Opinion issued August 3, 2021

In The

Court of Appeals 

For The 

First District of Texas 

————————————

NO. 01-20-00260-CV

———————————

GEORGE T. KUHN, M.D., GEORGE T. KUHN M.D., P.A. D/B/A 

WOMEN’S HEALTHCARE ASSOCIATES, PAUL JAMES, M.D.,

METROPOLITAN HOUSTON SURGERY ASSOCIATES, PLLC, ADAM 

MORALES, M.D., WEST HOUSTON RADIOLOGY ASSOCIATES, L.L.P., 

AND SINGLETON ASSOCIATES, P.A. D/B/A RADIOLOGY PARTNERS 

GULF COAST, Appellants

V.

ANGIE SAM, Appellee

On Appeal from the 151st District Court

Harris County, Texas

Trial Court Case No. 2019-45200

MEMORANDUM OPINION
2

In this interlocutory appeal,1appellants, George T. Kuhn, M.D., George T. 

Kuhn M.D., P.A., doing business as Women’s Healthcare Associates (“Women’s 

Healthcare”), Paul James, M.D., Metropolitan Houston Surgery Associates, PLLC 

(“Metropolitan Houston”), Adam Morales, M.D., West Houston Radiology 

Associates, L.L.P. (“West Houston Radiology”), and Singleton Associates, P.A., 

doing business as Radiology Partners Gulf Coast (“Radiology Partners”)

(collectively, “appellants”), challenge the trial court’s order overruling their

objections and denying their motions to dismiss the health care liability claims

2

brought against them by appellee, Angie Sam, in her suit for negligence. In multiple 

issues, appellants contend that the trial court erred in overruling their objections and 

denying their motions to dismiss Sam’s claims against them.

3

We affirm.

Background

In her petition, Sam alleges that on April 12, 2018, she was admitted to St. 

Joseph Hospital with pelvic pain, uterine fibroids, and a right ovarian cyst. Sam 

underwent an exploratory laparotomy,4a lysis of adhesions, a right 

1 See TEX. CIV. PRAC. & REM. CODE ANN. § 51.014(a)(9).

2 See id. § 74.001(a)(13) (defining “[h]ealth care liability claim” (internal quotations 

omitted)).

3 See id. § 74.351 (governing expert reports).

4 A “laparotomy” is a “surgical incision of the abdominal wall.” Laparotomy, 

MERRIAM-WEBSTER’S COLLEGIATE DICTIONARY (11th ed. 2014). 
3

salpingo-oophorectomy,5and a supracervical hysterectomy.6 The friable adhesions 

found during surgery required “sharp and cautery dissection to free the uterus and 

right [fallopian] tube and ovary for removal.” Sam experienced excessive blood loss 

due to the adhesions which required an “inter-operative blood transfusion.” “[A]

decision to stop with a supra[cervical] hysterectomy was made.” Extensive cautery 

and suturing were required “to obtain hemostasis.” According to Sam, “[t]he frozen 

section on the ovarian cyst was benign and cystoscopy was normal prior to [the] 

closing [of her] abdomen.” (Internal quotations omitted.)

Soon after surgery, Sam developed pain, fever, nausea, and vomiting. A 

computed tomography (“CT”) scan of Sam’s abdomen was done on the third day 

after her surgery. The CT scan showed “a collection of fluid and [a] probable blood 

clot in [Sam’s] pelvis.” A drain was placed by the interventional radiology

department, which “noted that 50 cc of brown and bloody fluid was obtained from 

[Sam’s] pelvis at th[e] time.” Sam continued to experience pain and fever and 

5 A “[s]alpingo-oophorectomy” is the “[surgical] excision of a fallopian tube and an 

ovary.” See Young v. Pinto, No. 09-08-299-CV, 2008 WL 4998346, at *8 n.3 (Tex. 

App.—Beaumont Nov. 26, 2008, no pet.) (mem. op.) (internal quotations omitted).

6 A “supracervical hysterectomy” is the “surgical removal of the uterus.” See Tex. 

Tech Univ. of Health Scis. Ctr. v Lozano, 570 S.W.3d 740, 743 n.1 (Tex. App.—El 

Paso 2018, pet. denied); see also Young, 2008 WL 4993846, at 8 n.3.
4

leukocytosis.7 On the sixth day after Sam’s surgery, another CT scan was taken, and 

it showed “air, fluid, and contrast leakage within the peritoneal cavity.”8 After Sam 

was diagnosed with a bowel perforation, “with evidence of wide spread [sic] 

peritoneal cavity involvement,” a decision was made to treat Sam’s bowel 

perforation conservatively by draining the area even though there was “fluid and 

bowel gas . . . throughout the peritoneal cavity.” This course of treatment continued 

for the next four days, and Sam’s condition continued to deteriorate.

On the tenth day after Sam’s initial surgery, Sam underwent an exploratory 

laparotomy, a repair of her bowel perforation, and a diverting ileostomy.9 The 

ileostomy was required because of a “marked inflammatory reaction to bowel 

leakage” that had occurred for an extended length of time. After Sam’s second 

7

“[L]eukocytosis” is “an increase in the number of white blood cells in the circulating 

blood.” Leukocytosis, MERRIAM-WEBSTER’S COLLEGIATE DICTIONARY (11th ed. 

2014).

8 The “peritoneal cavity” is “the space within a person’s abdomen that contains the 

intestines, stomach, and liver.” Univ. of Tex. M.D. Anderson Cancer Ctr. v. 

McKenzie, 578 S.W.3d 506, 510 n.2 (Tex. 2019). 

9 An “ileostomy” is “a surgical operation in which a damaged part is removed from 

the ileum,” the third portion of the small intestine, “and the cut end [is] diverted to 

an artificial opening in the abdominal wall.” Ileostomy, OXFORD DICTIONARY OF 

ENGLISH (2d ed. 2009); see also Thetford v. State, No. 02-18-00488-CR, 2021 WL 

278913, at *1 n.3 (Tex. App.—Fort Worth Jan. 28, 2021, pet. filed) (mem. op., not 

designated for publication) (physician described ileostomy as follows: “[W]e 

essentially brought the small intestine to the skin and bypassed the large intestine, 

essentially tak[ing] it out of the equation so the small intestine just empties to a bag 

instead of going through the large intestine.” (second alteration in original) (internal 

quotations omitted)).
5

surgery, she suffered peritonitis and sepsis. Sam’s condition slowly improved, and 

she was discharged from St. Joseph Hospital on April 29, 2018.

Sam brings health care liability claims against appellants, alleging that Sam 

was their patient and appellants had a duty to act as reasonably prudent health care 

providers. Drs. Kuhn, James, and Morales breached the applicable standards of care 

required for treating and caring for Sam in many ways, including, but not limited to, 

failing to recognize her bowel perforation, failing to diagnose her bowel perforation 

until the sixth day after her initial surgery, and failing to consult about immediately 

exploring Sam’s abdomen to repair her bowel perforation upon its diagnosis. Sam 

also alleges that Women’s Healthcare, Metropolitan Houston, West Houston 

Radiology, and Radiology Partners are vicariously liable for the acts and omissions 

of Drs. Kuhn, James, and Morales. Sam requests damages for past and future

physical pain and suffering, past and future mental anguish, past and future physical 

impairment, past and future medical expenses, past and future disfigurement, loss of 

earnings, future lost earning capacity, exemplary damages, and interest.

To support her claim, Sam timely served appellants with an initial expert 

report authored by J.M. Paine, M.D., F.A.C.O.G.10 Appellants objected to the initial 

10 Dr. Paine attached his curriculum vitae (“CV”) to his expert report.
6

expert report, and the trial court signed an agreed order allowing Sam thirty days to 

supplement or amend Dr. Paine’s initial expert report.11

Sam timely served appellants with a supplemental expert report authored by 

Dr. Paine. Dr. Paine’s supplemental expert report states that it is “intended sole[ly]

to supplement[] [and] not to replace[] [his] prior report.”12

In his expert reports, Dr. Paine states that he is a licensed physician and is 

board certified in obstetrics and gynecology. He has been practicing in the field of 

obstetrics and gynecology for thirty-five years. Currently, he is a member of the 

teaching faculty as an associate professor in the department of obstetrics and 

gynecology at the University of Texas Health Science Center in San Antonio, Texas. 

In his position as an associate professor, he trains residents and students in obstetrics 

and gynecology. He is also actively practicing medicine in the field of obstetrics 

and gynecology.

Dr. Paine states that he has extensive experience in the field of obstetrics and 

gynecology, and he has performed thousands of hysterectomies during his career. 

He has knowledge of the accepted standards of medical and surgical care required 

for patients needing hysterectomies. This includes knowledge of the standards of 

11 See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c).

12 Dr. Paine attached his CV to his supplemental expert report.
7

pre-operative, inter-operative, and post-operative care required for patients who 

have hysterectomies.

When Dr. Paine treats patients requiring hysterectomies, he provides 

pre-operative, inter-operative, and post-operative care to his patients. Post-operative 

care includes “following [a] patient after [a] surgery is complete[] to diagnose and 

treat any complications that may arise from the surgical procedure.” According to 

Dr. Paine, this case involves the purported failure of Drs. Kuhn, James, and Morales

to appropriately care for and treat Sam after a hysterectomy, and Dr. Paine is familiar 

with the type of post-operative care a patient, such as Sam, should receive and how 

post-operative complications, like those experienced by Sam, should be managed 

and treated.

In his expert reports, Dr. Paine states that on April 12, 2018, Sam was admitted 

to St. Joseph Hospital with pelvic pain, uterine fibroids, and a right ovarian cyst. 

She underwent an exploratory laparotomy, lysis of adhesions, right 

salpingo-oophorectomy, and supracervical hysterectomy. The friable adhesions 

found during surgery required “sharp and cautery dissection to free the uterus and 

right [fallopian] tube and ovary [for] removal.” Sam experienced excessive blood 

loss due to the adhesions which required an “inter-operative blood transfusion”; thus, 

“a decision to stop with a supra[cervical] hysterectomy was made.” Extensive 

cautery and suturing were required “to obtain hemostasis.” “The frozen section on 
8

the ovarian cyst was benign and cystoscopy was normal prior to [the] closing [of 

her] abdomen.” (Internal quotations omitted.)

Soon after surgery, Sam developed pain, fever, nausea, and vomiting. A CT 

scan of Sam’s abdomen was done on her third day after her surgery. The CT scan 

showed “a collection of fluid and [a] probable blood clot in [Sam’s] pelvis.” A drain 

was placed by the interventional radiology department, which “noted that 50 cc of 

brown and bloody fluid was obtained from [Sam’s] pelvis at th[e] time.” Sam 

continued to experience pain and fever and leukocytosis. On the sixth day after her 

surgery, another CT scan was taken, and it showed “air, fluid, and contrast leakage 

within the peritoneal cavity.” After Sam was diagnosed with a bowel perforation,

“with evidence of wide spread [sic] peritoneal cavity involvement,” a decision was 

made to treat Sam’s condition conservatively by draining the area even though there 

was “fluid and bowel gas . . . throughout the peritoneal cavity.” This course of 

treatment continued for the next four days, and Sam’s condition continued to 

deteriorate.

On the tenth day after her initial surgery, Sam was taken back to the operating 

room for an exploratory laparotomy, a repair of her bowel perforation, and a 

diverting ileostomy. The ileostomy was required because of a “marked 

inflammatory reaction to bowel leakage” that had occurred for an extended length 

of time. Had an exploratory laparotomy and repair of the bowel perforation been 
9

performed at the time Sam was diagnosed with the bowel perforation, “with 

evidence of wide spread [sic] peritoneal cavity involvement,” a colostomy13 would 

have been possible. After Sam’ssecond surgery, Sam suffered peritonitis and sepsis. 

Sam slowly improved and was discharged seventeen days after she was first 

admitted to the hospital.

As to the standard of care and breach of the standard of care for Dr. Kuhn, Dr. 

Paine states that bowel injuries, like a bowel perforation, are a well-known 

complication of a hysterectomy. On average they occur in one out of every 700 

cases. But if a hysterectomy is performed when adhesions are present and when an 

extensive bowel dissection is also required, the rate of bowel injuries increases. A 

bowel perforation should be diagnosed three days after a hysterectomy. Given the 

difficulties with Sam’s hysterectomy and the extensive bowel dissection that was 

required during her surgery, Dr. Kuhn, Sam’s gynecologist, should have considered 

and suspected a bowel perforation by the third day after Sam’s surgery, when Sam 

was experiencing pain, fever, nausea, and vomiting and a CT scan showed “a 

collection of fluid and [a] probable blood clot in [her] pelvis.” The standard of care 

required Dr. Kuhn to suspect, recognize, and diagnose a bowel perforation by the 

13 A “colostomy” is “where the bowel is diverted to exit the abdomen. A colostomy 

bag is then attached that permits the [person] to pass stool into the bag, which must 

be drained by the [person], instead of the normal waste elimination process.” 

