Court Opinion

ID: 4047410
Source: CourtListenerOpinion
Date Created: 2016-09-29 00:24:10.887682+00
Date Added: 2024-06-11T08:43:38.200463
License: Public Domain

ACCEPTED
                                                                              03-14-00726-CV
                                                                                     4089429
                                                                    THIRD COURT OF APPEALS
                                                                               AUSTIN, TEXAS
                                                                        2/10/2015 12:09:14 PM
                                                                             JEFFREY D. KYLE
                                                                                       CLERK
                        NO. 03-14-00726-CV
__________________________________________________________________
                                                          FILED IN
                                                   3rd COURT OF APPEALS
               IN THE COURT OF APPEALS FOR THE AUSTIN, TEXAS
                    THIRD DISTRICT OF TEXAS        2/10/2015 12:09:14 PM
__________________________________________________________________
                                                       JEFFREY D. KYLE
                                                            Clerk
       TEXAS SAN MARCOS TREATMENT CENTER, L.P. d/b/a
              SAN MARCOS TREATMENT CENTER
                         Appellant

                                  v.

                        VERONICA PAYTON
                              Appellee
__________________________________________________________________

                 On Appeal from Hays County, Texas,
                     428th Judicial District Court
                  Trial Court Case Number: 13-2658
__________________________________________________________________

                      BRIEF FOR APPELLEE
__________________________________________________________________

                                Adam S. Ward
                                Texas Bar No. 00788615
                                Keely Allison Ward
                                Texas Bar No. 00790220
                                Allison & Ward
                                2001 North Lamar Blvd.
                                Austin, Texas 78705
                                Telephone: (512) 474-8153
                                Facsimile: (512) 474-9703
                                Email: allison-ward@sbcglobal.net

                                Attorneys for Appellee,
                                Veronica Payton

          ORAL ARGUMENT RESPECTFULLY REQUESTED
               I.     IDENTITY OF PARTIES AND COUNSEL

      In accordance with Rule 38.1(a) of the Texas Rules of Appellate Procedure,
Appellee provides the following complete list of all parties and counsel to the trial
court’s order that forms the basis of this appeal.
      Trial and Appellate Counsel for Appellee Veronica Payton:
      Adam S. Ward
      Texas Bar No. 00788615
      Keely Allison Ward
      Texas Bar No. 00790220
      Aaron Allison
      Texas Bar No. 24055098
      Allison & Ward
      2001 North Lamar Blvd.
      Austin, Texas 78705-4907
      Telephone: (512) 474-8153
      Facsimile: (512) 474-9703
      Email: allison-ward@sbcglobal.net
      Email: keely@allisonwardllp.com
      Email: aaron@allisonwardllp.com

      Trial and Appellate Counsel for Appellate Counsel for Appellant Texas San
Marcos Treatment Center, L.P. d/b/a San Marcos Treatment Center:
      Ryan L. Clement
      Texas Bar No. 24036371
      SERPE JONES ANDREWS
      CALLENDER & BELL, PLLC
      2929 Allen Parkway, Suite 1600
      Houston, Texas 77019
      Telephone: (713) 452-4400
      Facsimile: (713) 452-4499
      Emails: rclement@serpejones.com

                                           ii
                       II.   TABLE OF CONTENTS
                                                                          Page
IDENTITY OF PARTIES AND COUNSEL………………………………………ii
TABLE OF CONTENTS……………………….…………………………………iii
TABLE OF AUTHORITIES………………………………………………………iv
STATEMENT OF THE CASE…………………………………………………….2
ISSUES PRESENTED……………………………………………………………..3
STATEMENT OF FACTS…………………………………………………………4
SUMMARY OF THE ARGUMENT……………………………………………..11
ARGUMENT & AUTHORITY…………………………………………………..12
      A.    STANDARD OF REVIEW…………………………………………12
      B.    The Trial Court Did Not Abuse Its Discretion When Finding
            Dr. Reid’s Report Satisfied the Requirements of Chapter 74
            And Denying Appellant’s Motion to Dismiss……………………14

                  1.    Section 74.351 Requires Only a “Good Faith”
                        “Fair Summary” of an Expert’s Opinions……………..14

                  2.    Dr. Reid’s Report Provides A “Good Faith”
                        “Fair Summary” of Ms. Payton’s Claims Against
                         San Marcos Treatment Center……………………...…17

      C.    Dr. Reid’s Expert Report Satisfies the Legislative Purpose of
            Chapter 74’s Expert Report Requirement………………………….38

Conclusion & Prayer……………………………………………………………...39

Certificate of Compliance………………………………………………………...41

Certificate of Service……………………………………………………………..42

Appendix
A.   Expert report and curriculum vitae of Dr. William H. Reid, M.D. M.P.H.
B.   Cases

                                      iii
                      III.   TABLE OF AUTHORITIES

Cases
Am. Transitional Care Ctrs. Of Tex. Inc. v. Palacios,
46 S.W.3d 873 (Tex. 2001)………………………………………………….passim

Apodaca v. Russo,
228 S.W.3d 252 (Tex. App. – Austin 2007, no pet)………………………………16

Baylor All Saints Medical Center v. Martin,
340 S.W.3d 529 (Tex. App. – Fort Worth 2011, no pet)…………….………..20, 21

Certified EMS, Inc. v. Potts,
392 S.W.3d 625 (Tex. 2013)…………………………………………………passim

Chadha, M.D. v. Rothert,
No. 03-13-00153-CV, 2014 WL 538815
(Tex. App. – Austin Feb. 5, 2014, no pet.)………………………………………38

Christian Care Center, Inc. v. Golenko,
328 S.W.3d 637 (Tex. App. – Dallas 2011, pet denied)…………………………36

Christus Spohn Health Sys. Corp. v. Sanchez,
299 S.W.3d 868, 877-78 (Tex. App. – Corpus Christi 2009, pet. denied)…..37, 38

Downer v. Aquamarine Operators, Inc.,
701 S.W.2d 238 (Tex. 1985)……………………………………………………...12

Flores v. Fourth Court of Appeals,
777 S.W.2d 38 (Tex. 1989)……………………………………………………….12

Herbert v. Hopkins,
395 S.W.3d 884 (Tex. App. – Austin 2013, no pet.)……………………………...13

Jelenek v. Casas,
328 S.W.3d 526 (Tex. 2010)……………………………………………………...35

Kingwood Pines Hospital, LLC. V. Gomez,
362 S.W.3d 740 (Tex. App. – Houston [14th Dist.] 2011, no pet.)…………....20, 21
                                       iv
Kloeris v. Stockdale,
No. 01-09-00711-CV, 2010 WL 1241305
(Tex. App. - Houston [1st Dist.] 2010, no pet.)……………………………….25, 26

Kocurek v. Colby,
No. 03-13-00057, 2014 WL 4179454
(Tex. App. – Austin Aug. 22, 2014, no pet.)…………………………….………..35

Methodist Hosp. v. Shepherd-Sherman,
296 S.W.3d 193 (Tex. App. Houston [14th Dist] 2009, no pet.)…………………..25

Nexion Health at Garland, Inc. v. Treybig,
No. 05-14-00498-CV, 2014 WL 7499373
(Tex. App. – Dallas, Dec. 31, 2014, no pet.)………………………………….19, 37

Presbyterian Cmty. Hosp. of Denton v. Smith,
314 S.W.3d 508 (Tex. App. – Fort Worth 2010, no pet.)…………………………19

Shenoy v. Jean,
No. 01-10-01116-CV, 2011 WL 6938538
(Tex. App. – Houston [1st Dist.] Dec. 29, 2011, no pet.)………………….23, 25, 32

Smith v. Wilson,
368 S.W.3d 574 (Tex. App. – Austin 2012, no pet.)……………………………..35

Texarkana Nursing & Healthcare Center, LLC v. Lyle,
388 S.W.3d 314 (Tex. App. – Texarkana 2012, no pet.)…………….……….20, 36

Texas West Oaks Hosp. L.P. v. Williams,
371 S.W.3d 171 (Tex. 2012)………………………………………………………2

TTHR Ltd. P’ship v. Moreno,
401 S.W.3d 41 (Tex. 2013)………………………………………………12, 15, 23

UHS of Timberlawn, Inc. v. S.B.,
281 S.W.3d 207, (Tex. App. – Dallas 2009, pet. denied)…………………………34

Wissa v. Voosen,
243 S.W.3d 165 (Tex. App. – San Antonio 2007, no pet.)………………...…25, 26

                                    v
Statutes

Tex. Civ. Prac. Rem. Code §74.351………….………………………………passim

Tex. Civ. Prac. Rem. Code §74.351(a)……………………………………………14
Tex. Civ. Prac. Rem. Code §74.351(b)………………………………………passim

Tex. Civ. Prac. Rem. Code §74.351(c).........................................................…...3, 41
Tex. Civ. Prac. Rem. Code §74.351(l)……………………………………………14
Tex. Civ. Prac. Rem. Code §74.351(r)(6)…………………………………….12, 14
Tex. Civ. Prac. Rem. Code §74.351(s)……………………………………………16

                                                 vi
                        NO. 03-14-00726-CV
__________________________________________________________________

               IN THE COURT OF APPEALS FOR THE
                    THIRD DISTRICT OF TEXAS
__________________________________________________________________

        TEXAS SAN MARCOS TREATMENT CENTER, L.P. d/b/a
               SAN MARCOS TREATMENT CENTER
                          Appellant

                                      v.

                        VERONICA PAYTON
                              Appellee
__________________________________________________________________

                 On Appeal from Hays County, Texas,
                     428th Judicial District Court
                  Trial Court Case Number: 13-2658
__________________________________________________________________

                      BRIEF FOR APPELLEE
__________________________________________________________________

TO THE HONORABLE JUSTICES OF THE THIRD COURT OF APPEALS:

      Appellee Veronica Payton (“Veronica Payton”, “Ms. Payton” or “Appellee”)

files this brief in response to Appellant’s, Texas San Marcos Treatment Center,

L.P. d/b/a San Marcos Treatment Center (“San Marcos Treatment Center”,

“SMTC” or “Appellant”) appeal from an order denying Appellant’s motion to

dismiss pursuant to section 74.351(b) of the Texas Civil Practices and Remedies

Code in Trial Court Case Number 13-2658; Veronica Payton v. Texas San Marcos
Treatment Center, L.P. d/b/a/ San Marcos Treatment Center, in the 428th Judicial

District Court of Hays County, Texas, before the Honorable R. Bruce Boyer.

                       IV.   STATEMENT OF THE CASE

Nature of the Case:

      This is a negligence case brought by Ms. Veronica Payton against her

employer, San Marcos Treatment Center L.P. d/b/a San Marcos Treatment Center.

San Marcos Treatment Center L.P. d/b/a San Marcos Treatment Center (“SMTC”)

is a nonsubscriber to the Texas Workers’ Compensation Act. SMTC is a health

care provider and pursuant to Texas West Oaks Hosp. L.P. v. Williams, 371 S.W.3d
171 (Tex. 2012), this is a health care liability claim. (CR 4-14).

Trial Court Proceeding and Disposition:

      This case was originally filed on December 18, 2013. (CR 4). On January

27, 2014, Ms. Payton timely served the 120-day expert report and Curriculum

Vitae of Mr. William H. Reid, M.D., M.P.H. (“Dr. Reid”) pursuant to Tex. Civ.

Prac. Rem. Code § 74.351. (CR 22). Appellant filed objections to the report on

February 18, 2014 (CR 22). Appellant also objected to discovery based on its

objections to the report. (RR 10, 18, 20). Appellant filed its motion to dismiss

pursuant to 74.351(b) on July 9, 2014. (CR 22). Ms. Payton filed her response to

Appellant’s motion to dismiss and filed a motion for sanctions against Appellant

                                          2
on July 29, 2014. (CR 92-107). A hearing on Appellant’s objections and Ms.

Payton’s motion for sanctions was held on September 22, 2014, before the

Honorable Judge R. Bruce Boyer. (CR 127; RR 1-26). Judge Boyer overruled

Appellant’s objections and denied its Motion to Dismiss and denied Ms. Payton’s

motion for sanctions in an order dated October 30, 2014. (CR 118). Appellant’s

Notice of Appeal was filed on November 19, 2014. (CR 119-121).

Requested Disposition from this Court:

      Ms. Veronica Payton requests that Judge R. Bruce Boyer’s order dated

October 30, 2014, be affirmed. In the alternative, should this Court find that the

trial court abused its discretion by holding that Ms. Payton’s expert report was

sufficient, Ms. Payton requests that this Court remand the case to the trial court

concerning Ms. Payton’s request for a 30-day extension to cure pursuant to Tex.

Civ. Prac. & Rem. Code 74.351(c). Ms. Payton requested such relief from the trial

court below, but the trial court did not address the request because it found that Ms.

Payton’s expert report was sufficient. (RR 21).

                           V.     ISSUE PRESENTED

      Did the trial court abuse its discretion by holding that Ms. Payton’s expert

report was sufficient, overruling Appellant’s objections to the report, and denying

Appellant’s Motion to Dismiss?

                                          3
                        VI.    STATEMENT OF FACTS

      This is an interlocutory appeal arising from an expert report challenge in a

health care liability case. San Marcos Treatment Center (“SMTC”) is a facility

licensed by the State of Texas to provide behavioral health care and treatment to

adolescent patients. (CR 5). San Marcos Treatment Center is divided into units,

providing care and services to patients based upon, among other things, gender and

treatment needs. (CR 5). At all relevant times Veronica Payton was an employee

of San Marcos Treatment Center working as an aide on a boys unit. (CR 5, 36).

On December 7, 2011, a patient, Mr. Leroy Simon, was admitted to SMTC. (CR

5). Mr. Simon was a 17 year old, “stocky”, male patient with a long history of

assaultive behavior, sex offenses, fights, borderline intellectual function or mild

retardation, and chronic symptoms of intermittent explosive disorder, lack of

impulse control, oppositional defiant disorder, and other mental and behavioral

problems. (CR 36). Mr. Simon also had an extensive criminal history, including

out of state theft and assault charges and drug abuse. (CR 6). On December 12,

2011 and December 13, 2011, Mr. Simon was evaluated at SMTC by, among

others, T. Walter Harrell, PH.D. acting on behalf of SMTC. (CR 6).               The

evaluation occurred in conjunction with a treatment plan for Mr. Simon’s potential

admission to SMTC (CR 6). Mr. Simon was admitted to SMTC with the diagnoses

of severe impulsivity or explosive expression of anger; severe defiant, disruptive or

                                         4
destructive behavior; dangerous self-injurious or unsafe behaviors; severe

deterioration of function in family, school, and or community; cognitive/processing

disturbance interfering with social adaption and learning; sexual reactive or

offending behavior; and sexual behavior problems (CR 6). Mr. Simon was housed

on the boys unit to which Ms. Payton was assigned. (CR 36). On January 2, 2012,

Ms. Payton and another female employee were responsible for 17 patients on the

unit. (CR 6, 36). Many, perhaps all, the patients, other than Mr. Simon were

younger than Mr. Simon, aged 11 years and up, and smaller than Mr. Simon. (CR

34, 35, 36). On January 2, 2012, Mr. Simon asked to do his laundry in preparation

for classes the following day. (CR 6). The laundry facility was located off the boys

unit in an unoccupied section of SMTC, because the laundry equipment located on

the boys unit had been broken for some time. (CR 7, 36). Ms. Payton escorted Mr.

Simon to the functioning laundry. (CR 36).        Mr. Simon was not under any

particular monitoring or containment order or special supervision. (CR 34). Ms.

Payton was not notified or otherwise advised that Mr. Simon was potentially

assaultive or otherwise dangerous, or that escorting him off the unit to the laundry

alone was unsafe. (CR 33). If Ms. Payton had been aware that Mr. Simon was

potentially assaultive or otherwise dangerous, she would not have escorted him to

the laundry alone. (CR 35). If there had been one more capable staff person on the

unit, Ms. Payton would not have believed it necessary to accompany Mr. Simon to

                                         5
the laundry alone. (CR 35). If there had been one more staff member who was

male on the boys unit, Ms. Payton would not have been a sole female alone with

Mr. Simon in the laundry. (CR 35). Ms. Payton received no training from SMTC

regarding her safety in the workplace, and particularly none related to recognizing

potentially dangerous patients, recognizing potentially assaultive patients or

protecting herself from patient assault and no training regarding the dangers of

escorting patients such as Mr. Simon off-unit alone. (CR 33, 35). If Ms. Payton

had received adequate training regarding the dangers of escorting patients such as

Mr. Simon off-unit alone, she would not have escorted him alone to the laundry

room. (CR35). While returning to the boys unit, Mr. Simon attacked Ms. Payton.

(CR 7).    Mr. Simon suddenly and violently assaulted Ms. Payton, quickly

overpowering her, choking her, knocking or otherwise forcing her to the ground,

hitting and kicking her, and forcing her head into a wall. (CR 36). Ms. Payton

could not call for help because she could not breathe. (CR 7). Mr. Simon threw

Ms. Payton to the ground while maintaining the choke hold on her. (CR 7). Ms.

Payton realized she was not going to get away from Mr. Simon so she “played

dead”. (CR 7). When Ms. Payton “played dead” Mr. Simon loosened his hold on

her. (CR 7). Ms. Payton grabbed her writing pen and began trying to stab Mr.

Simon by thrusting her arm next to her head in an attempt to strike Mr. Simon in

the face and make him release his strangle hold. (CR 7). Mr. Simon tightened his

                                        6
hold on Ms. Payton’s neck and she lost consciousness. (CR 7, 36). Once Ms.

Payton was unconscious, Mr. Simon released the choke hold. (CR 7). Ms. Payton

regained consciousness to find Mr. Simon was still there. (CR 7). Ms. Payton then

struck out at Mr. Simon and he began hitting and kicking her. (CR 7, 36). Then,

Mr. Simon ripped Ms. Payton’s keys, which she wore on a necklace, off her neck

and ran out of the area. (CR 7, 36). As Mr. Simon ran away, Ms. Payton was able

to yell for help and other staff members came to her aide. (CR 7, 36). The assault

was recorded on an unmonitored video camera. (CR 7). SMTC staff called 911.

(CR 36). Mr. Simon used Ms. Payton’s keys to flee SMTC’s facility. (CR 7). Mr.

Simon ran to a residence a few blocks away from SMTC and told the resident that

he (Mr. Simon) had been assaulted by a group home employee and needed help.

(CR 7-8, 36). San Marcos Police Department apprehended Mr. Simon and after

determining that Mr. Simon’s story was false, arrested him. (CR 8, 36). Mr. Simon

was indicted for aggravated assault with a deadly weapon (his fists and arms). (CR

8, 36). Ms. Payton was transported by ambulance to Central Texas Medical Center

(“CTMC”) from SMTC. (CR 7, 36). Ms. Payton received medical follow-up from

her primary care physician, Dr. Chris Larson. (CR 36).        Dr. Larson quickly

recognized symptoms of acute and chronic stress disorder due to the assault. (CR

36).   Ms. Payton was evaluated by psychiatrist Andrew Brylowski and

psychologist Dr. Edward Kotin. (CR 36). Dr. Brylowski found very significant

                                        7
anxiety and depression and diagnosed “acute stress reaction” and major depressive

disorder. (CR 36). Video of the assault, emergency room records, and outpatient

general medical records all indicate injuries, including neck and back injuries and

concussion as well as both acute and chronic post-traumatic mental symptoms,

including post traumatic stress disorder. (CR 34).

      In order to contradict or correct the “facts” in Appellant’s brief regarding

Ms. Payton’s allegations against SMTC, Appellee states the following allegations

from her original petition lettered A-E in this statement of facts. On December 18,

2013 Ms. Payton filed suit against San Marcos Treatment Center alleging

negligence on the part of SMTC for SMTC’s failure to meet five standards of care.

(CR 9-11). A) SMTC failed to meet the duty/standard for adequate staffing when

it failed to provide adequate staffing to meet foreseeable needs for patient care and

staff and patient safety. (CR 9). Staffing was inadequate on Ms. Payton’s unit on

January 2, 2012, and was lower than that required by plans of correction and/or

other agreements with the Texas Department of Family and Protective Services

(“DFPS”). (CR 10). The unit in question was supposed to have had at least three

staff on the shift during which the assault occurred (but instead only had two) and

that at least one of the staff was supposed to be male (not the case on the January 2,

2012, evening shift). (CR 10-11).         B) SMTC failed to meet the relevant

duty/standard regarding training when it failed to provide Ms. Payton with

                                          8
adequate training regarding safety in a workplace which contained foreseeable

threats to staff safety. (CR10). Ms. Payton never received any SMTC training

regarding her safety in the workplace related to recognizing potentially dangerous

patients, recognizing potentially assaultive patients, or protecting herself from

patient assault. (CR 10). C) SMTC failed to meet the relevant duty/standard

regarding adequate notification when it failed to provide Ms. Payton with

information or notification that Mr. Simon was likely to be assaultive or otherwise

dangerous to staff and/or patients. (CR 10). SMTC knew that Mr. Simon had a pre-

admission history of, among other things, “severe impulsivity or explosive

expression of anger”, yet Ms. Payton was not notified or otherwise advised that he

was potentially assaultive or otherwise dangerous, or that her escorting him alone

was unsafe. (CR 10). D) SMTC failed to meet the relevant duty/standard regarding

Mr. Simon’s admission when it admitted, allowed to be admitted, and/or allowed

housing on the children’s unit without adequate containment and/or supervision,

Mr. Simon was a 17 year old “stocky” male sex offender with a substantial history

of aggression, fights with staff and peers, criminal assault, severe problems with

physical and sexual conduct, conduct disorder, poor impulse control and/or

frequent inability to resist aggressive an sexual impulses, which had manifested

themselves both in and outside of residential treatment settings. (CR 10-11).

SMTC knew that Mr. Simon had a pre-admission history of, among other things,

                                        9
“severe impulsivity or explosive expression of anger” and other dangerous

behaviors and symptoms. (CR 11). SMTC was well aware, or should have been

aware, that Mr. Simon was inappropriate for admission to SMTC and/or was not

suited, in terms of staff and patient safety, for housing on the unit on which he was

housed, without special supervision or containment. (CR 11). E) SMTC failed to

meet the relevant duty/standard regarding amelioration or elimination of risks

when it failed to adequately contain, supervise, and/or monitor Mr. Simon to

ameliorate his danger to others and protect staff and patients on and before January

2, 2012. (CR 11).      Mr. Simon was not under any particular monitoring or

containment order, special supervision, or the like, which should have been

commensurate with his known history and behavioral/mental conditions. (CR 11).

SMTC knew or reasonable should have known that Mr. Simon was dangerous or

assaultive and should have been physically contained and/or supervised by more

than one female staff person. (CR 11). SMTC did nothing physically or clinically

to ameliorate the danger from Mr. Simon to staff and other patients. (CR 11).

Appellee also made other allegations in its original petition not addressed by

Appellant in its statement of facts. (CR 4-14).

      Also in response to Appellant’s statement of the “facts”, Dr. Reid’s report

contains relevant facts concerning the staffing on January 2, 2012; the education

and training or lack thereof provided to Ms. Payton, the information or lack thereof

                                         10
shared with health care staff concerning the patient’s condition and propensities,

factual information concerning the admission of Mr. Simon and placement on unit,

supervision and monitoring provided, and efforts to reduce the risk of danger and

protect patients and/or staff. (CR 32-39).

      On October 30, 2014, the trial court overruled Appellant’s motion to dismiss

pursuant to 74.351(b). (CR 118). Appellant filed its notice of appeal on November

19, 2014 and this interlocutory appeal ensued. (CR 119).

                   VII. SUMMARY OF THE ARGUMENT

      The expert report by Dr. Reid very clearly and specifically sets forth five

standards of care as they apply to San Marcos Treatment Center and specifically

details how those standards of care were breached. Dr. Reid’s report informs San

Marcos Treatment Center of the specific conduct called into question, notifying it

as to what it should have done differently. Dr. Reid’s report also describes how the

breaches in the standard of care led to Ms. Payton’s assault and subsequent

injuries. Appellant is asking this Court to hold Dr. Reid’s expert report to a much

higher standard than the “fair summary” standard mandated by Chapter 74.

Appellant wants the report to marshal all the evidence in detail without the benefit

of discovery of Appellant’s records and without any depositions. The law is clear

that Dr. Reid’s report must only provide a “good faith” “fair summary” of his

                                         11
opinions. Tex. Civ. Prac. Rem. Code §74.351(r)(6); Am. Transitional Care Ctrs. Of

Tex. Inc. v. Palacios, 46 S.W.3d 873 (Tex. 2001); Certified EMS, Inc. v. Potts,

392 S.W.3d 625 (Tex. 2013). Dr. Reid’s report provides a “good faith” “fair

summary” of his opinions and satisfies the Legislative goal of Chapter 74 to “deter

baseless claims, not to block earnest ones”. Id. The trial court did not abuse its

discretion by finding Dr. Reid’s report sufficient and overruling Appellant’s

motion to dismiss pursuant to 74.351(b).

                      IIX. ARGUMENT & AUTHORITY

   A. Standard of Review

      This Court reviews a trial court’s ruling on a §74.351 motion to dismiss

under an abuse of discretion standard of review. Am. Transitional Care Ctrs. of

Tex. Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001); TTHR Ltd. P’ship v.

Moreno, 401 S.W.3d 41, 44 (Tex. 2013). A trial court abuses its discretion if it

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

or principles. 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.

Flores v. Fourth Court of Appeals, 777 S.W.2d 38, 41 (Tex. 1989). This Court

described the abuse of discretion standard as it applied to a trial court’s ruling on a

                                          12
§74.351 motion to dismiss in Herbert v. Hopkins, 395 S.W.3d 884, 891 (Tex. App.

– Austin 2013, no pet.). This Court stated,

         We do not, in other words, examine the contents of Dr. White’s
         reports and make our own de novo determination as to whether
         he has provided sufficient information, with respect to his
         opinions regarding standard of care, breach, and causation, to (1)
         inform appellees of the specific conduct the Heberts have called
         into question; and (2) provide a basis for the district court to
         conclude that the claims have merit. See Jelinek, 328 S.W.3d at
         538-40 & n. 9; Wright, 79 S.W.3d at 52; Palacios, 46 S.W.3d at
         878-79. Instead we determine only whether the district court
         acted arbitrarily, unreasonably, and without reference to guiding
         rules and principles in determining that the reports failed to
         provide that information. See Wright, 79 S.W.3d at 52; see also
         Jelinek, 328 S.W.3d at 542 (Jefferson, C.J., dissenting) (“The
         dividing line between a sufficient and an inadequate report is
         impossible to draw precisely. We have said, therefore, that the
         determination must be made in the first instance by the trial
         court, and review of that decision asks not how an appellate court
         would have resolved that issue, but instead whether the trial
         court abused its discretion.”)(citing Jernigan v. Langley, 195
S.W.3d 91, 93 (Tex. 2006); Walker v. Gutierrez, 111 S.W.3d 56,
         63 (Tex. 2003)).

The trial court did not abuse its discretion in finding that Dr. Reid’s report satisfied

the requirement of Chapter 74 and in denying Appellant’s Motion to Dismiss,

because Dr. Reid’s report provides a “good faith” “fair summary” of Ms. Payton’s

claims against Appellant.

                                          13
B.    The Trial Court Did Not Abuse Its Discretion When Finding Dr. Reid’s
      Report Satisfied the Requirements of Chapter 74 and Denying
      Appellant’s Motion to Dismiss

      1.     Section 74.351 Requires Only a “Good Faith” “Fair Summary” of
             an Expert’s Opinions

      Section 74.351 requires a plaintiff asserting a health care liability claim to

submit an expert report, along with the expert’s curriculum vitae no later than the

120th day after filing suit. Tex. Civ. Prac. & Rem. Code Ann. §74.351(a). The Act

describes an expert report as a written report providing “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.” Tex. Civ. Prac. & Rem. Code Ann.

§74.351(r)(6).

      If the report filed constitutes a good faith effort to provide a fair summary of

the expert’s opinions regarding the plaintiff’s claims, a §74.351(b) motion to

dismiss must be denied. Tex. Civ. Prac. & Rem. Code Ann. §74.351(l).                A

“good-faith” effort only requires that the report discuss the elements of the

plaintiff’s claims with sufficient specificity to inform the defendant of the conduct

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

conclude that the claims have merit. Am. Transitional Care Ctrs. of Tex. Inc. v.

                                         14
Palacios, 46 S.W.3d 873, 875 (Tex. 2001). The plaintiff is not required to marshal

all its evidence. Palacios at 879. The plaintiff is not required to present evidence

in the report as if it were actually litigating the merits. Certified EMS, Inc. v. Potts,

392 S.W.3d 625, 631 (Tex. 2013) citing Palacios at 879. Rather, the report can be

informal in that 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.

Id.

      A report that satisfies the elements as to only one theory of liability, entitles

the claimant to proceed with a suit against the physician or health care provider.

Potts at 630. For a particular liability theory the report must sufficiently describe

the defendant’s alleged conduct. Id. Such a report both informs a defendant of the

behavior in question and allows the trial court to determine if the allegations have

merit. Id. If the trial court decides that a liability theory is supported, then the

claim is not frivolous, and the suit may proceed. Id.; TTHR Limited P’ship v.

Moreno, 401 S.W.3d 41 (Tex. 2013).

      The Texas Supreme Court described its reasoning in Certified EMS, Inc. v.

Potts, 392 S.W.3d 625, at 632 by stating, “The expert report requirement is a

threshold mechanism to dispose of claims lacking merit. . . while a full

development of all liability theories may be required for pretrial motions or to

convince a judge or jury during trial, there is no such requirement at the expert
                                           15
report stage.” An expert report is not required to prove defendant’s liability, but

rather to provide notice of what conduct forms the basis for the plaintiff’s

complaints. Apodaca v. Russo, 228 S.W.3d 252, 255 (Tex. App. – Austin 2007, no

pet.). The Act requires the expert report to summarize the expert’s opinions as of

the date of the report recognizing that those opinions are subject to further

refinement Potts, 392 S.W.3d at 632.

      Applying a less stringent standard at the Chapter 74 report stage versus at

summary judgment or trial makes sense when one considers the timing of Chapter

74 reports. Section 74.351(s) provides that until a plaintiff has served its expert

report(s) and curriculum vitae of its expert all discovery is stayed except for the

acquisition by the plaintiff of information related to the plaintiff’s health care

through written discovery, depositions on written questions, and discovery from

non-parties. Tex. Civ. Prac. & Rem. Code §74.351(s). Thus, expert reports are

generally produced before the defendant has been deposed, and even before any

oral depositions have been taken in the case. Requiring an expert to know all the

facts of the case exactly as they happened at this early stage of the lawsuit would

place an impossible burden upon plaintiff’s expert that could never be met. See

Potts, 392 S.W.3d at 632. This is why the statute requires only a “fair summary” of

the plaintiff’s claims. Dr. Reid’s report is a “fair summary” of his opinions as of

the date of the report regarding the applicable standard of care, the manner in

                                        16
which the care rendered by San Marcos Treatment Center failed to meet the

standard and the causal relationship between the failure and the injury, harm or

damages claimed.

2.    Dr. Reid’s Report Provides A “Good Faith” “Fair Summary” of
      Ms. Payton’s Claims Against San Marcos Treatment Center

      Dr. Reid’s report specifically states five separate standards of care,

specifically states how Appellant breached each of the standards of care and how

the breach of the standard of care caused harm to Ms. Payton. Dr. Reid’s report

satisfies the requirements of informing the defendant of the conduct the plaintiff

has called into question providing a basis for the trial court to conclude that the

claims have merit. See Am. Transitional Care Ctrs. of Tex. Inc. v. Palacios, 46
S.W.3d 873, 875 (Tex. 2001). Appellant’s arguments that Dr. Reid’s report failed

to identify any of the standards of care, failed to advise Appellant as to what it

should have done, and failed to link the breaches to the harm suffered by Mr.

Payton because Dr. Reid failed to link any facts to his opinions and therefore his

opinions are conclusory are incorrect.

        Dr. Reid states five standards of care that were breached by Appellant and

links facts to his conclusions for each standard of care and breach. For the first

                                         17
standard Dr. Reid states in relevant part,

         That employer (SMTC) by itself and through its various parts or
         assigns, had duties to its unit employee Ms. Payton which
         included… adequate staffing and staff support in her work
         environment sufficient to meet reasonable levels of staff safety,
         as well as patient safety and care.

(CR 32). Dr. Reid also states that SMTC failed to meet this standard when it

“failed to provide adequate staffing to meet the foreseeable needs for patient care

and staff and patient safety”. (CR 33). Dr. Reid continues his opinion with details

as to how SMTC breached the standard stating,

         [The] evening shift staffing was inadequate on Ms. Payton’s unit
         on January 2, 2012, and was lower than that required by plans of
         corrections and/or other agreements with the Texas Department
         of Family and Protective Services (DFPS). Specific staffing data
         from SMTC is not yet available to me; materials from DFPS,
         however, indicate a number of recent (to 1/02/2012) agency
         findings of inadequate staffing on the clinical units, as well as
         agreed upon DFPS specifications for correcting unit staffing
         deficiencies. It is my understanding (and this opinion is
         predicated on the accuracy of that understanding) that the unit in
         question was supposed to have had at least 3 staff persons on the
         shift on which the assault occurred (but instead only had 2) and
         that at least one of the staff was supposed to be male (not the
         case in the 1/02/2012, evening shift).

(CR 33). In discussing causation Dr. Reid states,

         SMTC’s failures to meet the applicable standards…foreseeably
         led to (i.e., were a significant cause of) damages to Ms.
         Payton…But for one or more of the breaches by SMTC…it is
         more likely than not that the January 2, 2012, assault would not
         have occurred, and thus …damages to Ms. Payton, would not
         have occurred. Specifically, if staffing had been adequate (that

                                             18
         is, at least one more capable staff person on the 17-patient unit),
         Ms. Payton would not have believed it necessary to accompany
         Leroy Simon to the laundry alone… if there had been adequate
         male staffing on the boy’s unit, Ms. Payton would not have been
         in the position of being a sole female vulnerable to attack by a
         physically stronger, younger male.

(CR 34-35). These statements by Dr. Reid regarding adequate staffing are not

conclusory but provide specific facts upon which his opinions are based and tell

the Appellant specifically what it should have done but failed to do and without

which the assault and injuries suffered by Ms. Payton would not have occurred.

      Dr. Reid explains the basis of his statements and links his conclusions to the

facts. Appellant mischaracterizes Dr. Reid’s report by simply citing the first page

of the report without including all the statements regarding the five standards,

breach, and causal nexus contained in the rest of the report as evidence that his

opinions are conclusory concerning the applicable standard of care. See

Appellant’s Brief at 16. The whole report, not just a few statements, determine if

the report is a “fair summary” of the expert’s opinions. Nexion Health at Garland,

Inc. v. Treybig, No. 05-14-00498-CV, 2014 WL 7499373, (Tex. App. – Dallas,

Dec. 31, 2014, no pet.); Presbyterian Cmty. Hosp. of Denton v. Smith, 314 S.W.3d
508, 514 (Tex. App. – Fort Worth 2010, no pet.)(in defining expert report rejected

a hospital’s argument that “several individual statements in [the expert’s] report

[were] insufficient” because the “report as a whole, provide[d] a ‘fair summary’ of

[the expert’s] opinions”). Dr. Reid’s report as a whole is a “good faith” “fair
                                         19
summary” his of opinions on each standard of care, breach and the causal nexus

between the breach and the harm, injuries or damages suffered by Ms. Payton.

      Appellant claims Dr. Reid’s statements concerning the standards of care

“mirror” those found in other assault cases wherein the expert’s report was found

to be deficient citing Texarkana Nursing & Healthcare Center, LLC v. Lyle, 388
S.W.3d 314 (Tex. App. – Texarkana 2012, no pet.); Baylor All Saints Medical

Center v. Martin, 340 S.W.3d 529 (Tex. App. – Forth Worth 2011, no pet.); and

Kingwood Pines Hospital, LLC. V. Gomez, 362 S.W.3d 740 (Tex. App. – Houston

[14th Dist.] 2011, no pet.). See Appellant’s Brief at 17. The report in Texarkana

was found to be deficient because the expert report only stated, “Texarkana

Nursing failed to provide ‘a safe and secure environment for its residents, allowing

the documented assault of Ms. Vest by one of its own employees’.” Texarkana at

319. The Texarkana Court of Appeals found this single statement by itself and

without any additional statements to inform the defendant as to what it should have

done differently did not advise the defendant of what should have been done in

order to prevent its employee from assaulting a patient. Texarkana at 320-21. In

contrast, Dr. Reid’s report goes well beyond a single statement like the one in

Texarkana and details exactly what SMTC should have done to prevent Ms.

Payton from being assaulted. For example, Dr. Reid’s statements regarding

adequate staffing do not “mirror” those found Texarkana. Dr. Reid makes clear

                                         20
what SMTC should have done regarding staffing: SMTC should have had one

more capable staff person on the 17 patient unit because they should have had 3

staff members but only had 2 and at least one of the staff members should have

been male, which was not the case.

      Appellant’s reliance on Baylor All Saints Medical Center v. Martin, 340
S.W.3d 529 (Tex. App.- Fort Worth 2011, no pet.) is also misplaced. In Baylor,

the court found the report to be insufficient because the report stated there must be

policies in place to safeguard patients from assault including employing a

sufficient number of security personnel. Baylor at 534. The court found the expert

report failed to indicate what specific policies and safeguards should have been in

place and the number of security personnel needed was not described. Id. Clearly

Dr. Reid’s report is more specific than the report in Baylor and does not “mirror”

the language of the expert report in Baylor. For example, regarding adequate

staffing Dr. Reid specifically states the number of staff members Appellant should

have had on the unit in which Ms. Payton was working when she was assaulted.

      The Kingwood case cited by Appellant is likewise distinguishable. In

Kingwood, the expert stated a failure “to ensure that there were appropriately

trained and adequate staffing and milieu structure such that a young girl … would

not be sexually molested” the report stated the standard of care was breached when

the physician failed to insure her patient’s safety using “any number of measures
                                         21
available”, by failing to “provided additional supervision” and not affording the

patient “the most basic supervision”. Kingwood at 748. The court found that the

report did not provide information about how the physician was to insure that the

hospital was adequately staffed and that staff members were appropriately trained

or what measures were available to insure the patient’s safety. Id. The expert’s

report in Kingwood did not indicate what kind of supervision by the hospital was

sufficient to provide a secure environment for the patient. Kingwood at 750. Dr.

Reid’s report clearly informs SMTC as to what it should have done but did not.

For example, regarding staffing, Dr. Reid does state specifically how many staff

members SMTC should have had on the unit at the time of the assault but did not.

(CR 33-36). Clearly Dr. Reid’s report is more specific than the one the court

considered in Kingwood and does not “mirror” the statements of the expert report

in Kingwood.

      Appellant argues that Dr. Reid’s opinions regarding adequate staffing are

conclusory because Dr. Reid states that “specific staffing data from SMTC is not

yet available to me”. See Appellant’s Brief at 26. The fact that Dr. Reid has not yet

seen staffing data from Appellant does not make his statements conclusory. The

Texas Supreme Court stated in Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 632

(Tex. 2013), “The Act requires the expert report to summarize the expert’s

opinions as of the date of the report recognizing that those opinions are subject to

                                         22
further refinement”.   Additional facts may give rise to additional theories of

liability and change theories of liability which are allowed. Id. Requiring an

expert to know all the facts of the case exactly as they happened at this early stage

of the lawsuit would place an impossible burden upon plaintiff’s expert that could

never be met. Id.      The court accepts the factual statement for purpose of

sufficiency of expert report inquiry. Shenoy v. Jean, No. 01-10-01116-CV, 2011
WL 6938538 (Tex. App. – Houston [1st Dist.] Dec. 29, 2011, no pet.). Dr. Reid’s

opinions are based upon the facts known at the time of the report which he links to

his opinions regarding the standard of care, breach and causation and his opinions

are neither speculative nor conclusory.

      It is necessary to address the additional four standards of care, breach and

causal nexus beyond adequate staffing that Dr. Reid discusses in his report because

if any of the five standards and their breach and causal nexus described in Dr.

Reid’s report represents a “good faith” “fair summary” of Dr. Reid’s opinions, then

the trial court did not abuse its discretion and the case proceeds on all theories of

liability against Appellant. See Potts at 630; TTHR Limited P’ship v. Moreno, 401
S.W.3d 41 (Tex. 2013).

       The second standard of care breached by SMTC relates to adequate training.

                                          23
Dr. Reid states in relevant part,

         SMTC… had duties to its unit employee Ms. Payton which
         included...adequate training with regard to recognizing, and
         managing situations that might arise in which her safety could be
         compromised…SMTC failed to meet the relevant duty/standard-
         per 1(b), above-when it failed to provide Ms. Payton with
         adequate training regarding safety in a workplace which
         contained foreseeable threats to staff safety. Review of Ms.
         Payton’s SMTC personnel file and relevant portions of the
         SMTC Employee Handbook reveals no indication that Ms.
         Payton received any SMTC training regarding her safety in the
         workplace, and particularly none related to recognizing
         potentially dangerous patients, recognizing potentially assaultive
         patients, or protecting herself from patient assault…SMTC’s
         failures to meet the applicable standards, individually and
         collectively, …foreseeably let to (i.e., were a significant cause
         of) damages to Ms. Payton …But for one or more of the
         breaches by SMTC, …it is more likely than not that the January
         2, 2012, assault would not have occurred, and thus the
         …damages to Ms. Payton, would not have occurred.
         Specifically, if Ms. Payton had received adequate training
         regarding the dangers of escorting patients such as Leroy Simon
         off-unit alone, she would not have escorted him alone to the
         laundry room.

(CR 32-35). These statements in Dr. Reid’s report clearly identify the standard of

care, detail what an reasonably prudent healthcare provider would have done and

states what the Appellant needed to do and how the breach gave rise to Ms.

Payton’s harm, injuries, or damages. Dr. Reid states the specific type of training

required, training related to recognizing potentially dangerous patients, recognizing

potentially assaultive patients, or protecting herself from patient assault and

                                         24
training regarding the dangers of escorting patients such as Leroy Simon off-unit

alone. (CR 33-35).

      Appellant was clearly put on notice as to what it should have done but did

not do, because Appellant responded to the allegation of inadequate training in its

brief with facts to argue against that allegation. See Appellant’s Brief at 21. This

Court should not consider these facts because they are not part of the trial court’s

record and because this Court is limited in its determination of whether the trial

court abused its discretion in finding Dr. Reid’s report was a “good faith” “fair

summary” of his opinions to the “four corners” of the expert report.            Am.

Transitional Care Ctrs. of Tex. Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex. 2001).

The facts within the expert report are taken as true in a Chapter 74 review of the

expert’s report. Jean v. Shenoy, No. 01-10-01116-CV, 2011 WL 6938538 (Tex.

App. – Houston [1st Dist.] Dec. 29, 2011, no pet.).

      The report of an expert under Chapter 74 is not reviewed like the evidence in

a summary judgment proceeding. Kloeris v. Stockdale, No. 01-09-00711-CV, 2010
WL 1241305 (Tex. App. - Houston [1st Dist.] 2010, no pet.); Methodist Hosp. v.

Shepherd-Sherman, 296 S.W.3d 193, 199 n. 2 (Tex. App. Houston [14 th Dist]

2009, no pet.); Wissa v. Voosen, 243 S.W.3d 165, 169 (Tex. App. – San Antonio

2007, no pet.). Whether an expert’s opinions are correct is an issue for summary

judgment, not a Chapter 74 motion to dismiss. Kloeris at 7. “A Motion to dismiss
                                         25
seeks to demonstrate that plaintiff has not satisfied the procedural requirements of

Chapter 74, while a motion for summary judgment seeks to demonstrate that the

substance of the claim lacks merit”. Wissa at 169. Dr. Reid’s expert report

provided a “good faith” “fair summary” of the standard of care applicable to

SMTC, how SMTC breached that standard and how the breach led to Ms. Payton’s

assault and injuries which is the focus of the Court in a Chapter 74 review, not

whether Dr. Reid is ultimately correct in his opinions. See Kloeris at 7. Dr. Reid’s

report is a “good faith” “fair summary” of his opinions related to adequate training

at the time his report was written.

      Dr. Reid’s expert report is also a “good faith” “fair summary” of his

opinions relating to the third standard, adequate notification, its breach and the

causal nexus. Dr. Reid states in his report,

         SMTC…had duties to its unit employee Ms. Payton, which
         included…adequate notification of work situations or persons in
         her work environment that could reasonably present a danger to
         her or others…SMTC failed to meet the relevant duty/standard..
         when it failed to provide Ms. Payton with information or
         notification that patient Leroy Simon was likely to be assaultive
         or otherwise dangerous to staff and/or patients. SMTC knew that
         Mr. Simon had a pre-admission history of, among other things,
         “severe impulsivity or explosive expression of anger” (See Dr.
         Harrell’s December, 2011, evaluation). Nevertheless, review of
         materials associated with the January 2, 2012, assault upon Ms.
         Payton reveals no indication that Ms. Payton or other unit staff
         had been notified or otherwise advised that Mr. Simon was
         potentially assaultive or otherwise dangerous, or that her
         escorting him off the unit to the laundry alone was
                                         26
         unsafe…SMTC’s failures to meet the applicable standards,
         individually and collectively,…foreseeably led to (i.e., were a
         significant cause of) damages to Ms. Payton…But for one or
         more of the breaches by SMTC …it is more likely than not that
         the January 2, 2012, assault would not have occurred, and thus
         the … damages to Ms. Payton, would not have occurred.
         Specifically, if Ms. Payton had been adequately informed by
         SMTC of Mr. Simon’s past history of such things as violence,
         impulsive and assaultive behavior, other behaviors noted above,
         and his pre-admission history of “sever impulsivity or explosive
         expression of anger” (cf. Dr. Harrell’s pre-incident evaluation,
         December 12-13, 2011), she would not have escorted him to the
         laundry room alone.

(CR 32-35). These statements regarding adequate notification detail the standard

of care, breach and causal nexus with facts underlying the breach and causal nexus

that inform Appellant of what it should have done but did not do, and allow the

court to determine the claims are not frivolous.

      Appellant complains that Dr. Reid’s opinions regarding notification are

conclusory because they do not state what SMTC’s methods of informing staff

about patient behaviors were or should have been. See Appellant’s Brief at 22. The

type of notification was not at issue because Ms. Payton received no notification, it

was the subject matter of the notification that mattered, because if Ms. Payton had

been adequately informed of the subject matter of the notification, she would not

have escorted Leroy Simon off the unit alone. Dr. Reid’s explanation of the

standard and breach are based upon Appellant’s complete failure to notify Ms.

Payton and specifically state the subject matter of what Ms. Payton should have

                                         27
been informed of regarding the patient who assaulted her. These opinions are not

conclusory and provide a “good faith” “fair summary” of Dr. Reid’s opinions.

Appellant’s argument again fails because the expert’s opinions for purposes of a

Chapter 74 review are based upon the facts known to the expert at the time of the

report. Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 631 (Tex. 2013).   Dr. Reid’s

report provides a “good faith” “fair summary” of his opinions regarding the

standard of adequate notification of work situations, or persons in Ms. Payton’s

work environment, that could reasonably present a danger to her or others. Dr.

Reid’s opinion regarding adequate notification clearly identifies the standard of

care, states what Appellant should have done but did not and how the breach led to

Ms. Payton’s harm and ties those opinions to the facts known to Dr. Reid at the

time of the report.

      The fourth standard regarding admission of Mr. Simon to SMTC also

provides a “good faith” “fair summary” of Dr. Reid’s opinions. Dr. Reid states in

relevant part,

          SMTC by itself and through its various parts or assigns, had
         duties to its unit employee Ms. Payton which included…
         adequate care in avoiding or declining admission of
         patients/clients who are inappropriate for the unit on which she
         worked… SMTC failed to meet the relevant duty/standard…
         when it admitted, allowed to be admitted, and/or allowed
         housing on the children’s unit without adequate containment
         and/or supervision, Leroy Simon, a 17 year-old, “stocky” (per
         911 call) male sex offender with a substantial history of
                                        28
        aggression, fights with staff (Dr. Coons, 3/14/2012, p. 2) and
        peers, criminal assault (cf. 1/2/2012 Hays County criminal
        complaint), severe problems with physical and sexual conduct,
        conduct disorder, poor impulse control and/or frequent inability
        to resist aggressive and sexual impulses, which had manifested
        themselves both in and outside residential treatment settings.
        SMTC knew that Mr. Simon had a pre-admission history of,
        among other things, “sever impulsivity or explosive expression
        of anger” (See Dr. Harrell’s December, 2011, evaluation), as
        well as other behaviors and symptoms enumerated above and
        below. Review of Mr. Simon’s pre and post-incident evaluation
        (with notes about his history prior to his assault on Ms. Payton)
        by Dr. Richard Coons and Dr. Walter Harrell (one performed
        white he was at SMTC, 18 days before the assault) indicates that
        SMTC was well aware, or should have been aware, that Simon
        was inappropriate for admission to SMTC and/or was not
        suited—in terms of staff and patient safety—for housing on the
        boys’ unit on which he was housed on January 2, 2012, (the date
        of the assault), without special supervision or containment.
        SMTC’s failures to meet the applicable standards, individually
        and collectively,…foreseeably let to (i.e., were a significant
        cause of) damages to Ms. Payton…But for one or more of the
        breaches by SMTC,…it is more likely than not that the January
        2, 2012, assault would not have occurred, and thus the …
        damages to Ms. Payton, would not have occurred. Specifically,
        If Mr. Simon had not been admitted to SMTC and housed on Ms.
        Payton’s boys’ unit (to the extent that he was negligently
        admitted and housed; see above) Ms. Payton would not have
        been assaulted and injured by him on January 2, 2012.

(CR 32-35). Dr. Reid identifies the standard of care, states how Appellant breached

that duty, states what Appellant should have done and states how the breach led to

the assault and damages to Ms. Payton.

      Dr. Reid discusses the supervision or containment of the patient further in

                                         29
his fifth standard of care where he states in relevant part,

         SMTC, by itself and through its various parts or assigns, had
         duties to its unit employee Ms. Payton which included, but may
         not have been limited to elimination or amelioration of
         reasonably known risks to Ms. Payton and other staff or patients
         created by patients/clients who are admitted to and housed on the
         unit on which she worked…SMTC failed to meet the relevant
         duty/standard…when it failed to adequately contain, supervise,
         and/or monitor Leroy Simon to ameliorate his danger to others
         and protect staff and patients on and before January 2, 2012.
         Review of materials associated with the January 2, 2012, assault
         upon Ms. Payton reveal no indication that Mr. Simon was under
         any particular monitoring or containment order, special
         supervision, or the like, which should have been commensurate
         with his known history and behavioral/mental condition (see
         above and below). SMTC knew or reasonably should have
         known that Leroy Simon was dangerous or assaultive, and
         should have been physically contained and/or supervised by
         more than one, female, staff person. There is no indication in the
         records available to me that SMTC did anything, physically or
         clinically, to ameliorate the danger from Leroy Simon to staff
         and other patients. (Many, perhaps all, other patients on the
         boys’ unit were apparently much younger and smaller than Mr.
         Simon)…SMTC’s failures to meet the applicable standards,
         individually and collectively,…foreseeably let to (i.e., were a
         significant cause of) damages to Ms. Payton…But for one or
         more of the breaches by SMTC…it is more likely than not that
         the January 2, 2012, assault would not have occurred, and thus
         the above damages to Ms. Payton, would not have occurred.
         Specifically… If Mr. Simon had been placed on adequate safety
         precautions, such as with the containment and/or supervision
         reasonably required given his past history, Ms. Payton would not
         have escorted him to the laundry room alone.

                                          30
(CR 32, 33-34). Dr. Reid’s opinions regarding adequate containment/supervision

clearly identifies the standard of care, the breach and causation. Dr. Reid informs

Appellant about the specific conduct about which Appellee complains.

      Appellant argues that Dr. Reid’s statements regarding supervision by more

than one female staff person are conclusory because Dr. Reid stated in his report

that specific staffing data from Appellant was not yet available to him. See

Appellants Brief at 22.    This is not the case because the facts reviewed by Dr.

Reid clearly reflect Ms. Payton was the only one supervising the assaultive patient

at the time she was assaulted. This argument by Appellant also fails for the same

reasons its argument fails regarding the standard of adequate staffing. The court is

limited in its review of whether the expert report makes a “good faith” effort to

“fairly summarize” the experts opinions by looking only at the “four corners” of

the report. Palacios, at 878.

      The fact that Dr. Reid has not yet seen staffing data from Appellant does not

make his statements conclusory. The Texas Supreme Court has stated, “The Act

requires the expert report to summarize the expert’s opinions as of the date of the

report recognizing that those opinions are subject to further refinement”. Potts,
392 S.W.3d at 632. Additional facts may give rise to additional theories of liability

and change theories of liability which are allowed. Id. Requiring an expert to

know all the facts of the case exactly as they happened at this early stage of the
                                         31
lawsuit would place an impossible burden upon plaintiff’s expert that could never

be met. Id. The court accepts the factual statement for purpose of sufficient of an

expert report inquiry. Jean v. Shenoy, No. 01-10-01116-CV, 2011 WL 6938538

(Tex. App. – Houston [1st Dist.] Dec. 29, 2011, no pet.). Dr. Reid’s opinions are

based upon the facts known at the time of the report which he links to his opinions

regarding the standard of care, breach and causation are not speculative or

conclusory.

       Dr. Reid’s report provides a “good faith” “fair summary” of the standard to

use adequate care in avoiding or declining admission of patients/clients who are

inappropriate for the unit on which Mr. Payton worked.   Dr. Reid provides factual

details of the patient who assaulted Ms. Payton, “Leroy Simon, a 17 year-old,

“stocky” (per 911 call) male sex offender with a substantial history of aggression,

fights with staff (Dr. Coons, 3/14/2012, p. 2) and peers, criminal assault (cf.

1/2/2012 Hays County criminal complaint), severe problems with physical and

sexual conduct, conduct disorder, poor impulse control and/or frequent inability to

resist aggressive and sexual impulses, which had manifested themselves both in

and outside residential treatment settings. (CR 33-34). Dr. Reid details how or

why SMTC knew that Mr. Simon had a pre-admission history of, among other

things, “severe impulsivity or explosive expression of anger” (See Dr. Harrell’s

December, 2011, evaluation), as well as other behaviors and symptoms. (CR 32-

                                        32
35). Dr. Reid bases his opinion in part on the preadmission history taken by

Appellant 18 days before the assault and states it indicates that, “SMTC was well

aware, or should have been aware, that Simon was inappropriate for admission to

SMTC and/or was not suited—in terms of staff and patient safety—for housing on

the boys’ unit on which he was housed on January 2, 2012, without special

supervision or containment”. (CR 34). Dr. Reid then states what Appellant failed

to do, “Review of materials associated with the January 2, 2012, assault upon Ms.

Payton reveal no indication that Mr. Simon was under any particular monitoring or

containment order, special supervision, or the like, which should have been

commensurate with his known history and behavioral/mental condition (see above

and below). (CR 34). Appellant knew or reasonably should have known that Leroy

Simon was dangerous or assaultive, and should have been physically contained

and/or supervised by more than one, female, staff person. (CR 34). There is no

indication in the records available to me that SMTC did anything, physically or

clinically, to ameliorate the danger from Leroy Simon to staff and other patients.

(Many, perhaps all, other patients on the boys’ unit were apparently much younger

and smaller than Mr. Simon)”. (CR 34). These statements reflect a “good faith”

“fair summary” of Dr. Reid’s opinions. Appellant’s complaints regarding these

standards is another example of Appellant arguing the facts of the case, which

clearly shows it has notice of what the expert is saying it should have done but

                                       33
failed to do. Simply because SMTC does not like the facts does not make the

opinions of the expert conclusory.

      Dr. Reid’s report specifically states the standards of care required, details

how those standards were breached and informs Appellant what is should have

done but failed to do and allows the trial court to determine the case is not

frivolous for all five theories of negligence in Dr. Reid’s report. Dr. Reid’s report

provides a “good faith” “fair summary” of his opinions on the elements required by

Chapter 74.

      Appellant also criticizes Dr. Reid’s report on the element of causation. See

Appellant’s Brief at 27-28.     Dr. Reid’s report provides a “good faith” “fair

summary” of his opinions on the element of causation.      Assault is not a medical

condition. UHS of Timberlawn, Inc. v. S.B., 281 S.W.3d 207, (Tex. App. – Dallas

2009, pet. denied).    Assault cases are different from those cases in which the

injury, harm, or damages claimed flow from the existence of a medical condition

that itself resulted from the breach and require not only explanation as to how

standard was breached but also how the breach gave rise to the medical condition.

Assault cases are also different from healthcare liability claims alleging that

breaches of a standard of care caused an exacerbation of a preexisting medical

condition, or hindered or prevented effective treatment of such a condition. Id.

Identifying the causal relationship in those cases may well require an expert to
                                         34
opine as to the existence, extent, and prognosis of a pre-existing medical condition

as well as how the breach aggravated, impeded, or prohibited treatment and

otherwise affected patient’s prognosis. Id.

      Several cases cited by Appellant in his brief on the causation element are not

assault cases but rather those types of healthcare liability claims differentiated from

assault cases by the court in Timberlawn. See Jelenek v. Casas, 328 S.W.3d 526

(Tex. 2010)(discussing causation required for prescription lapse to cause infection

causing additional pain and suffering beyond what plaintiff would have otherwise

experienced when other causes of infection are equally possible); Smith v. Wilson,

368 S.W.3d 574 (Tex. App. – Austin 2012, no pet.) (discussing statement that a

correlation exists between fluoxetine and suicide in adolescents as not supplying a

causal link between drug and suicide when plaintiff was not an adolescent);

Kocurek v. Colby, No. 03-13-00057, 2014 WL 4179454 (Tex. App. – Austin Aug.

22, 2014, no pet.) (discussing the insufficiency of the expert’s report on the

element of causation when plaintiff was claiming worsening of pain and numbness

because failed to specify how any injury would have been prevented or lessened

had plaintiff received “appropriate care” sooner and statement that referral to

specialist “might have made a difference”).

      In assault cases the expert report should link the defendant’s negligence with

                                          35
the alleged harm, the assault. Christian Care Centers, Inc., v. Golenko, 328 S.W.
3d 637, 648 (Tex. App. – Dallas 2011, pet. denied) citing Timberlawn. In the case

of Texarkana Nursing & Healthcare Center, LLC v. Lyle 338 S.W.3d 314, 323

(Tex. App. – Texarkana 2012, no pet.), the court held that if the expert report is

insufficient on the standard of care and breach and does not advise the defendant of

what it should have done differently then causation should be described in terms of

the specific shortcomings that created a situation in which assault could occur. Dr.

Reid’s report is sufficient on the standard of care and breach because it advises the

defendant of what it should have done differently and causation is also described in

terms of the specific shortcomings that created the situation in which the assault

occurred. Dr. Reid’s report links all the breaches of the standard of care to the

circumstances allowing assault.     Dr. Reid’s report describes the damages Ms.

Payton suffered as a result of the assault and the facts leading to his opinion that

the assault caused those damages. (CR 34-35). He also describes the standards and

breaches in further detail and gives his opinion that but for one or more breaches it

is more likely than not that the January 2, 2012 assault would not have occurred,

and thus the damages to Ms. Payton described in his report would not have

occurred. (CR 35).

       Dr. Reid’s expert report is at least as specific regarding the standard of care,

                                          36
breach and causation as the report found sufficient on those elements in Nexion v.

Treybig, No. 05-14-00498-CV, 2014 WL 7499373 (Tex. App. – Dallas, Dec. 31,

2014, no pet.) where the court found the standard of care articulated as,

         the facility must provide a safe environment for its patients such
         as securing qualified personnel, adequately supervising therapy
         sessions, providing proper equipment and facilities for all
         treatments necessary to meet the patient’s needs, and following
         up with the patient to verify the success of all procedures and
         treatments. . . The standard is not met when nursing home fails to
         properly investigate, treat and document the patient’s pain
         complaints over the course of time. The instance of Defendant’s
         failure to investigate and treat the patient’s back pain was during
         the therapy session when the therapists ignored Mr. Treybig’s
         cries of pain and requests to stop the session, continuing to push
         and pull using their combined bodyweight…reasonable
         investigation, documentation and treatment would have signified
         the danger in forceful hamstring stretches on a double below the
         knee amputee, and prevent fracture.

 Dr. Reid’s report is also more specific than the assault case of Christus Spohn

Health Sys. Corp. v. Sanchez, 299 S.W.3d 868, 877-78 (Tex. App. – Corpus

Christi 2009, pet. denied) in which the court concluded the expert reports

sufficiently linked the patient’s assault to the hospital’s failure to protect her from

the assaultive conduct of its employees, the report stated the hospital had a duty to

provide a safe recovery environment, described the alleged conduct of the

employees, and concluded that the fact that the patient was vulnerable, unable to

protect herself, and felt as if her person was violated has caused her to now have

symptoms of Major Depression and Post Traumatic Stress Disorder.            All five of

                                          37
the standards, breaches and causal nexus articulated in Dr. Reid’s report are more

specific than the report in Spohn. Dr. Reid’s report is also as specific as the one

this Court found sufficient in Chadha, M.D. v. Rothert, No. 03-13-00153-CV, 2014
WL 538815 (Tex. App. – Austin Feb. 5, 2014, no pet.) In Chadha, the expert

report stated the standard of care, “required that Dr. Chadha follow-up with the

patient regarding the elevated sedimentation rate in 2010”. The expert report then

detailed the breach, “should have called [Sharon] and had her return for a follow-

up”. The expert then gave facts as to support his opinion on the breach, and

connected the breach to the harm, vision loss by the patient. Dr. Reid’s report

likewise provides the standard of care, the breach, and the causal nexus with facts

to support his opinions. Dr. Reid’s entire expert report is a “good faith” “fair

summary” of his opinions regarding the standard of care, breach of the standard of

care and causation and is not conclusory. Therefore, the trial court did not abuse

its discretion in denying Appellants motion to dismiss.

      C.    Dr. Reid’s Expert Report Satisfies the Purpose of Chapter 74’s
            Expert Report Requirement

      Appellants argue that the purpose of the Texas Legislature in enacting

Chapter 74 would be thwarted unless this Court finds the trial court abused its

discretion in finding Dr. Reid’s report to be a “good faith” “fair summary” of his

opinions. This argument is simply incorrect. The Texas Supreme Court recently

                                        38
discussed the purpose of the Legislature in enacting Chapter 74 in Certified Ems,

Inc. V. Potts, 392 S.W.3d 625, 631-32 (Tex. 2013). There, the Texas Supreme

Court stated, “In amending the Act, the Legislature sought to reduce ‘the excessive

frequency and severity of …claims’, but to ‘do so in a manner that will not unduly

restrict a claimant’s rights any more than necessary to deal with the crisis’ (citing

the act)…In accordance with this goal…we have also stated that the purpose of

evaluating expert reports is to ‘deter frivolous claims, not to dispose of claims

regardless of their merits’ Scoresby v. Sullivan, 346 S.W.3d 546, 554 (Tex. 2011).”

The Texas Supreme Court continued stating, “If a healthcare liability claim

contains at least one viable liability theory, as evidenced by an expert report

meeting the statutory requirements, the claim cannot be frivolous.               The

Legislature’s goal was to deter baseless claims, not to block earnest ones.” Id. Dr.

Reid’s expert report meets the statutory requirements as to all five of the

negligence theories Ms. Payton claims.        So Ms. Payton’s claims cannot be

frivolous. The Legislative goal of Chapter 74 to “deter baseless claims, not to

block earnest ones” is satisfied with Dr. Reid’s report.

                           CONCLUSION & PRAYER

      In conclusion, the expert report by Dr. Reid very clearly and specifically sets

forth five standards of care as they apply to San Marcos Treatment Center and

specifically details how those standards of care were breached. Dr. Reid’s report
                                         39
informs San Marcos Treatment Center of the specific conduct called into question,

notifying it as to what it should have done differently. Dr. Reid’s report also

describes how the breaches in the standards of care led to Ms. Payton’s assault and

subsequent injuries. Appellant is asking this Court to hold Dr. Reid’s expert report

to a much higher standard than the “fair summary” standard mandated by Chapter

74. Appellant wants the report to marshal all the evidence in detail without the

benefit of discovery of Appellant’s records and without any depositions. The law

is clear that Dr. Reid’s report must only provide a “good faith” “fair summary” of

his opinions. Tex. Civ. Prac. Rem. Code §74.351(r)(6); Am. Transitional Care

Ctrs. of Tex. Inc. v. Palacios, 46 S.W.3d 873 (Tex. 2001); Certified EMS, Inc. v.

Potts, 392 S.W.3d 625 (Tex. 2013). Dr. Reid’s report provides just such a “good

faith” “fair summary” of his opinions and satisfies the Legislative goal of Chapter

74 to “deter baseless claims, not to block earnest ones”. Id. The trial court did not

abuse its discretion by finding Dr. Reid’s report sufficient and overruling

Appellant’s motion to dismiss pursuant to 74.351(b).

      Ms. Veronica Payton respectfully requests this Court affirm the trial court’s

order overruling San Marcos Treatment Centers’ motion to dismiss pursuant to

74.351(b). In the alternative, should this Court find the trial court abused its

discretion by finding Dr. Reid’s report sufficient, Ms. Payton prays this Court

remand the case to the trial court for a determination of whether to grant Ms.

                                         40
Payton a 30-day extension to cure under Tex. Civ. Prac. & Rem. Code §74.351(c).

Appellee also requests reasonable attorney’s fees and costs and all other relief to

which she may be entitled.

                                             Respectfully submitted,

                                             Allison & Ward

                                             By: /s/ Adam S. Ward
                                                   Adam S. Ward
                                                   Texas Bar No. 00788615
                                                   allison-ward@sbcglobal.net
                                             2001 North Lamar Blvd.
                                             Austin, Texas 78705
                                             Telephone: (512) 474-8153
                                             Facsimile: (512) 474-9703

                                             Attorneys for Appellee,
                                             Veronica Payton

                      CERTIFICATE OF COMPLIANCE

       I hereby certify that the foregoing Brief for Appellee is computer generated,
has been prepared in a conventional typeface no smaller than 14-point text and 12-
point for footnotes, contains 9762 words according to word count function of the
computer program used to prepare this Brief, excluding any parts exempted by
Tex. R. App. P. 9.4(i)(1), and otherwise complies with Texas Rule of Appellate
Procedure 9.4.

                                             /s/ Adam S. Ward
                                             Adam S. Ward

                                        41
                       CERTIFICATE OF SERVICE
      I hereby certify that a true and correct copy of the above and foregoing
instrument has been forwarded to all known counsel of record in accordance with
the Texas Rules of Appellate Procedure on this the 10th day of February, 2015.
Ryan L. Clement
Serpe Jones Andrews
Callender & Bell, PLLC
2929 Allen Parkway, Suite 1600
Houston, Texas 77019
Telephone: (713) 452-4400
Facsimile: (713) 452-4499
Email: rclement@serpejones.com

                                                /s/ Adam S. Ward
                                                Adam S. Ward

                                      42
             APPENDIX A

EXPERT REPORT AND CURRICULUM VITAE OF
     DR. WILLIAM H. REID, M.D. M.P.H.

                 A
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APPENDIX B

  CASES

    B
                                                                                                       Page 1
46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

                                                           mony
                                                                              198Hk821(1) k. In general. Most
              Supreme Court of Texas.                      Cited Cases
AMERICAN TRANSITIONAL CARE CENTERS                             (Formerly 299k18.80(6.1) Physicians and Sur-
   OF TEXAS, INC. d/b/a American Transitional              geons)
                 Hospital, Petitioner,                         Expert testimony is necessary in medical-
                          v.                               malpractice cases. Vernon's Ann.Texas Civ.St. art.
 Teofilo PALACIOS and Maria Palacios, individu-            4590i, § 13.01(d).
 ally and a/n/f of Gloria Janeth Palacios and Rocio
Daniela Palacios, minors, Maria Angelica Palacios,         [2] Appeal and Error 30       960(1)
and Sentry Insurance, a mutual company, Respond-
                         ents.                             30 Appeal and Error
                                                               30XVI Review
                  No. 99–1311.                                    30XVI(H) Discretion of Lower Court
              Argued Dec. 6, 2000.                                     30k960 Rulings on Motions Relating to
             Decided May 10, 2001.                         Pleadings
        Rehearing Overruled June 28, 2001.                                30k960(1) k. In general. Most Cited
                                                           Cases
     Medical malpractice action was brought against              (Formerly 198Hk809, 299k18.130 Physicians
hospital to recover for injuries patient allegedly         and Surgeons)
suffered in fall at hospital. The 280th District                A trial court's determination about the ad-
Court, Harris County, Tony Lindsay, J., dismissed          equacy of an expert report under the Medical Liab-
case for failure to file expert report, as required by     ility and Insurance Improvement Act is reviewed
Medical Liability and Insurance Improvement Act.           under an abuse-of-discretion standard. Vernon's
Patient appealed. The Houston Court of Appeals,            Ann.Texas Civ.St. art. 4590i, § 13.01(l), (r)(6).
First District, reversed and remanded, 4 S.W.3d
857. On petition for review, the Supreme Court,            [3] Appeal and Error 30       984(1)
Hankinson, J., held that: (1) trial court's determina-
tion about adequacy of expert report under Act is          30 Appeal and Error
reviewed under abuse-of-discretion standard, and              30XVI Review
(2) expert's report did not provide fair summary of              30XVI(H) Discretion of Lower Court
standard of care and how it was breached.                            30k984 Costs and Allowances
                                                                           30k984(1) k. In general. Most Cited
    Court of Appeals' judgment reversed.                   Cases
                                                               Sanctions are generally reviewed under an ab-
                  West Headnotes                           use-of-discretion standard.

