Court Opinion

ID: 3114683
Source: CourtListenerOpinion
Date Created: 2015-10-16 07:26:12.422703+00
Date Added: 2024-06-11T12:06:49.855300
License: Public Domain

COURT OF APPEALS
                        SECOND DISTRICT OF TEXAS
                             FORT WORTH

                            NO. 02-11-00231-CV

OLGA CORTEZ, M.D., MEDICAL                                        APPELLANTS
CLINIC OF NORTH TEXAS, P.A.,
AND DENTON OBSTETRICS &
GYNECOLOGY, P.A.

                                        V.

ELIZABETH EBBEN TOMAS                                                APPELLEE

                                     ----------

         FROM THE 431ST DISTRICT COURT OF DENTON COUNTY

                                     ----------

                       MEMORANDUM OPINION1
                                     ----------

                                  I. Introduction

     In this interlocutory appeal,2 Appellants Olga Cortez, M.D., Medical Clinics

of North Texas, P.A., and Denton Obstetrics and Gynecology, P.A. contend that

     1
      See Tex. R. App. P. 47.4.
     2
      See Tex. Civ. Prac. & Rem. Code Ann. § 51.014(a)(9) (West Supp. 2011).
the trial court abused its discretion by denying their motion to dismiss the

healthcare liability claim filed against them by Appellee Elizabeth Ebben Tomas.

Appellants contend in five issues that Tomas failed to provide an expert report as

defined by civil practice and remedies code section 74.3513 because the expert

is not qualified to address the applicable standard of care or causation and

because the expert‘s report does not adequately set forth the applicable standard

of care, breach of the standard of care, or causation. We affirm in part and

reverse and remand in part.

                                II. Background

      Tomas filed suit against Appellants in August 2010 alleging medical

negligence during and after a surgery to remove Tomas‘s ovary. Tomas pleaded

that she had her gallbladder surgically removed in July 2008 and that the

surgeon noted a cyst on her ovary during the surgery. Tomas‘s primary care

physician referred her to Dr. Cortez for examination of the ovarian cyst, and Dr.

Cortez recommended surgical removal of Tomas‘s ovary.

      Tomas alleged that she expressed concern to Dr. Cortez about undergoing

another surgery so soon but that Dr. Cortez represented that she had spoken

with Tomas‘s prior surgeon who indicated that a second surgery would not be a

problem.4 Tomas thereafter agreed to undergo the second surgery, which Dr.

      3
       See Tex. Civ. Prac. & Rem. Code Ann. § 74.351 (West Supp. 2011).
      4
      Tomas also alleged that this representation by Dr. Cortez was not
accurate.

                                        2
Cortez performed. Tomas alleged that Dr. Cortez ―sliced [Tomas]‘s small bowel

during the surgery and either never noticed it or attempted to cover up the

problem.‖ Tomas further alleged that she ―developed a severe wound, became

septic[,] had to undergo a subsequent bowel operation‖ eight days later, ―was

hospitalized for many months,‖ and ―is still undergoing medical treatment.‖

Tomas alleged that Medical Clinics of North Texas, P.A. and Denton Obstetrics

and Gynecology, P.A. are vicariously liable for Dr. Cortez‘s alleged negligence.

      Tomas filed and served the curriculum vitae (CV) and expert report of Dr.

Michael Heard. Appellants objected to Dr. Heard‘s CV and report and filed a

motion to dismiss Tomas‘s claims.       The trial court conducted a hearing and

denied Appellants‘ motion to dismiss.        Appellants then filed notice of this

interlocutory appeal.

                             III. Standard of Review

      A trial court‘s ruling concerning an expert report under section 74.351

(formerly article 4590i, section 13.01) of the Medical Liability and Insurance Act is

reviewable under the abuse of discretion standard. See Tex. Civ. Prac. & Rem.

Code Ann. § 74.351; Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.