Centocor, Inc. v. Hamilton, 310 S.W.3d 476, 481–82 (Tex. App.—Corpus Christi–

Edinburg 2010), rev’d on other grounds, 372 S.W.3d 140 (Tex. 2012).
10

third day after Sam’s initial surgery and it required Dr. Kuhn to take Sam to surgery 

“to look for and treat the injury.” Dr. Kuhn did not do such things, and thus, 

breached the standard of care.

Additionally, on the sixth day after Sam’s surgery, when Sam’s bowel 

perforation was actually diagnosed, the standard of care required Dr. Kuhn to 

recommend surgery to Sam and to immediately perform surgery to repair the bowel 

perforation. But Dr. Kuhn did not do either of those things. Instead, he decided to 

“treat [Sam’s] condition conservatively,” by draining the fluid that was present. 

(Internal quotations omitted.) There is no precedent for “conservative management” 

of a bowel perforation when there is evidence of bowel contents and gas free in the 

patient’s peritoneal cavity. (Internal quotations omitted.) Dr. Kuhn’s failure to take 

any action to repair Sam’s bowel perforation, including a failure to consult with 

someone from general surgery to explore Sam’s abdomen and repair the bowel 

perforation, after the bowel perforation diagnosis on the sixth day following Sam’s 

initial surgery was a breach of the standard of care. Further, Dr. Kuhn breached the 

standard of care by waiting until the tenth day after Sam’s initial surgery to return 

Sam to surgery to repair the bowel perforation because it should have been repaired 

immediately upon its diagnosis.

As to the standard of care and breach of the standard of care for Dr. James, 

Dr. Paine states that bowel injuries, like a bowel perforation, are a well-known 
11

complication of a hysterectomy. On average they occur in one out of every 700 

cases. But if a hysterectomy is performed when adhesions are present and when an 

extensive bowel dissection is also required, the rate of bowel injuries increases. A 

bowel perforation should be diagnosed three days after a hysterectomy.

According to Dr. Paine, Dr. James was the general surgeon 

“following . . . Sam[] post-hysterectomy.” Because Dr. James was the general 

surgeon “following” Sam after her surgery, once Sam’s bowel perforation was 

diagnosed on the sixth day after her surgery, the standard of care required Dr. James 

to immediately act upon the diagnosis by surgically repairing the bowel perforation

or at least recommending a surgical repair of the bowel perforation. But Dr. James

did not do so and instead joined in the “conservative” treatment plan with Dr. Kuhn. 

(Internal quotations omitted.) There is no precedent for “conservative management” 

of a bowel perforation when there is evidence of bowel contents and gas free in the 

peritoneal cavity. (Internal quotations omitted.) By failing to recommend surgical 

repair of Sam’s bowel perforation and by failing to surgically repair the bowel 

perforation immediately, Dr. James breached the standard of care. Dr. James also 

breached of the standard of care by waiting until the tenth day after Sam’s initial

surgery to return Sam to surgery to repair the bowel perforation because it should 

have been repaired immediately upon its diagnosis.
12

As to the standard of care and breach of the standard of care for Dr. Morales, 

Dr. Paine states that bowel injuries, like a bowel perforation, are a well-known 

complication of a hysterectomy. On average they occur in one out of every 700 

cases. But if a hysterectomy is performed when adhesions are present and when an 

extensive bowel dissection is also required, the rate of bowel injuries increases. A 

bowel perforation should be diagnosed three days after a hysterectomy.

According to Dr. Paine, Dr. Morales, an interventional radiologist, “drain[ed] 

the peritoneal cavity” after Sam was diagnosed with a bowel perforation on the sixth 

day after her surgery. But there is no precedent for “conservative management” of 

a bowel perforation when there is evidence of bowel contents and gas free in the 

peritoneal cavity. (Internal quotations omitted.) Based on Sam’s diagnosis of a 

bowel perforation on the sixth day after her surgery, Dr. Morales should have 

recommended immediate surgical exploration and repair of the bowel perforation. 

Dr. Morales did not do this, and thus, breached the standard of care.

As to causation, Dr. Paine states that because of the aforementioned breaches 

by Drs. Kuhn, James, and Morales, Sam’s condition worsened and endangered her 

life. A bowel perforation is a surgical emergency that requires immediate 

intervention. Immediate exploration, wash out of the peritoneal cavity, and repair 

of the bowel perforation is required. Any course of action other than immediate 

exploration, wash out, and repair, causes worsening peritonitis, sepsis, and possible
13

death. According to Dr. Paine, the physicians’ failure to timely diagnose the bowel 

perforation, decision to pursue “conservative management” of Sam’s bowel 

perforation after it was diagnosed on the sixth day after her initial surgery, failure to 

recommend surgical exploration and repair of the bowel perforation upon its 

diagnosis, failure to immediately repair the bowel perforation upon its diagnosis, and 

decision to delay the repair of Sam’s bowel perforation until the tenth day after her 

initial surgery, caused Sam’s condition to deteriorate and allowed for the continued 

leakage of bowel contents into the peritoneal cavity. (Internal quotations omitted.) 

Without a repair of the bowel perforation, bowel contents continued to flow into 

Sam’s peritoneal cavity “with all the bacteria, chemicals[,] and irritants [that] allow[] 

[an] infection to grow and worsen.” The bowel leakage caused severe damage to 

Sam’s physiology and permanent residual damage. And because the infection was 

allowed to grow, this led to a more complicated recovery process for Sam, a longer 

hospital stay, and long-term damage. Sam could not recover from the bowel 

perforation until it was actually repaired.

Dr. Paine also explains that during the surgery to repair Sam’s bowel 

perforation, a diverting ileostomy had to be performed. According to Dr. Paine, the 

ileostomy was required because of a marked inflammatory reaction to bowel leakage 

for an extended length of time, i.e., four days after the bowel-perforation diagnosis 
14

and ten days after Sam’s initial surgery. Had the bowel perforation been repaired at 

the time it was diagnosed, a colostomy would have been possible.

Additionally, Dr. Paine states that peritonitis and sepsis, which are 

life-threatening conditions, can arise from a bowel perforation, and in such cases,

they will not be resolved until the bowel perforation is repaired. Here, because of 

appellants’ aforementioned breaches, Sam’s peritonitis and sepsis grew worse—

which is what happens when an infection is not properly treated and the source of 

the infection is not appropriately and timely addressed.

Dr. Kuhn objected to Dr. Paine’s expert reports and requested that Sam’s 

health care liability claim against him be dismissed.14 Dr. Kuhn asserted that Dr. 

Paine’s expert reports do not provide a fair summary of the applicable standard of 

care and do not explain how Dr. Kuhn breached the standard of care. The reports 

also do not explain how any alleged breach by Dr. Kuhn caused or contributed to 

cause Sam’s injury.

Dr. James objected to Dr. Paine’s expert reports and requested that Sam’s 

health care liability claim against him be dismissed.15 Dr. James asserted that Dr. 

Paine’s expert reports do not provide a fair summary of the applicable standard of 

14 Women’s Healthcare joined Dr. Kuhn’s objection and requested that the trial court 

dismiss Sam’s vicarious liability health care liability claim against it.

15 Metropolitan Houston joined Dr. James’s objection and requested that the trial court 

dismiss Sam’s vicarious liability health care liability claim against it.
15

care and do not inform Dr. James of what he did to breach the standard of care. Dr. 

Paine’s opinion on causation is speculative and conclusory, and the reports do not 

state how Dr. James’s breach of the standard of care caused Sam harm. Dr. James 

also asserts that Dr. Paine is not qualified to offer an opinion on the standard of care 

and causation related to Dr. James.

Dr. Morales objected to Dr. Paine’s expert reports and requested that Sam’s 

health care liability claim against him be dismissed.16 Dr. Morales asserted that Dr. 

Paine is not qualified to offer an opinion on causation related to Dr. Morales.

After Sam responded to appellants’ objections and motions to dismiss, the 

trial court overruled appellants’ objections to Dr. Paine’s expert reports and denied 

appellants’ motions to dismiss the health care liability claims against them.

Standard of Review

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); Gray v. CHCA Bayshore L.P., 189 

S.W.3d 855, 858 (Tex. App.—Houston [1st Dist.] 2006, no pet.). We apply the same 

standard to a trial court’s determination that an expert is qualified. See Broders v. 

Heise, 924 S.W.2d 148, 151–52 (Tex. 1996); San Jacinto Methodist Hosp. v. 

16 West Houston Radiology and Radiology Partners joined Dr. Morales’s objection 

and requested that the trial court dismiss Sam’s vicarious liability health care 

liability claims against them.
16

Bennett, 256 S.W.3d 806, 811 (Tex. App.—Houston [14th Dist.] 2008, no pet.). A 

trial court abuses its discretion if it acts in an arbitrary or unreasonable manner 

without reference to guiding rules or principles. Jelinek v. Casas, 328 S.W.3d 526, 

539 (Tex. 2010). When reviewing matters committed to a trial court’s discretion, 

we may not substitute our own judgment for that of the trial court. Bowie Mem’l

Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). A trial court does not abuse its 

discretion merely because it decides a discretionary matter differently than an 

appellate court would in a similar circumstance. Harris Cty. Hosp. Dist. v. Garrett, 

232 S.W.3d 170, 176 (Tex. App.—Houston [1st Dist.] 2007, no pet.). But a trial 

court has no discretion in determining what the law is or in applying the law to the 

facts. See Walker v. Packer, 827 S.W.2d 833, 840 (Tex. 1992). In conducting our 

review, we always consider that the Legislature’s goal in requiring expert reports is 

to deter baseless claims, not block earnest ones. Jackson v. Kindred Hosps. Ltd. 

P’ship, 565 S.W.3d 75, 81 (Tex. App.—Fort Worth 2018, pet. denied); Gonzalez v. 

Padilla, 485 S.W.3d 236, 242 (Tex. App.—El Paso 2016, no pet.); see also Scoresby 

v. Santillan, 346 S.W.3d 546, 554 (Tex. 2011).

Under the Texas Medical Liability Act (“TMLA”), a plaintiff asserting a 

health care liability claim must timely serve each defendant physician and health 
17

care provider17 with at least one expert report, with a CV for the expert whose 

opinion is offered, to substantiate the merits of the plaintiff’s claim. TEX.CIV. PRAC.

& REM.CODE ANN. § 74.351(a), (i); see also Mangin v. Wendt, 480 S.W.3d 701, 705 

(Tex. App.—Houston [1st Dist.] 2015, no pet.). The expert report must provide a 

“fair summary” of the expert’s opinions on (1) the applicable standard of care, 

(2) the manner in which 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). A “fair summary” of the expert’s opinions means that, at the least, the 

report must state more than the expert’s mere conclusions as to the standard of care, 

breach, and causation; it must instead explain the basis of the expert’s opinion so as 

to link the conclusions to the facts of the case. See Jelinek, 328 S.W.3d at 539;

Wright, 79 S.W.3d at 52.

If a plaintiff fails to timely serve an expert report, then, on the motion of a 

defendant physician or health care provider, the trial court must dismiss the pertinent 

health care liability claim with prejudice and award attorney’s fees. TEX. CIV. PRAC.

& REM. CODE ANN. § 74.351(b); Baty v. Futrell, 543 S.W.3d 689, 692 (Tex. 2018). 

17 See TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(12)(A) (defining “[h]ealth 

care provider” (internal quotations omitted)).
18

But if a plaintiff timely serves an expert report and a defendant physician or health 

care provider files a motion challenging the adequacy of that report, then the trial 

court may only grant the motion “if it appears to the court, after [a] hearing, that the 

report does not represent an objective good faith effort to comply with the [TMLA’s] 

definition of an expert report.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(l); 

Baty, 543 S.W.3d at 692–93; see also TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(r)(6) (“[e]xpert report” means “a written report by an expert that provides 

a fair summary of the expert’s opinions as of the date of the report regarding 

applicable standards of care, the manner in which the care rendered by the physician 

or health care provider failed to meet the standards, and the causal relationship 

between that failure and the injury, harm, or damages claimed” (internal quotations 

omitted)).

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

dismissal if it discusses each element 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 liability claim has merit. 

Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d 510, 513 (Tex. 2017); 

see also Baty, 543 S.W.3d at 693–94. The expert report need not use any particular 
19

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.” Puppala v. Perry, 564 S.W.3d 190, 197 (Tex. App.—Houston [1st Dist.] 

