l y n e e d a n e a r l y C

- s e c t i o n d e l i v e r y f

o l l o w e d b y t h e s u r g i c a l r e m o v a l o f y o u r u t e r u s ( h y s t e r e c t o m y )

.
P l a c e n t a A c c r e t a , D e

f i n i t i o n , M A Y O C L IN IC ( M a r
. 2 8 , 2 0 1 5 ) , h t t p : / / w w w
. m a y o c l i n i c
. o r g / d i s e a s e s - c o n d i t i o n s / p l a c e n t a a c c r e t a / b a s i c s / d e f

i n i t i o n / c o n - 2 0 0 3 5 4 3 7 ( l a s t v i s i t e d J u n e 2 , 2 0 1 7 , c o p y i n c a s e f i l e )

. R i s k f

a c t o r s i n c l u d e p r i o r c e s a r e a n s e c t i o n s , a p l a c e n t a p a r t i a l l y o r t o t a l l y c o v e r i n g t h e c e r v i x ( p l a c e n t a p r e v i a ) , m a t e r n a l a g e , a n d p r i o r c h i l d b i r t h

. P l a c e n t a A c c r e t a , R i s k F a c t o r s , M A Y O C L IN IC ( M a r
. 2 8 , 2 0 1 5 ) , h t t p : / / w w w
. m a y o c l i n i c
. o r g / d i s e a s e s - c o n d i t i o n s / p l a c e n t a - a c c r e t a / b a s i c s / r i s k

- f

a c t o r s / c o n - 2 0 0 3 5 4 3 7 ( l a s t v i s i t e d J u n e 2 , 2 0 1 7 , c o p y i n c a s e f i l e )

.
A g a i n , a c c o r d i n g t o t h e M a y o C l i n i c w e b s i t e : 8

P l a c e n t a l a b r u p t i o n ( a b r u p t i o p l a c e n t a e ) i s a n u n c o m m o n y e t s e r i o u s c o m p l i c a t i o n o f p r e g n a n c y
. T h e p l a c e n t a i s a s t r u c t u r e t h a t d e v e l o p s i n t h e u t e r u s d u r i n g p r e g n a n c y t o n o u r i s h t h e g r o w i n g b a b y
. I f t h e p l a c e n t a p e e l s a w a y f

r o m t h e i n n e r w a l l o f t h e u t e r u s b e f o r e d e l i v e r y

— e i t h e r p a r t i a l l y o r c o m p l e t e l y

— i t ’ s k n o w n a s p l a c e n t a l a b r u p t i o n
. P l a c e n t a l a b r u p t i o n c a n d e p r i v e t h e b a b y o f o x y g e n a n d n u t r i e n t s a n d c a u s e h e a v y b l e e d i n g i n t h e m o t h e r
. P l a c e n t a l a b r u p t i o n o f t e n h a p p e n s s u d d e n l y
. L e f t u n t r e a t e d , p l a c e n t a l a b r u p t i o n p u t s b o t h m o t h e r a n d b a b y i n j e o p a r d y
.
P l a c e n t a l A b r u

p t i o n , D e

f i n i t i o n , M A Y O C L IN IC ( D e c
. 1 3 , 2 0 1 4 ) , h t t p : / / w w w
. m a y o c l i n i c
. o r g / d i s e a s e s - c o n d i t i o n s / p l a c e n t a l

- a b r u p t i o n / b a s i c s / d e f i n i t i o n / c o n - 2 0 0 2 4 2 9 2 ( l a s t v i s i t e d J u n e 2 , 2 0 1 7 , c o p y i n c a s e f i l e )

. 