2002); Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875

(Tex. 2001). To determine whether a trial court abused its discretion, we must

decide whether the trial court acted without reference to any guiding rules or

principles; in other words, we must decide whether the act was arbitrary or

unreasonable. Cire v. Cummings, 134 S.W.3d 835, 838–39 (Tex. 2004). An

                                         3
appellate court cannot conclude that a trial court abused its discretion merely

because the appellate court would have ruled differently in the same

circumstances. Bowie Mem’l, 79 S.W.3d at 52; E.I. du Pont de Nemours & Co. v.

Robinson, 923 S.W.2d 549, 558 (Tex. 1995).

                          IV. Statutory Requirements

      A health care liability claimant must serve an expert report on each

defendant no later than the 120th day after the claim is filed. See Tex. Civ. Prac.

& Rem. Code Ann. § 74.351(a). A defendant may challenge the adequacy of a

report by filing a motion to dismiss, and the trial court must grant the motion to

dismiss if it finds after a hearing that ―the report does not represent an objective

good faith effort to comply with the definition of an expert report‖ in the statute.

Id. § 74.351(l). While the expert report ―need not marshal all of the plaintiff‘s

proof,‖ it must provide a fair summary of the expert‘s opinions as to the

―applicable standard 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.‖ Id.

§ 74.351(r)(6); Palacios, 46 S.W.3d at 878 (construing former article 4590i,

§ 13.01).

      To constitute a good faith effort, the report must discuss the standards of

care, breach, and causation with sufficient specificity (1) to inform the defendant

of the conduct the plaintiff has called into question and (2) to provide the trial

court with a basis to conclude that the claims have merit. See Bowie Mem’l, 79
4
S.W.3d at 52; Palacios, 46 S.W.3d at 879.          A report does not fulfill this

requirement if it merely states the expert‘s conclusions or if it omits any of the

statutory requirements. Bowie Mem’l, 79 S.W.3d at 52; Palacios, 46 S.W.3d at

879.   But the information in the report ―does not have to meet the same

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

trial.‖ Palacios, 46 S.W.3d at 879.

       When reviewing the adequacy of a report, the only information relevant to

the inquiry is the information contained within the four corners of the document.

Bowie Mem’l, 79 S.W.3d at 52; Palacios, 46 S.W.3d at 878. This requirement

precludes a court from filling gaps in a report by drawing inferences or guessing

as to what the expert likely meant or intended. See Austin Heart, P.A. v. Webb,

228 S.W.3d 276, 279 (Tex. App.—Austin 2007, no pet.).          However, section

74.351 does not prohibit experts, as opposed to courts, from making inferences

based on medical history.     Marvin v. Fithian, No. 14-07-00996-CV, 2008 WL
2579824, at *4 (Tex. App.—Houston [14th Dist.] July 1, 2008, no pet.) (mem.

op.); see also Tex. R. Evid. 703 (providing that an expert may draw inferences

from the facts or data in a particular case); Tex. R. Evid. 705 (providing that an

expert may testify in terms of opinions and inferences).

                                 V. Discussion

       Appellants contend in five issues that Tomas failed to provide an expert

report as defined by civil practice and remedies code section 74.351 because her

expert witness is not qualified to address the applicable standard of care or

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causation and because the expert‘s report does not adequately set forth the

applicable standard of care, breach of the standard of care, or causation.

A. Qualifications

      Appellants argue in their first two issues that the expert report and

attached CV do not establish Dr. Heard‘s qualifications to address the applicable

standard of care or causation. Specifically, Appellants contend that the report

contains only conclusory assertions about Dr. Heard‘s qualifications and never

mentions Dr. Heard‘s qualifications to opine concerning the surgical procedure at

issue in this case.

      1. Applicable Law

      Not every licensed doctor is automatically qualified to testify as an expert

on every medical question. See Broders v. Heise, 924 S.W.2d 148, 152 (Tex.