2018, no pet.) (internal quotations omitted). And when the issue of adequacy hinges 

on an expert’s qualifications, the trial court may also consider the “four corners” of 

the expert’s CV. Id.; Mangin, 480 S.W.3d at 706. Courts must view the report in 

its entirety, rather than isolating specific portions or sections, to determine whether 

it is sufficient. See Baty, 543 S.W.3d at 694; see, e.g., Van Ness v. ETMC First 

Physicians, 461 S.W.3d 140, 144 (Tex. 2015); see also Austin Heart, P.A. v. Webb, 

228 S.W.3d 276, 282 (Tex. App.—Austin 2007, no pet.) (“The form of the report 

and the location of the information in the report are not dispositive.”). In reviewing 

the adequacy of an expert report, a trial court may not consider an expert’s

credibility, the data relied on by the expert, or the documents that the expert failed 

to consider at this pre-discovery stage of the litigation. See Mettauer v. Noble, 326 

S.W.3d 685, 691–92 (Tex. App.—Houston [1st Dist.] 2010, no pet.); Gonzalez, 485 

S.W.3d at 245.
20

Multiple expert reports may be considered together in determining whether a 

plaintiff has provided a report meeting the statutory requirements. See TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351(i); Salias v. Tex. Dep’t of Aging & Disability 

Servs., 323 S.W.3d 527, 534 (Tex. App.—Waco 2010, pet. denied); Walgreen Co. 

v. Hieger, 243 S.W.3d 183, 186 n.2 (Tex. App.—Houston [14th Dist.] 2007, pet. 

denied). A single report addressing both liability and causation issues related to a 

defendant physician or health care provider is not required. See TEX. CIV. PRAC. &

REM. CODE ANN. § 74.351(i); Gannon v. Wyche, 321 S.W.3d 881, 896 (Tex. App.—

Houston [14th Dist.] 2010, pet. denied). When an expert report has been 

supplemented, a court considers both the original expert report and the supplemental 

expert report when reviewing their adequacy. See Scherer v. Gandy, No. 

07-18-00341-CV, 2019 WL 988174, at *2 n.4 (Tex. App.—Amarillo Feb. 28, 2019, 

no pet.) (mem. op.); see also Packard v. Guerra, 252 S.W.3d 511, 527 (Tex. App.—

Houston [14th Dist.] 2008, pet. denied). The multiple expert reports, when read 

together, must provide a “fair summary” of the expert’s opinions on (1) the 

applicable standard of care, (2) the manner in which 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. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i), (r)(6); see also 

Gannon, 321 S.W.3d at 896.
21

Dr. Kuhn and Women’s Healthcare

In his sole issue, Dr. Kuhn argues that the trial court erred in overruling his 

objections to Dr. Paine’s expert reports and denying his motion to dismiss Sam’s 

health care liability claim against him because Dr. Paine’s expert reports do not 

adequately address the standard of care and causation as it relates to Dr. Kuhn. In 

its sole issue, Women’s Healthcare argues that the trial court erred in overruling its 

objections to Dr. Paine’s expert reports and denying its motion to dismiss Sam’s 

vicarious liability health care liability claim against it because Dr. Paine’s expert 

reports do not adequately address the standard of care and causation as it relates to 

Dr. Kuhn.

A. Standard of Care Related to Dr. Kuhn

In a portion of his sole issue, Dr. Kuhn argues that Dr. Paine’s expert reports

do not adequately address the standard of care as it relates to him because the expert

reports do not “provide Dr. Kuhn with specific information about what he should 

have done differently.” 

Identifying the standard of care in a health care liability claim is critical. 

Palacios, 46 S.W.3d at 880. To adequately identify the standard of care, an expert 

report must set forth “specific information about what the defendant [physician]

should have done differently.” Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 

226 (Tex. 2018) (internal quotations omitted). Thus, related to standard of care and 
22

breach, the expert report must explain what the defendant physician should have 

done under the circumstances and what the physician did instead. Palacios, 46 

S.W.3d at 880; see also Kline v. Leonard, No. 01-19-00323-CV, 2019 WL 6904720, 

at *7 (Tex. App.—Houston [1st Dist.] Dec. 19, 2019, pet. denied) (mem. op.) (“[A]n 

expert report must provide a fair summary of the expert’s opinion regarding the 

applicable standard of care and the manner in which the care rendered by the health 

care provider failed to meet the standard.” (internal quotations omitted)). It is not 

sufficient for the expert to simply state that he knows the standard of care and 

concludes that it was or was not met. Palacios, 46 S.W.3d at 880.

As to the applicable standard of care related to Dr. Kuhn, Dr. Paine, in his 

expert reports, states that bowel injuries, like a bowel perforation, are a well-known 

complication of a hysterectomy. On average they occur in one out of every 700 

cases. But if a hysterectomy is performed when adhesions are present and when an 

extensive bowel dissection is also required, the rate of bowel injuries increases. A 

bowel perforation should be diagnosed three days after a hysterectomy. Given the 

difficulties with Sam’s hysterectomy and the extensive dissection that was required 

during her initial surgery, Dr. Kuhn, Sam’s gynecologist, should have considered 

and suspected a bowel perforation by the third day after Sam’s surgery, when Sam 

was experiencing pain, fever, nausea, and vomiting and a CT scan showed “a 

collection of fluid and [a] probable blood clot in [her] pelvis.” The standard of care 
23

required Dr. Kuhn to suspect, recognize, and diagnose a bowel perforation by the 

third day after Sam’s surgery and also required him to take Sam to surgery “to look 

for and treat the injury.” Additionally, on the sixth day after surgery, when Sam’s 

bowel perforation was actually diagnosed, the standard of care required Dr. Kuhn to 

recommend surgery to Sam and to immediately perform surgery to repair her bowel 

perforation. See Baty, 543 S.W.3d at 694 (courts must view report in its entirety, 

rather than isolating specific portions or sections, to determine whether it is 

sufficient); Webb, 228 S.W.3d at 282 (“The form of the report and the location of 

the information in the report are not dispositive.”).

Dr. Paine’s statements about the applicable standard of care for Dr. Kuhn are 

not vague or conclusory. Rather, the expert reports identify the specific actions that 

should have been taken by Dr. Kuhn but were not. See Abshire, 563 S.W.3d at 226–

27; see also Baty, 543 S.W.3d at 695 (report not conclusory where it did not require 

one to infer what defendant physician should have done differently); Keepers v. 

Blessett, No. 01-18-01020-CV, 2019 WL 1523368, at *5 (Tex. App.—Houston [1st 

Dist.] Apr. 9, 2019, no pet.) (mem. op.) (expert report is adequate where it informs 

defendant physician of expert’s opinion on what defendant should have done and 

what the defendant did instead). The stated standard of care need not be complicated 

for it to be sufficient. See, e.g., Baty, 543 S.W.3d at 697; see also Keepers, 2019 

WL 1523368, at *5–6 (“At times, the standard of care can be fairly basic.” (internal 
24

quotations omitted)). Dr. Paine clearly identifies the applicable standard of care 

related to Dr. Kuhn. The expert reports provide “enough information” for the trial 

court to have concluded that they constitute a good-faith effort to set forth the 

applicable standard of care related to Dr. Kuhn.18 See Miller, 536 S.W.3d at 515–

17; see also New Med. Horizons, II, Ltd. v. Milner, 575 S.W.3d 53, 60, 64 (Tex. 

App.—Houston [1st Dist.] 2019, no pet.); Mettauer, 326 S.W.3d at 691 (not court’s 

role to determine truth or falsity of expert’s opinion, or truth or falsity of facts upon 

which expert bases such opinions, but only to act as gatekeeper in evaluating 

sufficiency of report itself).

We conclude that the trial court could have reasonably determined that Dr. 

Paine’s expert reports represent an “objective good faith effort” to inform Dr. Kuhn 

of the specific conduct called into question, the standard of care that should have 

been followed, and what Dr. Kuhn should have done differently. Thus, we hold that 

the trial court did not err in overruling Dr. Kuhn’s objections and denying Dr. Kuhn’s

18 To the extent Dr. Kuhn asserts that Dr. Paine has not accurately stated the standard 

of care, that complaint does not support a dismissal at this stage of the litigation. 

See Aggarwal v. Trotta, No. 01-19-00012-CV, 2019 WL 2426172, at *4 n.5 (Tex. 

App.—Houston [1st Dist.] June 11, 2019, no pet.) (mem. op.) (“To the extent [that 

the defendant physician] disputes that [the expert] has accurately stated the standard 

of care, his complaint does not support a Chapter 74 dismissal.”); Engh v. Reardon, 

No. 01-09-00017-CV, 2010 WL 4484022, at *8 (Tex. App.—Houston [1st Dist.] 

Nov. 10, 2010, no pet.) (mem. op.) (“The [physicians] also challenge the accuracy 

of [the expert’s] opinions with respect to [the] standard of care. Whether [the 

expert’s] opinions regarding the applicable standard[] of care are correct, however, 

is an issue for summary judgment, not a motion to dismiss under Chapter 74.”).
25

motion to dismiss Sam’s health care liability claim against him on the ground that 

Dr. Paine’s expert reports do not adequately address the standard of care as to Dr. 

Kuhn.

We overrule this portion of Dr. Kuhn’s sole issue.

B. Causation Related to Dr. Kuhn

In the remaining portion of his sole issue, Dr. Kuhn argues that Dr. Paine’s 

expert reports do not adequately address causation as it relates to him because the 

expert reports do not establish a causal link between Dr. Kuhn’s conduct and Sam’s 

injuries, the reports contain analytical gaps between Dr. Kuhn’s alleged breach of 

the standard of care and Sam’s alleged injury, and Dr. Paine’s causation opinion is 

conclusory.

An expert report must provide a “fair summary” of the expert’s opinion on the 

causal relationship between the failure of a defendant physician to provide care in 

accord with the applicable standard of care and the plaintiff’s claimed injury, harm, 

or damages. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6); see also Potts, 392 

S.W.3d at 630. The expert report must explain how and why the defendant 

physician’s breach of the standard of care proximately caused the plaintiff’s injury. 

Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 459–60 (Tex. 

2017). An expert report need not marshal all the plaintiff’s proof necessary to 

establish causation at trial, and it need not anticipate or rebut all possible defensive 
26

theories that may ultimately be presented to the trial court. Wright, 79 S.W.3d at 52; 

Cornejo v. Hilgers, 446 S.W.3d 113, 123 (Tex. App.—Houston [1st Dist.] 2014, pet. 

denied). But an expert cannot simply opine that the breach caused the injury. 

Jelinek, 328 S.W.3d at 539.

Causation consists of two components: (1) cause-in-fact and 

(2) foreseeability. Gunn v. McCoy, 554 S.W.3d 645, 658 (Tex. 2018). A defendant 

physician’s breach was a cause-in-fact of the plaintiff’s injury if the breach was a 

substantial factor in bringing about the harm, and absent the breach the harm would 

not have occurred. Id. Even if the harm would not have occurred absent the 

defendant physician’s breach, “the connection between the defendant and the 

plaintiff’s injuries simply may be too attenuated” for the breach to qualify as a 

substantial factor. Allways Auto Grp., Ltd. v. Walters, 530 S.W.3d 147, 149 (Tex. 

2017) (internal quotations omitted). A breach is not a substantial factor if it “does 

no more than furnish the condition that makes the plaintiff’s injury possible.” Id. A 

defendant physician’s breach is a foreseeable cause of the plaintiff’s injury if 

physician of ordinary intelligence would have anticipated the danger caused by the 

negligent act or omission. Puppala, 564 S.W.3d at 197.

As to standard of care and breach of the standard of care, Dr. Paine, in his

expert reports, states that bowel injuries, like a bowel perforation, are a well-known 

complication of a hysterectomy. On average they occur in one out of every 700 
27

cases. But if a hysterectomy is performed when adhesions are present and when an 

extensive bowel dissection is also required, the rate of bowel injuries increases. A 

bowel perforation should be diagnosed three days after a hysterectomy. Given the 

difficulties with Sam’s hysterectomy and the extensive dissection that was required 

during her initial surgery, Dr. Kuhn, Sam’s gynecologist, should have considered 

and suspected a bowel perforation by the third day after Sam’s surgery, when Sam 

was experiencing pain, fever, nausea, and vomiting and a CT scan showed “a 

collection of fluid and [a] probable blood clot in [her] pelvis.” The standard of care 

required Dr. Kuhn to suspect, recognize, and diagnose a bowel perforation by the 

third day after Sam’s surgery and take Sam to surgery “to look for and treat the 

injury.” Dr. Kuhn, by not doing either of those things, breached the standard of care.

Additionally, on the sixth day after her initial surgery, when Sam’s bowel 

perforation was actually diagnosed, the standard of care required Dr. Kuhn to 

recommend surgery to Sam and to immediately perform surgery to repair the bowel 

perforation. But Dr. Kuhn did not do either of those things. Instead, he decided to 

“treat [Sam’s] condition conservatively,” by draining the fluid that was present. 