[1] Health 198H        821(1)                              [4] Health 198H      804

198H Health                                                198H Health
    198HV Malpractice, Negligence, or Breach of                198HV Malpractice, Negligence, or Breach of
Duty                                                       Duty
     198HV(G) Actions and Proceedings                            198HV(G) Actions and Proceedings
        198Hk815 Evidence                                            198Hk804 k. Affidavits of merit or merit-
            198Hk821 Necessity of Expert Testi-            orious defense; expert affidavits. Most Cited Cases

                           © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                            Page 2
46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

   (Formerly 299k18.20 Physicians and Surgeons)              198H Health
     In determining the adequacy of an expert report              198HV Malpractice, Negligence, or Breach of
under the Medical Liability and Insurance Improve-           Duty
ment Act, the trial court should look no further than              198HV(G) Actions and Proceedings
the report. Vernon's Ann.Texas Civ.St. art. 4590i, §                    198Hk804 k. Affidavits of merit or merit-
13.01(l).                                                    orious defense; expert affidavits. Most Cited Cases
                                                                (Formerly 299k18.20 Physicians and Surgeons)
[5] Health 198H        804                                       A report that merely states the expert's conclu-
                                                             sions about the standard of care, breach, and causa-
198H Health
                                                             tion does not constitute a good-faith effort under
     198HV Malpractice, Negligence, or Breach of
                                                             the Medical Liability and Insurance Improvement
Duty
                                                             Act. Vernon's Ann.Texas Civ.St. art. 4590i, §
       198HV(G) Actions and Proceedings
                                                             13.01(l), (r)(6).
           198Hk804 k. Affidavits of merit or merit-
orious defense; expert affidavits. Most Cited Cases          [8] Health 198H        804
    (Formerly 299k18.20 Physicians and Surgeons)
     For an expert's report to satisfy the require-          198H Health
ments of the Medical Liability and Insurance Im-                  198HV Malpractice, Negligence, or Breach of
provement Act, the report need not marshal all the           Duty
plaintiff's proof, but it must include the expert's                 198HV(G) Actions and Proceedings
opinion on each of the elements identified in the                      198Hk804 k. Affidavits of merit or merit-
statute. Vernon's Ann.Texas Civ.St. art. 4590i, §            orious defense; expert affidavits. Most Cited Cases
13.01(l).                                                       (Formerly 299k18.20 Physicians and Surgeons)
                                                                 An expert's report that omits any of the stat-
[6] Health 198H        804                                   utory requirements does not constitute a good-faith
                                                             effort under the Medical Liability and Insurance
198H Health
                                                             Improvement Act. Vernon's Ann.Texas Civ.St. art.
     198HV Malpractice, Negligence, or Breach of
                                                             4590i, § 13.01(l), (r)(6).
Duty
       198HV(G) Actions and Proceedings                      [9] Health 198H        804
           198Hk804 k. Affidavits of merit or merit-
orious defense; expert affidavits. Most Cited Cases          198H Health
   (Formerly 299k18.20 Physicians and Surgeons)                   198HV Malpractice, Negligence, or Breach of
     For an expert's report to constitute a good-faith       Duty
effort under the Medical Liability and Insurance                    198HV(G) Actions and Proceedings
Improvement Act, the report must provide enough                         198Hk804 k. Affidavits of merit or merit-
information to fulfill two purposes: first, the report       orious defense; expert affidavits. Most Cited Cases
must inform the defendant of the specific conduct               (Formerly 299k18.20 Physicians and Surgeons)
the plaintiff has called into question; second, and               To avoid dismissal due to inadequacy of an ex-
equally important, the report must provide a basis           pert's report under the Medical Liability and Insur-
for the trial court to conclude that the claims have         ance Improvement Act, a plaintiff need not present
merit. Vernon's Ann.Texas Civ.St. art. 4590i, §              evidence in the report as if it were actually litigat-
13.01(l), (r)(6).                                            ing the merits. Vernon's Ann.Texas Civ.St. art.
                                                             4590i, § 13.01(l), (r)(6).
[7] Health 198H        804
                                                             [10] Health 198H        804

                             © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                          Page 3
46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

198H Health                                               faith effort under the Medical Liability and Insur-
      198HV Malpractice, Negligence, or Breach of         ance Improvement Act if it simply states that he or
Duty                                                      she knows the standard of care and that it was or
       198HV(G) Actions and Proceedings                   was not met. Vernon's Ann.Texas Civ.St. art. 4590i,
           198Hk804 k. Affidavits of merit or merit-      § 13.01(l), (r)(6).
orious defense; expert affidavits. Most Cited Cases
    (Formerly 299k18.20 Physicians and Surgeons)          *875 Matthew T. McCracken, John C. Marshall,
     The expert's report in a medical malpractice ac-     James C. Marrow, Dee L. Dawson, Marshall & Mc-
tion can be informal in that the information in the       Craken, Houston, for Petitioner.
report does not have to meet the same requirements
                                                          D. John Leger, Leger & Coplen, Levon G. Hov-
as the evidence offered in a summary-judgment
                                                          natanian, Martin Disiere & Jefferson, Houston,
proceeding or at trial. Vernon's Ann.Texas Civ.St.
                                                          Mickey C. Shyrock, Law Office of Mickey C.
art. 4590i, § 13.01(l), (r)(6).
                                                          Shyrock, Athens, for Respondents.
[11] Health 198H        804
                                                          Justice HANKINSON delivered the opinion of the
198H Health
                                                          Court.
     198HV Malpractice, Negligence, or Breach of
                                                               In this medical-malpractice case we determine
Duty
                                                          the standards for reviewing an expert report under
       198HV(G) Actions and Proceedings
                                                          section 13.01 of the Medical Liability and Insur-
           198Hk804 k. Affidavits of merit or merit-
                                                          ance Improvement Act. TEX.REV.CIV. STAT.
orious defense; expert affidavits. Most Cited Cases
                                                          ANN.. art. 4590i, § 13.01. The trial court dismissed
    (Formerly 198Hk961, 204k8 Hospitals)
                                                          the Palacioses' medical-malpractice claims against
     Conclusory statement in expert's report that de-
                                                          American Transitional Care Centers, Inc., d/b/a
fendant hospital did not use precautions to prevent
                                                          American Transitional Hospital, because it determ-
patient's fall was not good-faith effort to provide
                                                          ined that the Palacioses' expert report did not show
fair summary of standard of care and how it was
                                                          a good-faith effort to provide a fair summary of the
breached, and thus, dismissal of medical malprac-
                                                          expert's opinions about the standard of care, breach,
tice action was warranted under Medical Liability
                                                          and causation, as required by section 13.01. See id.
and Insurance Improvement Act; it could not be de-
                                                          § 13.01(d), (e), (l), (r)(6). The court of appeals,
termined from that statement if expert believed that
                                                          after evaluating the trial court's decision as it would
standard of care required hospital to have mon-
                                                          a summary-judgment decision, reversed, holding
itored patient more closely, restrained him more se-
                                                          that the report did meet the statutory requirements.
curely, or done something else entirely. Vernon's
                                                          4 S.W.3d 857, 860.
Ann.Texas Civ.St. art. 4590i, § 13.01(l), (r)(6).
                                                              We hold that a trial court's decision to dismiss
[12] Health 198H        804
                                                          a case under section 13.01(e) is reviewed for abuse
198H Health                                               of discretion. We further hold that to constitute a
    198HV Malpractice, Negligence, or Breach of           good-faith effort to provide a fair summary of an
Duty                                                      expert's opinions under section 13.01(l ), an expert
      198HV(G) Actions and Proceedings                    report must discuss the standard of care, breach,
          198Hk804 k. Affidavits of merit or merit-       and causation with sufficient specificity to inform
orious defense; expert affidavits. Most Cited Cases       the defendant of the conduct the plaintiff has called
   (Formerly 299k18.20 Physicians and Surgeons)           into question and to provide a basis for the trial
    An expert's report does not constitute a good-        court to conclude that the claims have merit. In this

                          © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                           Page 4
46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

case, the trial court did not abuse its discretion in      defendant.
concluding that the challenged report does not meet
the statutory requirements and in dismissing with               After 180 days passed from the date the Palaci-
prejudice the claims against American Transitional.        oses filed suit, American Transitional moved to dis-
Accordingly, we reverse the court of appeals' judg-        miss the case against it because the Palacioses did
ment and dismiss with prejudice the Palacioses'            not file an expert report and curriculum vitae, or
claims.                                                    nonsuit the claims against American Transitional,
                                                           as section 13.01(d) of the Act requires. Id. §
    Teofilo Palacios suffered brain damage and             13.01(d), (e). The Palacioses moved for an exten-
other severe injuries following a two-story fall at        sion of time to file the report, which the trial court
work. After almost a year in an intensive rehabilita-      granted. See id. § 13.01(f), (g). The Palacioses then
tion program, he was transferred to American               filed a report prepared by Dr. Catherine F. Bontke,
Transitional Hospital for further rehabilitation. Al-      who treated Palacios at the first rehabilitation hos-
though Palacios at that time was able to *876 com-         pital. American Transitional again moved to dis-
municate with others and respond to simple com-            miss under section 13.01(e), claiming that the re-
mands, he required assistance with most daily tasks.       port did not satisfy the statutory requirements. See
In addition, due to the severity of his brain damage,      id. § 13.01(l), (r)(6). The trial court granted the mo-
Palacios' physicians prescribed bed restraints for         tion, dismissed with prejudice the claims against
him. Nevertheless, while a patient at American             American Transitional, and severed those claims to
Transitional, Palacios fell from his bed and required      make the judgment against American Transitional
additional medical care for his injuries. His family       final. See id. § 13.01(e).
claims that this fall caused him to sustain further
brain injury, which impaired his ability to commu-              The Palacioses appealed, and with one justice
nicate with others and to assist them in his care.         dissenting, the court of appeals reversed and re-
                                                           manded after using summary-judgment review
     Palacios and his family sued American Trans-          standards to evaluate the sufficiency of the expert
itional and the treating doctors, respectively, for        report. 4 S.W.3d at 860. After indulging every reas-
negligently failing to prevent the fall and negli-         onable inference in the Palacioses' favor and elim-
gently treating him after the fall. After ninety days      inating any deference to the trial court's decision,
passed from the date the Palacioses filed suit,            the court of appeals concluded that the trial court
American Transitional, along with the other defend-        erred in dismissing the case because the Palacioses
ants, moved to require the Palacioses to file a            made a good-faith effort to provide a report that
$7,500 cost bond, as required by section 13.01(b) of       met the requirements of section 13.01(r)(6). Id. at
the Medical Liability and Insurance Improvement            862–63. American Transitional petitioned for re-
Act. See TEX.REV.CIV. STAT. ANN.. art. 4590i,              view challenging both the standard of review ap-
§ 13.01(b) (authorizing a trial court to order a           plied by the court of appeals and the sufficiency of
plaintiff to file a $7,500 cost bond for each defend-      the Palacioses' report.
ant physician or health-care provider if the plaintiff
has not complied with the expert-report or $5,000               [1] Texas courts have long recognized the ne-
cost-bond requirement in section 13.01(a)); id. §          cessity of expert testimony in medical-malpractice
13.01(a) (requiring the plaintiff to file either an ex-    cases. E.g., Hart v. Van Zandt, 399 S.W.2d 791,
pert report or a $5,000 cost bond for each defendant       792 (Tex.1965); Bowles v. Bourdon, 148 Tex. 1,
physician or health-care provider within ninety            219 S.W.2d 779, 782 (1949). “There can be no oth-
days of filing suit). The trial court granted the mo-      er guide [than expert testimony], and where want of
tion, and the Palacioses filed a cost bond for each        skill and attention is not thus shown by expert evid-
                                                           ence applied to the facts, there is no evidence of it

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46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

proper to be submitted to the jury.” Hart, 399                   American Transitional contends that a trial
S.W.2d at 792. Because expert testimony is crucial          court's determination about the adequacy of an ex-
to a medical-malpractice case, *877 knowing what            pert report should be reviewed under an abuse-
specific conduct the plaintiff's experts have called        of-discretion standard. The Palacioses respond that
into question is critical to both the defendant's abil-     whether a report meets the requirements of subsec-
ity to prepare for trial and the trial court's ability to   tions 13.01(l) and (r)(6) is a question of law. They
evaluate the viability of the plaintiff's claims. This      suggest that a trial court's decision on the adequacy
makes eliciting an expert's opinions early in the lit-      of a report should be reviewed as a court would re-
igation an obvious place to start in attempting to re-      view a summary-judgment decision: that is, by in-
duce frivolous lawsuits. See HOUSE COMM. ON                 dulging every reasonable inference and resolving
CIV. PRAC., BILL ANALYSIS, Tex. H.B. 971,                   any doubts in the nonmovant's favor, and eliminat-
74th Leg., R.S. (1995).                                     ing any deference to the trial court's decision. We
                                                            agree with American Transitional.
     Accordingly, in section 13.01, the Legislature
requires medical-malpractice plaintiffs, within 180              [2][3] The plain language of section 13.01
days of filing suit, either to provide each defendant       leads to the conclusion that abuse of discretion is
physician and health-care provider with an expert           the proper standard. First, the statute directs the tri-
report and the expert's curriculum vitae, or to non-        al court to grant a motion challenging the adequacy
suit the claims. TEX.REV.CIV. STAT. ANN.. art.              of an expert report if it “appears to the court” that
4590i, § 13.01(d). If the plaintiff fails within the        the plaintiffs did not make a good-faith effort to
time allowed either to provide the expert reports           meet the statutory requirements. Id. § 13.01(l). This
and curriculum vitae, or to nonsuit the case, the tri-      language plainly vests the trial court with discre-
al court must sanction the plaintiff by dismissing          tion. See TEX. GOV'T CODE § 312.002. (“[W]ords
the case with prejudice, awarding costs and attor-          shall be given their ordinary meaning.”). Second,
ney's fees to the defendant, and ordering the forfeit-      the statute states that dismissal under section
ure of any applicable cost bond necessary to pay            13.01(e) is a sanction: If the requirements of sec-
that award. Id. § 13.01(e). If the plaintiff does           tion 13.01(d) are not met, the court must “enter an
timely file a report, the defendant may move to             order as sanctions” dismissing the case and granting
challenge the adequacy of the report, and the trial         the defendant its costs and attorneys' fees.
court must grant the motion if “it appears to the           TEX.REV.CIV. STAT. ANN .. art. 4590i, §
court ... that the report does not represent a good         13.01(e). Sanctions are generally reviewed under an
faith effort to comply with the definition of an ex-        abuse-of-discretion standard. Koslow's v. Mackie,
pert report.” Id. § 13.01(l). The statute defines an        796 S.W.2d 700, 704 (Tex.1990). And we presume
expert report as “a written report by an expert that        the Legislature was aware of the standard of review
provides a fair summary of the expert's opinions ...        ordinarily applied in sanctions cases when it expli-
regarding applicable standards of care, the manner          citly identified a court's dismissal under section
in which the care rendered ... failed to meet the           13.01(e) as a sanction. *878 See McBride v.
standards, and the causal relationship between that         Clayton, 140 Tex. 71, 166 S.W.2d 125, 128 (1943)
failure and the injury, harm, or damages claimed.”          ( “All statutes are presumed to be enacted by the le-
Id. § 13.01(r)(6). If a trial court determines that an      gislature with full knowledge of the existing condi-
expert report does not meet these statutory require-        tion of the law and with reference to it.”).
ments and the time for filing a report has passed, it
must then dismiss with prejudice the claims against             Nevertheless, the court of appeals concluded
the defendant who has challenged the report. Id. §          that the usual standard of review for sanctions
13.01(e).                                                   should not apply here. The court reasoned that the

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46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

provisions of article 4590i at issue here were inten-      quiry—whether the report evidences a good-faith
ded to discourage frivolous lawsuits, while sanc-          effort to provide a fair summary of the expert's
tions, in contrast, are a response to litigation mis-      opinions. According to the Palacioses, the trial
conduct. We disagree with this distinction.                court does not have to make any factual determina-
                                                           tions because the only relevant information is in the
     Filing a frivolous lawsuit can be litigation mis-     report itself. We agree with the Palacioses that a tri-
conduct subject to sanction. See TEX.R. CIV. P. 13         al court should look no further than the report in
(imposing sanctions for filing groundless motions,         conducting a section 13.01(l ) inquiry.
pleadings, or other papers in bad faith or for the
purposes of harassment). And one purpose of the                The issue for the trial court is whether “the re-
expert-report requirement is to deter frivolous            port” represents a good-faith effort to comply with
claims. HOUSE COMM. ON CIV. PRAC., BILL                    the statutory definition of an expert report. Id. §
ANALYSIS, Tex. H.B. 971, 74th Leg., R.S. (1995).           13.01(l ). That definition requires, as to each de-
The Legislature has determined that failing to             fendant, a fair summary of the expert's opinions
timely file an expert report, or filing a report that      about the applicable standard of care, the manner in
does not evidence a good-faith effort to comply            which the care failed to meet that standard, and the
with the definition of an expert report, means that        causal relationship between that failure and the
the claim is either frivolous, or at best has been         claimed injury. Id. § 13.01(r)(6). Because the stat-
brought prematurely. See id. This is exactly the           ute focuses on what the report discusses, the only
type of conduct for which sanctions are appropriate.       information relevant to the inquiry is within the
See TransAmerican Natural Gas Corp. v. Powell,             four corners of the document.
811 S.W.2d 913, 918 (Tex.1991) (holding that
“death-penalty” sanctions are appropriate when a                [5][6] Under subsections 13.01(l ) and (r)(6),
party's discovery abuse justifies a presumption that       the expert report must represent only a good-faith
its claims lack merit). For these reasons, we hold         effort to provide a fair summary of the expert's
that an abuse-of-discretion standard of review ap-         opinions. A report need not marshal all the
plies to a trial court's decision to dismiss a case un-    plaintiff's proof, but it must include the expert's
der section 13.01(e).                                      opinion on each of the elements identified in the
                                                           statute. See *879Hart v. Wright, 16 S.W.3d 872,
     [4] We next consider whether the trial court ab-      877 (Tex.App.—Fort Worth 2000, pet. denied). In
used its discretion in dismissing the Palacioses'          setting out the expert's opinions on each of those
claims against American Transitional. The parties          elements, the report must provide enough informa-
disagree about how to determine a report's ad-             tion to fulfill two purposes if it is to constitute a
equacy under section 13.01(l ). American Trans-            good-faith effort. First, the report must inform the
itional argues that the trial court must engage in a       defendant of the specific conduct the plaintiff has
two-step process: (1) the trial court must determine       called into question. Second, and equally important,
whether the report constitutes a fair summary of the       the report must provide a basis for the trial court to
expert's opinions, TEX.REV.CIV. STAT. ANN..                conclude that the claims have merit. See 4 S.W.3d
art. 4590i, § 13.01(r)(6); and (2) if the trial court      at 865 (Taft, J. dissenting); Wood v. Tice, 988
concludes that the report is not a fair summary, it        S.W.2d 829, 830 (Tex.App.—San Antonio 1999,
must then look outside the report at the plaintiff's       pet. denied) (noting that one of the purposes of art-
conduct to determine whether the plaintiff made a          icle 4590i is to deter frivolous claims).
good-faith effort to meet the statutory requirements,
id. § 13.01(l ). The Palacioses, on the other hand,             [7][8][9][10] A report that merely states the ex-
argue that the statute requires only one in-               pert's conclusions about the standard of care,
                                                           breach, and causation does not fulfill these two pur-

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46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

poses. Nor can a report meet these purposes and               his restraints and precautions to prevent his fall
thus constitute a good-faith effort if it omits any of        were not properly utilized.
the statutory requirements. See, e.g., Hart, 16
S.W.3d at 877 (holding that a report was inadequate             ....
because it stated that the patient had a heart attack
                                                                All in all, Mr. Palacios sustained a second brain
and the doctor breached the standard of care,
                                                              injury with a left subdural hematoma while he
without describing the standard of care); Wood, 988
                                                              was an inpatient at [the Hospital].... [I]n my opin-
S.W.2d at 831–32 (holding that an expert report did
                                                              ion, the medical care rendered to Mr. Palacios at
not meet the statutory requirements because it did
                                                              the time of his second brain injury was below the
not name the defendants, state how the defendants
                                                              accepted and expected standard of care which he
breached the standard of care, demonstrate causa-
                                                              could expect to receive. Moreover, this [sic] be-
tion and damages, or include a curriculum vitae).
                                                              low the accepted standard of care extends to both
However, to avoid dismissal, a plaintiff need not
                                                              the cause of the second injury as well as the sub-
present evidence in the report as if it were actually
                                                              sequent treatment....
litigating the merits. The report can be informal in
that the information in the report does not have to              The Palacioses rely mostly on one sentence in
meet the same requirements as the evidence offered          the report to establish the standard of care: “Mr.
in a summary-judgment proceeding or at trial. See,          Palacios had a habit of *880 trying to undo his re-
e.g., TEX.R. CIV. P. 166(f) (setting out the require-       straints and precautions to prevent his fall were not
ments for the form and content of affidavits offered        properly utilized.” They argue that the inference
as summary-judgment proof); TEX.R. EVID. 802                can be made from that sentence, along with the
(stating that most hearsay is inadmissible).                statement that “[i]t is unclear how he could untie all
                                                            four of the restraints from the bed frame in under
     [11] American Transitional contends that Dr.
                                                            ten minutes,” that Dr. Bontke believes American
Bontke's report does not meet the statutory require-
                                                            Transitional's staff should have tied the restraints to
ments because it does not represent a good-faith ef-
                                                            the bed more securely.
fort to provide a fair summary of her opinion on the
standard of care and how American Transitional                   [12] The standard of care for a hospital is what
breached that standard. The Palacioses respond that         an ordinarily prudent hospital would do under the
the following parts of Dr. Bontke's report establish        same or similar circumstances. See Birchfield v.
these elements:                                             Texarkana Mem'l Hosp., 747 S.W.2d 361, 366
                                                            (Tex.1987). Identifying the standard of care is crit-
    Based on the available documentation I was
                                                            ical: Whether a defendant breached his or her duty
  able to conclude that: Mr. Palacios fell from his
                                                            to a patient cannot be determined absent specific in-
  bed on 5/14/94 while trying to get out of it on his
                                                            formation about what the defendant should have
  own. The nursing notes document that he was ob-
                                                            done differently. “While a ‘fair summary’ is
  served by nursing on the hour for two hours prior
                                                            something less than a full statement of the applic-
  to the fall. In addition, ten minutes before the
                                                            able standard of care and how it was breached, even
  fall, the nursing notes documents [sic] the his
                                                            a fair summary must set out what care was expec-
  wrist/vest restraints were on. Yet, at the time of
                                                            ted, but not given.” 4 S.W.3d at 865 (Taft, J. dis-
  his fall he was found on the floor with his vest/
                                                            senting). The statement the Palacioses rely
  wrist restraints on but not tied to the bed. It is un-
                                                            upon—that precautions to prevent Palacios' fall
  clear how he could untie all four of the restraints
                                                            were not properly used—is not a statement of a
  from the bedframe in under ten minutes. Obvi-
                                                            standard of care. Neither the trial court nor Americ-
  ously, Mr. Palacios had a habit of trying to undo
                                                            an Transitional would be able to determine from

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46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720
(Cite as: 46 S.W.3d 873)

this conclusory statement if Dr. Bontke believes
that the standard of care required American Trans-
itional to have monitored Palacios more closely, re-
strained him more securely, or done something else
entirely. “It is not sufficient for an expert to simply
state that he or she knows the standard of care and
concludes it was [or was not] met.” See Chopra v.
Hawryluk, 892 S.W.2d 229, 233 (Tex.App.—El
Paso 1995, writ denied). Knowing only that the ex-
pert believes that American Transitional did not
take precautions to prevent the fall might be useful
if American Transitional had an absolute duty to
prevent falls from its hospital beds. But as a general
rule, res ipsa loquitur does not apply in medical-
malpractice cases. TEX.REV.CIV. STAT. ANN..
art. 4590i, § 7.01 (limiting res ipsa loquitur in med-
ical malpractice to the limited classes of cases to
which it applied as of August 29, 1977); Haddock
v. Arnspiger, 793 S.W.2d 948, 951 (Tex.1990).

     When the expert report's conclusory statements
do not put the defendant or the trial court on notice
of the conduct complained of, section 13.01(l ) af-
fords the trial court no discretion but to conclude,
as the trial court did here, that the report does not
represent a good-faith effort to provide a fair sum-
mary of the standard of care and how it was
breached, as section 13.01(r)(6) requires. And be-
cause the statutory 180 day time period had passed
when the trial court here made that determination,
section 13.01(e) required the court to dismiss with
prejudice the Palacioses' claims against American
Transitional. See TEX.REV.CIV. STAT. ANN.. art.
4590i, § 13.01(e). Accordingly, we reverse the
court of appeals' judgment and dismiss with preju-
dice the Palacioses' claims.

Tex.,2001.
American Transitional Care Centers of Texas, Inc.
v. Palacios
46 S.W.3d 873, 44 Tex. Sup. Ct. J. 720

END OF DOCUMENT

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228 S.W.3d 252
(Cite as: 228 S.W.3d 252)

                                                            74.351(b).

           Court of Appeals of Texas,                       [2] Appeal and Error 30           946
                     Austin.
Barbara APODACA, Individually and on behalf of              30 Appeal and Error
  the Estate of Claudia J. McAulay, Appellant,                 30XVI Review
                        v.                                         30XVI(H) Discretion of Lower Court
          Dr. Penni RUSSO, Appellee.                                  30k944 Power to Review
                                                                            30k946 k. Abuse of discretion. Most
                No. 03–06–00258–CV.                         Cited Cases
                     May 2, 2007.                                A trial court abuses its discretion if it acts in an
                                                            arbitrary or unreasonable manner or without refer-
Background: Estate of patient, who died from pul-           ence to any guiding rules and principles.
monary embolism, brought action against doctor,
alleging that doctor negligently failed to timely im-       [3] Health 198H         804
plement precautions against pulmonary emboli and
anti-coagulant therapy. The District Court, Travis          198H Health
County, 200th Judicial District, Darlene Byrne, J.,              198HV Malpractice, Negligence, or Breach of
granted doctor's motion to dismiss, and estate ap-          Duty
pealed.                                                            198HV(G) Actions and Proceedings
                                                                       198Hk804 k. Affidavits of merit or merit-
Holding: The Court of Appeals, Jan P. Patterson,            orious defense; expert affidavits. Most Cited Cases
J., held that expert report filed by patient's estate            Expert report need not marshal all of the med-
did not constitute a good faith effort to comply with       ical malpractice plaintiff's proof, but it must include
requirements of medical liability statute and, there-       the expert's opinion on each of the elements identi-
fore, constituted “no report” as to doctor.                 fied in the statute. V.T.C.A., Civil Practice & Rem-
                                                            edies Code § 74.351(r)(6).
    Affirmed.
                                                            [4] Health 198H         804
                  West Headnotes
                                                            198H Health
[1] Appeal and Error 30         960(1)                           198HV Malpractice, Negligence, or Breach of
                                                            Duty
30 Appeal and Error
                                                                   198HV(G) Actions and Proceedings
    30XVI Review
                                                                      198Hk804 k. Affidavits of merit or merit-
       30XVI(H) Discretion of Lower Court
                                                            orious defense; expert affidavits. Most Cited Cases
             30k960 Rulings on Motions Relating to
                                                                 For expert's report to constitute a good-faith ef-
Pleadings
                                                            fort under medical liability statute, the report must
                 30k960(1) k. In general. Most Cited
                                                            inform the defendant of the specific conduct called
Cases
                                                            into question and provide a basis for the trial court
    (Formerly 198Hk809)
                                                            to determine that the claims have merit, and report
     Appellate courts review a trial court's ruling on
                                                            does not fulfill these purposes if it fails to address
a motion to dismiss medical malpractice action for
                                                            the standard of care, breach of the standard, and
failure to file expert report for an abuse of discre-
                                                            causation, or if it only states the expert's conclu-
tion. V.T.C.A., Civil Practice & Remedies Code §
                                                            sions regarding these elements. V.T.C.A., Civil

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                                                                                                            Page 2
228 S.W.3d 252
(Cite as: 228 S.W.3d 252)

Practice & Remedies Code § 74.351(r)(6).                         198HV Malpractice, Negligence, or Breach of
                                                            Duty
[5] Health 198H       804                                          198HV(G) Actions and Proceedings
                                                                       198Hk804 k. Affidavits of merit or merit-
198H Health
                                                            orious defense; expert affidavits. Most Cited Cases
     198HV Malpractice, Negligence, or Breach of
                                                                (Formerly 198Hk809)
Duty
                                                                 The only information relevant to whether an
       198HV(G) Actions and Proceedings
                                                            expert report represents a good faith effort to com-
           198Hk804 k. Affidavits of merit or merit-
                                                            ply with the requirements in medical liability stat-
orious defense; expert affidavits. Most Cited Cases
                                                            ute is the report itself, and therefore, appellate
    Expert report in medical malpractice action can
                                                            courts must consider whether the information with-
be informal in that the information in the report
                                                            in the four corners of the expert report demonstrates
does not have to meet the same requirements as the
                                                            a good faith effort to comply with the statutory re-
evidence offered in a summary-judgment proceed-
                                                            quirements. V.T.C.A., Civil Practice & Remedies
ing or at trial. V.T.C.A., Civil Practice & Remedies
                                                            Code § 74.351(r)(6).
Code § 74.351(r)(6).
                                                            [8] Health 198H        804
[6] Health 198H       804
                                                            198H Health
198H Health
                                                                 198HV Malpractice, Negligence, or Breach of
     198HV Malpractice, Negligence, or Breach of
                                                            Duty
Duty
                                                                   198HV(G) Actions and Proceedings
       198HV(G) Actions and Proceedings
                                                                       198Hk804 k. Affidavits of merit or merit-
           198Hk804 k. Affidavits of merit or merit-
                                                            orious defense; expert affidavits. Most Cited Cases
orious defense; expert affidavits. Most Cited Cases
                                                                 Expert report filed by patient's estate did not
    In medical malpractice action, expert report is
                                                            constitute a good faith effort to comply with re-
not required to prove the defendant's liability, but
                                                            quirements of medical liability statute and, there-
rather to provide notice of what conduct forms the
                                                            fore, constituted “no report” as to doctor; although
basis for the plaintiff's complaints. V.T.C.A., Civil
                                                            estate sued only doctor, other health-care providers
Practice & Remedies Code § 74.351(r)(6).
                                                            were implicated by the facts set forth in the expert
[7] Appeal and Error 30         840(4)                      report, the report failed to mention doctor at all, and
                                                            the report did not inform doctor of the specific con-
30 Appeal and Error                                         duct she allegedly performed that formed the basis
   30XVI Review                                             of the action. V.T.C.A., Civil Practice & Remedies
        30XVI(A) Scope, Standards, and Extent, in           Code § 74.351(r)(6).
General
          30k838 Questions Considered                       [9] Health 198H        804
              30k840 Review of Specific Questions
                                                            198H Health
and Particular Decisions
                                                                198HV Malpractice, Negligence, or Breach of
                  30k840(4) k. Review of questions
                                                            Duty
of pleading and practice. Most Cited Cases
                                                                  198HV(G) Actions and Proceedings
   (Formerly 198Hk809)
                                                                      198Hk804 k. Affidavits of merit or merit-
Health 198H        804                                      orious defense; expert affidavits. Most Cited Cases
                                                                If expert report fails to address the defendant
198H Health                                                 physician, it constitutes no report as to that defend-

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228 S.W.3d 252
(Cite as: 228 S.W.3d 252)

ant under medical liability statute, and the trial          from Brackenridge Hospital Emergency Depart-
court may not grant a 30–day extension. V.T.C.A.,           ment to Healthsouth Rehabilitation Hospital, and
Civil Practice & Remedies Code § 74.351(r)(6).              then transferred back to Brackenridge Hospital for
                                                            an evaluation of her altered mental state and a urin-
*253 Thomas C. Hall, Law Office of Thomas C.                ary tract infection.
Hall, P.C., San Antonio, for appellant.
                                                                 Dr. Penni Russo is a licensed physician who
Emily J. Davenport, Robert L. Hargett, Davis &              specializes in general surgery. At some point,
Wilkerson, P.C., Austin, for appellee.                      Russo evaluated Ms. McAulay for an inferior vena
                                                            cava (IVC) filter, which allows intravenous access
Before Justices PATTERSON, PEMBERTON and                    to prevent a blood clot from causing a pulmonary
WALDROP.                                                    embolism or stroke. No IVC filter was inserted. On
                                                            October 29, Ms. McAulay had a cardiopulmonary
                                                            arrest, and health care providers were unable to re-
                      OPINION                               suscitate her. The certificate of death showed that
JAN P. PATTERSON, Justice.                                  the cause of death was pulmonary embolism.
     This interlocutory appeal arises from a health-
care liability claim filed by appellant Barbara Apo-             As a representative of the estate, appellant filed
daca, individually and on behalf of the estate of           suit on October 31, 2005, alleging that Dr. Russo
Claudia J. McAulay, against Penni Russo, M.D.               negligently failed to timely implement precautions
The issue is whether Apodaca's expert report suffi-         against “pulmonary emboli, and anti-coagulant
                                                                       FN1
ciently meets the requirements of section 74.351 of         therapy.”         On February 17, 2006, appellant
the civil practice and remedies code so as to allow         filed the expert report and curriculum vitae of Dr.
her to receive an extension of time. See Tex. Civ.          Leslie S. Zun pursuant to section 74.351 of the civil
Prac. & Rem.Code Ann. § 74.351(a)-(c) (West                 practice and remedies code. See id. § 74.351(a).
                                                                                                  FN2
Supp.2006). Apodaca contends that the district              Appellant provided no other report         before the
                                                                                                         FN3
court erred by granting Dr. Russo's motion to dis-          expiration of the expert report deadline.           Dr.
miss the lawsuit without first granting Apodaca an          Russo filed a motion to dismiss under section
extension of time to cure her expert report's defi-         74.351(b), asserting that appellant had failed to file
ciencies. See id. § 74.351(c). Because the district         an expert report addressing the care and treatment
court did not abuse its discretion in granting Dr.          provided by Dr. Russo. See id. § 74.351(b). The
Russo's motion to dismiss and denying an extension          district court granted the motion to dismiss, finding
of time to file an additional report, we affirm the         that appellant had failed to provide a proper expert
order.                                                      report and further that she was not entitled to an ex-
                                                            tension of time to cure the report's inadequacies.
    FACTUAL AND PROCEDURAL BACK-                            See id. § 74.351(c). This interlocutory appeal fol-
                     GROUND                                 lowed.
     After she was involved in a serious automobile
accident on October 22, 2003, in which she sus-                      FN1. At the hearing, Dr. Russo's attorney
tained trauma to her head and multiple orthopedic                    argued that Dr. Russo's “sole involvement
injuries, Claudia McAulay was admitted to Brack-                     with this patient was on the 28th when she
enridge Hospital. From October 24 to October 27,                     got called by a nurse to come and evaluate
she was under the care of Dr. Thomas Coopwood,                       the patient for an IVC filter.”
an internal medicine physician, and others. During
the course of her treatment, according to her ex-                    FN2. Although Dr. Zun provided a second
pert's report,*254 Ms. McAulay was transferred                       report dated March 22, 2006, which is in-

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228 S.W.3d 252
(Cite as: 228 S.W.3d 252)

         cluded in the appendix to appellant's brief,       74.351(a). An “expert report” is:
         the report was not before the trial court at
         the time of the hearing, the trial court did         a written report by an expert that provides a fair
         not grant leave for appellant to file the            summary of the expert's opinions as of the date of
         second report, and it is not a part of the re-       the report regarding applicable standards of care,
         cord on appeal. See Tex.R.App. P. 34.                the manner in which the care rendered by the
                                                              physician or health care provider failed to meet
         FN3. Section 74.351(a) required Apodaca              the standards, and the causal relationship between
         to file expert reports within 120 days of fil-       that failure and the injury, harm, or damages
         ing her original petition. See Tex. Civ.             claimed.
         Prac. & Rem.Code Ann. § 74.351(a) (West
         Supp.2006). Thus, Apodaca's deadline to                 Id. § 74.351(r)(6). Failure to serve an adequate
         file expert reports was February 28, 2006.         expert report mandates dismissal with prejudice. Id.
                                                            § 74.351(b). A report need not marshal all of the
                     ANALYSIS                               plaintiff's proof, but it must include the expert's
     In her single issue on appeal, Apodaca argues          opinion on each of the elements identified in the
that dismissal was improper and that she is entitled        statute. Palacios, 46 S.W.3d at 878. To constitute a
to an extension of time to file an expert report. Ap-       good faith effort, the report must inform the de-
pellant urges that the district court erred in not          fendant of the specific conduct called into question
granting an extension of time to file an expert re-         and provide a basis for the trial court to determine
port to cure any deficiency in her expert's first re-       that the claims have merit. Id. at 879. A report does
port. Dr. Russo responds that because the report            not fulfill these purposes if it fails to address the
fails to mention her name or address any care she           standard of care, breach of the standard, and causa-
provided to the patient, the report is “no report” as       tion, or if it only states the expert's conclusions re-
to her and appellant is not entitled to an extension.       garding these elements. Id.

     [1][2] We review a trial court's ruling on a mo-            [5][6] The supreme court has stated that “to
tion to dismiss under section 74.351(b) for an abuse        avoid dismissal, a plaintiff need not present evid-
of discretion. American Transitional Care Ctrs. of          ence in the report as if it were actually litigating the
Tex., Inc. v. Palacios, 46 S.W.3d 873, 877–78               merits. The report can be informal in that the in-
(Tex.2001). A trial court abuses its discretion if it       formation in the report does not have to meet the
acts in an arbitrary or unreasonable manner or              same requirements as the evidence offered in a
without reference to any guiding rules and prin-            summary-judgment proceeding or at trial.” Id. The
ciples. Downer v. Aquamarine Operators, Inc., 701           expert report is not required to prove the defend-
S.W.2d 238, 241–42 (Tex.1985). When reviewing               ant's liability, but rather to provide notice of what
matters committed to the trial court's discretion, we       conduct forms the basis for the plaintiff's com-
may not substitute our own judgment for that of the         plaints. Longino v. Crosswhite ex rel. Crosswhite,
trial court. *255 Walker v. Gutierrez, 111 S.W.3d 183 S.W.3d 913, 916 (Tex.App.-Texarkana 2006,
56, 63 (Tex.2003).                                          no pet.).

The expert report requirement                               Dr. Zun's report
     [3][4] In a health-care liability claim, the               To comply with the expert report requirement,
claimant must provide each defendant with one or            appellant served Dr. Russo with a two-page report
more expert reports, including a curriculum vitae           from Dr. Zun setting forth the medical care Ms.
for each expert, within 120 days of filing the origin-      McAulay received. It does not mention Russo's
al petition. Tex. Civ. Prac. & Rem.Code Ann. §              name; it identifies another physician and otherwise

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228 S.W.3d 252
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fails to specify the identity of any other health care           The report then specified “the deviations from
provider involved in Ms. McAulay's treatment.               the standard of care”:
After recounting the patient's initial treatment by
Dr. Thomas Coopwood and her return to Bracken-                (1) Lack of treatment for DVT prophylaxis
ridge Hospital on October 28 for evaluation, the re-
                                                              Deep venous thrombosis prevention was not
port observed:
                                                              properly addressed. It is essential that prophylax-
  The physician order sheet of 10/28/03 at 1350               is for DVTs be given to patients in order to pre-
  states to stop the lovenox. In the same order sheet         vent pulmonary embolism and death. Heparin or
  dated 10/28/03, an order to place a temporary               low molecular weight heparins are indication for
  IVC filter was to be placed today. Patient was              prevention of DVT. Based on the medical record,
  noted to be restless and agitated the night of              it is unclear whether the patient received heparin
  10/28/03. On 10/28/03, the internal medicine                or lovenox during all of the days of all the hospit-
  consultant assessment stated, “the patient much             al stays to prevent DVT. Asprin [sic] is not con-
  less responsive that records report and there was           sidered adequate prophylaxis for DVT. If there
  a concern about delirium from alcoholism, head              was a concern about heparin induced thrombocyt-
  trauma”. His evaluation included STAT CT scan               openia, lepirudin (Refludan) is the drug of choice
  of the head, holding narcotics and monitoring for           for these patients. There was no finding that this
  worsening symptoms. In this same report, the in-            medication was ever considered or given by the
  ternal medicine consultant recommended that                 physicians carrying [sic] for the patient.
  stopping the heparin was not a good option. It
                                                              (2) Lack of IVC filter insertion
  was recommended that the patient receive an im-
  mediate IVC filter. The medication administra-              The other option for DVT prophylaxis is the in-
  tion record for 10/29/03 at 9am did not document            sertion of an IVC filter. Until IVC filters are
  any medication for DVT prophylaxis. On                      placed some other form of DVT prophylaxis
  10/29/03 at 9:30am, the patient had a cardiopul-            needs to be initiated. In this case, the IVC filter
  monary arrest. Resuscitation *256 was attempted             was not placed in a timely fashion nor was the
  but the patient did not survive.                            patient given DVT prophylaxis until the filter
                                                              was placed. It is uncertain why the IVC filter was
  Deep venous thrombosis (DVT) prophylaxis as
                                                              ordered and then cancelled.
  per Dr. Coopwood's note was aspirin and
  plexipulse foot pump. The medication adminis-               (3) Inadequate evaluation of the patient's altered
  tration report from Brackenridge Hospital did not           mental status
  note any heparin or lovenox being given to the
  patient from 10/23–10/27. The patient was dis-              The patient's altered mental status was not prop-
  charged to Healthsouth Rehabilitation hospital on           erly addressed. One of the likely causes for
  lovenox.                                                    altered mental status and agitation is pulmonary
                                                              embolism. Evaluation of altered mental status in
     After noting that the lovenox was discontinued           this patient focused around medications and head
on October 28 and the medication administration               trauma. The appropriate evaluation would have
report stated that stopping the heparin was “not a            included assessment of the respiratory status in-
good option for DVT prophylaxis and recommen-                 cluding pulse oximetry, blood gas analysis, and
ded that the patient get an IVC filter,” Dr. Zun's re-        chest radiograph. If the patient's altered mental
port observed that “[a] note in the chart stated that         status was properly evaluated, the pulmonary em-
an IVC filter was to be placed and an order to hold           bolism would have been discovered prior to car-
the IVC filter was noted on 10/28/03.”

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  diac arrest. Appropriate treatment for pulmonary          to whether a report represents a good faith effort to
  embolism could have started prior to the fatal            comply with the statutory requirements is the report
  embolism and thereby prevented the patient's de-          itself. Bowie Mem'l Hosp. v. Wright, 79 S.W.3d 48,
  mise.                                                     53 (Tex.2002). We must, therefore, consider wheth-
                                                            er the information within the four corners of the ex-
  (4) The patient's respiratory status was not ad-          pert report demonstrates a good faith effort to com-
  equately monitored                                        ply with the statutory requirements.

  The patient's pulmonary status was not properly                Section 74.351(r)(6) requires that an expert re-
  addressed. Pulse determinations are one means to          port explain how the care rendered by the physician
  determine whether a patient has pulmonary prob-           failed to meet the applicable standard of care and
  lems. Low pulse oxygenation readings in a post            the causal relationship between that failure and the
  surgical, post trauma patient would necessitate           injury suffered by the claimant. See Tex. Civ. Prac.
  that the patient be evaluated for pulmonary em-           & Rem.Code Ann. § 74.351(r)(6); Palacios, 46
  bolism. Identification of pulmonary problem               S.W.3d at 878.
  from pulmonary embolisms would have promp-
  ted immediate treatment that would have saved                  [8] Although appellant has sued only Dr.
  her life.                                                 Russo, other doctors and health-care providers are
                                                            implicated by the facts set forth in the report. The
    Zun concluded that “[e]ach of these four devi-          report references other providers as well as their
ations from the standard of care, alone *257 or in          conduct and refers to another doctor by name, but
combination, could have prevented the death of Ms.          fails to mention Dr. Russo at all. The report does
McAuley's.”                                                 not discuss how the care rendered by Dr. Russo
                                                            failed to meet the applicable standard of care or
    [7] In considering whether an expert report rep-
                                                            how Dr. Russo's failure caused Ms. McAulay to
resents an objective good faith effort, the supreme
                                                            suffer injury, harm or damages. Thus, the report did
court has established that a trial court is limited to a
                                                            not inform Dr. Russo of the specific conduct she al-
review of the report itself:
                                                            legedly performed that forms the basis of the peti-
  The issue for the trial court is whether “the re-         tion.
  port” represents a good-faith effort to comply
                                                                 [9] If a report fails to address the defendant
  with the statutory definition of an expert report.
                                                            physician, it constitutes no report as to that defend-
  [former Tex.Rev.Civ. Stat. Ann. art. 4590i] §
                                                            ant, and the trial court may not grant a 30–day ex-
  13.01(l ). That definition requires, as to each de-
                                                            tension. Garcia v. Marichalar, 185 S.W.3d 70, 74
  fendant, a fair summary of the expert's opinions
                                                            (Tex.App.-San Antonio 2005, no pet.). The ques-
  about the applicable standard of care, the manner
                                                            tion is whether the trial court abused its discretion
  in which the care failed to meet that standard, and
                                                            in determining that the report failed to provide Dr.
  the causal relationship between that failure and
                                                            Russo a proper expert report and that it constituted
  the claimed injury. Id. § 13.01(r)(6). Because the
                                                            “no report” so as to preclude an extension of time
  statute focuses on what the report discusses, the
                                                            to cure any deficiency. Tex. Civ. Prac. &
  only information relevant to the inquiry is within
                                                            Rem.Code Ann. § 74.351(a)-(c).
  the four corners of the document.
                                                                In support of her contention that Apodaca's re-
    Palacios, 46 S.W.3d at 878; see also Horizon/
                                                            port did not satisfy the statutory requirements so as
CMS Healthcare Corp. v. Fischer, 111 S.W.3d 67,
                                                            to allow an extension of time to cure any defi-
68 (Tex.2003). The only information, then, relevant
                                                            ciency, Dr. Russo relies upon Garcia, 185 S.W.3d

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70. In Garcia, the plaintiff filed suit against three       trial court's denial of Dr. Longino's motion to dis-
doctors, two nurses, and a hospital. Garcia v.              miss).
Marichalar, 198 S.W.3d 250, 252 (Tex.App.-San
Antonio 2006, no pet.) (later proceeding). The                   After reviewing the report in its entirety, we
plaintiff served two expert reports, but neither re-        cannot conclude that the trial court abused its dis-
port mentioned Dr. Garcia. Id. The court concluded          cretion in determining that the report fails to repres-
that the trial court had no authority to grant an ex-       ent a good faith effort to address the conduct of Dr.
tension because the report was not merely deficient,        Russo and constitutes no report as to Dr. Russo.
but constituted no report as to Dr. Garcia. Garcia,
                                                                               CONCLUSION
185 S.W.3d at 74. The court further held that
                                                                 Because we conclude that the district court did
“neither report informed Dr. Garcia of the specific
                                                            not abuse its discretion in finding that the report did
conduct he allegedly performed that [the *258
                                                            not constitute a good faith effort to comply with the
plaintiff] had called into question,” and, thus, the
                                                            statutory requirements and therefore constitutes “no
expert reports did not constitute a good faith effort
                                                            report” as to Dr. Russo, we affirm the district
to comply with the statutory requirements. Garcia,
                                                            court's order.
198 S.W.3d at 255.
                                                            Tex.App.–Austin,2007.
     As in Garcia, in this case, the report refers to
                                                            Apodaca v. Russo
the conduct and care provided by several providers.
                                                            228 S.W.3d 252
But unlike Garcia, in this case, appellant has filed a
lawsuit complaining of the actions of only one doc-         END OF DOCUMENT
tor, Dr. Russo. Appellant seeks to distinguish Gar-
cia because she has sued only Dr. Russo. In Garcia,
the plaintiffs made a similar argument, claiming
that the report applied to Dr. Garcia because he was
involved in the single incident made the basis of
that suit. Id. at 254–55. The court concluded that
the report must identify the physician's specific
conduct, as well as the causal relationship to repres-
ent a good faith effort to comply with section
74.351. See id. The report does not satisfy section
74.351(a) for a specific defendant merely because
he or she is a defendant; the report must specific-
ally identify the defendant and apply the statutory
elements to that defendant. See Jernigan v.
Langley, 195 S.W.3d 91, 93–94 (Tex.2006)
(affirming a dismissal under the prior statute,
Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.03, be-
cause although the report made passing mention of
Dr. Jernigan, it failed to state how he breached the
standard of care or how his alleged breach caused
injury); Longino, 183 S.W.3d at 917–18 (finding
that the expert report did not represent a good faith
effort because it failed to differentiate between Dr.
Longino and another physician, and reversing the

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340 S.W.3d 529
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                                                                   30XVI(H) Discretion of Lower Court
                                                                      30k944 Power to Review
          Court of Appeals of Texas,                                       30k946 k. Abuse of discretion. Most
                 Fort Worth.                                Cited Cases
BAYLOR ALL SAINTS MEDICAL CENTER, Ap-                            A trial court has no discretion in determining
                   pellant,                                 what the law is, or in applying the law to the facts,
                      v.                                    and thus a clear failure by the trial court to analyze
  Pamela MARTIN and John Martin, Appellees.                 or apply the law correctly will constitute an abuse
                                                            of discretion.
              No. 02–10–00402–CV.
                  April 14, 2011.                           [2] Health 198H        804
Background: Patient sued hospital for negligence            198H Health
based on alleged sexual assault on patient in her                198HV Malpractice, Negligence, or Breach of
hospital room. Hospital objected to sufficiency of          Duty
patient's expert report, moved to dismiss, and re-                198HV(G) Actions and Proceedings
quested attorney fees. Following a hearing, the 17th                  198Hk804 k. Affidavits of merit or merit-
District Court, Tarrant County, Melody Wilkinson,           orious defense; expert affidavits. Most Cited Cases
J., overruled hospital's objections and denied mo-              The purpose of the expert report requirement in
tion and request for attorney fees. Hospital ap-            health care liability claims is to inform the defend-
pealed.                                                     ant of the specific conduct the plaintiff has called
                                                            into question and to provide a basis for the trial
Holding: The Court of Appeals, Bob McCoy, J.,
                                                            court to conclude that the claims have merit.
held that patient's expert report was deficient in es-
                                                            V.T.C.A., Civil Practice & Remedies Code §
tablishing appropriate standard of care for the hos-
                                                            74.351.
pital and the breach of that standard.
                                                            [3] Health 198H        804
    Reversed and remanded.
                                                            198H Health
                  West Headnotes
                                                                 198HV Malpractice, Negligence, or Breach of
[1] Appeal and Error 30         941                         Duty
                                                                  198HV(G) Actions and Proceedings
30 Appeal and Error                                                   198Hk804 k. Affidavits of merit or merit-
   30XVI Review                                             orious defense; expert affidavits. Most Cited Cases
      30XVI(H) Discretion of Lower Court                         Because the statute governing sufficiency of an
          30k940 Nature and Extent of Discretion-           expert report in a health care liability claim focuses
ary Power                                                   on what the report discusses, the only information
                30k941 k. In general. Most Cited            relevant to the inquiry is within the four corners of
Cases                                                       the document. V.T.C.A., Civil Practice & Remedies
                                                            Code § 74.351.
Appeal and Error 30          946
                                                            [4] Health 198H        804
30 Appeal and Error
   30XVI Review                                             198H Health
                                                               198HV Malpractice, Negligence, or Breach of

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340 S.W.3d 529
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Duty                                                        198H Health
      198HV(G) Actions and Proceedings                          198HV Malpractice, Negligence, or Breach of
          198Hk804 k. Affidavits of merit or merit-         Duty
orious defense; expert affidavits. Most Cited Cases               198HV(C) Particular Procedures
    Alleged sexual assault on patient in her hospit-                  198Hk655 Hospitals in General
al room following surgery was covered, in negli-                            198Hk656 k. In general. Most Cited
gence action against hospital, by the expert report         Cases
requirement for health care liability claims.                   The standard of care for a hospital on a health
V.T.C.A., Civil Practice & Remedies Code §                  care liability claim is what an ordinarily prudent
74.351.                                                     hospital would do under the same or similar cir-
                                                            cumstances.
[5] Health 198H       804
                                                            [8] Health 198H        804
198H Health
     198HV Malpractice, Negligence, or Breach of            198H Health
Duty                                                             198HV Malpractice, Negligence, or Breach of
       198HV(G) Actions and Proceedings                     Duty
            198Hk804 k. Affidavits of merit or merit-              198HV(G) Actions and Proceedings
orious defense; expert affidavits. Most Cited Cases                    198Hk804 k. Affidavits of merit or merit-
     An expert report served by plaintiff in a health       orious defense; expert affidavits. Most Cited Cases
care liability action need not marshal all the                   Identifying the standard of care is critical in an
plaintiff's proof. V.T.C.A., Civil Practice & Remed-        expert report served by plaintiff in a health care li-
ies Code § 74.351.                                          ability action is critical: whether a defendant
                                                            breached his or her duty to a patient cannot be de-
[6] Health 198H       804                                   termined absent specific information about what the
                                                            defendant should have done differently. V.T.C.A.,
198H Health
                                                            Civil Practice & Remedies Code § 74.351.
     198HV Malpractice, Negligence, or Breach of
Duty                                                        [9] Health 198H        804
        198HV(G) Actions and Proceedings
           198Hk804 k. Affidavits of merit or merit-        198H Health
orious defense; expert affidavits. Most Cited Cases              198HV Malpractice, Negligence, or Breach of
     While plaintiff's expert report in a health care       Duty
liability action must do more than simply state the                198HV(G) Actions and Proceedings
expert's conclusions about the standard of care,                       198Hk804 k. Affidavits of merit or merit-
breach, and causation, to avoid dismissal a plaintiff       orious defense; expert affidavits. Most Cited Cases
need not present evidence in the report as if it were            While a fair summary of expert's opinions, as
actually litigating the merits, and report can be in-       required in an expert report served by plaintiff in a
formal in that information in report does not have          health care liability action, is something less than a
to meet same requirements as the evidence offered           full statement of the applicable standard of care and
in a summary judgment proceeding or at trial.               how it was breached, even a fair summary must set
V.T.C.A., Civil Practice & Remedies Code §                  out what care was expected, but not given.
74.351.                                                     V.T.C.A., Civil Practice & Remedies Code §
                                                            74.351.
[7] Health 198H       656
                                                            [10] Health 198H         804

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340 S.W.3d 529
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198H Health                                                 expert report, except for discovery of information
     198HV Malpractice, Negligence, or Breach of            related to plaintiff's health care, did not limit dis-
Duty                                                        covery by patient of information relating to alleged
       198HV(G) Actions and Proceedings                     sexual assault on her in her hospital room following
           198Hk804 k. Affidavits of merit or merit-        surgery; provision only stated that information re-
orious defense; expert affidavits. Most Cited Cases         lated to a plaintiff's health care “included” medical
     Patient's expert report was deficient in negli-        and billing records. V.T.C.A., Civil Practice &
gence action against hospital arising from an al-           Remedies Code § 74.351(s).
leged sexual assault on patient in her hospital room
following surgery, in establishing appropriate              *531 Cantey Hanger LLP, Stephen L. Tatum, Carol
standard of care for the hospital and the breach of         J. Traylor and David Speed, Fort Worth, TX, for
that standard; while report opined that there must          Appellant.
be policies in place to safeguard patients from as-
                                                            King Law Office, P.C. and Russell W. King, Steph-
sault and that hospital must employ sufficient se-
                                                            enville, TX, for Appellee.
curity personnel, it did not state what specific
policies and safeguards should have been in place,
state the number of security personnel required, or         PANEL: LIVINGSTON, C.J.; McCOY and GAB-
establish the training that hospital staff should have      RIEL, JJ.
received in identifying persons not authorized to
enter patients' rooms. V.T.C.A., Civil Practice &
                                                                                  OPINION
Remedies Code § 74.351.
                                                            BOB McCOY, Justice.
[11] Health 198H         804                                                   I. Introduction
                                                                 In one issue, Appellant Baylor All Saints Med-
198H Health                                                 ical Center asserts that the trial court erred when it
     198HV Malpractice, Negligence, or Breach of            determined that the expert report filed by the Ap-
Duty                                                        pellees Pamela and John Martin met the require-
       198HV(G) Actions and Proceedings                     ments of section 74.351 of the civil practice and
           198Hk804 k. Affidavits of merit or merit-        remedies code. See Tex. Civ. Prac. & Rem.Code
orious defense; expert affidavits. Most Cited Cases         Ann. § 74.351 (Vernon 2011). We reverse and re-
     Mere conclusions about the standard of care in         mand.
a plaintiff's expert report are insufficient in a health
care liability action. V.T.C.A., Civil Practice &                   II. Factual and Procedural History
Remedies Code § 74.351.                                          The Martins sued Baylor for negligence, al-
                                                            leging that Pamela was sexually assaulted in her
[12] Pretrial Procedure 307A           39                   hospital room as she recovered from surgery. In
                                                            support of their claim, the Martins served Baylor
307A Pretrial Procedure                                     with Dr. John C. Shershow, M.D.'s expert report
    307AII Depositions and Discovery                        and curriculum vitae. Baylor objected to the report's
       307AII(A) Discovery in General                       sufficiency, moved to dismiss the Martins' claim,
            307Ak36 Particular Subjects of Disclos-         and requested attorney's fees. The trial court over-
ure                                                         ruled Baylor's objections after a hearing and denied
              307Ak39 k. Facts known and opinions           Baylor's motion to dismiss and request for attor-
held by experts. Most Cited Cases                           ney's fees. This appeal followed.
     Statutory provision that stayed discovery in a
health care liability claim until service of plaintiff's                    III. Expert Report

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340 S.W.3d 529
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     Baylor appeals the trial court's order overruling        (c) If an expert report has not been served within
its objections that the Martins' expert witness report        the period specified by Subsection (a) because
does not comply with section 74.351, arguing that             elements of the report are found deficient, the
the report failed to adequately set forth the standard        court may grant one 30–day extension to the
of care applicable to Baylor and how that standard            claimant in order to cure the deficiency....
was breached.
                                                              ....
A. Standard of Review
     [1] We review a trial court's denial of a motion         (l ) A court shall grant a motion challenging the
to dismiss for an abuse of discretion. Jernigan v.            adequacy of an expert report only if it appears to
Langley, 195 S.W.3d 91, 93 (Tex.2006); *532Maris              the court, after hearing, that the report does not
v. Hendricks, 262 S.W.3d 379, 383 (Tex.App.-Fort              represent an objective good faith effort to comply
Worth 2008, pet. denied); Ctr. for Neurological               with the definition of an expert report in Subsec-
Disorders, P.A. v. George, 261 S.W.3d 285,                    tion (r)(6).
290–91 (Tex.App.-Fort Worth 2008, pet. denied). A
                                                              ....
trial court abuses its discretion when it acts in an
arbitrary or unreasonable manner or without refer-            (r) In this section:....
ence to any guiding rules or principles. Downer v.
Aquamarine Operators, Inc., 701 S.W.2d 238,                      (6) “Expert report” means a written report by
241–42 (Tex.1985), cert. denied, 476 U.S. 1159,                  an expert that provides a fair summary of the
106 S. Ct. 2279, 90 L. Ed. 2d 721 (1986). Merely be-                expert's opinions as of the date of the report re-
cause a trial court may decide a matter within its               garding applicable standards of care, the man-
discretion in a different manner than an appellate               ner in which the care rendered by the physician
court would in a similar circumstance does not                   or health care provider failed to meet the stand-
demonstrate that an abuse of discretion has oc-                  ards, and the causal relationship between that
curred. Id. However, a trial court has no discretion             failure and the injury, harm, or damages
in determining what the law is, or in applying the               claimed.
law to the facts, and thus “a clear failure by the trial
court to analyze or apply the law correctly will con-         (s) Until a claimant has served the expert report
stitute an abuse of discretion.” Walker v. Packer,            and curriculum vitae as required by Subsection
827 S.W.2d 833, 840 (Tex.1992) (orig. proceed-                (a), all discovery in a health care liability claim is
ing); Ehrlich v. Miles, 144 S.W.3d 620, 624                   stayed except for the acquisition by the claimant
(Tex.App.-Fort Worth 2004, pet. denied).                      of information, including medical or hospital re-
                                                              cords or other documents or tangible things, re-
B. Applicable Law                                             lated to the patient's health care[.]
     Section 74.351 of the civil practice and remed-
ies code, entitled “Expert Report,” provides,                    Tex. Civ. Prac. & Rem.Code Ann. § 74.351.

  (a) In a health care liability claim, a claimant              [2][3] The purpose of the expert report require-
  shall, not later than the 120th day after the date        ment is to inform the defendant of the specific con-
  the original petition was filed, serve on each            duct the plaintiff has called into question and to
  party or the party's attorney one or more expert          provide a basis for the trial court to conclude that
  reports, ...                                              the claims have merit. Bowie Mem'l Hosp. v.
                                                            Wright, 79 S.W.3d 48, 52 (Tex.2002) (citing Am.
  ....                                                      Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46
S.W.3d 873, 879 (Tex.2001)). When a defendant

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340 S.W.3d 529
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moves to dismiss a plaintiff's claims for failure to        Rubio, 185 S.W.3d 842, 853, 855 (Tex.2005)
provide the required expert report,                         (holding that a patient's claim against a nursing
                                                            home for negligence in failing to provide sufficient
  The issue for the trial court is whether “the re-         staff and supervision to prevent her sexual assault
  port” represents a good-faith effort to comply            by another patient is a health care liability claim).
  with the statutory definition of an expert report.
  That definition *533 requires, as to each defend-         C. Analysis
  ant, a fair summary of the expert's opinions about             [10] Baylor argues that Dr. Shershow's report
  the applicable standard of care, the manner in            fails to adequately identify the standard of care and
  which the care failed to meet that standard, and          that he does not include specific information about
  the causal relationship between that failure and          what Baylor should have done differently. Dr. Sher-
  the claimed injury. Because the statute focuses on        show's report presents the following as Baylor's
  what the report discusses, the only information           standard of care under the facts of this case:
  relevant to the inquiry is within the four corners
  of the document.                                            Standard of Care

    Palacios, 46 S.W.3d at 878 (citations omitted).           A hospital such as Baylor All Saints Medical
                                                              [C]enter is expected to adhere to specific stand-
     [4][5][6][7][8][9] An expert report “need not            ards of care in regard to all of its patients. A bed-
marshal all the plaintiff's proof.” Id. at 878–79.            rock principal [sic] in providing care to its pa-
While the report must do more than simply state the           tients is the understanding that all of a hospital's
expert's conclusions about the standard of care,              patients by nature of their disease or injury are
breach, and causation, to avoid dismissal “a                  potentially vulnerable and necessarily need to re-
plaintiff need not present evidence in the report as          ceive treatment in a safe and secure environment.
if it were actually litigating the merits. The report         The Joint Commission on Accreditation of Health
can be informal in that the information in the report         Care Organizations (JCAHO) has established in
does not have to meet the same requirements as the            its Hospital Standards that all healthcare organiz-
evidence offered in a summary-judgment proceed-               ations must have in place policies which safe-
ing or at trial.” Id. at 879.                                 guard patients from assault by hospital staff and
                                                              by strangers that enter the hospital. The JCAHO
  [t]he standard of care for a hospital is what an or-        requires that hospitals adequately implement
  dinarily prudent hospital would do under the                these standards, and monitor this implementation.
  same or similar circumstances. Identifying the              The JCAHO patient security and safety expecta-
  standard of care is critical: Whether a defendant           tions would require at a minimum that hospitals
  breached his or her duty to a patient cannot be             should employ a sufficient number of security
  determined absent specific information about                personal [sic] to insure that no unauthorized per-
  what the defendant should have done differently.            sons enter patients ['] rooms and physically as-
  “While a ‘fair summary’ is something less than a            sault their patients. Additionally, the JCAHO
  full statement of the applicable standard of care           standards would expect that all hospital staff
  and how it was breached, even a fair summary                should be trained to identify persons that are not
  must set out what care was expected, but not giv-           authorized to enter patients['] rooms and should
  en.”                                                        monitor and prevent unauthorized persons from
                                                              *534 having access to patients receiving treat-
    Id. at 880 (citations omitted). Assaults of the
                                                              ment at the hospital.
type alleged by the Martins are covered by section
74.351. See, e.g., Diversicare Gen. Partner, Inc. v.            The Martins reply that the trial court did not

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                                                                                                            Page 6
340 S.W.3d 529
(Cite as: 340 S.W.3d 529)

abuse its discretion by denying Baylor's motion to               [12] And although the Martins specifically
dismiss, claiming that Dr. Shershow's report was            complain that section 74.351(s) only allows discov-
adequate. They alternatively argue that the medical         ery of medical records and billing records, which
records that section 74.351(s) allows them to dis-          do not contain the circumstances surrounding the
cover do not contain adequate information to estab-         assault and hence provide no discovery as to wheth-
lish the appropriate standard of care and breach            er security standards were met, this is a misreading
thereof, and hence, further discovery should be al-         of the discovery allowed under section 74.351(s).
lowed.                                                      Section 74.351(s) allows discovery “of information,
                                                            including medical or hospital records or other doc-
     We observe that the Martins were well aware,           uments or tangible things, related to the patient's
as set out in their petition, of the alleged facts of the   health care.” See Tex. Civ. Prac. & Rem.Code Ann.
assault. Hence, it was incumbent upon their expert          § 74.351(s) (emphasis added). Furthermore, as as-
to articulate the standard of care applicable to the        saults of the type here are covered by section
hospital to prevent such an assault, which does not         74.351, see Rubio, 185 S.W.3d at 851, logically,
require a factual inquiry into the measures taken by        discovery of the hospital's policies and procedures
the hospital to meet this standard of care.                 regarding the protection of patients from assault
                                                            must be covered by section 74.351(s). See Tex. Civ.
     Dr. Shershow's report opines (1) that Baylor is
                                                            Prac. & Rem.Code Ann. § 74.351(s) (stating that all
expected to adhere to “specific standards of care”
                                                            discovery is stayed except for acquisition by the
for its patients, (2) that there must be policies in
                                                            claimant of information related to the patient's
place to safeguard patients from assault, including
                                                            health care); see also Bogar v. Esparza, 257
employing “a sufficient number of security person-
                                                            S.W.3d 354, 371–72 (Tex.App.-Austin 2008, no
al [sic] to insure that no unauthorized persons as-
                                                            pet.) (op. on reh'g) (noting that the plaintiff has the
sault patients and training staff to identify persons
                                                            burden to establish that section 74.351's discovery
not authorized to enter patients['] rooms and pre-
                                                            limitations have in fact prevented her from satisfy-
vent them from doing so,” and (3) that these stand-
                                                            ing the statute's expert report requirements and pur-
ards must be adequately implemented. These opin-
                                                            suing her claim). But cf. Simmons v. Texoma Med.
ions do not establish what specific policies and
                                                            Ctr., 329 S.W.3d 163, 174 (Tex.App.-El Paso 2010,
safeguards should have been in place. For example,
                                                            no pet. h.) (interpreting section 74.351(s) to pre-
the “policies in place to safeguard patients” are not
                                                            clude “[d]iscovery of issues such as financial in-
identified; neither are the number of security per-
                                                            formation, insurance and indemnity agreements,
sonnel required nor the training the staff should
                                                            corporate organization, *535 and even bylaws,
have received regarding identifying unauthorized
                                                            policies, and procedures” until an expert report is
persons. See Wright, 79 S.W.3d at 52 (stating that
                                                            served).
the expert must explain the basis of his statements
to link his conclusions to the facts).                           Therefore, we hold that with respect to the es-
                                                            tablishment of the appropriate standard of care for
     [11] Keeping in mind that mere conclusions
                                                            Baylor and the breach of that standard, the Martins'
about the standard of care are insufficient, that the
                                                            expert report was deficient, and the trial court ab-
standard is “what an ordinary prudent hospital
                                                            used its discretion by finding otherwise. We sustain
would do under the same or similar circumstances,”                               FN1
                                                            Baylor's sole issue.
and that “even a fair summary must set out what
care was expected,” see Palacios, 46 S.W.3d at                       FN1. Based on our resolution, we do not
880, we cannot agree that Dr. Shershow's report                      reach Baylor's other arguments. See
fulfills the required specificity.                                   Tex.R.App. P. 47.1.