### 3

## Midmorning, Dr. Ellis order ed Flore s transfe rre d to the Corpus Christi Medica l Center - Ba y
Are a (“B ay Ar ea ”) 1 59 miles awa y
. The rea son, acc ording to medical rec ords, was a “medica l 9



## nece ssity upg rade in car e,” though there was no emer g ency
. Dr. Whit ney Gonsoulin, a Ba y Are a phy s i cian, ag ree d to acc ept the transfe r. A Hidalg o County Emerg ency Medica l Service (“EMS”)
ambulance left Valley Reg ional with Flore s at 1:22 p.m. Flore s was diaphore tic and felt “pre ssure” pain in her abdomen. Midway throug h the trip, she beg an to bleed and beca me anxious and restless,

an d wh en EMS would not stop for ice or to open the vehicle doors, she beca me extremely
combative. An EMS medic called Ba y Are a for permission to divert to another fac ility so that Flore s
could be evalua ted but was instructed to continue on. When the ambulance beca me stuck in a sever e
traff ic jam, Flore s beg an scre aming to g et to the hospit al, then collapsed onto her side in car diac

arr est. She was pulseless and apneic , and the medics beg an car diopulmonary resusc itation. Shortly
afte r 4:00 p.m., the ambulance arr ived at Ba y Are a. An emer g ency cesa rian section and hy sterec tomy

wer e immediately perf

ormed, and Flore s was stable at first. But trag ically , she died at 11:02 p.m. Her baby g irl was stillborn.
Maria Z amar

ripa, g uardia

n o f Flore s’s two minor children, sued Ellis, Gonsoulin, Valley Reg ional, Ba

y Are a, EMS, and others

. A g a in s t V a ll e y Re g ional, Z amar ripa alleg es that its “[n] urses 10


## allowed [Flores] to be discharg ed

. . . when she was not suitable for discharg e”, and that “[p] ersonne l

. . . allowed a g round ambulance transfer

. . . when [ Flore s] s h o u l d n o t h av e b een transfe rre d”, as

B a y A r e a i s o w n e d b y t h e B a y A r e a H e a l t h c a r e G r o u p , L t d

. , a n d i s a l s o a n a f f i l i a t e o f H C A H e a l t h c a r e
. 9

R e y n a l d o R a m i r e z i n i t i a l l y f i l e d s u i t o n b e h a l f o f F l o r e s a n d h e r m i n o r c h i l d r e n a n d Z a m a r r i p a l a t e r 10 i n t e r v e n e d

. W e u s e “ Z a m a r r i p a ” t o r e f e r t o l e g a l a c t i o n s t a k e n b y b o t h Z a m a r r i p a h e r s e l f a n d R a m i r e z i n t h e t r i a l c o u r t

.



### 4

## well as “[o] ther acts/omissions of neg lige nce” unspecifie d. To satisfy the Act’s expert-re p ort

require ment, Z amar

ripa timely serve d on Valley Reg ional two repor ts, one by Gra ce Spears, a nurse
with experience in the labor and delivery setting as well as the emer g ency room, and the other by Dr.

Fr eder ick Har lass, an obstetricia n/gy necolog ist.
An expert repor

t require d by the Act must addre ss the applicable standards of car e, the failure
of a health car e provider to meet them, and the causa l rela tionship betwee n that failure and the injury , harm, or damag es claimed. We f ocus here on Valley

Reg ional’s ar g ument that the expert repor ts 1 1


## do not a dequate ly show causa tion. Spea rs’s repor t sta ted that Valley Reg ional nurses brea ched the
standard of

car e:

• “by

not advoca ting f

or”:

• “additional trea tment of [preterm labor] when [Flores’s] co ntrac tions

. . . continued . . .”;

• “fur

ther investig ation and tre atment of [Flore s’s] low fibrinoge n levels”;

• “fur

ther investig ation of [Flores’s] c ontinued abdominal pain/pre ssure with diag nosis of place nta ac cre ta”;

• “[Flores] t o re main at [Valley Reg ional] rathe r than permitting and fac ilitating her transfe r acr oss Texas to [Bay Are a] by g round ambulance ”; and

• “by allowing [Flores] to be transfe rre d to another fac ility many miles awa y while she [was] clea

rly in [ prete rm labor] . . .”.