There is no precedent for “conservative management” of a bowel perforation when 

there is evidence of bowel contents and gas free in the peritoneal cavity. (Internal 

quotations omitted.) Dr. Kuhn’s failure to take any action to repair Sam’s bowel 

perforation, including his failure to consult with someone from general surgery to 
28

explore Sam’s abdomen and repair the bowel perforation, after the bowel perforation 

diagnosis on the sixth day following Sam’s initial surgery was a breach of the 

standard of care. Further, Dr. Kuhn breached the standard of care by waiting until 

the tenth day after Sam’s initial surgery to return Sam to surgery to repair the bowel 

perforation because it should have been repaired immediately upon its diagnosis.

As to causation, Dr. Paine, in his expert reports, states that because of the 

aforementioned breaches by Dr. Kuhn, Sam’s condition worsened and endangered 

her life. Dr. Paine explained that a bowel perforation is a surgical emergency that 

requires immediate intervention. Immediate exploration, wash out of the peritoneal 

cavity, and repair of the bowel perforation is required. Any course of action other 

than immediate exploration, wash out, and repair, causes worsening peritonitis, 

sepsis, and possible death. According to Dr. Paine, Dr. Kuhn’s failure to timely 

diagnose the bowel perforation, decision to pursue “conservative management” of 

Sam’s bowel perforation after it was diagnosed on the sixth day after her initial 

surgery, failure to recommend surgical exploration and repair of the bowel 

perforation upon diagnosis, failure to not immediately repair the bowel perforation 

upon diagnosis, and decision to delay the repair of Sam’s bowel perforation until the 

tenth day after her initial surgery, caused Sam’s condition to deteriorate and allowed 

for the continued leakage of bowel contents into the peritoneal cavity. (Internal 

quotations omitted.) Without a repair of Sam’s bowel perforation, bowel contents 
29

continued to flow into Sam’s peritoneal cavity “with all the bacteria, chemicals[,] 

and irritants [that] allow[] [an] infection to grow and worsen.” The bowel leakage 

caused severe damage to Sam’s physiology and permanent residual damage. And 

because the infection was allowed to grow, this led to a more complicated recovery 

process for Sam, a longer hospital stay, and long-term damage. Sam could not 

recover from the bowel perforation until it was actually repaired.

Further, during the surgery to repair Sam’s bowel perforation, a diverting 

ileostomy had to be performed. According to Dr. Paine, the ileostomy was required 

because of a marked inflammatory reaction to bowel leakage for an extended length 

of time, i.e., four days after the bowel-perforation diagnosis and ten days after Sam’s 

initial surgery. Had the bowel perforation been repaired at the time it was diagnosed, 

a colostomy would have been possible.

Dr. Paine also explains that peritonitis and sepsis, which are life-threatening 

conditions, can arise from a bowel perforation, and in such cases, they will not be 

resolved until the bowel perforation is repaired. Here, because of Dr. Kuhn’s

aforementioned breaches, Sam’s peritonitis and sepsis grew worse—which is what 

happens when an infection is not properly treated and the source of the infection is 

not appropriately and timely addressed. Sam’s condition worsened and endangered 

her life.
30

In determining whether an expert’s causation opinion is conclusory, we must 

remain mindful that expert-report challenges are made at an early, pre-discovery 

stage in the litigation, not when the merits of the health care liability claim are being 

presented to the fact finder to determine liability. Puppala, 564 S.W.3d at 198. To 

provide more than a conclusory statement on causation, an expert report must 

include an “explanation tying the conclusion to the facts” and showing “how and 

why the breach caused the injury based on the facts presented.” Jelinek, 328 S.W.3d 

at 539–40; see also Puppala, 564 S.W.3d at 197. The expert report need only 

provide some basis that the defendant physician’s act or omission proximately 

caused injury. Owens v. Handyside, 478 S.W.3d 172, 187–88 (Tex. App.—Houston 

[1st Dist.] 2015, pet. denied); see also Palacios, 46 S.W.3d at 879 (explaining “a 

plaintiff need not present evidence in the report as if it were actually litigating the 

merits. . . . [T]he information in the report does not have to meet the same 

requirements as the evidence offered in a summary-judgment proceeding or at 

trial”).

Here, Dr. Paine’s causation opinion is in line with those found sufficient in 

other health-care-liability cases at this stage of the litigation where experts have 

opined that had the defendant physician not breached the standard of care, a proper 

diagnosis and medical intervention would have been achieved and the plaintiff’s 

injury, harm, or damages would have been avoided. See, e.g., Whitmire v. Feathers, 
31

No. 01-19-00094-CV, 2020 WL 4983321, at *15–16 (Tex. App.—Houston [1st 

Dist.] Aug. 25, 2020, no pet.) (mem. op.); Puppala, 564 S.W.3d at 198–202; Owens, 

478 S.W.3d at 187–91. An expert may show causation by explaining a chain of 

events that begins with the defendant physician’s negligence and ends in injury to 

the plaintiff. See Whitmire, 2020 WL 4983321, at *16; Owens, 478 S.W.3d at 189; 

McKellar v. Cervantes, 367 S.W.3d 478, 485–86 (Tex. App.—Texarkana 2012, no 

pet.); see also Christus Spohn Health Sys. Corp. v. Hinojosa, No. 04-16-00288-CV, 

2016 WL 7383819, at *6 (Tex. App.—San Antonio Dec. 21, 2016, no pet.) (mem. 

op.) (expert report specified signs and symptoms that should have prompted 

defendant physician to admit patient to hospital for treatment; expert then opined 

that if patient had been admitted at least two things would have occurred). Here, Dr. 

Paine’s expert reports explain the connection between Dr. Kuhn’s alleged negligent 

conduct and the claimed injury, harm, or damages. See THN Physicians Ass’n v. 

Tiscareno, 495 S.W.3d 599, 614 (Tex. App.—El Paso 2016, no pet.) (“[T]he expert 

must at a minimum explain the connection between [the physician’s] conduct and 

the injury to the patient.”); see also Whitmire, 2020 WL 4983321, at *16; Owens, 

478 S.W.3d at 189 (expert may show causation by explaining chain of events that 

begins with defendant physician’s negligence and ends in injury to plaintiff); 

McKellar, 367 S.W.3d at 485–86.
32

Finally, we note that Dr. Kuhn asserts that Dr. Paine’s expert reports “do not 

address whether treating conservatively, by treating the symptoms of [the] infection 

without treating the source, might have reasonably ke[pt] . . . Sam’s condition from 

worsening.” But an expert report need not address all hypothetical scenarios. See 

Whitmire, 2020 WL 4983321, at *16; VHS San Antonio Partners LLC v. Garcia, 

No. 04-09-00297-CV, 2009 WL 3223178, at *6 (Tex. App.—San Antonio Oct. 7. 

2009, pet. denied) (mem. op.). And although the law requires an expert report to 

link the expert’s conclusion on causation with the alleged breach of the standard of 

care, nothing requires the expert report to address or rule out all other possible 

scenarios. See Whitmire, 2020 WL 4983321, at *16; Garcia, 2009 WL 3223178, at 

*6; see also Owens, 478 S.W.3d at 187 (report “need not anticipate or rebut all 

possible defensive theories that may ultimately be presented” in case). The 

correctness of Dr. Paine’s opinion is not at issue in this stage of the litigation. See 

Potts, 392 S.W.3d at 632; Whitmire, 2020 WL 4983321, at *16.

We conclude that the trial court could have reasonably determined that Dr.

Paine’s expert reports represent an “objective good faith effort” to inform Dr. Kuhn 

of the causal relationship between Dr. Kuhn’s purported failure to provide care in 

accord with the appliable standard of care and the claimed injury, harm, or damages. 

See Zamarripa, 526 S.W.3d at 460 (as long as report makes “a good-faith effort to 

explain, factually, how proximate cause is going to be proven,” it satisfies TMLA’s
33

threshold requirement); Kelly v. Rendon, 255 S.W.3d 665, 679 (Tex. App.—Houston 

[14th Dist.] 2008, no pet.) (emphasizing expert reports “are simply a preliminary 

method to show a plaintiff has a viable cause of action that is not frivolous or without 

expert support”). Thus, we hold that the trial court did not err in overruling Dr. 

Kuhn’s objections and denying Dr. Kuhn’s motion to dismiss Sam’s health care 

liability claim against him on the ground that Dr. Paine’s expert reports do not 

adequately address causation as to Dr. Kuhn.

We overrule the remaining portion of Dr. Kuhn’s sole issue.19

C. Vicarious Liability Related to Women’s Healthcare

In its sole issue, Women’s Healthcare argues that the trial court erred in 

overruling its objections to Dr. Paine’s expert reports and denying its motion to 

dismiss Sam’s vicarious liability health care liability claim against it because Dr. 

Paine’s expert reports do not adequately address the standard of care and causation 

as it relates to Dr. Kuhn.

In her petition, Sam alleges that Women’s Healthcare is vicariously liable for 

the conduct of Dr. Kuhn. Generally, when a plaintiff brings health care liability 

claims against more than one defendant physician or health care provider, the expert 

report must set forth the standard of care and breach of the standard of care as to

19 Due to our disposition, we need not address Dr. Kuhn’s request for attorney’s fees 

and costs. See TEX. R. APP. P. 47.1.
34

each defendant and explain the causal relationship between each defendant’s 

individual acts or omissions and the claimed injury. See TEX. CIV. PRAC. & REM.

CODE ANN. § 74.351(a), (r)(6); Seton Family of Hosps. v. White, 593 S.W.3d 787, 

792 (Tex. App.—Austin 2019, pet. denied); Pharmacy Healthcare Sols., Ltd. v. 

Pena, 530 S.W.3d 169, 175 (Tex. App.—Eastland 2015, pet. denied). Yet, when a 

plaintiff brings a health care liability claim based on a vicarious liability theory 

against a defendant health care provider, an expert report that adequately implicates 

the actions of that party’s agent or employee is sufficient as to the defendant health 

care provider. Gardner v. U.S. Imaging, Inc., 274 S.W.3d 669, 671–72 (Tex. 2008); 

Seton Family, 593 S.W.3d at 792; see also Owens, 478 S.W.3d at 191 (“[W]hen a 

health care liability claim involves a vicarious liability theory, either alone or in 

combination with other theories, an expert report that meets the statutory standards 

as to the employee is sufficient to implicate the employer’s conduct under the 

vicarious theory.” (alteration in original) (internal quotations omitted)). In other 

words, when a health care liability claim against a defendant health care provider is 

based on vicarious liability, an expert report that meets the statutory standards as to 

an agent or employee is sufficient to implicate the health care provider’s conduct. 

Potts, 392 S.W.3d at 632; Seton Family, 593 S.W.3d at 792; see also Owens, 478 

S.W.3d at 191–92 (expert report that is sufficient as to employee or agent, on whose 
35

alleged negligent conduct vicarious liability claim was based, is also sufficient as to 

employer health care provider).

Having held that the trial court did not err in overruling Dr. Kuhn’s objections

to Dr. Paine’s expert reports and denying Dr. Kuhn’s motion to dismiss Sam’s direct

liability health care liability claim against him because Dr. Paine’s expert reports

meet the requirements of chapter 74 related to Dr. Kuhn, we hold that Sam may also 

proceed on the vicarious liability health care liability claim against Women’s 

Healthcare which is based on the conduct of Dr. Kuhn. See Potts, 392 S.W.3d at 

632; Gardner, 274 S.W.3d at 671–72; Owens, 478 S.W.3d at 191–92; see also Ctr. 

for Neurological Disorders, P.A. v. George, 261 S.W.3d 285, 295 (Tex. App.—Fort 

Worth 2008, pet. denied) (“[I]f the expert report is sufficient as to the claims against

Dr. Ward, and we have held that it is[,] . . . then the report is sufficient as to [the]

claims against CND that are based on Dr. Ward’s alleged negligence.”).

We overrule Women’s Healthcare’s sole issue.

Dr. James and Metropolitan Houston

In his sole issue, Dr. James argues that the trial court erred in overruling his 

objections to Dr. Paine’s expert reports and denying his motion to dismiss Sam’s 

health care liability claim against him because Dr. Paine is not qualified to offer an 

opinion on the standard of care and causation related to Dr. James and Dr. Paine’s 

expert reports do not adequately address causation as it relates to Dr. James. In its 
36

sole issue, Metropolitan Houston argues that the trial court erred in overruling its 

objections to Dr. Paine’s expert reports and denying its motion to dismiss Sam’s 

vicarious liability health care liability claim against it because Dr. Paine is not 

qualified to offer an opinion on the standard of care and causation related to Dr. 

James and Dr. Paine’s expert reports do not adequately address causation as it relates 

to Dr. James.

A. Dr. Paine’s Qualifications Related to Standard of Care

In a portion of his sole issue, Dr. James argues that Dr. Paine is not qualified 

to offer an opinion on the standard of care related to Dr. James because Dr. Paine’s 

expert reports and CV do not “reflect that he is qualified . . . to opine on the standard 

of care for a consulting surgeon such as Dr. James with respect to surgical 

post-operative management of a patient who has undergone a hysterectomy with a 

bowel perforation.” Dr. James further asserts that his practice area is general 

surgery, while Dr. Paine’s practice area is obstetrics and gynecology, and “the fact 

that Dr. Paine is familiar with post-operative care for hysterectomy patients does not 

mean that he is knowledgeable about the standard of care applicable to a general 

surgeon . . . who is consulted in the circumstances presented in this case.” 