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340 S.W.3d 529
(Cite as: 340 S.W.3d 529)

                    IV. Conclusion
     Having sustained Baylor's sole issue, we re-
verse the trial court's order and remand this case to
the trial court to consider whether to grant a thirty-
day extension to cure the deficiency. See Tex. Civ.
Prac. & Rem.Code Ann. § 74.351(c); Leland v.
Brandal, 257 S.W.3d 204, 207 (Tex.2008); Foster
v. Richardson, 303 S.W.3d 833, 845–46
(Tex.App.-Fort Worth 2009, no pet.).

Tex.App.–Fort Worth,2011.
Baylor All Saints Medical Center v. Martin
340 S.W.3d 529

END OF DOCUMENT

                            © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                            Page 1
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

                                                                   106VI(B) Courts of Particular States
                                                                      106k247 Texas
          Supreme Court of Texas.                                        106k247(1) k. Appellate jurisdiction of
CERTIFIED EMS, INC. d/b/a CPNS Staffing, Peti-             Supreme Court in general. Most Cited Cases
                  tioner,                                       Conflicts between appellate courts over the ex-
                     v.                                    tent to which an expert report must examine every
        Cherie POTTS, Respondent.                          liability theory alleged in a case brought under the
                                                           Texas Medical Liability Act provided Supreme
                  No. 11–0517.
                                                           Court with jurisdiction over interlocutory appeal
             Argued Oct. 17, 2012.
                                                           brought by nurse staffing agency following denial
            Delivered Feb. 15, 2013.
                                                           of agency's motion to dismiss patient's action.
        Rehearing Denied March 29, 2013.
                                                           V.T.C.A., Civil Practice & Remedies Code §
Background: Patient brought vicarious liability            74.351; V.T.C.A., Government Code § 22.225(c).
and direct liability action against nurse staffing
                                                           [2] Health 198H         805
agency that employed contract nurse who assaulted
patient while she was in hospital. The 270th Dis-          198H Health
trict Court, Harris County, Brent C. Gamble, J.,                 198HV Malpractice, Negligence, or Breach of
denied nurse staffing agency's motion to dismiss,          Duty
and nurse staffing agency filed interlocutory ap-                  198HV(G) Actions and Proceedings
peal. The Court of Appeals, 355 S.W.3d 683, af-                        198Hk805 k. Sanctions for failing to file
firmed. Staffing agency petitioned for review.             affidavits; dismissal with or without prejudice.
                                                           Most Cited Cases
Holding: Upon grant of review, the Supreme
                                                                Dismissal of patient's claim against nurse staff-
Court, Jefferson, C.J., held that as long as patient's
                                                           ing agency under the Medical Liability Act, which
health care liability claim contained at least one vi-
                                                           alleged both vicarious liability and direct liability,
able liability theory, as evidenced by an expert re-
                                                           was not warranted, even though expert reports sub-
port meeting the statutory requirements, the entire
                                                           mitted by patient only supported her vicarious liab-
case was allowed to move forward, disapproving
                                                           ility claims; as long as patient's health care liability
MSHC the Waterton at Cowhorn Creek, LLC v.
                                                           claim contained at least one viable liability theory,
Miller, 391 S.W.3d 551, Fung v. Fischer, 365
                                                           as evidenced by an expert report meeting the stat-
S.W.3d 507, Hendrick Med. Ctr. v. Miller, 2012
                                                           utory requirements, the entire case was allowed to
WL 314062, River Oaks Endoscopy Ctrs., L.L.P. v.
                                                           move forward; disapproving MSHC the Waterton at
Serrano, 2011 WL 303795, Beaumont Bone &
                                                           Cowhorn Creek, LLC v. Miller, 391 S.W.3d 551,
Joint, P.A. v. Slaughter, 2010 WL 730152, and Azle
                                                           Fung v. Fischer, 365 S.W.3d 507, Hendrick Med.
Manor, Inc. v. Vaden, 2008 WL 4831408.
                                                           Ctr. v. Miller, 2012 WL 314062, River Oaks Endo-
    Affirmed.                                              scopy Ctrs., L.L.P. v. Serrano, 2011 WL 303795,
                                                           Beaumont Bone & Joint, P.A. v. Slaughter, 2010
                  West Headnotes                           WL 730152, and Azle Manor, Inc. v. Vaden, 2008
WL 4831408. V.T.C.A., Civil Practice & Remedies
[1] Courts 106       247(1)                                Code § 74.351.

106 Courts                                                 [3] Health 198H         804
   106VI Courts of Appellate Jurisdiction

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                                                                                                            Page 2
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

198H Health                                                       Under the Medical Liability Act, an expert re-
     198HV Malpractice, Negligence, or Breach of             port that adequately addresses at least one pleaded
Duty                                                         liability theory satisfies the statutory requirements,
      198HV(G) Actions and Proceedings                       and the trial court must not dismiss in such a case.
          198Hk804 k. Affidavits of merit or merit-          V.T.C.A., Civil Practice & Remedies Code §
orious defense; expert affidavits. Most Cited Cases          74.351.
     An expert report that satisfies the statutory re-
quirements under the Medical Liability Act, even if          [6] Health 198H        804
as to only one theory of liability, entitles the
                                                             198H Health
claimant to proceed with a suit against the physi-
                                                                  198HV Malpractice, Negligence, or Breach of
cian or health care provider. V.T.C.A., Civil Prac-
                                                             Duty
tice & Remedies Code § 74.351(r)(6).
                                                                    198HV(G) Actions and Proceedings
[4] Health 198H        804                                              198Hk804 k. Affidavits of merit or merit-
                                                             orious defense; expert affidavits. Most Cited Cases
198H Health                                                       When a health care liability claim involves a
     198HV Malpractice, Negligence, or Breach of             vicarious liability theory, either alone or in combin-
Duty                                                         ation with other theories, an expert report that
       198HV(G) Actions and Proceedings                      meets the statutory standards as to the employee is
          198Hk804 k. Affidavits of merit or merit-          sufficient to implicate the employer's conduct under
orious defense; expert affidavits. Most Cited Cases          the vicarious theory, and if any liability theory has
     An expert report filed pursuant to the Medical          been adequately covered, the entire case may pro-
Liability Act must inform the defendant of the spe-          ceed. V.T.C.A., Civil Practice & Remedies Code §
cific conduct the plaintiff has called into question         74.351.
and must provide a basis for the trial court to con-
clude that the claims have merit. V.T.C.A., Civil            *626 Debra Ibarra Mayfield, Harris County Civil
Practice & Remedies Code § 74.351(r)(6).                     Courts at Law # 1, Harris County Civil Courthouse,
                                                             Houston, TX, Laura Denise Wilson Slay and Nath-
[5] Health 198H        804                                   an Montgomery Rymer, Rymer Moore Jackson &
                                                             Echols, P.C., Houston, TX, for Certified EMS, Inc.
198H Health
    198HV Malpractice, Negligence, or Breach of              Clinton E. Wells Jr., John T. McDowell, McDowell
Duty                                                         Wells LLP, Houston, TX, Vincent L. Marable III,
      198HV(G) Actions and Proceedings                       Paul Webb PC, Wharton, TX, for Cherie Potts.
          198Hk804 k. Affidavits of merit or merit-
orious defense; expert affidavits. Most Cited Cases
                                                             Chief Justice JEFFERSON delivered the opinion of
Health 198H        805                                       the Court.
                                                                  A patient alleged that a hospital nurse, who
198H Health                                                  was temporarily placed with the hospital by a staff-
     198HV Malpractice, Negligence, or Breach of             ing service, assaulted her. The patient sued under
Duty                                                         the Texas Medical Liability Act, asserting that the
      198HV(G) Actions and Proceedings                       staffing service was directly and vicariously liable
           198Hk805 k. Sanctions for failing to file         for the nurse's conduct. The staffing service sought
affidavits; dismissal with or without prejudice.             dismissal because the patient's expert reports did
Most Cited Cases                                             not specify how the service was directly negligent.

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                                                                                                          Page 3
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

The service has not challenged, in this Court, the         court gave Potts thirty days to cure the alleged defi-
reports' adequacy concerning its vicarious liability.      ciencies. See id. § 74.351(c). In response, Potts sup-
                                                           plemented Nurse Foster's original report and
     The trial court denied the motion to dismiss,         provided a new one from Dr. Milton Altschuler,
and the court of appeals affirmed. It held that be-        M.D.
cause the reports support a theory of vicarious liab-
ility against the staffing service, the lack of a de-           The relevant portions of Nurse Foster's supple-
scription supporting direct liability is not fatal to      mented report outline the appropriate standard of
the claimant's maintaining her cause of action. We         care for nurses and nursing agencies, describe the
agree with the court of appeals, but for different         steps that should have been taken by Hardin and
reasons. Accordingly, we affirm the court of ap-           Certified EMS to prevent the assaults, and conclude
peals' judgment.                                           that Hardin's and Certified EMS's failures caused
                                                           Potts's injuries. Dr. Altschuler's report states that
I. Background                                              Hardin engaged in sexually inappropriate and in-
     Cherie Potts was admitted to Christus St. Cath-       trusive conduct, causing the injuries that Potts has
erine's Hospital for treatment of a kidney infection.      alleged.
One of the nurses assigned to her care, Les Hardin,
was referred to the hospital by a staffing service              Certified EMS objected to the newly submitted
owned by Certified EMS. Potts claims that Hardin           reports and moved to dismiss on numerous grounds,
assaulted her sexually and verbally during her hos-        among them that the reports omitted any explicit
pital stay. Potts alleges that the assaults caused her     reference to Certified EMS's direct liability for
anxiety and physical pain. She sued the hospital,          Hardin's conduct.
                             FN1
Hardin, and Certified EMS.
                                                                The trial court denied the motion, and Certified
         FN1. Christus St. Catherine's Hospital and        EMS appealed. See TEX. CIV. PRAC. &
         Les Hardin are not parties to this inter-         REM.CODE § 51.014(a)(9) (allowing interlocutory
         locutory appeal.                                  appeal of an order denying relief sought by motion
                                                           under section 74.351(b) in certain circumstances).
     Potts claimed that Certified EMS was directly         The court of appeals affirmed, holding (as relevant
liable for Hardin's conduct because it failed to           here) that “if the claimant timely serves an expert
properly train and oversee its staff, enforce applic-      report that adequately addresses at least one liabil-
able standards of care, and employ protocols to en-        ity theory against a defendant health care provider,
sure quality patient care and adequate staff supervi-      the suit can proceed, including discovery, without
sion. Potts also alleged that Certified*627 EMS was        the need for every liability theory to be addressed
vicariously liable under the theory of respondeat                                                 FN2
                                                           in the report.” 355 S.W.3d 683, 693.        We gran-
superior.                                                  ted Certified EMS's petition for review, which
                                                           raises a single issue: Must a claimant in a health
    Because Potts sued under the Texas Medical
                                                           care liability suit provide an expert report for each
Liability Act, she was required to serve each de-
                                                           pleaded liability theory? 55 Tex. Sup. Ct. J. 461
fendant with an expert report that met certain stat-
                                                           (Mar. 30, 2012).
utory requirements. See TEX. CIV. PRAC. &
REM.CODE § 74.351 (outlining requirements and                       FN2. The court of appeals also determined
guidelines for expert reports in health care liability              that the expert reports that Potts provided
claims). Potts timely served reports from Nurse S.                  to Certified EMS sufficiently addressed
Francis Scholl Foster and Dr. Kit Harrison, Ph.D.                   her vicarious liability theory, but failed to
Certified EMS challenged the reports, and the trial                 address her direct liability theories. 355

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392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

        S.W.3d at 686. Neither party has chal-                    of action in order for the claimant to pro-
        lenged those conclusions.                                 ceed with the entire cause of action against
                                                                  the defendant”); Nexion Health at Duncan-
II. Conflict Among the Courts of Appeals                          ville, Inc. v. Ross, 374 S.W.3d 619, 626
     [1] Numerous appellate decisions have dis-                   (Tex.App.-Dallas 2012, pet. denied)
cussed the extent to which an expert report must ex-              (holding that an expert report need “not ad-
amine every liability theory alleged. The cases                   dress each ‘specific act of negligence’
reach varied results. Several courts of appeals, like             pleaded by a plaintiff ... [to] satisfy the two
the court of appeals in this case, have determined                intended purposes of the expert report re-
that a claimant's expert report(s) need address only              quirement”); Univ. of Tex. Med. Branch at
                                                 FN3
a single theory for the entire suit to proceed.                   Galveston v. Qi, 370 S.W.3d 406, 415–16
Some of those decisions rely on *628 Potts, either                (Tex.App.-Houston [14th Dist.] 2012, no
                          FN4
indirectly or explicitly.     The Potts court focused             pet.) (referencing the Potts court's reason-
on the Act's plain language, specifically on the re-              ing when it held that an expert report need
quirement that an expert report be served “[i]n a                 not address “every act or omission men-
health care liability claim,” which the statute fur-              tioned in the pleadings, so long as at least
ther defines as a “cause of action.” See 355 S.W.3d               one liability theory within each cause of
at 690–92; see also TEX. CIV. PRAC. &                             action is sufficiently addressed”); Clear
REM.CODE § 74.001(a)(13) ( “ ‘Health care liabil-                 Lake Rehab. Hosp., L.L.C. v. Karber, No.
ity claim’ means a cause of action against a health               01–09–00883–CV, 2010 WL 987758, at *5
care provider or physician for treatment, lack of                 n. 7 (Tex.App.-Houston [1st Dist.] Mar.
treatment, or other claimed departure from accepted               18, 2010, no pet.) (mem.op.) (suggesting
standards of medical care, or health care, or safety              that a report that is adequate as to one the-
or professional or administrative services directly               ory of liability can move an entire cause of
related to health care, which proximately results in              action past the expert report stage).
injury to or death of a claimant, whether the
claimant's claim or cause of action sounds in tort or             FN4. See, e.g., Laurel Ridge Treatment
contract.”). Relying on our discussion of “cause of               Ctr., 2012 WL 3731748, at *1; Nexion
action” in In re Jorden, 249 S.W.3d 416 (Tex.2008)                Health, 374 S.W.3d at 626–27.
, the Potts court reasoned that the Act requires an
expert report only for each set of operative facts             Other courts insist that an expert report must
                                                                                                      FN5
that give rise to one or more bases for suing. 355        specifically address each liability theory.       Un-
S.W.3d at 691. Thus, if an expert report adequately       supported theories must be dismissed. Those courts
addresses a single liability theory within a cause of     also look to the statute's language. Some interpret
action, the entire case may proceed. Id.                  “health care liability claim” to mean a single*629
                                                                               FN6
                                                          theory of liability.     Thus, when the statute re-
        FN3. See Laurel Ridge Treatment Ctr. v.           quires that a “liability claim” be supported by an
        Garcia, No. 04–12–00098–CV, 2012 WL               expert report, these courts reason that the report
        3731748, at *1 (Tex.App.-San Antonio              must address each liability theory. Other courts of
        Aug. 29, 2012, pet. filed) (mem.op.)              appeals interpret “health care liability claim” to
        (holding that the trial court did not abuse       mean a cause of action, or set of operative facts,
        its discretion when it denied defendant's         like the Potts court did. But unlike the Potts court,
        motion to dismiss because an “expert re-          they reason that different theories of liability must
        port is required to be adequate with regard       be based on different sets of operative facts and
        to only one liability theory within a cause       each, therefore, requires its own expert report. In

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                                                                                                          Page 5
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

that respect, several cases have held that direct and               pet.) (mem. op.) (holding that a claimant
vicarious liability theories involve different sets of              alleging theories of direct and vicarious li-
operative facts because “the facts required to estab-               ability must provide an expert report that
lish the defendant's vicarious liability, i.e., the acts            addresses all theories so that the defendant
of [the agent and his relationship] to [the principal],             can be made aware of the specific conduct
differ from the facts required to establish the ... de-             being called into question); Beaumont
fendant's direct liability, i.e., [its] provision of par-           Bone & Joint, P.A. v. Slaughter, No.
ticular policies and procedures.” Fung v. Fischer,                  09–09–00316–CV, 2010 WL 730152, at
365 S.W.3d 507, 522 (Tex.App.-Austin 2012, no                       *3–4 (Tex.App.-Beaumont Mar. 4, 2010,
pet.); see also MSHC the Waterton at Cowhorn                        pet. denied) (mem.op.) (holding that al-
Creek, LLC v. Miller, 391 S.W.3d 551, 560                           though vicarious liability claims were suf-
(Tex.App.-Texarkana, no pet.) (“The facts required                  ficiently addressed in an expert report, dir-
to establish direct liability here are qualitatively                ect liability claims were not, and should
different from the facts necessary to establish ... vi-             have been dismissed); Azle Manor, Inc. v.
carious liability....”).                                            Vaden, No. 2–08–115–CV, 2008 WL
4831408, at *10 (Tex.App.-Fort Worth
         FN5. See MSHC the Waterton at Cowhorn                      Nov. 6, 2008, no pet.) (mem.op.) (holding
         Creek, LLC v. Miller, 391 S.W.3d 551, 560                  that although vicarious liability claims
         (Tex.App.-Texarkana, no pet.) (holding                     against two doctors were sufficiently ad-
         that the claimant's expert reports must ad-                dressed in two expert reports, the direct li-
         dress vicarious and direct liability claims                ability claims were not, and thus the trial
         separately because the theories were based                 court abused its discretion when it denied
         on two different sets of operative facts,                  the defendant doctors' motion to dismiss
         which were “qualitatively different from                   the direct liability claims).
         the facts necessary to establish [the em-
         ployer's] vicarious liability for the acts or              FN6. See, e.g., Hendrick Med. Ctr., 2012
         omissions of its staff”); Fung v. Fischer,                 WL 314062, at *3.
         365 S.W.3d 507 (Tex.App.-Austin 2012,
         no pet.) (finding that because the                     Still other courts have addressed questions that
         claimant's theories of liability were both         vary slightly from the one before us today. These
         vicarious and direct and thus based on dif-        courts have engaged in analyses that demonstrate
         ferent sets of operative facts, the expert re-     the need to definitively resolve the question of how
         port that only addressed the employee's            expert reports treat multiple theories of liability.
                                                            FN7
         conduct was not sufficient to impose direct
         liability on the employer); Hendrick Med.
                                                                    FN7. See Marino v. Wilkins, No.
         Ctr. v. Miller, No. 11–11–00141–CV, 2012
                                                                    01–11–00835–CV, 2012 WL 749997, at
         WL 314062, at *3 (Tex.App.-Eastland Jan.
                                                                    *8–10 (Tex.App.-Houston [1st Dist.] Mar.
         26, 2012, no pet.) (mem. op.) (holding that
                                                                    8, 2012, pet. denied) (holding, under the
         direct and vicarious liability claims must
                                                                    Potts reasoning, that a health care liability
         be evaluated separately to determine
                                                                    suit may proceed under one liability theory
         whether each claim was sufficiently sup-
                                                                    if the defendant does not move to dismiss
         ported by an expert report); River Oaks
                                                                    all theories of liability in his challenge to
         Endoscopy Ctrs., L.L.P. v. Serrano, No.
                                                                    the expert reports); Petty v. Churner, 310
         09–10–00201–CV, 2011 WL 303795, at *2
                                                                    S.W.3d 131, 138 (Tex.App.-Dallas 2010,
         (Tex.App.-Beaumont Jan. 27, 2011, no
                                                                    no pet.) (concluding that the trial court

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                                                                                                            Page 6
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

         properly dismissed direct liability claims        theory, the trial court must dismiss those theories
         because the vicarious and direct liability        that are unsupported by a report. Thus, if a
         theories were based on two different stand-       plaintiff's allegations include both direct and vicari-
         ards of care, and an expert report that only      ous liability claims, the report is deficient if it does
         addressed the vicarious theory did not meet       not cover both. We are not persuaded.
         the statutory requirements); Obstetrical
         and Gynecological Assocs., P.A. v. McCoy,              *630 Several courts of appeals rely on the stat-
         283 S.W.3d 96,       105–06       ute's use of the term “cause of action” to decide this
         (Tex.App.-Houston [14th Dist.] 2009, pet.         issue. When we discussed the phrase in In re
         denied) (deciding that a claimant need not        Jorden, we noted that it “generally applies to facts,
         provide an expert report addressing an em-        not filings.” Jorden, 249 S.W.3d at 421. We also
         ployer's conduct if the claimant only seeks       looked to Black's Law Dictionary, which “defines
         to hold the employer liable under a vicari-       ‘cause of action’ as [a] group of operative facts giv-
         ous liability theory, noting that there is a      ing rise to one or more bases for suing; a factual
         distinction between allegations of liability      situation that entitles one person to obtain a remedy
         made against the employer based on the            in court from another person.” Id. (quoting
         conduct of employees versus allegations of        BLACK'S LAW DICTIONARY 235 (8th
         direct liability based on the conduct of the      ed.2004)). From this, several appellate courts have
         employer entity itself); Methodist Charlton       relied on “operative facts” to reach opposing res-
         Med. Ctr. v. Steele, 274 S.W.3d 47, 50–51         ults—either that an expert report must address
                                                                                            FN9
         (Tex.App.-Dallas 2008, pet. denied)               every pleaded liability theory,        or that it need
                                                                FN10
         (holding that because the claimant failed to      not.         The competing conclusions demonstrate
         timely serve expert reports related to the        the pitfalls of this approach.
         direct liability claims against defendants
                                                                    FN9. See, e.g., MSHC the Waterton, 391
         that were added in an amended petition,
                                                                    S.W.3d at 558–59.
         those particular claims should have been
         dismissed; but, the vicarious liability                    FN10. See, e.g., Qi, 370 S.W.3d at 415–16.
         claims, based on the conduct of a nurse
         employee, were addressed in a timely re-               The focus on operative facts raises more ques-
         port and could move forward).                     tions than it answers. Are the “operative facts” un-
                                                           derlying alleged liability for failure to train differ-
     These conflicts give us jurisdiction over this in-    ent from the underlying allegations of vicarious li-
terlocutory appeal. TEX. GOV'T CODE §                      ability for medical malpractice? The court of ap-
           FN8                                                                 FN11
22.225(c).                                                 peals here said no,        but others would say yes.
                                                           FN12
                                                                  Would each of Potts 's direct liability theories
         FN8. See also TEX. GOV'T CODE §
                                                           against Certified EMS—for failing to train its em-
         22.225(e) (noting that “one court holds dif-
                                                           ployees, failing to enforce accepted standards of
         ferently from another when there is incon-
                                                           care, and failing to employ protocols to ensure
         sistency in their respective decisions that
                                                           quality care for patients—require its own expert re-
         should be clarified to remove unnecessary
                                                           port, because the facts underlying each allegation
         uncertainty in the law and unfairness to lit-
                                                           may differ? Will, as the cases suggest, the relevant
         igants”).
                                                           operative facts be disputed in every case, leading to
III. Addressing Theories of Liability                      additional time, expense, and interlocutory appeals?
     [2] Certified EMS contends that if a claimant's
                                                                    FN11. 355 S.W.3d at 690–92.
report does not adequately address each asserted

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                                                                                                            Page 7
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

        FN12. See, e.g., MSHC the Waterton, 391            ence. Rather, “to avoid dismissal ... [t]he report can
        S.W.3d at 558–59; Fung, 365 S.W.3d at              be informal in that the information in the report
        522.                                               does not have to meet the same requirements as the
                                                           evidence offered in a summary-judgment proceed-
     [3] We appreciate the courts of appeals' reason-      ing or at trial.” Id. For the particular liability theory
ing, but decline to follow that approach. No provi-        addressed, the report must sufficiently describe the
sion of the Act requires an expert report to address       defendant's alleged conduct. Such a report both in-
each alleged liability theory. The Act requires a          forms a defendant of the behavior in question and
claimant to file an expert report “[i]n a health care      allows the trial court to determine if the allegations
liability claim.” TEX. CIV. PRAC. & REM.CODE               have merit. If the trial court decides that a liability
§ 74.351(a). Once an expert report is timely served        theory is supported, then the claim is not frivolous,
and properly challenged, the trial court:                  and the suit may proceed.

  shall grant a motion challenging the adequacy of         IV. Legislative Intent
  an expert report only if it appears to the court,             This approach is consistent with the Legis-
  after hearing, that the report does not represent an     lature's intent. See Molinet v. Kimbrell, 356 S.W.3d
  objective good faith effort to comply with the           407, 411 (Tex.2011) (“Our primary objective in
  definition of an expert report.                          construing statutes is to give effect to the Legis-
                                                           lature's intent.”). In amending the Act, the Legis-
     Id. § 74.351(l ); see also Loaisiga v. Cerda,
                                                           lature sought to reduce “the excessive frequency
379 S.W.3d 248, 260 (Tex.2012) (same). A valid
                                                           and severity of ... claims,” but to “do so in a man-
expert report has three elements: it must fairly sum-
                                                           ner that will not unduly restrict a claimant's rights
marize the applicable standard of care; it must ex-
                                                           any more than necessary to deal with the crisis.”
plain how a physician or health care provider failed
                                                           Act of June 11, 2003, 78th Leg., R.S., ch. 204, §
to meet that standard; and it must establish the
                                                           10.11(b)(1), (3), 2003 Tex. Gen. Laws 847, 884. In
causal relationship between the failure and the harm
                                                           accordance with this goal, we have opined that one
alleged. TEX. CIV. PRAC. & REM.CODE §
                                                           purpose of the report requirement is “to expedi-
74.351(r)(6); see Scoresby v. Santillan, 346 S.W.3d
                                                           tiously weed out claims that have no merit.”
546, 556 (Tex.2011). A report that satisfies these
                                                           Loaisiga, 379 S.W.3d at 263. We have also stated
requirements, even if as to one theory only, entitles
                                                           that the purpose of evaluating expert reports is “to
the claimant to proceed with a suit against the phys-
                                                           deter frivolous claims, not to dispose of claims re-
ician or health care provider.
                                                           gardless of their merits.” Scoresby, 346 S.W.3d at
     [4] The report serves two functions. “First, the      554; see also Loaisiga, 379 S.W.3d at 258
report must inform the defendant of the specific           (recognizing that the expert report “requirements
conduct the plaintiff has called into question.            are meant to identify frivolous claims and reduce
Second, and equally important, the report must             the expense and time to dispose of any that are
provide a basis for the trial court to conclude that       filed”); In re Jorden, 249 S.W.3d at 421.
the claims have merit.” Am. Transitional Care Ctrs.
                                                               Our holding today satisfies these purposes. If a
of Tex., Inc. v. Palacios, 46 S.W.3d 873, 879
                                                           health care liability claim contains at least one vi-
(Tex.2001).
                                                           able liability theory, as evidenced by an expert re-
     A report need not cover every alleged liability       port meeting the statutory requirements, the claim
theory to make the defendant aware of the conduct          cannot be frivolous. The Legislature's goal was to
that is at issue. Palacios recognized that an expert       deter baseless claims, not to block earnest ones.
report *631 does not require litigation-ready evid-        Potts demonstrated to the trial court that at least

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392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

one of her alleged theories—vicarious liabil-                   It may be difficult or impossible for a claimant
ity—had expert support. She cleared the first              to know every viable liability theory within 120
hurdle, and the appeals court correctly recognized         days of filing suit, and the Act reflects this reality.
her right to have the entire case move forward. 355        It strictly limits discovery until expert reports have
S.W.3d at 693.                                             been provided, and we have held that the statute's
                                                           plain language prohibits presuit depositions author-
V. Efficient and Practical Litigation                      ized under Rule 202 of the Texas Rules of Civil
     Certified EMS argues that this holding will           Procedure. See TEX. CIV. PRAC. & REM.CODE §
prolong litigation by forcing defendants to defend         74.351(s); TEX.R. CIV. P. 202; In re Jorden, 249
meritless claims. For two reasons, we disagree.            S.W.3d at 418. The Act requires the expert report to
First, if there is at least one valid theory, the de-      summarize the expert's opinions “as of the date of
fendant will be engaged in further litigation regard-      the report,” recognizing that those opinions are sub-
less of the merits of the remaining theories. De-          ject to further refinement. Id. § 74.351(r)(6). Dis-
fending those theories would not be unduly burden-         covery can reveal facts supporting additional liabil-
some. The converse is not true. To require an expert       ity theories, and the Act does not prohibit a
report for each and every theory would entangle the        claimant from amending her petition accordingly.
courts and the parties in collateral fights about in-      Under Certified EMS's reasoning, a claimant would
tricacies of pleadings rather than the merits of a         have to serve an expert report each time a new the-
cause of action, creating additional expense and           ory is discovered. Not only would that be imprac-
delay as trial and appellate courts parse theories         tical, it would prohibit altogether those theories as-
that could be disposed of more simply through oth-         serted more than 120 days after the original petition
er means as the case progresses. Cf. Scoresby, 346         was filed—effectively eliminating a claimant's abil-
S.W.3d at 549 (applying a “lenient standard” to a          ity to add newly discovered theories. See id. §
plaintiff's right to cure a deficient report, noting       74.351(a) (requiring that expert report be filed “not
that approach “avoids the expense and delay of             later than the 120th day after the date the original
multiple interlocutory appeals and assures a               petition was filed”). We see no indication that the
claimant a fair opportunity to demonstrate that his        Legislature intended such a result.
claim is not frivolous”).
                                                               [5] In sum, an expert report that adequately ad-
     This leads to our second point. The expert re-        dresses at least one pleaded liability theory satisfies
port requirement is a threshold mechanism to dis-          the statutory requirements, and the trial court must
pose of claims lacking merit, but reports are not the      not dismiss in such a case. To the extent other cases
only means to address weak subsets of those                hold differently, we disapprove of them.
claims. *632 The original and amended petitions
inform a defendant of the claims against it and limit      VI. Gardner v. U.S. Imaging, Inc., 274 S.W.3d
what a plaintiff may argue at trial. Discovery al-         669 (Tex. 2008) (per curiam)
lows a claimant to refine her pleadings to abandon              Finally, we address Certified EMS's argument
untenable theories and pursue supported ones. Sum-         that Gardner, precludes the result we reach today.
mary judgment motions permit trial courts to dis-          In Gardner, we stated that “[w]hen a party's alleged
pose of claims that lack evidentiary support. But          health care liability is purely vicarious, a report that
while a full development of all liability theories         adequately implicates the actions of that party's
may be required for pretrial motions or to convince        agents or employees is sufficient.” Gardner v. U.S.
a judge or jury during trial, there is no such require-    Imaging, Inc., 274 S.W.3d 669, 671–72 (Tex.2008)
ment at the expert report stage. See Palacios, 46          (per curiam). Certified EMS argues that because
S.W.3d at 879.                                             Potts's theories are not purely vicarious, Gardner

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                                                                                     Page 9
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298
(Cite as: 392 S.W.3d 625)

implies that each must be addressed in an expert re-
port.

     [6] We disagree that Gardner compels such a
conclusion. Our statement distinguished between
expert reports required for vicarious liability
claims, in which merely implicating the agent's
conduct is sufficient, and those required for direct
ones, in which the employer's conduct must be im-
plicated. But we did not address the effect of such a
report in a claim involving both vicarious and direct
liability. To clarify, when a health care liability
claim involves a vicarious liability theory, either
alone or in combination with other theories, an ex-
pert report that meets the statutory standards as to
the employee is sufficient to implicate the employ-
er's conduct under the vicarious theory. And if any
liability theory has been adequately covered, the
entire case may proceed.

VII. Conclusion
    Because Potts's reports sufficiently addressed
one liability theory, the trial court *633 correctly
denied the motion to dismiss. We affirm the court
of appeals' judgment. TEX.R.APP. P. 60.2(a).

Tex.,2013.
Certified EMS, Inc. v. Potts
392 S.W.3d 625, 56 Tex. Sup. Ct. J. 298

END OF DOCUMENT

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                                                                                                           Page 1
Not Reported in S.W.3d, 2014 WL 538815 (Tex.App.-Austin)
(Cite as: 2014 WL 538815 (Tex.App.-Austin))

                                                           Dr. Chadha told her to take prednisone to treat the
Only the Westlaw citation is currently available.          symptoms that she was experiencing in her hands,
                                                           hips, and neck. Dr. Chadha also mentioned the el-
SEE TX R RAP RULE 47.2 FOR DESIGNATION                     evated sedimentation rate. At the end of the con-
AND SIGNING OF OPINIONS.                                   sultation, Dr. Chadha asked Sharon to call him and
                                                           let him know how she was responding to the medic-
MEMORANDUM OPINION
                                                           ation. Sharon did not call. Approximately one year
          Court of Appeals of Texas,                       later, Sharon went to the emergency room because
                    Austin.                                she was experiencing vision loss. During her treat-
 Anurekha CHADHA, M.D. and Austin Regional                 ment, Sharon was diagnosed with temporal arteritis.
           Clinic, P.A., Appellants                        As a result of her condition, Sharon is now legally
                      v.                                   blind.
 Sharon ROTHERT and Fred Rothert, Appellees.
                                                                Subsequent to Sharon receiving her diagnosis,
              No. 03–13–00153–CV.                          the Rotherts filed suit against Austin Regional.
                   Feb. 5, 2014.                           After the Rotherts filed an expert report, see Tex.
                                                           Civ. Prac. & Rem.Code § 74.351 (requiring
From the District Court of Travis County, 201st Ju-        claimant in health care claim to file expert report),
dicial District, No. D–1–Gn–12–001752, Honorable           Austin Regional asserted that the report was defi-
Lora J. Livingston, Judge Presiding.                       cient and not a good faith effort to comply with the
Michelle M. Cheng, William O. Whitehurst, Eu-              governing statutory framework, id. § 74.351(c)
gene W. Brees, II, Whitehurst, Harkness, Brees &           (explaining that report may be challenged if ele-
Cheng, P.C., Austin, TX, for appellee.                     ments of report are deficient). Accordingly, Austin
                                                           Regional asked the district court to dismiss the
Beth Harkins Miller, Ballard & Simmons, LLP,               case. Id. § 74.351(b) (stating that if expert report
Austin, TX, for appellant.                                 has not been timely served, trial court must dismiss
                                                           claim if defendant files motion seeking dismissal), (
Before Justices PURYEAR, ROSE, and GOOD-                   l ) (allowing court to grant motion challenging ad-
WIN.                                                       equacy of report if “report does not represent good
                                                           faith effort to comply with the definition of an ex-
                                                           pert report”). After considering Austin Regional's
            MEMORANDUM OPINION                             motion and the responses by the Rotherts, the dis-
DAVID PURYEAR, Justice.                                    trict court overruled Austin Regional's objections to
    *1 Sharon and Fred Rothert filed a health-             the report and denied its motion to dismiss. Austin
care-liability claim against Anurekha Chadha,              Regional appeals the order of the district court. See
M.D., and Austin Regional Clinic, P.A.                     id. § 51.014(a)(9) (authorizing interlocutory appeal
(cumulatively Austin Regional). In June 2010,              of denial of motion to dismiss for failure to file ex-
Sharon went to see Dr. Chadha regarding pain in            pert report); Ogletree v. Matthews, 262 S.W.3d
her hands, hips, and neck. In the course of treat-         316, 320–21 (Tex.2007) (discussing statutory pro-
ment, Dr. Chadha ordered an erythrocyte sediment-          visions governing appeals of rulings challenging
ation rate test for inflammation. The test revealed        expert reports).
that Sharon had an elevated sedimentation rate.
Sharon returned to Dr. Chadha one month later, and              In its appeal, Austin Regional challenges the
                                                           district court's ruling regarding its objections to the

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                                                                                                          Page 2
Not Reported in S.W.3d, 2014 WL 538815 (Tex.App.-Austin)
(Cite as: 2014 WL 538815 (Tex.App.-Austin))

adequacy of the expert report and its accompanying         standard of care. Instead, Austin Regional limits its
motion to dismiss. We review a trial court's ruling        challenge to the causation element.
regarding the adequacy of an expert report for an
abuse of discretion. TTHR Ltd. P'ship v. Moreno,                In his report, Dr. Rushing stated that the stand-
401 S.W.3d 41, 44 (Tex.2013); see also Bowie               ard of care in these circumstances “required that
Mem'l Hosp. v. Wright, 79 S.W.3d 48, 52                    Dr. Chadha follow-up with the patient regarding the
(Tex.2002) (describing abuse-of-discretion stand-          elevated sedimentation rate in 2010.” Specifically,
ard).                                                      the report opined that Dr. Chadha “should have
                                                           called [Sharon] and had her return for a follow-up”
     An expert report serves two purposes: it in-          because “Dr. Chadha knew or should have known
forms the defendant about the specific conduct that        that a sedimentation rate of 52 mm in one hour is a
the claimant believes to be improper, and it               major abnormality and requires a comprehensive
provides “ ‘a basis for the trial court to conclude        evaluation to try to find the cause.” In fact, Dr.
that the claims have merit.’ “ Certified EMS, Inc. v.      Rushing related that Dr. Chadha should have per-
Potts, 392 S.W.3d 625, 630 (Tex.2013) (quoting             formed “a comprehensive workup to determine the
American Transitional Care Ctrs. of Tex., Inc. v.          cause of the elevated sedimentation rate, including
Palacios, 46 S.W.3d 873, 879 (Tex.2001)). Under            an examination of the temporal arteries; a thorough
the governing statute, an expert report is “a written      inquiry of [Sharon] regarding the presence of other
report by an expert that provides a fair summary of        symptoms signaling temporal arteritis”; and a tem-
the expert's opinions as of the date of the report re-     poral artery biopsy “if necessary and if [Sharon]'s
garding applicable standards of care, the manner in        sedimentation rate continued to stay elevated.” Fur-
which the care rendered by the physician or health         thermore, Dr. Rushing explained that temporal ar-
care provider failed to meet the standards, and the        teritis can be present for months and that the dis-
causal relationship between that failure and the in-       ease and symptoms can evolve over time. Accord-
jury, harm, or damages claimed.” Tex. Civ. Prac. &         ingly, Dr. Rushing stated that the elevated sedi-
Rem.Code § 74.351(r)(6). If a report satisfies these       mentation rate was, in his opinion, an early symp-
requirements, “even if as to one theory only,” the         tom of temporal arteritis. In light of the above, Dr.
claimant may proceed with his “suit against the            Rushing related that it “was more likely than not”
physician or health care provider.” Potts, 392             that a thorough “workup ... would have revealed
S.W.3d at 630. In determining whether the report is        that the cause of the elevated sedimentation rate
sufficient, courts “look no further than the report it-    was temporal arteritis,” that a follow up would have
self.” HEB Grocery Co., L.L.P. v. Farenik, 243             lead to a diagnosis of and treatment for temporal ar-
S.W.3d 171, 174 (Tex.App.-San Antonio 2007, no             teritis, and that it was “more likely than not” that
pet.). Moreover, the report may be informal, mean-         early treatment would have prevented Sharon from
ing “that the information in the report does not have      suffering any visual loss. Finally, Dr. Rushing
to meet the same requirement as the evidence               stated that Dr. Chadha's actions “proximately
offered in a summary judgment proceeding,” id.,            caused” Sharon to suffer visual loss.
and the report need not “rule out every possible
cause of the injury, harm, or damages claimed,”                 Given the language of the report, we cannot
Baylor Med. Ctr. v. Wallace, 278 S.W.3d 552, 562           conclude that the district court abused its discretion
(Tex.App.-Dallas 2009, no pet.).                           by determining that the report provided the requis-
                                                           ite causal relationship. See Farenik, 243 S.W.3d at
    *2 In this case, Austin Regional does not chal-        174 (explaining that report must explain basis of
lenge the qualification of the expert preparing the        expert's statements “to link his conclusions to the
report, Dr. Life Rushing, and does not challenge the       facts”). For that reason, we also cannot conclude

                           © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                      Page 3
Not Reported in S.W.3d, 2014 WL 538815 (Tex.App.-Austin)
(Cite as: 2014 WL 538815 (Tex.App.-Austin))

that the district court abused its discretion by over-
ruling Austin Regional's objections to the expert re-
port or by denying Austin Regional's motion to dis-
miss. Accordingly, we overrule Austin Regional's
issue on appeal and affirm the district court's order.

Tex.App.-Austin,2014.
Chadha v. Rothert
Not Reported in S.W.3d, 2014 WL 538815
(Tex.App.-Austin)

END OF DOCUMENT

                           © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                          Page 1
328 S.W.3d 637
(Cite as: 328 S.W.3d 637)

                                                               30XVI Review
                                                                  30XVI(H) Discretion of Lower Court
            Court of Appeals of Texas,                                  30k960 Rulings on Motions Relating to
                      Dallas.                               Pleadings
 CHRISTIAN CARE CENTERS, INC., Appellant,                                   30k960(1) k. In general. Most Cited
                        v.                                  Cases
Jane GOLENKO, Jean Miller, and Judy Miller, In-                 Appellate court reviews a trial court's order on
dividually and on Behalf of The Estate of Nell Con-         a motion to dismiss a health care liability claim for
            nally, Deceased, Appellees.                     an abuse of discretion.

             No. 05–09–01521–CV.                            [2] Appeal and Error 30        946
                  Nov. 4, 2010.
         Rehearing Overruled Jan. 6, 2011.                  30 Appeal and Error
                                                               30XVI Review
Background: Estate of deceased nursing home res-                   30XVI(H) Discretion of Lower Court
ident, who died after hitting her head when pushed                    30k944 Power to Review
to the floor by another resident who had                                    30k946 k. Abuse of discretion. Most
Alzheimer's disease, brought health care liability          Cited Cases
action against nursing home. The 192nd Judicial                 A trial court abuses its discretion when it acts
District Court, Dallas County, Craig Smith, J.,             in an arbitrary or unreasonable manner without ref-
denied nursing home's motion to dismiss. Nursing            erence to any guiding rules or principles.
home filed interlocutory appeal.
                                                            [3] Appeal and Error 30        946
Holdings: The Court of Appeals, Fillmore, J., held
that:                                                       30 Appeal and Error
(1) doctor was qualified to testify as an expert re-           30XVI Review
garding assessment and care of individuals with                    30XVI(H) Discretion of Lower Court
Alzheimer's disease;                                                  30k944 Power to Review
(2) nurse was qualified to testify as an expert re-                         30k946 k. Abuse of discretion. Most
garding standard of care for nursing home staff;            Cited Cases
(3) nursing home administrator was qualified to                  A trial court abuses its discretion when it
testify as an expert regarding standard of care for         clearly fails to analyze and determine the law cor-
admission of a patient with Alzheimer's disease;            rectly or applies the law incorrectly to the facts.
(4) doctor was qualified to testify to causation; and
(5) expert reports constituted good faith efforts to        [4] Health 198H       804
comply with requirements for expert reports in
                                                            198H Health
health care liability actions.
                                                                 198HV Malpractice, Negligence, or Breach of
    Affirmed.                                               Duty
                                                                  198HV(G) Actions and Proceedings
                  West Headnotes                                      198Hk804 k. Affidavits of merit or merit-
                                                            orious defense; expert affidavits. Most Cited Cases
[1] Appeal and Error 30         960(1)                          In determining sufficiency of expert's report in
                                                            health care liability action, the court may not look
30 Appeal and Error
                                                            beyond the report itself because all information rel-

                            © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                             Page 2
328 S.W.3d 637
(Cite as: 328 S.W.3d 637)

evant to the inquiry should be contained with the               Not every licensed doctor is automatically
document's four corners. V.T.C.A., Civil Practice &         qualified to testify on every medical question in a
Remedies Code § 74.351.                                     health care liability action. V.T.C.A., Civil Practice
                                                            & Remedies Code § 74.402(b).
[5] Appeal and Error 30         714(5)
                                                            [8] Evidence 157        538
30 Appeal and Error
   30X Record                                               157 Evidence
       30X(N) Matters Not Apparent of Record                    157XII Opinion Evidence
              30k714 Matters Appearing Otherwise                   157XII(C) Competency of Experts
Than by Record                                                          157k538 k. Due care and proper conduct
             30k714(5) k. Briefs. Most Cited Cases          in general. Most Cited Cases
     Appellate court cannot consider documents at-               Expert qualifications should not be too nar-
tached to a brief if they are not formally included in      rowly drawn in health care liability litigation;
the record on appeal.                                       rather, the trial court should determine whether the
                                                            proffered expert has knowledge, skill, experience,
[6] Evidence 157       538                                  training, or education regarding the specific issue
                                                            before the court which would qualify the expert to
157 Evidence
                                                            give an opinion on that particular subject.
    157XII Opinion Evidence
                                                            V.T.C.A., Civil Practice & Remedies Code §
       157XII(C) Competency of Experts
                                                            74.402(b).
            157k538 k. Due care and proper conduct
in general. Most Cited Cases                                [9] Evidence 157        538
     Doctor licensed to practice medicine in the
state and board certified in internal medicine,             157 Evidence
rheumatology, and geriatrics was qualified to testi-           157XII Opinion Evidence
fy as an expert regarding assessment and care of in-               157XII(C) Competency of Experts
dividuals with Alzheimer's disease in health care li-                   157k538 k. Due care and proper conduct
ability action brought against nursing home by es-          in general. Most Cited Cases
tate of nursing home patient who died after hitting             In determining qualifications to testify as an
her head when pushed to the floor by another resid-         expert in health care liability litigation, the focus is
ent who had Alzheimer's disease; doctor had treated         on whether the expert's expertise goes to the very
patients with similar conditions and had been in-           matter on which he is to give an opinion. V.T.C.A.,
volved in the assessment of such patients for trans-        Civil Practice & Remedies Code § 74.402(b).
fer and admission to various facilities, and doctor
had also supervised nurses in the care and assess-          [10] Evidence 157         538
ment of such patients. V.T.C.A., Civil Practice &
                                                            157 Evidence
Remedies Code § 74.402(b).
                                                               157XII Opinion Evidence
[7] Evidence 157       538                                         157XII(C) Competency of Experts
                                                                        157k538 k. Due care and proper conduct
157 Evidence                                                in general. Most Cited Cases
   157XII Opinion Evidence                                       Nurse certified in gerontological care and
      157XII(C) Competency of Experts                       wound care was qualified to testify as an expert re-
            157k538 k. Due care and proper conduct          garding the standard of care applicable to nursing
in general. Most Cited Cases                                staff at nursing home in health care liability action

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                                                                                                           Page 3
328 S.W.3d 637
(Cite as: 328 S.W.3d 637)

brought against nursing home by estate of nursing           tion brought against nursing home by estate of
home patient who died after hitting her head when           nursing home patient who died after hitting her
pushed to the floor by another resident who had             head when pushed to the floor by another resident
Alzheimer's disease; although nurse had never been          who had Alzheimer's disease. V.T.C.A., Civil Prac-
a full-time employee of a nursing home, nurse had           tice & Remedies Code §§ 74.351(r)(5)(C),
worked as a nurse and nursing supervisor and edu-           74.403(a).
cated students about caring for Alzheimer's pa-
tients, administering medication, transcribing or-          [13] Evidence 157        544
ders, supervising residents, and notifying physi-
                                                            157 Evidence
cians of resident behaviors.
                                                                157XII Opinion Evidence
[11] Evidence 157       538                                        157XII(C) Competency of Experts
                                                                       157k544 k. Cause and effect. Most Cited
157 Evidence                                                Cases
    157XII Opinion Evidence                                      Doctor licensed to practice medicine in the
       157XII(C) Competency of Experts                      state and board certified in internal medicine,
            157k538 k. Due care and proper conduct          rheumatology, and geriatrics was qualified to testi-
in general. Most Cited Cases                                fy regarding causation in health care liability action
     Certified nursing home administrator was qual-         brought against nursing home by estate of nursing
ified to testify as an expert regarding the standard        home patient who died after hitting her head when
of care for the admission of a patient with                 pushed to the floor by another resident who had
Alzheimer's disease to a nursing facility in health         Alzheimer's disease; doctor regularly engaged in
care liability action brought against nursing home          the diagnosis and treatment of patients with
by estate of nursing home patient who died after            Alzheimer's disease, doctor had had patients with
hitting her head when pushed to the floor by anoth-         violent behavior who represented a threat to others
er resident who had Alzheimer's disease; although           as well as themselves, and doctor had knowledge of
administrator was not a licensed health care pro-           the admission assessment process and the care
vider and did not practice health care, administrator       needed for these patients. V.T.C.A., Civil Practice
was licensed in nursing home administration and             & Remedies Code §§ 74.351(r)(5)(C), 74.403(a);
managed a nursing home for eight years, adminis-            Rules of Evid., Rule 702.
trator had knowledge of rules and regulations ap-
plicable to nursing facilities, and administrator           [14] Health 198H        804
taught and performed consulting work in the field
                                                            198H Health
of long-term care. V.T.C.A., Civil Practice & Rem-
                                                                 198HV Malpractice, Negligence, or Breach of
edies Code § 74.402.
                                                            Duty
[12] Evidence 157       544                                        198HV(G) Actions and Proceedings
                                                                      198Hk804 k. Affidavits of merit or merit-
157 Evidence                                                orious defense; expert affidavits. Most Cited Cases
   157XII Opinion Evidence                                       To constitute a good faith effort to comply with
      157XII(C) Competency of Experts                       the statutory requirements for expert reports in
          157k544 k. Cause and effect. Most Cited           health care liability actions, an expert report must
Cases                                                       inform the defendant of the specific conduct called
    Nurse and nursing home administrator who                into question and provide a basis for the trial court
were not physicians were not qualified to render an         to determine that the claims have merit; it does not
opinion about causation in health care liability ac-        need to marshal all of the plaintiff's proof, but it

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328 S.W.3d 637
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must include a fair summary of the expert's opinion         198H Health
on each of the elements identified in the statute,               198HV Malpractice, Negligence, or Breach of
i.e., the applicable standard of care, the breach or        Duty
deviation from the standard of care, and the causal                198HV(G) Actions and Proceedings
relationship between the breach and the injury.                        198Hk804 k. Affidavits of merit or merit-
V.T.C.A., Civil Practice & Remedies Code §                  orious defense; expert affidavits. Most Cited Cases
74.351.                                                          Doctor's expert report's opinion on causation
                                                            was not improperly conclusory in health care liabil-
[15] Health 198H         804                                ity action brought against nursing home by estate of
                                                            nursing home patient who died after hitting her
198H Health
                                                            head when pushed to the floor by another resident
     198HV Malpractice, Negligence, or Breach of
                                                            who had Alzheimer's disease; report stated that oth-
Duty
                                                            er resident was allegedly aggressive prior to and
       198HV(G) Actions and Proceedings
                                                            after being admitted to nursing home, standard of
           198Hk804 k. Affidavits of merit or merit-
                                                            care required nursing home to properly assess and
orious defense; expert affidavits. Most Cited Cases
                                                            report other resident's condition and properly super-
     Expert filing expert report in health care liabil-
                                                            vise him, despite foreseeable risk, nursing home ad-
ity action must explain the basis of his statements
                                                            mitted other resident and failed to supervise him,
to link his conclusions to the facts. V.T.C.A., Civil
                                                            and while other resident was unsupervised, he in-
Practice & Remedies Code § 74.351.
                                                            jured decedent and caused her death. V.T.C.A.,
[16] Health 198H         804                                Civil Practice & Remedies Code § 74.351.

198H Health                                                 *640 Delta Sue Best, Allison L. Spruill, Best &
     198HV Malpractice, Negligence, or Breach of            Spruill, P.C., Austin, TX, Appellant.
Duty
                                                            Michael Tate Barkley, Sugar Land, TX, Susan Cas-
       198HV(G) Actions and Proceedings
                                                            sidy Cooley, Schell, Mitchell & Cooley LLP, Ad-
           198Hk804 k. Affidavits of merit or merit-
                                                            dison, TX, Roger Arash Farahmand, Farahmand
orious defense; expert affidavits. Most Cited Cases
                                                            Law Firm, P.C., Dallas, TX, R. Alan York, Good-
     Expert reports filed by estate of nursing home
                                                            win Pappas Langley Ronquillo, LLP, Houston, TX,
resident, in action against nursing home when res-
                                                            for Appellees.
ident died after hitting her head when pushed to the
floor by another resident who had Alzheimer's dis-
ease, adequately informed nursing home of the spe-          Before Justices FITZGERALD, MURPHY, and
cific conduct called into question and provided a           FILLMORE.
basis for trial court to determine that the claims had
merit; experts identified nursing home's failure to
                                                                                 OPINION
properly assess condition of other resident and to
                                                            Opinion By Justice FILLMORE.
properly assess, supervise, medicate, and care for
                                                                 This interlocutory appeal follows the trial
such patient, and doctor testified that nursing
                                                            court's refusal to dismiss the health care liability
home's failure to properly care for resident with
                                                            claims of appellees Jane Golenko, Jean Miller, and
Alzheimer's disease presented a danger to and
                                                            Judy Miller, Individually and on behalf of the Es-
caused death of deceased resident. V.T.C.A., Civil
                                                            tate of Nell Connally, against Christian Care Cen-
Practice & Remedies Code § 74.351.
                                                            ters, Inc. Christian Care complains the trial court
[17] Health 198H         804                                erred by denying its motion to dismiss because ap-

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328 S.W.3d 637
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pellees' experts are not qualified to render opinions       render opinions concerning the applicable standard
contained in their reports and the reports do not           of care and causation and the expert reports do not
constitute good faith efforts to comply with chapter        constitute good faith efforts to meet the require-
74 of the civil practice and remedies code. We af-          ments of section 74.351 of the civil practice and
firm the trial court's order.                               remedies code. The trial court denied the motion to
                                                            dismiss, and Christian Care brought this inter-
                     Background                             locutory appeal.
     Jay Haberman suffered from early-onset
Alzheimer's disease. After having a seizure at                              Standard of Review
home, Haberman was admitted to Centennial Med-                   [1][2][3] We review a trial court's order on a
ical Center. While he was hospitalized, Haberman            motion to dismiss a health care liability claim for
allegedly exhibited aggressive and combative beha-          an abuse of discretion. Am. Transitional Care Ctrs.
vior that required restraints and supervision by a          of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877
personal attendant. Haberman was subsequently               (Tex.2001). A trial court abuses its discretion when
transferred to Christian Care's Alzheimer's Unit.           it acts in an arbitrary or unreasonable manner
Haberman allegedly continued to exhibit aggressive          without reference to any guiding rules or principles.
behavior at *641 Christian Care. Appellees assert           Bowie Mem'l Hosp. v. Wright, 79 S.W.3d 48, 52
that the day following his admission to Christian           (Tex.2002) (per curiam). A trial court abuses its
Care, Haberman was unsupervised in the dining               discretion when it clearly fails to analyze and de-
room of the facility. Nell Connally, a resident of          termine the law correctly or applies the law incor-
Christian Care, was also in the dining room using           rectly to the facts. Petty v. Churner, 310 S.W.3d
her “merry walker,” which is a walker that includes         131, 134 (Tex.App.-Dallas 2010, no pet.)
a seat for the user. Haberman allegedly grabbed the
walker and turned it over, causing Connally to hit                                 Analysis
her head on the floor. Connally later died from a                [4] Within 120 days of filing a health care liab-
subdural hematoma caused by the fall.                       ility claim, a plaintiff must serve an expert report
                                                            with the expert's curriculum vitae on each defend-
     Appellees brought a wrongful death action              ant against whom a liability claim is asserted. TEX.
against Haberman. In their second amended peti-             CIV. PRAC. & REM.CODE ANN. § 74.351(a)
tion, appellees also asserted health care liability         (West Supp. 2010). An “expert report” is a:
claims against Christian Care. Appellees alleged
Christian Care was negligent in its care of Connally          written report by an expert that provides a fair
by failing to properly evaluate Haberman prior to             summary of the expert's opinions as of the date of
admitting him to Christian Care, failing to manage,           the report regarding applicable standards of care,
restrain, and evaluate Haberman following his ad-             the manner in which the care rendered by the
mission, and failing to protect Connally from                 physician failed to meet the standards, and the
Haberman. Appellees timely served Christian Care              causal relationship between that failure and the
with expert reports by Dr. Lige Rushing, a physi-             injury, harm, or damages claimed.
cian who is board certified in internal medicine,
                                                                Id. § 74.351(r)(6). The trial court is required to
rheumatology, and geriatrics, Suzanne Frederick, a
                                                            grant a motion challenging the adequacy of a report
registered nurse, and Sid Gerber, a licensed nursing
                                                            only if the report does not constitute an objective
home administrator.
                                                            good faith effort to comply with the statutory re-
    Christian Care objected to the expert reports           quirements. Id. § 74.351(b)(2), (l ). In determining
and moved to dismiss appellees' claims on the               a report's sufficiency, the court may not look bey-
grounds that appellees' experts are not qualified to        ond the report itself because all information relev-

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ant to the inquiry should be contained with the doc-        asserts that, although Dr. Rushing is board certified
ument's four corners. Palacios, 46 S.W.3d at 878.           in internal medicine and geriatrics, he does not
                                                            have the “nursing home experience” to testify as to
               *642 Standard of Care                        the standard of care applicable to nurses and nurses
    Christian Care first argues that appellees' ex-         aides employed in nursing facilities. Finally, Chris-
perts are not qualified to render an opinion as to the      tian Care contends Dr. Rushing has never worked
standard of care applicable to Christian Care. An           for a nursing home screening patients for admission
expert is qualified to render an opinion regarding          to a certified Alzheimer's unit and, therefore, is not
whether a health care provider departed from the            qualified to opine about Christian Care's decision to
accepted standards of care if the expert:                   admit Haberman.

  (1) is practicing health care in a field of practice           [5] Christian Care asserts we should consider
  that involves the same type of care or treatment          deposition testimony given by Dr. Rushing in an-
  as that delivered by the defendant health care            other case to “disqualify” him from opining about
  provider, if the defendant health care provider is        issues relating to nursing care in a certified
  an individual, at the time the testimony is given         Alzheimer's unit. We question whether a defendant
  or was practicing that type of health care at the         can rely on evidence not contained within the ex-
  time the claim arose;                                     pert's reports to attack the expert's qualifications.
                                                            See Mem'l Hermann Healthcare Sys. v. Burrell, 230
  (2) has knowledge of accepted standards of care
                                                            S.W.3d 755, 758 (Tex.App.-Houston [14th Dist.]
  for health care providers for the diagnosis, care or
                                                            2007, no pet.) (declining to consider excerpts from
  treatment of the illness, injury, or condition in-
                                                            expert's deposition in other cases, affidavit of an-
  volved in the claim; and
                                                            other doctor, and standards promulgated by Infec-
  (3) is qualified on the basis of training or experi-      tious Diseases Society of America because
  ence to offer an expert opinion regarding those           “analysis of the qualifications of an expert under
  accepted standards of health care.                        section 74.351 is limited to the four corners of the
                                                            expert's report and curriculum vitae”); In re
     TEX. CIV. PRAC. & REM.CODE ANN. §                      Windisch,        138 S.W.3d 507,      511
74.402(b) (West 2005). To assist the court in mak-          (Tex.App.-Amarillo 2004, orig. proceeding)
ing a determination as to whether the expert is qual-       (declining to consider expert's testimony given at
ified on the basis of training or experience, the trial     hearing on motion to dismiss because determination
court must consider whether, at the time the claim          of expert's “qualifications to provide an expert re-
arose or at the time the testimony is given, the wit-       port must be made on the basis of the contents of
ness: (1) is certified by a licensing agency or a pro-      the report and curriculum vitae”); see also Mosely
fessional certifying agency, or has other substantial       v. Mundine, 249 S.W.3d 775, 779 (Tex.App.-Dallas
training or experience, in the area of health care rel-     2008, no pet.) (analysis of expert's qualifications
evant to the claim; and (2) is actively practicing          limited to expert's report and curriculum vitae).
health care in rendering health care services relev-        However, we need not reach the issue because the
ant to the claim. Id. § 74.402(c).                          testimony relied*643 upon by Christian Care, while
                                                            attached to its brief, is not in the record. We cannot
                     Dr. Rushing                            consider documents attached to a brief “if they are
    Christian Care contends Dr. Rushing is not              not formally included in the record on appeal.”
qualified to testify about the applicable standard of       Cantu v. Horany, 195 S.W.3d 867, 870
care because he is not actively practicing health           (Tex.App.-Dallas 2006, no pet.).
care in an area relevant to the claim. Christian Care

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     [6] We, therefore, turn to whether Dr. Rush-           records and assess his condition. Dr. Rushing ques-
ing's report and curriculum vitae demonstrate he is         tions the nursing staffs' failure to provide one-
qualified to opine about the applicable standard of         on-one supervision of Haberman, including the fail-
care. Dr. Rushing is licensed to practice medicine          ure to adequately supervise Haberman in the dining
in Texas and is board certified in internal medicine,       room at the time he turned over Connally's walker,
rheumatology, and geriatrics. He is actively en-            and failure to report Haberman's clinical status and
gaged in the practice of these three specialties and        behavior to the director of nurses or the adminis-
is an attending physician at Presbyterian Hospital in       trator of the facility.
Dallas. He has “served as a primary care physician
for more than 10,000 patients in hospitals, nursing              [7][8][9] Not every licensed doctor is automat-
homes, assisted living facilities, and patients who         ically qualified to testify on every medical question.
had Alzheimer's disease.” He regularly engages in           Broders v. Heise, 924 S.W.2d 148, 152 (Tex.1996).
the diagnosis and treatment of patients with                However, “expert qualifications should not be too
Alzheimer's disease. He has had patients with viol-         narrowly drawn.” Larson v. Downing, 197 S.W.3d
ent behavior similar to Haberman's behavior who             303, 305 (Tex.2006) (per curiam). Rather, the trial
represented a threat to others as well as themselves        court should determine whether the proffered ex-
and patients who required geriatric psychiatric care.       pert has “knowledge, skill, experience, training, or
He has “worked closely with and written orders for,         education regarding the specific issue before the
and supervised the execution of these orders for the        court which would qualify the expert to give an
care and treatment of [his] patients and supervised         opinion on that particular subject.” Broders, 924
the nurses (registered nurses, licensed vocational          S.W.2d at 153–54; see Chester v. El–Ashram, 228
nurses, and [certified nursing assistants] ), who           S.W.3d 909, 912 (Tex.App.-Dallas 2007, no pet.).
have been assigned to provide nursing care, includ-         The focus is on whether the expert's expertise goes
ing assessment for transfer and admission assess-           to the very matter on which he is to give an opin-
ments for [his] patients under similar circum-              ion. Broders, 924 S.W.2d at 153.
stances” as Haberman. As a result, he is “intimately
                                                                 *644 The essential claim in this case involves
familiar with the specific standards of care that are
                                                            the standard of care applicable to the assessment
required of the facilities and caregivers and the
                                                            and care of individuals with Alzheimer's disease.
physicians who provide care and treatment for pa-
                                                            Thus, the relevant question is not the narrow issue
tients” such as Haberman.
                                                            of whether Dr. Rushing has worked in a nursing
     According to Dr. Rushing, the standard of care         home or served on a committee evaluating potential
required Christian Care and its staff to “properly as-      patients for admission to a nursing home. Rather, it
sess Mr. Haberman's needs prior to his admission to         is the broader issue of whether Christian Care and
be certain that they indeed could meet his needs.”          its staff should have recognized Haberman's condi-
Dr. Rushing specifically questions Christian Care's         tion was such that Christian Care could not provide
“failure to properly assess Mr. Haberman prior to           the care Haberman needed or could not protect its
accepting him for transfer” and opines that if “a           other residents from Haberman. Dr. Rushing's re-
proper assessment had been done, it would have              port and curriculum vitae show he is certified in
been obvious that the Christian Care Center could           geriatrics and internal medicine. He has treated pa-
not meet Mr. Haberman's needs i.e. one-on-one su-           tients with conditions similar to Haberman's condi-
pervision, restraints, and intensive psychiatric care       tion and has been involved in the assessment of
and treatment that Mr. Haberman required.” Fur-             these patients for transfer and admission to various
ther, after Haberman's transfer, the nursing staff          facilities. He has also supervised nurses in the care
had the opportunity to review Haberman's medical            and assessment of his patients. The trial court did

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not abuse it discretion by finding Dr. Rushing is           his admission. Because Dr. Rushing and Gerber are
qualified to testify about the standard of care ap-         qualified to opine about the standard of care applic-
plicable to assessing a patient with a condition sim-       able to Christian Care in deciding to admit Haber-
ilar to Haberman's for admission into a particular          man into the facility, we need not decide whether
facility and the needs of the patient once admitted.        Frederick was also qualified to do so. See
See Baylor Med. Ctr. at Waxahachie v. Wallace,              TEX.R.APP. P. 47.1. Turning to the nursing staff,
278 S.W.3d 552, 558 (Tex.App.-Dallas 2009, no               Frederick opined that the standard of care required
pet.) (physician who stated he was familiar with            the nurses at Christian Care to accurately transcribe
standard of care for nurses and for prevention and          Haberman's medications onto the physician's or-
treatment of injury involved in claim qualified to          ders, have a verification system to ensure the accur-
opine about standard of care for nurses); IHS Ac-           acy of the orders and the medication administration
quisition No. 140 Inc. v. Travis, No.                       record, administer only the medications prescribed
13–07–00481–CV, 2008 WL 1822780, at *5                      by the physician, contact the physician to verify the
(Tex.App.-Corpus Christi 2008, pet. denied) (mem.           orders as written on the medication profile report,
op.) (doctor specializing in geriatrics qualified to        *645 notify the physician of Haberman's behavior,
opine about standard of care applicable to nursing          and adequately assess and supervise Haberman.
home).
                                                                 Issues relating to administering medication, as-
                  Suzanne Frederick                         sessing a patient's condition, and contacting a phys-
     [10] Christian Care next argues Frederick is not       ician about a patient's medication and condition are
qualified to testify about the applicable standard of       not unique to the care of residents in a nursing
care because she has never been a full-time em-             home. Frederick's curriculum vitae demonstrates
ployee of a nursing home, never held a job that en-         she has worked as a nurse and nursing supervisor
tailed admitting patients into a nursing home, and          and educated students about caring for Alzheimer's
does not actively practice health care in a nursing         patients, administering medication, transcribing or-
home. Frederick is a board certified gerontological         ders, supervising residents, and notifying physi-
nurse and a certified wound care nurse. She has a           cians of resident behaviors. We conclude the trial
master of science degree in nursing administration.         court did not abuse its discretion in finding Freder-
She teaches nursing students at McLennan Com-               ick was qualified to testify about the standard of
munity College and educates nursing students in             care applicable to the nursing staff at Christian
nursing home and hospital settings, including               Care.
caring for Alzheimer's patients, administering med-
ication, transcribing orders, supervising residents,                            Sidney Gerber
and notifying physicians of residents' behaviors.                [11] Christian Care contends Gerber, a licensed
From 2003 through 2005, she taught a nursing ad-            nursing home administrator, is not qualified to
ministration class at the University of Texas at Ar-        opine about the standard of care applicable to
lington. She has worked as a nursing supervisor and         Christian Care because he is not a licensed health
a staff nurse at a hospital and served as the Sub-          care provider and does not practice health care in
acute Program Director/Staff RN at a nursing home           an area relevant to appellees' claims. In determining
for seven years.                                            whether an expert is qualified on the basis of train-
                                                            ing and experience to render an opinion about the
     Frederick opined on the standard of care ap-           standard of care, a trial court must consider wheth-
plicable to Christian Care for the admission of             er, at the time the claim arose or at the time the ex-
Haberman to Christian Care and the care of Haber-           pert gave his opinion, that person (1) is certified by
man by the Christian Care nursing staff following           a licensing agency or a professional certifying