1996); Hagedorn v. Tisdale, 73 S.W.3d 341, 350 (Tex. App.—Amarillo 2002, no

pet.). For the author of an expert report to satisfy section 74.351, he must be

qualified to render opinions regarding the medical care which is the subject of the

claim against the defendant.       See Tex. Civ. Prac. & Rem. Code Ann.

§ 74.351(r)(5).   The issue is the specific subject matter and the expert‘s

familiarity with it. Hagedorn, 73 S.W.3d at 350; see Broders, 924 S.W.2d at 153;

Blan v. Ali, 7 S.W.3d 741, 745 (Tex. App.—Houston [14th Dist.] 1999, no pet.).

      Analysis of expert qualifications under section 74.351 is limited to the four

corners of the report and the expert‘s CV. Baylor Coll. of Med. v. Pokluda, 283
S.W.3d 110, 117 (Tex. App.—Houston [14th Dist.] 2009, no pet.); see Palacios,

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46 S.W.3d at 878. To be qualified, the expert must satisfy the requirements of

section 74.401. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(5)(A). Under

section 74.401, the expert must be a physician who:

      (1) is practicing medicine 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.

Id. § 74.401(a) (West 2011). ―Practicing 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 provide direct

patient care, upon the request of such other physicians. Id. § 74.401(b). In

determining whether a witness is qualified on the basis of training or experience,

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.

Id. § 74.401(c).

      A person may qualify as an expert witness on the issue of the causal

relationship between the alleged breach and the injury claimed ―only if the person

is a physician and is otherwise qualified to render opinions on that causal

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relationship under the Texas Rules of Evidence.‖ Id. § 74.403(a). Texas Rule of

Evidence 702 requires an expert witness to be qualified on the basis of

―knowledge, skill, experience, training, or education.‖ Tex. R. Evid. 702.

      2. Applicable Facts

      At issue in this case are Dr. Cortez‘s decision to proceed with surgery to

remove Tomas‘s ovary and the care Dr. Cortez provided Tomas during and after

that surgery. Relevant to his qualifications concerning the applicable standard of

care and causation, Dr. Heard‘s report states as follows:

             I am currently a physician practicing obstetrics, gynecology,
      and reproductive endocrinology in the state of Texas. I have been
      board certified and recertified by the American [B]oard of Obstetrics
      and Gynecology (ABOG) and have been in practice postresidency
      since 1995. I completed a fellowship and board certification in
      reproductive endocrinology and infertility. I am currently voluntary
      faculty as clinical assistant professor for Baylor College of Medicine
      Department of Obstetrics and Gynecology and assist in resident
      training with the Methodist Residency Program, UT Health Science
      Center, and UT Medical Branch Residencies programs as well.
      Besides my involvement with residency education, I am also
      involved with the American Congress of Obstetrics and Gynecology
      (ACOG) on a national level, as well as Medical Director of a national
      board review courses [sic] for obstetrics and gynecology which helps
      to prepare practicing OB/GYN candidates for written and oral board
      examination that leads to board certification. My current resume,
      which is attached to this report, contains a complete listing of my
      previous teaching appointments as well as past publications.

             Based on my education, training, and past experience, I am
      qualified to render an opinion on the medical care of Elizabeth
      Ebben-Tomas, including the diagnosis and surgical treatment of her
      ovarian cyst . . . .

      In addition, Dr. Heard‘s CV reflects that he completed his residency in

obstetrics and gynecology in 1995, served as an assistant professor of obstetrics

                                         8
and gynecology from 1995 to 1999, and was a ―Clinical/Research Fellow‖ in

obstetrics and gynecology from 1999 to 2002. The CV also lists twenty different

abstracts or publications that Dr. Heard authored or co-authored and almost as

many committees and projects, all involving obstetrics and gynecology. But none

of the abstracts, publications, committees, or projects obviously involves or

relates to surgical procedures, and neither Dr. Heard‘s report nor his CV

expressly list or describe any surgical training or experience.