An expert report by a person not qualified to testify does not constitute a 

good-faith effort to comply with the TMLA’s definition of an expert report and 

warrants dismissal. See Mettauer, 326 S.W.3d at 693; Hendrick Med. Ctr. v. 
37

Conger, 298 S.W.3d 784, 789 (Tex. App.—Eastland 2009, no pet.) (where expert 

not qualified to offer opinion, expert report is rendered deficient); see also TEX. CIV.

PRAC. & REM.CODE ANN. § 74.351(l), (r)(6). Whether an expert witness is qualified 

to offer an expert opinion lies within the sound discretion of the trial court. Cornejo, 

446 S.W.3d at 121. The expert’s qualifications must appear in the four corners of 

the expert report or in the expert’s accompanying CV. Puppala, 564 S.W.3d at 197, 

202; see also Cornejo, 446 S.W.3d at 121.

In a suit involving a health care liability claim against a physician, a person is 

qualified as an expert on the issue of whether the physician departed from the 

accepted standard of care, if the expert is a physician who:

1. is practicing medicine[20]at the time such testimony is given or 

was practicing medicine at the time the claim arose;

2. has knowledge of accepted standards of medical care for the 

diagnosis, care, or treatment of the illness, injury, or condition 

involved in the claim; and

3. is qualified on the basis of training or experience to offer an 

expert opinion regarding those accepted standards of medical 

care.

20 “[P]racticing medicine . . . includes, but is not limited to, training residents or 

students at an accredited school of medicine or osteopathy or serving as a consulting 

physician to other physicians who provided direct patient care, upon the request of 

such other physicians.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.401(b) (internal 

quotations omitted).
38

TEX. CIV. PRAC. & REM. CODE ANN. § 74.401(a); see also id. § 74.351(r)(5)(A) 

(“[e]xpert” means “with respect to a person giving opinion testimony regarding 

whether a physician departed from accepted standards of medical care, an expert 

qualified to testify under the requirements of [s]ection 74.401” (internal quotations 

omitted); Methodist Hosp. v. Addison, 574 S.W.3d 490, 503 (Tex. App.—Houston 

[14th Dist.] 2018, no pet.). In determining whether a witness is “qualified on the 

basis of training or experience” to offer an expert opinion about the applicable 

standard of medical care,

the court shall consider whether, at the time the claim arose or at the 

time the testimony is given, the witness: (1) is board certified or has 

other substantial training or experience in an area of medical practice 

relevant to the claim; and (2) is actively practicing medicine in 

rendering medical care services relevant to the claim.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.401(c).

A physician serving as an expert need not be a specialist in the particular area

of the profession for which his testimony is offered. See Owens, 478 S.W.3d at 185; 

Rittger v. Danos, 332 S.W.3d 550, 558–59 (Tex. App.—Houston [1st Dist.] 2009, 

no pet.); see also Bailey v. Amaya Clinic Inc., 402 S.W.3d 359, 363–64 (Tex. App.—

Houston [14th Dist.] 2013, no pet.) (orthopedic surgeon qualified to opine about 

standard of care applicable to dermatologist who was treating plaintiff for weight 

loss with liposuction); Blan v. Ali, 7 S.W.3d 741, 745–46 (Tex. App.—Houston 

[14th Dist.] 1999, no pet.) (“Despite the fact that we live in a world of niche medical 
39

practices and multilayer specializations, there are certain standards of medical care 

that apply to multiple schools of practice and any medical [physician]. To 

categorically disqualify a physician from testifying as to the standard of care solely 

because he is from a different school of practice than the [physicians] charged with 

malpractice ignores the criteria set out in [TMLA] and [Texas] Rule [of Evidence]

702.”). The plain language of the TMLA does not focus on the physician’s area of 

expertise, but on the particular condition or circumstances involved in the plaintiff’s 

claim. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.401(a)(2); Rittger, 332 S.W.3d 

at 558; see also Lee v. Le, No. 01-18-00309-CV, 2018 WL 4923938, at *4 (Tex. 

App.—Houston [1st Dist.] Oct. 11, 2018, no pet.) (mem. op.) (“[T]he applicable 

standard of care and an expert’s ability to opine on it are dictated by the medical 

condition involved in the claim and the expert’s familiarity and experience with that 

condition.” (internal quotations omitted)). The critical inquiry is whether the 

expert’s expertise goes to the very matter on which he is to give an opinion. See 

Broders, 924 S.W.2d at 152–53; Mangin, 480 S.W.3d at 707. It is Sam’s burden to 

show that Dr. Paine is qualified to opine on the applicable standard of care as to Dr. 

James. See Rittger, 332 S.W.3d at 558–59; Mem’l Hermann Healthcare Sys. v. 

Burrell, 230 S.W.3d 755, 757, 762 (Tex. App.—Houston [14th Dist.] 2007, no pet.).

Dr. Paine’s expert reports and CV show that he is a licensed physician and is 

board certified in obstetrics and gynecology. He has been practicing medicine in the 
40

field of obstetrics and gynecology for thirty-five years. Currently, he is a member 

of the teaching faculty as an associate professor in the department of obstetrics and 

gynecology at the University of Texas Health Science Center in San Antonio. In his 

position as an associate professor, he trains residents and students in obstetrics and 

gynecology. He is actively practicing medicine in the field of obstetrics and 

gynecology, and he was practicing medicine at the time Sam’s claims arose. See

TEX. CIV. PRAC. & REM. CODE ANN. § 74.401.

Dr. Paine has extensive experience in the field of obstetrics and gynecology, 

and he has performed thousands of hysterectomies during his career. He has 

knowledge of the accepted standards of medical and surgical care required for 

patients needing hysterectomies. This includes knowledge of the standards of 

pre-operative, inter-operative, and post-operative care required for patients who 

have hysterectomies.

When Dr. Paine treats patients requiring hysterectomies, he provides 

pre-operative, inter-operative, and post-operative care to his patients. Post-operative 

care includes “following [a] patient after [a] surgery is complete[] to diagnose and 

treat any complications that may arise from the surgical procedure.” This case 

involves the purported failure of appellants, including Dr. James, to appropriately 

care for and treat Sam after a hysterectomy, and Dr. Paine is familiar with the type 

of post-operative care a patient, such as Sam, should receive and how post-operative 
41

complications, like those experienced by Sam, should be managed and treated. See 

Broders, 924 S.W.2d at 152–53 (focus is on “whether the expert’s expertise goes to 

the very matter on which he . . . is to give an opinion”); Baylor Univ. Med. Ctr. v. 

Biggs, 237 S.W.3d 909, 916 (Tex. App.—Dallas 2007, pet. denied) (“[T]he focus is 

on the fit between the subject matter at issue and the expert’s familiarity with it, not 

on a comparison of the expert’s title or specialty with that of the defendant . . . .”

(internal quotations omitted)); see also Owens, 478 S.W.3d at 186–87 (specific issue 

in case was whether defendant physicians failed to timely and appropriately 

diagnose and treat plaintiff’s condition and expert report showed that expert had 

experience treating patients with condition suffered by plaintiff and he was familiar 

with the standard of care applicable to physicians who care for patients with same 

condition with which plaintiff presented).

We note that as to the standard of care and breach of the of the standard of 

care for Dr. James, Dr. Paine, in his expert reports, states that bowel injuries, like a 

bowel perforation, are a well-known complication of a hysterectomy. On average 

they occur in one out of every 700 cases. But if a hysterectomy is performed when 

adhesions are present and when an extensive bowel dissection is also required, the 

rate of bowel injuries increases. A bowel perforation should be diagnosed three days 

after a hysterectomy.
42

According to Dr. Paine, Dr. James was the general surgeon 

“following . . . Sam[] post-hysterectomy.” Because Dr. James was the general 

surgeon “following” Sam after her surgery, once Sam’s bowel perforation was 

diagnosed on the sixth day after her surgery, the standard of care required Dr. James 

to act upon the diagnosis by surgically repairing the bowel perforation immediately 

or at least recommending surgical repair of the bowel perforation. But Dr. James 

did not do so, and instead joined in the “conservative” treatment plan with Dr. Kuhn. 

(Internal quotations omitted.) There is no precedent for “conservative management” 

of a bowel perforation when there is evidence of bowel contents and gas free in the 

peritoneal cavity. (Internal quotations omitted.) By failing to recommend surgical 

repair of Sam’s bowel perforation and by failing to surgically repair the bowel 

perforation immediately, Dr. James breached the standard of care. Further, Dr. 

James breached the standard of care by waiting until the tenth day after Sam’s initial 

surgery to return Sam to surgery to repair the bowel perforation because it should 

have been repaired immediately upon its diagnosis.

Here, we conclude that Sam has met her burden of establishing that Dr. Paine 

is qualified to offer an opinion on the standard of care related to Dr. James. See TEX.

CIV. PRAC. & REM. CODE ANN. § 74.401(a) (expert meets requirements of Texas 

Civil Practice and Remedies Code [section] 74.401 if he (1) is practicing medicine, 

(2) has knowledge of accepted standard of care for diagnosis, care, or treatment of 
43

illness, injury, or condition involved in claim, and (3) is qualified on basis of training 

or experience to offer expert opinion about accepted standard of care); Lee, 2018 

WL 4923938, at *4 (“[T]he applicable standard of care and an expert’s ability to 

opine on it are dictated by the medical condition involved in the claim and the 

expert’s familiarity and experience with that condition.” (internal quotations 

omitted)). The Texas Supreme Court has cautioned reviewing courts from drawing 

expert qualifications too narrowly, as Dr. James has requested us to do in this case, 

and we reemphasize that a proffered expert need not practice in the same specialty

as the defendant physician to qualify as an expert in the case. See Larson v. 

Downing, 197 S.W.3d 303, 305 (Tex. 2006); Roberts v. Williamson, 111 S.W.3d 

113, 122 (Tex. 2003); see also Owens, 478 S.W.2d at 186; Blan, 7 S.W.3d at 745 

(general surgeon qualified to testify about standard of care for post-operative 

procedures performed by gynecologist because post-operative procedures are 

common to both fields).

We hold that the trial court did not err in overruling Dr. James’s objections

and denying Dr. James’s motion to dismiss Sam’s health care liability claim against 

him on the ground that Dr. Paine is not qualified to offer an opinion on the standard 

of care related to Dr. James.

We overrule this portion of Dr. James’s sole issue.
44

B. Dr. Paine’s Qualifications Related to Causation

In another portion of his sole issue, Dr. James argues that Dr. Paine is not 

qualified to offer an opinion on causation related to Dr. James because Dr. Paine’s 

expert reports and CV do not show that Dr. Paine has “experience in handling 

patients with peritonitis and sepsis secondary to a bowel perforation” or that he has 

the qualifications “to opine on the cause of [Sam’s] alleged damages” and the 

ramifications of the “alleged four[-]day delay in [the] surgical repair of [Sam’s] 

bowel perforation.”

To be qualified to opine on the causal relationship between a defendant 

physician’s alleged failure to meet an applicable standard of care and the plaintiff’s 

claimed injury, harm, or damages, the author of an expert report must be a physician 

who is qualified to render opinions on such causal relationships under the Texas 

Rules of Evidence. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.403(a); see id.

§ 74.351(r)(5)(C) (“[e]xpert” means “with respect to a person giving opinion 

testimony about the causal relationship between the injury, harm, or damages 

claimed and the alleged departure from the applicable standard of care in any health 

care liability claim, a physician who is otherwise qualified to render opinions on 

such causal relationship under the Texas Rules of Evidence” (internal quotations 

omitted)); Cornejo, 446 S.W.3d at 120.
45

An expert witness may be qualified on the basis of knowledge, skill, 

experience, training, or education to testify on scientific, technical, or other 

specialized subjects if the testimony would “assist the trier of fact” in understanding 

the evidence or determining a fact issue. Cornejo, 446 S.W.3d at 121 (internal 

quotations omitted); see TEX. R. EVID. 702. Thus, a plaintiff must show that her

expert has “knowledge, skill, experience, training, or education” about the specific 

issue before the court that would qualify the expert to give an opinion on that 

particular subject. Broders, 924 S.W.2d at 153–54 (internal quotations omitted); see 

also Cornejo, 446 S.W.3d at 121.

Not every licensed physician is qualified to testify on every medical question. 

See Broders, 942 S.W.2d at 152–53; Cornejo, 446 S.W.3d at 121. Yet, a physician 

need not practice in the particular field about which he is testifying so long as he can 

demonstrate that he has knowledge, skill, experience, training, or education about 

the specific issue before the court that would qualify him to give an opinion on that 

subject. Cornejo, 446 S.W.3d at 121. Simply put, what is required is that the 

physician demonstrate that he is qualified to opine on the specific issue before the 

court. Puppala, 564 S.W.3d at 202.

