Case Name: Jean TEFFETELLER, as trustee for the heirs of Thad Roddy, Respondent, v. UNIVERSITY OF MINNESOTA, dba University of Minnesota Hospital and Clinics, petitioner, Appellant, Pediatric Research and Education Foundation, Petitioner, Appellant
Court: Minnesota Supreme Court
Jurisdiction: Minnesota
Decision Date: 2002-06-13
Citations: 645 N.W.2d 420
Docket Number: No. C8-00-1935
Parties: Jean TEFFETELLER, as trustee for the heirs of Thad Roddy, Respondent, v. UNIVERSITY OF MINNESOTA, dba University of Minnesota Hospital and Clinics, petitioner, Appellant, Pediatric Research and Education Foundation, Petitioner, Appellant.
Judges: BLATZ, C.J., and PAGE, J. took no part in the consideration or decision of this case.
Reporter: North Western Reporter 2d
Volume: 645
Pages: 420–437

Head Matter:
Jean TEFFETELLER, as trustee for the heirs of Thad Roddy, Respondent, v. UNIVERSITY OF MINNESOTA, dba University of Minnesota Hospital and Clinics, petitioner, Appellant, Pediatric Research and Education Foundation, Petitioner, Appellant.
No. C8-00-1935.
Supreme Court of Minnesota.
June 13, 2002.
Geraghty, O’Loughlin & Kenney, P.A., David C. Hutchinson, Jean B. Hoppe, St. Paul, MN, for Appellant U of M Hosp. <& Clinics.
Gislason <& Hunter, LLP, David D. Alsop, Elliot L. Olsen, Minnetonka, MN, for Appellant Pediatric Research & Educ. Foundation.
Rischmiller, Knippel & Aronson, Roger J. Aronson, Minneapolis, MN, for Respondent.

Opinion:
OPINION
STRINGER, Justice.
Respondent Jean Teffeteller, as trustee for the heirs of Thad Roddy, commenced this medical malpractice action against appellant University of Minnesota, doing business as University of Minnesota Hospital and Clinics, and appellant Pediatric Research and Education Foundation (PREF) alleging that both appellants negligently failed to recognize signs of morphine toxicity, and faded to appropriately treat morphine toxicity resulting in Rod-dy's death. The district court granted appellants' motions for dismissal ruling that respondent's expert was not qualified to testify as to the applicable standard of care and that, even if the expert had the appropriate qualifications, the expert affidavit submitted by respondent failed to meet the requirements of Minn.Stat. § 145.682 (2000). The court of appeals reversed and remanded. We reverse the court of appeals and reinstate the ruling of the district court.
In November 1995, 14-year-old Thad Roddy was diagnosed with leukemia. He was admitted to the University of Minnesota Hospital on December 4, 1996 and underwent a bone marrow transplant on December 12,1996. In the week following the transplant, Roddy received morphine to help manage his pain. The morphine dosage was increased on December 18, 1996 in an attempt to reduce his worsening throat pain.
At approximately 7:05 a.m. on December 19, 1996, members of the University of Minnesota nursing staff and Dr. Cynthia Wetmore, a medical resident employed by the University of Minnesota, checked on Roddy and found him to be alert, oriented, and responsive. Around 8:30 a.m., Sima Perry, a nurse employed by the University of Minnesota, checked on Roddy and found him to be unresponsive. Specifically, Nurse Perry wrote in her progress notes that she was unable to arouse Roddy with "verbal, vigorous tactile stimulation as well as sternal pressure." She also noted that Roddy's pupils were sluggish and that he had "dusky nailbeds." Nurse Perry notified Dr. Wetmore who immediately went to Roddy's bedside. Dr. Wetmore found that while Roddy was not completely unresponsive and did arouse some, he was not in his normal state of arousal. Dr. Wet-more also found that Roddy was respirat-ing, that his blood pressure and heart rate were fine, and that his nailbeds were not in fact dusky.
