Court Opinion

ID: 9947126
Source: CourtListenerOpinion
Date Created: 2024-03-02 18:13:12.817169+00
Date Added: 2024-06-11T14:25:47.685113
License: Public Domain

NUMBER 13-23-00234-CV

                            COURT OF APPEALS

                   THIRTEENTH DISTRICT OF TEXAS

                     CORPUS CHRISTI – EDINBURG

DR. NOLAN PEREZ AND
GASTROENTEROLOGY
CONSULTANTS OF SOUTH
TEXAS, PLLC,                                                             Appellants,

                                           v.

ELIZABETH HANAWA AND
BEN HANAWA,                                                                Appellees.

                   On appeal from the 138th District Court
                        of Cameron County, Texas.

                          MEMORANDUM OPINION

                  Before Justices Longoria, Silva, and Peña
                   Memorandum Opinion by Justice Silva
      Appellants Dr. Nolan Perez and Gastroenterology Consultants of South Texas,

PLLC (GCST), appeal the trial court’s denial of their motion to dismiss, which challenged
appellees Elizabeth Hanawa and Ben Hanawa’s preliminary expert report for a medical

malpractice claim. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351. By a single issue,

appellants argue that the expert report was deficient because it does not explain how or

why Dr. Perez’s alleged breach of care caused Elizabeth’s injuries. We reverse and

remand.

                                      I.      BACKGROUND

       The Hanawas filed their original petition alleging that Dr. Perez, while working for

GCST, performed an endoscopic retrograde cholangiopancreatography (ERCP) on

Elizabeth. 1 The Hanawas alleged that during the procedure, Dr. Perez perforated

Elizabeth’s duodenum, a part of the small intestine immediately beyond the stomach,

resulting in further injuries. The Hanawas subsequently provided appellants with an

expert report (the report) written by gastroenterologist, Dr. Kenneth Vega. See id. The

report identifies Dr. Vega’s qualifications, the materials he relied on to make his report, a

summary of medical facts, the standard of care, and the alleged breaches by Dr. Perez.

A.     The Report

       According to the report, Elizabeth presented to GCST with right upper quadrant

pain. After an examination and ultrasound, a GCST physician discovered a possible stone

in one of Elizabeth’s bile ducts. The physician recommended an ERCP, which Dr. Perez

performed. The ERCP “revealed a periampullary diverticulum[,] and [a] careful common

bile duct cannulation [was] performed. . . . Following that[,] a biliary sphincterotomy was

       1   The Hanawas filed an amended petition that was substantially and materially similar to the
original petition.

                                                 2
performed,” which extracted small stone fragments and sludge. Within about twenty

minutes of the procedure, Elizabeth started complaining “of abdominal distension

followed by nausea and vomiting.” GCST administered medication to help with Elizabeth’s

nausea, vomiting, and pain; however, Elizabeth continued to complain of discomfort,

prompting Dr. Perez to order x-rays of her abdomen.

       The x-rays did not reveal the cause of Elizabeth’s symptoms, and the radiologist

recommended a computed topography (CT) scan “if clinically warranted.” Dr. Perez

ordered an abdominal CT scan without contrast, which revealed “duodenal wall thickening

and a focal area with air collection . . . most likely representing [a] walled off perforation.”

However, the radiologist suggested repeating the scan due to “impending free air.”

Instead, Elizabeth was admitted to the hospital where she received a family medicine

consult. Her symptoms persisted into the next day and a surgical consult was ordered.

The surgeon recommended “conservative therapy” but suggested exploratory surgery in

six to twelve hours if Elizabeth did not improve. Approximately three hours later, the

surgeon conducted exploratory surgery due to Elizabeth’s worsening condition and found

a “gross perforation around the right colon” and “gross bilious spillage . . . thought to be

due to perforation of the second portion of the duodenum.” The surgeon repaired the

perforations, and although Elizabeth “tolerated the surgery well,” she developed sepsis

and was admitted to a long-term acute care hospital.

       The report explained that

       [t]he standard of care when managing a patient with increasing abdominal
       pain and distension following an ERCP with intervention is to exclude
       perforation with radiologic evaluation, including CT abdomen with and
       without contrast, along with immediate surgical consultation. Depending on

                                               3
        the perforation discovered, intervention can then occur to limit morbidity[ 2]
        or mortality.