Here it is asserted that Dr. James was the general surgeon 

“following . . . Sam[] post-hysterectomy.” Because Dr. James was the general 

surgeon “following” Sam after her surgery, once Sam’s bowel perforation was 
46

diagnosed on the sixth day after her surgery, Dr. James should have acted upon the 

diagnosis by surgically repairing the bowel perforation immediately or at least 

recommending surgical repair of the bowel perforation. Instead, Dr. James joined 

in the “conservative” treatment plan with Dr. Kuhn, although there is no precedent 

for “conservative management” of a bowel perforation when there is evidence of 

bowel contents and gas free in the peritoneal cavity. (Internal quotations omitted.) 

By failing to recommend surgical repair of Sam’s bowel perforation and by failing 

to surgically repair the bowel perforation immediately, Dr. James breached the 

standard of care. Dr. James also breached the standard of care by waiting until the 

tenth day after Sam’s initial surgery to return Sam to surgery to repair the bowel 

perforation because it should have been repaired immediately upon its diagnosis.

It is also asserted that Dr. James’s breaches of the standard of care caused 

Sam’s condition to worsen and endangered her life. A bowel perforation is a surgical 

emergency that requires immediate intervention. Immediate exploration, wash out 

of the peritoneal cavity, and repair of the bowel perforation is required. Any course 

of action other than immediate exploration, wash out, and repair, causes worsening 

peritonitis, sepsis, and possible death. Dr. James’s failure to recommend surgical 

exploration and repair of Sam’s bowel perforation upon its diagnosis, to not 

immediately repair the bowel perforation upon its diagnosis, and to not repair Sam’s 

bowel perforation until the tenth day after her initial surgery caused Sam’s condition 
47

to deteriorate and allowed for the continued leakage of bowel contents into the 

peritoneal cavity. Without a repair of Sam’s bowel perforation, bowel contents 

continued to flow into Sam’s peritoneal cavity “with all the bacteria, chemicals[,] 

and irritants [that] allow[] [an] infection to grow and worsen.” The bowel leakage 

caused severe damage to Sam’s physiology and permanent residual damage, and it 

allowed for Sam’s peritonitis and sepsis to grow worse. And because Sam’s 

infection was allowed to grow, this led to a more complicated recovery process for 

Sam, a longer hospital stay, and long-term damage. Sam could not recover from the 

bowel perforation until it was actually repaired.

Further, during the surgery to repair Sam’s bowel perforation, a diverting 

ileostomy had to be performed. The ileostomy was required because of a marked 

inflammatory reaction to bowel leakage for an extended length of time, i.e., four 

days after the bowel-perforation diagnosis and ten days after Sam’s initial surgery. 

Had the bowel perforation been repaired at the time it was diagnosed, a colostomy 

would have been possible.

Sam has the burden of establishing that Dr. Paine has “knowledge, skill, 

experience, training, or education” about whether Dr. James’s breaches of the 

standard of care—by failing to recommend surgical exploration and repair of Sam’s 

bowel perforation upon its diagnosis, not immediately repairing the bowel 

perforation upon its diagnosis, and not repairing Sam’s bowel perforation until the 
48

tenth day after Sam’s initial surgery—caused Sam’s claimed injury, harm, or 

damages. See Matagorda v. Nursing & Rehab. Ctr., L.L.C. v. Brooks, No. 

13-16-00266-CV, 2017 WL 127867, at *6 (Tex. App.—Corpus Christi–Edinburg 

Jan. 12, 2017, no pet.) (mem. op.) (internal quotations omitted); Diagnostic 

Research Grp. v. Vora, 473 S.W.3d 861, 869–70 (Tex. App.—San Antonio 2015, 

no pet.); see also Cornejo, 446 S.W.3d at 121 (plaintiffs required to establish expert 

qualified on basis of knowledge, skill, experience, training, or education to offer 

opinion concerning causal link between alleged breaches of standard of care and 

injuries suffered); Burrell, 230 S.W.3d at 757, 762 (party offering witness as expert 

must establish witness is qualified).

In his expert reports, Dr. Paine states that he is a licensed physician and is 

board certified in obstetrics and gynecology. He has been practicing in the field of 

obstetrics and gynecology for thirty-five years. Currently, he is a member of the 

teaching faculty as an associate professor in the department of obstetrics and 

gynecology at the University of Texas Health Science Center in San Antonio. In his 

position as an associate professor, he trains residents and students in obstetrics and 

gynecology.

Dr. Paine is actively practicing medicine in the field of obstetrics and 

gynecology, and he was practicing medicine at the time Sam’s claims arose. Dr. 

Paine has extensive experience in the field of obstetrics and gynecology, and he, as 
49

part of his medical practice, has performed thousands of hysterectomies during his 

career. He has knowledge of the accepted standards of medical and surgical care 

required for patients needing hysterectomies. This includes knowledge of the 

standards of pre-operative, inter-operative, and post-operative care required for 

patients who have hysterectomies.

When Dr. Paine treats patients requiring hysterectomies, he provides 

pre-operative, inter-operative, and post-operative care to his patients. Post-operative 

care includes “following [a] patient after [a] surgery is complete[] to diagnose and 

treat any complications that may arise from the surgical procedure.” This case 

involves the purported failure of appellants, including Dr. James, to appropriately 

care for and treat Sam after a hysterectomy, and Dr. Paine is familiar with the type 

of post-operative care a patient, such as Sam, should receive and how post-operative 

complications, like those experienced by Sam, should be managed and treated.

We conclude that Dr. Paine’s expert reports and CV demonstrate that he is 

qualified to offer an opinion on the causal link between Dr. James’s alleged breaches

while providing post-operative care after Sam’s hysterectomy and Sam’s injuries, 

harm, and damages. See Jassin v. Bennett, No. 10-12-00053-CV, 2012 WL 

5974020, at *5 (Tex. App.—Waco Nov. 29, 2012, no pet.) (mem. op.) (“We cannot 

say that the trial court abused its discretion in . . . finding that Dr. Branch is qualified 

to provide an expert report on causation for the complications that allegedly arose 
50

from Dr. Jassin’s post-operative care following a sinus surgery that Dr. Branch says 

he has performed approximately 200 times, along with providing the follow-up care 

for those surgeries.”); Sloman-Moll v. Chavez, No. 04-06-00589-CV, 2007 WL 

595134, at *3–4 (Tex. App.—San Antonio Feb. 28, 2007, pet. denied) (mem. op.) 

(“It is axiomatic that a physician trained to perform a surgery is also trained to 

manage surgical complications.”); Keo v. Vu, 76 S.W.3d 725, 733 (Tex. App.—

Houston [1st Dist.] 2002, pet. denied) (holding physician who regularly performed 

surgery on head and neck was qualified to give opinion about issues common to all 

surgeries, including treatment of post-operative infections); see also Columbia N. 

Hills Hosp. Subsidiary, L.P. v. Alvarez, 382 S.W.3d 619, 630 (Tex. App.—Fort 

Worth 2012, pet. denied) (“[A] physician needs only to show how he is qualified to 

opine on the cause of the plaintiff’s injury.”).

Further, because we have concluded that that the trial court properly

determined that Dr. Paine is qualified to offer an opinion on the standard of care as 

to Dr. James, it would have been reasonable for the trial court to also conclude that 

Dr. Paine is qualified to offer an opinion on Dr. James’s failure to meet the standard

of care and the resulting harm. See Healy v. Mowat-Cudd, No. 04-20-00479-CV, 

2021 WL 603369, at *2 n.1 (Tex. App.—San Antonio Feb. 17, 2021, no pet.) (mem. 

op.); Legend Oaks-S. San Antonio, LLC v. Molina ex rel. Estates of Rocamontes, No. 

04-14-00289-CV, 2015 WL 693225, at *5 (Tex. App.—San Antonio Feb. 18, 2015, 
51

no pet.) (mem. op.); Jassin, 2012 WL 5974020, at *5; Hillcrest Baptist Med. Ctr. v. 

Payne, No. 10-11-00191-CV, 2011 WL 5830469, at *7 (Tex. App.—Waco Nov. 16, 

2011, pet. denied) (mem. op.); Whisenant v. Arnett, 339 S.W.3d 920, 927–28 (Tex. 

App.—Dallas 2011, no pet.).

We hold that the trial court did not err in overruling Dr. James’s objections 

and denying Dr. James’s motion to dismiss Sam’s health care liability claim against 

him on the ground that Dr. Paine is not qualified to offer an opinion on causation

related to Dr. James.

We overrule this portion of Dr. James’s sole issue.

C. Causation Related to Dr. James

In the remaining portion of his sole issue, Dr. James argues that Dr. Paine’s 

expert reports do not adequately address causation as it relates to him because the 

expert reports do not establish a causal link between Dr. James’s conduct and Sam’s 

injuries, Dr. Paine’s causation opinion is conclusory and speculative, and “Dr. Paine 

fails to establish that ‘but for’ Dr. James’[s] alleged negligence, Sam’s outcome 

would have been any different.”

An expert report must provide a “fair summary” of the expert’s opinion about

the causal relationship between the failure of a defendant physician to provide care 

in accord with the applicable standard of care and the plaintiff’s claimed injury, 

harm, or damages. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6); see also 
52

Potts, 392 S.W.3d at 630. The expert report must explain how and why the 

defendant physician’s breach of the standard of care proximately caused the 

plaintiff’s injury. Zamarripa, 526 S.W.3d at 459–60. An expert report need not 

marshal all the plaintiff’s proof necessary to establish causation at trial, and it need 

not anticipate or rebut all possible defensive theories that may ultimately be 

presented to the trial court. Wright, 79 S.W.3d at 52; Cornejo, 446 S.W.3d at 123. 

But an expert cannot simply opine that the breach caused the injury. Jelinek, 328 

S.W.3d at 539.

Causation consists of two components: (1) cause-in-fact and 

(2) foreseeability. McCoy, 554 S.W.3d at 658. A defendant physician’s breach was 

a cause-in-fact of the plaintiff’s injury if the breach was a substantial factor in 

bringing about the harm, and absent the breach the harm would not have occurred. 

Id. Even if the harm would not have occurred absent the defendant physician’s

breach, “the connection between the defendant and the plaintiff’s injuries simply 

may be too attenuated” for the breach to qualify as a substantial factor. Allways Auto 

Grp., 530 S.W.3d at 149 (internal quotations omitted). A breach is not a substantial

factor if it “does no more than furnish the condition that makes the plaintiff’s injury 

possible.” Id. A defendant physician’s breach is a foreseeable cause of the 

plaintiff’s injury if a physician of ordinary intelligence would have anticipated the 

danger caused by the negligent act or omission. Puppala, 564 S.W.3d at 197.
53

As to standard of care and breach of the standard of care related to Dr. James, 

Dr. Paine, in his expert reports, states that bowel injuries, like a bowel perforation, 

are a well-known complication of a hysterectomy. On average they occur in one out 

of every 700 cases. But if a hysterectomy is performed when adhesions are present 

and when an extensive bowel dissection is also required, the rate of bowel injuries 

increases. 

Because Dr. James was the general surgeon “following . . . Sam[] 

post-hysterectomy,” once Sam’s bowel perforation was diagnosed on the sixth day 

after surgery, the standard of care required Dr. James to act upon the diagnosis by 

surgically repairing the bowel perforation immediately or at least recommending

surgical repair of the bowel perforation. But James did not do so. Instead, he joined 

in the “conservative” treatment plan with Dr. Kuhn. (Internal quotations omitted.) 

There is no precedent for “conservative management” of a bowel perforation when 

there is evidence of bowel contents and gas free in the peritoneal cavity. (Internal 

quotations omitted.) By failing to recommend surgical repair of Sam’s bowel 

perforation and failing to surgically repair the bowel perforation immediately after 

its diagnosis, Dr. James breached the standard of care. Dr. James also breached the 

standard of care by waiting until the tenth day after Sam’s initial surgery to return 

Sam to surgery to repair the bowel perforation because it should have been repaired 

immediately upon its diagnosis.
54

As to causation, Dr. Paine, in his expert reports, states that because of the 

aforementioned breaches of the standard of care by Dr. James, Sam’s condition 

worsened and endangered her life. Dr. Paine explained that a bowel perforation is a 

surgical emergency that requires immediate intervention. Immediate exploration, 

wash out of the peritoneal cavity, and repair of the bowel perforation is required. 

Any course of action other than immediate exploration, wash out, and repair, causes 

worsening peritonitis, sepsis, and possible death. According to Dr. Paine, Dr.