T E X

. C IV

. P R A C

. & R E M

. C O D E § § 7 4

. 3 5 1 ( a ) ( r e q u i r i n g e x p e r t r e p o r t ) a n d ( r ) ( 6 ) ( d e f i n i n g e x p e r t r e p o r t )

. 11


### 5

## Spears’ s repor t did not, of course , addre ss how these brea ches cause d Flore s’s death beca use under the Act, only

phy sicians ca

n be experts on ca

usation. Har lass’s re port stated that

1 2


## due [t o] the breach es of car e by the [Valley Reg ional] personne l in permitting and fac ilitating the transfe r,
. . . Flore s was in a location (ambulanc e on the highw ay ) when and wher e timely emer g ent c-se ction and hy sterec tomy surg ery was not available when she beg an to bleed from the abrupte d place nta. Her bleeding cause d her car diovascular ar re s t d u e to lack of ox y g en car ried to the hear

t for sufficie nt pumping. This collapse led to DI C and her death. 1 3 

## Valley Reg ional objected to the repor ts and moved to dismiss , in part, on the g round that they

wer e insufficient to show how Valley Reg ional cause d Flore s’s death when it was Dr. Ellis, not the hospital, who order ed Flore s transfe rre d. The trial court overr uled Valley Reg ional’s objection and
denied its motion to dismiss

. Valley Reg ional appe aled the interlocutory order , and the court of

appea ls affirme d. 1 4 

## We gr anted Va lley

Reg ional’s petition for re view. 1 5

I d

. § 7 4

. 3 5 1 ( r ) ( 5 ) ( C ) ( r e q u i r i n g t h a t a n e x p e r t o n t h e c a u s a l r e l a t i o n s h i p b e t w e e n a b r e a c h o f t h e s t a n d a r d o f 12

c a r e a n d i n

j u r y b e a p h y s i c i a n )

.
A c c o r d i n g t o t h e M e r c k M a n u a l : “ D i s s e m i n a t e d i n t r a v a s c u l a r c o a g u l a t i o n i s a c o n d i t i o n i n w h i c h s m a l l b l o o d 13

c l o t s d e v e l o p t h r o u g h o u t t h e b l o o d s t r e a m , b l o c k i n g s m a l l b l o o d v e s s e l s
. T h e i n c r e a s e d c l o t t i n g d e p l e t e s t h e p l a t e l e t s a n d
c l o t t i n g f

a c t o r s n e e d e d t o c o n t r o l b l e e d i n g , c a u s i n g e x c e s s i v e b l e e d i n g
. ” J o e l L

. M o a k , D i s s e m i n a t e d I n t r a v a s c u l a r C o a g u l a t i o n , M E R C K M A N U A L C O N S U M E R V E R S IO N ( S e p t

. 2 0 1 6 ) , h t t p : / / w w w
. m e r c k m a n u a l s
. c o m / h o m e / b l o o d

- d i s o r d e r s / b l e e d i n g - d u e - t o - c l o t t i n g - d i s o r d e r s / d i s s e m i n a t e d

- i n t r a v a s c u l a r - c o a g u l a t i o n - d i c ( l a s t v i s i t e d J u n e 2 , 2 0 1 7 , c o p y i n c a s e f i l e )

.