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agency, or has other substantial training or experi-        safety, professional, or administrative services
ence, in the area of health care relevant to the            provided by nursing facilities at an accredited edu-
claim; and (2) is actively practicing health care in        cation institution, (2) is serving as a consultant in
rendering health care services relevant to the claim.       safety, professional, or administrative services rel-
TEX. CIV. PRAC. & REM.CODE § 74.402(c).                     evant to nursing facilities, or (3) is licensed, certi-
However, the factors in section 74.402(c) are not           fied, or *646 registered relating to the provision of
mandatory elements that must be proved before a             safety, professional, or administrative services by
witness is qualified as an expert. Heritage Gardens         nursing facilities. See id. § 74.402(a).
Healthcare Ctr. v. Pearson, No. 05–07–00772–CV,
2008 WL 3984053, at *5 (Tex.App.-Dallas 2008,                    Appellees claim Christian Care failed to prop-
no pet.) (mem. op.). Whether Gerber is certified by         erly assess Haberman's condition prior to admitting
a licensing agency or a professional certifying             him into Christian Care's facility. Gerber is licensed
agency or is actively practicing health care are only       as a nursing facility administrator in Texas and has
two factors to be considered in determining whether         eight years of experience managing and operating
Gerber is qualified on the basis of training and ex-        nursing home facilities. He has knowledge of the
perience to offer the opinions contained in his re-         state and federal regulations governing nursing
port. Id.                                                   home facilities. As a nursing home administrator,
                                                            he worked closely with nursing home management
    Further, for purposes of determining whether            and staff. He is currently a consultant in the field of
an expert witness is qualified to opine about the           long-term care management and provides quality
standard of care applicable to a health care pro-           assurance monitoring and inspection of facilities on
vider, “practicing health care” includes:                   behalf of the facilities' management. He also assists
                                                            families of nursing home residents with long-term
  (1) training health care providers in the same            care planning and management support, including
  field as the defendant health care provider at an         the verification of care compliance, care coordina-
  accredited educational institution; or                    tion, and review of care with physicians and long-
                                                            term care facilities. He teaches classes in long-term
  (2) serving as a consulting health care provider
                                                            care management and administration to nursing
  and being licensed, certified, or registered in the
                                                            home administrator candidates at the University of
  same field as the defendant health care provider.
                                                            Texas Health Science Center and San Jacinto Col-
    TEX. CIV. PRAC. & REM.CODE ANN. §                       lege.
74.402(a). “Health care” includes any act
                                                                 In Gerber's opinion, the standard of care for a
“performed or furnished, or that should have been
                                                            nursing facility includes an assessment of the pro-
performed or furnished” by the health care provider
                                                            spective resident at the hospital prior to admission.
for, to, or on behalf of the patient. Id. §
                                                            The purpose of this assessment is for a nursing fa-
74.001(a)(10). A “health care liability claim” in-
                                                            cility professional to thoroughly and accurately as-
cludes a cause of action against the health care pro-
                                                            sess a prospective resident's medical or mental con-
vider for a departure from the standard of care for
                                                            ditions to determine whether the placement is ap-
“safety or professional or administrative services
                                                            propriate, the nursing facility's capabilities to
directly related to health care, which proximately
                                                            provide the necessary care, and the safety risks to
results in injury to or death of a claimant.” Id. §
                                                            both the resident and other residents. The standard
74.001(a)(13). Christian Care's provision of safety,
                                                            of care requires the facility to admit “only residents
professional, or administrative services to Connally
                                                            who it can assure that it has the abilities to provide
constitutes health care. Gerber is “practicing health
                                                            adequate and sufficient care by competent staff,
care” if he (1) is educating health care providers in

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328 S.W.3d 637
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owners, operators, and administration based on the          physician and is otherwise qualified to render opin-
care needs of the individual resident and in compli-        ions on that causal relationship under the Texas
ance with all standards that regulate the nursing fa-       Rules of Evidence.” TEX. CIV. PRAC. &
cility.”                                                    REM.CODE §§ 74.351(r)(5)(C); 74.403(a) (West
                                                            2005). Neither Frederick nor Gerber is a physician
     Gerber opined that Christian Care failed to            and, therefore, neither is qualified to render an
comply with the applicable standards of care by not         opinion about causation. See Petty, 310 S.W.3d at
adequately assessing Haberman prior to admission.           135.
In Gerber's opinion, if Christian Care had sent a
nurse to evaluate Haberman prior to admission, it                [13] Christian Care argues Dr. Rushing is not
would have “had a much greater understanding of             qualified to opine about causation “for the same
the significant risk of admitting Mr. Haberman into         reasons” he is not qualified to opine about the
the general population with other residents at the          standard of care. Under rule of evidence 702, the
facility, would have been prepared to manage his            expert must have knowledge, skill, experience,
aggression and violent behavior, would have taken           training, or education regarding the specific issue
steps to protect other residents from potential harm        before the court. See TEX.R. EVID. 702. As set out
inflicted by Mr. Haberman, could have refused his           above, Dr. Rushing is licensed to practice medicine
admission and acceptance to the nursing facility,           in Texas. He is board certified in internal medicine
and ultimately could have prevented Ms. Connally's          and geriatrics and is actively engaged in the prac-
death.” Finally, in Gerber's opinion, Christian Care        tice of these specialties. He regularly engages in the
failed to adhere to its own policies and procedure          diagnosis and treatment of patients with
for evaluating Haberman for placement and, if it            Alzheimer's disease. He has had patients with viol-
had done so, Haberman would not have been                   ent behavior like Haberman's behavior and who
deemed appropriate for admission under Christian            represented a threat to others as well as themselves.
Care's criteria.                                            He has knowledge of the admission assessment pro-
                                                            cess and the care needed for these patients. In his
     Gerber is licensed in nursing home administra-         opinion, it was reasonably foreseeable that Christi-
tion and managed a nursing home for eight years.            an Care could not meet Haberman's needs and that
He has knowledge of rules and regulations applic-           Haberman's behavior would likely result in injury
able to nursing facilities. He teaches and performs         to himself or others. We conclude the trial court did
consulting work in the field of long-term care. The         not err by concluding Dr. Rushing was qualified to
trial court did not abuse its discretion by finding         opine about causation.
Gerber is qualified to opine about the standard of
care for the admission of a patient with Alzheimer's                          Good Faith Effort
disease to a nursing facility.                                   Christian Care finally argues the trial court
                                                            erred by denying the motion to dismiss because ap-
                    Causation                               pellees' expert reports do not constitute good faith
    [12] Christian Care next argues that appellees'         efforts to comply with chapter 74. Specifically,
experts are not qualified to address causation be-          Christian Care asserts all three reports pertain only
cause Gerber and Frederick are not licensed physi-          to its care of Haberman, not its care of Connally,
cians and Dr. Rushing is not qualified on the very          and that Dr. Rushing's opinions about causation are
matter *647 at issue in this case. “[A] person may          conclusory.
qualify as an expert witness on the issue of the
causal relationship between the alleged departure               [14][15] To constitute a good faith effort to
from accepted standards of care and the injury,             comply with the statutory requirements, an expert
harm, or damages claimed only if the person is a            report must inform the defendant of the specific

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328 S.W.3d 637
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conduct called into question and provide a basis for        mary, the care and treatment rendered to Jay Haber-
the trial court to determine that the claims have           man by Centennial Medical Center and its staff, the
merit. Palacios, 46 S.W.3d at 879. It does not need         Christian Care Center and its staff, and Dr. Swathi
to marshal all of the plaintiff's proof, but it must in-    Bayya fell below the accepted standard of care for
clude a fair summary of the expert's opinion on             the reasons described in this report and proximately
each of the elements identified in the statute: the         caused the death of Nell D. Connally.” Christian
applicable standard of care, the breach or deviation        Care claims this statement shows a lack of differen-
from the standard of care, and the causal relation-         tiation between the health care providers and does
ship between the breach and the injury. Id. at 878.         not address viable treatment options for Connally.
The report cannot merely state the expert's conclu-
sions about these elements. Id.; Petty, 310 S.W.3d               The issue is whether Dr. Rushing's report, not
at 134. The expert must explain the basis of his            the one statement relied upon by Christian Care, ar-
statements to link his conclusions to the facts.            ticulated a causal relationship between Christian
Bowie Mem'l Hosp., 79 S.W.3d at 52; Petty, 310              Care's alleged failure to meet the applicable stand-
S.W.3d at 134.                                              ards of care and Connally's death. See
                                                            TEX.CIV.PRAC. & REM.CODE 74.351(r)(6). This
     [16] Contrary to Christian Care's argument, its        required Dr. Rushing to link Christian Care's al-
alleged failure to properly care for Haberman is rel-       leged negligence with appellees' alleged harm—the
evant to whether it breached the standard of care           assault on Connally by Haberman. See UHS of Tim-
owed to Connally. See Diversicare Gen. Partner,             berlawn, Inc. v. S.B., 281 S.W.3d 207, 213–14
Inc. v. Rubio, 185 S.W.3d 842, 850 (Tex.2005)               (Tex.App.-Dallas 2009, pet. denied) (expert report
(nursing home as a heath care provider had duty to          sufficiently linked health care provider's negligence
protect resident and patient population from harm-          to sexual assault of complainant by another pa-
ing themselves and each other). Dr. Rushing, Fred-          tient). Haberman was allegedly aggressive and
erick, and Gerber identified the conduct of Christi-        combative prior to being admitted to Christian Care
an Care that was called into question—the failure to        and required physical restraints and supervision by
properly assess Haberman's condition and needs              a personal attendant. His aggressive behavior al-
prior to his admission, to correctly administer med-        legedly continued at Christian Care. According to
ication to Haberman after admission, and to prop-           Dr. Rushing, the standard of care required Christian
erly assess, supervise, and care for *648 Haberman          Care to properly assess Haberman's condition prior
after admission. In Dr. Rushing's opinion, Christian        to admitting him to Christian Care and required the
Care's failure to properly care for Haberman                nursing staff at Christian Care to report Haberman's
presented a danger to Connally and caused her               condition following his admission and to properly
death. The trial court did not abuse its discretion by      supervise Haberman. Dr. Rushing opined that, even
finding appellees' expert reports informed Christian        though it was reasonably foreseeable that Haber-
Care of the specific conduct called into question           man was a danger to himself or others, he was ad-
and provided a basis for the trial court to determine       mitted to the Christian Care facility and was not
that the claims have merit.                                 properly cared for or supervised. While Haberman
                                                            was unsupervised in the dining room at Christian
    [17] Christian Care also asserts Dr. Rushing's          Care, he injured Connally by turning over her walk-
report does not constitute a good faith effort to           er, leading to her death. We conclude the trial court
comply with section 74.351 because his opinions             did not abuse its discretion by finding Dr. Rushing's
about causation are conclusory. In claiming the re-         report articulated the required causal relationship.
port is deficient as to causation, Christian Care fo-
cuses on Dr. Rushing's statement that, “In sum-                 We overrule Christian Care's sole issue and af-

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328 S.W.3d 637
(Cite as: 328 S.W.3d 637)

firm the trial court's order.

Tex.App.–Dallas,2010.
Christian Care Centers, Inc. v. Golenko
328 S.W.3d 637

END OF DOCUMENT

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                                                                                                          Page 1
299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

                                                                Affirmed.
          Court of Appeals of Texas,
          Corpus Christi–Edinburg.                                            West Headnotes
 CHRISTUS SPOHN HEALTH SYSTEM COR-
                                                            [1] Appeal and Error 30        893(1)
PORATION d/b/a Christus Spohn Hospital Corpus
         Christi–Shoreline, Appellant,                      30 Appeal and Error
                      v.                                       30XVI Review
Sandra SANCHEZ and Omar Aleman, Appellees.                        30XVI(F) Trial De Novo
  Edwin DeJesus and Alain Njoh, Appellants,                          30k892 Trial De Novo
                      v.                                                     30k893 Cases Triable in Appellate
 Sandra Sanchez and Omar Aleman, Appellees.                 Court
                                                                            30k893(1) k. In general. Most Cited
    Nos. 13–09–00055–CV, 13–09–00092–CV.
                                                            Cases
                 Oct. 29, 2009.
                                                                 Whether a claim is a health care liability claim
Background: Patient brought action against hospit-          within meaning of statute requiring plaintiff to
al, alleging negligent hiring, supervision, training,       provide an expert's report is a question of law and
and retention of employees, as well as vicarious li-        is reviewed de novo. V.T.C.A., Civil Practice &
ability for employees' conduct, and against employ-         Remedies Code § 74.351.
ees in their individual capacities for assault and in-
                                                            [2] Health 198H       800
tentional infliction of emotional distress. The
County Court at Law, Nueces County, Jon Martinez            198H Health
, J., denied motion to dismiss for failure to file an            198HV Malpractice, Negligence, or Breach of
adequate expert report, and hospital and employees          Duty
appealed.                                                          198HV(G) Actions and Proceedings
                                                                      198Hk800 k. In general. Most Cited Cases
Holdings: The Court of Appeals, Rodriguez, held
                                                                 A cause of action alleges a departure from ac-
that:
                                                            cepted standards of medical care or health care, and
(1) claims based on conduct of hospital employees
                                                            requires submission of expert report, if act or omis-
towards patient was not a “health care liability
                                                            sion complained of is an inseparable part of rendi-
claim” which required expert report;
                                                            tion of medical services. V.T.C.A., Civil Practice &
(2) claim against hospital based on negligence in
                                                            Remedies Code § 74.001(a)(13).
hiring, training, supervising and retaining employ-
ees was a “health care liability claim;”                    [3] Health 198H       800
(3) underlying nature of patient's common law vi-
carious liability claim was a “health care liability        198H Health
claim;”                                                         198HV Malpractice, Negligence, or Breach of
(4) nurse's expert report adequately set forth hospit-      Duty
al's standard of care or safety and its breach as re-             198HV(G) Actions and Proceedings
quired; and                                                          198Hk800 k. In general. Most Cited Cases
(5) expert physician's report on hospital's duty of             Standards of safety directly related to health
care, its breach, and resulting damages adequately          care implicate claimants' exposure to unreasonably
established causation element.                              dangerous or defective conditions or things in the

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299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

course of their care, for purposes of determining           care provider are indeed health care liability claims
whether claim is a health liability claim requiring         which require submission of expert report, court is
an expert report. V.T.C.A., Civil Practice & Rem-           not bound by form of pleading, and nature of claim
edies Code § 74.001(a)(13).                                 is not determined simply by status of defendant or
                                                            place of injury. V.T.C.A., Civil Practice & Remed-
[4] Health 198H       804                                   ies Code §§ 74.001(a)(13), 74.351.

198H Health                                                 [7] Assault and Battery 37        19
     198HV Malpractice, Negligence, or Breach of
Duty                                                        37 Assault and Battery
      198HV(G) Actions and Proceedings                         37I Civil Liability
           198Hk804 k. Affidavits of merit or merit-              37I(B) Actions
orious defense; expert affidavits. Most Cited Cases                   37k19 k. Grounds and conditions preced-
    Necessity of expert testimony to establish rel-         ent. Most Cited Cases
evant standard of care and whether it was deviated
from is an important factor in determining whether          Health 198H        804
a plaintiff's claim against a health care provider is
                                                            198H Health
inseparable from rendition of health care, and thus,
                                                                  198HV Malpractice, Negligence, or Breach of
a “health care liability claim” subject to statutory
                                                            Duty
requirement of an expert report. V.T.C.A., Civil
                                                                   198HV(G) Actions and Proceedings
Practice & Remedies Code §§ 74.001(a)(13),
                                                                      198Hk804 k. Affidavits of merit or merit-
74.351(a).
                                                            orious defense; expert affidavits. Most Cited Cases
[5] Health 198H       800                                        Conduct of registered nurse and certified
                                                            nurse's assistant toward patient was not related to
198H Health                                                 health care being provided to patient nor did it in-
     198HV Malpractice, Negligence, or Breach of            volve their professional judgment; thus, patient ac-
Duty                                                        tion against those hospital employees for assault
      198HV(G) Actions and Proceedings                      and intentional infliction of emotional distress was
         198Hk800 k. In general. Most Cited Cases           not a “health care liability claim” which required an
    In determining whether claims against a health          expert report on standard of care, failure to meet it,
care provider are indeed health care liability claims       and resulting damages, where their alleged conduct
which require submission of expert report, courts           consisted of making comments and unwanted sexu-
focus on gravamen, or underlying nature, of claim.          al advances while they were undressing her, trying
V.T.C.A., Civil Practice & Remedies Code §                  to lie down with her, and writing personal messages
74.001(a)(13).                                              on the white board in her room. V.T.C.A., Civil
                                                            Practice & Remedies Code §§ 74.001(a)(13),
[6] Health 198H       804                                   74.351.

198H Health                                                 [8] Assault and Battery 37        19
    198HV Malpractice, Negligence, or Breach of
Duty                                                        37 Assault and Battery
      198HV(G) Actions and Proceedings                         37I Civil Liability
          198Hk804 k. Affidavits of merit or merit-               37I(B) Actions
orious defense; expert affidavits. Most Cited Cases                   37k19 k. Grounds and conditions preced-
    In determining whether claims against a health          ent. Most Cited Cases

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299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

Health 198H        804                                       sional judgment; it follows that proper staffing for
                                                             care and protection of patients is related to and part
198H Health                                                  of rendition of health care, for purposes of determ-
     198HV Malpractice, Negligence, or Breach of             ining whether a claim regarding the decisions is a
Duty                                                         health care liability claim which requires an expert
       198HV(G) Actions and Proceedings                      report. V.T.C.A., Civil Practice & Remedies Code
           198Hk804 k. Affidavits of merit or merit-         §§ 74.001(a)(13), 74.351.
orious defense; expert affidavits. Most Cited Cases
     When a claim is based on injurious actions of           [11] Health 198H        800
an individual unrelated to provision of health care,
that individual cannot hide behind procedural safe-          198H Health
guards of statute requiring an expert report when                 198HV Malpractice, Negligence, or Breach of
there is a health liability claim merely because he          Duty
or she was also a health care provider at time of as-               198HV(G) Actions and Proceedings
sault or other harmful conduct. V.T.C.A., Civil                         198Hk800 k. In general. Most Cited Cases
Practice & Remedies Code §§ 74.001(a)(13),                        Determining appropriate number, training, and
74.351.                                                      certifications of medical professionals necessary to
                                                             care for and protect patients in weakened conditions
[9] Health 198H        804                                   requires health care expertise, which is but another
                                                             indicator that staffing decisions are inseparable
198H Health                                                  from provision of health care; thus, when a patient
     198HV Malpractice, Negligence, or Breach of             is injured because of an alleged lapse in this profes-
Duty                                                         sional decision-making, the lawsuit complaining of
       198HV(G) Actions and Proceedings                      that injury is a “health care liability claim” which
           198Hk804 k. Affidavits of merit or merit-         requires an expert report. V.T.C.A., Civil Practice
orious defense; expert affidavits. Most Cited Cases          & Remedies Code §§ 74.001(a)(13), 74.351.
     Patient's claims against hospital for alleged
negligence in hiring, training, supervising and re-          [12] Health 198H        804
taining two employees who allegedly assaulted her
was essentially a claim that hospital did not care for       198H Health
her within accepted standards of care and safety by               198HV Malpractice, Negligence, or Breach of
protecting her from alleged unwanted sexual ad-              Duty
vances and was thus a “health care liability claim”                198HV(G) Actions and Proceedings
which required patient to provide an expert report.                     198Hk804 k. Affidavits of merit or merit-
V.T.C.A., Civil Practice & Remedies Code §§                  orious defense; expert affidavits. Most Cited Cases
74.001(a)(13), 74.351.                                            Underlying nature of patient's common law vi-
                                                             carious liability claim against hospital, arising from
[10] Health 198H         800                                 alleged sexual assault on her by a registered nurse
                                                             and a certified nurse's assistant, was that through
198H Health                                                  lapses in professional judgment and treatment hos-
    198HV Malpractice, Negligence, or Breach of              pital negligently breached standards of care and
Duty                                                         safety owed patient by failing to protect her from
      198HV(G) Actions and Proceedings                       alleged assault, was actually a “health care liability
         198Hk800 k. In general. Most Cited Cases            claim” and, as such, was subject to statutory re-
    Decisions regarding protection of patients and           quirement that patient furnish an expert report on
supervision and monitoring of staff involve profes-          standard of care, failure to meet it, and resulting

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299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

damages. V.T.C.A., Civil Practice & Remedies                     Nurse's expert report adequately set forth a
Code §§ 74.001(a)(13), 74.351.                              hospital's standard of care or safety and its breach
                                                            as required in patient's action against hospital, a re-
[13] Health 198H        804                                 gistered nurse and a certified nurse's assistant,
                                                            arising out of alleging unwanted sexual advances
198H Health
                                                            by the nurse and assistant; report stated that stand-
     198HV Malpractice, Negligence, or Breach of
                                                            ard of care required hospital and nursing staff to
Duty
                                                            provide adequate supervision to certified nursing
       198HV(G) Actions and Proceedings
                                                            assistants and licensed nursing personnel, that hos-
           198Hk804 k. Affidavits of merit or merit-
                                                            pital and nursing staff were to protect patients from
orious defense; expert affidavits. Most Cited Cases
                                                            sexual harassment and abuse, and that they failed to
     In its review of expert report on medical pro-
                                                            do so by their specific actions. V.T.C.A., Civil
vider's standard of care, failure to meet it, and res-
                                                            Practice & Remedies Code § 74.351(i).
ulting damages, courts are limited to four corners of
report in determining whether report manifests a            [16] Health 198H         804
good-faith effort to comply with statutory definition
of an expert report. V.T.C.A., Civil Practice &             198H Health
Remedies Code §§ 74.001(a)(13), 74.351.                          198HV Malpractice, Negligence, or Breach of
                                                            Duty
[14] Health 198H        804                                         198HV(G) Actions and Proceedings
                                                                       198Hk804 k. Affidavits of merit or merit-
198H Health
                                                            orious defense; expert affidavits. Most Cited Cases
     198HV Malpractice, Negligence, or Breach of
                                                                 Expert physician's report on hospital's duty of
Duty
                                                            care, its breach, and resulting damages adequately
       198HV(G) Actions and Proceedings
                                                            established causation element required in connec-
           198Hk804 k. Affidavits of merit or merit-
                                                            tion with a “health care liability claim” as asserted
orious defense; expert affidavits. Most Cited Cases
                                                            by patient in action against hospital arising out of
     Statutorily required expert reports in health
                                                            alleged unwanted sexual advances by hospital em-
care liability actions, detailing medical provider's
                                                            ployees; report opined at length about alleged con-
standard of care, failure to meet it, and resulting
                                                            duct of employees and described psychological
damages, need not marshal all of patient's proof; if
                                                            symptoms patient suffered following her stay at
expert report puts medical provider on notice of
                                                            hospital, and observed that patient was unable to
specific conduct complained of and provides trial
                                                            protect herself, and felt vulnerable and harassed by
court a basis on which to conclude claims have
                                                            people who were supposed to be caring for her,
merit, report represents a good-faith effort to com-
                                                            which linked report to other expert's report on hos-
ply with statute. V.T.C.A., Civil Practice & Remed-
                                                            pital's duty to provide a safe recovery environment.
ies Code § 74.351(i).
                                                            V.T.C.A., Civil Practice & Remedies Code §
[15] Health 198H        804                                 74.351(i).

198H Health                                                 *871 David R. Iler, Erin L. Leeser, Warren Szutse
    198HV Malpractice, Negligence, or Breach of             Huang, Fulbright & Jaworski, Houston, for Appel-
Duty                                                        lant in No. 13-09-00055-CV.
      198HV(G) Actions and Proceedings
                                                            Stephen J. Chapman, F. Edward Barker, The Chap-
          198Hk804 k. Affidavits of merit or merit-
                                                            man Law Firm, Corpus Christi, for appellants in
orious defense; expert affidavits. Most Cited Cases
                                                            No. 13-09-00092-CV.

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299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

Kevin W. Grillo, Robert C. Hilliard, Hilliard Mun-          that during these physical contacts, Njoh and DeJe-
oz Guerra, L.L.P., Corpus Christi, for Appellees.           sus were making sexual overtures and comments
                                                            and that the improper conduct continued until she
                                                            was discharged from the hospital a few days later.
Before Chief Justice VALDEZ and Justices
RODRIGUEZ and GARZA.                                             In     February      2008,      appellees    sued
                                                            Spohn–Shoreline for negligent hiring, supervision,
                      OPINION                               training, and retention of its employees and vicari-
Opinion by Justice RODRIGUEZ.                               ous liability for the conduct of Njoh and DeJesus.
     This consolidated appeal involves the alleged          Appellees timely served the expert report and cur-
sexual assault of a patient by nursing staff in a hos-      riculum vitae of Laura Burchell–Henson, a re-
                                     FN1                                      FN2
pital intensive care unit (ICU).           Appellants       gistered nurse.           TEX. CIV. PRAC. &
Christus Spohn Health System Corporation d/b/a              REM.CODE ANN. § 74.351(a). Spohn–Shoreline
Christus Spohn Hospital Corpus Christi–Shoreline            filed objections to the report and a motion to dis-
*872 (Spohn–Shoreline), Edwin DeJesus, and Alain            miss appellees' lawsuit on the basis that their expert
Njoh challenge the trial court's denial of their mo-        report did not constitute a good-faith effort to com-
tions to dismiss a lawsuit filed by appellees Sandra        ply with the requirements of the statute. Appellees
Sanchez and Omar Aleman for failure to serve an             responded to the motion, arguing that their claims
adequate expert report as required by section               were not health care liability claims subject to sec-
74.351. See TEX. CIV. PRAC. & REM.CODE                      tion 74.351 and that the expert report requirement
ANN. § 74.351(a)-(b) (Vernon Supp. 2009). By                was unconstitutional under the United States and
three issues on appeal, appellants argue that: (1) ap-      Texas Constitutions. In August 2008, appellees
pellees' claims are health care liability claims; (2)       amended their petition to add causes of action
appellees' expert reports did not constitute a good-        against DeJesus and Njoh, in their individual capa-
faith effort to comply with the statute and were            cities, for assault and intentional infliction of emo-
fatally deficient; and (3) section 74.351's expert re-      tional distress. After the trial court granted ap-
port requirement is constitutional under the United         pellees an extension of time to amend their expert
States and Texas Constitutions. We affirm.                  report, appellees filed a report by George S. Glass,
                                                            M.D. Spohn–Shoreline filed objections to the
         FN1. This opinion consolidates the Court's         second report and all appellants filed motions to
         analysis of both appeals. See TEX.R.APP.           dismiss the suit for failure to file an adequate expert
         P. 47.1.                                           report. The trial court denied both motions to dis-
                                                            miss, and these appeals ensued. See TEX. CIV.
                 I. BACKGROUND                              PRAC. & REM.CODE ANN. § 51.014(a)(9)
     In October 2007, Sanchez underwent spinal fu-          (Vernon 2008) (authorizing an interlocutory appeal
sion surgery at Spohn–Shoreline. She was recover-           of the denial of a motion to dismiss filed under sec-
ing in the ICU when she alleges that Njoh and               tion 74.351(b)).
DeJesus, a registered nurse and a certified nurse's
assistant, entered her room and made unwanted                        FN2. Appellees maintain that their claims
sexual advances toward her. Sanchez alleges that                     are not health care liability claims and that
one of the men undressed her and exposed her body                    they served an expert report in an
for the other to see. She claims that they turned her                “abundance of caution” to preserve their
over using their hands instead of a turning pad and,                 rights to proceed with the lawsuit.
while they were moving her from the bed to a chair
in her room, they danced with her. Sanchez alleges                         II. DISCUSSION
                                                            A. Health Care Liability Claims

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299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

     By the first issue, appellants assert that ap-                  FN3. The statute's definition of health care
pellees' claims are health care liability claims gov-                provider includes hospitals, registered
erned by chapter 74 of the civil practice and remed-                 nurses, and employees acting in the course
ies code. Specifically, appellants argue that the un-                and scope of their employment with the
derlying nature of appellees' claims is that appel-                  health care provider. See TEX. CIV.
lants *873 breached the standards of care and safety                 PRAC. & REM.CODE ANN. § 74.001
owed to Sanchez. With regard to appellees' claims                    (a)(11)(G), (12)(A)(i), (12)(B)(ii) (Vernon
against Spohn–Shoreline, we agree. However, we                       2005).
cannot so conclude with respect to appellees' claims
against Njoh and DeJesus in their individual capa-               [5][6] In determining whether appellees' claims
cities.                                                     are indeed health care liability claims, we focus on
                                                            the “gravamen,” or underlying nature, of the claim.
1. Standard of Review and Applicable Law                    Id. “[W]e are not bound by the form of the plead-
     [1][2][3][4] “[W]hether a claim is a health care       ing,” and the nature of the claim is not determined
liability claim pursuant to section 74.351 is a ques-       simply by the status of the defendant or the place of
tion of law and is reviewed de novo.” Valley                injury. Id.; see Marks, 2009 WL 2667801, at *8. In-
Baptist Med. Ctr. v. Stradley, 210 S.W.3d 770, 773          stead, “it is the cause of the injury and its relation-
(Tex.App.-Corpus Christi 2006, pet. denied). A              ship to medical or professional judgment that de-
health care liability claim is defined as:                  termines” the nature of the claim and the applicabil-
                                                            ity of the health care liability statute. Marks, 2009
  [A] cause of action against a health care provider        WL 2667801, at *8.
  ... for treatment, lack of treatment, or other
  claimed departure from accepted standards of              2. Claims against Njoh and DeJesus
  medical care, or health care, or safety or profes-             Njoh and DeJesus argue that appellees' claims
  sional or administrative services directly related        against them for assault and intentional infliction of
  to health care, which proximately results in injury       emotional distress actually center on their rendering
  to or death of a claimant, whether the claimant's         of health care services to Sanchez. They contend
  claim or cause of action sounds in tort or con-           that Sanchez's allegations—that they undressed her
  tract.                                                    so they could view her naked body, moved her with
                                                            their hands instead of a turning pad, and danced
     TEX. CIV. PRAC. & REM.CODE ANN. §                      with her while they were moving her from the bed
                               FN3
74.001(a)(13) (Vernon 2005).        “A cause of ac-         to a chair—are all subjective interpretations of
tion alleges a departure from accepted standards of         what, in reality, were specific tasks routinely per-
medical care or health care if the act or omission          formed by nursing staff, i.e. changing her clothes in
complained of is an inseparable part of the rendi-          preparation for the doctor, turning her over in her
tion of medical services.” Diversicare Gen. Part-           bed, and helping her to the chair in her room. Njoh
ner, Inc. v. Rubio, 185 S.W.3d 842, 848 (Tex.2005)          and DeJesus argue that Sanchez's differing percep-
. Standards of safety implicate claimants' “exposure        tion of the conduct does not take her claims outside
to unreasonably dangerous or defective conditions           the confines of the health care liability statute. We
or things” in the course of their care. Marks v. St.        disagree.
Luke's Episcopal Hosp., No. 07–0783, 2009 WL
2667801, at *8 (Tex. Aug. 28, 2009). The necessity               *874 [7] Although we acknowledge that the
of expert testimony is an important factor in de-           previously described tasks may be part and parcel
termining whether the plaintiff's claim is insepar-         of the care given to hospital patients by nursing
able from the rendition of health care. Diversicare,        staff, we do not view the conduct challenged by ap-
185 S.W.3d at 848.                                          pellees in isolation from the surrounding circum-

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(Cite as: 299 S.W.3d 868)

stances, as do Njoh and DeJesus. Because in addi-           assault to occur, but rather, that the doctor injured
tion to describing the undressing, turning over, and        the plaintiff “by his own actions”). Appellees'
moving of Sanchez, appellees also allege that Njoh          claims against Njoh and DeJesus in their individual
and DeJesus made sexual overtures toward Sanchez            capacities are, therefore, not health care liability
in the process of performing these tasks. Appellees         claims, and we overrule the first issue as it applies
                                                                                 FN4
claim that Njoh and DeJesus commented to Sanc-              to Njoh and DeJesus.
hez about her body while they were undressing her
and allegedly danced with her and, at one point,                     FN4. Having decided that appellees' claims
even tried to climb in the bed with her. Appellees                   against Njoh and DeJesus are not health
further allege that one of the two wrote “I love you”                care liability claims, we need not reach
on the white board in Sanchez's room. We would be                    Njoh and DeJesus's contentions regarding
remiss to conclude that such conduct was related to                  the adequacy of appellees' expert reports or
the health care being provided to Sanchez or some-                   concerning the constitutionality of the ex-
how involved the professional judgment of Njoh                       pert report requirement. See TEX.R.APP.
and DeJesus. See Jones v. Khorsandi, 148 S.W.3d                      P. 47.1.
201, 206 (Tex.App.-Eastland 2004, pet. denied)
                                                            3. Claims against Spohn–Shoreline
(holding that allegations of sexual assault against a
                                                                 [9] Similarly, Spohn–Shoreline contends that
doctor did not involve “a breach of the applicable
                                                            the underlying nature of appellees' claims is that it
standards of care for health care providers”).
                                                            did not care for Sanchez within the accepted stand-
     [8] Appellees' amended petition alleges causes         ards of care and safety. However, unlike appellees'
of action against Njoh and DeJesus for assault and          claims against Njoh and DeJesus, appellees' claims
intentional infliction of emotion distress, and we          against Spohn–Shoreline are based on negligence,
conclude that the underlying nature of appellees'           implicate the standards of care and safety contem-
claims, indeed, rests squarely in these intentional         plated by chapter 74, and directly relate to its ren-
actions that had “nothing to do with a health care          dering of health care to Sanchez. See TEX. CIV.
provider's lapse in professional judgment or failure        PRAC. & REM.CODE ANN. § 74.001(a)(13); see
to protect a patient due to an absence of supervision       also Stradley, 210 S.W.3d at 775. In their amended
or monitoring.” Holguin v. Laredo Reg'l Med. Ctr.,          petition, appellees allege that Spohn–Shoreline
L.P., 256 S.W.3d 349, 354 (Tex.App.-San Antonio             *875 owed a duty to Sanchez “to provide a reason-
2008, no pet.); see Jones, 148 S.W.3d at 206. “It           ably safe recovery environment free from offensive
would defy logic to suggest that a sexual assault ‘is       contact” and that Spohn–Shoreline “breached this
an inseparable part of the rendition of medical care’       duty by failing to properly hire, supervise, train,
or a departure from accepted standards of care.”            and retain its employees.” In other words, ap-
Holguin, 256 S.W.3d at 353 (citing Diversicare,             pellees' claims are that Spohn–Shoreline failed to
185 S.W.3d at 848). When a claim is based on the            protect her from the alleged unwanted sexual ad-
injurious actions of an individual unrelated to the         vances made by Njoh and DeJesus.
provision of health care, that individual cannot hide
                                                                 [10][11] Decisions regarding the protection of
behind the procedural safeguards of chapter 74
                                                            patients and the supervision and monitoring of staff
merely because he or she was also a health care
                                                            involve professional judgment, see Diversicare,
provider at the time of the assault or other harmful
185 S.W.3d at 851, and “[i]t follows that proper
conduct. See id. (reasoning that the plaintiff's claim
                                                            staffing for the care and protection of patients is re-
that his doctor sexually assaulted him was not a
                                                            lated to and part of the rendition of health care.”
health care liability claim because the allegation
                                                            Holguin, 256 S.W.3d at 356. Moreover, determin-
was not that the doctor had negligently allowed the
                                                            ing “the appropriate number, training, and certifica-

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299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

tions of medical professionals necessary to care for        against Spohn–Shoreline therefore constituted
and protect patients in weakened conditions” re-            health care liability claims subject to the expert re-
quires health care expertise, which is but another          port requirement of section 74.351. See id.; see also
indicator that staffing decisions are inseparable           TEX. CIV. PRAC. & REM.CODE ANN. § 74.351
from the provision of health care. Diversicare, 185         (a). We sustain the first issue as it applies to
S.W.3d at 848, 851. Thus, as here, when a patient is        Spohn–Shoreline.
injured because of an alleged lapse in this profes-
sional decision-making, the lawsuit complaining of          B. Expert Reports
that injury is a health care liability claim. See id. at         In the second issue, Spohn–Shoreline argues
851.                                                        that appellees' expert reports were fatally deficient.
                                                            FN5
     [12] Appellees respond that their claim against
Spohn–Shoreline for vicarious liability, in particu-                 FN5. By a sub-issue, Spohn–Shoreline
lar, is not a health care liability claim subject to the             complains that the trial court erred in
expert report requirement. However, Texas courts                     granting appellees' request for a thirty-day
have clearly held that a plaintiff cannot circumvent                 extension to amend the report of Nurse
the expert report requirement by artfully pleading                   Burchell–Henson. Spohn–Shoreline argues
her health care liability claim based upon the negli-                that because the only expert report served
gence of the health care provider as some other                      by appellees within the 120–day deadline
cause of action, such as vicarious liability. See Gar-               was authored by a nurse who, under the
land Cmty. Hosp. v. Rose, 156 S.W.3d 541, 543                        express terms of the statute, cannot offer
(Tex.2004); NCED Mental Health, Inc. v. Kidd, 214                    an opinion regarding causation, appellees
S.W.3d 28, 34–35 (Tex.App.-El Paso 2006, no pet.)                    effectively failed to serve any expert report
; Oak Park, Inc. v. Harrison, 206 S.W.3d 133,                        on Spohn–Shoreline within the time frame
140–41 (Tex.App.-Eastland 2006, no pet.). Ap-                        required by section 74.351. See TEX. CIV.
pellees' claim is not that Spohn–Shoreline, through                  PRAC. & REM.CODE ANN. § 74.351(c)
its employees, committed the sexual assault. In-                     (“If an expert report has not been served
stead, despite the recasting of their claim as com-                  within the period specified ... because ele-
mon law vicarious liability, the underlying nature                   ments of the report are found deficient, the
of appellees' claim is, nonetheless, that “through                   court may grant one thirty-day extension to
lapses in professional judgment and treatment                        the claimant in order to cure the defi-
[Spohn–Shoreline] negligently allowed the sexual                     ciency.”). In other words, Spohn–Shoreline
assault to occur.” Diversicare, 185 S.W.3d at 851;                   argues that the report by Nurse
see Harrison, 206 S.W.3d at 141. We are, there-                      Burchell–Henson was not merely deficient
fore, unpersuaded by appellees' vicarious liability                  but, rather, no report at all and that, even if
argument.                                                            they were entitled to a thirty-day exten-
                                                                     sion, appellees could use the extension
     We conclude that the “gravamen” of appellees'                   only to amend the Burchell–Henson report,
claims is that Spohn–Shoreline breached the stand-                   not to file a new report by a separate ex-
ards of care and safety owed to Sanchez by failing                   pert. However, the Texas Supreme Court
to protect her from the allegedly assaultive conduct                 has held that objections to a nurse's quali-
of its nursing staff. See Marks, 2009 WL 2667801,                    fications to act as an expert in a health care
at *8. The complained-of conduct was an insepar-                     liability claim go to the sufficiency of the
able part of the care provided to Sanchez as a pa-                   report and not to its existence. Ogletree v.
tient at Spohn–Shoreline, and appellees' claims                      Matthews, 262 S.W.3d 316, 322

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         (Tex.2007). Moreover, appellees were well          are limited to the four corners of the report in de-
         within their rights to supplement Nurse            termining whether the report manifests a good-faith
         Burchell–Henson's report with a report on          effort to comply with the statutory definition of an
         causation by Dr. Glass, because deficien-          expert report. Palacios, 46 S.W.3d at 878; see TEX.
         cies in an expert report can be cured during       CIV. PRAC. & REM.CODE ANN. § 74.351(l )
         the thirty-day extension period by serving         (requiring that the trial court “grant a motion chal-
         a report by a separate expert. Lewis v. Fun-       lenging the adequacy of the expert report only if
         derburk, 253 S.W.3d 204, 208 (Tex.2008).           appears to the court, after hearing, that the report
         As such, we are unpersuaded by                     does not represent an objective good faith effort to
         Spohn–Shoreline's argument and overrule            comply” with the statutory definition). “Nothing in
         the second issue to the extent that it chal-       [section 74.351] should be construed to mean that a
         lenges the trial court's decision to grant ap-     single expert report must address all liability and
         pellees a thirty-day extension.                    causation issues....” TEX. CIV. PRAC. &
                                                            REM.CODE. ANN. § 74.351(i). Moreover, the re-
*876 1. Standard of Review and Applicable Law               ports “need not marshal all the plaintiff's proof.”
     We review a trial court's decision on a motion         Palacios, 46 S.W.3d at 878; see Jernigan, 195
to dismiss under section 74.351 of the civil practice       S.W.3d at 93. If the expert report puts the defendant
and remedies code for abuse of discretion. Jernigan         on notice of the specific conduct complained of and
v. Langley, 195 S.W.3d 91, 93 (Tex.2006); Am.               provides the trial court a basis on which to con-
Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46       clude the claims have merit, the report represents a
S.W.3d 873, 878 (Tex.2001). The trial court abuses          *877 good-faith effort to comply with the statute.
its discretion if it acts unreasonably or arbitrarily or    Palacios, 46 S.W.3d at 879.
without reference to any guiding rules or principles.
Walker v. Gutierrez, 111 S.W.3d 56, 62 (Tex.2003).          2. Analysis
The trial court's ruling is arbitrary and unreasonable           [15] Spohn–Shoreline first argues that Nurse
only if “the appellant establishes that the trial court     Burchell–Henson's report did not adequately set
could reasonably have reached only one decision.”           forth the standard of care and/or safety and breach
Taylor v. Christus Spohn Health Sys. Corp., 169             because the report is conclusory, speculative, and
S.W.3d 241, 244 (Tex.App.-Corpus Christi 2004,              does not differentiate between the standards of care
no pet.).                                                   applicable to Spohn–Shoreline as opposed to the in-
                                                            dividual defendants. See Taylor, 169 S.W.3d at 244
     Under section 74.351 of the Texas Civil Prac-          (“An expert report may not assert that multiple de-
tice and Remedies Code, a claimant must “serve on           fendants are all negligent for failing to meet the
each party or the party's attorney” an expert report        standard of care without providing an explanation
and curriculum vitae “not later than the 120th day          of how each defendant specifically breached the
after the date the original petition was filed.” See        standard....”). Spohn–Shoreline further argues that
TEX. CIV. PRAC. & REM.CODE ANN. § 74.351                    the report does not provide specific information
(a). An expert report is “a written report by an ex-        about what it should have done differently. See
pert that provides a fair summary of the expert's           Palacios, 46 S.W.3d at 880 (holding that a “fair
opinions ... regarding applicable standards of care,        summary” of the applicable standard of care and
the manner in which the care rendered ... failed to         breach identifies the type of care expected but not
meet the standards, and the causal relationship             rendered). We disagree.
between that failure and the injury, harm, or dam-
ages claimed.” Id. § 74.351(r)(6).                              Nurse Burchell–Henson's report states that the
                                                            “standard of care requires that the hospital and its
    [13][14] In our review of the expert report, we

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nursing staff provide adequate supervision to their         (Tex.2002) (holding that an expert report “cannot
certified nursing assistants and licensed nursing           merely state the expert's conclusions” regarding
personnel.” The report further states that the              causation; rather, the basis of the expert's state-
“standard of care requires that the hospital and its        ments must link his conclusions to the facts). Spe-
nursing staff protect their patients from sexual har-       cifically, Spohn–Shoreline contends that Dr. Glass's
assment and abuse.” It is clear to this Court that, al-     report is conclusory, does not show that
though she references the “nursing staff” in these          Spohn–Shoreline's conduct caused the events upon
articulated     standards      of      care,    Nurse       which appellees' claims are based, and does not dif-
Burchell–Henson is describing the duties owed by            ferentiate*878     between      the    conduct   of
Spohn–Shoreline to its patients. See Univ. of Tex.          Spohn–Shoreline, versus that of Njoh and DeJesus,
Sw. Med. Ctr. v. Dale, 188 S.W.3d 877, 879                  as the cause of injury. Again, we disagree.
(Tex.App.-Dallas 2006, no pet.) (holding that an
expert report need not explicitly refer to the hospit-           In his report, Dr. Glass opines at length about
al employer by name where a plaintiff is asserting          the alleged conduct of Njoh and DeJesus and de-
vicarious, and not direct, liability, and where it is       scribes the depression, severe anxiety, panic, night-
clear that the conduct of the hospital employer is          mares, and social isolation that Sanchez suffered
implicated). By specifying that the hospital is to ad-      following her stay at Spohn–Shoreline. Dr. Glass
equately supervise its “certified nursing assistants        observes that Sanchez was “unable to care [sic] and
and     licensed    nursing     personnel,”     Nurse       protect herself [sic] felt vulnerable, harassed by the
Burchell–Henson effectively differentiates between          people who were supposed to be caring for her in
Spohn–Shoreline and the individual defendants.              the hospital ICU.” He then concludes that: “The
                                                            fact that [Sanchez] was vulnerable, unable to pro-
     Moreover,      we     conclude      that   Nurse       tect herself, and felt as if her person was violated
Burchell–Henson identified the care that was ex-            has caused her to now have symptoms of Major De-
pected but not rendered under the applicable stand-         pression and Post Traumatic Stress Disorder.”
ard of care. She states that Spohn–Shoreline
“[f]ailed to provide adequate supervision to the                 Dr. Glass's emphasis on Sanchez's vulnerable
CNA [DeJesus] and the RN [Njoh],” “[f]ailed to              condition, in particular, puts Spohn–Shoreline on
protect Ms. Sanchez from sexual harassment and              notice of the conditions called into question by ap-
sexual abuse,” and “[f]ailed to provide safety to           pellees' claims. See Palacios, 46 S.W.3d at 879;
Ms. Sanchez in her immediate post operative [sic]           Wright, 79 S.W.3d at 53 (agreeing that plaintiffs
when the CNA lifted Ms. Sanchez up and began                are not required to use any sort of magic words to
dancing with her.” She explains the specific tasks          meet the section 74.351 expert report obligation).
and responsibilities required of Spohn–Shoreline            Read in combination with Nurse Burchell–Henson's
and notes that it failed to perform as such. In short,      report on the standard of care, which provided that
the report put Spohn–Shoreline on notice of the             Spohn–Shoreline had a duty to provide a safe re-
specific complained-of conduct, and we cannot say           covery environment for its vulnerable post-op-
that the trial court abused its discretion in finding       erative patients, we conclude that Dr. Glass suffi-
that the report sufficiently set forth the standard of      ciently      linked    Sanchez's      assault     to
care and breach. See Palacios, 46 S.W.3d at 879.            Spohn–Shoreline's failure to protect her from the
                                                            assaultive conduct of Njoh and DeJesus. See TEX.
    [16] Spohn–Shoreline next complains that the            CIV. PRAC. & REM.CODE ANN. § 74.351(i)
report of Dr. Glass did not establish the causation         (allowing standard of care and causation to be es-
element required under the statute. See Bowie               tablished in separate reports); see also Wright, 79
Mem'l Hosp. v. Wright, 79 S.W.3d 48, 52                     S.W.3d at 52. The trial court did not abuse its dis-

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299 S.W.3d 868
(Cite as: 299 S.W.3d 868)

cretion in finding the report sufficient as to causa-
tion. See TEX. CIV. PRAC. & REM.CODE ANN.
§ 74.351(r)(6).

     Based on the foregoing, we conclude that the
expert reports of Nurse Burchell–Henson and Dr.
Glass adequately set forth the standard of care,
identified how Spohn–Shoreline breached the
standard, and explained how the breach caused the
injuries claimed by appellees. See Palacios, 46
S.W.3d at 878. The reports constituted a good faith
effort to comply with the statute because they put
Spohn–Shoreline on notice of the specific conduct
complained of and provided the trial court with a
basis on which to conclude appellees' claims have
merit. See TEX. CIV. PRAC. & REM.CODE ANN.
§ 74.351(l ); Palacios, 46 S.W.3d at 879. We over-
                       FN6
rule the second issue.

        FN6. Having concluded that appellees' ex-
        pert reports met the requirements of sec-
        tion 74.351 and that the trial court did not
        err in denying Spohn–Shoreline's motion
        to dismiss, we need not reach its third issue
        regarding appellees' argument that the ex-
        pert report requirement is unconstitutional.
        See TEX.R.APP. P. 47.1.

               III. CONCLUSION
    The orders of the trial court denying appellants'
motions to dismiss are affirmed.

Tex.App.–Corpus Christi,2009.
Christus Spohn Health System Corp. v. Sanchez
299 S.W.3d 868

END OF DOCUMENT

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                                                                                                           Page 1
701 S.W.2d 238
(Cite as: 701 S.W.2d 238)

                                                            ition, where president testified he was in complete
                                                            charge of all operations of the company. Vernon's
        Supreme Court of Texas.                             Ann.Texas Rules Civ.Proc., Rule 215a(c)
      Ida E. DOWNER, Petitioner,                            (Repealed).
                 v.
AQUAMARINE OPERATORS, INC., Respondent.                     [2] Pretrial Procedure 307A         748

                   No. C–4141.                              307A Pretrial Procedure
                   Dec. 4, 1985.                                307AV Pretrial Conference
          Rehearing Denied Jan. 15, 1986.                           307Ak747 Order and Record or Report
                                                                         307Ak748 k. Amendment or modifica-
     Wife of deceased seaman brought action for             tion. Most Cited Cases
damages against shipowner. Trial court struck                    Trial court's plenary jurisdiction gives it not
shipowner's answer as discovery abuse sanction and          only authority but responsibility to review any pre-
signed interlocutory default judgment as to liability.      trial order upon proper motion, and in doing so, it is
Jury trial on issue of damages was had in the 334th         presumed that court is familiar with entire record of
District Court, Harris County, Ken Harrison, J.             case up to and including motion to be considered.
Shipowner appealed. The Court of Appeals, 689
S.W.2d 472, reversed judgment of trial court. Wife          [3] Pretrial Procedure 307A         225
appealed. The Supreme Court, Wallace, J., held
that: (1) trial court had authority under rule regard-      307A Pretrial Procedure
ing failure of party to appear at oral deposition to           307AII Depositions and Discovery
strike answer of shipowner; (2) trial court correctly             307AII(C) Discovery Depositions
imposed discovery sanction of striking shipowner's                    307AII(C)6 Failure to Appear or Testify;
answer; and (3) trial court correctly refused to ad-        Sanctions
mit evidence of contributory negligence.                                 307Ak225 k. Striking pleadings. Most
                                                            Cited Cases
    Judgment of Court of Appeals reversed and
judgment of trial court affirmed.                           Pretrial Procedure 307A         226

                  West Headnotes                            307A Pretrial Procedure
                                                                307AII Depositions and Discovery
[1] Pretrial Procedure 307A         101                            307AII(C) Discovery Depositions
                                                                        307AII(C)6 Failure to Appear or Testify;
307A Pretrial Procedure                                     Sanctions
   307AII Depositions and Discovery                                           307Ak226 k. Dismissal or default
       307AII(C) Discovery Depositions                      judgment. Most Cited Cases
          307AII(C)1 In General                                  In refusing to grant new trial and reinstate
                307Ak96 Persons Who May Be Ex-              party's answer which had been struck at prior hear-
amined                                                      ing on Motion for Sanctions as discovery sanction,
                   307Ak101 k. Corporate officers,          trial court could consider evidence introduced sub-
agents, and employees. Most Cited Cases                     sequent to original sanctions hearing. Vernon's
     President of company which was party to ac-            Ann.Texas Rules Civ.Proc., Rule 215a(c)
tion was a “party” within meaning of Rule 215a(c)           (Repealed).
regarding failure of party to appear at oral depos-

                            © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                            Page 2
701 S.W.2d 238
(Cite as: 701 S.W.2d 238)

[4] Appeal and Error 30         946                         have to fly to another city to take depositions on
                                                            following day, and shipowner failed to produce
30 Appeal and Error                                         president of shipowner and immediate supervisor of
    30XVI Review                                            captain for deposition and did not explain this fail-
        30XVI(H) Discretion of Lower Court                  ure. Vernon's Ann.Texas Rules Civ.Proc., Rule
          30k944 Power to Review                            215a(c) (Repealed).
               30k946 k. Abuse of discretion. Most
Cited Cases                                                 [6] Appeal and Error 30         1045(2)
     Test for whether trial court abused its discre-
tion is whether court acted without reference to any        30 Appeal and Error
guiding rules and principles, i.e., whether the act             30XVI Review
was arbitrary or unreasonable, and mere fact that                  30XVI(J) Harmless Error
trial judge may decide matter within his discretion-                    30XVI(J)6 Interlocutory and Preliminary
ary authority in different manner than appellate            Proceedings
judge in similar circumstance does not demonstrate                         30k1045 Selection and Impaneling of
that an abuse of discretion has occurred.                   Jurors
                                                                             30k1045(2) k. Sustaining challenge
[5] Pretrial Procedure 307A           225                   or excusing juror. Most Cited Cases
                                                                 Alleged error of trial court in refusing to strike
307A Pretrial Procedure                                     a juror for cause did not result in harm, where chal-
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      307AII(C) Discovery Depositions
          307AII(C)6 Failure to Appear or Testify;          [7] Damages 115         203
Sanctions
             307Ak225 k. Striking pleadings. Most           115 Damages
Cited Cases                                                    115X Proceedings for Assessment
                                                                   115k193 Inquest on Default or Interlocutory
Pretrial Procedure 307A         226                         Judgment
                                                                      115k203 k. Scope of issues and questions
307A Pretrial Procedure                                     considered. Most Cited Cases
    307AII Depositions and Discovery                            Trial court correctly refused to admit evidence
       307AII(C) Discovery Depositions                      of contributory negligence in trial to determine
           307AII(C)6 Failure to Appear or Testify;         damages, where defendant's answer had been struck
Sanctions                                                   and default judgment rendered as to liability and
                  307Ak226 k. Dismissal or default          defendant had no pleading to support contributory
judgment. Most Cited Cases                                  negligence.
     Trial court correctly imposed discovery sanc-
tion of striking defendant's answer and signing in-         [8] Appeal and Error 30         221
terlocutory default judgment as to liability under
Rule 215a(c)(Repealed) regarding failure of party           30 Appeal and Error
to appear at oral deposition, where shipowner vol-                 30V Presentation and Reservation in Lower
untarily sent crew to sea rather than producing them        Court of Grounds of Review
for depositions as agreed on two occasions, attor-                  30V(B) Objections and Motions, and Rulings
ney for wife of deceased seaman stated shipowner's          Thereon
attorney waited until one hour past deposition time                     30k221 k. Amount of recovery or extent
to advise wife's attorney that wife's attorney would        of relief. Most Cited Cases

                            © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                            Page 3
701 S.W.2d 238
(Cite as: 701 S.W.2d 238)

    Alleged error of trial court in awarding pre-           of Edward Downer's personnel file. On June 1,
judgment interest was not presented to trial court          Aquamarine notified Downer that the crew was at
and was thus waived on appeal.                              sea and would not appear. Aquamarine at that time
                                                            agreed to produce the requested persons on June 22.
*239 John O'Quinn, Frank M. Staggs, Jr., O'Quinn            On June 21, Aquamarine again notified Downer
& Hagans, Houston, for petitioner.                          that the crew was at sea and would not appear. It
                                                            agreed to produce them on July 5.
Terry P. Ayre and Thomas A. Brown, Brown, Sims,
Wise & White, Houston, for respondent.                           Downer filed written Notice of Intent to Take
                                                            Depositions of the same individuals for July 5. On
WALLACE, Justice.                                           that date, the requested deponents did not appear,
     This is an appeal from a judgment for damages          whereupon Downer filed a Motion for Sanctions. A
in a suit brought under the Jones Act and under ad-         hearing on the Motion for Sanctions was set for Au-
miralty law. The trial dealt only with damages be-          gust 22. Aquamarine made no appearance at the
cause the trial court struck the defendant's answer         hearing; the trial court granted the Motion for Sanc-
as a discovery abuse sanction and signed an inter-          tions and signed an Order Striking Aquamarine's
locutory default judgment as to liability. The court        Answer.
of appeals reversed the trial court judgment, hold-
                                                                 Downer filed a Motion for Interlocutory De-
ing that the action of *240 that court was an error
                                                            fault Judgment to which Aquamarine responded.
of law and an abuse of discretion. 689 S.W.2d 472.
                                                            The response contained Aquamarine's reasons for
We reverse the judgment of the court of appeals
                                                            not producing the requested individuals for depos-
and affirm the judgment of the trial court.
                                                            itions and its failure to appear at the sanctions hear-
    The     issues     before   us     are   whether        ing.
TEX.R.CIV.P. 215a(c), as it existed prior to the
                                                                 The reason offered for the first two occasions
amendment effective August 1, 1984, authorized
                                                            was that work for the FOUR POINT IV was scarce
the trial court to strike defendant's answer, and, if
                                                            and, when work was available, it was necessary to
so, whether the exercise of that authority consti-
                                                            send the vessel and crew to sea rather than produce
tuted an abuse of discretion.
                                                            them for depositions. On the third occasion, the
     Edward P. Downer was a seaman aboard the               vessel was in port at New Iberia, Louisiana, but
vessel Four Point IV. He drowned while attempting           Coast Guard regulations required a skeleton crew to
to free a line that had fouled the vessel's propeller.      be kept aboard at all times. Aquamarine's attorney
Ida E. Downer, his widow, brought this action               stated that he notified Downer's attorney on July 1
against Aquamarine Operators, Inc., the owner and           of the necessity to take the depositions in New Iber-
operator of the vessel. The case was filed in the           ia. Downer's attorney stated that he first learned
151st District Court of Harris County. Both Downer          that the individuals would not appear as noticed
and Aquamarine are residents of Harris County,              when Aquamarine's attorney called him an hour
Texas.                                                      after the depositions were scheduled to commence.
                                                            Both agreed that Aquamarine requested that the de-
     Downer filed Notice of Intent to Take the De-          positions be taken in New Iberia on July 6.
positions of All Members of The Crew on June 1.             However, Downer's attorney stated that he could
The notice identified each crew member, including           not do so because he was preferentially set for trial
the captain, Chester P. Dalfrey, by name only.              in Houston starting at 9:00 a.m. on July 6.
Downer also requested depositions of the immedi-
ate supervisor of Chester Dalfrey and the custodian             The reason given by Aquamarine for not ap-

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pearing at the sanctions hearing was that Hurricane         operations. Mr. Clark Ivans testified that he was
Alicia had struck La Porte, the residence of Mr.            president of Aquamarine at all times pertinent to
Ayres, Aquamarine's lead counsel, four days previ-          this case, and that as such, he was the immediate
ously. Mr. Ayres was involved in cleaning up after          supervisor of Chester Dalfrey.
the hurricane and mitigating the damages to his
home. Also, he had a hearing set in federal court in             [1] We now address the issue of whether the
Beaumont on the following day and was directing             trial court had authority under Rule 215a(c) to
all of his available attention to that matter.              strike Aquamarine's answer. That rule stated in per-
                                                            tinent part:
     To his Motion to Reconsider the Sanctions, Mr.
Ayres attached an affidavit from his secretary,               If a party or an officer or managing agent of a
which stated that she had called the clerk of the             party, except for good cause shown, fails to ap-
court on July 7, and had advised her that Mr. Ayres           pear before the officer who is to take his oral de-
had to make a docket call in Angleton on August               position ... the court in which the action is
22. She understood the clerk to say that the sanc-            pending on motion and notice may strike out all
tions hearing would be reset for September 6. In re-          or any part of the pleading of that party or dis-
sponse to this motion, Downer's attorney advised              miss the action or proceeding or any part there-
the court by letter of his version of the circum-             of....
stances leading up to the non-appearance on July 5,
                                                                 As noted above, Ivans testified that as president
and the time when he was first advised *241 that
                                                            of Aquamarine he was in complete charge of all op-
the named individuals would not appear. Attached
                                                            erations of the company. Thus he was a party as
to this letter to the court was a copy of a letter dated
                                                            contemplated by Rule 215a(c).
July 28, written by Mr. Bales, an associate of Mr.
Ayres, which confirmed that the sanctions hearing                [2][3] The next question is whether the trial
was set for August 22.                                      court, in refusing to grant a new trial and reinstate
                                                            Aquamarine's answer, could consider the evidence
     With the above information before it, the trial
                                                            introduced subsequent to the original sanctions
court overruled Aquamarine's Motion to Reconsider
                                                            hearing. Aquamarine contends that the trial court,
the Sanctions and to reinstate its answer. The court
                                                            in imposing sanctions, could consider only the
signed an order granting an interlocutory default
                                                            evidence before it at the time of the sanctions hear-
judgment as to liability. Aquamarine filed a Motion
                                                            ing, and not any evidence subsequently produced.
to Set Aside the Default Judgment. The motion
                                                            A trial court's plenary jurisdiction gives it not only
contained practically the same information as the
                                                            the authority but the responsibility to review any
Motion to Reconsider Sanctions set out above. The
                                                            pre-trial order upon proper motion. In doing so, it is
trial court considered this motion and overruled it.
                                                            presumed that the court is familiar with the entire
On April 16, 1984, the case was preferentially set
                                                            record of the case up to and including the motion to
for trial for June 4, and the trial court refused to
                                                            be considered. The plenary jurisdiction of the trial
consider Aquamarine's Second Motion to Set Aside
                                                            court in this case continued through the final judg-
the Interlocutory Default Judgment and Reinstate
                                                            ment and overruling of Aquamarine's motion for
Defendant's Pleadings.
                                                            new trial. When considering the motion for new tri-
    A jury trial was had in a different court, the          al, the court had before it the reasons advanced by
334th District, on the issue of damages. At the trial,      Aquamarine for not appearing for depositions or the
Chester Dalfrey testified that he was captain of the        sanctions hearing; Downer's response to Aquamar-
FOUR POINT IV and as such he was in complete                ine's motions; and the evidence produced at the trial
charge of the vessel with authority over all of its         on damages. Thus, the court of appeals erred in

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holding that the trial court did not have authority         215. The use of sanctions by trial courts to prevent
under Rule 215a(c) to strike Aquamarine's answer.           discovery abuse has developed steadily over the
                                                            past several years. These changes reflect the con-
     We now turn to the court of appeals holding            tinuing pattern both to broaden the discovery pro-
that the trial court abused its discretion in striking      cess and to encourage sanctions for failure to com-
Aquamarine's answer. The court of appeals con-              ply.
cluded its review of the abuse of discretion issue by
stating: “The facts of the case simply do not, in our           The United States Supreme Court in National
opinion, show this to be an appropriate case to im-         Hockey League v. Metropolitan Hockey Club, Inc.,
pose the ultimate sanctions of striking the pleadings       427 U.S. 639, 96 S. Ct. 2778, 49 L. Ed. 2d 747
and entering default judgment.” We interpret that           (1976) approved the use of sanctions not only to as-
statement to mean that the court of appeals dis-            sure compliance with the discovery process but also
agreed with the decision of the two trial judges who        to deter those who might be tempted to abuse dis-
reviewed the matter.                                        covery in the absence of a deterrent.

     [4] The test for abuse of discretion is not                 This court and various courts of appeals have
whether, in the opinion of the reviewing court, the         also followed this progression. See, e.g., Dyson v.
facts present an appropriate case for the trial court's     Olin Corp., 692 S.W.2d 456 (Tex.1985), (Kilgarlin,
action. Rather, it is a question of whether the court       J., concurring) (unnamed witness not permitted to
acted without reference to any guiding rules and            testify); Jarrett v. Warhola, 695 S.W.2d 8
*242 principles. Craddock v. Sunshine Bus Lines,            (Tex.App.—Houston [14th Dist.] 1985, writ ref'd),
134 Tex. 388, 133 S.W.2d 124, 126                           (plaintiff's cause of action dismissed); City of Hous-
(Tex.Comm.App.—1939, opinion adopted). Anoth-               ton v. Arney, 680 S.W.2d 867 (Tex.App.—Houston
er way of stating the test is whether the act was ar-       [1st Dist.] 1984, no writ) (defendant's answer struck
bitrary or unreasonable. Smithson v. Cessna Air-            for failure to answer interrogatories); Southern Pa-
craft Co., 665 S.W.2d 439, 443 (Tex.1984); Landry           cific Transportation v. Evans, 590 S.W.2d 515
v. Travelers Insurance Co., 458 S.W.2d 649, 651             (Tex.Civ.App.—Houston [1st Dist.] 1979, writ ref'd
(Tex.1970). The mere fact that a trial judge may de-        n.r.e.) (defendant's answer struck and interlocutory
cide a matter within his discretionary authority in a       default judgment rendered as to liability), cert.
different manner than an appellate judge in a simil-        denied, 449 U.S. 994, 101 S. Ct. 531, 66 L.Ed.2d
ar circumstance does not demonstrate that an abuse          291 (1980).
of discretion has occurred. Southwestern Bell Tele-
phone Co. v. Johnson, 389 S.W.2d 645, 648                        In various speeches and law review articles,
(Tex.1965); Jones v. Strayhorn, 159 Tex. 421, 321           different members of this court have encouraged
S.W.2d 290, 295 (Tex.1959).                                 trial judges to use sanctions to the degree necessary
                                                            to assure compliance with discovery procedures and
     To determine the trial judge's guiding rules and       deter abuse of the process. Barrow and Henderson,
principles in imposing sanctions for discovery ab-          1984 Amendments to the Texas Rules of Civil Pro-
use, we must look to the Texas Rules of Civil Pro-          cedure Affecting Discovery, 15 ST. MARY'S L.J.
cedure as promulgated and amended by this Court             713 (1984) (presented to the Texas College of the
as well as the decisions of appellate courts of this        Judiciary Nov. 29, 1984); Kilgarlin and Jackson,
State and of the United States. The Texas Rules of          Sanctions for Discovery Abuse Under New Rule
Civil Procedure pertaining to discovery and sanc-           215, 15 ST. MARY'S L.J. 767 (1984); Pope and
tions for noncompliance have been amended sever-            McConnico, Practicing Law With the 1981 Texas
al times, culminating in Rule 215a as it existed at         Rules, 32 BAYLOR L.REV. 457 (1981); Spears,
the time of this case, and now embodied in Rule             The Rules of Civil Procedure: 1981 Changes In

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701 S.W.2d 238
(Cite as: 701 S.W.2d 238)

Pretrial Discovery, 12 ST. MARY'S L.J. 633                  short statement of the cause of action sufficient to
(1981).                                                     give fair notice of the claim involved. Our rules do
                                                            not require pleadings to contain evidence or factual
     The trial court in this case was free to examine       detail. That point is overruled.
the factors before it to determine whether to levy
sanctions. Among these were the following: (1)                  [6] The second point was that the trial court
whether voluntarily sending the crew to sea rather          improperly refused to strike a juror for cause. After
than producing them for depositions as agreed on            the court had ruled on challenges for cause, there
two occasions was in conscious disregard of this            were 26 names left on the jury list. Each party was
court's rules; (2) whether the contradictory state-         given six jury strikes, so, after making those strikes,
ments of both attorneys indicated that Aquamarine's         14 names remained on the list. The challenged juror
attorney did in fact wait until one hour past the           was Number 14 and was thus a spare. There was no
scheduled time for depositions on July 5, to advise         harm in refusing to dismiss him for cause.
Downer's attorney that he would have to fly to New
Iberia and take depositions on the following day;               [7] The third point was that the trial court im-
(3) whether Aquamarine's attorney consciously dis-          properly refused to admit evidence of Downer's
regarded the sanctions hearing in preference to his         contributory negligence. Contributory negligence is
personal needs and the federal court case set the           an affirmative defense which must be pleaded.
following day; (4) whether the information con-             Aquamarine's answer had been struck and default
tained in the secretary's affidavit as to the date of       judgment rendered as to liability. Thus, defendant
the sanctions hearing conflicted with the letter from       had no pleading to support contributory negligence,
an attorney *243 in that law firm confirming that           so the court did not err in refusing to admit the re-
the hearing was set on August 22; and (5) the unex-         quested evidence.
plained failure of Aquamarine to produce for de-
                                                                 [8] Aquamarine's remaining point before the
positions on any of the occasions in question Clark
                                                            court of appeals was that the trial court erred in
Ivans, the immediate supervisor of Chester Dalfrey
                                                            awarding prejudgment interest in a Jones Act case
and the president of Aquamarine.
                                                            tried to a jury. This point was not presented to the
     [5] The record contains no indication that the         trial court and was thus waived.
trial court was capricious, arbitrary, or unreason-
                                                                 Aquamarine's points of error presented to the
able. Thus, the court of appeals erred in holding
                                                            court of appeals but not considered by that court
that the trial court abused its discretion.
                                                            concerned questions of law over which we have jur-
     In determining whether to reverse and render           isdiction. There is no merit to these points so it is
this cause or to remand it to the court of appeals,         not necessary for this cause to be remanded to the
we must look to the four points of error raised by          court of appeals.
Aquamarine before the court of appeals but not ad-
                                                                The judgment of the court of appeals is re-
dressed by that court. If those points raise questions
                                                            versed and the judgment of the trial court is af-
of law, as opposed to questions of fact, they can be
                                                            firmed.
addressed by this court.
                                                            Tex.,1985.
    The first point was that Downer's First
                                                            Downer v. Aquamarine Operators, Inc.
Amended Original Petition was insufficient to sup-
                                                            701 S.W.2d 238
port the judgment. The contention is that the facts
supporting the cause of action were not pleaded.            END OF DOCUMENT
TEX.R.CIV.P. 47 requires that a petition contain a

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777 S.W.2d 38
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                                                              (Formerly 413k1167)
                                                                Term “litigation,” as used in rule governing
          Supreme Court of Texas.                          party communications privilege, refers only to court
         George FLORES, Relator,                           proceedings and does not encompass proceedings
                   v.                                      before Industrial Accident Board. Vernon's
The FOURTH COURT OF APPEALS, Respondent.                   Ann.Texas Rules Civ.Proc., Rule 166b, subd. 3,
                                                           par. d.
                   No. C–7815.
                  June 28, 1989.                           [2] Pretrial Procedure 307A          35
          Rehearing Denied Oct. 11, 1989.
                                                           307A Pretrial Procedure
     Claimant brought writ of mandamus to compel               307AII Depositions and Discovery
vacation of order of Court of Appeals, 751 S.W.2d                 307AII(A) Discovery in General
551, directing trial court to vacate order requiring                      307Ak35 k. Work-Product Privilege.
city to produce accident report in workers' com-           Most Cited Cases
pensation suit. The Supreme Court, Mauzy, J., held             (Formerly 307Ak33)
that: (1) report was not protected by party commu-              Determination of whether there is good cause
nications privilege, and (2) trial court was within its    to believe suit will be filed, so that investigation is
authority in ordering discovery of report.                 done in anticipation of litigation for purposes of
                                                           party communication privilege, requires considera-
    Writ issued with conditions.
                                                           tion of outward manifestations which indicate litig-
    Gonzales, J., dissented and filed opinion in           ation is imminent, and consideration of whether
which Phillips, C.J., and Cook, J., joined.                party opposing discovery had a good-faith belief
                                                           that litigation would ensue. Vernon's Ann.Texas
                  West Headnotes                           Rules Civ.Proc., Rule 166b, subd. 3, par. d.