At approximately 8:45 a.m., Dr. Wet-more called the intensive care unit and spoke with Dr. Kenneth Tegtmeyer, a fellow in pediatric intensive care employed by the University of Minnesota. Dr. Wet-more presented Roddy's condition to Dr. Tegtmeyer and the two discussed the possible reasons for Roddy's change in condition, including sepsis, a head bleed, and morphine toxicity. Dr. Wetmore believed that morphine toxicity was an unlikely cause of Roddy's change in condition because he had been doing fine for the preceding nine hours when he had been on a continuous morphine drip. Dr. Wetmore discussed the possibility of morphine toxicity with Dr. Tegtmeyer, recognizing that toxicity must always be considered when a patient is on morphine. In their discussion, Dr. Wetmore and Dr. Tegtmeyer agreed that they had four different options: (1) give a dose of Narcan (also known as naloxone), (2) give a dose of Nubain, (3) turn off the morphine drip completely, or (4) wait, watch, and do nothing. Dr. Wetmore and Dr. Tegtmeyer ultimately agreed that Dr. Wetmore would order a small test dose of 0.5 milligrams of Nubain be given to Roddy in an effort to assess whether a component of morphine toxicity was present. Dr. Wetmore preferred to order Nubain rather than Narcan, because she believed that administering Nubain was a more conservative diagnostic test for determining whether morphine was playing a role in Roddy's condition, while Narcan would have immediately and abruptly reversed any morphine toxicity. Dr. Wetmore feared that any such immediate reversal of morphine toxicity caused by administering Narcan could lead to a number of undesirable side effects, including a sudden increase in in-tracranial pressure, a sudden rise in blood pressure, a sudden onset of extreme pain, or vomiting.
Dr. Wetmore testified at her deposition that she then called Dr. Michael Shannon, an attending physician in the pediatric intensive care unit employed by PREF, at approximately 9:00 a.m. She presented Roddy's condition to Dr. Shannon and explained the decision she and Dr. Tegtmeyer had reached about administering Nu-bain instead of Narcan. According to Dr. Wetmore, Dr. Shannon agreed with her assessment that, given the fact Roddy's vital signs were still stable, as well as the potential side effects of Narcan, ordering a small test dose of Nubain was reasonable and also a more compassionate and conservative approach than administering Nar-can. Dr. Shannon testified in deposition that he did not recall any of this discussion with Dr. Wetmore and that he was not consulted about Roddy's care until shortly before he arrived at Roddy's room later that morning. He also testified that he was unfamiliar with the use of Nubain under the circumstances of this case. In any event, Roddy's morphine drip was stopped and 0.5 milligrams of Nubain were administered around 9:15 or 9:20 a.m.
Dr. Bruce Blazar, a pediatric pulmonary transplant staff physician employed by PREF, and Dr. Brenda Weigel, a pediatric bone marrow transplant fellow employed by the University of Minnesota, were getting ready to begin their rounds when they were called into Roddy's room between 9:25 and 9:30 a.m. Dr. Blazar testified in deposition that either he or Dr. Weigel ordered the first dose of Narcan to be administered shortly after assessing Rod-dy's condition. A total of two or three doses of Narcan were administered between 9:30 and 10:23 a.m.
Dr. Shannon testified that he arrived with Dr. Tegtmeyer at Roddy's room sometime between 10:00 and 10:15 a.m. to assist in Roddy's care. According to the nurses' progress notes, Roddy began deteriorating shortly after Dr. Shannon arrived, during the administration of a dose of Narcan. At approximately 10:23 a.m., Roddy experienced a respiratory arrest and a code was called. Roddy was immediately intubated and two or three more doses of Narcan were administered between 10:25 and 11:30 a.m. Roddy never regained consciousness. He was placed on mechanical ventilation but died on January 3, 1997 after being removed from life support. Roddy's autopsy report indicated that he died as a result of multi-organ system failure, but that his decreased respiratory state before his arrest on December 19,1996 was caused by the administration of morphine.