_ _ _ S

. W

. 3 d

_ _ _ ,

_ _ _ ( T e x
. A p p
. — C o r p u s C h r i s t i

- E d i n b u r g 2 0 1 5 ) ( m e m
. o p
. )

. I n a s e p a r a t e a p p e a l , t h e c o u r t

14

o f a p p e a l s a f

f i r m e d t h e d i s m i s s a l o f Z a m a r r i p a ’ s c l a i m s a g a i n s t B a y A r e a a n d E M S , c o n c l u d i n g t h a t Z a m a r r i p a ’ s e x p e r t
r e p o r t s f a i l e d t o s h o w h o w t h e f a i l u r e t o d i v e r t a l o n g t h e w a y f r o m V a l l e y R e g i o n a l t o B a y A r e a c a u s e d F l o r e s ’ s d e a t h

. Z a m a r r i p a v

. B a y A r e a H e a l t h C a r e G r o u p , L t d

. , N o
. 1 3

- 1 5

- 0 0 0 2 4

- C V , 2 0 1 6 W L 6 9 6 2 0 0 9 ( T e x
. A p p
. — C o r p u s C h r i s t i

E d i n b u r g 2 0 1 6 , p e t

. d e n i e d [ 1 7

- 0 1 3 2 ] )

.

6 0 T e x
. S u p
. C t

. J

. 2 2 3 ( J a n
. 2 0 , 2 0 1 7 )

. 15


### 6

## II

After briefing was completed, and six day s befor e oral arg ument, Z amar ripa arg ued for the
first time that an interlocutory appea l is permitted from the denial of a motion to dismiss under the
Act only when an expert repor t is untimely , not when it is inadequa te. The arg ument g oes as follows:

• Section 51.014(a) (9), the in te r lo c u to r y a p p e al authority invoked by Valley Reg ional, allows 1 6 

## an appe al from a

n order deny ing r elief soug ht by

motion “under” Section 74.351(b). 1 7



## • Section 74.351(b) permits a motion to di smiss a health car e li ability claim when an ex pert repor t has not been se rved w ithin the prescr ibed per iod. 1 8



## • A motion under Section 74.351(b) is thus one that complains a report i s untimely , not that it is deficient.

• Even if defic ient, Z amar ripa’s reports qualified as ex pert reports because eac h “conta ins a statement of opinion by an individual with expertise indicating that the claim asser ted by the plaintiff ag ainst the defe ndant has mer it.” 1 9



## • Z amar

ripa’s e x pert re ports wer e unquestionably timely

.

• There fore , Section 51.014(a) (9) doe s not allow this int erloc utory appea l.

We reje cted this arg ument in Lewis v. Funderburk beca use Section 74.351(b) specific ally 2 0


## ref ere nces and must be rea d with the para g raph that follows it, Section 74.351(c) , which rec og nizes

T E X

. C IV

. P R A C

. & R E M

. C O D E § 5 1

. 0 1 4 ( a ) ( 9 ) ( “ A p e r s o n m a y a p p e a l f r o m a n i n t e r l o c u t o r y o r d e r [ t h a t ] d e n i e s 16

a l l o r p a r t o f t h e r e l i e f s o u g h t b y a m o t i o n u n d e r S e c t i o n 7 4

. 3 5 1 ( b )

. . . . ” )

.

I d

. § 7 4

. 3 5 1 ( b ) ( “ I f

, a s t o a d e f

e n d a n t

. . . h e a l t h c a r e p r o v i d e r , a n e x p e r t r e p o r t h a s n o t b e e n s e r v e d w i t h i n 17 t h e p e r i o d s p e c i f

i e d b y S u b s e c t i o n ( a ) , t h e c o u r t , o n
. . . m o t i o n
. . . s h a l l , s u b j e c t t o S u b s e c t i o n ( c ) , e n t e r a n o r d e r t h a t

. . . d i s m i s s e s t h e c l a i m w i t h r e s p e c t t o t h e
. . . h e a l t h c a r e p r o v i d e r
. . . . ” )

.