[1] Administrative Law and Procedure 15A                   [3] Administrative Law and Procedure 15A
466                                                        466

15A Administrative Law and Procedure                       15A Administrative Law and Procedure
    15AIV Powers and Proceedings of Administrat-               15AIV Powers and Proceedings of Administrat-
ive Agencies, Officers and Agents                          ive Agencies, Officers and Agents
      15AIV(D) Hearings and Adjudications                        15AIV(D) Hearings and Adjudications
        15Ak466 k. Discovery. Most Cited Cases                     15Ak466 k. Discovery. Most Cited Cases

Workers' Compensation 413            1703.5                Workers' Compensation 413            1703.5

413 Workers' Compensation                                  413 Workers' Compensation
   413XVI Proceedings to Secure Compensation                  413XVI Proceedings to Secure Compensation
      413XVI(P) Hearing or Trial                                 413XVI(P) Hearing or Trial
         413XVI(P)2 Production and Reception of                     413XVI(P)2 Production and Reception of
Evidence and Examination of Witnesses                      Evidence and Examination of Witnesses
             413k1703.5 k. Privileges. Most Cited                       413k1703.5 k. Privileges. Most Cited
Cases                                                      Cases
                                                              (Formerly 413k1167)

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777 S.W.2d 38
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    Report relating to workers' compensation               hold that the trial court did not abuse its discretion,
claim, of kind prepared in every case set for pre-         we conditionally grant the writ of mandamus.
hearing conference before Industrial Accident
Board, was prepared in usual and customary course               *39 In the underlying action, Flores filed a
of business and not in preparation of litigation, and      workers' compensation suit against the City of San
therefore was not protected by party communica-            Antonio, which is selfinsured. As part of his pretrial
tions privilege. Vernon's Ann.Texas Rules                  discovery, he propounded a set of interrogatories
Civ.Proc., Rule 166b, subd. 3, par. d.                     and requests for production of documents to the
                                                           City. The City objected to two interrogatories and a
[4] Workers' Compensation 413           1167               request for production that sought discovery of any
                                                           investigations conducted by or on behalf of the City
413 Workers' Compensation                                  after Flores' injury. The City asserted that such in-
   413XVI Proceedings to Secure Compensation               vestigations were privileged under rule 166b(3)(d).
        413XVI(A) In General                               Flores filed a motion to compel answers to the in-
            413k1167 k. Proceedings Before Boards,         terrogatories and request for production, and the
Commissions, or Arbitrators. Most Cited Cases              City responded by filing a motion for protective or-
     District court was within its authority in order-     der.
ing production of investigative report prepared after
notice of injury was filed with Industrial Accident             The judge of the 73rd District Court of Bexar
Board but before appeal to a district court. Vernon's      County conducted a hearing on both motions which
Ann.Texas Rules Civ.Proc., Rule 166b, subd. 3,             included an in camera inspection of the documents
par. d.                                                    and testimony from George Vasill, a claims super-
                                                           visor employed by an independent adjusting firm
*38 Roy D. Quillian, III, Susan Stone, San Antonio,        hired by the City. Vasill had become involved in
for relator.                                               the case after Flores filed his claim for compensa-
                                                           tion with the Industrial Accident Board. After in-
Charles S. Frigerio, Hector X. Saenz, San Antonio,
                                                           vestigating Flores' claim, he filed a prehearing re-
for respondent.
                                                           port.

MAUZY, Justice.                                                 The trial judge granted Flores' motion to com-
     At issue in this mandamus proceeding is               pel and ordered that the prehearing report prepared
whether the trial court in the underlying workers'         by Vasill be produced. The City petitioned the
compensation case abused its discretion by ordering        Fourth Court of Appeals for a writ of mandamus
the production of an investigative report prepared         which was conditionally granted. Flores now seeks
after notice of injury was filed with the Industrial       a writ of mandamus in this court contending that
Accident Board but before an appeal to a district          the court of appeals abused its discretion by grant-
court. The Court of Appeals for the Fourth District        ing the City's writ and ordering the trial court to va-
of Texas held that the trial court abused its discre-      cate its order.
tion and that the information obtained in the post-
                                                                Rule 166b(3)(d) sets out the party communica-
accident investigation was privileged under rule                            FN1
                                                           tions privilege.     At the heart of the controversy
166b(3)(d) of the Texas Rules of Civil Procedure.
                                                           is the language in the rule which states that a com-
The court of appeals directed the trial court to va-
                                                           munication is privileged if it is prepared “in anti-
cate its order. 751 S.W.2d 551. Relator George
                                                           cipation of the prosecution or defense of the claims
Flores seeks mandamus from this court directing
                                                           made a part of the pending litigation.” Tex.R.Civ.P.
the court of appeals to vacate its order. Because we
                                                           166b(3)(d). The City claims that the report prepared

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by Vasill is privileged because it was prepared in         appeals agreed, and accordingly held that litigation
anticipation of litigation.                                commenced when Flores filed his claim for com-
                                                           pensation, and that the report subsequently prepared
         FN1. Rule 166b(3)(d) states:                      was privileged. 751 S.W.2d at 554.

           3. Exemptions. The following matters                 [1] The court of appeals also held that the
           are protected from disclosure by priv-          terms “litigation,” “suit,” and “lawsuit,” as used in
           ilege:                                          rule 166b(3)(d), encompassed proceedings before
                                                           the Industrial Accident Board and thus extended the
           ....
                                                           definition of litigation to include proceedings be-
           d. Party Communications. With the ex-           fore an administrative agency having quasi-judicial
           ception of discoverable communications          powers and employing quasi-judicial procedures.
                                                           FN2
           prepared by or for experts, and other dis-             Id. We cannot sanction*40 this expansive
           coverable communications, between               definition. Therefore, we hold that the term
           agents or representatives or the employ-        “litigation” refers only to court proceedings, which
           ees of a party to the action or communic-       in this case commenced when Flores filed suit in
                                                                               FN3
           ations between a party and that party's         the district court.     Other states have recognized
           agents, representatives or employees,           that a proceeding before workers' compensation
           when made subsequent to the occurrence          agencies does not constitute litigation. Bearns v.
           or transaction upon which the suit is           Department of Indus., Labor & Human Relations,
           based, and in anticipation of the prosecu-      102 Wis. 2d 70, 306 N.W.2d 22 (1981) (litigation
           tion or defense of the claims made a part       refers only to proceedings after the filing of a peti-
           of the pending litigation. For the purpose      tion in district court); Kochinsky v. Independent
           of this paragraph, a photograph is not a        Pier Co., 157 Pa.Super. 15, 41 A.2d 409 (1945)
           communication.                                  (proceedings before the workers' compensation
                                                           agency are not litigation).
           Tex.R.Civ.P. 166b(3)(d).
                                                                    FN2. As support for its definition of litiga-
     The City, as the party resisting discovery, has                tion, the court of appeals cites to G. & C.
the burden of producing evidence to establish the                   Merriam Co., Webster's Third New Inter-
privilege. McKinney v. National Union Fire Ins.                     national Dictionary 1322 (1961) which
Co., 772 S.W.2d 72 (Tex.1989); Turbodyne Corp.                      defines “litigation” as “a controversy in-
v. Heard, 720 S.W.2d 802, 804 (Tex.1986); Giffin                    volving adverse parties before an executive
v. Smith, 688 S.W.2d 112, 114 (Tex.1985). The                       governmental agency having quasi-judicial
City can only invoke the privilege if Vasill pre-                   powers and employing quasi-judicial pro-
pared the report after there was good cause to be-                  cedures.” However, Black's Law Diction-
lieve suit would be filed or after the institution of a             ary 814 (5th ed. 1979) defines litigation as
lawsuit. Stringer v. Eleventh Court of Appeals, 720                 “[a] lawsuit. Legal action, including all
S.W.2d 801, 802 (Tex.1986); Allen v. Humphreys,                     proceedings therein. Contest in a court of
559 S.W.2d 798, 802 (Tex.1977).                                     law for the purpose of enforcing a right or
                                                                    seeking a remedy. A judicial contest, a ju-
     The first inquiry is whether filing a notice of                dicial controversy, a suit at law.”
claim for workers' compensation commences litiga-
tion. The City contends that when a worker files a                  FN3. Rule 166b(3)(e) states:
claim for compensation with the Industrial Acci-
dent Board litigation has commenced. The court of                     3. Exemptions. The following matters

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          are protected from disclosure by priv-           tion commences, but concerned the issue of wheth-
          ilege:                                           er the attorney general could intervene in utility
                                                           rate cases before the Public Utility Commission.
          ....
                                                               Judicial review of a workers' compensation
          e. Other Privileged Information. Any             case is vastly different from a utility rate case. A
          matter protected from disclosure by any          workers' compensation claim differs from other
          other privilege.                                 matters considered by administrative agencies be-
                                                           cause the Industrial Accident Board is a “way sta-
          Upon a showing that the party seeking
                                                           tion” a party must pass through to reach the trial
          discovery has substantial need of the ma-
                                                           court. Either party, including the City as a self-
          terials and that the party is unable
                                                           insured entity, can appeal the board's award and de-
          without undue hardship to obtain the
                                                           mand a trial by jury.
          substantial equivalent of the materials by
          other means, a party may obtain discov-              A party or intervenor appealing from an ad-
          ery of the materials otherwise exempted          verse decision of the Public Utility Commission is
          from discovery by subparagraphs c and d          only entitled to a review under the substantial evid-
          of this paragraph 3. Nothing in this para-       ence rule. It may not remake the record at the trial
          graph 3 shall be construed to render non-        court level and cannot contest issues of fact found
          discoverable the identity and location of        by the Commission. Tex.Rev.Civ.Stat.Ann. art.
          any potential party, any person having           1446c,       §      69     (Vernon      Supp.1989);
          knowledge of relevant facts, any expert          Tex.Rev.Civ.Stat.Ann. art. 6252–13a, § 19 (Vernon
          who is expected to be called as a witness        Supp.1989); see Railroad Comm'n v. Entex, Inc.,
          in the action, or of any consulting expert       599 S.W.2d 292 (Tex.1980). In contrast, a party ap-
          whose opinions or impressions have               pealing an Industrial Accident Board award is not
          been reviewed by a testifying expert.            bound by the record made at the agency level and
                                                           can make a new record at the trial court level,
          Tex.R.Civ.P. 166b(3)(e).
                                                           where the jury determines contested issues of fact.
    Based upon the theory that in State v. Thomas,         Tex.Rev.Civ.Stat.Ann. art. 8307, § 5 (Vernon
766 S.W.2d 217 (Tex.1989), we elevated a                   Supp.1989).
“contested case” before a utility rate agency to the
                                                                [2] Since we have concluded that litigation did
level of an action “in the courts,” the dissent con-
                                                           not commence when Flores' filed his notice of
cludes that proceedings before the Industrial Acci-
                                                           claim, the next inquiry is whether the report was
dent Board constitute litigation. This analysis is
                                                           prepared in anticipation of litigation. Determining
severely flawed. Unlike the Public Utility Commis-
                                                           whether there is good cause to believe a suit will be
sion, the Industrial Accident Board is not an agency
                                                           filed, so that an investigation is done in anticipation
which determines “contested cases” within the
                                                           of litigation, requires a two-prong analysis. The
meaning of the Administrative Procedure and Texas
                                                           first prong requires *41 an objective examination of
Register Act. Tex.Rev.Civ.Stat.Ann. art. 6252–13a,
                                                           the facts surrounding the investigation. Considera-
§ 3(1) (Vernon Supp.1989).
                                                           tion should be given to outward manifestations
     Our holding, that proceedings before the Indus-       which indicate litigation is imminent. The second
trial Accident Board do not constitute litigation,         prong utilizes a subjective approach. Did the party
does not conflict with our holding in Thomas.              opposing discovery have a good faith belief that lit-
Thomas did not address discovery or when litiga-           igation would ensue? There cannot be good cause
                                                           to believe a suit will be filed unless elements of

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(Cite as: 777 S.W.2d 38)

both prongs are present. Looking at the totality of        interlocutory matter is ordinarily quite broad,
the circumstances surrounding the investigation, the       whereas the discretion exercised by an appellate
trial court must then determine if the investigation       court possessing mandamus power is much more
was done in anticipation of litigation. Unless there       confined.” Johnson v. Fourth Court of Appeals, 700
is an abuse of discretion, the trial court's ruling        S.W.2d 916, 917 (Tex.1985). A writ of mandamus
should not be disturbed.                                   is only issued to correct a clear abuse of discretion
                                                           or the violation of a duty imposed by law when
    [3] In the present case, the report was printed        there is no adequate remedy by appeal. State v.
on a standard form and contained the following in-         Walker, 679 S.W.2d 484, 485 (Tex.1984). The
formation: (1) whether there was a question of cov-        court of appeals abuses its discretion when it grants
erage, claimant's employment, compensable injury,          relief absent these circumstances. Johnson, 700
whether the injury occurred in the course and scope        S.W.2d at 917.
of employment; (2) the average weekly wage on the
date of the accident; (3) amount of temporary total             By contrast, a trial court abuses its discretion
disability paid claimant; (4) any advance payments;        when it reaches a decision so arbitrary and unreas-
(5) whether the claim had been previously heard at         onable that it results in a clear and prejudical error
a prehearing conference; (6) summary of medical            of law. The relator must establish that the law and
findings; (7) whether claimant had returned to             the facts of the case only allow the trial court to
work; (8) calculations of the claimant's injuries; (9)     reach one decision, since mandamus will not issue
current indemnity reserves; (10) attorney for the          to control the action of a trial court in a matter in-
claimant; and (11) claims examiner.                        volving discretion. Johnson, 700 S.W.2d at 917.

     During the hearing on the City's motion for                [4] To determine whether the court of appeals
protective order, Vasill testified that it was usual       abused its discretion we must make an independent
and customary to prepare such a report and that this       inquiry as to whether the trial court's order was so
was done in every case that was set for a prehearing       arbitrary and unreasonable that it resulted in a clear
conference. Other than his own conclusion that lit-        and prejudicial error of law. If determination of the
igation would ensue, he observed no outward mani-          matter lies within the discretion of the trial court,
festation of litigation until he received the notice of    its ruling will not be disturbed unless there has been
intention to appeal. Flores' counsel stated he sought      a clear abuse of discretion. Johnson, 700 S.W.2d at
only statements that dealt with the facts of the case      917.
and that he was not interested in any evaluations
made by Vasill or the indemnity reserves. The City              The scope of discovery and the admission of
made no specific attempt to protect the indemnity          evidence is principally within the discretion of the
reserves from disclosure.                                  trial court. Ginsberg v. Fifth Court of Appeals, 686
S.W.2d 105, 108 (Tex.1985). In the present case,
     From the circumstances surrounding its prepar-        the trial judge held a hearing on the City's motion
ation, this report was clearly prepared in the usual       for protective order and an in camera inspection
and customary course of business. Vasill's subject-        pursuant to rule 166b(4) of the Texas Rules of Civil
ive conclusion that Flores would file suit was un-         Procedure. Tex.R.Civ.P. 166b(4); see *42Peeples v.
supported by any objective indications that litiga-        Honorable Fourth Supreme Judicial Dist., 701
tion was imminent; in fact, Vasill himself testified       S.W.2d 635 (Tex.1985). Our review of the record
there were no outward manifestations of litigation.        reveals that the trial court did not reach a decision
                                                           “so arbitrary and unreasonable as to amount to a
     We have previously recognized that “[t]he dis-        clear and prejudicial error of law.” Johnson, 700
cretion exercised by a trial court when ruling on an       S.W.2d at 917. The trial court was properly within

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777 S.W.2d 38
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its discretion when it deemed the investigative re-                  (3) Trial Preparation: Materials. Subject
port discoverable. Accordingly, we hold that the tri-                to the provisions of subdivision (b)(4) of
al court did not abuse its discretion by granting                    this rule, a party may obtain discovery of
Flores' motion to compel and ordering the prehear-                   documents and tangible things otherwise
ing report be produced.                                              discoverable under subdivision (b)(1) of
                                                                     this rule and prepared in anticipation of
     Besides an absence of abuse of discretion, we                   litigation or for trial by or for another
have another reason to uphold the trial court's rul-                 party or by or for that other party's rep-
ing. In 1988 rule 166b(3)(e) was amended; a sen-                     resentative (including the other party's
tence was added to allow one seeking information                     attorney, consultant, surety, indemnitor,
that was otherwise privileged under rule 166b(3)(d)                  insurer, or agent) only upon a showing
, to obtain such discovery by showing that party's                   that the party seeking discovery has sub-
substantial need for materials and inability without                 stantial need of the materials in the pre-
undue hardship to obtain the substantial equivalent                  paration of the party's case and that the
of the materials by other means. Although not ad-                    party is unable without undue hardship
dressed by the parties and often overlooked by                       to obtain the substantial equivalent of
those seeking discovery of privileged materials,                     the materials by other means. In ordering
section (3)(e) is the proper vehicle to alleviate                    discovery of such materials when the re-
much of the bench's and bar's struggle over what in-                 quired showing has been made, the court
vestigations will be deemed in anticipation of litig-                shall protect against disclosure of the
ation.                                                               mental impressions, conclusions, opin-
                                                                     ions, or legal theories of an attorney or
     Similarly, under rule 26(b)(3) of the Federal
                             FN4                                     other representative of a party concern-
Rules of Civil Procedure,          a party may obtain
                                                                     ing the litigation.
discovery of documents and tangible things pre-
pared in anticipation of litigation upon a showing of                A party may obtain without the required
both substantial need and an inability absent undue                  showing a statement concerning the ac-
hardship to obtain the substantial equivalent from                   tion or its subject matter previously
other means. This rule also directs the court to                     made by that party. Upon request, a per-
“protect against disclosure of mental impressions,                   son not a party may obtain without the
conclusions, opinions, or legal theories of an attor-                required showing a statement concerning
ney or other representative of a party.” The utiliza-                the action or its subject matter previ-
tion of this rule in the federal courts has greatly                  ously made by that person. If the request
furthered the purpose of discovery—to prevent trial                  is refused, the person may move for a
by ambush. In Texas, the bar could be similarly                      court order. The provisions of Rule
well-served by utilizing section (3)(e) during dis-                  37(a)(4) apply to the award of expenses
covery.                                                              incurred in relation to the motion. For
                                                                     purposes of this paragraph, a statement
        FN4. Rule 26(b)(3) states:
                                                                     previously made is (A) a written state-
           (b) Discovery Scope and Limits. Unless                    ment signed or otherwise adopted or ap-
           otherwise limited by order of the court in                proved by the person making it, or (B) a
           accordance with these rules, the scope of                 stenographic, mechanical, electrical, or
           discovery is as follows:                                  other recording, or a transcription there-
                                                                     of, which is a substantially verbatim re-
           ....                                                      cital of an oral statement by the person

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777 S.W.2d 38
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           making it and contemporaneously recor-          garding documents the City claimed were priv-
           ded.                                            ileged, with the exception of one document entitled,
                                                           “Pre–Hearing Conference Preliminary Report.” The
           Fed.R.Civ.P. 26(b)(3).                          pre-hearing report had been prepared by a claims
                                                           supervisor after Flores filed his workers' compensa-
     For the above reasons, we hold that the trial
                                                           tion claim to the IAB and it contained, among other
court's ruling should not have been disturbed and
                                                           things, information regarding the indemnity re-
that the court of appeals abused its discretion by
                                                           serves.
granting the City's writ and ordering the trial court
to vacate its order. We conditionally grant Flores'            The City successfully sought a writ of manda-
petition for writ of mandamus. The writ will issue         mus to the court of appeals to compel the trial court
only if the court of appeals refuses to rescind its or-    to vacate part of the order compelling discovery of
der.                                                       the pre-hearing report. For the following reasons, I
                                                           agree that the report was privileged information and
GONZALEZ, J., files a dissenting opinion in which
                                                           therefore warranted the shield of a protective order.
PHILLIPS, C.J., and COOK, J., join.
                                                                The party communications privilege is embod-
GONZALEZ, Justice, dissenting.
                                                           ied in Tex.R.Civ.P. 166b(3)(d), which provides:
     Ordinarily, I would agree with any decision of
this court according greater deference to trial courts       3. Exemptions. The following matters are protec-
in pre-trial matters. See e.g., Loftin v. Martin, 776        ted from disclosure by privilege:
S.W.2d 145 (Tex.1989) (Hecht, J., dissenting).
However,*43 under the peculiar facts of this case,              d. Party Communications. With the exception
the court should not hide behind a false deference           of discoverable communications prepared by or
to judicial discretion, but should announce a simple         for experts, and other discoverable communica-
rule which most parties can understand and follow.           tions, between agents or representatives or the
By failing to propound such a rule, the court has            employees of a party to the action or communica-
left both the bench and the bar adrift. In order to re-      tions between a party and that party's agents, rep-
duce the hemorrhaging of delay, uncertainty, and             resentatives or employees, when made sub-
expense in this muddled area of the law, I would             sequent to the occurrence or transaction upon
adopt a bright line rule in cases where an agency            which the suit is based, and in anticipation of the
determination must precede litigation and hold that          prosecution or defense of the claims made a part
the filing of a claim with the agency constitutes            of the pending litigation. For the purpose of this
commencement of litigation. Because I agree with             paragraph, a photograph is not a communication.
the court of appeals that litigation commenced
when Flores filed his workers' compensation claim,              It is undisputed that the report is a communica-
I would deny the writ of mandamus.                         tion between representatives of the City and was
                                                           prepared subsequent to Flores' injury which gave
    George Flores appealed the Industrial Accident         rise to this suit. However, there is a dispute as to
Board's (IAB) ruling of his workers' compensation          whether the report was prepared in anticipation of
claim in district court. He served his employer, the       litigation. This privilege protects “[o]nly informa-
City of San Antonio, with interrogatories and a re-        tion obtained by a party after there is good cause to
quest for production seeking discovery of any in-          believe a suit will be filed or after the institution of
vestigations conducted by or on behalf of the City         a lawsuit.” Stringer v. Eleventh Court of Appeals,
subsequent to Flores' injury. The trial court granted      720 S.W.2d 801, 802 (Tex.1986); see also Turbo-
a motion for a protective order filed by the City re-      dyne Corp. v. Heard, 720 S.W.2d 802, 804

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              FN1
(Tex.1986).                                                 hearing report was privileged and it was not within
                                                            the discretion of the trial court to order its produc-
         FN1. This is not the first time this court         tion.
         has had difficulty in determining when a
         communication is made in connection with                Also, the two-prong analysis suggested by the
         anticipation of litigation. We have been           court is unworkable. How can a party establish or a
         criticized, and rightfully so, that when           trial court decide whether an investigation made
         there is a collision between two freight           prior to an IAB award was made “with good cause
         trains of different railroads resulting in ser-    to believe” that the claim would later proceed to lit-
         ious injury or death, any “fool” would             igation? It is no longer enough for a party to estab-
         know that a suit would be filed. Stringer          lish this in his or her own state of mind with re-
         and Turbodyne, were per curiam opinions,           gards to another party's conduct, which was diffi-
         and up to now, our court has not allowed           cult enough. To succeed, a party must now not only
         dissents in per curiam opinions.                   demonstrate that it possessed clairvoyant know-
                                                            ledge of the IAB's future reaction to the claim and
     Flores contends that the report is not privileged      the parties response to that reaction (subjective ap-
because it was made prior to his filing suit in dis-        proach), but it must also demonstrate how others in
trict court, and therefore, was not in anticipation of      the same or similar circumstances would react to
litigation. The report was made after the workers'          the claim (objective approach). I submit that today's
compensation claim was filed. Although the IAB is           decision requires litigants and judges to accomplish
not a court, it nonetheless entertains formal adjudic-      the impossible.
ative proceedings in which it performs quasi-ju-
dicial functions. Vestal v. Texas Employers' Ins.               For the above reasons, I dissent.
Ass'n, 285 S.W. 1041, 1044 (Tex. Comm'n
App.1926, judgm't adopted); Moore v. Means, 549             PHILLIPS, C.J. and COOK, J., join in this dissent-
S.W.2d 417, 418 (Tex.Civ.App.—Beaumont 1977,                ing opinion.
writ ref'd n.r.e.). The IAB may order *44 claimants
                                                            Tex.,1989.
to submit to physical examinations, subpoena wit-
                                                            Flores v. Fourth Court of Appeals
nesses, administer oaths, inquire into matters of fact
                                                            777 S.W.2d 38
and punish for contempt in the same manner and to
the same degree as a district court.                        END OF DOCUMENT
Tex.Rev.Civ.Stat.Ann. art. 8307, § 4 (Vernon
Supp.1988). Therefore, in light of these functions, I
agree with the court of appeals that the term
“litigation” contemplated by Rule 166b(3)(d)
should be read to encompass proceedings before the
IAB. This conclusion is consistent with this court's
recent holding in State v. Thomas, 766 S.W.2d 217,
219 (Tex.1989), wherein the court equated a
“contested case” to being the same as an action “in
the courts,” thereby allowing the Attorney General
to intervene under its constitutional authority to
take action “in the courts.” Thus, I would hold that
the filing of a claim with the IAB constitutes the
commencement of a lawsuit. Therefore, the pre-

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395 S.W.3d 884
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                                                                              West Headnotes

           Court of Appeals of Texas,                       [1] Health 198H        804
                    Austin.
 Richard HEBERT and Janet Hebert, Appellants                198H Health
                      v.                                        198HV Malpractice, Negligence, or Breach of
Timothy E. HOPKINS, M.D., and Shannon Clinic,               Duty
                   Appellees.                                      198HV(G) Actions and Proceedings
                                                                      198Hk804 k. Affidavits of merit or merit-
                  No. 03–11–00419–CV.                       orious defense; expert affidavits. Most Cited Cases
                      March 1, 2013.                            To constitute a “good faith effort” to comply
                                                            with statutory definition of the expert report re-
Background: Patient filed health care liability             quired for a health care liability claim (HCLC), the
claim (HCLC) against neurosurgeon and clinic in             report must include the expert's opinion on each of
connection with spinal-fracture surgery that pur-           the three main elements, i.e., standard of care,
portedly rendered patient a quadriparetic. The Dis-         breach, and causation, and must provide enough in-
trict Court, Tom Green County, 391st Judicial Dis-          formation to fulfill two purposes with respect to
trict, Thomas J. Gossett, J., dismissed claim after         each element: (1) it must inform the defendant of
concluding patient had failed to serve an expert re-        the specific conduct the plaintiff has called into
port meeting statutory requirements. Patient ap-            question; and (2) it must provide a basis for the trial
pealed.                                                     court to conclude that the claims have merit.
                                                            V.T.C.A., Civil Practice & Remedies Code §
Holdings: The Court of Appeals, Bob Pemberton,
                                                            74.351(l ), (r)(6).
J., held that:
(1) trial court did not abuse its discretion in con-        [2] Health 198H        804
cluding that patient's expert report did not ad-
equately describe standard of care or alleged breach        198H Health
thereof;                                                         198HV Malpractice, Negligence, or Breach of
(2) statutory requirements applicable to expert re-         Duty
ports in support of HCLCs were rationally related                  198HV(G) Actions and Proceedings
to legitimate state purpose and therefore did not vi-                  198Hk804 k. Affidavits of merit or merit-
olate equal protection based on disparate treatment         orious defense; expert affidavits. Most Cited Cases
of health care liability claimants and other litigants;          Although statutory provisions relating to the
(3) those requirements did not violate separation-          adequacy of an expert report served in support of
of-powers principles; and                                   health care liability claim (HCLC) do not require a
(4) patient failed to demonstrate that those require-       plaintiff to marshal all of his or her proof or to
ments, as applied to him, violated open-courts pro-         present expert testimony in a form that would be
vision of Texas constitution.                               admissible at trial, they do necessitate that the ex-
                                                            pert must explain the basis for his statements to link
      Affirmed.                                             his conclusions to the facts and not merely state
                                                            conclusions. V.T.C.A., Civil Practice & Remedies
      J. Woodfin Jones, C.J., filed a dissenting opin-      Code § 74.351(l ), (r)(6).
ion
                                                            [3] Appeal and Error 30         1024.1

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395 S.W.3d 884
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30 Appeal and Error                                          198H Health
   30XVI Review                                                   198HV Malpractice, Negligence, or Breach of
         30XVI(I) Questions of Fact, Verdicts, and           Duty
Findings                                                            198HV(G) Actions and Proceedings
           30XVI(I)6 Questions of Fact on Motions                       198Hk804 k. Affidavits of merit or merit-
or Other Interlocutory or Special Proceedings                orious defense; expert affidavits. Most Cited Cases
                30k1024.1 k. In general. Most Cited               Trial court did not abuse its discretion, when
Cases                                                        dismissing health care liability claim (HCLC)
                                                             against neurosurgeon for spinal-fracture surgery
Health 198H        804                                       that purportedly rendered patient a quadriparetic, in
                                                             concluding that patient's expert report did not ad-
198H Health
                                                             equately describe standard of care or alleged breach
     198HV Malpractice, Negligence, or Breach of
                                                             thereof; while report suggested anterior-only plate/
Duty
                                                             screw fixation was inconsistent with standard of
       198HV(G) Actions and Proceedings
                                                             care, it also stated there could be “clinical situ-
          198Hk804 k. Affidavits of merit or merit-
                                                             ations” in which anterior-only fixation and supple-
orious defense; expert affidavits. Most Cited Cases
                                                             mental protection such as external braces or activity
     The only information relevant to determining
                                                             limits would meet standard of care, and it did not
whether an expert report served in support of a
                                                             address whether neurosurgeon met the standard
health care liability claim (HCLC) complies with
                                                             through use of such supplemental protection.
statutory requirements as to adequacy is that con-
                                                             V.T.C.A., Civil Practice & Remedies Code §
tained within “the four corners” of the report itself,
                                                             74.351(l ), (r)(6).
and, consequently, neither the trial court nor the ap-
pellate court may infer additional opinions or un-           [6] Appeal and Error 30        333
derlying facts to fill in gaps that the report itself
leaves open. V.T.C.A., Civil Practice & Remedies             30 Appeal and Error
Code § 74.351(l ), (r)(6).                                      30VI Parties
                                                                    30k331 Death
[4] Appeal and Error 30          960(1)                                30k333 k. Pending appeal or writ of error.
                                                             Most Cited Cases
30 Appeal and Error
                                                                  Appellate court would address argument, asser-
    30XVI Review
                                                             ted by patient and his wife on appeal from dismissal
       30XVI(H) Discretion of Lower Court
                                                             of their health care liability claim (HCLC) for fail-
             30k960 Rulings on Motions Relating to
                                                             ure to serve adequate expert report, that statutory
Pleadings
                                                             requirements relating to expert reports in support of
                 30k960(1) k. In general. Most Cited
                                                             an HCLC violated state constitution's open-courts
Cases
                                                             provision as applied to patient, though his death
     The Court of Appeals reviews for abuse of dis-
                                                             during pendency of claim may have terminated his
cretion a trial court's determination as to whether an
                                                             open-courts claim, as substance of open-courts ar-
expert report served in support of a health care liab-
                                                             gument implicated due-process and due-
ility claim (HCLC) meets statutory requirements
                                                             course-of-law concerns also raised on appeal.
for adequacy. V.T.C.A., Civil Practice & Remedies
                                                             U.S.C.A. Const.Amend. 14; Vernon's Ann.Texas
Code § 74.351(l ), (r)(6).
                                                             Const. Art. 1, §§ 13, 19; V.T.C.A., Civil Practice &
[5] Health 198H        804                                   Remedies Code § 74.351(l ), (r)(6).

                                                             [7] Constitutional Law 92        2314

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395 S.W.3d 884
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92 Constitutional Law                                                     92k4418 Torts and Personal Injuries
     92XIX Rights to Open Courts, Remedies, and                                92k4422 k. Professional malprac-
Justice                                                     tice. Most Cited Cases
        92k2313 Conditions, Limitations, and Other               Statutory requirements for expert reports in
Restrictions on Access and Remedies                         support of health care liability claims (HCLCs), as
          92k2314 k. In general. Most Cited Cases           challenged on due process and equal protection
     Wrongful-death and survival claimants cannot           grounds, would be evaluated to determine whether
establish an open-courts violation because they             those requirements bore a rational relationship to a
have no common law right to bring either claim.             legitimate state interest and whether legislature had
Vernon's Ann.Texas Const. Art. 1, § 13.                     a rational basis in differentiating between health
                                                            care liability claimants and other litigants; require-
[8] Constitutional Law 92         3847                      ments did not impinge on a fundamental or import-
                                                            ant right, and they were facially neutral and applied
92 Constitutional Law
                                                            to any party asserting an HCLC. U.S.C.A.
   92XXVII Due Process
                                                            Const.Amend. 14; Vernon's Ann.Texas Const. Art.
       92XXVII(A) In General
                                                            1, § 19; V.T.C.A., Civil Practice & Remedies Code
          92k3847 k. Relationship to other constitu-
                                                            § 74.351.
tions. Most Cited Cases
     While the Texas constitution is textually differ-      [10] Constitutional Law 92         3877
ent from federal constitution in that it refers to “due
course” rather than “due process,” Texas courts re-         92 Constitutional Law
gard those terms as without substantive distinction             92XXVII Due Process
unless and until a party demonstrates otherwise.                         92XXVII(B) Protections Provided and
U.S.C.A. Const.Amend. 14; Vernon's Ann.Texas                Deprivations Prohibited in General
Const. Art. 1, § 19.                                                     92k3877 k. Reasonableness, rationality,
                                                            and relationship to object. Most Cited Cases
[9] Constitutional Law 92         3754                           Under federal and state guarantees of due pro-
                                                            cess, legislation that does not affect a fundamental
92 Constitutional Law
                                                            right or interest is valid if it bears a rational rela-
    92XXVI Equal Protection
                                                            tionship to a legitimate state interest. U.S.C.A.
        92XXVI(E) Particular Issues and Applica-
                                                            Const.Amend. 14; Vernon's Ann.Texas Const. Art.
tions
                                                            1, § 19.
           92XXVI(E)17 Tort or Financial Liabilit-
ies                                                         [11] Constitutional Law 92         3053
             92k3750 Personal Injuries
                   92k3754 k. Medical malpractice.          92 Constitutional Law
Most Cited Cases                                               92XXVI Equal Protection
                                                                   92XXVI(A) In General
Constitutional Law 92         4422                                    92XXVI(A)6 Levels of Scrutiny
                                                                              92k3052 Rational Basis Standard;
92 Constitutional Law
                                                            Reasonableness
    92XXVII Due Process
                                                                              92k3053 k. In general. Most Cited
       92XXVII(G) Particular Issues and Applica-
                                                            Cases
tions
                                                                Constitutional guarantee of equal protection re-
          92XXVII(G)19 Tort or Financial Liabilit-
                                                            quires only that disparate treatment of different
ies
                                                            classifications be rationally related to a legitimate

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395 S.W.3d 884
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state purpose, unless the classification impinges on                  92XXVI(E)17 Tort or Financial Liabilit-
the exercise of a fundamental right or distinguishes        ies
between people on a “suspect” basis, such as race                       92k3750 Personal Injuries
or national origin. U.S.C.A. Const.Amend. 14.                                92k3754 k. Medical malpractice.
                                                            Most Cited Cases
[12] Constitutional Law 92         3062
                                                            Health 198H       604
92 Constitutional Law
   92XXVI Equal Protection                                  198H Health
       92XXVI(A) In General                                      198HV Malpractice, Negligence, or Breach of
           92XXVI(A)6 Levels of Scrutiny                    Duty
                92k3059 Heightened Levels of Scru-                 198HV(A) In General
tiny                                                                     198Hk601 Constitutional and Statutory
                  92k3062 k. Strict scrutiny and com-       Provisions
pelling interest in general. Most Cited Cases                                 198Hk604 k. Validity. Most Cited
     Classifications that impinge upon the exercise         Cases
of a fundamental right or distinguish between                    Statutory requirements applicable to expert re-
people on a suspect basis, i.e., race, national origin,     ports in support of health care liability claims
and alienage, are subject to strict scrutiny on an          (HCLCs) were rationally related to legitimate state
equal protection challenge and will be sustained            purpose of ensuring that medical practitioners were
only if they are suitably tailored to serve a compel-       not being placed in the situation of defending
ling state interest. U.S.C.A. Const.Amend. 14.              frivolous claims at a high cost to the health care
                                                            system and therefore did not violate equal protec-
[13] Constitutional Law 92         3061                     tion based on disparate treatment of health care li-
                                                            ability claimants and other litigants. U.S.C.A.
92 Constitutional Law
                                                            Const.Amend. 14; V.T.C.A., Civil Practice & Rem-
    92XXVI Equal Protection
                                                            edies Code § 74.351.
       92XXVI(A) In General
           92XXVI(A)6 Levels of Scrutiny                    [15] Constitutional Law 92       3057
                92k3059 Heightened Levels of Scru-
tiny                                                        92 Constitutional Law
                 92k3061 k. Intermediate scrutiny in           92XXVI Equal Protection
general. Most Cited Cases                                          92XXVI(A) In General
     When a statute burdens a sensitive class or im-                  92XXVI(A)6 Levels of Scrutiny
pinges on an important right, the statute is subject                          92k3052 Rational Basis Standard;
on an equal protection challenge to an intermediate         Reasonableness
level of scrutiny, which requires a showing that the                         92k3057 k. Statutes and other writ-
statute is substantially related to an important state      ten regulations and rules. Most Cited Cases
interest. U.S.C.A. Const.Amend. 14.
                                                            Constitutional Law 92        3877
[14] Constitutional Law 92         3754
                                                            92 Constitutional Law
92 Constitutional Law                                          92XXVII Due Process
   92XXVI Equal Protection                                              92XXVII(B) Protections Provided and
        92XXVI(E) Particular Issues and Applica-            Deprivations Prohibited in General
tions                                                                  92k3877 k. Reasonableness, rationality,

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395 S.W.3d 884
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and relationship to object. Most Cited Cases                an award of attorney fees upon dismissal for non-
     It is not a court's place to question the legis-       compliance, did not violate separation-of-powers
lature's policy decisions when conducting a rational        principles; they imposed a threshold procedural re-
basis review of a statute challenged on due process         quirement aimed at filtering out meritless or prema-
or     equal     protection    grounds.     U.S.C.A.        ture lawsuits from proceeding until a claimant made
Const.Amend. 14; Vernon's Ann.Texas Const. Art.             a good-faith effort to demonstrate that at least one
1, § 19.                                                    expert believes that a breach of applicable standard
                                                            of care caused claimed injury, and courts retained
[16] Constitutional Law 92         2357                     judicial power to determine whether a timely served
                                                            report was adequate in that regard and to render a
92 Constitutional Law
                                                            decision accordingly. Vernon's Ann.Texas Const.
   92XX Separation of Powers
                                                            Art. 2, § 1, Art. 5, § 1; V.T.C.A., Civil Practice &
      92XX(B) Legislative Powers and Functions
                                                            Remedies Code § 74.351(a-c), (l ), (r)(6).
         92XX(B)2 Encroachment on Judiciary
             92k2357 k. Remedies and procedure in           [17] Constitutional Law 92       2350
general. Most Cited Cases
                                                            92 Constitutional Law
Constitutional Law 92         2380                             92XX Separation of Powers
                                                                  92XX(B) Legislative Powers and Functions
92 Constitutional Law
                                                                     92XX(B)2 Encroachment on Judiciary
   92XX Separation of Powers
                                                                            92k2350 k. In general. Most Cited
      92XX(B) Legislative Powers and Functions
                                                            Cases
         92XX(B)2 Encroachment on Judiciary
             92k2377 Costs and Fees                         Constitutional Law 92        2623
                   92k2380 k. Attorney fees. Most
Cited Cases                                                 92 Constitutional Law
                                                               92XX Separation of Powers
Costs 102      194.48                                              92XX(D) Executive Powers and Functions
                                                                      92k2622 Encroachment on Judiciary
102 Costs
                                                                              92k2623 k. In general. Most Cited
   102VIII Attorney Fees
                                                            Cases
        102k194.48 k. On dismissal, nonsuit, default,
                                                                 Only when the executive or legislative branch
or settlement. Most Cited Cases
                                                            interferes with the functioning of the judicial pro-
Health 198H        604                                      cess in a field constitutionally committed to the
                                                            control of the courts does a constitutional separa-
198H Health                                                 tion-of-powers problem arise. Vernon's Ann.Texas
     198HV Malpractice, Negligence, or Breach of            Const. Art. 2, § 1, Art. 5, § 1.
Duty
      198HV(A) In General                                   [18] Constitutional Law 92       2314
             198Hk601 Constitutional and Statutory
                                                            92 Constitutional Law
Provisions
                                                                 92XIX Rights to Open Courts, Remedies, and
                  198Hk604 k. Validity. Most Cited
                                                            Justice
Cases
                                                                    92k2313 Conditions, Limitations, and Other
    Statutory requirements concerning adequacy
                                                            Restrictions on Access and Remedies
and timely service of expert reports in support of
                                                                      92k2314 k. In general. Most Cited Cases
health care liability claims (HCLCs), and requiring

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Health 198H        604                                           92XIX Rights to Open Courts, Remedies, and
                                                            Justice
198H Health                                                         92k2313 Conditions, Limitations, and Other
     198HV Malpractice, Negligence, or Breach of            Restrictions on Access and Remedies
Duty                                                                  92k2314 k. In general. Most Cited Cases
       198HV(A) In General                                       Open-courts provision of Texas constitution is
             198Hk601 Constitutional and Statutory          premised on the rationale that the legislature has no
Provisions                                                  power to make a remedy by due course of law con-
                  198Hk604 k. Validity. Most Cited          tingent upon an impossible condition. Vernon's
Cases                                                       Ann.Texas Const. Art. 1, § 13.
     Patient whose health care liability claim
(HCLC) against neurosurgeon was dismissed for               [21] Constitutional Law 92         2314
noncompliance with statutory requirements govern-
ing expert reports failed to demonstrate that those         92 Constitutional Law
requirements, as applied to him, violated open-                  92XIX Rights to Open Courts, Remedies, and
courts provision of Texas constitution; patient did         Justice
not prove how the statutory provisions, as opposed                   92k2313 Conditions, Limitations, and Other
to his own failure to provide an adequate report,           Restrictions on Access and Remedies
prevented him from pursuing his claims, or show                        92k2314 k. In general. Most Cited Cases
that expert-report requirement was unreasonable or               To prove that a statute violates the open-courts
arbitrary when balanced with purpose of ensuring            provision of Texas constitution, the claimant must
that medical practitioners were not being placed in         show that: (1) a cognizable common law cause of
the situation of defending frivolous claims at a high       action is being restricted, and (2) the restriction is
cost to the health care system. Vernon's Ann.Texas          unreasonable or arbitrary when balanced with the
Const. Art. 1, § 13; V.T.C.A., Civil Practice &             statute's purpose and basis. Vernon's Ann.Texas
Remedies Code § 74.351.                                     Const. Art. 1, § 13.

[19] Constitutional Law 92         2315                     [22] Constitutional Law 92         2314

92 Constitutional Law                                       92 Constitutional Law
     92XIX Rights to Open Courts, Remedies, and                  92XIX Rights to Open Courts, Remedies, and
Justice                                                     Justice
        92k2313 Conditions, Limitations, and Other                  92k2313 Conditions, Limitations, and Other
Restrictions on Access and Remedies                         Restrictions on Access and Remedies
            92k2315 k. Time for proceedings. Most                     92k2314 k. In general. Most Cited Cases
Cited Cases                                                      A claimant bringing an as-applied open-courts
     Open-courts provision of Texas constitution            challenge to statutory requirements governing ex-
protects a person from having his or her right to sue       pert reports in support of health care liability claims
cut off by a legislative act before the individual has      (HCLCs) must show that the requirements actually
been afforded a reasonable opportunity to discover          prevented him from bringing his claims. Vernon's
the wrong and bring suit. Vernon's Ann.Texas                Ann.Texas Const. Art. 1, § 13; V.T.C.A., Civil
Const. Art. 1, § 13.                                        Practice & Remedies Code § 74.351.

[20] Constitutional Law 92         2314                     [23] Constitutional Law 92         2315

92 Constitutional Law                                       92 Constitutional Law

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     92XIX Rights to Open Courts, Remedies, and                 The right to a jury trial is not an absolute right
Justice                                                     in civil cases, but is subject to certain procedural
        92k2313 Conditions, Limitations, and Other          rules.
Restrictions on Access and Remedies
            92k2315 k. Time for proceedings. Most           [26] Jury 230        31.2(1)
Cited Cases
                                                            230 Jury
Health 198H        604                                          230II Right to Trial by Jury
                                                                   230k30 Denial or Infringement of Right
198H Health                                                             230k31.2 Rights of Action and Procedure
     198HV Malpractice, Negligence, or Breach of            in Civil Cases
Duty                                                                        230k31.2(1) k. In general. Most Cited
       198HV(A) In General                                  Cases
             198Hk601 Constitutional and Statutory               Dismissal of a health care liability claim
Provisions                                                  (HCLC) for failing to serve an adequate expert re-
                  198Hk604 k. Validity. Most Cited          port as required by statute does not violate an asser-
Cases                                                       ted right to jury trial on the merits; such a dismissal
     The statutory expert-report requirement for a          is not based on the merits, but merely operates to
health care liability claim (HCLC) does not violate         dismiss the case on a procedural requirement which
the open-courts provision of Texas Constitution by          is directly related to statute's purpose of limiting the
requiring an expert report sooner rather than later in      number of frivolous suits. V.T.C.A., Civil Practice
the litigation. Vernon's Ann.Texas Const. Art. 1, §         & Remedies Code § 74.351(l ), (r)(6).
13; V.T.C.A., Civil Practice & Remedies Code §
74.351(a, c).                                               *888 Dana D. Banks, Smith Rose Finley, P.C., San
                                                            Angelo, TX, for appellee.
[24] Courts 106         85(1)
                                                            William E. Zook, Jr., David W. Townend, Ted B.
106 Courts                                                  Lyon & Associates, P.C., Mesquite, TX, for appel-
    106II Establishment, Organization, and Proced-          lant.
ure
          106II(F) Rules of Court and Conduct of
                                                            Before Chief Justice JONES, Justices PEMBER-
Business
                                                            TON and ROSE.
         106k85 Operation and Effect of Rules
                106k85(1) k. In general. Most Cited
Cases                                                                             OPINION
     When a rule of procedure conflicts with a stat-        BOB PEMBERTON, Justice.
ute, the statute prevails unless the rule has been               Richard Hebert and his wife, Janet Hebert, ap-
passed subsequent to the statute and repeals the            peal from a district court judgment dismissing, for
statute.                                                    failure to serve the expert report required by
                                                            chapter 74 of the civil practice and remedies code, a
[25] Jury 230       9                                       health care liability claim they asserted against
                                                                                                             FN1
                                                            Timothy Hopkins, M.D., and Shannon Clinic.
230 Jury
                                                            The Heberts bring two issues, urging respectively
   230II Right to Trial by Jury
                                                            that (1) the district court abused its discretion in
       230k9 k. Nature and scope in general. Most
                                                            concluding that they failed to serve an expert report
Cited Cases
                                                            complying with chapter 74; and (2) chapter 74's ex-

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pert-report requirement violates various constitu-          bases of, opinions regarding the applicable standard
tional protections. We will overrule these conten-          of care for Hebert in light of his underlying medical
tions and affirm the district court's judgment.             conditions, the manner in which Hopkins's care had
                                                            failed to meet that standard, or a causal linkage to
        FN1. The parties have advised us that                                                            FN3
                                                            the fusion failure and Richard's injuries.        By
        Richard Hebert died shortly after the               now, the 120–day period for serving an “expert re-
        Heberts perfected their appeal. As contem-          port” had expired, so appellees also moved to dis-
        plated by rule 7.1 of the rules of appellate        miss the Heberts' suit with prejudice and sought a
        procedure, the parties have proceeded on                                                  FN4
                                                            mandatory award of attorney's fees.        Both sides
        appeal as if all parties are alive, and so          submitted briefing on the merits of appellees' objec-
        have we. See Tex.R.App. P. 7.1(a)(1).               tions. Following a hearing at which the parties
                                                            presented argument, the district court sustained ap-
                   BACKGROUND
                                                            pellees' objections but granted the Heberts a thirty-
     The Heberts filed the underlying suit alleging                                                 FN5
                                                            day extension to cure any deficiencies.
that Dr. Hopkins, a neurosurgeon, committed pro-
fessional negligence in performing spinal surgery                   FN2. See Tex. Civ. Prac. & Rem.Code
on Richard Hebert at Shannon in September 2008                      Ann. § 74.351(a) (West 2011) (“In a health
after Richard broke his neck in a fall. Specifically,               care liability claim, a claimant shall, not
they pled that Richard had presented with a fracture                later than the 120th day after the date the
of the cervical 6(C6) vertebra that was “very un-                   original petition was filed, serve on each
stable” due to a preexisting condition known as an-                 party or the party's attorney one or more
kylosing spondylitis that had self-fused his spinal                 expert reports, with a curriculum vitae of
vertebrae on either side of the fracture; that the                  each expert listed in the report for each
standard of care in such circumstances had required                 physician or health care provider against
Hopkins to perform “an anterior and posterior fu-                   whom a liability claim is asserted.”).
sion surgery” to ensure stability; that Hopkins had
performed “an anterior fusion with plates and                          In the absence of material intervening
screws at C4–C7 but took no appropriate surgical                       substantive changes, we have cited the
measures to stabilize the fusion posteriorly;” and                     current version of chapter 74 for con-
that the anterior-only fusion had subsequently                         venience.
“failed as one or more of the screws had pulled out
causing the vertebral segments to move and com-                     FN3. See id. (“Each defendant physician or
press the spinal cord at C4–C7,” rendering Richard                  health care provider whose conduct is im-
a quadriparetic (i.e., paralyzed in all four limbs).                plicated in a report must file and serve any
The Heberts asserted that Shannon was vicariously                   objection to the sufficiency of the report
liable for Hopkins's negligence by virtue of Hop-                   not later than the 21st day after the date it
kins's status as a “partner or member” of the clinic.               was served, failing which all objections are
                                                                    waived.”).
     Within 120 days thereafter, in an attempt to
comply with chapter 74's expert-report requirement,                 FN4. See id. § 74.351(b) (“If, as to a de-
the Heberts served a report from P. Merrill White,                  fendant physician or health care provider,
                                                FN2                 an expert report has not been served within
M.D., along with Dr. White's curriculum vitae.
Hopkins*889 and Shannon timely objected to the                      the period specified by Subsection (a), the
sufficiency of Dr. White's report, asserting that the               court, on the motion of the affected physi-
report had failed to adequately set forth, and was                  cian or health care provider, shall ... enter
“conclusory” with respect to the underlying factual                 an order that: (1) awards to the affected

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        physician or health care provider reason-           are well established. Chapter 74 defines an “expert
        able attorney's fees and costs of court in-         report” as “a fair summary of the expert's opinion
        curred by the physician or health care pro-         as of the date of the report regarding applicable
        vider; and (2) dismisses the claim with re-         standards of care, the manner in which the care
        spect to the physician or health care pro-          rendered by the physician or health care provider
        vider, with prejudice to the refiling of the        failed to *890 meet the standards, and the causal re-
        claim.”); see also id. § 74.351(c)                  lationship between that failure and the injury, harm,
                                                                                     FN8
        (recognizing that “an expert report has not         or damages claimed.”           “A court shall grant a
        been served within the period specified by          motion challenging the adequacy of an expert re-
        Subsection (a)” when “elements of the re-           port only if it appears to the court, after hearing,
        port are found deficient”).                         that the report does not represent an objective good
                                                            faith effort to comply” with this definition of
        FN5. See id. § 74.351(c).                                             FN9
                                                            “expert report.”       To constitute a “good faith ef-
                                                            fort,” as the Texas Supreme Court has explained,
     Within the extension period, the Heberts served
                                                            the report must include the expert's opinion on
a supplemental report from White. Contending that
                                                            “each of the three main elements: standard of care,
White's supplemental report had failed to cure the
                                                            breach, and causation,” and must provide enough
deficiencies in his original report, appellees again
                                                            information to fulfill two purposes with respect to
moved to dismiss the Heberts' suit with prejudice.
FN6                                                         each element: (1) it must inform the defendant of
      The Heberts filed a response joining issue re-
                                                            the specific conduct the plaintiff has called into
garding the sufficiency of the two reports and also
                                                            question; and (2) it must provide a basis for the trial
asserting that chapter 74's expert-report require-
                                                            court to conclude that the claims have merit. See
ment violates various protections of the U.S. or
                                                            Jelinek v. Casas, 328 S.W.3d 526, 538–40 & n. 9
Texas constitutions. Following a hearing, the dis-
                                                            (Tex.2010); Bowie Mem'l Hosp. v. Wright, 79
trict court granted appellees' motion to dismiss.
                                                            S.W.3d 48, 52 (Tex.2002) (per curiam); American
Subsequently, after hearing evidence, the district
                                                            Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46
court awarded appellees attorney's fees as required
                 FN7                                        S.W.3d 873, 878–79 (Tex.2001). Although these
by chapter 74,        and this order also served to
                                                            requirements do not require a plaintiff to marshal
make the court's prior dismissal order final. The
                                                            all of his or her proof or to present expert testimony
Heberts then timely perfected this appeal.
                                                            in a form that would be admissible at trial, see
        FN6. See id. § 74.351(b), (c).                      Jelinek, 328 S.W.3d at 539–40 & n. 9, they do ne-
                                                            cessitate that “the expert must explain the basis for
        FN7. See id. § 74.351(b)(1).                        his statements to link his conclusions to the facts”
                                                            and not merely state conclusions. Id. (quoting
                      ANALYSIS                              Wright, 79 S.W.3d at 52 (quoting Earle v. Ratliff,
Sufficiency of expert reports                               998 S.W.2d 882, 890 (Tex.1999))); see also id. at
     In their first issue, the Heberts urge that the        539–40 (observing, with respect to the causation
district court abused its discretion in holding that        element, “the expert must ... explain, to a reason-
Dr. White's report, either in its original form or as       able degree, how and why the breach caused the in-
supplemented, did not represent an objective good           jury based on the facts presented”). This is so, in
faith effort to comply with the statutory definition        the supreme court's view, because “ ‘[a] report that
of an expert report.                                        merely states the expert's conclusions about the
                                                            standard or care, breach, and causation’ does not
    [1][2] The standards governing the contents of
                                                            fulfill the two purposes of a good-faith effort.” Id.
the expert report or reports required by chapter 74
                                                            at 539 (quoting Palacios, 46 S.W.3d at 879); see

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also id. at 540 (expert “must include sufficient de-        the court ....”) (emphasis added). But the linchpin
tail” regarding how breach caused plaintiff's injur-        determination that controls which of these two al-
ies “to allow the trial court to determine if the claim     ternative sets of mandatory duties applies—whether
has merit”).                                                “it appears to the court” that the report does not
                                                            comply with the requirements—has been commit-
         FN8. See id. § 74.351(r)(6). Chapter 74            ted to the trial court's sound discretion by the Legis-
         also imposes requirements regarding the            lature. See Palacios, 46 S.W.3d at 877–78. Con-
         qualifications of the “expert” who may             sequently, we review the trial court's determination
         prepare an “expert report,” see id. §              for abuse of that discretion. See Wright, 79 S.W.3d
74.351(r)(5), but appellees have not dis-          at 52 (citing Palacios, 46 S.W.3d at 878).
         puted that White meets those standards
         here.                                                   A trial court abuses its discretion when it acts
                                                            in an arbitrary or unreasonable manner without ref-
         FN9. Id. § 74.351(l ).                             erence to any guiding rules or principles. See id.
                                                            (citing Downer v. Aquamarine Operators, Inc., 701
    [3] Importantly, the only information relevant
                                                            S.W.2d 238, 241–42 (Tex.1985)). “When reviewing
to determining whether an expert report complies
                                                            matters committed to the trial court's discretion, a
with these requirements is that contained within
                                                            court of appeals may not substitute its own judg-
“the four corners” of the report itself. Palacios, 46
                                                            ment for the trial court's judgment.” Id. (citing
S.W.3d at 878. Consequently, neither the trial court
                                                            Flores v. Fourth Court of Appeals, 777 S.W.2d 38,
nor this Court may infer additional opinions or un-
                                                            41 (Tex.1989)). We do not, in other words, examine
derlying facts to fill in gaps that the report itself
                                                            the contents of Dr. White's reports and make our
leaves open. See Wright, 79 S.W.3d at 53; see also
                                                            own de novo determination as to whether he has
Austin Heart, P.A. v. Webb, 228 S.W.3d 276, 279
                                                            provided sufficient information, with respect to his
(Tex.App.-Austin 2007, no pet.) (this requirement
                                                            opinions regarding standard of care, breach, and
“precludes a court from filling gaps in a report by
                                                            causation, to (1) inform appellees of the specific
drawing inferences or guessing as to what the ex-
                                                            conduct the Heberts have called into question; and
pert likely meant or intended” (citing Wright, 79
                                                            (2) provide a basis for the district court to conclude
S.W.3d at 53)).
                                                            that the claims have merit. See Jelinek, 328 S.W.3d
     [4] Our standard of review is likewise limited.        at 538–40 & n. 9; Wright, 79 S.W.3d at 52; Pala-
Chapter 74 imposes a mandatory duty on a trial              cios, 46 S.W.3d at 878–79. Instead, we determine
court to grant a motion challenging the adequacy of         only whether the district court acted arbitrarily, un-
an expert report “if it appears to the court” that the      reasonably, and without reference to guiding rules
report does not meet the above-described require-           and principles in determining that the reports failed
ments. See Tex. Civ. Prac. & Rem.Code Ann. §                to provide that information. See Wright, 79 S.W.3d
74.351(l ) (“A court shall grant a motion challen-          at 52; see also Jelinek, 328 S.W.3d at 542
ging the adequacy of an expert report only if it ap-        (Jefferson, C.J., dissenting) (“The dividing line
pears to the court ... that the report does not repres-     between a sufficient and an inadequate report is im-
ent an objective good faith effort to comply with           possible to draw precisely. We have said, therefore,
the definition of an expert report in Subsection            that the determination must be made in the first in-
(r)(6).”) (emphasis added). *891 Conversely, the            stance by the trial court, and review of that decision
trial court is prohibited from granting such a motion       asks not how an appellate court would have re-
unless such noncompliance “appears to the court.”           solved that issue, but instead whether the trial court
Id. (“A court shall grant a motion challenging the          abused its discretion.”) (citing Jernigan v. Langley,
adequacy of an expert report only if it appears to          195 S.W.3d 91, 93 (Tex.2006); Walker v. Gutier-

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rez, 111 S.W.3d 56, 63 (Tex.2003)).                         method, Richard ended up with “increased neurolo-
                                                            gical deficit (quadriparesis).”
     [5]    Applying      this    deferential     abuse-
of-discretion standard of review, we cannot con-                 The medical records, as summarized by White,
clude that the district court acted arbitrarily, unreas-    additionally reflected that Richard had a history of
onably, and without guiding rules and principles in         “coronary artery disease treated with cardiac stints,
determining that Dr. White's reports did not supply         Plavix, and aspirin; cerebrovascular accident [ (i.e.,
it sufficient information regarding his opinions con-       a stroke) ] on two occasions with residual left hand
cerning standard of care and breach, as they relate         paraesthesias [ (tingling or prickling sensations) ]
to the underlying facts, to enable it to determine          treated with Plavix and aspirin; and hypertension,”
whether the Heberts' claims had merit.                      as well as “ankylosing spondylitis,” a degenerative
                                                            condition of the spine that causes both brittleness of
     In his initial report, White summarized medical        bones and self-fusion of vertebrae.
records reflecting that Richard Hebert sought treat-
ment at Shannon in the early morning hours of                   Although he did not indicate whether or how
September 7, 2008, following a fall in which he in-         Richard's other medical conditions impacted the
jured his neck, and that Richard was placed under           standard of care, White emphasized his opinion that
Hopkins's care. According to White, CT scans and            a patient with ankylosing spondylitis warranted
other evaluations revealed that Richard had                 special precautions when performing surgery to ad-
suffered “a trace traumatic subarachnoid hemor-             dress spinal fracture:
rhage ” (i.e., bleeding on the brain) and a “fracture
through the superior vertebral body of C6 with a              In the surgical treatment of cervical spine frac-
fracture extending through the posterior elements of          tures complicating ankylosing spondylitis, the
C5–6.” The injury “was initially managed in a cer-            prudent spine surgeon must recognize the un-
vical collar which was changed to a Philadelphia              stable nature of these fractures. The instability is
collar and spinal precautions were ordered” within            contributed to by the long level arms cranial and
about five hours. That same evening, White indic-             caudal to the fracture site resulting from the mul-
ated, Hopkins performed a surgical procedure in               tilevel autofusion and poor bone quality associ-
which the neurosurgeon *892 fused Richard's                   ated with ankylosing spondylitis. These two
C5–C6 vertebrae and implanted “C4 through C7 an-              factors result in increased susceptibility to spine
terior instrumentation”—a plate over or along the             fractures as a result of relatively minor trauma,
front of Richard's spine, attached by screws to his           greater instability, and a greater likelihood of
bone—to provide stability and support while the               neurologic deficit resulting from a cervical frac-
fracture healed. On the following day, White con-             ture than found in patients with cervical spine
tinued, the medical records indicated that Richard            fractures and otherwise normal spinal anatomy.
had showed signs of recovery progress and that
                                                              The prudent spine surgeon should design a sur-
“[c]ervical collar is discontinued per Dr. Hop-
                                                              gical plan of care allowing decompression of the
kins'[s] order.” But four days later, during the after-
                                                              spinal cord, reduction of the traumatic deformity,
noon of September 12, Richard had a decline in
                                                              and immediate stabilization of the spinal column
neurological function and subsequent CT scans
                                                              to protect the spinal cord and to facilitate mobil-
“confirm[ed] failure of implant fixation at C6 and
                                                              ization and nursing care to the patient in the short
C7” and injury to the spinal cord. Although another
                                                              term and healing of the spinal fusion in the longer
neurosurgeon, Dr. Duarte, operated on Richard
                                                              term.
thereafter to remove the failed anterior instrumenta-
tion and implement a different type of fixation                 As for the standard of care regarding the spe-

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395 S.W.3d 884
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cific means by which these objectives should be             breached an applicable standard. Consistent with
achieved, White initially suggested that anterior-          the first portion of his explanation of the standard
only internal instrumentation was inconsistent with         of care, White began by asserting that Hopkins
the standard of care and that some form of posterior        breached the standard by utilizing “anterior only
internal instrumentation, either additionally or as an      plate/screw fixation”:
alternative to anterior instrumentation, would in-
stead be preferable:                                          Dr. Timothy Hopkins'[s] choice of anterior only
   Over the recent years, the debate of the spinal            plate/screw fixation fails to meet the applicable
   community has been in which circumstances fu-              standard of care. Constrained anterior cervical
   sion with posterior only fixation or fusion with           plates function as tension band devices and re-
   anterior and posterior fixation is appropriate. An-        quire relative stability of the posterior elements.
   terior instrumentation only is predictably inad-           In extension these devices resist distraction of the
   equate in a fracture pattern with gross anterior           anterior column. These devices do not effectively
   and posterior column instability such as Mr.               resist flexion forces and require stable posterior
   Hebert's. Adequate treatment of Mr. Herbert's              elements to limit deformity resulting from flexion
   [sic] fracture requires anterior and posterior in-         forces. In the absence of adequate posterior sta-
   strumentation in order to meet the standard of             bility, anterior plate/screw constructs typically
   care.                                                      fail in flexion by plate breakage or, as in this
                                                              case, by screw pullout. Mr. Herbert's [sic] frac-
  In Mr. Herbert's [sic] situation, the standard of           ture resulted in significant instability of both the
  care requires fixation stable *893 enough to al-            anterior and posterior elements at the C5–6 level.
  low mobilization of the patient without loss of             Anterior only plate/screw fixation, in this setting,
  fixation resulting in increased neurological defi-          is predictably doomed to failure.
  cits. This goal is more likely to be achieved by
  multilevel posterior internal fixation in addition              But in the next sentence, White seemed to al-
  to at least single level anterior internal fixation       lude to his previously expressed view that a sur-
  with fusion at appropriate levels.                        geon could act within the standard of care by
                                                            “supplementing” otherwise “inadequate internal
      However, in the next sentence, within the same        fixation” with some form of “external bracing and/
paragraph, White acknowledged that “clinical situ-          or activity limitations” as an alternative to posterior
ations” could arise in which anterior-only instru-          surgical fixation:
mentation, coupled with “supplemental protection”              The prudent spine surgeon must recognize the
other than posterior implementation, would be con-             limitations of the various internal fixation con-
sistent with the standard of care:                             structs available and if necessary must com-
   If the clinical situation in which the surgeon finds        pensate for the predictable weaknesses by ad-
   himself and the patient allows only inadequate in-          equate external bracing and/or activity limitation.
   ternal fixation, the surgeon is obligated to protect
   the patient supplementing the internal fixation               Then White ended his discussion of breach
   with external bracing and/or activity limitations.       with the following conclusion:
   The supplemental protection should continue un-            The standard of care for the surgical treatment of
   til the patient can be returned to the operating           this fracture requires a multilevel posterior fixa-
   room for additional internal fixation or the frac-         tion and a fusion in conjunction with anterior fix-
   ture becomes stable through healing.                       ation and fusion with or without supplemental ex-
                                                              ternal fixation as was ultimately performed by
    Following these statements regarding standard             Dr. Duarte on September 12, 2008.
of care, White turned to whether or how Hopkins