James’s failure to recommend surgical exploration and repair of Sam’s bowel 

perforation upon its diagnosis, to not surgically repair the bowel perforation 

immediately upon its diagnosis, and to not repair Sam’s bowel perforation until the 

tenth day after her initial surgery caused Sam’s condition to deteriorate and allowed 

for the continued leakage of bowel contents into the peritoneal cavity. Without a 

repair of Sam’s bowel perforation, bowel contents continued to flow into Sam’s

peritoneal cavity “with all the bacteria, chemicals[,] and irritants [that] allow[] [an]

infection to grow and worsen.” The bowel leakage caused severe damage to Sam’s 

physiology and permanent residual damage. And because the infection was allowed 

to grow, this led to a more complicated recovery process for Sam, a longer hospital 

stay, and long-term damage. Sam could not recover from the bowel perforation until 

it was actually repaired.
55

Further, during the surgery to repair Sam’s bowel perforation, a diverting 

ileostomy had to be performed. According to Dr. Paine, the ileostomy was required 

because of a marked inflammatory reaction to bowel leakage for an extended length 

of time, i.e., four days after the bowel-perforation diagnosis and ten days after Sam’s 

initial surgery. Had the bowel perforation been repaired at the time it was diagnosed, 

a colostomy would have been possible.

Dr. Paine also explains that peritonitis and sepsis, which are life-threatening 

conditions, can arise from a bowel perforation, and in such cases, they will not be 

resolved until the bowel perforation is repaired. Here, because of Dr. James’s 

breaches of the standard of care, Sam’s peritonitis and sepsis grew worse—which is 

what happens when an infection is not properly treated and the source of the 

infection is not appropriately and timely addressed. Sam’s condition worsened and 

endangered her life.

In determining whether an expert’s causation opinion is conclusory, we must 

remain mindful that expert-report challenges are made at an early, pre-discovery 

stage in the litigation, not when the merits of the health care liability claim are being 

presented to the fact finder to determine liability. Puppala, 564 S.W.3d at 198. To 

provide more than a conclusory statement on causation, an expert report must simply 

include an “explanation tying the conclusion to the facts” and showing “how and 

why the breach caused the injury based on the facts presented.” Jelinek, 328 S.W.3d 
56

at 539–40; see also Puppala, 564 S.W.3d at 197. The expert report need only 

provide some basis that the defendant physician’s act or omission proximately 

caused injury. Owens, 478 S.W.3d at 187–88; see also Palacios, 46 S.W.3d at 879 

(explaining “a plaintiff need not present evidence in the report as if it were actually 

litigating the merits. . . . [T]he information in the report does not have to meet the 

same requirements as the evidence offered in a summary-judgment proceeding or at 

trial”).

Here, Dr. Paine’s causation opinion is in line with those found sufficient in

other health-care-liability cases at this stage of the litigation where experts have 

opined that had the defendant physician not breached the standard of care, a proper 

diagnosis and medical intervention would have been achieved and the plaintiff’s 

injury, harm, or damages would have been avoided. See, e.g., Whitmire, 2020 WL 

4983321, at *15–16; Puppala, 564 S.W.3d at 198–202; Owens, 478 S.W.3d at 187–

91. An expert may show causation by explaining a chain of events that begins with 

the defendant physician’s negligence and ends in injury to the plaintiff. See

Whitmire, 2020 WL 4983321, at *16; Owens, 478 S.W.3d at 189; McKellar, 367 

S.W.3d at 485–86; see also Hinojosa, 2016 WL 7383819, at *6 (expert report 

specified signs and symptoms that should have prompted defendant physician to 

admit patient to hospital for treatment; expert then opined that if patient had been 

admitted at least two things would have occurred). Dr. Paine’s expert reports explain 
57

the connection between Dr. James’s alleged negligent conduct and the claimed 

injury, harm, or damages. See Tiscareno, 495 S.W.3d at 614 (“[T]he expert must at 

a minimum explain the connection between [the physician’s] conduct and the injury 

to the patient.”); see also Whitmire, 2020 WL 4983321, at *16; Owens, 478 S.W.3d 

at 189 (expert may show causation by explaining chain of events that begins with 

defendant physician’s negligence and ends in injury to plaintiff); McKellar, 367 

S.W.3d at 485–86.

Finally, we note that Dr. James asserts that Dr. Paine’s expert reports do not 

establish that without Dr. James’s purported negligence “Sam’s outcome would have 

been any different.” But an expert report need not address all hypothetical scenarios. 

See Whitmire, 2020 WL 4983321, at *16; Garcia, 2009 WL 3223178, at *6. And 

although the law requires an expert report to link the expert’s conclusion on 

causation with the alleged breach of the standard of care, nothing requires the expert 

report to address or rule out all other possible scenarios. See Whitmire, 2020 WL 

4983321, at *16; Garcia, 2009 WL 3223178, at *6; see also Owens, 478 S.W.3d at 

187 (report “need not anticipate or rebut all possible defensive theories that may 

ultimately be presented” in case). The correctness of Dr. Paine’s opinion is not at 

issue in this stage of the litigation. See Potts, 392 S.W.3d at 632; Whitmire, 2020 

WL 4983321, at *16.
58

We conclude that the trial court could have reasonably determined that Dr. 

Paine’s expert reports represent an “objective good faith effort” to inform Dr. James 

of the causal relationship between Dr. James’s purported failure to provide care in 

accord with the appliable standard of care and the claimed injury, harm, or damages. 

See Zamarripa, 526 S.W.3d at 460 (as long as report makes “a good-faith effort to 

explain, factually, how proximate cause is going to be proven,” it satisfies TMLA’s

threshold requirement); Kelly, 255 S.W.3d at 679 (emphasizing expert reports “are 

simply a preliminary method to show a plaintiff has a viable cause of action that is 

not frivolous or without expert support”). Thus, we hold that the trial court did not 

err in overruling Dr. James’s objections and denying Dr. James’s motion to dismiss 

Sam’s health care liability claim against him on the ground that Dr. Paine’s expert 

reports do not adequately address causation as to Dr. James.

We overrule the remaining portion of Dr. James’s sole issue.21

D. Vicarious Liability Related to Metropolitan Houston

In its sole issue, Metropolitan Houston argues that the trial court erred in 

overruling its objections to Dr. Paine’s expert reports and denying its motion to 

dismiss Sam’s vicarious liability health care liability claim against it because Dr. 

Paine is not qualified to offer an opinion on the standard of care and causation related 

21 Due to our disposition, we need not address Dr. James’s request for attorney’s fees 

and costs. See TEX. R. APP. P. 47.1.
59

to Dr. James and Dr. Paine’s expert reports do not adequately address causation as 

it relates to Dr. James.

In her petition, Sam alleges that Metropolitan Houston is vicariously liable for 

the conduct of Dr. James. Generally, when a plaintiff brings health care liability 

claims against more than one defendant physician or health care provider, the expert 

report must set forth the standard of care and breach of the standard of care as to

each defendant and explain the causal relationship between each defendant’s 

individual acts or omissions and the claimed injury. See TEX. CIV. PRAC. & REM.

CODE ANN. § 74.351(a), (r)(6); Seton Family, 593 S.W.3d at 792; Pena, 530 S.W.3d 

at 175. Yet, when a plaintiff brings a health care liability claim based on a vicarious

liability theory against a defendant health care provider, an expert report that 

adequately implicates the actions of that party’s agent or employee is sufficient as 

to the defendant health care provider. Gardner, 274 S.W.3d at 671–72; Seton 

Family, 593 S.W.3d at 792; see also Owens, 478 S.W.3d at 191 (“[W]hen a health 

care liability claim involves a vicarious liability theory, either alone or in 

combination with other theories, an expert report that meets the statutory standards 

as to the employee is sufficient to implicate the employer’s conduct under the 

vicarious theory.” (alteration in original) (internal quotations omitted)). In other 

words, when a health care liability claim against a defendant health care provider is 

based on vicarious liability, an expert report that meets the statutory standards as to 
60

an agent or employee is sufficient to implicate the health care provider’s conduct. 

Potts, 392 S.W.3d at 632; Seton Family, 593 S.W.3d at 792; see also Owens, 478 

S.W.3d at 191–92 (expert report that is sufficient as to employee or agent, whose 

alleged negligent conduct vicarious liability claim was based, is also sufficient as to 

employer health care provider).

Having held that the trial court did not err in overruling Dr. James’s objections 

to Dr. Paine’s expert reports and denying Dr. James’s motion to dismiss Sam’s direct

liability health care liability claim against him because Dr. Paine’s expert reports 

meet the requirements of chapter 74 related to Dr. James, we hold that Sam may also 

proceed on the vicarious liability health care liability claim against Metropolitan 

Houston which is based on the conduct of Dr. James. See Potts, 392 S.W.3d at 632; 

Gardner, 274 S.W.3d at 671–72; Owens, 478 S.W.3d at 191–92; see also George, 

261 S.W.3d at 295 (“[I]f the expert report is sufficient as to the claims against Dr. 

Ward, and we have held that it is[,] . . . then the report is sufficient as to [the] claims 

against CND that are based on Dr. Ward’s alleged negligence.”).

We overrule Metropolitan Houston’s sole issue.22

22 Due to our disposition, we need not address Metropolitan Houston’s request for 

attorney’s fees and costs. See TEX. R. APP. P. 47.1.
61

Dr. Morales, West Houston Radiology, and Radiology Partners

In his sole issue, Dr. Morales argues that the trial court erred in overruling his 

objections to Dr. Paine’s expert reports and denying his motion to dismiss Sam’s 

health care liability claim against him because Dr. Paine is not qualified to offer an 

opinion on the standard of care and causation related to Dr. Morales and Dr. Paine’s 

expert reports do not adequately address causation as it relates to Dr. Morales. In 

their sole issues, West Houston Radiology and Radiology Partners argue that the 

trial court erred in overruling their objections to Dr. Paine’s expert reports and 

denying their motions to dismiss Sam’s vicarious liability health care liability claim 

against them because Dr. Paine is not qualified to offer an opinion on the standard 

of care and causation related to Dr. Morales and Dr. Paine’s expert reports do not 

adequately address causation as it relates to Dr. Morales.

A. Preservation

In portions of their sole issues, Dr. Morales, West Houston Radiology, and 

Radiology Partners argue that the trial court erred in overruling their objections to 

Dr. Paine’s expert reports and in denying their motions to dismiss Sam’s health care 

liability claims against them because Dr. Paine is not qualified to offer an opinion 

on the standard of care related to Dr. Morales and Dr. Paine’s expert reports do not 

adequately address causation as it relates to Dr. Morales.
62

To preserve a complaint for appellate review, the record must show that the 

complaint was made to the trial court by a timely request, objection, or motion and 

the trial court either ruled on the party’s request, objection, or motion, or refused to 

rule, and the party objected to that refusal. TEX. R. APP. P. 33.1(a). If a party fails 

to do this, error is not preserved, and the complaint is waived. Bushell v. Dean, 803 

S.W.2d 711, 712 (Tex. 1991); see also Humble Surgical Hosp., LLC v. Davis, 542 

S.W.3d 12, 21 (Tex. App.—Houston [14th Dist.] 2017, pet. denied) (“Rule 33.1 

requires the appealing party to adequately raise issues before the trial court to give 

the trial court notice of [the party’s] complaint.”).

Texas Civil Practice and Remedies Code section 74.351(a) states, in pertinent 

part, that a defendant physician or health care provider “whose conduct is implicated 

in a[n] [expert] report must file and serve any objection to the sufficiency of the 

report not later than the 21st day after the date the report is served or the 21st day 

after the date the defendant’s answer is filed” and the failure to do so waives the 

defendant’s objections. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a). In the 

trial court, Dr. Morales, West Houston Radiology, and Radiology Partners timely

objected to Dr. Paine’s expert reports and requested that Sam’s health care liability 

claims against them be dismissed. In doing so, they only objected that Dr. Paine is 

not qualified to offer an opinion on causation related to Dr. Morales. Dr. Morales, 

West Houston Radiology, and Radiology Partners did not assert in their objections 
63

and motions to dismiss that Dr. Paine is not qualified to offer an opinion on the 

standard of care related to Dr. Morales or that Dr. Paine’s expert reports do not 

adequately address causation as it relates to Dr. Morales.

Because Dr. Morales, West Houston Radiology, and Radiology Partners did 

not raise in the trial court their complaints that Dr. Paine is not qualified to offer an 

opinion on the standard of care and that Dr. Paine’s expert reports do not adequately 

address causation, we hold that they have not preserved those complaints for our 

review. See id.; TEX. R. APP. P. 33.1(a); Armenta v. Jones, No. 01-17-00439-CV, 

2018 WL 1095388, at *2, *7 (Tex. App.—Houston [1st Dist.] Mar. 1, 2018, no pet.) 

(mem. op.) (where defendant physician did not object to expert report “on the basis 

of inadequacy of the report as to causation,” defendant’s complaint about causation 

waived because it was not raised in trial court); Arnett, 339 S.W.3d at 925–26 

(defendant physician’s complaint that expert report did not sufficiently address 

causation because it did not rule out potential causes of wound infection and pain 

not preserved when it was raised for first time on appeal); Williams v. Mora, 264 

S.W.3d 888, 890–91 (Tex. App.—Waco 2008, no pet.) (defendant physician’s only 

timely objection to expert report was that two statements were speculative; all other

complaints about expert report that were not raised in trial court were waived, 

including complaints raised for the first time on appeal). We address the remaining 
64

portions of the issues raised by Dr. Morales, West Houston Radiology, and 

Radiology Partners that are preserved for our review.