Dr. Vega opined that within a reasonable medical probability

        Dr. []Perez breached the requisite standards of care with respect to
        [Elizabeth] from 7-8 September 2018 by failing to adequately evaluate and
        obtain urgent surgical consultation when concerned about perforation
        following ERCP. When [Elizabeth] developed abdominal pain and
        distension immediately following ERCP, Dr. Perez should have ordered a
        CT abdomen including contrast to determine if perforation is present. This
        type of study could have determined if free per[f]oration was present when
        compared to a non-contrast study, indicating need for emergent repair.
        Furthermore, immediate surgical consultation would have provided input
        into care when such perforation is a concern. Rapid recognition of free
        perforation combined with rapid surgical repair would have limited morbidity
        following the perforation event.

B.      Objection to the Report and Motion to Dismiss

        Appellants filed an objection to the Hanawas’ expert report along with a motion to

dismiss. 3 Appellants asserted that the report “is vague and speculative in that it does not

explain how much sooner [Dr. Perez] should have ordered the radiology study” and

“assumes that Dr. Perez could control how much sooner the radiological studies were

done, and that he could determine what type of study was performed.” Appellants also

claim that the report “is completely speculative as to how the alleged breach would have

changed [Elizabeth’s] treatment, or her outcome in any way.”

        Appellants also challenged Dr. Vega’s assertions that had Dr. Perez ordered a

        2 Morbidity means “a diseased state or symptom,” “a complication or undesirable side effect
following surgery or medical treatment,” or “the incidence of disease [or] the rate of illness.” Morbidity,
Merriam-Webster’s Online Dictionary, https://www.merriam-webster.com/dictionary/morbidity (last visited
on January 29, 2024).
        3   Our recitation of the appellants’ objections refers to their first amended objection and motion to
dismiss.

                                                       4
surgical consult sooner, the surgeon would have ordered emergency surgery. Appellants

argued that Dr. Vega was unqualified to opine on the standard of care for a surgeon and

that Dr. Vega’s “assumptions [were] completely inaccurate.” Appellants noted that the

records demonstrate that the surgeon recommended continuing conservative treatment

with a possible need for exploratory surgery in six to twelve hours if Elizabeth did not

improve. Finally, appellants complained that Dr. Vega’s opinion that if Dr. Perez had

ordered radiological studies and surgical consultation sooner than he did, Elizabeth’s

“morbidity or mortality would have been limited” is vague, speculative, and conclusory.

       As to GCST, appellants argued that

       Dr. Vega’s report is completely lacking in criticisms of [GCST]. The report
       does not set out the standard of care for the clinic, its staff, or establish
       causation. Therefore, [GCST] objects to Dr. Vega’s qualifications as it
       relates to it, and to his report because it does not [i]nform this defendant of
       the specific conduct called into question or provide a basis for the trial court
       to conclude the claims have merit.

       Ultimately, appellants requested the trial court to sustain its objection to the report

and dismiss the Hanawas’ suit with prejudice because the report was so deficient as to

constitute no report at all.

C.     Response to Objection

       The Hanawas responded to appellants’ objection to the report, arguing that the

report sufficiently linked the alleged substandard care to Elizabeth’s injuries. The

Hanawas noted that the report stated that Elizabeth “did develop sepsis due to the

perforation[,] requiring antibiotics.” The Hanawas further explained that Dr. Vega was “not

necessarily critical in his report of the time lapse between the onset of [Elizabeth’s] signs

of a serious medical emergency and the taking of diagnostic images by way of x-rays and

                                              5
CT scans.” Rather, Dr. Vega was critical of “Dr. Perez’s failure to obtain a CT with

contra[s]t even after the radiologist who read the studies suspected ‘impending free air’

and suggested additional studies.” The Hanawas argued that they were not required to

set out a standard of care or establish causation for GCST because a health care liability

claim based on vicarious liability may be established by an expert report that is adequate

to implicate the employer.

D.     Trial Court’s Ruling

       The trial court denied appellants’ motion to dismiss. This interlocutory appeal

followed. See id. § 51.014(a)(9).