I d

. 18

S c o r e s b y v

. S a n t i l l a n , 3 4 6 S

. W

. 3 d 5 4 6 , 5 4 9 ( T e x
. 2 0 1 1 )

. 19

2 5 3 S

. W

. 3 d 2 0 4 ( T e x
. 2 0 0 8 )

. 20


### 7

## that “an expert repor t has not been serve d within the period specifie d by S u b s ec t i o n (a) [when]
elements of the repor

t are found defic ient”. Z amar ripa arg ues that Lewis is distinguishable beca use 2 1


## there , the trial court initially found the expert repor t defic ient. We fail to g rasp the distinction. I n any
event, we rea ffirme d Lewis just last y ear in Hebne r v. Reddy , a case in which the trial court did not 2 2


## find the expert repor

t de ficient. I n Hebne r , we state d point-blank: “a motion to dismiss based on a timely but defic ient re p o rt can be revie wed by interlocutory appea l”. Thus, Valley Reg ional’s 2 3 

## interlocutory

appea l is permitted.

Z amar ripa also arg ues that this Court lacks jurisdiction ove r Valley Reg ional’s petition f or
revie w. We have jurisdiction in interlocutory appea ls “whe n there is inconsistency in [Tex as courts’]
decisions that should be clar ified t o re m o ve unnece ssary uncer tainty in the law and unfairne ss to litigants.” That inconsistency here , as we shall see, is in the decisions of the court of appea ls a nd 2 4


## this Court i nterpre ting the A ct’s expert-r eport re quirement.

III
We have held that to satisfy the Act’s expert-re port require ment, “[a]n expert must explain,
based on fac ts set out in the repor t, how and why [a he alth car e provider’ s] bre ach [of the standard

I d

. a t 2 0 7

– 2 0 8 ; T E X

. C IV

. P R A C

. & R E M

. C O D E § 7 4

. 3 5 1 ( c )

. 21

4 9 8 S

. W

. 3 d 3 7 ( T e x
. 2 0 1 6 )

. 22

I d

. a t 4 0 n
. 5

. 23

T E X

. G O V ’ T C O D E § § 2 2

. 0 0 1 ( a ) ( 2 ) , ( e ) a n d 2 2

. 2 2 5 ( c ) , ( e )

. T h i s a n d o t h e r l i m i t a t i o n s o n t h e C o u r t ’ s 24 j u r i s d i c t i o n h a v e b e e n r e m o v e d

. A c t o f M a y 1 9 , 2 0 1 7 , 8 5 t h L e g
. , R

. S

. , c h

.

_ _ _ , § § 1 , 5

– 6 , 2 0 1 7 T e x
. G e n
. L a w s

_ _ _ ,

_ _ _ [ H B 1 7 6 1 ] ( e f

f e c t i v e S e p t

. 1 , 2 0 1 7 )

. 

### 8

## of car e] cause d the injury

. A bare expert opinion that the brea ch cause d the injury will not suffice .” 2 5



## By ag ree ing with Z amar ippa that “an expert repor t is not r equire d to a ddress ‘proximate c ause’ ”, 2 6


## the court of appea ls simply confuse s the matter, as it has befor e in writing that “an expert repor t need
not contain a state ment on fore seea bility to be ade quate”

. 2 7



## T h e A c t’ s e xp e r

t- r e p o r t r e q u ir e me nt seeks “to deter frivolous lawsuits by requiring a claimant

ear ly in litigat i o n t o produce the opinion of a suitable expert that his claim has merit.” 2 8 

## Unquestionably , a plaintiff a sserting a hea lth care liability claim based on neg lige nce, w ho cannot

prove that her injury was proxi mately cause d by the defe ndant’s failure to meet applicable standards of care, does not have a m eritorious claim. Whil e the plaintiff i s not require d t o p rove her claim 2 9


## with the expert repor

t, the repor

t must show that a quali fi ed expert is of the opinion she can. The

repor t need not use the words “proximate cause ,” “for esee ability ,” or “ca use in fac t.” “[A] repor

t’s adequa cy does not depend on whether the expert uses any particula r ‘mag ical words.’” And mere ly 3 0

V a n N e s s v

. E T

M C F i r s t P h y s i c i a n s , 4 6 1 S

. W

. 3 d 1 4 0 , 1 4 2 ( T e x
. 2 0 1 5 ) ; a c c o r d J e l i n e k v

. C a s a s , 3 2 8 S

. W

. 3 d 25 5 2 6 , 5 3 9

– 5 4 0 ( T e x
. 2 0 1 0 )

.