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     White then offered the following opinions as to        court was within its discretion also to consider
causation, now referencing perceived inadequacies           White's recognition of an apparent exception, quali-
in internal and external fixation without elaborating       fication, or limitation to his broader criticisms of
as to the nature or identity of any of the latter cat-      anterior fixation: “the clinical situation in which the
egory:                                                      surgeon finds himself and the patient” may “allow[
                                                            ] only inadequate internal fixation,” in which case
  The failure to choose the internal and external           the standard of care could be met by
  fixation construct capable of providing stability         “supplementing the internal fixation with external
  to allow mobilization of the patient, prevent spin-       bracing and/or activity limitations.” Along with
  al displacement, and protect the spinal cord is the       White's recognition of this aspect of the standard of
  proximate cause of Mr. Herbert's [sic] *894 in-           care, the court also could have reasonably con-
  creased neurologic deficit (quadriparesis). This          sidered that White never elaborated on the nature or
  occurred as a result of the constrained anterior          type of “clinical situation” that would “allow [ ]
  plate/screw construct's predictable inability to          only inadequate internal fixation” or whether such a
  neutralize flexion forces resulting in screw pul-         situation did or did not exist in regard to Richard, a
  lout at C6 and C7 levels followed by displace-            patient who, as White acknowledged in his report,
  ment of the spinal column through the C5–6 frac-          had a history of coronary artery disease, two
  ture/allograft site with subsequent spinal cord in-       strokes, and hypertension, not to mention bleeding
  jury and deterioration of neurologic function.            on the brain from his fall. The court likewise could
                                                            reasonably have viewed White's references to
     Among their objections to the sufficiency of
                                                            “external bracing” or “activity limitations” as an al-
White's initial report, appellees urged that the re-
                                                            ternative to further internal fixation as begging the
port did not represent an objective good faith at-
                                                            question as to whether the unspecified “spinal pre-
tempt to comply with chapter 74's require-
                                                            cautions” Hopkins had ordered, the cervical collar
ments—i.e., that it discussed the standard of care,
                                                            Richard wore following surgery, or other “external
breach, and causation with sufficient specificity to
                                                            bracing” or “activity limitations” Hopkins imposed
(1) inform them of the conduct called into question
                                                            had or had not satisfied the standard of care.
and (2) provide a basis for the district court to de-
termine that the claims have merit—because it was                In short, we cannot conclude that the district
internally inconsistent as to the standard of care          court acted arbitrarily, unreasonably, or without re-
that applied and did not address whether or not             gard to guiding principles in determining that
Hopkins complied with the standard of care through          White's initial report fell short of describing the ap-
the use of the “external bracing and/or activity lim-       plicable standard or care or breach thereof, as ap-
itation” White had contemplated. And these asser-           plicable to the underlying facts, with sufficient spe-
ted deficiencies, appellees further suggested, in turn      cificity to provide the court a basis to determine
undermined any factual bases underlying White's             that White's claims have merit. See Jelinek, 328
assertions that the standard of care either required        S.W.3d at 538–40 & n. 9; Wright, 79 S.W.3d at 52;
Hopkins's use of anterior-only internal fixation or         Palacios, 46 S.W.3d at 878–79. And in the face of
was breached by his choice not to use posterior in-         such deficiencies regarding standard of care and
terior fixation.                                            breach, the district court would have acted within
                                                            its discretion in determining that any assertions by
     In arguing that the district court abused its dis-
                                                            White to the effect that anterior-only internal fixa-
cretion in sustaining appellees' objections, the
                                                            tion breaches the standard of care or that only pos-
Heberts emphasize the portions of White's initial
                                                            terior internal fixation can suffice lack an underly-
report focusing on the relative merits of anterior
                                                            ing factual basis—*895 i.e., are “conclusory”—and
versus posterior internal fixation. But the district

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fail to satisfy chapter 74. See Wright, 79 S.W.3d at        expert-report requirement: (1) the fixed deadline of
52 (“the expert must explain the basis of his state-        120 days to serve an expert report, subject to a
ments to link his conclusions to the facts” (quoting        single 30–day extension; (2) the requirements fo-
Earle, 998 S.W.2d at 890)).                                 cusing judicial analysis of a report's sufficiency
                                                            solely on the “four corners” of the report and pro-
      The Heberts urge us to indulge a “fair reading”       hibiting courts from considering extrinsic evidence
that White's opinions regarding unspecified                 of a claim's merits; and (3) the mandatory require-
“clinical situations” refers to a surgeon who is at-        ment that courts dismiss health care liability claims
tempting to perform a combined anterior and pos-            with prejudice for failing to serve an adequate ex-
terior procedure but gets interrupted by “surgical          pert report and also award attorney's fees. The
complications such as delays or blood loss,” and            Heberts contend that these mechanisms unfairly
that no such complications arose here. The dissent          “single out” health care liability claimants for un-
similarly relies on inferences or implications that         constitutional “disparate treatment,” deprive courts
such “extraordinary circumstances” were not                 of judicial discretion in violation of the separation-
present. But the problem with these arguments is            of-powers protections of the Texas Constitution,
that White never actually says any of this in his ini-      and deprive claimants of access to the courts in vi-
tial report, and the established rule is that the report    olation of due-process or open-courts protections.
must stand or fall on the contents within its “four         FN10
corners.” Palacios, 46 S.W.3d at 878. This require-
ment, again, “precludes a court from filling gaps in                 FN10. The Heberts acknowledge that
a report by drawing inferences or guessing as to                     Richard's death during the pendency of this
what the expert likely meant or intended.” Austin                    appeal may have terminated his open-
Heart, P.A., 228 S.W.3d at 279 (citing Wright, 79                    courts claim. “[W]rongful-death and sur-
S.W.3d at 53).                                                       vival claimants cannot establish an open-
                                                                     courts violation because they ‘have no
    Nor did the district court abuse its discretion in               common law right to bring either.’ ” Hori-
holding that such deficiencies were not cured by                     zon/CMS Healthcare Corp. v. Auld, 34
White's supplemental report. In his supplement, al-                  S.W.3d 887, 903 (Tex.2000) (quoting Bala
though White reiterates and emphasizes at length                     v. Maxwell, 909 S.W.2d 889, 893
his conclusions and assertions regarding anterior                    (Tex.1995)). The Texas Supreme Court
versus posterior fixation generally, nowhere does                    also has declined to rule on an open-courts
he address the deficiencies concerning the standard                  argument in a similar situation when the
of care and breach that the district court could have                claimant died during the pendency of the
perceived in his initial report.                                     appeal. Kallam v. Boyd, 232 S.W.3d 774,
                                                                     776 (Tex.2007) (per curiam). While we
    We overrule the Heberts' first issue.
                                                                     have similar reservations, we will address
Constitutional claims                                                the Heberts' open-courts argument to the
     [6][7] In their second issue, the Heberts bring                 extent its substance implicates due-process
forward constitutional challenges to chapter 74's                    and due-course-of-law protections they
expert-report requirement. While not appearing to                    have also raised. See, e.g., Bogar v. Espar-
quarrel with the general concept that the Legis-                     za, 257 S.W.3d 354, 370 n. 6
lature can validly impose some form of threshold                     (Tex.App.-Austin 2008, no pet.) (noting
report requirement for asserting health care liability               open-court protections not directly implic-
claims or other types of civil claims, the Heberts                   ated in statutory wrongful-death and sur-
complain about three basic features of chapter 74's                  vivor action before conducting similar due-

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        process analysis).                                  196972, at *6 (Tex.App.-Corpus Christi Jan.21,
                                                            2010, no pet.) (mem. op.) (rejecting due-process
     *896 When reviewing the constitutionality of a         and due-course-of-law challenges); Bogar v. Espar-
statute, we begin with a presumption that it is con-        za, 257 S.W.3d 354, 372–73 (Tex.App.-Austin
stitutional. Herrera v. Seton Nw. Hosp., 212                2008, no pet.) (same); Wilson–Everett v. Christus
S.W.3d 452, 460–61 (Tex.App.-Austin 2006, no                St.     Joseph,     242 S.W.3d 799,    802–04
pet.) (citing Walker, 111 S.W.3d at 66); see also           (Tex.App.-Houston [14th Dist.] 2007, pet. denied)
Tex. Gov't Code Ann. § 311.021(1) (West 2005).              (rejecting       separation-of-powers      challenge);
The wisdom or expediency of the law is the Legis-           Ledesma v. Shashoua, No. 03–05–00454–CV, 2007
lature's prerogative, not ours. Smith v. Davis, 426 WL 2214650, at *9 (Tex.App.-Austin Aug. 3, 2007,
S.W.2d 827, 831 (Tex.1968). We presume that the             pet. denied) (mem. op.) (rejecting due-process and
Legislature has not acted unreasonably or arbitrar-         open-courts challenges); Thoyakulathu v. Brennan,
ily. Sax v. Votteler, 648 S.W.2d 661, 664                   192 S.W.3d 849, 855–56 (Tex.App.-Texarkana
(Tex.1983) (quoting Davis, 426 S.W.2d at 831).              2006, no pet.) (due process does not require
The party challenging a statute's constitutionality         “exceptions [to the expert-report requirement] that
has the burden of proving that the statute fails to         would encompass any conceivable complication in
meet constitutional requirements. Walker, 111               order to pass constitutional muster”); Herrera, 212
S.W.3d at 66. A party must show that a statute is           S.W.3d at 461–62 (rejecting equal-protection, due-
unconstitutional either on its face or as applied to        process, due-course-of-law, and open-courts chal-
that party. Texas Workers' Comp. Comm'n v. Gar-             lenges). Texas courts also uniformly rejected con-
cia, 893 S.W.2d 504, 518 n. 16 (Tex.1995); see              stitutional challenges to an expert-report require-
also City of Corpus Christi v. Public Util. Comm'n,         ment under chapter 74's predecessor statute, article
51 S.W.3d 231, 240–41 (Tex.2001) (per curiam)               4590i. See, e.g., Strom v. Memorial Hermann Hosp.
(Owen, J., concurring). To sustain a facial chal-           Sys., 110 S.W.3d 216, 227 (Tex.App.-Houston [1st
lenge, the party must show that the statute, by its         Dist.] 2003, pet. denied) (rejecting due-process,
terms, always operates unconstitutionally. Garcia,          equal-protection, and jury-trial challenges); Villa v.
893 S.W.2d at 528 n. 16. To sustain an as-applied           Hargrove, 110 S.W.3d 74, 81 (Tex.App.-San Anto-
challenge, the party must show that the statute is          nio 2003, pet. denied) (rejecting due-process and
unconstitutional when applied to that particular per-       equal-protection challenges); Walker, 111 S.W.3d
son or set of facts. Id.                                    at 66 (rejecting due-process challenge); *897Perry
                                                            v.      Stanley,     83 S.W.3d 819,      825
    We note at the outset that the Heberts face an
                                                            (Tex.App.-Texarkana 2002, no pet.) (rejecting
uphill battle because every court that has con-
                                                            open-courts challenge); Mocega v. Urquhart, 79
sidered similar challenges to chapter 74's expert-re-
                                                            S.W.3d 61, 64 (Tex.App.-Houston [14th Dist.]
port requirement, including this Court, has rejected
                                                            2002, pet. denied) (same); Gill v. Russo, 39 S.W.3d
them. See, e.g., Stockton v. Offenbach, 336 S.W.3d
717, 718–19 (Tex.App.-Houston [1st Dist.] 2001,
610, 618 (Tex.2011) (denying open-courts chal-
                                                            pet. denied) (same); Knie v. Piskun, 23 S.W.3d 455,
lenge); Hightower v. Baylor Univ. Med. Ctr., 348
                                                            467 (Tex.App.-Amarillo 2000, pet. denied)
S.W.3d 512, 521–22 (Tex.App.-Dallas 2011, pet.
                                                            (rejecting equal-protection, due-process, open-
denied) (rejecting special-law, vagueness, due-
                                                            courts and free-speech challenges); Schorp v.
course-of-law, and separation-of-powers chal-
                                                            Baptist Mem'l Health Sys., 5 S.W.3d 727, 736–38
lenges); Broxterman v. Carson, 309 S.W.3d 154,
                                                            (Tex.App.-San Antonio 1999, no pet.) (rejecting
159 (Tex.App.-Dallas 2010, pet. denied) (rejecting
                                                            due-process, open-courts, and jury-trial challenges).
due-process challenge); Gulf Coast Med. Ctr., LLC           FN11
v. Temple, No. 13–09–00350–CV, 2010 WL

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         FN11. In their reply brief, the Heberts at-        authorization for the court to summarily dismiss the
         tempt to distinguish some of these cases on        case based on the deficiencies in the language of
         the basis that they involved “a complete           the report.” They also contend that parties opposing
         failure to file an expert report,” instead of      an article 4590i expert report had to “satisfy sum-
         “addressing the legislature's restriction          mary judgment procedures to secure a dismissal
         placed on the courts in deciding the issue”        with prejudice.” To the contrary, a court consider-
         of a report's sufficiency. However, Texas          ing the sufficiency of an expert report under article
         courts, including this Court, have rejected        4590i, as under chapter 74, was limited to the “four
         constitutional challenges where, as here, an       corners” of the report. See Palacios, 46 S.W.3d at
         expert report was served, but found defi-          878. Likewise, if a claimant failed to serve a report,
         cient. See, e.g., Hightower v. Baylor Univ.        or served a report that the trial court concluded did
         Med. Ctr., 348 S.W.3d 512, 520 (Tex.               not represent a good faith effort to comply with the
         App.-Dallas 2011, pet. denied) (upholding          statutory definition of expert report, the trial court
         dismissal of deficient reports); Ledesma v.        was required to dismiss the case with prejudice and
         Shashoua, No. 03–05–00454–CV, 2007                 award costs and attorney's fees to the opposing
         WL 2214650, at *7–8 (Tex.App.-Austin               party. See former art. 4590i, § 13.01(e), (l ), (r)(6);
         Aug. 3, 2007, pet. denied) (mem. op.)              see also Palacios, 46 S.W.3d at 877.
         (same).
                                                            “Disparate treatment ”
     The Heberts acknowledge the constitutional                  [8] The Heberts contend that chapter 74 irra-
validity of the expert-requirement in chapter 74's          tionally singles them out for disparate treatment in
predecessor statute, article 4590i, but attempt to          violation of their rights to due process and equal
distinguish it as “less draconian.” See Act of May          protection. The due-course-of-law guarantee of the
5, 1995, 74th Leg., R.S., ch. 140, § 1, sec. 13.01,         Texas Constitution provides: “No citizen of this
1995 Tex. Gen. Laws 985, 985–88, repealed and               State shall be deprived of liberty, property, priv-
recodified as amended by Act of June 2, 2003, 78th          ileges or immunities, or in any manner disenfran-
Leg., R.S., ch. 204, § 10.01, sec. 74.351, 2003 Tex.        chised, except by due course of the law of the
Gen. Laws 847, 875–77 (amended 2005) (current               land.” Tex. Const. art. I, § 19. Similarly, the federal
version at Tex. Civ. Prac. & Rem.Code Ann. §                due-*898 process clause provides: “No state shall
74.351). They emphasize differences in the dead-            make or enforce any law which shall abridge the
lines article 4590i imposed for serving expert re-          privileges or immunities of the citizens of the
ports and the extent of discretion vested in trial          United States; nor shall any State deprive any per-
courts to extend deadlines. Specifically, article           son of life, liberty, or property, without due process
4590i allowed claimants to either serve an expert           of law;....” U.S. Const. amend. XIV, § 1. While the
report within 90 days of filing suit or file a cost         Texas Constitution is textually different in that it
bond. See former art. 4590i, § 13.01(a). An expert          refers to “due course” rather than “due process,”
report was required within 180 days of suit, though         Texas courts regard these terms as without sub-
the court could grant a 30–day extension if the fail-       stantive distinction unless and until a party demon-
ure to serve was not intentional or the result of con-      strates otherwise, and the Heberts suggest no reason
scious indifference, but was the result of an acci-         to construe them differently here. See University of
dent or mistake. Id. § 13.01(d), (g).                       Tex. Med. Sch. at Houston v. Than, 901 S.W.2d
926, 929 (Tex.1995) (citing Mellinger v. City of
     The Heberts also assert that “4590i did not            Houston, 68 Tex. 37, 3 S.W. 249, 252–53 (1887)).
mandate what had to be included in the contents of
the report,” and that “there was no requirements or             [9][10][11][12][13] Under federal and state

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guarantees of due process, legislation that does not                 ant state interest. Id. at 440–41, 105 S.Ct.
affect a fundamental right or interest is valid if it                3249.
bears a rational relationship to a legitimate state in-
terest. Rylander v. B & A Mktg. Co. ex rel. Atl.                 In enacting chapter 74, the Legislature made a
Richfield Co., 997 S.W.2d 326, 333–34                       number of findings about the state of the health
(Tex.App.-Austin 1999, no pet.) (citing Williamson          care system in Texas. See Act of June 2, 2003, 78th
v. Lee Optical, 348 U.S. 483, 491, 75 S. Ct. 461, 99         Leg., R.S., ch. 204, § 10.11, 2003 Tex. Gen. Laws
L.Ed. 563 (1955); Garcia, 893 S.W.2d at 525).               847, 884–85. Specifically, it found the frequency of
Similarly, the constitutional guarantee of equal pro-       claims and the amounts paid out by insurers in
tection requires only that disparate treatment of dif-      judgments and settlements had risen inordinately
ferent classifications be rationally related to a legit-    since 1995, which created a public problem in the
imate state purpose, unless the classification im-          availability and affordability of adequate medical
pinges on the exercise of a fundamental right or            professional liability insurance. Id. § 10.11(a)(1),
distinguishes between people on a “suspect” basis,          (3), (4). This “crisis” increased costs to physicians,
                                   FN12                     hospitals, patients, and the public. Id. § 10.11(a)(5),
such as race or national origin.          The Heberts
have not demonstrated that chapter 74 impinges on           (7). As a result, the Legislature concluded the
a fundamental or important right or a suspect class.        “adoption of certain modifications in the medical,
By its terms, chapter 74 is facially neutral and ap-        insurance and legal systems” would “have a posit-
plies to any party asserting a health care liability        ive effect on the rates charged by insurers for med-
claim. Consequently, in addressing the Heberts'             ical professional liability insurance.” Id. §
due-process and equal-protection claims, we must            10.11(a)(12). In enacting various measures, includ-
determine whether chapter 74 bears a rational rela-         ing chapter 74, the Legislature intended to reduce
tionship to a legitimate state interest and whether         the frequency and severity of health care liability
the Legislature had a rational basis in differentiat-       claims, decrease costs of claims, and ensure*899
ing between health care liability claimants and oth-        that awards were rationally related to costs, but “do
er litigants. “In so doing, we must uphold the law if       so in a manner that will not unduly restrict a
we can conceive of any rational basis for the Legis-        claimant's rights any more than necessary to deal
lature's action.” Owens Corning v. Carter, 997              with the crisis.” Id. § 10.11(b)(1), (2), (3).
S.W.2d 560, 581 (Tex.1999).
                                                                 In Smalling v. Gardner, the Fourteenth Court
         FN12. Classifications that impinge upon            of Appeals recognized that the “legislature has
         the exercise of a fundamental right or dis-        broad authority to create classifications for legislat-
         tinguish between people on a suspect basis         ive purposes, so long as they have a reasonable
         (i.e., race, national origin, and alienage)        basis and operate equally on all persons within the
         “are subject[ ] to strict scrutiny and will be     class.” 203 S.W.3d 354, 371 (Tex.App.-Houston
         sustained only if they are suitably tailored       [14th Dist.] 2005, pet. denied) (addressing special-
         to serve a compelling state interest.” City        law challenge to constitutionality of article 4590i).
                                                            FN13
         of Cleburne v. Cleburne Living Ctr. Inc.,                 The expert report is required only for claims
         473 U.S. 432, 440, 105 S. Ct. 3249, 87              against healthcare providers for departures from ac-
         L.Ed.2d 313 (1985) (plurality opinion).            cepted standards of medical or health care or safety.
         When a statute burdens a sensitive class or        Id. Accordingly, the expert-report requirement ap-
         impinges on an important right, the statute        plies equally to all physicians and health care pro-
         is subject to an intermediate level of scru-       viders and rationally relates to the interests of the
         tiny, which requires a showing that the            State “in ensuring that medical practitioners were
         statute is substantially related to an import-     not ‘being placed in the situation of defending

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frivolous claims at a high cost’ to the health care         acted to curb frivolous medical malpractice claims
system.” Id. (quoting Schorp, 5 S.W.3d at 737). Re-         by enacting article 4590i, its subsequent enactment
cently, the Dallas Court of Appeals adopted the             of chapter 74 reflects intent to “single out medical
Smalling analysis and applied it to chapter 74. See         malpractice claimants for special and harsh treat-
Hightower, 348 S.W.3d at 521.                               ment by making it so onerous to file and prosecute
                                                            [a claim] that they or their counsel will not take the
         FN13. Though the Heberts did not expli-            case, or once it is filed, to make it so difficult to
         citly claim chapter 74 was an unconstitu-          prosecute the case that they or their counsel will
         tional special law prohibited by the Texas         just give up.” The Heberts likewise complain that
         Constitution, many of their complaints             chapter 74 strips them “of all the rights accorded to
         track arguments raised by parties who have         other litigants in the Texas Rules of Civil Proced-
         raised such claims. Accordingly, we find           ure,” but does not place similar restrictions on
         cases addressing special-law challenges in-        “major corporations like insurance companies and
         structive.                                         banks suing for breach of contract, or on individual
                                                            or corporate clients suing attorneys,*900 account-
     While Smalling and Hightower dealt with spe-
                                                            ants, bankers and brokers.” According to the
cial-law challenges, we previously rejected an
                                                            Heberts, no compelling state interest or rational
equal-protection challenge to chapter 74's prede-
                                                            basis supports this “arbitrary” classification.
cessor for similar reasons. Fields v. Metroplex
Hosp. Found., No. 03–04–00516–CV, 2006 WL                        [14][15] We find no merit in the Heberts' argu-
2089171, at *4 (Tex.App.-Austin July 28, 2006, no           ment that the Legislature, evaluating the impact of
pet.) (mem. op.) (“[T]he legislature determined that        4590i, could not have rationally concluded that a
medical liability plaintiffs should be treated differ-      problem had nonetheless persisted in the cost and
ently because of the negative effects of the numbers        availability of health care due to the prevalence of
and cost of their lawsuits had on the provision of          medical-malpractice suits. To the extent the Heberts
health care.”). In that case, the claimant failed to        challenge the underlying policies of chapter 74, it is
show article 4590i's expert-report requirement was          not our place to question the Legislature's policy
not rationally or substantially related to the govern-      decisions when conducting a rational basis review.
ment's interest in reducing the aggregate costs of          See Bell v. Low Income Women of Tex., 95 S.W.3d
defending against frivolous costs and reducing the          253, 264 (Tex.2002) (“The restriction clearly serves
costs of insurance and medical care to all. Id.; see        [the act's] purposes, and it is not for us to second-
also Bogar, 257 S.W.3d at 373 (in addressing due-           guess the Legislature's policy choices.”). The
process challenge to chapter 74: “We disagree that          Heberts fail to demonstrate that the Legislature
it is irrational, in light of the legislature's goal of     lacked any rational basis in differentiating between
curtailing frivolous health care liability claims, for      health care liability claimants and other litigants.
it to require that appellees serve an expert report         Accordingly, we reject the Heberts' “disparate treat-
explaining why or how this outcome was actually             ment” constitutional challenges.
caused by the conduct of [the defendant], as op-
posed to some other person or health care pro-              Separation of powers
vider.”).                                                        [16][17] For similar reasons, the Heberts' other
                                                            constitutional challenges fail. They claim the Legis-
    The Heberts challenge the Legislature's ra-             lature has impermissibly interfered with the judicial
tionale as “pre-textual, not supported by empirical         branch through chapter 74. The Texas Constitution
data and refuted by surveys showing there aren't ex-        vests the judicial power of the State in the courts.
cessive frivolous medical malpractice suits.” They          Tex. Const. art. V, § 1. The separation-of-powers
reason that because the Legislature had previously

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requirement prohibits one branch of government              to the contrary. Accordingly, we reject the *901
from exercising a power inherently belonging to an-         Heberts' separation-of-powers constitutional chal-
other branch. Id. art. II, § 1; Wilson–Everett, 242         lenge.
S.W.3d at 802 (citing General Servs. Comm'n v.
Little–Tex Insulation Co., 39 S.W.3d 591, 600               Right of access
(Tex.2001)). Only when the executive or legislative              [18][19][20][21] Finally, the Heberts argue
branch interferes with the functioning of the judi-         chapter 74 violates their right of access to the
cial process in a field constitutionally committed to       courts and due course of law. The open-courts pro-
the control of the courts does a constitutional prob-       vision of the Texas Constitution guarantees litigants
lem arise. Wilson–Everett, 242 S.W.3d at 802.               the right to redress their grievances. Tex. Const. art.
                                                            I, § 13; LeCroy v. Hanlon, 713 S.W.2d 335, 341
     Chapter 74's expert report imposes a threshold         (Tex.1986). It protects a person from having his or
procedural requirement aimed at filtering out merit-        her right to sue cut off by a legislative act before
less or premature lawsuits from proceeding until a          the individual has been afforded a reasonable op-
claimant makes a good-faith effort to demonstrate           portunity to discover the wrong and bring suit. Shah
that at least one expert believes that a breach of the      v. Moss, 67 S.W.3d 836, 842 (Tex.2001). It is
applicable standard of care caused the claimed in-          premised on the rationale that the Legislature has
jury. Id. at 802–04 (rejecting argument that chapter        no power to make a remedy by due course of law
74 “interefere[d] with the judiciary's constitutional       contingent upon an impossible condition.
power to decide when and how to render judg-                Hightower, 348 S.W.3d at 522 (citing Moreno v.
ments” (citing Murphy v. Russell, 167 S.W.3d 835,           Sterling Drug, Inc., 787 S.W.2d 348, 355
838 (Tex.2005) (per curiam); Walker, 111 S.W.3d             (Tex.1990)); see also Stockton, 336 S.W.3d at 618
at 66). Though the Heberts contend chapter 74               (rejecting open-courts challenge based on chapter
“prohibits the courts from using the rules of proced-       74's 120–day deadline). To prove that the statute vi-
ure and directs the courts in every respect,” in actu-      olates the open-courts provision, the Heberts must
ality, the courts retain the judicial power to determ-      show that: (1) a cognizable common law cause of
ine whether a timely served report is adequate in           action is being restricted, and (2) the restriction is
this regard and to render a decision accordingly.           unreasonable or arbitrary when balanced with the
See Tex. Civ. Prac. & Rem.Code Ann. § 74.351(l ),           statute's purpose and basis. Sax, 648 S.W.2d at 666.
(r)(6); see also Carrick v. Summers, 294 S.W.3d
886, 891 (Tex.App.-Beaumont 2009, no pet.)                       [22] A claimant bringing an as-applied open-
(“[I]mposing a strict, non-discretionary time limit         courts challenge to chapter 74 must show that the
on serving the expert report does not restrict the tri-     expert-report requirements actually prevented him
al court's power to hear evidence, determine the            from bringing his claims. Herrera, 212 S.W.3d at
facts of a case and the rights of the parties, apply        461; McGlothlin v. Cullington, 989 S.W.2d 449,
the law to the facts and to enter a judgment appro-         453 (Tex.App.-Austin 1999, pet. denied). The
priate to the case, any more than a statute of limita-      Heberts failed to prove how the provisions of
tions does.”). The same is true of chapter 74's re-         chapter 74, as opposed to their own failure to
quirement that courts award attorney's fees upon            provide an adequate report, prevented them from
dismissal. Hightower, 348 S.W.3d at 522 (rejecting          pursuing their claims. See Ledesma, 2007 WL
separation-of-powers challenge based on attorneys'          2214650, at *9 (rejecting open-courts challenge
fees provision because “court still retains its consti-     when plaintiff failed to serve sufficient reports); see
tutional authority to determine the reasonable fees         also Stockton, 336 S.W.3d at 618–19 (rejecting as-
based on the law and the evidence presented by the          applied open-courts challenge when plaintiff failed
parties”). The Heberts offer no persuasive authority        to exercise due diligence in serving expert report on

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395 S.W.3d 884
(Cite as: 395 S.W.3d 884)

defendant physician).                                               90 was approved in 1940 and amended in
                                                                    1980. Thus, to the extent chapter 74 and
      [23][24] As discussed above, the Heberts have                 rule 90 conflict, chapter 74 controls. See
also failed to show chapter 74 is unreasonable or                   Mitchell v. Berry, No. 05–06–01328–CV,
arbitrary when balanced with the statute's purpose                  2007 WL 4111923, at *4 (Tex.App.-Dallas
and basis. Health care liability claims require expert              Nov. 20, 2007, pet. denied) (mem. op.)
testimony at trial. See Smalling, 203 S.W.3d at 371.                (rejecting argument Tex. Civ. Prac. &
The expert-report requirement “ ‘does not violate                   Rem.Code Ann. § 13.001 allowing for dis-
the open-courts provision by requiring an expert re-                missal in inability-to-pay cases was a gen-
port sooner rather than later in the litigation.’ ” Id.             eral demurrer in contravention of Rule 90);
(addressing article 4590i (quoting Mocega, 79                       see also Smalling v. Gardner, 203 S.W.3d
S.W.3d at 64)); see also Gill, 39 S.W.3d at 718–19                  354, 367 n. 8 (Tex.App.-Houston [14th
(article 4590i expert-report requirement did not vi-                Dist.] 2005, pet. denied) (distinguishing
olate open-courts provision because plaintiff raising               dismissal under general demurrer from dis-
medical negligence claim required to prove claim                    missal for failure to serve expert report).
by competent expert testimony to avoid summary
judgment and/or prevail at trial); Bankhead v.                  *902 [25][26] The Heberts have failed to
Spence, 314 S.W.3d 464, 466 (Tex.App.-Waco                  demonstrate a constitutional defect in chapter 74's
                                                                                        FN15
2010, pet. denied) (“This Court and others have de-         expert-report requirement.        Accordingly, we
                                                                                         FN16
termined that the expert-report requirement itself          overrule their second issue.
does not violate the open-courts guarantee because
it ‘is rationally related to the purpose of the statute             FN15. The Heberts make passing reference
to discourage frivolous malpractice suits.’ ”                       to infringement of their right to trial by
(quoting Powell v. Clements, 220 S.W.3d 138, 140                    jury, but provide no authority or argument
(Tex.App.-Waco 2007, pet. denied))); Fields, 2006                   in support of any challenge based on that
WL 2089171, at *4 (holding report requirement not                   provision that is distinct from their other
so onerous that it “effectively deprived the litigant               arguments. To the extent the Heberts inten-
                          FN14                                      ded to advance a distinct challenge based
of access to the court”).
                                                                    on their right to jury trial, it too would fail.
         FN14. The Heberts also argue that chapter                  The right to a jury trial is not an absolute
         74 “effectively revives the general demur-                 right in civil cases, but is subject to certain
         rer practice which permitted judges to dis-                procedural rules. Schorp v. Baptist Mem'l
         miss cases on the pleadings.” They argue                   Health Sys., 5 S.W.3d 727, 738
         that summary judgment is the preferred                     (Tex.App.-San Antonio 1999, no pet.)
         method for defendants to obtain a dis-                     (citing Wooten v. Dallas Hunting & Fish-
         missal on the merits. Our rules of proced-                 ing Club, Inc., 427 S.W.2d 344, 346
         ure prohibit the use of general demurrers.                 (Tex.Civ.App.-Dallas 1968, no writ)).
         Tex.R. Civ. P. 90. However, “[w]hen a                      “Imposing the requirement to file an expert
         rule of procedure conflicts with a statute,                report and the failure to meet that require-
         the statute prevails unless the rule has been              ment allows the trial court to dismiss the
         passed subsequent to the statute and re-                   case. This dismissal is not based on the
         peals the statute....” Johnstone v. State, 22              merits, but merely operates to dismiss the
         S.W.3d 408, 409 (Tex.2000) (per curiam).                   case on a procedural requirement which is
         The current version of chapter 74 was                      directly related to the statute's purpose of
         passed in 2003 and amended in 2005; rule                   limiting the number of frivolous suits.” Id.

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395 S.W.3d 884
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        (addressing article 4590i (citing Buckholts                  S.W.3d 799, 803 (Tex.App.-Houston [1st
        Indep. Sch. Dist. v. Glaser, 632 S.W.2d                      Dist.] 2007, pet. denied) (rejecting argu-
        146, 149 (Tex.1982) (holding that failure                    ment that chapter 74 “interfere[d] with the
        of plaintiff to fulfill bonding requirement                  judiciary's constitutional power to decide
        for challenging school board election did                    when and how to render judgments”). In
        not deny taxpayer right to jury trial on                     any event, cases from other jurisdictions
        merits))).                                                   have no precedential value for this Court.
                                                                     Instead, we are bound to follow the Su-
        FN16. The Heberts point to decisions from                    preme Court of Texas and our own preced-
        other jurisdictions that, in their view,                     ent, as well as the persuasive cases of our
        struck down expert-report requirements                       sister courts. Texas authorities have con-
        similar to chapter 74 based on constitution-                 sistently rejected constitutional challenges
        al provisions analogous to the protections                   similar to those advanced by the Heberts.
        on which they rely here. See, e.g., Putman
        v. Wenatchee Valley Med. Ctr., 166                                    CONCLUSION
        Wash.2d 974, 216 P.3d 374, 378–79                       Having overruled the Heberts' issues on appeal,
        (2009) (law requiring certificate of merit          we affirm the district court's judgment.
        from expert at time of filing violated separ-
        ation of powers and right of access as it cut       *903 Jones, C.J., dissent.
        off rights of discovery and abrogated
                                                            J. WOODFIN JONES, Chief Justice, dissenting.
        pleading requirements in rules of proced-
                                                                 Because I believe the expert report in this case
        ure); Wimley v. Reid, 991 So. 2d 135, 138
                                                            represents a good-faith effort to comply with the
        (Miss.2008) (law requiring certificate of
                                                            statutory definition of an expert report, I respect-
        merit violated separation of powers); Sum-
                                                            fully dissent.
        merville v. Thrower, 369 Ark. 231, 253
S.W.3d 415, 421 (2007) (law requiring ex-                 The three significant Texas Supreme Court
        pert affidavit within 30 days of suit viol-         opinions that address the issue of determining the
        ated separation of powers); Zeier v. Zim-           adequacy of an expert report are American Trans-
        mer, Inc. 152 P.3d 861, 873 (Okla.2006)             itional Care Centers of Texas, Inc. v. Palacios, 46
        (law requiring affidavit of merit with peti-        S.W.3d 873 (Tex.2001); Bowie Memorial Hospital
        tion barred right of access). They also ac-         v. Wright, 79 S.W.3d 48 (Tex.2002); and Jelinek v.
        knowledge that courts in at least two juris-        Casas, 328 S.W.3d 526 (Tex.2010). Together, those
        dictions upheld laws similar to chapter 74.         three cases describe and clarify the standards by
        See McAlister v. Schick, 147 Ill. 2d 84, 167         which courts are to evaluate an expert report. Be-
        Ill.Dec. 1021, 588 N.E.2d 1151, 1157–58             cause those standards are appropriately set forth in
        (1992); Mahoney v. Doerhoff Surgical                the majority opinion, I will not repeat them all. But
        Servs. Inc., 807 S.W.2d 503, 512–13                 it is crucial to remember that all that is necessary to
        (Mo.1991). Additionally, they favorably             avoid dismissal is that the report represent a “good
        cite cases from other jurisdictions that up-        faith effort” to comply with the statutory definition
        held similar laws “so long as the Legis-            of an expert report, which in turn requires only that
        lature [does] not direct[ ] the Courts how          the report provide “a fair summary of the expert's
        to decide the legitimacy of the case.”              opinions” regarding standard of care, breach, and
        Texas decisions regarding chapter 74 are            causation. Most important, the supreme court has
        consistent with that reasoning. See, e.g.,          defined “good faith effort” as “one that provides in-
        Wilson–Everett v. Christus St. Joseph, 242          formation sufficient to (1) ‘inform the defendant of

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395 S.W.3d 884
(Cite as: 395 S.W.3d 884)

the specific conduct the plaintiff has called into            • “Dr. Hopkins performed an anterior (front) only
question,’ and (2) ‘provide a basis for the trial court       plate and screw fixation.... The standards of care
to conclude that the claims have merit.’ ” Jelinek,           governing a prudent surgeon require that he not
328 S.W.3d at 539 (quoting Wright, 79 S.W.3d at               perform anterior only fixation with plate and
52). I believe the report in the present case easily          screws....”
meets that test.
                                                              • “The standards of care governing a prudent sur-
     The first prong of the good-faith test is that the       geon require that he perform a multilevel posteri-
report must “inform the defendant of the specific             or instrumented fusion alone or in conjunction
conduct the plaintiff has called into question.” In           with an anterior instrumented fusion....”
this regard, the expert report in this case could not
be clearer: the standard of care requires that a spin-        *904 • “My opinion is that Dr. Hopkins breached
al fracture complicated by pre-existing ankylosing            the standard of care by performing a multi-level
spondylitis must be treated by posterior internal fix-        anterior only fusion and fixation with plate/
ation, either alone or in combination with anterior           screws without also performing a multi-level pos-
internal fixation, not by anterior fixation alone, as         terior fusion and fixation with instrumentation.”
was done by the defendant physician here. By my
                                                              • “The factual basis for this opinion is that a
count, the medical expert's report contains no less
                                                              prudent surgeon following the standards of care
than nine separate statements and/or explanations
                                                              would not have performed an anterior only fusion
of this requirement, four in his original report and
                                                              with instrumentation to attempt to stabilize this
five more in his supplemental report.
                                                              very unstable fracture but would have performed
  • “Anterior instrumentation only is predictably             an anterior instrumented fusion with plates/
  inadequate in a fracture pattern with gross anteri-         screws and a multilevel posterior instrumented
  or and posterior column instability such as Mr.             fusion or a multilevel posterior instrumented fu-
  Hebert's. Adequate treatment of Mr. Herbert's               sion alone.”
  fracture requires anterior and posterior instru-
                                                              • “[P]erforming an anterior only fusion with in-
  mentation in order to meet the standard of care.”
                                                              strumentation without also performing the pos-
  • “Dr. Timothy Hopkins' choice of anterior only             terior fusion and fixation was a breach of the
  plate/screw fixation fails to meet the applicable           standard of care because the standards of care re-
  standard of care.”                                          quire performing both procedures to adequately
                                                              stabilize the very unstable fracture and anterior
  • “In the absence of adequate posterior stability,          only surgery was doomed to fail....”
  anterior plate/screw constructs typically fail in
  flexion by plate breakage or, as in this case, by              There can be no doubt what conduct is being
  screw pullout.... Anterior only plate/screw fixa-         called into question.
  tion, in this setting, is predictably doomed to fail-
                                                                 The second prong of the supreme court's good-
  ure.”
                                                            faith definition is that the report must “provide a
  • “The standard of care for the surgical treatment        basis for the trial court to conclude that the claims
  of this fracture requires a multilevel posterior fix-     have merit.” Here, the expert report goes into great
  ation and a fusion in conjunction with anterior           detail in explaining the standard of care, why the
  fixation and fusion with or without supplemental          actions of the defendant physician constituted a
  external fixation....”                                    breach of the standard, and “how and why the
                                                            breach caused the injury based on the facts presen-

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395 S.W.3d 884
(Cite as: 395 S.W.3d 884)

ted.” Jelinek, 328 S.W.3d at 539–40. The report               *905 with external bracing and/or activity limita-
does not contain mere conclusions of the expert.              tions.
Quite the contrary. As to causation, for example,
the report explains at length the process by which               There are several things to note about this sen-
the breach of the standard of care resulted in the          tence. First, it does not say that anterior only intern-
plaintiff's paralysis:                                      al fixation could ever meet the standard of care in
                                                            treating a patient with the conditions existing here.
  My opinion is that performing an anterior only            Indeed, the sentence does not explicitly reference
  fusion with instrumentation without also per-             anterior internal fixation at all. It is simply a gener-
  forming a multilevel posterior instrumented fu-           al reference to a hypothetical situation in which
  sion caused permanent and irreversible spinal             “inadequate internal fixation” is, temporarily, the
  cord injury when the screw predictably pulled out         only available option under some presumably ex-
  in the post perioperative period.... When the             traordinary circumstances. Second, whatever the
  screw pulled out of the vertebral segments of C–6         general references to “clinical situation” and
  and C–7, the C–5 vertebral body was allowed to            “inadequate internal fixation” mean, the report goes
  move on C–6 resulting in cord compression. The            on to specify that the defendant breached the stand-
  screw predictably failed because the anterior only        ard of care in this case, as to this patient. This is an
  approach was insufficient in the absence of inher-        implicit statement that, to the best of the expert's
  ent or surgically created posterior element stabil-       knowledge, there were no extraordinary circum-
  ity, to stabilize the fracture and resist deformation     stances in this case. Third, and perhaps most im-
  due to flexion forces. When the screws failed, the        portant, the possible existence of extraordinary cir-
  vertebral segments moved resulting in cord com-           cumstances that might—or might not—justify the
  pression. As a result, Mr. Hebert is now a quadra-        defendant physician's temporary use of anterior
  paretic, meaning he is nearly completely para-            only internal fixation is a matter to be fleshed out
  lyzed from the chest down. If, instead of the an-         during discovery and possibly trial, not as part of a
  terior only surgery, Dr. Hopkins had performed            gatekeeper effort to deter frivolous lawsuits. This is
  an anterior and posterior instrumented fusion,            especially true in light of the fact that the medical
  like Dr. Duarte did on 9/12/08, it is highly prob-        records available to the expert in preparing his re-
  able the anterior implants would not have failed          port may not have reflected whether any such ex-
  as they did, the resulting cord compression would         traordinary circumstances existed at the time of the
                                                                     FN1
  have been avoided and Mr. Hebert would not                surgery.       To require a report to negate possible
  have sustained his spinal cord injury and paralys-        defenses at this stage of the litigation creates an ex-
  is.                                                       tra-statutory burden and is unfair to both the
                                                            plaintiff and the medical expert.
     In the face of the expert report's highly detailed
explanation of all of the elements required by Pala-                 FN1. Medical issues, like legal ones, are
cios, Wright, and Jelinek, the majority holds that a                 seldom black and white. One can imagine
single sentence from the original report was so                      a hypothetical conversation between a
“internally inconsistent” as to the applicable stand-                plaintiff's attorney and the plaintiff's med-
ard of care that all of the report's detailed explana-               ical expert, in which the expert says
tions and opinions were vitiated:                                    something like, “In the overwhelming ma-
                                                                     jority of cases like this, the standard of
  If the clinical situation in which the surgeon finds               care is X. But I have to be candid: in a
  himself and the patient allows only inadequate in-                 very small percentage of such cases, ex-
  ternal fixation, the surgeon is obligated to protect               traordinary circumstances may call for a
  the patient supplementing the internal fixation

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395 S.W.3d 884
(Cite as: 395 S.W.3d 884)

        different treatment approach. Nothing in
        the medical records I have seen indicates
        that such extraordinary circumstances exis-
        ted in this case, but I would not be com-
        pletely honest if I did not at least mention
        that possibility.”

     I believe the expert report in this case consti-
tuted a good-faith effort to comply with the defini-
tion of an expert report, as required by the applic-
able statutes and supreme court precedent. Accord-
ingly, I respectfully dissent.

Tex.App.–Austin,2013.
Hebert v. Hopkins
395 S.W.3d 884

END OF DOCUMENT

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                                                                                                         Page 1
328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

                                                              Lehrmann, J., filed opinion dissenting in part.
            Supreme Court of Texas.
  Michael T. JELINEK, M.D. and Columbia Rio                                 West Headnotes
Grande Healthcare, L.P. d/b/a Rio Grande Regional
                                                          [1] Health 198H        631
              Hospital, Petitioners,
                         v.                               198H Health
Francisco CASAS and Alfredo DeLeon, Jr., as Per-               198HV Malpractice, Negligence, or Breach of
sonal Representatives of the Estate of Eloisa Casas,      Duty
             Deceased, Respondents.                              198HV(B) Duties and Liabilities in General
                                                                    198Hk630 Proximate Cause
                   No. 08–1066.
                                                                          198Hk631 k. In general. Most Cited
               Argued Feb. 18, 2010.
                                                          Cases
               Decided Dec. 3, 2010.
                                                               At a trial concerning a medical malpractice
Background: Patient's surviving family members            claim, the plaintiff must establish two causal nex-
brought medical malpractice action against hospital       uses in order to be entitled to recovery: (1) a causal
and physician, arising out of treatment of patient at     nexus between the defendant's conduct and the
hospital. Following non-suiting of physician, and         event sued upon; and (2) a causal nexus between
following jury trial, the 275th District Court,           the event sued upon and the plaintiff's injuries.
Hidalgo County, Juan R. Partida, J., entered judg-
                                                          [2] Appeal and Error 30         1001(3)
ment for family members. Hospital and physician
appealed. The Corpus Christi Court of Appeals,            30 Appeal and Error
2008 WL 2894889, affirmed. Hospital and physi-                30XVI Review
cian petitioned for review.                                         30XVI(I) Questions of Fact, Verdicts, and
                                                          Findings
Holdings: The Supreme Court, Guzman, J., held
                                                                     30XVI(I)2 Verdicts
that:
                                                                           30k1001 Sufficiency of Evidence in
(1) lay testimony of family members did not
                                                          Support
present some evidence in support of finding that
                                                                                  30k1001(3) k. Total failure of
hospital's alleged negligence caused patient's addi-
                                                          proof. Most Cited Cases
tional pain and suffering;
                                                                In a legal sufficiency review, when the evid-
(2) expert testimony did not present some evidence
                                                          ence offered to prove a vital fact is so weak as to do
in support of finding that hospital's alleged negli-
                                                          no more than create a mere surmise or suspicion of
gence caused patient's additional pain and suffer-
                                                          its existence, the evidence is no more than a scin-
ing; and
                                                          tilla and, in legal effect, is no evidence.
(3) expert report was conclusory with regard to
causation and, thus, was deficient.                       [3] Appeal and Error 30         1001(3)
   Reversed and rendered in part; reversed and re-        30 Appeal and Error
manded in part.                                              30XVI Review
                                                                   30XVI(I) Questions of Fact, Verdicts, and
    Jefferson, C.J., dissented in part, and filed         Findings
opinion in which Green and Lehrmann, JJ., joined.                   30XVI(I)2 Verdicts

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                                                                                                        Page 2
328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

                30k1001 Sufficiency of Evidence in         198H Health
Support                                                         198HV Malpractice, Negligence, or Breach of
                       30k1001(3) k. Total failure of      Duty
proof. Most Cited Cases                                           198HV(G) Actions and Proceedings
     In a legal sufficiency review, when the circum-                 198Hk815 Evidence
stances are equally consistent with either of two                           198Hk823 Weight and Sufficiency,
facts, neither fact may be inferred.                       Particular Cases
                                                                                198Hk823(8) k. Diagnosis and
[4] Appeal and Error 30         1002                       treatment of cancer. Most Cited Cases
                                                                Lay testimony of patient's surviving husband
30 Appeal and Error
                                                           and son regarding patient's discomfort while obtain-
   30XVI Review
                                                           ing treatment for cancer in hospital did not present
         30XVI(I) Questions of Fact, Verdicts, and
                                                           some evidence in support of finding that hospital's
Findings
                                                           alleged negligence caused patient's additional pain
          30XVI(I)2 Verdicts
                                                           and suffering, in their medical malpractice action
                30k1002 k. On conflicting evidence.
                                                           against hospital; testimony of husband and son
Most Cited Cases
                                                           raised no more than mere suspicion of causation,
     In a legal sufficiency review, when the evid-
                                                           inasmuch as they were unable to assert whether it
ence equally supports two alternatives, the Supreme
                                                           was cancer, surgery, other infections, or lapse in
Court must view each piece of circumstantial evid-
                                                           medication that caused such discomfort.
ence, not in isolation, but in light of all the known
circumstances, and must consider not just favorable        [7] Health 198H       821(3)
but all the circumstantial evidence, and competing
inferences as well.                                        198H Health
                                                               198HV Malpractice, Negligence, or Breach of
[5] Health 198H        822(3)                              Duty
                                                                198HV(G) Actions and Proceedings
198H Health
                                                                    198Hk815 Evidence
     198HV Malpractice, Negligence, or Breach of
                                                                        198Hk821 Necessity of Expert Testi-
Duty
                                                           mony
       198HV(G) Actions and Proceedings
                                                                            198Hk821(3) k. Proximate cause.
          198Hk815 Evidence
                                                           Most Cited Cases
               198Hk822 Weight and Sufficiency in
General                                                    Health 198H       821(4)
                  198Hk822(3) k. Proximate cause.
Most Cited Cases                                           198H Health
     To meet the legal sufficiency standard in med-            198HV Malpractice, Negligence, or Breach of
ical malpractice cases, plaintiffs are required to ad-     Duty
duce evidence of a reasonable medical probability,               198HV(G) Actions and Proceedings
or reasonable probability, that their injuries were                 198Hk815 Evidence
caused by the negligence of one or more defend-                         198Hk821 Necessity of Expert Testi-
ants, meaning simply that it is more likely than not       mony
that the ultimate harm or condition resulted from                           198Hk821(4) k. Gross or obvious
such negligence.                                           negligence and matters of common knowledge.
                                                           Most Cited Cases
[6] Health 198H        823(8)                                  Lay testimony may be used as evidence of

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                                                                                                         Page 3
328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

causation in certain circumstances in medical mal-                         198Hk821 Necessity of Expert Testi-
practice actions, but when expert testimony is re-          mony
quired, lay evidence supporting liability is legally                          198Hk821(4) k. Gross or obvious
insufficient.                                               negligence and matters of common knowledge.
                                                            Most Cited Cases
[8] Health 198H       821(3)                                     Non-expert evidence alone is sufficient in a
                                                            medical malpractice action to support a finding of
198H Health
                                                            causation in limited circumstances where both the
     198HV Malpractice, Negligence, or Breach of
                                                            occurrence and conditions complained of are such
Duty
                                                            that the general experience and common sense of
       198HV(G) Actions and Proceedings
                                                            laypersons are sufficient to evaluate the conditions
          198Hk815 Evidence
                                                            and whether they were probably caused by the oc-
               198Hk821 Necessity of Expert Testi-
                                                            currence.
mony
                   198Hk821(3) k. Proximate cause.          [11] Evidence 157         571(9)
Most Cited Cases
     A general rule in medical malpractice actions is       157 Evidence
that expert testimony is necessary to establish caus-          157XII Opinion Evidence
ation as to medical conditions outside the common                 157XII(F) Effect of Opinion Evidence
knowledge and experience of jurors.                                  157k569 Testimony of Experts
                                                                        157k571 Nature of Subject
[9] Health 198H       631                                                     157k571(9) k. Cause and effect.
                                                            Most Cited Cases
198H Health
     198HV Malpractice, Negligence, or Breach of            Evidence 157        574
Duty
       198HV(B) Duties and Liabilities in General           157 Evidence
          198Hk630 Proximate Cause                             157XII Opinion Evidence
                198Hk631 k. In general. Most Cited                157XII(F) Effect of Opinion Evidence
Cases                                                                 157k574 k. Conflict with other evidence.
     Correlation does not necessarily imply causa-          Most Cited Cases
tion, for purposes of a medical malpractice action;
evidence of an event followed closely by manifesta-         Health 198H         823(6)
tion of or treatment for conditions which did not
                                                            198H Health
appear before the event raises suspicion that the
                                                                 198HV Malpractice, Negligence, or Breach of
event at issue caused the conditions, but suspicion
                                                            Duty
has not been and is not legally sufficient to support
                                                                   198HV(G) Actions and Proceedings
a finding of legal causation.
                                                                      198Hk815 Evidence
[10] Health 198H        821(4)                                               198Hk823 Weight and Sufficiency,
                                                            Particular Cases
198H Health                                                                    198Hk823(6) k. Infections and in-
    198HV Malpractice, Negligence, or Breach of             fectious diseases. Most Cited Cases
Duty                                                             Expert testimony did not present some evid-
     198HV(G) Actions and Proceedings                       ence in support of finding that hospital's alleged
        198Hk815 Evidence                                   negligence through lapse in medication caused pa-

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

tient's additional pain and suffering, in medical         ences from the evidence and state that “in medical
malpractice action by patient's surviving family          probability” the injury was caused by the defend-
members against hospital; competing explanations          ant's negligence; rather, the expert must explain
existed for presence of negligence-induced infec-         why the inferences drawn are medically preferable
tion, and expert did not explain why presence of          to competing inferences that are equally consistent
such infection was medically more probable than           with the known facts, and thus, when the facts sup-
competing explanations.                                   port several possible conclusions, only some of
                                                          which establish that the defendant's negligence
[12] Evidence 157       555.10                            caused the plaintiff's injury, the expert must explain
                                                          to the fact finder why those conclusions are superi-
157 Evidence
                                                          or based on verifiable medical evidence, not simply
   157XII Opinion Evidence
                                                          the expert's opinion.
      157XII(D) Examination of Experts
         157k555 Basis of Opinion                         [14] Health 198H        822(3)
                157k555.10 k. Medical testimony.
Most Cited Cases                                          198H Health
                                                               198HV Malpractice, Negligence, or Breach of
Trial 388      105(3)                                     Duty
                                                                 198HV(G) Actions and Proceedings
388 Trial
                                                                    198Hk815 Evidence
   388IV Reception of Evidence
                                                                         198Hk822 Weight and Sufficiency in
        388IV(C) Objections, Motions to Strike Out,
                                                          General
and Exceptions
                                                                             198Hk822(3) k. Proximate cause.
              388k105 Effect of Failure to Object or
                                                          Most Cited Cases
Except
                                                              The proof in a medical malpractice action must
                388k105(3) k. Expert and other opin-
                                                          establish causal connection beyond the point of
ion evidence. Most Cited Cases
                                                          conjecture; it must show more than a possibility.
     If no basis for the expert opinion in a medical
malpractice action is offered, or the basis offered       [15] Health 198H        822(2)
provides no support, the opinion is merely a con-
clusory statement and cannot be considered probat-        198H Health
ive evidence, regardless of whether there is no ob-            198HV Malpractice, Negligence, or Breach of
jection; a claim will not stand or fall on the mere       Duty
ipse dixit of a credentialed witness.                            198HV(G) Actions and Proceedings
                                                                    198Hk815 Evidence
[13] Evidence 157       555.10                                           198Hk822 Weight and Sufficiency in
                                                          General
157 Evidence
                                                                             198Hk822(2) k. Degree of proof.
   157XII Opinion Evidence
                                                          Most Cited Cases
       157XII(D) Examination of Experts
                                                               Verdicts in a medical malpractice action must
          157k555 Basis of Opinion
                                                          rest upon reasonable certainty of proof.
                 157k555.10 k. Medical testimony.
Most Cited Cases                                          [16] Appeal and Error 30         1001(1)
    When the only evidence of a vital fact is cir-
cumstantial, an expert witness in a medical mal-          30 Appeal and Error
practice action cannot merely draw possible infer-           30XVI Review

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

           30XVI(I) Questions of Fact, Verdicts, and             102k1 Nature and Grounds of Right
Findings                                                            102k2 k. In general. Most Cited Cases
           30XVI(I)2 Verdicts
               30k1001 Sufficiency of Evidence in          Health 198H        804
Support
                                                           198H Health
                     30k1001(1) k. In general. Most
                                                                198HV Malpractice, Negligence, or Breach of
Cited Cases
                                                           Duty
Trial 388        140(1)                                           198HV(G) Actions and Proceedings
                                                                      198Hk804 k. Affidavits of merit or merit-
388 Trial                                                  orious defense; expert affidavits. Most Cited Cases
    388VI Taking Case or Question from Jury                     Expert report was conclusory with regard to
          388VI(A) Questions of Law or of Fact in          causation, and thus, was deficient, in medical mal-
General                                                    practice action by patient's surviving family mem-
          388k140 Credibility of Witnesses                 bers against physician arising out of treatment of
               388k140(1) k. In general. Most Cited        patient, so as to entitle physician to award of attor-
Cases                                                      ney fees and costs in action; report offered no more
     Courts should not usurp the jury's role as fact       than bare assertion that physician's alleged breach
finder, nor should they question the jury's right to       resulted in increased pain and suffering as well as
believe one witness over another; but when review-         prolonged hospital stay, but did not offer explana-
ing a verdict for sufficiency of the evidence, courts      tion of how breach caused injury. Vernon's
need not, indeed, must not, defer to the jury's find-      Ann.Texas Civ.St. art. 4590i, § 13.01(e)
ings when those findings are not supported by cred-        (Repealed).
ible evidence.
                                                           [19] Health 198H         804
[17] Appeal and Error 30         1001(3)
                                                           198H Health
30 Appeal and Error                                             198HV Malpractice, Negligence, or Breach of
   30XVI Review                                            Duty
          30XVI(I) Questions of Fact, Verdicts, and               198HV(G) Actions and Proceedings
Findings                                                             198Hk804 k. Affidavits of merit or merit-
           30XVI(I)2 Verdicts                              orious defense; expert affidavits. Most Cited Cases
                 30k1001 Sufficiency of Evidence in             If a plaintiff in a medical malpractice action
Support                                                    timely files an expert report and the defendant
                        30k1001(3) k. Total failure of     moves to dismiss because of the report's inad-
proof. Most Cited Cases                                    equacy, the trial court must grant the motion only if
     When the evidence compels the jury to guess if        it appears to the court, after a hearing, that the re-
a vital fact exists, a reviewing court does not under-     port does not represent a good faith effort to com-
mine the jury's role by sustaining a no-evidence           ply with the definition of an expert report in the
challenge.                                                 governing statute. Vernon's Ann.Texas Civ.St. art.
                                                           4590i, § 13.01(l ), (r)(6) (Repealed).
[18] Costs 102       2
                                                           [20] Health 198H         804
102 Costs
    102I Nature, Grounds, and Extent of Right in           198H Health
General                                                       198HV Malpractice, Negligence, or Breach of

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

Duty                                                       ground of a deficient expert report under the abuse-
       198HV(G) Actions and Proceedings                    of-discretion standard. Vernon's Ann.Texas Civ.St.
            198Hk804 k. Affidavits of merit or merit-      art. 4590i, § 13.01(e) (Repealed).
orious defense; expert affidavits. Most Cited Cases
     All information needed for an inquiry into            [23] Appeal and Error 30          946
whether a good-faith effort was made to comply
                                                           30 Appeal and Error
with expert report requirements in the governing
                                                              30XVI Review
statute is found within the four corners of the expert
                                                                 30XVI(H) Discretion of Lower Court
report, which need not marshal all the plaintiff's
                                                                     30k944 Power to Review
proof, but must include the expert's opinion on each
                                                                           30k946 k. Abuse of discretion. Most
of the three main elements: standard of care,
                                                           Cited Cases
breach, and causation. Vernon's Ann.Texas Civ.St.
                                                               A district court abuses its discretion if it acts in
art. 4590i, § 13.01(l ), (r)(6) (Repealed).
                                                           an arbitrary or unreasonable manner without refer-
[21] Health 198H        804                                ence to any guiding rules or principles.

198H Health                                                *529 Ronald G. Hole, Ida Cecilia Garza, Hole &
     198HV Malpractice, Negligence, or Breach of           Alvarez, L.L.P., McAllen, for Michael T. Jelinek,
Duty                                                       M.D.
       198HV(G) Actions and Proceedings
                                                           John N. Mastin, San Antonio, Francisco J. Rodrig-
           198Hk804 k. Affidavits of merit or merit-
                                                           uez, Rodriguez Tovar & Lopez, LLP, McAllen, for
orious defense; expert affidavits. Most Cited Cases
                                                           Francisco Casas.
     An expert report in a medical malpractice ac-
tion cannot merely state the expert's conclusions          Mike A. Hatchell, Sarah B. Duncan, Elissa Gail
about the elements of standard of care, breach, and        Underwood, Locke Lord Bissell & Liddell, LLP,
causation, but must explain the basis of the state-        Austin, Raul Javier Guerra, Green, DuBois &
ments to link the conclusions to the facts; a report       Guerra, San Antonio, Susan A. Kidwell, Locke
that merely states the expert's conclusions about the      Lord Bissell & Liddell, LLP, Austin, for Columbia
elements does not fulfill the purposes of a good-          Rio Grande Healthcare, L.P.
faith effort in complying with the expert report re-
quirements in the governing statute. Vernon's
Ann.Texas Civ.St. art. 4590i, § 13.01(l ), (r)(6)          Justice GUZMAN delivered the opinion of the
(Repealed).                                                Court, in which Justice HECHT, Justice WAIN-
                                                           WRIGHT, Justice MEDINA, Justice JOHNSON,
[22] Appeal and Error 30         960(1)                    and Justice WILLETT joined, and in which Chief
                                                           Justice JEFFERSON, Justice GREEN, and Justice
30 Appeal and Error                                        LEHRMANN joined as to Parts I and II.A.
   30XVI Review                                                 When circumstantial evidence is consistent
      30XVI(H) Discretion of Lower Court                   with several possible medical conclusions, only one
           30k960 Rulings on Motions Relating to           of which establishes that the defendant's negligence
Pleadings                                                  caused the plaintiff's injury, an expert witness must
               30k960(1) k. In general. Most Cited         explain why, based on the particular facts of the
Cases                                                      case, that conclusion is medically superior to the
    The Supreme Court reviews the trial court's            others. If the expert fails to give any reason beyond
grant or denial of a motion for sanctions and dis-         an unsupported opinion, the expert's testimony is
missal of a medical malpractice action on the              legally insufficient evidence of causation. In this

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

case, we determine whether legally sufficient evid-                        *530 I. Background
ence supports the jury's verdict in favor of the es-            In 2000, Eloisa Casas was diagnosed with
                      FN1
tate of Eloisa Casas        against Rio Grande Re-         colon cancer and underwent surgery, radiation, and
                                 FN2
gional Hospital (the Hospital).       Following her        chemotherapy. A year later, doctors told her that
admission to the Hospital with abdominal pain,             the cancer appeared to be in remission, and she
doctors placed Casas on antibiotics used to treat          thought she was cured. But on July 10, 2001, she
and prevent certain intra-abdominal infections. Two        was admitted to the Hospital with abdominal pains;
days later she underwent major abdominal surgery           she also had a fever and a mildly elevated white-
and continued on the antibiotics for another five          blood-cell count, potentially indicating an infection.
days, but the Hospital allowed the prescriptions to        To treat this possible infection, her surgeon and
lapse for four-and-a-half days. The Hospital admits        primary physician, Dr. Carlos Garcia–Cantu, con-
it should have continued the antibiotics but denies        sulted with an infectious disease specialist at the
that the lapse caused Casas any additional pain. We        Hospital, Dr. Michael Jelinek, who on July 11 pre-
hold that the Casases failed to present legally suffi-     scribed two medications, Maxipime (a broad-
cient evidence that Casas suffered from an infection       spectrum antibiotic), and Flagyl (an antibiotic used
the omitted antibiotics would have treated. Accord-        to treat anaerobic bacteria).
ingly, we reverse the court of appeals' judgment
and render judgment that the Casases take nothing.              The Hospital performed several diagnostic
FN3                                                        tests, which revealed abnormal collections of fluid
                                                           in Casas's abdomen. On July 13, she underwent ma-
         FN1. Francisco Casas and Alfredo DeLeon           jor abdominal surgery during which Dr. Gar-
         Jr., Casas's husband and son, respectively,       cia–Cantu discovered that “fairly extensive” meta-
         serve as personal representatives of her es-      static cancer had perforated Casas's colon and al-
         tate. We refer to them collectively as “the       lowed material to leak into her abdominal cavity,
         Casases.”                                         causing an intra-abdominal abscess. Dr. Gar-
                                                           cia–Cantu drained the abscess, repaired Casas's
         FN2. Columbia Rio Grande Regional                 colon, and inserted a Jackson–Pratt drain to prevent
         Healthcare, L.P., d/b/a/ Rio Grande Re-           further problems. Following the surgery, Dr. Gar-
         gional Hospital.                                  cia–Cantu continued the Maxipime and Flagyl pre-
                                                           scriptions, and a culture of the removed abscess re-
         FN3. Because we conclude legally insuffi-
                                                           vealed an E. coli infection, which is effectively
         cient evidence supports the jury's verdict,
                                                           treated with Maxipime. Casas received Maxipime
         we do not reach the Hospital's second is-
                                                           and Flagyl for another five days, but hospital staff
         sue—whether the Hospital preserved error
                                                           inadvertently failed to place a prescription renewal
         regarding its proposed unavoidable acci-
                                                           form on Casas's chart, resulting in a four-
         dent instruction.
                                                           and-a-half-day period between July 18 and 23 dur-
     In a separate petition, Dr. Michael Jelinek, one      ing which Casas did not receive either medication.
of Casas's treating physicians sued by the Casases,        Even so, Casas never tested positive for E. coli
argues that the trial court should have granted his        again and a culture of the incision site on July 18
motion for sanctions and dismissal because the Cas-        instead grew Candida (a fungus) for which Diflucan
ases' expert report was deficient. We agree and hold       (an antifungal) was prescribed. Then, on July 21, a
that an award of attorney's fees is proper. There-         second culture from a blood sample grew coagu-
fore, we reverse and remand to the trial court for an      lase-negative staph, for which Vancomycin was
                                                                       FN4
award of attorney's fees and costs.                        prescribed.       Neither Maxipime nor Flagyl
                                                           would have treated the Candida or coagulase-negat-

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

ive staph infection.                                      to Casas and that within “reasonable medical prob-
                                                          ability” this negligence resulted in a prolonged hos-
         FN4. There was a several-day lag between         pital stay and increased pain and suffering. Dr.
         taking the culture and ordering the pre-         Jelinek later filed a motion for sanctions and dis-
         scription, presumably to allow the culture       missal under article 4590i § 13.01(e), alleging that
         to grow and to transmit the results to the       the expert report was deficient because, among oth-
         treating physicians. Thus, the Diflucan was      er things, it failed to explain any causal connection
         prescribed on July 21 and the Vancomycin         between the negligence and the purported injury.
         on July 23.                                      The trial court denied the motion. Before trial
                                                          began, however, the Casases nonsuited Dr. Jelinek
     On July 23, Dr. Garcia–Cantu noted an abscess
                                                          and Dr. Garcia–Cantu.
in the wound, which he drained by removing the
staples and opening the wound. The next day, re-                  FN5. See Act of May 5, 1995, 74th Leg.,
cords indicate that a foul smell was emanating from               R.S., ch. 140, § 1, 1995 Tex. Gen. Laws
the wound site, and hospital staff brought fans into              985, 986, amending the Medical Liability
the room to dissipate the odor. When Dr. Jelinek                  and Insurance Improvement Act of Texas,
learned of the lapsed prescription on July 23, he in-             Act of May 30, 1977, 65th Leg., R.S., ch.
formed Casas and then prescribed different antibi-                817, 1977 Tex. Gen. Laws 2039, 2041, re-
otics, Levaquin and Vancomycin. On July 25, after                 pealed by Act of June 2, 2003, 78th Leg.,
a CAT scan showed no abscess, Dr. Garcia–Cantu                    R.S., ch. 204, § 10.09, 2003 Tex. Gen.
removed the drain. Casas left the Hospital on Au-                 Laws 847, 884. Former article 4590i §
gust 23, but she returned in early September and                  13.01 was replaced by Texas Civil Practice
died two months later.                                            and Remedies Code § 74.351, as amended.

     In May 2003, several members of Casas's fam-              At trial, Dr. Daller testified as the Casases'
ily, including her husband and son, filed suit            medical expert. During direct examination, he ana-
against the Hospital, Dr. Garcia–Cantu, and Dr.           lyzed the Hospital's daily patient notes regarding
Jelinek. The plaintiffs claimed that the defendants'      Casas and identified the significant events. He
negligence caused Eloisa Casas to “suffer grievous        noted changes in Casas's vital signs on July 21 and
embarrassment and humiliation, as well as excruci-        22, such as increased heart rate and temperature, in-
ating pain the remainder of her life which she            flammation, and tenderness of the surgery site. Dr.
would not have suffered to such degree or extent if       Daller stated that “in medical probability” there
properly diagnosed, treated and cared for.” The           was an infection in the abdomen, but on cross-
plaintiffs sought to recover damages for Casas's in-      examination he admitted that “there was no object-
juries and mental anguish. They twice amended             ive evidence present to demonstrate that intra-
their petition, ultimately leaving the Casases as the     abdominal infection.” When reviewing the patient
sole plaintiffs.                                          notes for July 24, which noted the presence of a
                                                          foul smell, he suggested that the smell was consist-
     *531 As required by former article 4590i §
                                                          ent with an anaerobic infection that would be diffi-
13.01 of the Medical Liability and Insurance Im-
                                                          cult to culture because anaerobic bacteria die when
provement Act, see TEX.REV.CIV. STAT. art.
                FN5                                       exposed to air. Dr. Carl Berkowitz, the Hospital's
4590i § 13.01,        the Casases filed an expert re-
                                                          expert, offered several other explanations for the
port within 180 days of filing the original petition.
                                                          smell, such as the Candida infection or dying tissue.
In the report, Dr. John Daller opined that Dr. Gar-
cia–Cantu and Dr. Jelinek were negligent in failing            The Casases also called Casas's relatives to
to discover that the antibiotics were not being given     testify about her condition. Consistent with Dr.