                               II.    STANDARD OF REVIEW

       We review a trial court’s ruling on a motion to dismiss for failure to comply with

§ 74.351’s expert report requirements for abuse of discretion. Bowie Mem’l Hosp. v.

Wright, 79 S.W.3d 48, 52 (Tex. 2002) (per curiam). “A trial court abuses its discretion if it

acts in an arbitrary or unreasonable manner without reference to any guiding rules or

principles.” Walker v. Gutierrez, 111 S.W.3d 56, 62 (Tex. 2003) (citing Downer v.

Aquamarine Operators, Inc., 701 S.W.2d 238, 241–42 (Tex. 1985)). “When reviewing

matters committed to the trial court’s discretion, a court of appeals may not substitute its

own judgment for the trial court’s judgment.” Id. (citing Flores v. Fourth Court of Appeals,

777 S.W.2d 38, 41–42 (Tex. 1989)). The denial of a motion to dismiss under § 74.351(b)

is interlocutory and may be appealed immediately. TEX. CIV. PRAC. & REM. CODE ANN.

§ 51.014(a)(9); see Ogletree v. Matthews, 262 S.W.3d 316, 319 (Tex. 2007). The trial

court’s decision must result in a “clear and prejudicial error” to be reversible. Flores, 777

                                             6
S.W.2d at 41–42.

                                   III.   APPLICABLE LAW

A.     Expert Report

       A party who brings a health care liability claim shall, “not later than the 120th day

after the date each defendant’s original answer is filed, serve on that party or the party’s

attorney one or more expert reports . . . .” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a).

The claimant must also serve the curriculum vitae of each expert who provided a report.

Id. Each defendant must object to the sufficiency of the report within twenty-one days of

receiving the report or twenty-one days of the filing of the defendant’s answer. Id. Failure

to timely serve the expert report shall result in the trial court dismissing the suit with

prejudice. Id. § 74.351(b)(2). Conversely, failure to timely object results in a waiver of any

objections. Id. § 74.351(a). The court may grant one thirty-day extension to cure a report

that is found to be deficient. Id. § 74.351(c). In general, “trial courts should err on the side

of granting claimants’ extensions.” Samlowski v. Wooten, 332 S.W.3d 404, 411 (Tex.

2011). “The purpose of the expert report requirement is to deter frivolous claims, not to

dispose of claims regardless of their merits.” Scoresby v. Santillan, 346 S.W.3d 546, 554

(Tex. 2011).

       The report must “represent an objective good faith effort to comply” with the

definition of an expert report. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(l). To meet the

requirements of a report, it must represent a “fair summary of the expert’s opinions” of

(1) the applicable standard of care, (2) the failure of the health care provider to meet them,

and (3) the causal relationship between that failure and the injury, harm, or damages

                                               7
claimed. Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 457 (Tex.

2017). At a minimum, the expert report must “inform the defendant of the specific conduct

the plaintiff has called into question” and “provide a basis for the trial court to conclude

that the claims have merit.” Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010) (quoting

Bowie Mem’l Hosp., 79 S.W.3d at 52). A report does not constitute a good faith effort if it

omits any of the statutory requirements. Id. (citing Am. Transitional Care Ctrs. of Tex.,

Inc. v. Palacios, 46 S.W.3d 873, 879 (Tex. 2001)). Although the claimant is not required

to present evidence in the report as if they were actually litigating the merits, they may

not merely state the expert’s conclusions regarding the standard of care, breach, and

causation. Id. The report must explain the basis of the expert’s statements to link his or

her conclusions to the facts. Id.

       Since the enactment of the Texas Medical Liability Act (the Act), codified in

Chapter 74 of the Texas Civil Practice and Remedies Code, the Supreme Court of Texas

has clarified what constitutes an adequate expert report. See Abshire v. Christus Health

Se. Tex., 563 S.W.3d 219, 226 (Tex. 2018) (per curium); Certified EMS, Inc. v. Potts, 392

S.W.3d 625 (Tex. 2013); Scoresby, 346 S.W.3d at 549–50; Samlowski, 332 S.W.3d at

411; Jelinek, 328 S.W.3d at 539–40; Ogletree, 262 S.W.3d at 322. The Court has

recognized that the Act distinguishes between a deficient report and no report at all. See

Ogletree, 262 S.W.3d at 320–21. The court has also noted that a report may be so

deficient as to constitute no report at all. See Scoresby, 346 S.W.3d at 556 (concluding

that a statement by an expert that the defendant violated the standard of care and as a

result caused damages, without more, warranted an extension rather than dismissal, but

                                             8
noting that a sheet of paper with “expert report” written on it “would mock the Act’s

requirements”). A report that is deemed deficient should result in a thirty-day extension to

cure the deficiencies, while a report so deficient as to constitute no report at all should

result in dismissal. See id. at 557.