_ _ _ S

. W

. 3 d

_ _ _ ,

_ _ _ ( T e x
. A p p
. — C o r p u s C h r i s t i

- E d i n b u r g 2 0 1 5 ) ( m e m
. o p
. )

. 26

V a l l e y R e g ’ l M e d

. C t r

. , I

n c

. v

. G o n z a l e z , N o
. 1 3

- 1 2

- 0 0 5 7 2

- C V , 2 0 1 3 W L 2 2 9 8 4 7 0 , a t * 3 ( T e x
. A p p
. — 27 C o r p u s C h r i s t i 2 0 1 3 , n o p e t

. ) ( m e m
. o p
. ) ( “ T h e r e i s n o m e n t i o n i n t h e s t a t u t e o f

. . . p r o x i m a t e c a u s e , a n d T e x a s l a w d o e s n o t i m p o s e a r e q u i r e m e n t t o e s t a b l i s h t h e e l e m e n t s t h a t m u s t b e p r o v e d a t t r i a l a t t h i s s t a g e i n t h e p r o c e e d i n g s
. ” ) ; R i o G r a n d e R e g ’ l H o s

p

. v

. A y a l a , N o
. 1 3

- 1 1

- 0 0 6 8 6

- C V , 2 0 1 2 W L 3 6 3 7 3 6 8 , a t * 1 9 ( T e x
. A p p
. — C o r p u s C h r i s t i 2 0 1 2 , p e t

. d e n i e d ) ( m e m
. o p
. ) ( d i s a g r e e i n g t h a t “ a n e x p e r t r e p o r t m u s t o p i n e o n w h e t h e r t h e s p e c i f i c i n j u r i e s s u s t a i n e d b y t h e c l a i m a n t c o u l d h a v e b e e n f o r e s e e n b y t h e h e a l t h c a r e d e f e n d a n t s ” )

.
S c o r e s b y v

. S a n t i l l a n , 3 4 6 S

. W

. 3 d 5 4 6 , 5 5 2 ( T e x
. 2 0 1 1 )

. 28

I H S C e d a r s T

r e a t m e n t C t r

. o

f D e S o t o , T

e x

. , I n c

. v

. M a s o n , 1 4 3 S

. W

. 3 d 7 9 4 , 7 9 8 ( T e x
. 2 0 0 4 ) ( “ T h e e l e m e n t s 29

o f a n e g l i g e n c e c a u s e o f

a c t i o n a r e t h e e x i s t e n c e o f a l e g a l d u t y , a b r e a c h o f t h a t d u t y , a n d d a m a g e s p r o x i m a t e l y c a u s e d b y t h e b r e a c h

. ” )

.

B o w i e M e m ’ l H o s

p

. v

. W r i g h t , 7 9 S

. W

. 3 d 4 8 , 5 3 ( T e x
. 2 0 0 2 )

. 30


### 9

## incanting words does not suffice

. “An expert’s simple ipse dixit is insufficient to establish a matter;

rathe r, the expert must ex plain the basis of his statements to link his conclusions to the fac ts.” I n 3 1 

## showing how and why

a bre ach of

the standar d of car e ca

used injury , the expert repor t must m ake

a g ood-fa ith effor

t to ex plain, fac tually , how proxim ate c ause is g oing to be proven:
Prox imate cause has two components: (1) fore seea bility and (2) cause -in-fa ct. For a n egl i gent act or omission to have been a cause -in-fa ct of the harm, the ac t o r omission must have been a substantial fac tor in bring ing about the harm, and absent the act or omission— i.e. , but for th e ac t o r omission—t he harm would not have
occur red. 3 2