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

Daller's testimony, Casas's son linked the smell          appeal: the legal sufficiency of the causation evid-
with the opening of the wound to drain the abscess:       ence and the sufficiency of the Casases' expert re-
“The odor that I noticed was after they had taken         port.
out the staples on her incision, and one day that I
went to see her as soon as they opened the door the       A. Sufficiency of the Evidence
whiff of this putrid smell just engulfed me.” He               [1] The facts of this case are unfortunate: a wo-
also testified that Casas was upset upon learning         man with advanced colon cancer underwent surgery
that she had not received the antibiotics but was         to repair her cancer-perforated and infected colon,
even more upset when the incision had to be               and in the course of treatment for her many symp-
opened and drained: “Well, after she was told and I       toms the Hospital failed to renew her antibiotic pre-
was told that she wasn't getting antibiotics, like I      scriptions for a four-and-a-half-day period. The
said, she was upset. What really upset her more was       Hospital admits it should have continued the antibi-
when they had to—they had to take out the staples         otics. Even so, the plaintiff bears the burden to
out of her incision, and they had to open her in-         prove that the negligence caused an injury: “[A]t
cision up again.” Casas's husband testified that,         trial the plaintiff must establish two causal nexuses
while she was upset and did not trust the nurses or       in order to be entitled to recovery: (a) a causal nex-
doctors after learning of the lapsed prescription,        us between the defendant's conduct and the event
“she was still fighting. She ... wanted to beat this      sued upon; and (b) a causal nexus between the
cancer she had.” The son testified that Casas did         event sued upon and the plaintiff's injuries.” Mor-
not lose hope until she witnessed the events of           gan v. Compugraphic Corp., 675 S.W.2d 729, 731
September 11, 2001, following her re-admission to         (Tex.1984). Only the second nexus is at issue here.
the Hospital: “That's why I remember that day so
                                                               [2][3][4] In City of Keller v. Wilson, we con-
vividly in my mind because that was the turning
                                                          sidered at length the parameters of legal sufficiency
point in my mom. She seemed to just give up, not
                                                          review, quoting with approval Chief Justice Cal-
fight, not want to fight anymore like she used to.
                                                          vert's seminal article on the topic:
And that was a very, very sad day.”
                                                            “No evidence” points must, and may only, be
     *532 The jury found that the negligence of the
                                                            sustained when the record discloses one of the
Hospital, Dr. Jelinek, and Dr. Garcia–Cantu prox-
                                                            following situations: (a) a complete absence of
imately caused Casas's injury. The jury apportioned
                                                            evidence of a vital fact; (b) the court is barred by
ninety percent of the negligence to the Hospital,
                                                            rules of law or of evidence from giving weight to
five percent to Dr. Jelinek, and five percent to Dr.
                                                            the only evidence offered to prove a vital fact; (c)
Garcia–Cantu. It awarded $250,000 in damages to
                                                            the evidence offered to prove a vital fact is no
the Casases as compensation for Casas's pain and
                                                            more than a mere scintilla; (d) the evidence es-
mental anguish.
                                                            tablishes conclusively the opposite of the vital
     The Hospital appealed, arguing that the evid-          fact.
ence was legally and factually insufficient to prove
                                                              168 S.W.3d 802, 810 (Tex.2005) (quoting
causation or damages for mental anguish. Dr.
                                                          Robert W. Calvert, “ No Evidence” and
Jelinek also appealed, challenging the trial court's
                                                          “Insufficient Evidence” Points of Error, 38 TEX.
denial of his motion for sanctions and dismissal.
                                                          L.REV. 361, 362–63 (1960)). “When the evidence
The court of appeals affirmed on all issues. –––
                                                          offered to prove a vital fact is so weak as to do no
S.W.3d ––––.
                                                          more than create a mere surmise or suspicion of its
                   II. Analysis                           existence, the evidence is no more than a scintilla
    We address in turn the two issues raised in this      and, in legal effect, is no evidence.” Kindred v.

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

Con/Chem, Inc., 650 S.W.2d 61, 63 (Tex.1983).             circumstantial evidence and make proper inferences
The same is true when the evidence equally sup-           from it. In reviewing the record, we initially decide
ports two alternatives: “ ‘When the circumstances         if jurors can determine causation under these facts
are equally consistent with either of two facts,          unaided by expert testimony—that is, whether lay
neither fact may be inferred.’ ” City of Keller, 168      testimony regarding causation is legally sufficient.
S.W.3d at 813 (quoting Tubelite, a Div. of Indal,
Inc. v. Risica & Sons, Inc., 819 S.W.2d 801, 805                     1. Lay Testimony of Causation
(Tex.1991)). When considering such cases, “we                  [6][7][8][9] Lay testimony may be used as
must ‘view each piece of circumstantial evidence,         evidence of causation in certain circumstances, but
not in isolation, but in light of all the known cir-      “[w]hen expert testimony is required, lay evidence
cumstances,’ ” id. at 813–14 (quoting Lozano v.           supporting liability is legally insufficient.” City of
Lozano, 52 S.W.3d 141, 167 (Tex.2001) (per curi-          Keller, 168 S.W.3d at 812. In medical malpractice
am)), and we “must consider not just favorable but        cases, expert testimony regarding causation is the
all the circumstantial evidence, and competing in-        norm: “The general rule has long been that expert
ferences as well.” Id. at 814.                            testimony is necessary to establish causation as to
                                                          medical conditions outside the common knowledge
     [5] To meet the legal sufficiency standard in        and experience of jurors.” Guevara v. Ferrer, 247
medical malpractice cases “plaintiffs are required to     S.W.3d 662, 665 (Tex.2007); see also Bowles v.
adduce evidence of a *533 ‘reasonable medical             Bourdon, 148 Tex. 1, 219 S.W.2d 779, 782 (1949)
probability’ or ‘reasonable probability’ that their       (“It is definitely settled with us that a patient has no
injuries were caused by the negligence of one or          cause of action against his doctor for malpractice,
more defendants, meaning simply that it is ‘more          either in diagnosis or recognized treatment, unless
likely than not’ that the ultimate harm or condition      he proves by a doctor of the same school of practice
resulted from such negligence.” Kramer v. Lewis-          as the defendant: (1) that the diagnosis or treatment
ville Mem'l Hosp., 858 S.W.2d 397, 399–400                complained of was such as to constitute negligence
(Tex.1993) (citations omitted). Thus, we examine          and (2) that it was a proximate cause of the patient's
the record to determine if the Casases presented          injuries.”). We have allowed lay evidence to estab-
legally sufficient evidence that “in reasonable med-      lish causation “in those cases in which general ex-
ical probability” the Hospital's negligence caused        perience and common sense will enable a layman to
Casas additional pain and suffering.                      determine, with reasonable probability, the causal
                                                          relationship between the event and the condition.”
     When distilled to its essence, the Casases'          Morgan, 675 S.W.2d at 733 (citing Lenger v. Physi-
claim is predicated on the presence of an infec-          cian's Gen. Hosp., Inc., 455 S.W.2d 703, 706
tion—treatable by the lapsed antibiotics—that             (Tex.1970)). Care must be taken to avoid the post
caused Casas pain and mental anguish above and            hoc ergo propter hoc fallacy, that is, finding an
beyond that caused by the cancer, the surgery, and        earlier event caused a later event merely because it
the other known infections. The absence of an in-         occurred first. Stated simply, correlation does not
fection treatable by Maxipime and Flagyl would            necessarily imply causation. As we noted in
undermine the Casases' claim, for then the prescrip-      Guevara, “[e]vidence of an event followed closely
tion lapse would amount to an unfortunate, but            by manifestation of or treatment for conditions
harmless, occurrence. The Hospital argues that the        which did not appear before the event raises suspi-
Casases presented no evidence that the Hospital's         cion that the event at issue caused the conditions.
negligence caused such an infection. The Casases'         But suspicion has not been and is not legally suffi-
expert admitted there is no direct evidence of an an-     cient to support a finding of legal causation.” 247
aerobic infection, leaving the jury to consider the       S.W.3d at 668.

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     [10] When lay testimony is credited as evid-          the prescription lapse to an infection causing addi-
ence of causation, it usually highlights a connection      tional pain and suffering beyond what she would
between two events that is apparent to a casual ob-        otherwise have experienced. See Kaster v. Wood-
server. In Morgan, for example, a previously               son, 123 S.W.2d 981, 983 (Tex.Civ.App.-Austin
healthy employee, upon exposure to leaking chem-           1938, writ ref'd) (“What is an infection and from
icals, suffered watering of the eyes, blurred *534         whence did it come are matters determinable only
vision, headaches, and swelling of the breathing           by medical experts.”); see also Hart v. Van Zandt,
passages. 675 S.W.2d at 733. In such a circum-             399 S.W.2d 791, 792 (Tex.1966) (“In determining
stance, lay testimony sufficed to connect the specif-      negligence in a case such as this, which concerns
ic injury to the negligence with no evidence of            the highly specialized art of treating disease, the
causation beyond the leaking chemicals. Id. Like-          court and jury must be dependent on expert testi-
wise in Guevara, we stated that determining causa-         mony. There can be no other guide, and where want
tion of “certain types of pain, bone fractures, and        of skill and attention is not thus shown by expert
similar basic conditions” following an automobile          evidence applied to the facts, there is no evidence
accident was within the competence of lay jurors.          of it proper to be submitted to the jury.”).
247 S.W.3d at 668. But we held that expert testi-
mony was required to prove that a patient's medical             The Casases point to testimony by Casas's hus-
expenses resulted from the accident, noting that           band and son to support their argument that she de-
“[p]atients in hospitals are often treated for more        teriorated rapidly after discovering she did not re-
than one condition brought on by causes independ-          ceive the antibiotics. But this characterization over-
ent of each other.” Id. at 669. These cases illustrate     states the evidence. While Casas's husband testified
this basic premise: “[N]on-expert evidence alone is        she was upset and did not trust her doctors follow-
sufficient to support a finding of causation in lim-       ing the discovery, she was still determined to fight
ited circumstances where both the occurrence and           her cancer. The son also observed Casas's anger and
conditions complained of are such that the general         lack of trust but testified that the opening of her
experience and common sense of laypersons are              wound, which occurred the same day she learned of
sufficient to evaluate the conditions and whether          the lapse, upset her even more. As Dr. Daller ad-
they were probably caused by the occurrence.” Id.          mitted, Candida likely caused the abscess that re-
at 668.                                                    quired Dr. Garcia–Cantu to drain the wound. Fur-
                                                           ther, based on his experience at Casas's bedside, her
     The present case does not fall within this rule.      son pinpointed the tragic events of September 11,
Unlike in Morgan, an otherwise healthy person did          2001, and their effect on his mother as the turning
not suddenly experience health difficulties follow-        point in her mental state. The latter event was some
ing the defendant's negligent conduct when the             seven weeks after discovery of the lapsed prescrip-
plaintiff's symptoms were reasonably attributable to       tions and after Casas's discharge from and re-
the negligence and to nothing else. Rather, a patient      admission to the Hospital. This evidence does not
with terminal colon cancer did not receive antibiot-       bear out the Casases' claim of a marked shift in Ca-
ics for four-and-a-half days following major ab-           sas's mental resilience following the omission of
dominal surgery and after having received the med-         the medications.
ications for eight days. There is no direct evidence
that she suffered from an infection treatable by the           *535 More importantly, Casas's husband and
omitted antibiotics, but there is evidence that she        son were unable to precisely identify the cause of
had two other infections that accounted for all of         her suffering. While they could accurately describe
her symptoms during that time. Given Casas's med-          her discomfort, they were unable to say if it was the
ical condition, expert testimony was crucial to link       cancer, the surgery, the other infections, or the

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lapse that caused it. Even testimony that Casas                      day, two days, three days, I cannot say
suffered after learning of the omission raises no                    that. What I would say from a scientific
more than a mere suspicion of causation, and that is                 standpoint is that for four and a half days
not enough, see Guevara, 247 S.W.3d at 668, par-                     she did not receive appropriate therapy.
ticularly in light of the evidence that Casas thought                Had she received the appropriate therapy
she was cured of cancer before the surgery and then                  then you would expect her length of stay
learned that not only was it “back with a ven-                       to be shortened somewhat. To quantitate
geance,” it was terminal. The testimony of Casas's                   that, I could not do that.
husband and son is evidence of her suffering, but
not of its cause. Thus, we hold that the lay testi-                  ....
mony presented by the Casases is legally insuffi-
                                                                     A. Obviously, not receiving antibiotics is
cient to establish that the Hospital's negligence
                                                                     not going to shorten your stay. There-
caused Casas additional pain and suffering.
                                                                     fore, if it impacted the stay it must have
                2. Expert Testimony                                  lengthened it. (emphases added).
     [11] The Casases also presented expert testi-
                                                               Q. Now, Candida, infection of a wound like
mony regarding causation. The Casases' expert, Dr.
                                                             this, they can cause high temperatures. Correct?
Daller, testified that the Hospital's negligence “in
medical probability” caused Casas additional pain              A. Fungal infections can cause a high temperat-
and suffering. He based this opinion on the pres-            ure, yes.
ence of an intra-abdominal infection that could
have been treated using Maxipime and Flagyl. Ad-               Q. It can cause increased heart rate?
mitting that no direct evidence indicated such an in-
fection, Dr. Daller pointed to various circumstantial          A. That is correct.
indicators that suggested an infection. These indic-
                                                               Q. And inflammation?
ators were primarily Casas's changed vital signs,
such as fever and increased heart rate: “Well, given           A. That is correct.
the fact that two to three days after the antibiotics
had been mistakingly [sic] stopped her fever curve             Q. Pain?
went up and her heart rate went up, to me that sug-
                                                 FN6           A. That is correct.
gests the presence of on going [sic] infection.”
But on cross-examination, he conceded these data
                                                               Q. How about an abscess?
were equally consistent with two other infections
cultured from Casas's incision and blood—Candida               A. It caused or is part of the abscess in that
and coagulase—negative staph—neither of which is             wound that was present, that wound infection that
treatable by Maxipime or Flagyl:                             needed to be opened.
        FN6. When asked if the lapsed prescrip-                Q. So when Doctor Garcia went in on 7/23 ...
        tions affected Casas's hospital stay, Dr.            and drained that wound at bedside that abscess
        Daller equivocated:                                  was within a reasonable degree of medical prob-
                                                             ability caused by the Candida?
           A. I think that it certainly did impact it.
           However, I cannot quantitate that be-               *536 A. That was one of the organisms that
           cause there are multiple variables that           was there. It was the organism that was cultured.
           are present in a clinical condition.              That is correct.
           Whether it lengthened her stay by one

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    ....                                                    more probable or less probable.”). When the only
                                                            evidence of a vital fact is circumstantial, the expert
    Q. ... This coagulase negative staph causes             cannot merely draw possible inferences from the
  fever?                                                    evidence and state that “in medical probability” the
                                                            injury was caused by the defendant's negligence.
    A. Correct.
                                                            The expert must explain why the inferences drawn
    Q. Increased heart rate?                                are medically preferable to competing inferences
                                                            that are equally consistent with the known facts.
    A. The fever will cause increased heart rate.           Thus, when the facts support several possible con-
                                                            clusions, only some of which establish that the de-
    ....                                                    fendant's negligence caused the plaintiff's injury,
                                                            the expert must explain to the fact finder why those
    Q. It can cause pain?
                                                            conclusions are superior based on verifiable medic-
    A. Depending upon the site. Correct.                    al evidence, not simply the expert's opinion. See
                                                            Lenger, 455 S.W.2d at 707 (“[E]xpert testimony
    Q. Okay. All of these things can be caused by           that the event is a possible cause of the condition
  coagulase negative staph and Candida, which we            cannot ordinarily be treated as evidence of reason-
  know were present 7/18 through 7/23, the time             able medical probability except when, in the ab-
  period she did not get antibiotics?                       sence of other reasonable causal explanations, it be-
                                                            comes more likely than not that the condition did
    A. That's correct.                                      result from the event.”); Hart, 399 S.W.2d at 792
                                                            (“The burden of proof is on the plaintiff to show
   Q. Neither one would have been killed by
                                                            that the injury was negligently caused by the de-
  Maxipime or Flagyl?
                                                            fendant and it is not enough to show the injury to-
    A. That's correct.                                      gether with the expert opinion that it might have
                                                            occurred from the doctor's negligence and from oth-
     [12][13] It is not enough for an expert simply         er causes not the fault of the doctor. Such evidence
to opine that the defendant's negligence caused the         has no tendency to show that negligence did cause
plaintiff's injury. The expert must also, to a reason-      the injury.”).
able degree of medical probability, explain how and
why the negligence caused the injury. We have re-                By conceding that Casas's symptoms were con-
jected expert opinions not grounded in a sound              sistent with infections not treatable by Maxipime or
evidentiary basis: “[I]f no basis for the opinion is        Flagyl, Dr. Daller undermined his conclusion that
offered, or the basis offered provides no support,          an undetected infection was also present. While it is
the opinion is merely a conclusory statement and            possible that Casas did have such an infection, its
cannot be considered probative evidence, regardless         presence can only be inferred from facts that are
of whether there is no objection. ‘[A] claim will not       equally consistent with the Candida and coagulase-
stand or fall on the mere ipse dixit of a credentialed      negative staph infections. “ ‘When the circum-
witness.’ ” City of San Antonio v. Pollock, 284             stances are *537 equally consistent with either of
S.W.3d 809, 818 (Tex.2009) (quoting Burrow v.               two facts, neither fact may be inferred.’ ” City of
Arce, 997 S.W.2d 229, 235 (Tex.1999)); see also             Keller, 168 S.W.3d at 813 (quoting Tubelite, 819
Whirlpool Corp. v. Camacho, 298 S.W.3d 631, 637             S.W.2d at 805). Here, objective data—the cul-
(Tex.2009) ( “Conclusory or speculative opinion             tures—support the Candida and staph infections but
                                                                                                   FN7
testimony is not relevant evidence because it does          not the supposed anaerobic infection.
not tend to make the existence of material facts

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           FN7. Admittedly, anaerobic bacteria are               A. When you have foul smelling, it suggests
           hard to culture because they are averse to         that the organism is an anaerobe. In other words,
           oxygen.                                            one of those bacteria that didn't need oxygen in
                                                              order to grow that, for example, Flagyl would
     [14][15] Based on the record evidence, an an-            treat.
aerobic infection cannot be proved or disproved. It
is equally plausible that Casas had such an infection           Q. Okay. Does that give you clinical evidence
or that she did not. Dr. Daller opined that she did,          that had she been continued on Maxipime and
but he did not explain why that opinion was superi-           Flagyl that they would have had some effect with
or to the opposite view. Such evidence raises no              regards to the condition as we see it on the 24th?
more than a possibility of causation, which is insuf-
ficient. As we said in Bowles v. Bourdon, “ ‘[t]he              A. Well, like I said, most anaerobes are sensit-
proof must establish causal connection beyond the             ive or susceptible to Flagyl. And she had previ-
point of conjecture. It must show more than a pos-            ously been on Flagyl and at this time she is not.
sibility. Verdicts must rest upon reasonable cer-             So I would have expected that that would be an
tainty of proof. Where the proof discloses that a             appropriate antibiotic that would have covered
given result may have occurred by reason of more              the organism that's causing that foul smell.
than one proximate cause, and the jury can do no
                                                                 Dr. Berkowitz, the Hospital's expert, offered
more than guess or speculate as to which was, in
                                                            several other explanations for the smell, including
fact, the efficient cause, the submission of such
                                                            necrotic tissue, dead cancer tissue, and the Candida
choice to the jury has been consistently condemned                     FN8
                                                            infection.      As *538 noted, Casas's son noticed
by this court and by other courts.’ ” 219 S.W.2d at
                                                            the smell after the incision was opened to drain the
785 (quoting Ramberg v. Morgan, 209 Iowa 474,
                                                            abscess, which Dr. Daller admitted was likely
218 N.W. 492, 498–99 (1928)).
                                                            caused by Candida.
     The Casases argue that the foul smell, which is
                                                                    FN8. Dr. Berkowitz testified:
consistent with an anaerobic infection, is strong
evidence of such an infection. Looking at the pa-                     I think that there are a number of things
tient notes for July 24, Dr. Daller commented on                      that can cause things smelling bad be-
the smell:                                                            sides just infection. Tissue that dies
                                                                      doesn't smell good. There's bacteria and
    A. The text says something about drainage to
                                                                      products released by the dead tissue that
  the abdomen with moderate amount of drainage.
                                                                      don't smell good.
  And it says that it is foul smelling.
                                                                      And we know based on the pathology re-
    ....
                                                                      port of the cancer that they took out of
    Q. The [previous notes] that I remember that                      her abdomen, that this had grown
  we have gone over didn't say anything about foul                    enough that it was dying. In other words,
  smelling?                                                           it was probably outgrowing it's [sic]
                                                                      blood supply and was starting to die.
     A. That's correct. They were just described as I                 That in and of itself can smell bad. Then
  recall as being purulent and looking like puss                      you have a wound that is infected; al-
  [sic].                                                              though Candida itself does not typically
                                                                      smell bad, not like something dead. It
    Q. What does that mean when it says “foul                         smells funky and people don't like the
  smelling”?

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           way it smells. The wound itself when it         prescriptions caused a painful infection. But the
           wasn't healing was probably having              Casases shouldered that burden and must prove the
           some necrotic tissue, as well, or dead tis-     causal link with reasonable certainty. In that quest,
           sue that is in the wound. I'm sure that         the Casases offered the testimony of Dr. Daller, but
           smelled bad, as well. And they were nev-        he did not explain why an undetected, anaerobic in-
           er able to completely get rid of all that       fection is medically more probable than one based
           dead cancer tissue that was in her abdo-        on the known infections and the dying tissue, leav-
           men.                                            ing the jury to guess if the lapsed prescriptions
                                                           caused additional pain and suffering. Without pro-
           I think there's a number of reasons why         bative medical testimony that the lapse caused—by
           she would have had a bad smell, none of         means of an infection treatable by Maxipime and
           which can be explained by four or five          Flagyl—more pain than the cancer, the surgery, and
           days of not getting Flagyl [or]                 the other infections already inflicted, there is no
           Maxipime.                                       legally sufficient evidence of causation. Dr. Daller
                                                           did not provide that causal link; accordingly, we
     [16][17] Here again, there are competing ex-
                                                           hold that his testimony is legally insufficient to
planations for the smell, which amounts to no more
                                                           support the jury's verdict. Because the Casases
than circumstantial evidence of some kind of infec-
                                                           failed to prove causation, we reverse the judgment
tion or possibly dying tissue. Because there is no
                                                           of the court of appeals and render judgment that the
direct evidence of the infection and the circumstan-
                                                           Casases take nothing.
tial evidence is meager, we “must consider not just
favorable but all the circumstantial evidence, and         B. Adequacy of the Expert Report
competing inferences as well.” City of Keller, 168               [18][19] In his petition, Dr. Jelinek raises a
S.W.3d at 814. Courts should not usurp the jury's          single issue: whether the trial court abused its dis-
role as fact finder, nor should they question the          cretion by denying his motion for sanctions and dis-
jury's right to believe one witness over another. But      missal because the Casases' expert report was defi-
when reviewing a verdict for sufficiency of the            cient under former article 4590i § 13.01, the statute
evidence, courts need not—indeed, must not—defer           in effect at the time. See TEX.REV.CIV. STAT. art.
to the jury's findings when those findings are not         4590i § 13.01. Article 4590i required the report to
supported by credible evidence. When the evidence          provide “a fair summary of the expert's opinions as
compels the jury to guess if a vital fact exists, a re-    of the date of the report regarding applicable stand-
viewing court does not undermine the jury's role by        ards of care, the manner in which the care rendered
sustaining a no-evidence challenge. The evidence in        by the physician or health care provider failed to
this case—being consistent with an anaerobic infec-        meet the standards, and the causal relationship
tion that was treatable by Flagyl, a fungal infection      between that *539 failure and the injury, harm, or
that was not, or even with dying tissue, cancerous         damages claimed.” Id. § 13.01(r)(6). “If a plaintiff
or otherwise—did not provide the jury a reasoned           timely files an expert report and the defendant
basis from which to infer the presence of a negli-         moves to dismiss because of the report's inad-
gence—induced infection. Because the jury could            equacy, the trial court must grant the motion ‘ only
not reasonably infer an infection caused by the            if it appears to the court, after hearing, that the re-
Hospital's negligence, we agree with the Hospital          port does not represent a good faith effort to com-
that no evidence supports the jury's verdict.              ply with the definition of an expert report in Sub-
                                                           section (r)(6) of this section.’ ” Bowie Mem'l Hosp.
    We understand the Casas family's predicament
                                                           v. Wright, 79 S.W.3d 48, 51–52 (Tex.2002) (per
and frustration at the Hospital's conduct, and we re-
                                                           curiam) (quoting § 13.01(l )). Dismissal for failure
cognize the difficulty of proving that the lapsed

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to serve an adequate expert report also carried man-       prolonged hospital course and increased pain and
datory sanctions, requiring an award to the defend-        suffering being experienced by Ms. Casas.” Aside
ant of his costs and attorney's fees against the           from repeating essentially the same phrase twice
plaintiff or the plaintiff's attorney. See Am. Trans-      more, the report says nothing more regarding caus-
itional Care Ctrs. of Tex., Inc. v. Palacios, 46           ation. The Casases argue this statement is sufficient
S.W.3d 873, 877 (Tex.2001) (citing § 13.01(e)).            to meet the good-faith requirement. We disagree.

     [20][21] We have defined a “good-faith effort”             An expert cannot simply opine that the breach
as one that provides information sufficient to (1)         caused the injury. Stated so briefly, the report fails
“inform the defendant of the specific conduct the          the second Palacios element—it does not give the
plaintiff has called into question,” and (2) “provide      trial court any reasonable basis for concluding that
a basis for the trial court to conclude that the claims    the lawsuit has merit. See 46 S.W.3d at 879. An ex-
have merit.” Wright, 79 S.W.3d at 52 (citing Pala-         pert's conclusion that “in medical probability” one
cios, 46 S.W.3d at 879). All information needed for        event caused another differs little, without an ex-
this inquiry is found within the four corners of the       planation tying the conclusion to the facts, from an
expert report, which need not “marshal all the             ipse dixit, which we have consistently criticized.
plaintiff's proof” but must include the expert's opin-     See Pollock, 284 S.W.3d at 818 (citing Burrow, 997
ion on each of the three main elements: standard of        S.W.2d at 235); Earle, 998 S.W.2d at 890 (“An ex-
care, breach, and causation. Id. Importantly for this      pert's simple ipse dixit is insufficient to establish a
case, the “report cannot merely state the expert's         matter; rather, the expert must explain the basis of
conclusions about these elements,” but “ ‘the expert       his statements to link his conclusions to the facts.”).
must explain the basis of his statements to link his       Instead, the expert must go further and explain, to a
conclusions to the facts.’ ” Id. (quoting Earle v.         reasonable degree,*540 how and why the breach
Ratliff, 998 S.W.2d 882, 890 (Tex.1999)). “A report        caused the injury based on the facts presented.
that merely states the expert's conclusions about the      While we have said that no “magical words” need
standard of care, breach, and causation” does not          be used to meet the good-faith requirement, mere
fulfill the two purposes of a good-faith effort. Pala-     invocation of the phrase “medical probability” is
cios, 46 S.W.3d at 879.                                    likewise no guarantee that the report will be found
                                                           adequate. See Wright, 79 S.W.3d at 53.
     [22][23] We review the trial court's grant or
denial of a motion for sanctions and dismissal un-              Under these standards, the Casases' report is
der the abuse-of-discretion standard. Palacios, 46         conclusory on causation. It offers no more than a
S.W.3d at 877–78. A district court “abuses its dis-        bare assertion that Dr. Jelinek's breach resulted in
cretion if it acts in an arbitrary or unreasonable         increased pain and suffering and a prolonged hos-
manner without reference to any guiding rules or           pital stay. Beyond that statement, the report offers
principles.” Wright, 79 S.W.3d at 52 (citing Down-         no explanation of how the breach caused the injury.
er v. Aquamarine Operators, Inc., 701 S.W.2d 238,          Again, the plaintiff need not marshal all of his
241–42 (Tex.1985)).                                        proof in the report, but he must include sufficient
                                                           detail to allow the trial court to determine if the
     Dr. Jelinek argues that the Casases' report is        claim has merit. Because the Casases' report lacks
deficient in two ways, failing (1) to state the applic-    any explanation linking the expert's conclusion to
able standard of care, and (2) to provide more than        the relevant facts, we hold that the trial court ab-
conclusory statements of causation. We focus on            used its discretion by denying Dr. Jelinek's motion
the latter. Dr. Daller's report concluded that Dr.         and the court of appeals erred by affirming that rul-
Jelinek's breach of the appropriate standard of care            FN9
                                                           ing.      See id. at 52. Accordingly, we remand the
in “reasonable medical probability, resulted in a

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case to the trial court for an award of attorney's fees            lief that was not sought); Fed. Sign v. Tex.
             FN10
and costs            under former article 4590i §                  S. Univ., 951 S.W.2d 401, 410 (Tex.1997)
13.01(e) against the Casases and their counsel.                    (noting that ordinarily, failure to brief an
FN11
                                                                   argument waives error on appeal);
                                                                   TEX.R.APP. P. 38.1(h).
         FN9. In his dissent, CHIEF JUSTICE JEF-
         FERSON argues that an expert report need                  FN11. We briefly note that under former
         not meet the legal sufficiency requirements               article 4590i a trial court's order denying a
         necessary to support a judgment and sug-                  motion to dismiss premised on an inad-
         gests that we hold it must. We agree that                 equate expert report was not immediately
         an expert report need not “meet the same                  appealable, as it now is under Texas Civil
         requirements as the evidence offered in a                 Practice and Remedies Code §§ 51.014 and
         summary-judgment proceeding or at trial.”                 74.351. Nor did we definitively say that
         Palacios, 46 S.W.3d at 879. But, as we                    mandamus review was appropriate for such
         stated earlier, the report must provide more              orders until almost four years after the trial
         than conclusory statements concerning ap-                 court denied Dr. Jelinek's motion for dis-
         plicable standards of care, breach of those               missal and sanctions. See In re McAllen
         standards, and causation. See id. An expert               Med. Ctr., Inc., 275 S.W.3d 458, 461–62
         report must instead, within its four corners,             (Tex.2008). Thus, we do not fault Dr.
         provide some explanation as to each of                    Jelinek for waiting until final judgment to
         these elements. TEX.REV.CIV. STAT. art.                   seek review of the trial court's order. See
         4590i § 13.01(r)(6); Wright, 79 S.W.3d at                 Hernandez v. Ebrom, 289 S.W.3d 316, 318
         52. The report here offered only a conclus-               (Tex.2009) (“Generally, appeals may only
         ory statement concerning causation with                   be taken from final judgments....”).
         no explanation as to how the lapse in anti-
         biotic treatment resulted in longer hospital-               We mention this point because we have
         ization, increased pain and suffering, or ul-               since cautioned that a defend-
         timately Casas's death.                                     ant—having foregone the interlocutory
                                                                     appeal now available—risks losing the
         FN10. In her dissent, JUSTICE LEHR-                         right to appeal following final judgment
         MANN indicates that (1) she would re-                       if, after a trial on the merits, the jury
         mand the case to allow the Casases an op-                   finds the defendant liable. See id. at 321.
         portunity to show that their failure to                     Even if the present statute applied here,
         present an adequate report was not inten-                   this caution would not bar Dr. Jelinek's
         tional or the result of conscious indiffer-                 appeal because he was not a party at tri-
         ence, and (2) Dr. Jelinek should not be en-                 al, having been nonsuited earlier. We
         titled to attorney's fees and costs if the                  will not bar a nonsuited defendant's ap-
         Casases can make this showing and submit                    peal after final judgment because the
         an adequate report. We note that the Cas-                   jury finds him liable at a former code-
         ases did not request a remand of this                       fendant's trial. Such a defendant did not
         nature, nor brief the attorney's fees issue.                call or cross-examine witnesses, present
         See State v. Brown, 262 S.W.3d 365, 370                     evidence, or otherwise participate at trial
         (Tex.2008) (observing that “[a] party gen-                  and should not be bound by what hap-
         erally is not entitled to relief it does not                pens there.
         seek” and refusing to sua sponte grant re-
                                                                         *541 III. Conclusion

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    For the foregoing reasons, we reverse the court        scriptions expired, Casas's surgical incision began
of appeals' judgment, render judgment that the Cas-        to emit a putrid odor. She developed several infec-
ases take nothing, and remand to the trial court for       tions in addition to E. coli, exacerbating her pain
an award of Dr. Jelinek's attorney's fees and costs        and extending her stay in the hospital. Casas died
consistent with this opinion.                              two months after she was discharged.

Chief Justice JEFFERSON filed an opinion, dis-                  Casas's estate sued the Hospital and two of the
senting in part, in which Justice GREEN and                treating doctors, Dr. Garcia–Cantu and Dr. Jelinek,
Justice LEHRMANN joined.                                   for negligently causing Mrs. Casas “grievous em-
Justice LEHRMANN filed an opinion, dissenting in           barrassment and humiliation, as well as excruciat-
part.                                                      ing pain the remainder of her life which she would
                                                           not have suffered to such degree if properly dia-
Chief Justice JEFFERSON, joined by Justice                 gnosed, treated and cared for....” The trial court
GREEN and Justice LEHRMANN, dissenting in                  denied Dr. Jelinek's motion to dismiss the case
part.                                                      against him. Nevertheless, the estate nonsuited both
     We must decide whether an expert report gave          doctors more than a year before Casas's claim
a “fair summary” of the expert's opinions regarding        against the Hospital was tried to a jury. At that trial,
standard of care, failure to meet the standard, and        the jury found the hospital 90% negligent, and each
the link between that failure and the patient's dam-       doctor 5% negligent. The trial court rendered judg-
ages. We must consider the expert's opinions “as of        ment against the hospital, and the court's order non-
the date of the report.” TEX.REV.CIV. STAT. art.           suiting Dr. Jelinek “with prejudice” merged into
4590i § 13.01(r)(6) (repealed 2003). To do so, we          that final judgment.
must disregard today's holding that, at trial, there
was no evidence linking the discontinuation of anti-            Dr. Jelinek and the hospital appealed the trial
biotics to increased suffering by Casas. The expert        court's judgment. The hospital complained that the
report submitted in this case gave fair notice of a        evidence was legally insufficient to support the ver-
meritorious claim—that the doctor failed to ensure         dict. Dr. Jelinek complained that the trial court im-
that his patient received antibiotics, thereby in-         properly denied him attorney's fees, as the expert
creasing her pain and suffering. I would affirm the        report was not a good faith effort to comply with
court of appeals' judgment with respect to the doc-        statutory requirements. The court of appeals af-
tor.                                                       firmed, 2008 WL 2894889, *9–*10, 2008 Tex.App.
                                                           LEXIS 5647, *28–*29 (Tex.App.-Corpus Christi
I. Background                                              July 29, 2008), and the appellants below are now
     Eloisa Casas, a patient recently diagnosed with       petitioners here. I fully join the *542 Court's rendi-
colon cancer, was admitted to Rio Grande Hospital          tion of judgment for the hospital. I disagree with
for abdominal pain. The cancer had perforated her          the Court's holding as to the doctor.
colon, the contents of which leaked into her abdom-
inal cavity, causing an abscess. After the doctor          II. Good faith effort; fair summary
drained and surgically removed the abscess, he dis-             Former article 4590i provided that “[a] court
covered that Casas had an E. coli infection, for           shall grant a motion challenging the adequacy of an
which the doctor prescribed two antibiotics. Al-           expert report only if it appears to the court, after
though those prescriptions were supposed to have           hearing, that the report does not represent a good
been renewed five days later, they lapsed. Casas           faith effort to comply with the definition of an ex-
contends this mistake occurred because the doctor          pert report in [the statute].” TEX.REV.CIV. STAT.
failed to ensure that hospital staff complied with his     art. 4590i § 13.01(l ). “That definition requires, as
renewal order. During the four days after the pre-         to each defendant, a fair summary of the expert's

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

opinions about the applicable standard of care, the         to recognize that the antibiotics were not being ad-
manner in which the care failed to meet that stand-         ministered as ordered.” Dr. Daller concludes that
ard, and the causal relationship between that failure       “[t]his breach in the standard of care ..., within
and the claimed injury.” Am. Transitional Care              reasonable medical probability, resulted in a pro-
Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 878         longed hospital course and increased pain and suf-
(Tex.2001) (citing TEX.REV.CIV. STAT. art.                  fering....”
4590i § 13.01(r)(6)). Because an expert report is
filed long before discovery is complete, we cannot          IV. Dr. Daller gave a “fair summary” of the re-
judge it according to what subsequent discovery re-         quired standard of care and how the allegedly
veals or how the evidence develops at trial. The            inadequate care fell below that standard.
question is whether the report fairly summarizes the             The Court concludes that Dr. Daller's report
malpractice elements before the case is tested in a         lacks the detail necessary to conclude that the es-
full adversary process. For that reason, “to avoid          tate's lawsuit has merit. But the cases it cites as
dismissal, a plaintiff need not present evidence in         support involve situations in which a hindsight
the report as if it were actually litigating the merits.    view is entirely appropriate. Earle v. Ratliff, for ex-
The report can be informal in that the information          ample, is a summary judgment case; it presents the
in the report does not have to meet the same re-            higher evidentiary standard that Palacios rejected
quirements as the evidence offered in a summary-            for expert reports. Earle v. Ratliff, 998 S.W.2d 882,
judgment proceeding or at trial.” Id. at 879.               890 (Tex.1999) (“Summary judgment can be gran-
                                                            ted on the affidavit of an interested expert *543
     The report must also give the defendant notice         witness, ... but the affidavit must not be conclus-
of the conduct the plaintiff challenges, and the trial      ory.... [R]ather, the expert must explain the basis of
court must have a basis to determine whether the            his statements to link his conclusions to the facts.”).
claim has merit. Id. The dividing line between a            Similarly, the standard employed in City of San
sufficient and an inadequate report is impossible to        Antonio v. Pollock, 284 S.W.3d 809, 817–18
draw precisely. We have said, therefore, that the           (Tex.2009), also cited by the Court, is inapplicable
determination must be made in the first instance by         here, since it examined an expert report under the
the trial court, and review of that decision asks not       “no evidence” standard of review. See ––– S.W.3d
how an appellate court would have resolved the is-          at ––––.
sue, but instead whether the trial court abused its
discretion. See, e.g., Jernigan v. Langley, 195                  In Palacios we held that an expert report that
S.W.3d 91, 93 (Tex.2006); Walker v. Gutierrez,              failed to articulate a standard of care or explain
111 S.W.3d 56, 63 (Tex.2003).                               how the defendant hospital breached that standard
                                                            was not a good faith effort to comply with the stat-
III. Dr. Daller's report                                    utory requirements. Palacios, 46 S.W.3d at 880.
     Dr. Daller is a physician and an expert on intra-      The expert in that case blamed the hospital for tak-
abdominal abscesses and infection. His report states        ing no action to prevent a patient from falling out of
that a doctor treating a patient like Casas must en-        his bed, even though the patient “had a habit of try-
sure that the antibiotics he prescribes are actually        ing to undo his restraints.” Id. at 879–880. The re-
administered. Despite that standard, Dr. Daller             port, as such, was not a fair summary of the evid-
states that antibiotics prescribed for Ms. Casas were       ence because it neglected to articulate what actions
not administered from July 17 through July 23,              the hospital should have taken that it did not. Id. at
even though “[t]here [wa]s no order to discontinue          880. Thus, the trial court did not abuse its discre-
the antibiotic therapy.” He concluded that Dr.              tion by dismissing the plaintiff's claim for lack of a
Jelinek breached the standard of care by his “failure       good faith effort to summarize the expert's opin-

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

ions.                                                      offered in a summary-judgment proceeding or at
                                                           trial”; therefore, an expert report does not fail the
     Subsequently, in Bowie Memorial Hospital v.           good faith effort test merely because it may not
Wright, we held that the trial court did not abuse its     later prove legally sufficient to support a judgment.
discretion in concluding that an expert report failed      Id. at 879. So, here, whether the Casas estate ulti-
to comply with the statute, as the report did not          mately amassed sufficient proof in an adversarial
“establish how any act or omission of employees of         trial is beside the point; the claim itself was far
Bowie Memorial Hospital caused or contributed to           from frivolous. See id. at 878 (noting that “one pur-
[the patient's] injuries.” See Bowie Mem'l Hosp. v.        pose of the expert-report requirement is to deter
Wright, 79 S.W.3d 48, 51–53 (Tex.2002) (quoting            frivolous *544 claims”). The law imposes a penalty
the expert in that case as speculating, “I do believe      for filing a frivolous suit. Only by today's decree
that it is reasonable to believe that if the x-rays        does it also punish a claimant for failing to win an
would have been correctly read and the appropriate         arguably meritorious case. Cf. TransAmerican Nat-
medical personnel acted upon those findings then           ural Gas Corp. v. Powell, 811 S.W.2d 913, 918
[the plaintiff] would have had the possibility of a        (1991) (holding that “sanctions cannot be used to
better outcome.”). We observed that a report must          adjudicate the merits of a party's claims or defenses
satisfy Palacios's two-part test. Id. at 52. Because       unless a party's hindrance of the ... process justifies
the report “lack[ed] information linking the expert's      a presumption that its claims or defenses lack mer-
conclusion (that [the plaintiff] might have had a          it.”).
better outcome) to [the defendant's] alleged breach
(that it did not correctly read and act upon the x-             I agree with the Court that the Estate failed to
rays), the trial court could have reasonably determ-       prove causation at trial; I disagree that, as to Dr.
ined that the report was conclusory.” Id. at 53.           Jelinek, the expert report was not a good faith at-
                                                           tempt to comply with the statute. I respectfully dis-
     In each of those cases, the trial court could not     sent in part from the Court's judgment.
have evaluated the claim's merit without speculat-
ing about actions the defendant could have taken to        Justice LEHRMANN, dissenting in part.
prevent injury. No such speculation is required                 I fully join Chief Justice Jefferson's dissent. I
here. Dr. Daller states that had the antibiotics been      write separately, however, to highlight the incon-
administered from July 17 through July 23, Eloisa          gruity inherent in the Court's decision to remand the
Casas would have suffered less. Dr. Daller could           case for an award of attorney's fees and costs under
have stated that conclusion in greater detail, of          former article 4590i § 13.01(e), given this case's
course, but “[a] report need not marshal all the           circumstances. See TEX.REV.CIV. STAT. art.
                                                                                                 FN1
plaintiff's proof.” Palacios, 46 S.W.3d at 878. Dal-       4590i § 13.01(e) (repealed 2003)           . The Court
ler's report includes his opinions on (1) the applic-      presumes that Dr. Michael Jelinek is entitled to at-
able standard of care (to maintain vigilance over a        torney's fees because the expert report filed by
                                                                                   FN2
patient's treatment), (2) the manner in which the          Eloisa Casas's estate         was, on appeal, determ-
care failed to meet that standard (failing to ensure       ined to be insufficient. But, after a pre-trial hearing
the treatment he ordered was actually admin-               was held on the defendant's motion to dismiss the
istered), and (3) the causal connection between the        lawsuit, the trial court rejected Dr. Jelinek's conten-
failure and the claimed injury (without the antibiot-      tion that the report was inadequate; consequently,
ics, the patient's pain and suffering increased and        the Casases had no opportunity to rectify any defi-
she required additional hospitalization).                  ciencies as the statute and our precedent would
                                                           have allowed.
    A “good faith effort” does not require that the
report “meet the same requirements as the evidence                  FN1. See Act of May 5, 1995, 74th Leg.,

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328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
(Cite as: 328 S.W.3d 526)

         R.S., ch. 140, § 1, 1995 Tex. Gen. Laws            Casases may have been in a better position *545
         985, 986, amending the Medical Liability           than they are now if the trial court had found that
         and Insurance Improvement Act of Texas,            the report was inadequate; they might have had an
         Act of May 30, 1977, 65th Leg., R.S., ch.          opportunity to eliminate any deficiencies.
         817, 1977 Tex. Gen. Laws 2039, 2041, re-
         pealed by Act of June 2, 2003, 78th Leg.,               I agree fully with Chief Justice Jefferson that
         R.S., ch. 204, § 10.09, 2003 Tex. Gen.             the report represents a good-faith effort to comply
         Laws 847, 884. For ease of reference, I            with section 13.01. Even if it did not, however, I
         will refer to the relevant provisions as they      would remand the case to allow the Casases an op-
         were identified in article 4590i.                  portunity to show that their failure to present an ad-
                                                            equate report was not intentional or the result of
         FN2. I refer to the estate, which was rep-         conscious indifference. See City of DeSoto v. White,
         resented by Casas's husband and son, as            288 S.W.3d 389, 401 (Tex.2009) (remanding in the
         “the Casases.”                                     interest of justice sua sponte to allow police officer
                                                            “to make an appellate election with full knowledge
     Section 13.01(e) of article 4590i provided for         of his appellate rights and with knowledge of” the
an order awarding attorney's fees and costs if a            guidance provided in Court's opinion). In my view,
health care claimant failed to supply an expert re-         the Casases should not be assessed attorney's fees
port within the time required under subsection              and costs if they can make the showing section
(d)—180 days. But the statute provided several av-          13.01(g) requires and then submit a report comply-
enues for health care claimants to obtain an exten-         ing with the statute. For these reasons, as well as
sion of the 180–day deadline, including section             those expressed by Chief Justice Jefferson, I re-
13.01(g). That provision required the trial court to        spectfully dissent in part.
grant a thirty-day extension of the statutory dead-
line if a claimant's failure to provide an expert re-       Tex.,2010.
port was not intentional or the result of conscious         Jelinek v. Casas
indifference. And we have expressly held that “a            328 S.W.3d 526, 54 Tex. Sup. Ct. J. 272
party who files a timely but inadequate expert re-
port may seek relief under the grace period provi-          END OF DOCUMENT
sions of section 13.01(g).” Walker v. Gutierrez, 111
S.W.3d 56, 62 (Tex.2003). Thus, health care
claimants could receive an opportunity to rectify
deficiencies in a report if they could show that they
did not intentionally, or with conscious indiffer-
ence, submit an inadequate report.

     Here, the Casases never had the chance to re-
quest an opportunity to cure any deficiencies in
their report because the trial court determined that
the report adequately complied with section
13.01(d). In Gutierrez, we were guided by our re-
cognition that it would be “perverse” to allow a
claimant who filed no report a second chance to
comply with the statute's expert report requirement,
while “punishing those who attempt to comply with
the statute but fail.” Id. In this case, perversely, the

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                                                                                                            Page 1
362 S.W.3d 740
(Cite as: 362 S.W.3d 740)

                                                            30 Appeal and Error
                                                                30XVI Review
           Court of Appeals of Texas,                              30XVI(H) Discretion of Lower Court
              Houston (14th Dist.).                                      30k960 Rulings on Motions Relating to
 KINGWOOD PINES HOSPITAL, LLC, Horizon                      Pleadings
Health Corporation, Psychiatric Solutions, Inc. and                         30k960(1) k. In general. Most Cited
          Yolanda Bassett, Appellants,                      Cases
                       v.                                        A trial court's denial of a motion to dismiss in a
 R. GOMEZ, Individually and a/n/f of V.G., Ap-              health care liability action under the expert report
                     pellee.                                statute is reviewed for abuse of discretion.
                                                            V.T.C.A., Civil Practice & Remedies Code §
               No. 14–11–00050–CV.
                                                            74.351.
                   Nov. 22, 2011.
                                                            [2] Appeal and Error 30         971(2)
Background: Mother, individually and as next
friend of her daughter, brought negligence, aiding          30 Appeal and Error
and abetting assault, assisting or encouraging as-              30XVI Review
sault and medical malpractice action against physi-                30XVI(H) Discretion of Lower Court
cian, counselor and hospital, where daughter was                      30k971 Examination of Witnesses
being evaluated for a psychiatric condition follow-                        30k971(2) k. Competency of witness.
ing a history of sexual abuse, after daughter was           Most Cited Cases
molested by another patient. The 127th District                  A trial court's determination of whether a phys-
Court, Harris County, R.K. Sandill, J., denied de-          ician is qualified to opine in a health care liability
fendants' motion to dismiss based on an inadequate          case is reviewed for an abuse of discretion stand-
expert report. Defendants filed interlocutory appeal.       ard. V.T.C.A., Civil Practice & Remedies Code §
                                                            74.351.
Holdings: The Court of Appeals, Martha Hill Jam-
ison, J., held that:                                        [3] Health 198H        804
(1) trial court did not abuse its discretion by finding
that mother's expert was qualified to give an opin-         198H Health
ion; but                                                        198HV Malpractice, Negligence, or Breach of
(2) expert report did not adequately set forth the          Duty
standards of care and how those standards were                    198HV(G) Actions and Proceedings
breached;                                                             198Hk804 k. Affidavits of merit or merit-
(3) expert report did not adequately describe the           orious defense; expert affidavits. Most Cited Cases
causal relationship between defendants' failure to              A trial court in a health care liability case
meet the standards of care and daughter's injury;           should err on the side of granting an extension to
and                                                         cure an expert report and must grant it if the defi-
(4) doctrine of res ipsa loquitur did not apply.            ciencies are curable. V.T.C.A., Civil Practice &
                                                            Remedies Code § 74.351.
    Reversed and remanded.
                                                            [4] Health 198H        804
                  West Headnotes
                                                            198H Health
[1] Appeal and Error 30         960(1)                         198HV Malpractice, Negligence, or Breach of

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                                                                                                            Page 2
362 S.W.3d 740
(Cite as: 362 S.W.3d 740)

Duty                                                          meet that standard; and (3) the causal relationship
       198HV(G) Actions and Proceedings                       between that failure and the injury, harm, or dam-
           198Hk804 k. Affidavits of merit or merit-          ages claimed. V.T.C.A., Civil Practice & Remedies
orious defense; expert affidavits. Most Cited Cases           Code § 74.351.
     When determining if a good faith effort has
been made to comply with the expert report statute            [7] Health 198H       804
in a health care liability case, a trial court is limited
                                                              198H Health
to the four corners of the report and cannot consider
                                                                   198HV Malpractice, Negligence, or Breach of
extrinsic evidence. V.T.C.A., Civil Practice &
                                                              Duty
Remedies Code § 74.351.
                                                                     198HV(G) Actions and Proceedings
[5] Health 198H         804                                             198Hk804 k. Affidavits of merit or merit-
                                                              orious defense; expert affidavits. Most Cited Cases
198H Health                                                        An expert report in a health care liability case
    198HV Malpractice, Negligence, or Breach of               must incorporate sufficient information to inform
Duty                                                          the defendant of the specific conduct the plaintiff
      198HV(G) Actions and Proceedings                        has called into question and provide a basis for the
          198Hk804 k. Affidavits of merit or merit-           trial court to conclude the claims have merit.
orious defense; expert affidavits. Most Cited Cases           V.T.C.A., Civil Practice & Remedies Code §
                                                              74.351.
Health 198H         817
                                                              [8] Health 198H       804
198H Health
     198HV Malpractice, Negligence, or Breach of              198H Health
Duty                                                              198HV Malpractice, Negligence, or Breach of
       198HV(G) Actions and Proceedings                       Duty
          198Hk815 Evidence                                         198HV(G) Actions and Proceedings
                 198Hk817 k. Presumptions. Most                         198Hk804 k. Affidavits of merit or merit-
Cited Cases                                                   orious defense; expert affidavits. Most Cited Cases
     In a health care liability case, qualifications              An expert report in a health care liability case
must appear in the expert report and cannot be in-            does not comply with the expert report statute by
ferred. V.T.C.A., Civil Practice & Remedies Code              merely containing the expert's conclusions about
§ 74.351.                                                     the standard of care, breach and causation.
                                                              V.T.C.A., Civil Practice & Remedies Code §
[6] Health 198H         804                                   74.351.

198H Health                                                   [9] Health 198H       804
     198HV Malpractice, Negligence, or Breach of
Duty                                                          198H Health
       198HV(G) Actions and Proceedings                            198HV Malpractice, Negligence, or Breach of
          198Hk804 k. Affidavits of merit or merit-           Duty
orious defense; expert affidavits. Most Cited Cases                   198HV(G) Actions and Proceedings
     An expert report in a health care liability case                    198Hk804 k. Affidavits of merit or merit-
must provide a fair summary of the expert's opin-             orious defense; expert affidavits. Most Cited Cases
ions regarding: (1) the applicable standard of care;               An expert in an export report in a health care
(2) the manner in which the care provided failed to           liability case must explain the basis for his state-

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362 S.W.3d 740
(Cite as: 362 S.W.3d 740)

ments and must link his conclusions to the facts.           by finding that mother's expert was qualified to
V.T.C.A., Civil Practice & Remedies Code §                  render an opinion on the standard of care; expert
74.351.                                                     had practiced psychiatry for almost 35 years, was a
                                                            clinical professor in the Department of Psychiatry
[10] Health 198H         804                                of a university for almost 35 years, was board certi-
                                                            fied in child and adolescent psychiatry and general
198H Health
                                                            psychiatry, maintained a private practice, had been
     198HV Malpractice, Negligence, or Breach of
                                                            the clinical director of a psychiatric hospital, and
Duty
                                                            examined child psychiatrists for certification by the
       198HV(G) Actions and Proceedings
                                                            American Board of Psychiatry and Neurology for
          198Hk804 k. Affidavits of merit or merit-
                                                            over ten years. V.T.C.A., Civil Practice & Remed-
orious defense; expert affidavits. Most Cited Cases
                                                            ies Code § 74.402.
     A plaintiff need not present all the evidence ne-
cessary to litigate the merits of his case, in an ex-       [13] Health 198H        804
port report for a health care liability case. V.T.C.A.,
Civil Practice & Remedies Code § 74.351.                    198H Health
                                                                 198HV Malpractice, Negligence, or Breach of
[11] Health 198H         804                                Duty
                                                                   198HV(G) Actions and Proceedings
198H Health
                                                                       198Hk804 k. Affidavits of merit or merit-
     198HV Malpractice, Negligence, or Breach of
                                                            orious defense; expert affidavits. Most Cited Cases
Duty
                                                                 Expert report submitted by mother, in health
       198HV(G) Actions and Proceedings
                                                            care liability action that mother brought against
           198Hk804 k. Affidavits of merit or merit-
                                                            physician, counselor and hospital, which had been
orious defense; expert affidavits. Most Cited Cases
                                                            evaluating her daughter who had a history of sexual
     An expert report in a health care liability case
                                                            molestation for a psychiatric condition, after her
may be informal in that the information need not
                                                            daughter was sexually abused by a patient, did not
fulfill the same requirements as the evidence
                                                            adequately set forth the applicable standards of care
offered in a summary judgment proceeding or at tri-
                                                            and how the standards were breached, as required
al. V.T.C.A., Civil Practice & Remedies Code §
                                                            by expert report statute; expert's articulation of the
74.351.
                                                            standards of care was conclusory in that expert did
[12] Health 198H         804                                not specify how providing a safe and secure envir-
                                                            onment could be accomplished, and expert's articu-
198H Health                                                 lation of how the standards were breached was sim-
     198HV Malpractice, Negligence, or Breach of            ilarly conclusory in that the expert did not provide
Duty                                                        specific information about what the defendants
       198HV(G) Actions and Proceedings                     should have done differently. V.T.C.A., Civil Prac-
           198Hk804 k. Affidavits of merit or merit-        tice & Remedies Code § 74.351.
orious defense; expert affidavits. Most Cited Cases
     Trial court did not abuse its discretion, in           [14] Health 198H        618
health care liability action that mother brought
                                                            198H Health
against physician, counselor and hospital, which
                                                                198HV Malpractice, Negligence, or Breach of
had been evaluating her daughter who had a history
                                                            Duty
of sexual molestation for a psychiatric condition,
                                                                 198HV(B) Duties and Liabilities in General
after her daughter was sexually abused by a patient,
                                                                    198Hk617 Standard of Care

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               198Hk618 k. In general. Most Cited                      198Hk804 k. Affidavits of merit or merit-
Cases                                                       orious defense; expert affidavits. Most Cited Cases
     Standard of care in a health care liability case            When a plaintiff sues more than one defendant
is defined by what an ordinarily prudent health care        in a health care liability case, the expert report must
provider or physician would have done under the             set forth the standard of care for each defendant and
same or similar circumstances. V.T.C.A., Civil              explain the causal relationship between each de-
Practice & Remedies Code § 74.351.                          fendant's individual acts and the injury. V.T.C.A.,
                                                            Civil Practice & Remedies Code § 74.351.
[15] Health 198H        804
                                                            [18] Health 198H         804
198H Health
     198HV Malpractice, Negligence, or Breach of            198H Health
Duty                                                            198HV Malpractice, Negligence, or Breach of
       198HV(G) Actions and Proceedings                     Duty
           198Hk804 k. Affidavits of merit or merit-               198HV(G) Actions and Proceedings
orious defense; expert affidavits. Most Cited Cases                    198Hk804 k. Affidavits of merit or merit-
     Identifying the standard of care in an expert re-      orious defense; expert affidavits. Most Cited Cases
port for a health care liability case is critical;              While it is possible that a single standard of
whether a defendant breached his or her duty to a           care may apply to several defendants in a health
patient cannot be determined absent specific in-            care liability case, generic statements in an expert
formation about what the defendant should have              report that the same standard of care attaches to
done differently. V.T.C.A., Civil Practice & Rem-           each defendant without further explanation are con-
edies Code § 74.351.                                        clusory. V.T.C.A., Civil Practice & Remedies Code
                                                            § 74.351.
[16] Health 198H        804
                                                            [19] Evidence 157        555.4(3)
198H Health
     198HV Malpractice, Negligence, or Breach of            157 Evidence
Duty                                                            157XII Opinion Evidence
       198HV(G) Actions and Proceedings                            157XII(D) Examination of Experts
          198Hk804 k. Affidavits of merit or merit-                    157k555 Basis of Opinion
orious defense; expert affidavits. Most Cited Cases                       157k555.4 Sources of Data
     While a fair summary required by the expert                               157k555.4(3) k. Hearsay or evid-
report statute in a health care liability case is           ence otherwise incompetent. Most Cited Cases
something less than a full statement of the applic-              An expert may rely on a statement that other-
able standard of care and how it was breached, even         wise would not be admissible in evidence in formu-
a fair summary must set out what care was expec-            lating his opinions.
ted, but not given. V.T.C.A., Civil Practice & Rem-
edies Code § 74.351.                                        [20] Health 198H         804

[17] Health 198H        804                                 198H Health
                                                                198HV Malpractice, Negligence, or Breach of
198H Health                                                 Duty
    198HV Malpractice, Negligence, or Breach of                   198HV(G) Actions and Proceedings
Duty                                                                  198Hk804 k. Affidavits of merit or merit-
     198HV(G) Actions and Proceedings                       orious defense; expert affidavits. Most Cited Cases

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     Expert report submitted by mother, in health            of accident or injury. Most Cited Cases
care liability action that mother brought against
physician, counselor and hospital, which had been            Negligence 272        1614
evaluating her daughter who had a history of sexual
                                                             272 Negligence
molestation for a psychiatric condition, after her
                                                                 272XVIII Actions
daughter was sexually abused by a patient, did not
                                                                    272XVIII(C) Evidence
adequately describe the causal relationship between
                                                                       272XVIII(C)3 Res Ipsa Loquitur
defendants' failure to meet the standards of care and
                                                                            272k1611 Elements or Conditions of
daughter's injury, as required by expert report stat-
                                                             Application
ute; expert did not explain how and why the failures
                                                                                272k1614 k. Control or manage-
to meet the standards of care resulted in daughter's
                                                             ment of instrumentality. Most Cited Cases
molestation. V.T.C.A., Civil Practice & Remedies
                                                                  Res ipsa loquitur applies to situations in which
Code § 74.351.
                                                             two factors are present: (1) the character of the ac-
[21] Negligence 272         1610                             cident is such that it would not ordinarily occur in
                                                             the absence of negligence, and (2) the instrumental-
272 Negligence                                               ity causing the injury is shown to have been under
   272XVIII Actions                                          the management and control of the defendant.
      272XVIII(C) Evidence
         272XVIII(C)3 Res Ipsa Loquitur                      [23] Health 198H         818
               272k1610 k. In general. Most Cited
                                                             198H Health
Cases
                                                                  198HV Malpractice, Negligence, or Breach of
Negligence 272        1620                                   Duty
                                                                    198HV(G) Actions and Proceedings
272 Negligence                                                         198Hk815 Evidence
   272XVIII Actions                                                         198Hk818 k. Res ipsa loquitur. Most
       272XVIII(C) Evidence                                  Cited Cases
          272XVIII(C)3 Res Ipsa Loquitur                          Res ipsa loquitur applies in a health care liabil-
                 272k1618 Operation and Effect of            ity case only when the nature of the alleged mal-
Doctrine                                                     practice and injuries are plainly within the common
                  272k1620 k. Creation of inference          knowledge of laypersons, requiring no expert testi-
or presumption. Most Cited Cases                             mony.
     Res ipsa loquitur is not a cause of action separ-
ate from negligence; rather, it is a rule of evidence        [24] Health 198H         818
by which the jury may infer negligence.
                                                             198H Health
[22] Negligence 272         1613                                  198HV Malpractice, Negligence, or Breach of
                                                             Duty
272 Negligence                                                      198HV(G) Actions and Proceedings
   272XVIII Actions                                                    198Hk815 Evidence
      272XVIII(C) Evidence                                                  198Hk818 k. Res ipsa loquitur. Most
         272XVIII(C)3 Res Ipsa Loquitur                      Cited Cases
             272k1611 Elements or Conditions of                   The three recognized areas in which res ipsa
Application                                                  loquitur applies to health care claims are negligence
                272k1613 k. Nature and character             in the use of mechanical instruments, operating on

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the wrong body part, and leaving surgical instru-           found the report deficient, and trial court had not
ments or sponges inside the body. V.T.C.A., Civil           ruled on the request for an extension. V.T.C.A.,
Practice & Remedies Code § 74.201.                          Civil Practice & Remedies Code § 74.351.

[25] Health 198H        818                                 *743 Ryan Lee Clement, Houston, for appellants.

198H Health                                                 David K. Mestemaker, Norman Louis Straub,
     198HV Malpractice, Negligence, or Breach of            Jonathan Brian Zumwalt, Houston, for appellee.
Duty
       198HV(G) Actions and Proceedings
                                                            Panel consists of Justices FROST, SEYMORE, and
           198Hk815 Evidence
                                                            JAMISON.
                198Hk818 k. Res ipsa loquitur. Most
Cited Cases
     Doctrine of res ipsa loquitur was not applicable                             OPINION
in health care liability case that mother brought           MARTHA HILL JAMISON, Justice.
against psychiatric hospital, physician and coun-                This is a health care liability case governed by
                                                                                        FN1
selor after daughter, who was being evaluated for a         the Medical Liability Act.        Appellants bring an
psychiatric condition after a history of sexual mo-         interlocutory appeal from the trial court's order
lestation, was sexually abused by a patient; though         denying appellants' motions to dismiss based on the
mother's claims, that defendants placed daughter in         asserted inadequacy of an expert report served by
a room with a known sexual abuser, might fall               appellee R. Gomez, individually and as next friend
within the common knowledge of laypersons, res              of her daughter V.G. We reverse the trial court's or-
ipsa loquitur could only be applied in health care li-      der denying the motions to dismiss and remand this
ability cases involving the negligent use of mechan-        cause to the trial court to consider whether a
ical instruments, operating on the wrong body part,         30–day extension of the deadline for serving the re-
or leaving surgical instruments or sponges inside           port to allow Gomez to address deficiencies is ap-
the body. V.T.C.A., Civil Practice & Remedies               propriate.
Code §§ 74.201, 74.351.
                                                                     FN1. Tex. Civ. Prac. & Rem.Code §§
[26] Appeal and Error 30         1178(1)                             74.001 –.507. All references to the Act are
                                                                     to these provisions.
30 Appeal and Error
   30XVII Determination and Disposition of Cause                                 Background
       30XVII(D) Reversal                                        V.G., a minor, was admitted into Kingwood
           30k1178 Ordering New Trial, and Direct-          Pines Hospital for evaluation of a psychiatric con-
ing Further Proceedings in Lower Court                      dition relating to her past history of being raped and
               30k1178(1) k. In general. Most Cited         subjected to sexual molestation in two separate in-
Cases                                                       cidents. As alleged, while in the care of Kingwood
    Health care liability case that mother brought          Pines Hospital, V.G. was molested by another fe-
                                                                            FN2
against hospital, physician and counselor, after            male patient.         According to Gomez's expert,
daughter was sexually abused by a patient, would            Dr. Mark Blotcky, Gomez asserted in an affidavit
be remanded for the trial court to consider mother's        that hospital staff knew the other patient was ag-
motion for an extension to cure deficiencies in her         gressive, had been sexually abused, and had sexu-
expert report, when the Court of Appeals reversed           ally molested others, but allowed the two patients
the trial court and found that the report deficient;        to share a room and, accordingly,*744 did not pre-
mother had requested an extension if the trial court        vent the other patient from having physical access

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          FN3
to V.G.                                                     port was inadequate because Blotcky (1) did not es-
                                                            tablish his qualifications to opine regarding the
          FN2. The other patient, also a minor, al-         standards of care for the admission, treatment, and
          legedly got into bed with V.G., “made out         care of patients in a psychiatric facility; (2) failed
          with her,” touched her private parts, left        to articulate a fair summary of his opinions regard-
          visual marks (hickeys) on her, and                ing the applicable standards of care, the manner in
          threatened to beat her up if she told any-        which those standards were breached by appellants,
          one.                                              and the causal relationship between any breach and
                                                            the injury and damages claimed; and (3) attempted
          FN3. The affidavit is not in the record, but
                                                            to apply a single standard of care to multiple health
          the expert reported prepared by Dr. Mark
                                                            care providers. After considering appellants' chal-
          Blotcky describes the affidavit and states
                                                            lenges to the expert report and supplemental report
          that Blotcky relied on the affidavit in
                                                            and hearing arguments of the parties, the trial court
          reaching his conclusions.
                                                            entered an order denying appellants' motions to dis-
    Gomez filed suit on February 24, 2010, against          miss.
                       FN4
appellants and others,     alleging that they failed
                                                                     FN5. The supplemental report was served
to provide a reasonably safe environment for V.G.
                                                                     on June 24, 2010, the 120th day after
and the other patient by allowing them to share a
                                                                     Gomez filed suit, so both reports were
room. Gomez asserted claims against appellants for
                                                                     timely under the Act. See Tex. Civ. Prac.
negligence, aiding and abetting assault, assisting or
                                                                     & Rem.Code § 74.351(a).
encouraging assault, and medical malpractice. She
seeks actual and special damages.                                    FN6. Kingwood Pines Hospital, Horizon
                                                                     Health Corporation, and Psychiatric Solu-
          FN4. Gomez sued Kingwood Pines Hospit-
                                                                     tions, Inc. jointly filed their objections and
          al, LLC; Horizon Health Corporation; Psy-
                                                                     motion to dismiss, and Bassett filed her
          chiatric Solutions, Inc.; Psychiatric Solu-
                                                                     objections and motion to dismiss separ-
          tions, P.C.; Fernando Guillermo Torres,
                                                                     ately. All of appellants' objections were
          M.D. and Yolanda Bassett. Gomez alleged
                                                                     based on the same grounds.
          that Kingwood Pines Hospital is owned by
          the other corporate defendants. Only King-                             Discussion
          wood Pines Hospital, Horizon Health Cor-               In two issues, appellants contend the trial court
          poration, Psychiatric Solutions, Inc., and        abused its discretion in denying appellants' motions
          Bassett filed this appeal.                        to dismiss because the expert and supplemental re-
                                                            ports neither establish Blotcky's qualifications to
     On May 28, 2010, Gomez served an expert re-
                                                            render an opinion regarding licensed professional
port and curriculum vitae prepared by Dr. Mark
                                                            counselors, nursing staff, and hospital personnel
Blotcky, a board certified psychiatrist, in support of
                                                            nor include a fair summary of Blotcky's opinions in
her claims. After appellants objected to the ad-
                                                            connection with the statutory elements required by
equacy of the report, Gomez served a supplemental
               FN5                                          section 74.351—the applicable standards of care,
expert report.     Appellants objected to the ad-
                                                            the manner in which the care rendered failed to
equacy of the supplemental report on the same
                                                            meet those standards, and the causal relationship
grounds as their former objections and moved to
                                                            between the failure and the injury, harm, or dam-
dismiss the claims with prejudice pursuant to the
     FN6                                                    ages claimed. See id. Gomez contends the reports
Act.      See Tex. Civ. Prac. & Rem.Code §
                                                            meet the standards required by section 74.351, but
74.351(b). Appellants contended that the initial re-
                                                            even if they do not, an expert report was not re-

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quired because the doctrine of res ipsa loquitur ap-        ing if a good faith effort has been made, the trial
plies.                                                      court is limited to the four corners of the report and
                                                            cannot consider extrinsic evidence. See Jelinek, 328
*745 A. Standard of Review and Applicable Law               S.W.3d at 539; Palacios, 46 S.W.3d at 878.
     [1][2] The Act entitles a defendant to dismissal
of a health care liability claim if he is not served             [5][6][7][8][9][10][11] An expert must estab-
with an expert report showing that the claim has            lish that he is qualified to provide an acceptable re-
merit within 120 days of the date suit was filed.           port. Tex. Civ. Prac. & Rem.Code §
Tex. Civ. Prac. & Rem.Code § 74.351(b); Scoresby            74.351(r)(5)(B). Qualifications must appear in the
v. Santillan, 346 S.W.3d 546, 549 (Tex.2011). The           expert report and cannot be inferred. Baylor Coll. of
trial court's refusal to dismiss may be immediately         Med. v. Pokluda, 283 S.W.3d 110, 117
appealed. Tex. Civ. Prac. & Rem.Code §                      (Tex.App.-Houston [14th Dist.] 2009, no pet.). Ad-
51.014(a)(9); Scoresby, 346 S.W.3d at 549. We re-           ditionally, an expert report must provide a fair sum-
view a trial court's denial of a motion to dismiss un-      mary of the expert's opinions regarding (1) the ap-
der section 74.351 for abuse of discretion. Jelinek         plicable standard of care; (2) the manner in which
v. Casas, 328 S.W.3d 526, 539 (Tex.2010); Am.               the care provided failed to meet that standard; and
Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46       (3) the causal relationship between that failure and
S.W.3d 873, 875, 878 (Tex.2001); Group v. Vi-               the injury, harm, or damages claimed. See Tex. Civ.
cento, 164 S.W.3d 724, 727 (Tex.App.-Houston                Prac. & Rem.Code § 74.351(r)(6); Palacios, 46
[14th Dist.] 2005, pet. denied). Similarly, we re-          S.W.3d at 879. In compliance with these standards,
view a trial court's determination of whether a             the expert report must incorporate sufficient in-
physician is qualified to opine in a health care liab-      formation to inform the defendant of the specific
ility case under an abuse of discretion standard.           conduct the plaintiff has called into question and
Larson v. Downing, 197 S.W.3d 303, 304–05                   provide a basis for the trial court to conclude the
(Tex.2006) (per curiam); Mem'l Hermann Health-              claims have merit. Patel v. Williams, 237 S.W.3d
care Sys. v. Burrell, 230 S.W.3d 755, 757                   901, 904 (Tex.App.-Houston [14th Dist.] 2007, no
(Tex.App.-Houston [14th Dist.] 2007, no pet.). A            pet.) (citing Palacios, 46 S.W.3d at 879). A report
trial court abuses its discretion if it acts in an un-      may not merely contain the expert's conclusions
reasonable or arbitrary manner or without reference         about these elements. Jelinek, 328 S.W.3d at 539;
to any guiding rules or principles. Larson, 197             Palacios, 46 S.W.3d at 879. The expert must ex-
S.W.3d at 304–05; see also Jelinek, 328 S.W.3d at           plain the basis for his statements and must link his
539.                                                        conclusions to the facts. Jelinek, 328 S.W.3d at
                                                            539. However, a plaintiff need not present all the
     [3][4] The Act specifies requirements for an           evidence necessary to litigate the merits of his case.
adequate report and mandates “an objective good             Palacios, 46 S.W.3d at 879; Patel, 237 S.W.3d at
faith effort to comply” with the requirements. Tex.         904. The report may be informal in that the inform-
Civ. Prac. & Rem.Code § 74.351(l ), (r)(6);                 ation need not *746 fulfill the same requirements as
Scoresby, 346 S.W.3d at 549. It also authorizes a           the evidence offered in a summary judgment pro-
trial court to give a plaintiff who meets the 120–day       ceeding or at trial. Palacios, 46 S.W.3d at 879; Pa-
deadline an additional 30 days to cure any deficien-        tel, 237 S.W.3d at 904.
cies in the report. Tex. Civ. Prac. & Rem.Code §
74.351(c); Scoresby, 346 S.W.3d at 549. The trial           B. Dr. Blotcky's Qualifications
court should err on the side of granting the exten-              Within their second issue, appellants argue that
sion and must grant it if the deficiencies are cur-         the expert and supplemental reports do not establish
able. Scoresby, 346 S.W.3d at 549. When determin-           that Blotcky was qualified to render an opinion re-

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                                              FN7
garding a licensed professional counselor           or           Id. § 74.402(a). To determine whether an ex-
nursing staff and hospital personnel.                       pert is “qualified on the basis of training or experi-
                                                            ence,” a court must consider whether the expert:
        FN7. Bassett is a licensed professional               (1) is certified by a licensing agency of one or
        counselor.                                            more states of the United States or a national pro-
                                                              fessional certifying agency, or has other substan-
    To be qualified to provide opinion testimony
                                                              tial training or experience, in the area of health
regarding whether a health care provider departed
                                                              care relevant to the claim; and
from the accepted standard of health care, an expert
must satisfy section 74.402. See Tex. Civ. Prac. &            (2) is actively practicing health care in rendering
Rem.Code § 74.351(r)(5)(B). Section 74.402 lists              health care services relevant to the claim.
three specific qualifications an expert witness must
possess to provide opinion testimony on how a                   Id. § 74.402(c).
health care provider departed from accepted stand-
ards of health care. The expert must:                            [12] Blotcky has been a licensed physician for
                                                            40 years and has practiced psychiatry for almost 35
  (1) [be] practicing health care in a field of prac-       years. He also has been a clinical professor in the
  tice that involves the same type of care or treat-        Department of Psychiatry of The University of
  ment as that delivered by the defendant health            Texas Southwestern Medical Center at Dallas for
  care provider, if the defendant health care pro-          almost 35 years. He is board certified in child and
  vider is an individual, at the time the testimony is      adolescent psychiatry and general psychiatry. When
  given or was practicing that type of health care at       the expert report was served, he maintained a
  the time the claim arose;                                 private practice, and approximately 66% of his pa-
                                                                                                  FN8
                                                            tients were children and adolescents.       He previ-
  (2) [have] knowledge of accepted standards of             ously served on the managing board of directors of
  care for health care providers for the diagnosis,         a psychiatric hospital, was director of the hospital's
  care, or treatment of the illness, injury, or condi-      Child and Adolescent Psychiatry Residency Pro-
  tion involved in the claim; and                           gram, and clinical director of the hospital. He ex-
                                                            amined*747 child psychiatrists for certification by
  (3) [be] qualified on the basis of training or ex-
                                                            the American Board of Psychiatry and Neurology
  perience to offer an expert opinion regarding
                                                            for over ten years and served as Chair of the Com-
  those accepted standards of health care.
                                                            mittee for Certification of Child and Adolescent
    Id. § 74.402(b) (emphases added).                       Psychiatry for that board.