       1.     Standard of Care and Breach

       The standard of care relevant to a healthcare provider is what an ordinarily prudent

healthcare provider would do under the same or similar circumstances. Strom v. Mem’l

Hermann Hosp. Sys., 110 S.W.3d 216, 222 (Tex. App.—Houston [1st Dist.] 2003, pet.

denied) (citing Palacios, 46 S.W.3d at 880). “Whether a defendant breached the standard

of care due [to] a patient cannot be determined without ‘specific information about what

the defendant should have done differently.’” Id. (quoting Palacios, 46 S.W.3d at 880).

       2.     Causation

       “[A] plaintiff asserting a health care liability claim based on negligence, who cannot

prove that her injury was proximately caused by the defendant’s failure to meet applicable

standards of care, does not have a meritorious claim.” Zamarripa, 526 S.W.3d at 460.

Addressing causation in the expert reports, the supreme court has noted that

       [p]roximate cause has two components: (1) foreseeability and (2) cause-in-
       fact. For a negligent act or omission to have been a cause-in-fact of the
       harm, the act or omission must have been a substantial factor in bringing
       about the harm, and absent the act or omission—i.e., but for the act or
       omission—the harm would not have occurred.

Id. (quoting Rodriguez-Escobar v. Goss, 392 S.W.3d 109, 113 (Tex. 2013) (per curiam)).

No magic words, such as “proximate cause” or “foreseeability,” are necessary. Id. at 460.

Similarly, “merely incanting words does not suffice.” Id. The expert report must sufficiently

                                             9
demonstrate that the behavior called into question caused the harm, without leaving too

many analytical gaps for the trial court. Abshire, 563 S.W.3d at 226.

        “An expert must explain, based on facts set out in the report, how and why the

breach caused the injury.” Van Ness v. ETMC First Physicians, 461 S.W.3d 140, 142

(Tex. 2015) (per curiam) (citing Jelinek, 328 S.W.3d at 539–40). “A bare expert opinion

that the breach caused the injury will not suffice.” Id. (citing Jelinek, 328 S.W.3d at 539–

40). “To determine whether the expert’s causation conclusions are detailed enough, as

with standard of care and breach, we read the expert’s conclusions on causation in the

context of the entire report, not piecemeal or in a vacuum.” Bedi v. Cornett, 635 S.W.3d

775, 782 (Tex. App.—Houston [14th Dist.] 2021, no pet.) (citing Harvey v. Kindred

Healthcare Operating, Inc., 578 S.W.3d 638, 653 (Tex. App.—Houston [14th Dist.] 2019,

no pet.)).

                                             IV.     ANALYSIS

        Appellants complain that the report fails to satisfy the causation aspect of the

expert report requirement. 4 According to appellants, the report “fails to connect the sepsis

to a breach of the standard of care by Dr. Perez.” Moreover, the only statement “that

might be considered a causation opinion recites simply, ‘[r]apid recognition of free

perforation combined with rapid surgical repair would have limited morbidity following the

perforation event.’” Appellants argue that such a causation opinion is conclusory and as

such is insufficient under § 74.351. See Jelinek, 328 S.W.3d at 539. The Hanawas, in

        4    Appellants do not challenge the timeliness of the expert report, Dr. Vega’s qualifications, or his
recitation of the standard of care or the alleged breach. Moreover, appellants do not challenge Dr. Vega’s
failure to apply the standard of care, alleged breach, or causation as it relates to GCST as they did in the
trial court.

                                                     10
contrast, contend the report is sufficient to establish the causal relationship between the

breach and the injury, harm, or damages claimed.