Respondent commenced this lawsuit on or about December 1, 1998. With the summons and complaint, respondent served an affidavit of respondent's attorney as required by Minn.Stat. § 145.682, subds. 2, 3 (2000), stating that the facts in the case had been reviewed by respondent's attorney with a medical expert whose qualifications provided a reasonable expectation that the expert's opinion could be admissible at trial and, in the opinion of the expert, the appellants' deviations from the applicable standard of care caused injury to respondent. There is no contention that this affidavit failed to meet the statutory requirements of Minn.Stat. § 145.682, subd. 3.
In February 1999, respondent and both appellants entered into a stipulation that the 180-day deadline for meeting the expert affidavit requirements of Minn.Stat. § 145.682, subd. 4 (2000) was extended to 90 days following the completion of certain discovery depositions. The last of these depositions occurred on June 17, 1999. On or about August 25, 1999, respondent served appellants with an affidavit of the expected testimony of respondent's expert, Dr. William Perloff. Dr. Perloffs curriculum vitae indicated that (1) he has been board certified in pediatrics and pediatric critical care, (2) he has held numerous teaching positions related to pediatric care, (3) he served as the medical director of the pediatric intensive care unit at the University of Wisconsin Children's Hospital in Madison, Wisconsin from 1982 to 1998, (4) he has served on multiple pediatric and critical care committees, and (5) he has published articles and given presentations on various aspects of pediatric care. The affidavit stated, in part:
Dr. Perloff is expected to testify that the medical and nursing care provided by the defendants fell below acceptable levels of care practiced by reasonably prudent physicians and nurses, under the circumstances of this case. It is Dr. Perloffs opinion that it was below accepted standards of care for the defendants to fail to timely recognize that Thad Roddy was experiencing Morphine toxicity on the morning of December 19, 1996. At 8:30 a.m., when the nurses noted that they were unable to rouse him with verbal, vigorous or tactile stimulation, or with sternal pressure, and Thad had pinpoint and sluggish pupils, the applicable standard of care would require recognition that Thad was in a state of Morphine toxicity.
An acceptable level of care between 8:30 and 9:25 would have required frequent boluses or a continuous infusion of naloxone, under continuous medical supervision, until there was evidence of ongoing reversal of narcotic toxicity . It was below accepted standards of care for the defendants to administer Nubain, as ordered by Cynthia Wet-more, M.D., which may well have exacerbated the effects of the Morphine.
Further, it is Dr. Perloffs opinion that had Thad Roddy's clinical status [been] appreciated as Morphine toxicity at about 8:30 a.m., and had appropriate treatment measures been utilized, i.e. frequent boluses or a continuous infusion of naloxone continuously monitored by a physician, Thad Roddy, to a reasonable degree of medical probability would have been revived successfully. Finally, it is Dr. Perloffs opinion that the departures from accepted levels of care, as above identified, were a direct cause of Thad Roddy's death.
Over 7 months later, on or about April 5, 2000, respondent served appellants with an affidavit supplementing Dr. Perloffs opinions, this time pertaining to Dr. Shannon and Dr. Blazar. The supplemental affidavit stated, in part:
It is Dr. Perloffs opinion that Drs. Shannon and Blazar, in their involvement in Thad Roddy's care, departed from an acceptable level of care expected of specialists in the practice of pediatric care. Specifically, it was below the acceptable standard of care to approve the administration of Nubain in this case. An acceptable level of care at about 8:30 a.m., would have required frequent boluses of or continuous infusion of Naloxone, under continuous medical supervision, until there was evidence of ongoing reversal of the narcotic toxicity . [A]t about 8:30 a.m. up until the time of the arrest, all of the physicians caring for or providing medical input to the care of Thad Roddy, should have recognized that Thad Roddy was experiencing Morphine toxicity. As such, the applicable standard of care would have required the administration of Naxolone as above described. In addition, had Thad Roddy's clinical status been appreciated as Morphine toxicity at about 8:30 a.m. and thereafter, and had appropriate treatment measures been utilized as above outlined, Thad Roddy's death would have, to a reasonable degree of medical probability, have [sic] been avoided.