## This is the causa l rela tionship betwee n brea ch and injury that an expert repor t must explain to satisfy
the Act.

Nurse Spears’ s repor

t states that Valley Reg ional nurses’ standard s o f ca re wer e (1) to
advocate for further trea tment there and ag ainst transfe r to Ba y Are a, and (2) to not allow Flore s to
be transfe rre d to Ba

y Are a, and that they brea ched those standards. Spears, as we have noted, could

not opine on causa tion. That was left to Har lass, who stated only that by “per mitti ng and fac ilitating 3 3


## the transfe r,” Valley Reg ional cause d Flore s to be in an ambulance when she suffe red a place ntal abruption and c ardia c arr est, leading to he r death. But as Har lass himself explains, i t was Dr. E llis
who order ed Flore s’s transfe r, not Valley Reg ional. Har lass does not e x plain how Valley Reg ional permitted or fac ilitated Flore s’s transfe r, or even whether Valley Reg ional had any say in the matter.

E a r l e v

. R a t l i

f f , 9 9 8 S

. W

. 2 d 8 8 2 , 8 9 0 ( T e x
. 1 9 9 9 )

. 31

R o d r i g u e z - E s c o b a r v

. G o s s , 3 9 2 S

. W

. 3 d 1 0 9 , 1 1 3 ( T e x
. 2 0 1 3 ) ( p e r c u r i a m )

. 32

T E X

. C IV

. P R A C

. & R E M

. C O D E § 7 4

. 3 5 1 ( r ) ( 5 ) ( C ) ( r e q u i r i n g t h a t a n e x p e r t o n t h e c a u s a l r e l a t i o n s h i p b e t w e e n 33

a b r e a c h o f t h e s t a n d a r d o f c a r e a n d i n j u r y b e a p h y s i c i a n )

.



### 1 0

## Nor does Spears. Spears states that Valley Reg ional should have investiga ted Flore s’s fibrinog en

levels and abdominal pain further , but neither she nor Har lass explains how that would have aver ted
the transfe r. Neither Spears n o r Har lass explains how Valley Reg ional had either the rig ht or the
means to per suade D r. Ellis not to order the tra nsfer or to stop it when he did.

Z amar ripa’s response is that the Act does not require such explanations in expert repor ts. But
without f actua l e x planations, the repor ts a re nothing more than the ipse dixit of the e x perts, which
we ha ve held a re c lear ly insufficient. The court of a ppeals e rre d in holding to the contr ary
. The Act allows a trial court to g rant one 30-day extension t o cure a def

iciency in an expert

repor t, and a court must g rant an extension if a repor t’s defic iencies are cura

ble. Valley Reg ional 3 4 3 5



## arg ues that whether to transfe r Flore s was a medical decision which its nurses could not make, and 3 6


## there fore Z amar

ripa’s expert repor

ts cannot be cure d to show that it cause d Flore s’s transfe r. Valley Reg ional appea

rs to be corr ect with respe ct to statements in the expert repor ts indicating that Valley Reg ional permitted Flore s’s transfe r. But Nurse Spears’ s repor t seems to sug g est that Valley Reg ional brea ched its standard of car e in not providing Dr. Ellis information that would have

persua ded him to chang e his mind. Whil e the repor t does not explain how that could have happene d,

I d

. § 7 4

. 3 5 1 ( c ) ( “ I f a n e x p e r t r e p o r t h a s n o t b e e n s e r v e d w i t h i n t h e p e r i o d s p e c i f i e d b y S u b s e c t i o n ( a ) b e c a u s e 34

e l e m e n t s o f

t h e r e p o r t a r e f

o u n d d e f i c i e n t , t h e c o u r t m a y g r a n t o n e 3 0

- d a y e x t e n s i o n t o t h e c l a i m a n t i n o r d e r t o c u r e t h e d e f i c i e n c y
. ” )