B. Dr. Paine’s Qualifications to Opine on Causation

In the remaining portion of his sole issue, Dr. Morales argues that Dr. Paine 

is not qualified to offer an opinion on causation related to Dr. Morales because Dr. 

Paine “does not address his experience in caring for patients with peritonitis and 

sepsis secondary to a bowel perforation” and Dr. Paine’s expert reports and CV “do 

not reflect qualifications allowing him to opine on the cause of [Sam’s] alleged 

damages” or the ramifications of the “alleged four[-]day delay in [the]surgical repair 

of [Sam’s] bowel perforation.”

To be qualified to opine on the causal relationship between a defendant

physician’s alleged failure to meet an applicable standard of care and the plaintiff’s 

claimed injury, harm, or damages, the author of an expert report must be a physician 

who is qualified to render opinions on such causal relationships under the Texas 

Rules of Evidence. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.403(a); see id.

§ 74.351(r)(5)(C) (“[e]xpert” means “with respect to a person giving opinion 

testimony about the causal relationship between the injury, harm, or damages 

claimed and the alleged departure from the applicable standard of care in any health 

care liability claim, a physician who is otherwise qualified to render opinions on 
65

such causal relationship under the Texas Rules of Evidence” (internal quotations 

omitted)); Cornejo, 446 S.W.3d at 120.

An expert witness may be qualified on the basis of knowledge, skill, 

experience, training, or education to testify on scientific, technical, or other 

specialized subjects if the testimony would “assist the trier of fact” in understanding 

the evidence or determining a fact issue. Cornejo, 446 S.W.3d at 121 (internal 

quotations omitted); see TEX. R. EVID. 702. Thus, a plaintiff must show that her

expert has “knowledge, skill, experience, training, or education” about the specific 

issue before the court that would qualify the expert to give an opinion on that 

particular subject. Broders, 924 S.W.2d at 153–54 (internal quotations omitted); see 

also Cornejo, 446 S.W.3d at 121.

Not every licensed physician is qualified to testify on every medical question. 

See Broders, 942 S.W.2d at 152–53; Cornejo, 446 S.W.3d at 121. Yet, a physician 

need not practice in the particular field about which he is testifying so long as he can 

demonstrate that he has knowledge, skill, experience, training, or education about 

the specific issue before the court that would qualify him to give an opinion on that 

subject. Cornejo, 446 S.W.3d at 121. Simply put, what is required is that the 

physician demonstrate that he is qualified to opine on the specific issue before the 

court. Puppala, 564 S.W.3d at 202.
66

Here, it is asserted that Dr. Morales “drain[ed] the peritoneal cavity” after Sam 

was diagnosed with a bowel perforation on the sixth day after her initial surgery. 

Yet, there is no precedent for “conservative management” of a bowel perforation 

when there is evidence of bowel contents and gas free in the peritoneal cavity. 

(Internal quotations omitted.) Based on Sam’s diagnosis of a bowel perforation on 

the sixth day after her surgery, Dr. Morales should have recommended immediate 

surgical exploration and repair of the bowel perforation. Dr. Morales did not do this,

and thus, breached the standard of care.

It is also asserted that Dr. Morales’s breach of the standard of care caused 

Sam’s condition to worsen and endangered her life. A bowel perforation is a surgical 

emergency that requires immediate intervention. Immediate exploration, wash out 

of the peritoneal cavity, and repair of the bowel perforation is required. Any course 

of action other than immediate exploration, wash out, and repair, causes worsening 

peritonitis, sepsis, and possible death. Dr. Morales’s failure to recommend surgical 

exploration and repair of Sam’s bowel perforation upon its diagnosis caused Sam’s 

condition to deteriorate and allowed for the continued leakage of bowel contents into 

the peritoneal cavity. Without a repair of Sam’s bowel perforation, bowel contents 

continued to flow into Sam’s peritoneal cavity “with all the bacteria, chemicals[,] 

and irritants [that] allow[] [an] infection to grow and worsen.” The bowel leakage 

caused severe damage to Sam’s physiology and permanent residual damage, and it 
67

allowed for Sam’s peritonitis and sepsis to grow worse. And because Sam’s 

infection was allowed to grow, this led to a more complicated recovery process for 

Sam, a longer hospital stay, and long-term damage. Sam could not recover from the 

bowel perforation until it was actually repaired.

Further, during the surgery to repair Sam’s bowel perforation, a diverting 

ileostomy had to be performed. The ileostomy was required because of the marked 

inflammatory reaction to bowel leakage for an extended length of time, i.e., four 

days after the bowel-perforation diagnosis and ten days after Sam’s initial surgery. 

Had the bowel perforation been repaired at the time it was diagnosed, a colostomy 

would have been possible.

Sam has the burden of establishing that Dr. Paine has “knowledge, skill, 

experience, training, or education” about whether Dr. Morales’s breach of the 

standard of care—by failing to recommend immediate surgical exploration and 

repair of the bowel perforation upon its diagnosis on the sixth day after Sam’s

surgery—caused Sam’s claimed injury, harm, or damages. See Brooks, 2017 WL 

127867, at *6 (internal quotations omitted); Vora, 473 S.W.3d at 869–70; see also 

Cornejo, 446 S.W.3d at 121 (plaintiffs required to establish expert qualified on basis 

of knowledge, skill, experience, training, or education to offer opinion concerning 

causal link between alleged breaches of standard of care and injuries suffered); 
68

Burrell, 230 S.W.3d at 757, 762 (party offering witness as expert must establish 

witness is qualified).

In his expert reports, Dr. Paine states that he is a licensed physician and is 

board certified in obstetrics and gynecology. He has been practicing in the field of 

obstetrics and gynecology for thirty-five years. Currently, he is a member of the 

teaching faculty as an associate professor in the department of obstetrics and 

gynecology at the University of Texas Health Science Center in San Antonio. In his 

position as an associate professor, he trains residents and students in obstetrics and 

gynecology,

Dr. Paine is actively practicing medicine in the field of obstetrics and 

gynecology, and he was practicing medicine at the time Sam’s claims arose. Dr. 

Paine has extensive experience in the field of obstetrics and gynecology, and he, as 

part of his medical practice, has performed thousands of hysterectomies during his 

career. He has knowledge of the accepted standards of medical and surgical care 

required for patients needing hysterectomies. This includes knowledge of the 

standards of pre-operative, inter-operative, and post-operative care required for 

patients who have hysterectomies.

When Dr. Paine treats patients requiring hysterectomies, he provides 

pre-operative, inter-operative, and post-operative care to his patients. Post-operative 

care includes “following [a] patient after [a] surgery is complete[] to diagnose and 
69

treat any complications that may arise from the surgical procedure.” This case 

involves the purported failure of appellants, including Dr. Morales, to appropriately 

care for and treat Sam after a hysterectomy, and Dr. Paine is familiar with the type 

of post-operative care a patient, such as Sam, should receive and how post-operative 

complications, like those experienced by Sam, should be managed and treated.

We conclude that Dr. Paine’s expert reports and CV demonstrate that he is 

qualified to offer an opinion on the causal link between Dr. Morales’s alleged breach 

while providing post-operative care after Sam’s hysterectomy and Sam’s injuries, 

harm, and damages. See Jassin, 2012 WL 5974020, at *5 (“We cannot say that the 

trial court abused its discretion in . . . finding that Dr. Branch is qualified to provide 

an expert report on causation for the complications that allegedly arose from Dr. 

Jassin’s post-operative care following a sinus surgery that Dr. Branch says he has 

performed approximately 200 times, along with providing the follow-up care for 

those surgeries.”); Chavez, 2007 WL 595134, at *3–4 (”It is axiomatic that a 

physician trained to perform a surgery is also trained to manage surgical 

complications.”); Keo, 76 S.W.3d at 733 (holding physician who regularly 

performed surgery on head and neck was qualified to give opinion about issues 

common to all surgeries, including treatment of post-operative infections); see also 

Alvarez, 382 S.W.3d at 630 (“[A] physician needs only to show how he is qualified 

to opine on the cause of the plaintiff’s injury.”). Further, because Dr. Morales did 
70

not dispute in the trial court that Dr. Paine is qualified to offer an opinion on the 

standard of care as to Dr. Morales, it would have been reasonable for the trial court 

to have concluded that Dr. Paine is qualified to offer an opinion on Dr. Morales’s

failure to meet the standard of care and the resulting harm. See Healy, 2021 WL 

603369, at *2 n.1; Legend Oaks-S. San Antonio, 2015 WL 693225, at *5; Jassin, 

2012 WL 5974020, at *5; Payne, 2011 WL 5830469, at *7; Arnett, 339 S.W.3d at

927–28.

We hold that the trial court did not err in overruling Dr. Morales’s objections 

and denying Dr. Morales’s motion to dismiss Sam’s health care liability claim 

against him on the ground that Dr. Paine is not qualified to offer an opinion on

causation related to Dr. Morales.

We overrule the remaining portion Dr. Morales’s sole issue.23

C. Vicarious Liability of West Houston Radiology and Radiology Partners

In the remaining portion of their sole issues, West Houston Radiology and 

Radiology Partners argue that the trial court erred in overruling their objections to 

Dr. Paine’s expert reports and denying their motions to dismiss Sam’s vicarious

liability health care liability claims against them because Dr. Paine is not qualified 

to offer an opinion on causation related to Dr. Morales.

23 Due to our disposition, we need not address Dr. Morales’s request for attorney’s 

fees and costs. See TEX. R. APP. P. 47.1.
71

In her petition, Sam alleges that West Houston Radiology and Radiology 

Partners are vicariously liable for the conduct of Dr. Morales. Generally, when a 

plaintiff brings health care liability claims against more than one defendant

physician or health care provider, the expert report must set forth the standard of 

care and breach of the standard of care as to each defendant and explain the causal 

relationship between each defendant’s individual acts or omissions and the claimed 

injury. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a), (r)(6); Seton Family, 

593 S.W.3d at 792; Pena, 530 S.W.3d at 175. Yet, when a plaintiff brings a health 

care liability claim based on a vicarious liability theory against a defendant health

care provider, an expert report that adequately implicates the actions of that party’s 

agent or employee is sufficient as to the defendant health care provider. Gardner, 

274 S.W.3d at 671–72; Seton Family, 593 S.W.3d at 792; see also Owens, 478 

S.W.3d at 191 (“[W]hen a health care liability claim involves a vicarious liability 

theory, either alone or in combination with other theories, an expert report that meets 

the statutory standards as to the employee is sufficient to implicate the employer’s

conduct under the vicarious theory.” (alteration in original) (internal quotations 

omitted)). In other words, when a health care liability claim against a defendant 

health care provider is based on vicarious liability, an expert report that meets the 

statutory standards as to an agent or employee is sufficient to implicate the health 

care provider’s conduct. Potts, 392 S.W.3d at 632; Seton Family, 593 S.W.3d at 
72

792; see also Owens, 478 S.W.3d at 191–92 (expert report that is sufficient as to 

employee or agent, whose alleged negligent conduct vicarious liability claim was

based, is also sufficient as to employer health care provider).

Having held that the trial court did not err in overruling Dr. Morales’s

objections to Dr. Paine’s expert reports and in denying Dr. Morales’s motion to 

dismiss Sam’s direct liability health care liability claim against him because Dr. 

Paine’s expert reports meet the requirements of chapter 74 related to Dr. Morales, 

we hold that Sam may also proceed on the vicarious liability health care liability 

claims against West Houston and Radiology Partners which are based on the conduct 

of Dr. Morales. See Potts, 392 S.W.3d at 632; Gardner, 274 S.W.3d at 671–72; 

Owens, 478 S.W.3d at 191–92; see also George, 261 S.W.3d at 295 (“[I]f the expert 

report is sufficient as to the claims against Dr. Ward, and we have held that it 

is[,] . . . then the report is sufficient as to [the] claims against CND that are based on 

Dr. Ward’s alleged negligence.”).

We overrule the remaining portions of West Houston Radiology’s and 

Radiology Partners’ sole issues.

24

24 Due to our disposition, we need not address West Houston Radiology’s and 

Radiology Partners’ requests for attorney’s fees and costs. See TEX.R. APP. P. 47.1.
73

Conclusion

We affirm the order of the trial court.

Julie Countiss

Justice

Panel consists of Chief Justice Radack and Justices Landau and Countiss.