Both appellants moved for dismissal in June of 2000, arguing that respondent's expert affidavit and supplemental affidavit were insufficient as to negligence and causation, thereby failing to meet the requirements of Minn.Stat. § 145.682. The University of Minnesota also argued that Dr. Perloffs supplemental affidavit was untimely and that he was not qualified to render an opinion about the standard of care for treating Roddy. The district court, applying a summary judgment standard, granted both appellants' motions to dismiss. The court held that appellants were entitled to dismissal with prejudice under Minn.Stat. § 145.682 because of respondent's "failure to identify an expert qualified to testify to the applicable standard of care," noting that Dr. Perloff lacked practical and clinical experience in treating bone marrow transplant patients. Relying in part on deposition testimony from Dr. Blazar, a physician experienced in bone marrow transplant procedures, the court concluded that this specific experience was necessary to state an opinion because following a high risk procedure of this nature a physician would have several additional factors to consider when diagnosing complications. The court also held that even if Dr. Perloff were qualified to render an opinion in this case, both appellants were entitled to have the case dismissed with prejudice because Dr. Perloff failed to detail a chain of causation between appellants' alleged malpractice and Roddy's death. Finally, the court concluded that Dr. Perloffs affidavits were "wholly deficient" under Minn.Stat. § 145.682 as they related to appellant PREF.
The court of appeals reversed, holding that Dr. Perloff was qualified to testify about the standards of care related to morphine toxicity in pediatric patients and that Dr. Perloffs first affidavit satisfied the requirements of Minn.Stat. § 145.682 for both appellants. Tejfeteller v. Univ. of Minn., 626 N.W.2d 201, 208 (Minn.App. 2001). This appeal followed.
I.
We will reverse a district court's dismissal of a claim pursuant to Minn.Stat. § 145.682 only if we find that the district court abused its discretion. Anderson v. Rengachary, 608 N.W.2d 843, 846 (Minn. 2000). At the same time, statutory construction is a question of law and subject to de novo review. Stroud v. Hennepin County Med. Ctr., 556 N.W.2d 552, 555 (Minn.1996).
In a medical malpractice case where expert testimony is necessary to establish a prima facie case, the plaintiff must satisfy two requirements provided in Minn.Stat. § 145.682. Anderson, 608 N.W.2d at 846; Minn.Stat. § 145.682, subds. 2-4. First, the plaintiff must serve the defendant with the summons and complaint accompanied by an affidavit of the plaintiffs attorney stating:
[T]he facts of the case have been reviewed by the plaintiffs attorney with an expert whose qualifications provide a reasonable expectation that the expert's opinions could be admissible at trial and that, in the opinion of this expert, one or more defendants deviated from the applicable standard of care and by that action caused injury to the plaintiff
Minn.Stat. § 145.682, subd. 3. Then, within 180 days after commencement of the suit, the plaintiff must serve upon the defendant a second affidavit setting forth:
[T]he identity of each person whom plaintiff expects to call as an expert witness at trial to testify with respect to the issues of malpractice or causation, the substance of the facts and opinions to which the expert is expected to testify, and a summary of the grounds for each opinion.
Id., subd. 4. Failure to comply with these requirements results, upon motion, in mandatory dismissal with prejudice of each cause of action as to which expert testimony is required to establish a prima facie case. Id., subd. 6; see also Lindberg v. Health Partners, Inc., 599 N.W.2d 572, 578 (Minn.1999).