      3. Standard of Care

      In In re Windisch, our sister court held that an expert report offered only

conclusory assertions of an expert‘s qualification to opine on the applicable

standard of care involved with an embolization procedure in preparation for

surgery, even though the expert and the defendant physician were both

radiologists.5 See 138 S.W.3d 507, 509, 513 (Tex. App.—Amarillo 2004, orig.

proceeding). Specifically, the court stated,

             Except for some conclusory statements, Shenk‘s report
      contains only brief statements referencing his qualifications. Both
      Shenk and [Defendant] Windisch are radiologists. Nothing in Ray‘s
      pleadings or in Shenk‘s report or curriculum vitae allows us to
      presume, though, that the issues involved in this case are so
      common to radiology that any credentialed radiologist can testify to
      the applicable standard of care. His fellowship in neuroradiology
      and his teaching appointments earlier in his career might indicate
      familiarity with the interventional procedure Windisch performed on
      Powell, but cannot reasonably be said to demonstrate that he has

      5
       An embolization procedure ―involves [the] placement of small particles
and wires into the blood vessels for the purpose of cutting off the blood supply to
a tumor.‖ Id. at 509 n.2.

                                         9
      knowledge of the accepted standard of care for the procedure. . . .
      [N]othing in the report connects Shenk‘s positions since 1988 as
      medical director of MRI facilities to expertise in the procedure
      performed by Windisch. Absent from the report and curriculum vitae
      is any explanation of the manner in which Shenk‘s credentials carry
      with them familiarity with the ―very matter‖ on which he proposes to
      opine. . . . From the four corners of the report and curriculum vitae,
      we find no basis for a conclusion that Shenk‘s training or experience
      qualify him to offer an expert opinion on the standard of care for the
      performance of embolization of brain tumors, and we must conclude
      that the report and curriculum vitae cannot reasonably be read to
      demonstrate that Shenk is so qualified.

Id. at 513–14 (citations omitted). Similarly, the court in CHCA Mainland, L.P. v.

Dickie held that the expert‘s report and CV did not establish the expert‘s

qualifications because the expert did not describe any of his experience treating

or teaching others about decubitus ulcers, even though ―it might be reasonable to

infer from the [report and CV] that [the expert] might have acquired experience in

the treatment and care of decubitus ulcers in his seventeen years of practice and

teaching.‖ No. 14-07-00831-CV, 2008 WL 3931870, at *5 (Tex. App.—Houston

[14th Dist.] Aug. 21, 2008, no pet.) (mem. op.); see also Carreras v. Trevino, 298
S.W.3d 721, 725–26 (Tex. App.—Corpus Christi 2009, no pet.) (holding report

did not establish expert‘s qualifications because it, other than ―summarily

asserting‖ the requisite knowledge, did not demonstrate the expert‘s training or

experience with the surgical and post-operative care of total knee replacement).

      In this case, both Dr. Heard and Dr. Cortez practice obstetrics and

gynecology, and Dr. Heard is board certified in that specialty. Tomas argues that

it is sufficient that Dr. Heard and Dr. Cortez have the same medical specialty

                                       10
because experts are routinely qualified to testify, even when they are not of the

same specialty, and because this case involves a simple gynecological

procedure. But Dr. Heard‘s report does not state that the surgery here was a

simple gynecological procedure. To the contrary, Dr. Heard‘s report describes

the procedure as it relates to Tomas, given her surgical history, as complex and

beyond the experience and training of most physicians practicing obstetrics and

gynecology.    Furthermore, simply having the same medical specialty is not

sufficient, standing alone, to qualify Dr. Heard to offer opinions about Dr. Cortez‘s

surgical and post-operative care and treatment of Tomas. See Windisch, 138
S.W.3d at 513 (discussing former section 13.01 and stating that ―[t]he

requirement that a Section 13.01 report and curriculum vitae set forth the expert‘s

knowledge of the procedure being questioned obtains even when the defendant

physician and the expert share certification in the same specialty‖). Moreover, it

appears from Dr. Heard‘s CV that he has limited his practice since 2003 to

reproductive matters within the field of obstetrics and gynecology.