       In Jelinek, the supreme court examined the sufficiency of an expert’s conclusion

that the physician-defendant’s “breach of the appropriate standard of care in ‘reasonable

medical probability, resulted in a prolonged hospital course and increased pain and

suffering being experienced by [the patient].’” 328 S.W.3d at 539. The court concluded

that the report was conclusory on causation where it “offer[ed] no more than a bare

assertion that [the physician’s] breach resulted in increased pain and suffering and a

prolonged hospital stay. Beyond that statement, the report offer[ed] no explanation of how

the breach caused the injury.” Id. at 540. The Hanawas attempt to contrast the report in

the present case from that in Jelinek by casting the Jelinek report as failing “to state that

the negligent act of omitting those antibiotics would have made a difference in treating

the infection,” whereas here, the report states that “proper evaluation and surgical repair

would have limited morbidity.” We believe that is a distinction without a difference.

       In Jelinek, the supreme court did not strike down the report for failing to state that

breaching the standard of care “would have made a difference,” but rather, the court found

it to be deficient because it failed to explain how the breach caused the injury. See id.

Similarly, the report before us fails to explain how Dr. Perez’s breach—failing to order a

CT scan with contrast—caused Elizabeth’s injury. Indeed, it is not even entirely clear from

the report what injury, harm, or damages Elizabeth is complaining of. See TEX. CIV. PRAC.

& REM. CODE ANN. § 74.351(r)(6). Nonetheless, Dr. Vega’s statement that “[r]apid

recognition of free perforation combined with rapid surgical repair would have limited

                                             11
morbidity,” even when considered with the entire report, is a conclusory statement that

does no more than opine that the breach potentially caused some injury. See Van Ness,

461 S.W.3d at 142; Bedi, 635 S.W.3d at 782.

       Appellants also argue that the report does not address the foreseeability

component of causation. See Zamarripa, 526 S.W.3d at 460. The Hanawas respond that,

“If [it] was not foreseeable to Dr. Perez [that delaying a CT scan and surgery would

increase morbidity], he probably should not be practicing medicine.” The Hanawas go on

to argue that Zamarripa is distinguishable because the supreme court found the expert

report deficient as to the physician but not the hospital. See id. at 461. However, nothing

in Zamarripa limits the foreseeability component of proximate cause to institutional

defendants as opposed to individual physicians. See id. at 460–61. Indeed, the supreme

court expressly noted that failing to require an expert report to address foreseeability

“simply confuses the matter.” Id. at 460 (disavowing Valley Reg’l Med. Ctr., Inc. v.

Gonzalez, No. 13-12-00572-CV, 2013 WL 2298470, at *3 (Tex. App.—Corpus Christi—

Edinburg 2013, no pet.) (mem. op.); and Rio Grande Reg’l Hosp. v. Ayala, No. 13-11-

00686-CV, 2012 WL 3637368, at *19 (Tex. App.—Corpus Christi—Edinburg 2012, pet.

denied) (mem. op.)).

       Because the expert report’s assessment of causation is merely conclusory and

altogether fails to address foreseeability, the report does not constitute a good faith effort

and the trial court abused its discretion by denying appellants’ motion. See TEX. CIV. PRAC.

& REM. CODE ANN. § 74.351(b), (l), (r)(6); Zamarripa, 526 S.W.3d at 460. However, the

expert report is not so deficient as to constitute no report at all; accordingly, the Hanawas

                                             12
should be given an opportunity to cure the deficiencies in the report. See TEX. CIV. PRAC.

& REM. CODE ANN. § 74.351(c); Scoresby, 346 S.W.3d at 556–57 (concluding that the

expert report was sufficient to warrant a remand to cure deficiencies in the report, despite

the report’s failure to state the standard of care where it otherwise contained the opinion

of an individual with expertise that the claim has merit and implicated the defendant’s

conduct). Appellants’ sole issue is sustained to the extent they argue the trial court erred

in overruling their objection to the expert report but overruled to the extent that they argue

the trial court erred by failing to dismiss the Hanawas’s suit.

                                    V.      CONCLUSION

       We reverse the trial court’s judgment and remand the matter for further

proceedings consistent with this opinion.

                                                                  CLARISSA SILVA
                                                                  Justice

Delivered and filed on the
29th day of February, 2024.

                                             13