The district court found that respondent's affidavit did not satisfy the requirements of Minn.Stat. § 145.682 because it failed to identify an expert qualified to testify to the applicable standard of care. Accepting the evidence in a light most favorable to the nonmoving party, the district court ruled that although Dr. Perloff had extensive experience in general pediatrics, he was not qualified to testify as an expert on the medical issue before the court because there was nothing in his affidavit or accompanying curriculum vitae indicating he had treated cancer patients or patients who have undergone bone marrow transplants. As a result, the district court concluded that Dr. Perloffs opinion was not based upon knowledge of the customary response for physicians treating bone marrow transplant patients when they have decreased respiratory levels.
The dissent claims that in reaching its conclusion the district court erroneously imported language from subdivision 3 of Minn.Stat. § 145.682 when discussing the expert affidavit required by subdivision 4. According to the dissent, section 145.682 does not require that the expert affidavit be submitted by " 'an expert whose qualifications provide a reasonable expectation that the expert's opinions could be admissible at trial,' " as the court of appeals ruled. Teffeteller, 626 N.W.2d at 205 (quoting Minn.Stat. § 145.682, subd. 3). We disagree. The affidavit requirement simply cannot be met by a witness not reasonably expected to provide an admissible expert opinion at trial.
The statutory structure of section 145.682, subd. 2 provides that where a malpractice claim requires "expert testimony to establish a prima facie case" the expert affidavit in subdivision 4 is required. Expert testimony cannot be given by a witness who is not an expert— that is, someone who is not qualified or competent to give an expert opinion. See Comfeldt v. Tongen, 262 N.W.2d 684, 692 (Minn.1977) (indicating that in order for a medical witness to be competent to testify as an expert, the witness must have both sufficient scientific knowledge of and practical experience with the subject matter of the offered testimony); Swanson v. Ckat-terton, 281 Minn. 129,140,160 N.W.2d 662, 669 (Minn.1968) (noting that notwithstanding other impressive credentials, an expert witness in a malpractice case must make a substantial showing of qualification in the particular area necessary to support the claims at issue in the suit). Both the district court and the court of appeals appropriately considered Dr. Perloff s qualifications according to the standards articulated in Comfeldt, but the court of appeals concluded that the district court erred in holding that Dr. Perloff was not qualified. Teffeteller, 626 N.W.2d at 206. We disagree.
Our case law makes clear that we are to apply "a very deferential standard" to the district court when reviewing a determination as to expert qualification, reversing only if there has been a clear abuse of discretion. Gross v. Victoria Station Farms, Inc., 578 N.W.2d 757, 761 (Minn.1998); see also Benson v. N. Gopher Enters., Inc., 455 N.W.2d 444, 445-46 (Minn.1990). Although Gross arose in the context of a summary judgment motion, and Benson in the context of whether there was sufficient foundation for an expert opinion at trial, the distinction is immaterial because the discretion accorded the district court in determining whether a witness has the qualifications necessary to provide an expert affidavit pursuant to Minn.Stat. § 145.682 is the same. The district court did precisely that here based upon Dr. PerlofPs affidavit with attachments and significant discovery. It did not abuse its discretion in concluding that a doctor who is not specialized in the field of pediatric oncology, or experienced with the highly sophisticated procedure of bone marrow transplants, is not competent to testify as to this claim of medical malpractice. To hold otherwise ignores the very deferential standard we accord the trial court as well as the purpose served by the expert affidavit statute. Accordingly, we reverse the decision of the court of appeals on this issue.
II.