.
S e e S c o r e s b y v

. S a n t i l l a n , 3 4 6 S

. W

. 3 d 5 4 6 , 5 4 9 ( T e x
. 2 0 1 1 )

. 35

T e x a s l a w p r o h i b i t s n u r s e s f r o m p r a c t i c i n g m e d i c i n e
. T E X

. O C C

. C O D E § 1 5 5

. 0 0 1 , – . 0 0 3 ( p r o v i d i n g t h a t n o 36 p e r s o n m a y “ p r a c t i c e m e d i c i n e ” w i t h o u t a m e d i c a l l i c e n s e ) ; i d

. § 1 5 1

. 0 0 2 ( a ) ( 1 3 ) ( “ ‘ [ p ] r a c t i c i n g m e d i c i n e ’ m e a n s t h e d i a g n o s i s , t r e a t m e n t , o r o f f e r t o t r e a t a m e n t a l o r p h y s i c a l d i s e a s e o r d i s o r d e r
. . . o r i n j u r y
. . . . ” ) ; i d

. § 3 0 1

. 0 0 2 ( 2 ) , ( 4 )

– ( 5 ) ( b a r r i n g n u r s e s f r o m “ a c t s o f m e d i c a l d i a g n o s i s o r t h e p r e s c r i p t i o n o f t h e r a p e u t i c o r c o r r e c t i v e m e a s u r e s ” )

. 

### 1 1

## we cannot say it would be impossibl e. The trial court here must be g iven the opportunity to consider

an extension. 3 7



## * * * * *
Acc ording ly , the court of appea ls’ judgme nt is reve rsed and the case is rema nded to the trial
court for further proce eding s in acc ordanc e with this opinion.

Nathan L . Hec ht Chief J ustice Opinion delivere d: J une 9, 2017

V a l l e y R e g i o n a l a l s o c o n t e n d s t h a t N u r s e S p e a r s w a s u n q u a l i f i e d t o o p i n e o n t h e s t a n d a r d o f c a r e f o r a 37

r e g i s t e r e d n u r s e i n a l a b o r a n d d e l i v e r y u n i t b e c a u s e s h e w a s n o t p r a c t i c i n g i n t h a t f i e l d w h e n s h e p r o v i d e d h e r r e p o r t
o r w h e n F l o r e s d i e d , a n d s h e n o w p r a c t i c e s i n h e m o t o l o g y a n d o n c o l o g y a r e a s
. B u t S e c t i o n 7 4

. 3 5 1 ( r ) ( 5 ) ( B ) d o e s n o t
r e q u i r e a n e x p e r t t o h a v e t h e s a m e s p e c i a l t y a s t h e h e a l t h c a r e p r o v i d e r s h e e v a l u a t e s
. S e e C a v i g l i a v

. T a t e , 3 6 3 S

. W

. 3 d 2 9 8 , 3 0 3 ( T e x
. A p p
. — E l P a s o 2 0 1 2 , n o p e t

. ) ; s e e a l s o K e o v

. V

u , 7 6 S

. W

. 3 d 7 2 5 , 7 3 2 ( T e x
. A p p
. — H o u s t o n [ 1 s t D i s t

. ] 2 0 0 2 , p e t

. d e n i e d ) ( n o t i n g b r o a d a g r e e m e n t a m o n g t h e c o u r t s o f a p p e a l s )

. T h e t r i a l c o u r t w a s w i t h i n i t s d i s c r e t i o n t o d e t e r m i n e t h a t N u r s e S p e a r s ’ s t r a i n i n g a s a r e g i s t e r e d n u r s e a n d h e r p r i o r e x p e r i e n c e i n t h e l a b o r a n d d e l i v e r y u n i t q u a l i f i e d h e r t o o p i n e o n t h e s t a n d a r d o f c a r e
. S e e T E X

. C IV

. P R A C

. & R E M

. C O D E § 7 4

. 4 0 2 ( b ) ( 3 )

. 

### 1 2