      Tomas asserts that the procedure in this case is in Dr. Heard‘s

―professional wheelhouse‖ and is clearly within his specialty. Dr. Heard quite

possibly has sufficient qualifications to offer opinions concerning the care Dr.

Cortez provided during and after Tomas‘s surgery, but nothing within the report‘s

four corners discloses or describes Dr. Heard‘s training or experience

performing, observing, or teaching other physicians about the surgical removal of

an ovary and the patient‘s postoperative care. See id. at 513–14. Therefore, the

                                         11
report does not meet the statutory requirements concerning the care Dr. Cortez

provided during and after Tomas‘s surgery. See Tex. Civ. Prac. & Rem. Code

Ann. § 74.401 (containing standards for qualification to offer expert opinions).

Thus, we sustain this portion of Appellants‘ first issue.

         There is more, however, to Dr. Heard‘s opinion than Dr. Cortez‘s alleged

negligent care during and after Tomas‘s surgery. Dr. Heard also questions Dr.

Cortez‘s decision to proceed with the ovarian surgery given Tomas‘s complicated

medical history, and Dr. Heard‘s report and CV establish, within their four

corners, that he is qualified to offer opinions concerning the applicable standard

of care on that distinct issue because it involves the general lack of surgical

qualifications possessed by most physicians practicing obstetrics and gynecology

and whether a reasonably prudent physician would consult with another

physician with more qualifications when deciding whether to proceed with

surgery. Read as a whole, Dr. Heard‘s report and CV establish his qualifications

to offer opinions on the standard of care relevant to Dr. Cortez‘s decision to

proceed to surgery, but they do not establish his qualifications to offer opinions

on the standard of care relevant to Dr. Cortez‘s care and treatment of Tomas

during and after the surgery. Because the report and CV establish Dr. Heard‘s

qualifications to opine concerning the standard of care applicable to Dr. Cortez‘s

decision to proceed to surgery, we overrule the remainder of Appellants‘ first

issue.

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      4. Causation

      Appellants argue in their second issue that Dr. Heard‘s report and CV do

not establish his qualifications to opine concerning causation, and we agree.

Because Tomas‘s injuries and prolonged medical care are alleged to have been

caused by complications relating to her ovarian surgery, Tomas was required to

establish that Dr. Heard is qualified on the basis of ―knowledge, skill, experience,

training, or education‖ to offer opinions concerning the causal link between Dr.

Cortez‘s alleged negligence and Tomas‘s injuries. See Tex. R. Evid. 702; see

also Tex. Civ. Prac. & Rem. Code Ann. § 74.403(a). Similar to the deficiencies in

Dr. Heard‘s report and CV concerning the standard of care relating to Dr.

Cortez‘s care during and after Tomas‘s ovarian surgery, Dr. Heard‘s report and

CV do not establish his qualifications to offer opinions concerning causation. As

mentioned above, nothing within the four corners of Dr. Heard‘s report or CV

discloses or describes his training or experience performing, observing, or

teaching other physicians about the surgical removal of an ovary and the

patient‘s postoperative care, and nothing within the report or CV suggests that

Dr. Heard is qualified to opine concerning the causative chain that allegedly

followed the injury to Tomas‘s bowel that allegedly occurred during that surgery.

See Tex. Civ. Prac. & Rem. Code Ann. § 74.403 (referring to qualifications to

offer expert opinions on causation); Tex. R. Evid. 702; see also Collini v.

Pustejovsky, 280 S.W.3d 456, 466 (Tex. App.—Fort Worth 2009, no pet.) (stating

that ―while [the expert] may be well qualified to make these assertions

                                        13
[concerning causation], the four corners of his report simply do not provide any

details regarding such qualifications‖). We therefore sustain Appellant‘s second

issue.