We next consider the district court's finding that even if Dr. Perloff had the appropriate qualifications, his affidavit failed to meet the substantive requirements of section 145.682. Our medical malpractice jurisprudence has clearly defined a number of essential elements that must be included in the affidavit to avoid dismissal. Since 1990, we have reviewed four cases involving claims where expert testimony was necessary to establish a prima facie case. See Sorenson v. St. Paul Ramsey Med. Ctr., 457 N.W.2d 188 (Minn.1990); Stroud, 556 N.W.2d 552; Lindberg, 599 N.W.2d 572; Anderson, 608 N.W.2d 843. In Sorenson, we first established what plaintiffs would be expected to set forth in the expert affidavit in order to comply with the requirements of subdivision 4. 457 N.W.2d at 190. The expert affidavit must (1) disclose specific details concerning the expert's expected testimony, including the applicable standard of care, (2) identify the acts or omissions that the plaintiff alleges violated the standard of care, and (3) include an outline of the chain of causation between the violation of the standard of care and the plaintiffs damages. Id. In Sorenson, we concluded that the expert affidavit contained "empty conclusions" as to causation which could mask a frivolous claim in the absence of a showing as to how the defendant's alleged failure to properly diagnose the illness of the decedent's mother led to decedent's death. Id. at 192-93. Specifically, we held that the expert affidavit stating that the defendants "failed to properly evaluate" or "failed to properly diagnose" the patient did not set out how the expert will use the facts in the hospital record to arrive at opinions of malpractice and causation. Id. at 192-93.
Later, in Stroud, we ruled that it is not enough for the expert affidavit to simply repeat the facts in the hospital record; rather, " '[t]he affidavit should set out how the expert will use those facts to arrive at opinions of malpractice and causation.' " 556 N.W.2d at 555 (quoting Sorenson, 457 N.W.2d at 192). In Stroud, a case alleging malpractice based on the defendants' failure to timely diagnose and treat a sub-arachnoid hemorrhage, we concluded that the expert affidavit provided only broad and conclusory statements as to causation. 556 N.W.2d at 556. The expert affidavit failed to connect the decedent's cause of death to the defendant's alleged delay in properly diagnosing and treating the decedent. Id.
Then in Lindberg, a case alleging malpractice based on the defendant's failure to advise the pregnant plaintiff to seek medical treatment, the expert affidavit failed to state what the standard of care was and how the defendants departed from it. 599 N.W.2d at 577-78. It stated that the plaintiffs baby died as a result of the negligent and careless conduct of the defendants. Id. at at 575. We concluded that the expert affidavit, as in Stroud, contained no more than a broad and con-clusory statement as to causation. Lindberg, 599 N.W.2d at 578.
Finally, in Anderson, a case in which the plaintiff alleged that the defendant's negligence caused a severed vagus nerve and swelling of her esophagus and thyroid, we concluded that the expert affidavit failed to state what the standard of care was and how the defendant allegedly violated it; the affidavit even suggested that the cause of the plaintiffs injury was perhaps unrelated to defendant's acts. 608 N.W.2d at 848. Therefore, as to causation, we held that the affidavit failed to adequately de scribe the alleged negligence on the part of the defendant and its relationship to the plaintiffs injury. Id.
Applying the standards set forth in Sorenson, Stroud, Lindberg, and Anderson, and comparing the language of the affidavits in these cases to the first affidavit submitted by respondent's expert, we conclude that the district court did not abuse its discretion in holding that the affidavit failed to detail a chain of causation between the University of Minnesota's alleged negligence and Roddy's death. Although Dr. Perloffs affidavit states that defendants should have immediately recognized that Roddy was experiencing morphine toxicity and outlines what should have been done to comply with an acceptable level of care thereafter, the affidavit treats the cause of death summarily:
[T]he departures from accepted levels of care, as above identified, were a direct cause of Thad Roddy's death.
This statement is remarkably similar to the statement of causation found in the affidavit deemed insufficient in Stroud:
[A]s a result of the breach of the standard of care [previously identified], there was a failure to diagnose and treat a subarachnoid hemorrhage which ultimately resulted in death of the Plaintiff.
556 N.W.2d at 554. As in Stroud, the expert affidavit submitted by respondent here contains only broad, conclusory statements regarding causation and fails to set forth the chain of causation connecting the failure to treat Roddy for morphine toxicity and his death, as required by the statute. Id. at 556; Sorenson, 457 N.W.2d at 192-93. We therefore reverse the court of appeals and hold that the affidavits failed to meet the requirements of Minn.Stat. § 145.682, subd. 4.
We take this opportunity to correct the analysis in the opinion of the court of appeals. The court held that the statements contained in Dr. Perloffs affidavit "were sufficient to put the respondents on notice of appellant's proposed expert testimony." Teffeteller, 626 N.W.2d at 208 (citing Demgen v. Fairview Hosp., 621 N.W.2d 259, 265-66 (Minn.App.), rev. denied (Minn. Apr. 17, 2001)). The court cited Demgen for the erroneous proposition that an expert affidavit is sufficient under Minn.Stat. § 145.682, subd. 4 if it specifies the facts and circumstances of the defendant's alleged negligence in such a manner as to give defendants a "sneak preview" of the expert's testimony. 626 N.W.2d at 208. The affidavit required in the statute must provide more than a sneak preview, as noted clearly and repeatedly in Sorenson, Stroud, Lindberg, and Anderson. "The statute requires far more information than simply identification of the expert intended to be called at trial or a 'general disclosure' Lindberg, 599 N.W.2d at 578. At a minimum, a "meaningful disclosure" is required setting forth the standard of care, the act or omissions violating that standard, and the chain of causation. Anderson, 608 N.W.2d at 849; see also Lindberg, 599 N.W.2d at 577; Stroud, 556 N.W.2d at 555-56; Sorenson, 457 N.W.2d at 198.
III.
Finally, while we find Dr. Perloff s affidavits deficient as to both appellants on the issue of causation, we address as a separate matter the district court's conclusion that they were "wholly deficient" as to Dr. Shannon and Dr. Blazar, both employed by PREF. The district court concluded that it was a factual impossibility for either of Dr. Perloff s affidavits to satisfy the requirements of the statute as they relate to PREF. Its holding was based on the fact that both of Dr. Perloff s affidavits stated that the applicable standard of care would have required a continuous infusion of naloxone beginning at 8:30 a.m. and the evidence suggested that neither PREF doctors were involved with Roddy's care until about 9:30 a.m.
The record is unclear as to what time Dr. Shannon became involved in Roddy's care. Dr. Shannon contends that he was not involved until sometime between 10:00 and 10:15 a.m. Dr. Wetmore stated, however, that she spoke with Dr. Shannon at around 9:00 a.m. about his thoughts on whether or not to administer Nubain. Dr. Wetmore also claimed that she and Dr. Shannon discussed using Narcan instead of Nubain. Dr. Shannon does not recall this conversation. As for Dr. Blazar, the record indicates that he was not involved in Roddy's care until 9:25 to 9:30 a.m.
Dr. Perloff s first affidavit fails to identify what the standard of care for either Dr. Shannon or Dr. Blazar was, what they did to violate that standard, or even what their relation was to Roddy's care or to care provided by the treating physicians. The applicable standard of care identified in Dr. Perloff s first affidavit relates to recognizing the morphine toxicity at 8:30 a.m. and administering naloxone between 8:30 and 9:25 a.m. The acts allegedly falling below this standard were failing to timely recognize the morphine toxicity, administering Nubain, and failing to infuse nalox-one between 8:30 and 9:25 a.m. There are no allegations that Dr. Shannon should have recognized the morphine toxicity based on the information presented to him during his telephone conversation with Dr. Wetmore, nor is there anything to indicate why either Dr. Shannon or Dr. Blazar should have been involved with Roddy's care between 8:30 and 9:25 a.m. Finally, even if Dr. Shannon did approve the administering of Nubain, respondent's theory is not that the administration of the Nu-bain caused Roddy's death. Therefore, the district court properly concluded that Dr. Perloff s first affidavit failed to articulate the statutory requirements as to PREF.