B. Standard of Care and Breach of Standard of Care

         Appellants contend in their third and fourth issues that the expert report

does not adequately describe the applicable standard of care or how Dr. Cortez

allegedly breached that standard of care.

         Dr. Heard‘s report without question contains many conclusory assertions

concerning the standard of care and breach of the standard of care, but the

report also includes several nonconclusory assertions. For example, the report

provides that Tomas‘s complicated medical and surgical history required a

physician with the appropriate training and experience to perform the ovarian

surgery and that Dr. Cortez did not have the requisite training and experience

and did not consult with a more qualified surgeon or other physician before or

during the ovarian surgery. The report also states that Dr. Cortez breached the

standard of care by deciding to proceed with the surgery and by failing to consult

with Tomas‘s prior medical and surgical providers.

         Considering all of the information within the four corners of the report, we

hold that although Dr. Heard‘s report could have provided more detailed

descriptions of the applicable standards of care and Dr. Cortez‘s alleged

breaches of those standards, the report does provide a fair summary of Dr.

Heard‘s opinions.      As to the standard of care and alleged breaches of the

                                          14
standard of care, the report is sufficient to inform Dr. Cortez of the conduct

Tomas has called into question and to provide the trial court with a basis to

conclude that the claims have merit. See generally Bowie Mem’l, 79 S.W.3d at

52; Palacios, 46 S.W.3d at 879; cf. Dickie, 2008 WL 3931870, at *8 (holding

expert report conclusory as to breach of standard of care because it did not

include ―specific factual allegations setting forth the conduct that Dickie has

called into question‖ and did not ―discuss at all what actions were actually taken

. . . in Dickie‘s treatment, much less what actions [the defendant] failed to take‖).

We therefore overrule Appellants‘ third and fourth issues.

C. Causation

      Appellants argue in their fifth issue that Dr. Heard‘s report does not contain

sufficient descriptive information to establish the requisite causal connection

between Dr. Cortez‘s alleged negligence and Tomas‘s alleged injuries. Although

we held above that Dr. Heard‘s report and CV do not establish his qualifications

to opine concerning causation, we address Appellants‘ fifth issue in the interest

of judicial economy. See generally In re Estate of Webb, 266 S.W.3d 544, 553

(Tex. App.—Fort Worth 2008, pet. denied) (addressing in interest of judicial

economy an issue likely to be raised on remand).

      Relevant to causation, Dr. Heard‘s report states as follows:

             It is my opinion that the botched procedure performed by Dr.
      Cortez . . . , including the departure from the standards of care as
      highlighted above, caused serious bodily injury and damage to Ms.
      Ebben-Tomas. Based upon the information and documentation
      available, as well as my education, training, and experience, it is my

                                         15
      opinion within a reasonable degree of medical probability that the
      actions by Dr. Cortez . . . led to the patient‘s life threatening
      complications initiated during the first procedure and the immediate
      postoperative period that required additional surgery, intensive care
      treatment, and prolonged hospitalization and medical care. These
      complications would have been avoided if the appropriate
      preoperative consultation and planning and intraoperative surgical
      management would have been done.

      Appellants argue that Dr. Heard‘s report is inadequate to establish

causation because Dr. Heard does not explain or describe how different

preoperative planning or consultation or different intraoperative surgical

management would have prevented Tomas‘s bowel injury. Tomas responds that

the report provides a fair summary of causation because it provides that her life

threatening condition ―would have been avoided if the appropriate preoperative

consultation and planning and intraoperative surgical management would have

been done.‖

      In Castillo v. August, Castillo underwent spinal surgery, was subsequently

transferred to a rehabilitation facility under the care of Dr. August, and developed