Dr. Perloff s second affidavit also fails to comply with the statutory requirements as to PREF. In it he again asserts that it was below the acceptable standard of care to approve the administration of Nubain, but as noted above, no causal link is identified. The second affidavit also indicates that all of the physicians caring for or providing medical input to the care of Roddy should have administered naloxone starting at 8:30 a.m. until there was evidence of ongoing reversal of the narcotic toxicity. But Dr. Blazar was not present in Roddy's room until about 9:20 a.m. and Dr. Shannon did not arrive until 10:00 a.m. or shortly thereafter. There is nothing in Dr. Perloffs second affidavit indicating what these doctors could have done before they arrived in Roddy's room to satisfy the standard of care or that their care after arriving in Roddy's room caused his death. In fact, this second affidavit, like the first, seems to indicate that naloxone needed to be administered starting at 8:30 a.m. or shortly thereafter in order to have reversed the effects of morphine toxicity.
Thus, we conclude that both of Dr. Per-loffs affidavits fail to provide any meaningful disclosure regarding what the standard of care required of PREF's doctors was or how they violated it. Furthermore, neither of Dr. Perloffs affidavits detail a chain of causation between any alleged acts or omissions of PREF's doctors and Roddy's death. Accordingly, we hold that dismissal with prejudice as to the claim against appellant PREF was not an abuse of the district court's discretion and that the court of appeals erred by concluding that the initial affidavit was sufficient to satisfy the statute as to appellant PREF.
Reversed.
BLATZ, C.J., and PAGE, J. took no part in the consideration or decision of this case.
GILBERT, J., files an opinion concurring in part and dissenting in part, in which PAUL H. ANDERSON, J., joins.
. The dissent notes that Minnesota Statutes § 145.682 was amended in 2002. Act of May 22, 2002, ch. 403, § 1, 2002 Minn. Laws-. The resulting changes do not affect our analysis however, because the amendment is only effective for causes of action commenced on or after May 23, 2002. Id. Further, while the statute now provides additional days to comply, it still mandates dismissal if the affidavit fails to disclose the required information. Id.
. We do not dispute that Dr. Perloff has a long and distinguished career in pediatric medicine, as the dissent clearly points out. But in determining whether he was qualified as an expert in the field of pediatric oncology and with respect to bone marrow transplants, we cannot say that the trial court abused its discretion.
.The district court's holding that Dr. Perloff's first expert disclosure did not satisfy the requirements of Minn.Stat. § 145.682, subd. 4, was based on its conclusion that the affidavit failed to outline a detailed chain of causation, the third Sorenson requirement. Since this was the sole basis for the district court's holding, and because the district court also stated that the affidavit did "specify [the] acts and omissions of the defendants that fell below the standard of care," we need not consider whether Dr. Perloff's affidavit satisfied the first two Sorenson requirements. As to the supplemental affidavit, the district court agreed with the University of Minnesota that it was untimely. Nonetheless, because PREF allowed its consideration, the district court evaluated its content and concluded that it was also insufficient under section 145.682. We agree and, noting its substantial similarity to Dr. Perloff's initial affidavit and its lack of any additional statement relating to causation, we refer to our analysis of Dr. Perloff's initial affidavit above and Part III infra.
. The dissent cites this statement from Dr. Perloff's affidavit to vigorously challenge the district court conclusion that the affidavit fails to disclose causation. Causation is not established by such facile declarations however. See Lindberg, 599 N.W.2d at 578; Stroud, 556 N.W.2d at 556. The gist of expert opinion evidence as to causation is that it explains to the jury the "how" and the "why" the malpractice caused the injury. The dissent is no more illuminating as to this critical link than is Dr. Perloff's affidavit.
. Because the court of appeals concluded that the initial affidavit was sufficient, it did not evaluate the sufficiency of Dr. Perloff's supplemental affidavit, nor did it express an opinion as to its timeliness. 626 N.W.2d at 207.
. In response to the dissent's reference to nuisance suits, we of course make no such ruling. Where the affidavits required under Minn.Stat. § 145.682 fail to meet the statutory standards as interpreted in our case law, dismissal is mandated. See Minn.Stat. § 145.682, subd. 6.