a staph infection in the surgical site and meningitis. See 248 S.W.3d 874, 882–

83 (Tex. App.—El Paso 2008, no pet.).         Castillo sued Dr. August and other

defendants alleging that Dr. August had a duty to observe and monitor her

incision for any sign of infection and that his failure to do so resulted in the staph

infection and life-threatening meningitis. Id. at 878. The expert report opined

that Dr. August should have personally and vigilantly monitored Castillo‘s status

because she had presented upon admission to the rehabilitation facility with

                                         16
signs and symptoms of infection and that he should have identified, examined,

diagnosed, and taken measures to treat the infection.         Id. at 882.     As to

causation, however, the expert report by Dr. Pacheco stated only that ―Dr.

August‘s breach of the standard of care ‗caused Ms. Castillo to suffer the

meningitis and caused the need to remove the hardware that [the surgeon] had

implanted in Ms. Castillo‘s spine—given the advanced and uncontrolled state of

the infection in her back.‘‖ Id.

       Holding that the expert report was deficient concerning causation, the

Castillo court held,

             Dr. Pacheco does not adequately link Dr. August‘s actions to
       Ms. Castillo‘s subsequent ―raging infection‖ and staph meningitis.
       His narrative of events does not discuss delusional behavior,
       meningitis, or a subsequent surgery to debride the wound and
       remove the hardware. Nor does he explain how the infection in her
       back caused the meningitis. While a claimant is not required to
       conclusively prove her case through a preliminary expert report, the
       report may not merely state conclusions about any of the elements.
       Dr. Pacheco‘s expert report requires us to infer causation, which,
       under the ―four corners‖ rule, we are not permitted to do.

Id. at 882–83 (citations omitted).   Similarly, this court held in Collini that the

discussion of causation in the expert‘s report was conclusory because it did not

―provide any medical detail as to how the Reglan caused [the claimant‘s]

conditions or, more importantly, how Dr. Collini‘s specific prescriptions of Reglan

(beyond the taking of Reglan generally) attributed to the harm.‖ 280 S.W.3d at

467.

                                        17
      In this case, Dr. Heard‘s report does not contain any discussion as to why

Tomas developed the life threatening complications; why she required additional

surgery, intensive care treatment, and prolonged hospitalization; how Tomas‘s

medical condition progressed; or how Dr. Cortez‘s action or inaction brought

about each stage in Tomas‘s worsening medical condition. Thus, the trial court

was required to infer causation, meaning Dr. Heard‘s report does not sufficiently

address the link between Dr. Cortez‘s alleged breaches of the standard of care

and Tomas‘s injuries. See id. at 467–68; Castillo, 248 S.W.3d at 882–83. We

therefore sustain Appellants‘ fifth issue.

                      VI. Disposition After Partial Reversal

      Appellants contend that we should render judgment dismissing Tomas‘s

claims with prejudice, and Tomas counters that we should remand the case so

that the trial court may consider granting thirty additional days to cure the

deficiencies. As we stated in Collini, ―The Texas Supreme Court has held that

section ‗74.351‘s plain language permits one thirty-day extension when the court

of appeals finds deficient a report that the trial court considered adequate.‘‖ 280
S.W.3d at 468 (quoting Leland v. Brandal, 257 S.W.3d 204, 207 (Tex. 2008)).

Accordingly, we will remand this case to permit the trial court the opportunity to

consider granting Tomas an extension to cure the deficiencies in Dr. Heard‘s

report.

                                             18
                                  VII. Conclusion

      Having sustained part of Appellants‘ first issue all of their second and fifth

issues and having overruled the remainder of Appellants‘ first issue and all of

their third and fourth issues, we affirm in part and reverse in part the trial court‘s

order and remand this case to the trial court to determine whether Tomas should

be granted an extension to cure the deficiencies discussed in this opinion.

                                                    ANNE GARDNER
                                                    JUSTICE

PANEL: GARDNER, MCCOY, and GABRIEL, JJ.

DELIVERED: February 9, 2012

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