    The above emphasized terms are specifically                      FN8. We assume this is still the case, but
defined in subsections (a) and (c) of section 74.402.                the record reflects only Blotcky's qualifica-
“Practicing health care” includes:                                   tions when the report was served.

  (1) training health care providers in the same                 Based on Blotcky's education, training, and ex-
  field as the defendant health care provider at an         perience in treating patients similarly situated to
  accredited educational institution; or                    V.G.—an adolescent who was seeking treatment for
                                                            her psychiatric conditions—and in working in a
  (2) serving as a consulting health care provider          hospital setting, the trial court acted within its dis-
  and being licensed, certified, or registered in the       cretion in concluding that Blotcky is qualified to
  same field as the defendant health care provider.         render an opinion on the standard of care at issue in
                                                            this case. See Pokluda, 283 S.W.3d at 120. Simil-

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arly, Blotcky's hospital experience qualifies him to        explain the basis of his statements to link his con-
opine on the standards of care required for nursing         clusions to the facts.”); Davis v. Spring Branch
staff and hospital personnel. See Tex. Civ. Prac. &         Med.       Ctr.,    171 S.W.3d 400,    406
Rem.Code § 74.402(c)(2); see also Pokluda, 283              (Tex.App.-Houston [14th Dist.] 2005, no pet.)
S.W.3d at 118–19 (“The test is whether the report           (“[T]he expert report has to set out, in nonconclus-
and curriculum vitae establish the witness's know-          ory language, the expert's opinion about [the] three
ledge, skill, experience, training, or education re-        [statutorily required] elements of the claim.”).
garding the specific issue before the court that
would qualify the expert to give an opinion on that              [14][15][16][17][18] Standard of care is
particular subject.”).                                      defined by what an ordinarily prudent health care
                                                            provider or physician would have done under the
     We hold that the trial court acted within its dis-     same or similar circumstances. Palacios, 46 S.W.3d
cretion by denying appellants' motions to dismiss as        at 880; Strom v. Mem'l Hermann Hosp. Sys., 110
to Blotcky's qualifications, and we overrule that           S.W.3d 216, 222 (Tex.App.-Houston [1st Dist.]
portion of appellants' second issue attacking the ex-       2003, pet. denied). Identifying the standard of care
pert and supplemental reports on that basis.                is critical: whether a defendant breached his or her
                                                            duty to a patient cannot be determined absent spe-
C. Standard of Care and Breach                              cific information about what the defendant should
     [13] In both issues, appellants contend that the       have done differently. Palacios, 46 S.W.3d at 880.
expert and supplemental reports do not adequately           While a “fair summary” is something less than a
address each element required by subsection                 full statement of the applicable standard of care and
74.351(r)(6) (standards of care, breach, causation          how it was *748 breached, even a fair summary
and damages) because the reports are conclusory as          must set out what care was expected, but not given.
to each element and do not represent an objective           Id. When a plaintiff sues more than one defendant,
good faith effort to comply with the statutory defin-       the expert report must set forth the standard of care
ition of an expert report. We first address whether         for each defendant and explain the causal relation-
the reports set forth the applicable standards of care      ship between each defendant's individual acts and
and how appellants breached these standards. We             the injury. CHCA Mainland L.P. v. Burkhalter, 227
conclude that they do not.                                  S.W.3d 221, 227 (Tex.App.-Houston [1st Dist.]
                                                            2007, no pet.). While it is possible that a single
     As set forth above, the two-fold purpose of an
                                                            standard of care may apply to several defendants,
expert report under section 74.351 is to inform the
                                                            generic statements that the same standard of care
defendants of the specific conduct the plaintiff has
                                                            attaches to each defendant without further explana-
called into question and to provide the trial court
                                                            tion are conclusory. See Gray v. CHCA Bayshore
with a basis to determine whether or not the
                                                            L.P., 189 S.W.3d 855, 859 (Tex.App.-Houston [1st
plaintiff's claims have merit. Kelly v. Rendon, 255
                                                            Dist.] 2006, no pet.); see also Tenet Hosps. Ltd. v.
S.W.3d 665, 679 (Tex.App.-Houston [14th Dist.]
                                                            Love, 347 S.W.3d 743, 753 (Tex.App.-El Paso
2008, no pet.). A report that merely states the ex-
                                                            2011, no pet.) (“If the standard of care is the same
pert's conclusions about the standard of care,
                                                            for each defendant, then the report must state so.”).
breach, and causation does not fulfill these two pur-
poses. Palacios, 46 S.W.3d at 879. Rather, the ex-              [19] Blotcky's expert report addresses stand-
pert must explain the basis of his statements to link       ards of care and breach as follows:
his conclusions to the facts. Jelinek, 328 S.W.3d at
539; see also Earle v. Ratliff, 998 S.W.2d 882, 890           • Kingwood Pines Hospital was required to
(Tex.1999) (“An expert's simple ipse dixit is insuf-          “supervise[ ] closely and house [ ] safely” any
ficient to establish a matter; rather, the expert must        “aggressive [or] sexually aggressive 14 year old

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  girl with a history of being both sexually moles-         issues as follows:
  ted and perpetrating sexual molestation herself so
                                          FN9                 • While they “may each have different standards
  she could not harm another patient”           and
  provide treatment of patients such as V.G. “in a            of care in some areas,” Kingwood Pines Hospital,
  safe environment.” The hospital staff “breached             Torres, and Bassett “share the most rudimentary
  both these standards of care—effective, careful             responsibility for the safety and security of their
  supervision of a predator and careful, effective            patients ... in whatever therapeutic milieu their
  protection of a molestation victim.”                        patient is being treated. The safety and security
                                                              of any patient is always a most basic element in
                                                              the standard of care.” The “treating team” must
        FN9. We note that Blotcky bases his opin-             “provide additional supervision” to patients with
        ion on Gomez's affidavit stating that the             histories “of hurting themselves and being vul-
        patient who allegedly molested V.G. “was              nerable to being hurt by others.” Kingwood Pines
        known by the hospital staff to be aggress-            Hospital, Torres, and Bassett breached this stand-
        ive, to have been sexually abused and to be           ard of care, as “[V.G.] was not afforded the most
        a sexual molester.” We assume without de-             basic supervision under their care.”
        ciding the accuracy of this allegation be-
        cause we are confined to the four corners             • Kingwood Pines Hospital must not “allow any
        of the expert report in our consideration of          harm to occur to any of its patients.” The stand-
        its adequacy. See Palacios, 46 S.W.3d at              ard of care for the hospital “is to supervise the
        878. While an expert may rely on a state-             behavior*749 of each and every patient.” “Based
        ment that otherwise would not be admiss-              on the facts contained in the medical records,”
        ible in evidence in formulating his opin-             the hospital breached its standard of care by fail-
        ions, see Gannon v. Wyche, 321 S.W.3d                 ing to provide “a safe and secure environment”
        881, 890–91 (Tex.App.-Houston [14th                   and “allowing” V.G. “to be molested by another
        Dist.] 2010, pet. denied), it is unclear how          patient.”
        Gomez obtained this information. Cf. id. at
        892 (“[A]ll that is required is that [the] ex-        • Bassett was required to “do anything necessary”
        pert report informs the defendants of the             to “insure that any patient she treats in [the] hos-
        specific conduct the plaintiffs have called           pital ... has been admitted to a safe and secure
        into question and provides a basis for the            milieu” by “be[ing] aware of the treatment mi-
        trial court to conclude that the claims have          lieu, patient population, and the structure and
        merit.”).                                             safety measures” in place. She breached the
                                                              standard of care by failing to “insur[e] her pa-
                FN10
  • Dr. Torres       and Bassett were required “to            tient's basic safety using any number of measures
  ensure that there were appropriately trained and            available.”
  adequate staffing and milieu structure” so that a
  “young” patient “would not be sexually moles-                  Appellants complain that Blotcky's articulation
  ted.” They breached “their duties to [V.G.]” by           of the applicable standards of care is deficient in
  failing to do so.                                         two regards, first, that Blotcky improperly applies a
                                                            single standard of care to multiple health care pro-
        FN10. As set forth above, Torres is a de-           viders and second, that his articulation of the stand-
        fendant in the underlying case, but not an          ard is conclusory.
        appellant.
                                                               Single Standard of Care Applied to Multiple
    The supplemental report further addresses these         Health Care Providers. In the expert report,

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362 S.W.3d 740
(Cite as: 362 S.W.3d 740)

Blotcky applies a standard of care to Kingwood              supervision of patients, and the prevention of harm
Pines Hospital separate from the standard he ap-            to patients, the reports do not indicate what an or-
plies to Bassett and Torres. He states that the hos-        dinarily prudent health care provider would do un-
pital was required to supervise known sexually ag-          der the same or similar circumstances. See Pala-
gressive patients and protect molestation victims           cios, 46 S.W.3d at 880. They merely include
from aggressive patients. By contrast, he applies a         Blotcky's conclusion that appellants did not provide
single standard of care to Torres and Bassett—to            a safe and secure environment for V.G., but do not
insure that the hospital had properly trained and ad-       specify how this should have been accomplished.
equate staffing so that a patient would not be mo-          They are thus deficient in this regard. See id.
lested. In the supplemental report, Blotcky clarifies
that, although “they may have different standards of             *750 Breach of the Standard of Care.
care in some areas,” the hospital, Torres, and Bas-         Blotcky's statements regarding breach of the stand-
sett all shared the same responsibility for the safety      ard of care, such as Bassett's “failing to ensure that
and security of their patients. He further articulates      there were appropriately trained and adequate staff-
the standard as to each party. The hospital was re-         ing and milieu structure such that a young girl
quired to supervise every patient. Torres was re-           (about whom they were forewarned was vulnerable)
quired to “admit patients only to ... facilit[ies] that     would not be sexually molested” and “breach[ing]
provide[ ] a safe and secure environment,” “work            the standard of care by not insuring her patient's
with the treatment team to understand his patient's         safety using any of the number of measures avail-
treatment and other needs,” “consult with ... staff to      able ” and appellants' failing to “provide additional
insure ... his orders are understood and followed”          supervision” and “not afford[ing] [V.G.] ... the most
and “know the inpatient program and how it imple-           basic supervision ” are similarly conclusory.
ments a safe structure for patients who have been           (Emphases added.) Whether a defendant breached
either victims or perpetrators of sexual assault.”          the standard of care cannot be determined without
Similarly, Bassett was required to insure her pa-           “specific information about what the defendant
tients are being treated in a safe and secure environ-      should have done differently.” Id. For example, the
ment by being aware of the environment, patient             reports do not provide information about how Bas-
population, and safety measures taken by the hos-           sett was to insure that hospital staff were appropri-
pital.                                                      ately trained and adequately staffed or what
                                                            “measures” were available to her to insure her pa-
     We conclude that Blotcky articulates a standard        tient's safety. Nor do the reports indicate what kind
of care for each appellant, although conclusorily, as       of supervision by the hospital or Bassett was neces-
set forth below. In the supplemental report, he ad-         sary or “basic” to provide a secure environment for
                                                                  FN11
equately explains why the standards of care overlap         V.G.         Blotcky, moreover, states that the hos-
as to the parties, which cures any deficiencies with        pital breached its standard of care “[b]ased on the
regard to his applying the same standard to Torres          facts contained in the medical records,” but does
and Bassett in the expert report. See Tenet, 347            not indicate on what “facts” he relies to reach that
S.W.3d at 753. We thus find without merit appel-            conclusion.
lants' argument that Blotcky improperly applies the
same standard of care to multiple health care pro-                   FN11. Gomez argues that this case is akin
viders.                                                              to Russ v. Titus Hospital District, 128
S.W.3d 332 (Tex.App.-Texarkana 2004,
    Conclusory Articulation of Standard of Care.                     pet. denied), which held that an expert re-
Other than containing conclusory statements re-                      port was sufficient relating to a claim filed
garding the provision of a secure environment, the                   by a mentally ill patient who was allowed

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362 S.W.3d 740
(Cite as: 362 S.W.3d 740)

         access to an unsecured window out of               (holding reports that merely state expert's conclu-
         which she fell. Id. at 344. But the expert         sions about causation are deficient).
         report in that case specifically outlined that
         the standard of care required a suicidal pa-       E. Res Ipsa Loquitur
         tient not to be placed in a room with un-               Gomez also contends she was not required to
         locked windows and what steps the hospit-          serve expert reports because the *751 negligence
         al, doctors, and nurses should have taken          alleged in this case rises to the level of res ipsa
         to secure the windows, id. at 342, whereas         loquitur.
         the reports in this case merely state that
                                                                 [21][22][23] Res ipsa loquitur is not a cause of
         V.G. should have been placed in a secure
                                                            action separate from negligence; rather, it is a rule
         environment where patients were super-
                                                            of evidence by which the jury may infer negligence.
         vised, without specifying how this should
                                                            Losier v. Ravi, 362 S.W.3d 639, 642–43
         have been accomplished.
                                                            (Tex.App.-Houston [14th Dist.] 2009, no pet.). It
     We conclude that Blotcky's reports are defi-           applies to situations in which two factors are
cient because they do not adequately describe ap-           present: (1) the character of the accident is such
plicable standards of care or breaches of those             that it would not ordinarily occur in the absence of
standards by each appellant.                                negligence, and (2) the instrumentality causing the
                                                            injury is shown to have been under the management
D. Causation                                                and control of the defendant. Id. Further, the doc-
     [20] Conclusory statements also plague                 trine applies only when the nature of the alleged
Blotcky's efforts to satisfy the statutory element of       malpractice and injuries are plainly within the com-
causation. In the expert report, he simply states, “In      mon knowledge of laypersons, requiring no expert
medical probability, V.G. would be expected to suf-         testimony. Id.
fer significant psychological damage especially
from sexual molestation occurring to her in a treat-             [24] The legislature limited the applicability of
ment setting. The proximate cause of this was the           res ipsa loquitur in health care claims only to those
hospital's failure as well as that of ... Ms. Bassett to    instances in which the doctrine had been applied by
meet the standard of care.” Likewise, he states in          Texas appellate courts as of August 29, 1977. See
the supplemental report that appellants' breaches of        Tex. Civ. Prac. & Rem.Code § 74.201. The three
the standards of care caused V.G.'s damages and             recognized areas in which res ipsa loquitur applies
“[h]ad [V.G.] and the other patients been properly          to health care claims are negligence in the use of
supervised, [V.G.] would not have been assaulted.”          mechanical instruments, operating on the wrong
                                                            body part, and leaving surgical instruments or
     These reports do not adequately describe the           sponges inside the body. Losier, 362 S.W.3d at
causal relationship between appellants' failures to         642–43 (citing Haddock v. Arnspiger, 793 S.W.2d
meet the standards of care and V.G.'s injury:               948, 951 (Tex.1990)); Hector v. Christus Health
Blotcky provided no explanation regarding how and           Gulf     Coast,     175 S.W.3d 832,      837
why these failures resulted in the alleged molesta-         (Tex.App.-Houston [14th Dist.] 2005, pet. denied).
tion. Rather, he provided bare assertions that appel-
lants' failure to “properly supervise” the patients             [25] While the nature of Gomez's claims of
resulted in V.G.'s damages. He did not attempt to           malpractice and V.G.'s alleged injuries may be
explain what constitutes proper supervision. Be-            plainly within the common knowledge of layper-
cause the reports do not contain this required in-          sons, Gomez would still have to show that her
formation, they are deficient. See Jelinek, 328             claim fell within one of the pre–1977 categories of
S.W.3d at 539–40; Palacios, 46 S.W.3d at 879                cases in order for res ipsa loquitur to apply. See Lo-

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362 S.W.3d 740
(Cite as: 362 S.W.3d 740)

sier, 362 S.W.3d at 642–43; Hector, 175 S.W.3d at           motions to dismiss filed by appellants and remand
837. Because it does not, we find without merit             this cause to the trial court to consider whether a
Gomez's argument that she was not required to               30–day extension to allow Gomez to address the
serve an expert report.                                     deficiencies in the reports is appropriate.

     We hold that the trial court abused its discre-        Tex.App.–Houston [14 Dist.],2011.
tion by denying the motions to dismiss because              Kingwood Pines Hosp., LLC v. Gomez
they do not adequately describe the elements re-            362 S.W.3d 740
quired by subsection 74.351(r)(6). We thus sustain
that portion of appellants' issues attacking the ad-        END OF DOCUMENT
equacy of the expert and supplemental reports be-
cause they are deficient.

F. Opportunity to Cure
     [26] In their second issue, appellants assert that
because of the reports' deficiencies, no “expert re-
port” has been timely served and this case should
be dismissed. As discussed above, Gomez's reports
are deficient. But even with these deficiencies, the
trial court still has discretion to grant Gomez a
thirty-day extension under section 74.351(c). See
Tex. Civ. Prac. & Rem.Code § 74.351(c); Scoresby,
346 S.W.3d at 554. Gomez requested such an ex-
tension in the trial court, and the trial court has not
ruled on this request. The appellants have not
shown that Gomez is not entitled to a ruling on her
request for a thirty-day extension under section
            FN12
74.351(c).         See Tex. Civ. Prac. & Rem.Code §
74.351(c); Scoresby, 346 S.W.3d at 554. Therefore,
while we agree with appellants that the reports are
deficient, we conclude that this case should be re-
manded for the trial court to consider granting a
30–day extension to cure the reports' deficiencies
under *752section 74.351(c). Accordingly, we
overrule appellants' second issue.

         FN12. Even if appellants had argued that
         Gomez's reports amount to no report at all
         and even if it were appropriate to address
         that argument at this juncture, we would
         still conclude that the reports satisfy the
         minimal standard in Scoresby. See
         Scoresby, 346 S.W.3d at 557.

                  Conclusion
    We reverse the trial court's order denying the

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

                                                          tion drug abuse, to learn of the patient's drug seek-
Only the Westlaw citation is currently available.         ing behavior, to learn that the patient was married
                                                          to the husband, or how the doctor should have
SEE TX R RAP RULE 47.2 FOR DESIGNATION                    treated the patient for her complaints in those cir-
AND SIGNING OF OPINIONS.                                  cumstances. V.T.C.A., Civil Practice & Remedies
                                                          Code § 74.351(l).
MEMORANDUM OPINION
                                                          On Appeal from the 133rd District Court, Harris
            Court of Appeals of Texas,
                                                          County, Texas, Trial Court Cause No.2008–10581.
                 Houston (1st Dist.).
                                                          T. Marc Calvert, for Steven Philip Kloeris and
Steven Philip KLOERIS, M.D. and Rajeswari This-
                                                          Rajeswari Thisgara Rajan.
           gara Rajan, M.D., Appellants
                         v.                               Charles Alfred Sturm, for Charles and Jamie Stock-
Charles and Jamie STOCKDALE, Individually and             dale, Individually and as Representatives of the Es-
as Representatives of the Estate of Charles William       tate of Charles William Stockdale III, and James
Stockdale III, and James and Toren Dukes, as Legal        and Toren Dukes, as Legal Guardians Of Minor
   Guardians Of Minor Children, Allyson Lenora            Children, Allyson Lenora Stockdale and Charles
 Stockdale and Charles William Stockdale, IV, Ap-         William Stockdale, IV.
                      pellees.

              No. 01–09–00711–CV.                         Panel consists of Justices JENNINGS, HANKS,
                  April 1, 2010.                          and BLAND.

     West KeySummaryHealth 198H             804
                                                                      MEMORANDUM OPINION
198H Health                                               JANE BLAND, Justice.
     198HV Malpractice, Negligence, or Breach of               *1 Charles (Chuck) and Jamie Stockdale, indi-
Duty                                                      vidually and as representatives of the estate of
       198HV(G) Actions and Proceedings                   Charles Stockdale III, and James and Toren Dukes,
           198Hk804 k. Affidavits of merit or merit-      as legal guardians of Allyson and Charles Stockdale
orious defense; expert affidavits. Most Cited Cases       IV (collectively, the Stockdales), sued Dr. Steven
     Expert report regarding a witness for the estate     Kloeris and Dr. Rajeswari Rajan for medical mal-
of decedent did not represent an objective good-          practice arising out of Charles's death from a pre-
faith effort to provide a fair summary of the stand-      scription drug overdose. The trial court overruled
ard of care applicable to a doctor who allegedly          Dr. Kloeris and Dr. Rajan's objections to the suffi-
committed malpractice. The report did not state           ciency of the expert report and denied their motions
what the standard of care specifically required the       to dismiss the Stockdales' claims. See TEX. CIV.
doctor to do to determine that her patient's husband,     PRAC. & REM.CODE ANN. § 74.351(l ) (Vernon
who was not her patient, was currently abusing pre-       Supp.2009). In this interlocutory appeal, Dr. Kloer-
scription medication, and that the doctor should not      is and Dr. Rajan contend that the trial court abused
have prescribed those drugs to her patient who went       its discretion by denying their motions to dismiss
by a different last name in most of her medical re-       because the expert report served by the Stockdales
cords and who first presented to the doctor as an as-     does not represent a good faith effort to comply
sault victim. Report did not specify what the doctor      with the statutory expert report requirements. See
should have done to learn of the husband's prescrip-      id. § 74.351(r)(6). We hold that the expert report

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

provides a fair summary of the standard of care ap-        scriptions from Dr. Kloeris and Dr. Rajan for hy-
plicable to Dr. Kloeris, how he breached that stand-       drocodone, lorazepam, alprazolam, and Soma. On
ard, and how his breach caused Charles Stockdale's         December 16, 2005, one day after Charles's second
death. We also hold that the expert report does not        visit to Dr. Kloeris, he died of a prescription drug
present a fair summary of the standard of care ap-         overdose. The Harris County Medical Examiner lis-
plicable to Dr. Rajan and how she breached the             ted Charles's official cause of death as “the toxic ef-
standard of care, and we therefore remand the case         fects of Hydrocodone, Alprazolam, and Diazepam [
to the trial court to determine whether to grant the       Valium].”
Stockdales one thirty-day extension to cure the de-
ficiencies of the report regarding Dr. Rajan's con-             *2 Charles and Jamie Stockdale, Charles's par-
duct.                                                      ents, and James and Toren Dukes, the legal guardi-
                                                           ans of Charles's children, sued Dr. Kloeris and Dr.
                     Background                            Rajan for negligence, gross negligence, and wrong-
     Dr. Kloeris and Dr. Rajan both practice as part       ful death. Within 120 days of filing suit, the Stock-
of the Texas Gulf Coast Medical Group. On                  dales served an expert report by Dr. Hugh Poindex-
November 29, 2005, Charles Stockdale first visited         ter pursuant to Section 74.351 of the Civil Practice
Dr. Kloeris, complaining of severe anxiety and pan-        and Remedies Code. See TEX. CIV. PRAC. &
ic attacks. Charles informed Dr. Kloeris that he was       REM.CODE         ANN.      §   74.351(a)     (Vernon
currently taking 25 milligrams (mg) of atenolol            Supp.2009). Dr. Poindexter stated that he is board
once per day, vicoprofen, as needed, for headaches,        certified by the American Board of Family Medi-
and 2 mg of alprazolam (Xanax) twice per day. Dr.          cine, he has been in private practice since 1977,
Kloeris diagnosed Charles with generalized anxiety         first in Huntsville until 1989, and then at the Kel-
disorder, panic disorder, and migraines, and pre-          sey–Sebold clinic in The Woodlands, where he has
scribed ninety tablets of alprazolam (2 mg) and            been the managing physician since 1991, and he
twenty-eight tablets of hydrocodone (Vicodin, 7.5          has treated “many patients with the same or similar
mg). Charles returned to Dr. Kloeris on December           diagnosis as Mr. Stockdale[, and is] familiar with
15, 2005, sixteen days later, to receive prescription      and [has] prescribed the same medications pre-
refills and treatment for a staph infection. On this       scribed to Mr. Stockdale by Dr. Kloeris, and to his
occasion, Dr. Kloeris prescribed an additional             wife Kristen by Dr. Rajan.” Dr. Poindexter re-
ninety tablets of alprazolam and sixty tablets of hy-      viewed Charles's autopsy report, the Texas Gulf
drocodone (10 mg).                                         Coast Medical Group's medical records for both
                                                           Charles and Kristen, pharmacy records from six
     Charles' wife, Kristen, had been a patient of the     different pharmacies for both Charles and Kristen, a
Gulf Coast Medical Group for at least the previous         prescription summary report, an affidavit from
year and a half. Her chart included a statement that,      plaintiff Chuck Stockdale, and the plaintiffs' origin-
on January 24, 2005, she “confided to the nurse [at        al petition.
Clear Lake Regional Medical Center] that she regu-
larly visits emergency rooms complaining of differ-             Dr. Poindexter described Charles's two visits to
ent areas of pain in order to get Vicodin [hydro-          Dr. Kloeris and stated that Dr. Kloeris prescribed a
codone] prescriptions for her husband.” Most of            total of 180 tablets of alprazolam and eighty-eight
Kristen's medical records refer to her by her maiden       tablets of hydrocodone in a sixteen-day time period.
name, Arsement; however, the records do occasion-          Regarding Kristen, Dr. Poindexter noted that her
ally contain references to her as “Kristen Stock-          medical records included a statement from her that
dale” and also mention her husband, Charles Stock-         she routinely visited emergency rooms to obtain hy-
dale. During December 2005, Kristen received pre-          drocodone for her husband, and although both Dr.

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

Kloeris and Dr. Rajan were aware or should have           use.” Dr. Rajan should have recognized Charles's
been aware of this statement in their own records,        abuse and should not have prescribed hydrocodone
they still prescribed excessive amounts of medica-        and alprazolam to Kristen. According to Dr. Poin-
tion to Kristen during November and December of           dexter, “[h]ad Dr. Rajan not prescribed these drugs
2005, including hydrocodone and alprazolam. Dr.           to Kristen, then, to a reasonable degree of medical
Poindexter opined that, based on all the records he       certainty, Mr. Stockdale would not have died.”
reviewed, “Mr. Stockdale died as a result of the
toxic effects of hydrocodone, alprazolam and                   Within twenty-one days of the filing of the ex-
diazepam prescribed by Dr. Kloeris and Dr. Rajan.”        pert report, Dr. Kloeris and Dr. Rajan both objected
                                                          to the sufficiency of the report, arguing that Dr.
     According to Dr. Poindexter, “[b]ased on the         Poindexter made conclusory assumptions, failed to
frequent and excessive prescriptions for hydro-           establish a causal link between the doctors' conduct
codone and alprazolam to Kristen and Charles” and         and Charles's death, and did not specify the stand-
Kristen's admission that she procures prescription        ard of care applicable to Dr. Rajan and how she
medication for her husband, Dr. Kloeris “knew or          breached that standard. The doctors then moved to
should have known that Charles Stockdale was ab-          dismiss the case with prejudice due to the insuffi-
using prescription drugs.” The standard of care           ciency of the report. The trial court overruled the
“required Dr. Kloeris to recognize this addiction         doctors' objections to the report and denied their
and treat it” by either referring Charles to a sub-       motions to dismiss. Dr. Kloeris and Dr. Rajan then
stance abuse facility or lowering the amounts of          filed this interlocutory appeal. See TEX. CIV.
drugs prescribed. Dr. Poindexter then generally de-       PRAC. & REM.CODE ANN. § 51.014(a)(9)
scribed the characteristics and effects of alprazolam     (Vernon 2008) (allowing interlocutory appeal when
and hydrocodone, mentioning that both medications         trial court “denies all or part of the relief sought by
were potentially dangerous and that “[t]he quantity       a motion under Section 74.351(b)”).
of pills prescribed in such a short period of time
shows that caution was not used.” Specifically, Dr.                            Discussion
Kloeris prescribed more than the recommended              Standard of Review
daily dose of alprazolam. Charles only visited the             We review the trial court's decision on a sec-
practice twice; however, “he was prescribed an ex-        tion 74.351 motion to dismiss for abuse of discre-
cessive amount of medication over a very short            tion. Am. Transitional Care Ctrs. of Tex., Inc. v.
time span.” Dr. Poindexter concluded by opining           Palacios, 46 S.W.3d 873, 878 (Tex.2001). The trial
that “[i]f Dr. Kloeris had not prescribed excessive       court abuses its discretion if it acts in an arbitrary
quantities and dosages of these drugs to Charles, or      or unreasonable manner without reference to any
if he had referred him for drug abuse treatment,          guiding rules or principles. Walker v. Gutierrez,
then, to a reasonable degree of medical certainty,        111 S.W.3d 56, 62 (Tex.2003). When we review
Mr. Stockdale would not have died.”                       matters within the trial court's discretion, we may
                                                          not substitute our own judgment for that of the trial
     *3 Regarding Dr. Rajan, Dr. Poindexter stated        court. Bowie Mem'l Hosp. v. Wright, 79 S.W.3d 48,
that, based on the “frequent and excessive prescrip-      52 (Tex.2002) (per curiam). The trial court does not
tions for hydrocodone and alprazolam ” to Kristen         abuse its discretion merely because it decides a dis-
by both doctors, and Kristen's admission that she         cretionary matter differently than we would in sim-
obtained prescription drugs for her husband's use,        ilar circumstances. Downer v. Aquamarine Operat-
Dr. Rajan “knew or should have known that                 ors, Inc., 701 S.W.2d 238, 241–42 (Tex.1985).
Charles was abusing these drugs and that Kristen
was attempting to get them for her husband's ab-          Sufficiency of Expert Reports
                                                               Dr. Kloeris and Dr. Rajan contend that the trial

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

court abused its discretion by denying their motions       breach, and causation. See id. Instead, the expert
to dismiss because Dr. Poindexter's report is vague,       must give, for each defendant, a “fair summary of
conclusory, and does not represent a good faith ef-        the expert's opinions about the applicable standard
fort to comply with the expert report requirements         of care, the manner in which the care failed to meet
of section 74.351(r)(6). When a plaintiff brings a         that standard, and the causal relationship between
healthcare liability claim, section 74.351 of the          that failure and the claimed injury.” Id. The report
Civil Practice and Remedies Code requires the              must explain the basis of the expert's statements to
plaintiff to serve each health care provider defend-       link his conclusions to the facts. Wright, 79 S.W.3d
ant with an expert report within 120 days after the        at 52 (quoting Earle v. Ratliff, 998 S.W.2d 882, 890
original petition is filed. See TEX. CIV. PRAC. &          (Tex.1999)). Although the report must include the
REM.CODE          ANN.      §    74.351(a)    (Vernon      expert's opinion on each of the elements enumer-
Supp.2009); Harris County Hosp. Dist. v. Garrett,          ated in section 74.351(r)(6), the expert report does
232 S.W.3d 170, 176 (Tex.App.-Houston [1st Dist.]          not have to marshal all of the plaintiff's proof.
2007, no pet.). Section 74.351(r)(6) defines an            Palacios, 46 S.W.3d at 878. The plaintiff also does
“expert report” as a “written report by an expert          not have to present evidence in the report as if he
that provides a fair summary of the expert's opin-         were actually litigating the merits of the claim, and
ions as of the date of the report regarding applic-        thus the report can be informal and the information
able standards of care, the manner in which the care       does not have to meet the same requirements as
rendered by the physician or health care provider          evidence offered in a summary judgment proceed-
failed to meet the standards, and the causal relation-     ing or a trial. Id. at 879.
ship between that failure and the injury, harm, or
damages claimed.” TEX. CIV. PRAC. &                        A. Sufficiency of Report Regarding Dr. Kloeris's
REM.CODE ANN. § 74.351(r)(6). A defendant                  Conduct
must file and serve any objections to the sufficiency           Dr. Kloeris contends that Dr. Poindexter's re-
of the report not later than the twenty-first day after    port fails to articulate how Dr. Kloeris breached the
the date the report was served, failing which all ob-      standard of care. The expert report must state the
jections are waived. Id. § 74.351(a). The trial court      applicable standard of care as well as the manner in
shall grant a defendant's motion to dismiss only if,       which the health care provider failed to meet that
after a hearing, it appears to the court that the ex-      standard of care. TEX. CIV. PRAC. & REM.CODE
pert report does not represent an objective good-          ANN. § 74.351(r)(6). Whether a defendant
faith effort to comply with the definition of an ex-       breached the standard of care cannot be determined
pert report. Id. § 74.351(l ).                             “absent specific information about what the defend-
                                                           ant should have done differently.” Palacios, 46
     *4 In determining whether the expert report           S.W.3d at 880. The expert is not required to give a
represents an “objective good-faith effort” to com-        full statement of the standard of care and how it
ply with the statute, we look only to the four             was breached, but he must “set out what care was
corners of the report. Palacios, 46 S.W.3d at 878.         expected, but not given.” Id. With respect to Dr.
The expert report must fulfill two purposes to meet        Kloeris, Dr. Poindexter's report stated the follow-
the “good-faith effort” requirement: (1) The report        ing:
must inform the defendant of the specific conduct
that the plaintiff calls into question; and (2) The re-      Based on the frequent and excessive prescriptions
port must provide a basis for the trial court to con-        for hydrocodone and alprazolam to Kristen and
clude that the claims have merit. See id. The report         Charles by Dr. Kloeris and Dr. Rajan, and the ad-
does not fulfill these purposes if it merely states the      mission by Kristen that she frequented doctors to
expert's conclusions about the standard of care,             get hydrocodone for her husband, Dr. Kloeris

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

  knew or should have known that Charles Stock-                 Dr. Kloeris further contends that Dr. Poindex-
  dale was abusing prescription drugs. The medical         ter's report makes conclusory assumptions and fails
  standard of care required Dr. Kloeris to recognize       to establish a causal link between his conduct and
  this addiction and treat it, either by referring         Charles's death. An expert report must include a
  Charles to an abuse facility, or prescribing smal-       fair summary of the causal relationship between the
  ler quantities and doses of hydrocodone and al-          defendant's failure to meet the appropriate standard
  prazolam solely to prevent complications from            of care and the injury, harm, or damages claimed.
  the sudden withdrawal of these drugs.... The             TEX. CIV. PRAC. & REM.CODE ANN. § 74
  quantity of pills prescribed in such a short period      .351(r)(6). An expert cannot merely state his con-
  of time shows that caution was not used. The             clusions or “provide insight” about the plaintiffs'
  amount of alprazolam prescribed exceeds the re-          claims, but must instead “explain the basis of his
  commended daily dose. Mr. Stockdale had only             statements to link his conclusions to the facts.”
  had two visits for medical care to their clinic.         Wright, 79 S.W.3d at 52. Dr. Kloeris relies on
  However, he was prescribed an excessive amount           Wright for the contention that Dr. Poindexter's con-
  of medication over a very short time span.... If         clusion is based on speculation and conjecture.
  Dr. Kloeris had not prescribed excessive quantit-        After Wright was in a car accident, a physician's as-
  ies and dosages of these drugs to Charles, or if he      sistant at the hospital x-rayed Wright's foot and
  had referred him for drug abuse treatment, then,         knee and diagnosed her with a fractured knee, but
  to a reasonable degree of medical certainty, Mr.         did not discover that Wright also fractured her foot.
  Stockdale would not have died.                           Id. at 50. Another physician discovered this injury
                                                           approximately one month later, after surgeons
     *5 Dr. Poindexter specifically stated that the        already operated on Wright's knee. Id. Wright
standard of care required Dr. Kloeris to recognize         needed two additional surgeries to correct her foot
Charles' addiction to prescription medication and          injury. Id. The expert report stated only that “if the
treat it, by either referring him to a treatment facil-    x-rays would have been correctly read and the ap-
ity or lowering the quantities of drugs prescribed to      propriate medical personnel acted upon those find-
avoid sudden withdrawal. He also stated that Dr.           ings then Wright would have had the possibility of
Kloeris prescribed an “excessive amount of medica-         a better outcome.” Id. at 52–53. The Texas Su-
tion over a very short time span,” more than the re-       preme Court upheld the trial court's dismissal of
commended daily dose of alprazolam, and Dr. Klo-           Wright's claim, holding that the “report simply
eris did not refer Charles to a substance abuse facil-     opines that [Wright] might have had ‘the possibility
ity. “Magic words” are not necessary to provide a          of a better outcome’ without explaining how [the
fair summary of the standard of care, breach of that       hospital's] conduct caused injury to [Wright].” Id.
standard, and causation. See Wright, 79 S.W.3d at          at 54. The expert report lacked information that
53. In determining whether the expert complied             linked the conclusion—that Wright might have had
with the statute, we consider the “substance of the        a better outcome—to the breach-the hospital's fail-
opinions, not the technical words used.” Moore v.          ure to correctly read and act on the x-rays. Id.
Sutherland,        107       S.W.3d      786,      790
(Tex.App.-Texarkana 2003, pet. denied). Dr. Poin-               *6 Here, Dr. Poindexter specifically stated that
dexter's report gives fair notice to Dr. Kloeris that      the standard of care required Dr. Kloeris to recog-
he breached the standard of care by prescribing ex-        nize and treat Charles's prescription drug addiction,
cessive amounts of hydrocodone and alprazolam in           and that Dr. Kloeris breached the standard of care
a short period of time and by failing to refer             by not referring Charles to a substance abuse facil-
Charles to a substance abuse facility.                     ity and by prescribing excessive amounts of hydro-
                                                           codone and alprazolam in a very short period of

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

time. Specifically, Dr. Kloeris prescribed a total of      pet.) (mem.op.) (“Both Dr. Lutz and Dr. Korn state
180 tablets of alprazolam and eighty-eight tablets         in their respective reports that they reviewed
of hydrocodone in a sixteen-day period. Dr. Poin-          Melody's medical records; thus, in determining
dexter concluded by stating that, “[i]f Dr. Kloeris        whether their records represent a fair summary, the
had not prescribed excessive quantities and dosages        records that they referred to are within our pur-
of these drugs to Charles, or if he had referred him       view.”). In deciding that a review of the medical re-
for drug abuse treatment, then, to a reasonable de-        cords is permissible, the Beaumont Court observed
gree of medical certainty, Mr. Stockdale would not         that although courts cannot look outside an expert's
have died.” In contrast to Wright's expert, who did        report to supply statutorily required information,
not explain how the hospital's failure to meet the         the challenge to the report in Reddy addressed
standard of care caused Wright's injury, Dr. Poin-         “whether the opinions in the expert reports are sup-
dexter sufficiently links his conclusion, that Charles     ported by the medical records that the experts rep-
would not have died from a prescription drug over-         resented they reviewed.” Id. The Beaumont Court
dose, to Dr. Kloeris's alleged breach, his failure to      affirmed the trial court's denial of the doctors' mo-
refer Charles to a substance abuse facility and his        tion to dismiss, stating that even when it considered
excessive prescription of hydrocodone and al-              the medical records, it could not “conclude that the
prazolam. See Wright, 79 S.W.3d at 53. Dr. Poin-           medical records necessarily preclude the opinions
dexter's statement of causation “is not a conclusion       that were reached by Dr. Lutz and Dr. Korn.” Id.
or a statement of mere possibility, as in the Wright       Similarly, the medical and pharmacy records relied
case, but is a positive statement of fact.” Moore,         upon by Dr. Poindexter do not preclude the opin-
107 S.W.3d at 791. We hold that the trial court            ions that he reached.
could have reasonably determined that Dr. Poindex-
ter's report gave a fair summary of how Dr. Kloeris             *7 Dr. Kloeris notes that Dr. Poindexter's re-
caused Charles's death and thus the trial court did        port does not mention prescriptions written by other
not abuse its discretion in denying Dr. Kloeris's          doctors or the effects of these drugs on Charles, nor
motion to dismiss.                                         does Dr. Poindexter indicate how he arrived at the
                                                           conclusion that only Dr. Kloeris and Dr. Rajan's
     According to Dr. Kloeris, although Dr. Poin-          prescriptions caused Charles's death. A review of
dexter stated that he reviewed medical and phar-           Charles and Kristen's pharmacy records demon-
macy records, he “clearly ignores” the records' in-        strates that from the beginning of October 2005 to
dication that numerous other doctors prescribed            Charles's death on December 16, 2005, the Stock-
similar medication to Charles and Kristen during           dales filled prescriptions for fifteen different pre-
the same time period. In determining whether an            scription drugs from twenty-one different doctors.
expert report constitutes a “good-faith effort” to         In the month preceding Charles's death, Charles re-
comply with the requirements of section                    ceived a total of 118 tablets of Hydrocodone: 30 (5
74.351(r)(6), we look only to the four corners of the      mg) from a Dr. Mougouris on December 14, 28 (5
report. Palacios, 46 S.W.3d at 878. Dr. Kloeris            mg) from Dr. Kloeris on November 29, and 60 (10
cites the Beaumont Court of Appeals' unpublished           mg) from Dr. Kloeris on December 15. During this
decision in Reddy v. Seale for the proposition that        same time period, Kristen received a total of 125
we may look beyond the four corners of the expert          tablets of Hydrocodone: 23 total from Doctors
report when the health care provider can show that         Totz, Kung, and Le on November 19, 27, and 28,
the expert's opinion is based on an inaccurate or in-      respectively; 21 from Dr. Rajan on December 2; 21
complete reading of medical records. See No.               from Dr. Rajan on December 8; and 60 from Dr.
09–07–00372–CV, 2008 Tex.App. LEXIS 2000, at               Kloeris on December 12. Dr. Kloeris also pre-
*9 n. 1 (Tex.App.-Beaumont Mar. 20, 2008, no               scribed 90 tablets of Alprazolam to Charles on

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

November 29, 60 tablets to Kristen on December             of the standard of care applicable to Dr. Kloeris,
12, and 90 more to Charles on December 15.                 how Dr. Kloeris breached that standard, and how
Charles died on December 16 from the “toxic ef-            Dr. Kloeris's breach caused Charles' death, not
fects of hydrocodone, alprazolam and diazepam.”            whether Dr. Poindexter is ultimately correct in his
Even though the medical and pharmacy records re-           opinions and assertions. See id. at 169–70; see also
flect that Charles and Kristen received large quant-       Apodaca v. Russo, 228 S.W.3d 252, 255
ities of prescription drugs from multiple doctors,         (Tex.App.-Austin 2007, no pet.) (“The expert re-
the records also reflect that Dr. Kloeris prescribed       port is not required to prove the defendant's liabil-
the majority of the hydrocodone and alprazolam             ity, but rather to provide notice of what conduct
that Charles received in the month prior to his            forms the basis for the plaintiff's complaints.”).
death. Specifically, in the sixteen days leading up to
Charles's death, Dr. Kloeris prescribed eighty-eight            *8 Even though Dr. Poindexter did not address
tablets of hydrocodone and 180 tablets of al-              the prescriptions written by other doctors or the fact
prazolam to Charles. We conclude that the phar-            that Dr. Kloeris did not prescribe diazepam, in the
macy records of Charles and Kristen do not pre-            “History” section of his report, he detailed the
clude Dr. Poindexter's opinion that Dr. Kloeris's ex-      amount of hydrocodone and alprazolam prescribed
cessive prescription of hydrocodone and alprazolam         to Charles by Dr. Kloeris, as well as the short time
caused Charles's death.                                    period in which Dr. Kloeris prescribed that medica-
                                                           tion. Thus, this report linked Dr. Poindexter's con-
     Dr. Kloeris further contends that Dr. Poindex-        clusions on causation to the specific facts of this
ter's expert report is speculative, conclusory, and        case. See Wright, 79 S.W.3d at 52. This report ful-
insufficient as a matter of law because he states that     filled the twin purposes that Palacios requires to
Charles died due to the “toxic effects of hydro-           constitute an “objective good-faith effort” to com-
codone, alprazolam, and diazepam prescribed by             ply with Chapter 74:(1) it informed Dr. Kloeris of
Dr. Kloeris and Dr. Rajan,” but neither of these           the specific conduct the Stockdales called into
doctors prescribed diazepam to Charles or Kristen.         question; and (2) it provided a basis for the trial
Whether an expert's opinions are correct is an issue       court to conclude that the claim has merit. Palacios,
for summary judgment, not a Chapter 74 motion to 46 S.W.3d at 879. The trial judge could have reas-
dismiss. Methodist Hosp. v. Shepherd–Sherman,              onably determined that this report gave a fair sum-
296 S.W.3d 193, 199 n. 2 (Tex.App.-Houston [14th           mary of each of the statutory requirements, and
Dist.] 2009, no pet.). As the San Antonio Court of         therefore did not abuse its discretion by denying
Appeals noted, “[a] motion to dismiss seeks to             Dr. Kloeris's motion to dismiss.
demonstrate that a plaintiff has not satisfied the
procedural requirements of Chapter 74, while a             B. Sufficiency of Report Regarding Dr. Rajan's
motion for summary judgment seeks to demonstrate           Conduct
that the substance of the claim lacks merit.” Wissa             Dr. Rajan contends that Dr. Poindexter's report
v. Voosen, 243 S.W.3d 165, 169 (Tex.App.-San               does not articulate a specific standard of care ap-
Antonio 2007, no pet.). An issue such as the fact          plicable to her and contains a speculative conclu-
that neither Dr. Kloeris nor Dr. Rajan prescribed          sion regarding causation without any supporting
diazepam to Charles or Kristen but the Harris              evidence. Dr. Poindexter's report states the follow-
County Medical Examiner found that diazepam                ing relating to Dr. Rajan:
contributed to Charles's death is a substantive issue
                                                             Based on the frequent and excessive prescriptions
affecting the merits of the Stockdales' claim. Our
                                                             for hydrocodone and alprazolam to Kristen by
focus at this stage of the proceedings is whether Dr.
                                                             Dr. Kloeris and Dr. Rajan, and the admission by
Poindexter's expert report provided a fair summary
                                                             Kristen that she frequented doctors to get hydro-

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

  codone for her husband, Dr. Rajan knew or                standard of care and how she breached that stand-
  should have known that Charles was abusing               ard sufficient to give Dr. Rajan notice of the specif-
  these drugs and that Kristen was attempting to           ic conduct complained of by the Stockdales. See
  get them for her husband's abuse. Dr. Rajan              Gray v. CHCA Bayshore L.P., 189 S.W.3d 855,
  should have recognized this abuse and not pre-           859–60 (Tex.App.-Houston [1st Dist.] 2006, no
  scribed Kristen hydrocodone and alprazolam.              pet.). In this case, the trial court had no discretion
  Had Dr. Rajan not prescribed these drugs to              but to conclude that the expert report does not rep-
  Kristen, then, to a reasonable degree of medical         resent an “objective good-faith effort” to provide a
  certainty, Mr. Stockdale would not have died.            fair summary of the standard of care applicable to
                                                           Dr. Rajan and how she breached that standard as re-
    The standard of care for a physician is what a         quired by section 74.351(r)(6). See Palacios, 46
physician of ordinary prudence would do in the             S.W.3d at 880.
same or similar circumstance. Moore, 107 S.W.3d
at 789. We cannot determine whether a defendant                *9 Dr. Rajan requests that we reverse and
breached her duty to a patient “absent specific in-        render judgment that the trial court dismiss the
formation about what the defendant should have             Stockdales' claims against her with prejudice. The
done differently.” Palacios, 46 S.W.3d at 880. We          Civil Practice and Remedies Code provides,
do not require a full statement of the standard of         however, that “[i]f an expert report has not been
care and how the defendant breached that standard,         served within [120 days of the plaintiff filing suit]
but the “fair summary” must state what “care was           because elements of the report are found deficient,
expected, but not given.” Id.                              the court may grant one 30–day extension to the
                                                           claimant in order to cure the deficiency.” TEX.
     Dr. Poindexter opines that Dr. Rajan “knew or         CIV. PRAC. & REM.CODE ANN. § 74.351(c).
should have known” that Charles was abusing pre-           According to the Texas Supreme Court, the plain
scription drugs and that Kristen was obtaining these       language of this section “permits one thirty-day ex-
drugs for her husband's use, and therefore Dr. Rajan       tension when the court of appeals finds deficient a
should not have prescribed hydrocodone and al-             report that the trial court considered adequate.” Le-
prazolam to Kristen. Dr. Poindexter does not,              land v. Brandal, 257 S.W.3d 204, 207 (Tex.2008).
however, state what the standard of care specific-         We have discretion to remand consideration of the
ally required Dr. Rajan to do to determine that            extension issue to the trial court. See id. at 208. We
Charles Stockdale, who was not her patient, was            therefore remand the case to the trial court to de-
currently abusing prescription medication, and that        termine whether to grant the Stockdales one thirty-
she should not prescribe these drugs to Kristen,           day extension to cure the deficiencies of the report
who went by a different last name in most of her           regarding Dr. Rajan's conduct.
medical records and who first presented to Dr. Ra-
jan as an assault victim. The report does not, for ex-     Sanctions for Frivolous Appeal
ample, specify what Dr. Rajan should have done to               The Stockdales request that we sanction Dr.
learn of Charles's prescription drug abuse, what she       Kloeris for filing a frivolous appeal pursuant to
should have done to learn of Kristen's drug-seeking        Rule 45 of the Texas Rules of Appellate Procedure.
behavior, what she should have done to learn that          See TEX.R.APP. P. 45 (“If the court of appeals de-
Charles and Kristen were currently married, or how         termines that an appeal is frivolous, it may ... award
she should have treated Kristen, her patient, for her      each prevailing party just damages.”). The Stock-
complaints in these circumstances. Without specific        dales contend that Dr. Kloeris's appeal is “patently
information of this nature, Dr. Poindexter's report        frivolous,” since Dr. Kloeris agreed to be sanc-
does not provide a fair summary of the applicable          tioned by the Texas Medical Board (TMB) for,

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Not Reported in S.W.3d, 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2010 WL 1241305 (Tex.App.-Hous. (1 Dist.)))

among other things, his treatment of Charles Stock-             *10 We hold that Dr. Poindexter's expert report
dale. An agreed order from the TMB is considered           provides a fair summary of the standard of care ap-
a settlement agreement under Rule 408 of the Texas         plicable to Dr. Kloeris, how Dr. Kloeris breached
Rules of Evidence. TEX. OCC.CODE ANN. §                    that standard, and how Dr. Kloeris's breach caused
164.002(d) (Vernon Supp.2009). Settlement agree-           Charles Stockdale's death. We therefore affirm the
ments are not admissible to prove liability or in-         order of the trial court denying Dr. Kloeris's motion
validity of the claim or amount, but may be admiss-        to dismiss. We further hold that Dr. Poindexter's re-
ible when “offered for another purpose.” TEX.R.            port does not provide a fair summary of the stand-
EVID. 408. Determining whether an appeal regard-           ard of care applicable to Dr. Rajan and how her
ing the sufficiency of an expert report is frivolous       conduct breached that standard with respect to
when the doctor has agreed to be sanctioned for the        Charles Stockdale, who was not her patient. We
conduct at issue does not relate to liability or valid-    therefore remand the case to the trial court to de-
ity of the claim or amount, and is therefore a per-        termine whether to grant the Stockdales a thirty-day
missible purpose for which a settlement agreement          extension to cure the deficiencies in the expert re-
can be considered.                                         port regarding Dr. Rajan's conduct.

     When determining whether an appeal is frivol-         Tex.App.-Houston [1 Dist.],2010.
ous, we “look at the record from the viewpoint of          Kloeris v. Stockdale
the advocate and decide whether he had reasonable          Not Reported in S.W.3d, 2010 WL 1241305
grounds to believe the case could be reversed.”            (Tex.App.-Hous. (1 Dist.))
Smith v. Brown, P.C., 51 S.W.3d 376, 381
(Tex.App.-Houston [1st Dist.] 2001, pet. denied);          END OF DOCUMENT
see also Goss v. Houston Cmty. Newspapers, 252
S.W.3d 652, 657 (Tex.App.-Houston [14th Dist.]
2008, no pet.) (“If an appellant's argument on ap-
peal fails to convince us but has a reasonable basis
in law and constitutes an informed, good-faith chal-
lenge to the trial court's judgment, sanctions are not
appropriate.”). Dr. Kloeris's contention that Dr.
Poindexter's report is insufficient centers around
the fact that the report does not address records
upon which Dr. Poindexter stated he relied but un-
dermine his conclusion regarding causation. Al-
though we hold that the medical and pharmacy re-
cords from other doctors, relied upon but not men-
tioned by Dr. Poindexter in his report, do not pre-
clude his conclusions on causation, Dr. Kloeris as-
serted reasonable grounds for an appeal. See Reddy,
2008 Tex.App. LEXIS 2000, at *9 n. 1 (stating that
appellate courts can consider additional records to
determine whether the expert's opinions are suppor-
ted by the records he reviewed). We decline to con-
clude that Dr. Kloeris's appeal is frivolous.

                     Conclusion

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Not Reported in S.W.3d, 2014 WL 4179454 (Tex.App.-Austin)
(Cite as: 2014 WL 4179454 (Tex.App.-Austin))

                                                                  peal as he did in the trial court proceed-
Only the Westlaw citation is currently available.                 ings.

SEE TX R RAP RULE 47.2 FOR DESIGNATION                        FACTUAL AND PROCEDURAL BACK-
AND SIGNING OF OPINIONS.                                                        GROUND
                                                               Colby was under Kocurek's care for approxim-
MEMORANDUM OPINION                                        ately two months after sustaining injuries on the
                                                          job; his primary medical complaints were numbness
           Court of Appeals of Texas,
                                                          and pain in his left hip and tingling in his right
                     Austin.
                                                          hand. According to Colby, Kocurek performed no
 Kristen KOCUREK, M.D., and Texas MedClinic,
                                                          physical examination on him and instead had only
                   Appellants
                                                          oral conferences with him. Further, Kocurek indic-
                       v.
                                                          ated to him orally that she would refer him to a spe-
          Anthony D. COLBY, Appellee.
                                                          cialist, but never did.
              No. 03–13–00057–CV.
                                                              After receiving treatment from Kocurek, Colby
                  Aug. 22, 2014.
                                                          moved out of state and transferred his care to an or-
From the District Court of Travis County, 419th Ju-       thopedic specialist there. Shortly thereafter,
dicial District No. D–1–GN–12–000186, Tim Sulak           however, Colby returned to see Kocurek, claiming
, Judge Presiding.                                        new symptoms. According to Colby's petition, at
Anthony D. Colby, Austin, TX, pro se appellee.            that visit Kocurek again failed to examine him
                                                          physically, ignored his symptoms, and displayed an
Laura A. Macom, George F. Evans Jr., Brett B.             inappropriate demeanor toward him.
Rowe, Evans & Rowe, PC, San Antonio, TX, for
appellant.                                                     Colby filed suit against Kocurek and Texas
                                                                      FN2
                                                          MedClinic,        alleging departures from accepted
                                                          standards of medical care that proximately resulted
Before Chief Justice JONES, Justices GOODWIN              in injuries to him. Colby alleged that Kocurek
and FIELD.                                                failed to meet the applicable standards of care in
                                                          failing to (1) perform a thorough examination of
             MEMORANDUM OPINION                           him; (2) secure appropriate treatment for him; (3)
SCOTT K. FIELD, Justice.                                  properly diagnose and treat him; (4) refer him to or
     *1 Appellants Kristen Kocurek, M.D., and             consult with a specialist; and (5) monitor his condi-
Texas MedClinic appeal from the trial court's deni-       tion. Colby also made a claim for fraudulent mis-
al of their motion to dismiss appellee Anthony D.         representation/common-law fraud relating to Ko-
         FN1                                              curek's documentation of his injuries and treatment.
Colby's         suit for medical malpractice based on
Colby's alleged failure to provide an adequate ex-        In addition, Colby claimed that Kocurek's actions
pert report as required by chapter 74 of the Texas        caused (1) a pinched nerve in his right hand to be-
Civil Practice and Remedies Code. See Tex. Civ.           come entrapped, (2) his left hip to develop bursitis
Prac. & Rem.Code § 74.351. We will reverse the            and soft-tissue nerve damage, (3) limited range of
trial court's judgment and remand for dismissal and       motion in his hip, as well as constant pain and
a determination of attorneys' fees.                       nerve damage that will worsen with age, and (4) a
                                                          need for surgery in his right hand due to numbness,
        FN1. Colby represents himself in this ap-         tingling, and serious pain.

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Not Reported in S.W.3d, 2014 WL 4179454 (Tex.App.-Austin)
(Cite as: 2014 WL 4179454 (Tex.App.-Austin))

         FN2. Colby's claims against Texas Med-            does not support Colby's position. In Andra, the de-
         Clinic were solely for vicarious liability        fendant filed an interlocutory appeal of a denial of a
         arising from Kocurek's actions.                   motion to strike an expert report, not a motion to
                                                           dismiss as in this case. Id. at 186. Because of the
     After filing suit, Colby served appellants with       unique procedural posture in the Andra case, we
the expert report of Dr. Ronald Devere, a neurolo-         concluded that the motion for relief was a motion
gist, to comply with the expert-report requirement         under section 74.351(l ), for which there is no pro-
of section 74.351 of the Texas Civil Practice and          vision for an interlocutory appeal when denied. Id.
Remedies Code. See id. Appellants then filed a mo-         at 189; see Tex. Civ. Prac. & Rem.Code §
tion to dismiss the suit, claiming that Devere's ex-       51.014(a)(10) (allowing interlocutory appeal of or-
pert report failed to satisfy the statutory elements       der granting relief under section 74.351(1 )). That is
under section 74.351. After a hearing, the trial court     not the type of motion appellants filed in this case.
agreed with appellants that Devere's expert report
was deficient, but granted Colby a 30–day exten-                Appellants filed a motion to dismiss and re-
sion to cure the deficiencies. In response to the trial    quest for attorneys' fees under section 74.351(b).
court's ruling, Colby served appellants with an            See Tex. Civ. Prac. & Rem.Code § 74.351(b)
amended report from Devere. Appellants again               (providing that physician provider may move to
filed a motion to dismiss, contending that Devere's        dismiss when sufficient expert report not served
amended report remained deficient. After a hearing,        and 120–day deadline has expired). The denial of a
the trial court denied appellants' motion to dismiss.      motion to dismiss and request for attorneys' fees
FN3
      Appellants then filed this interlocutory appeal.     under section 74.351(b) is subject to interlocutory
See id. § 51.014(a)(9).                                    appeal under section 51.014(a)(9) of the Texas
                                                           Civil Practice and Remedies Code. Lewis v. Fun-
         FN3. The trial judge who denied appel-            derburk, 253 S.W.3d 204, 208 (Tex.2008). Colby's
         lants' motion to dismiss Devere's amended         jurisdictional complaint is overruled, and we now
         expert report was not the same trial judge        turn to the merits of this appeal.
         who ruled that Devere's expert report was
         deficient in the context of appellants' first     Sufficiency of Expert Report
         motion to dismiss.                                     In a health-care-liability claim, a claimant must
                                                           provide each defendant with an expert report and
                     ANALYSIS                              curriculum vitae for each expert within 120 days of
Jurisdiction                                               filing suit. Tex. Civ. Prac. & Rem.Code § 74.351(a)
     *2 In response to appellants' appeal, Colby           . The expert report must summarize the expert's
contends that this Court lacks jurisdiction over the       opinions “regarding applicable standards of care,
appeal. Colby appears to argue that once a trial           the manner in which the care rendered by the physi-
court grants a 30–day extension for a plaintiff to         cian or health care provider failed to meet the
file an amended report and the plaintiff files an          standards, and the causal relationship between that
amended report, no appeal may be taken with re-            failure and the injury, harm, or damages claimed.”
gard to the trial court's ruling on the adequacy of        Id. § 74.351(r)(6). After an expert report is filed,
the amended report. Colby argues that, in any              the defendant may object to the sufficiency of the
event, a party may not appeal the denial of a motion       report and move to dismiss the plaintiff's claims.
to dismiss relating to the adequacy of the expert re-      See id. § 74.351(a), (b). In two appellate issues, ap-
port. In support of his argument, Colby relies on          pellants contend that the trial court abused its dis-
this Court's opinion in Academy of Oriental Med.,          cretion in denying their motion to dismiss because
L.L.C. v. Andra, 173 S.W.3d 184 (Tex.App.-Austin           (1) Devere is not a qualified expert to provide a re-
2005, no pet.). Our opinion in Andra, however,

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Not Reported in S.W.3d, 2014 WL 4179454 (Tex.App.-Austin)
(Cite as: 2014 WL 4179454 (Tex.App.-Austin))

port in this case, and (2) Devere's report is conclus-     care applicable to those complaints, and an opinion
ory with regard to the element of causation. We            as to whether Kocurek breached the applicable
will begin with analysis of whether Devere's report        standards of care. Devere's report, however, con-
adequately demonstrates causation.                         tains nearly no discussion of causation to link
                                                           Colby's alleged harm to Kocurek's actions.
     *3 When a party challenges the adequacy of an
expert report, the trial court should sustain the ob-           Looking only to the four corners of the report,
jection only if it determines that the report does not     the following are the only statements from Devere's
represent an “objective good faith effort to comply        report that could potentially be considered as touch-
with the definition of an expert report.” Id. §            ing on causation:
74.351(l ). To constitute a good-faith effort, the re-
port must inform the defendant of the specific con-          • “Based on Dr. Kocurek's failure to act, secure
duct called into question and provide a basis for the        treatment and properly execute a referral for Mr.
trial court to determine whether the claims have             Colby, his condition has worsened and he has
merit. American Transitional Care Ctrs. of Tex.,             suffered tremendously and unnecessarily.” (from
Inc. v. Palacios, 46 S.W.3d 873, 879 (Tex.2001). A           Background Facts section of report)
report does not fulfill these purposes if it fails to
                                                             • “By not making this referral [to a specialist],
address the standard of care, breach of the standard
                                                             Defendant, Dr. Kocurek, deceived Mr. Colby,
of care, and causation, or if it merely states the ex-
                                                             created anxiety in Mr. Colby by making him
pert's conclusions regarding these elements. Id. The
                                                             think that a referral to a specialist was coming
expert must link his conclusions to the facts of the
                                                             when it was not and resulted in a delay in Mr.
case. Bowie Mem'l Hosp. v. Wright, 79 S.W.3d 48,
                                                             Colby receiving any needed care, treatment or
52 (Tex.2002). We review a trial court's denial of a
                                                             therapy that might have been recommended by a
motion to dismiss under section 74.351 under an
                                                             specialist, if that referral had been made.” (from
abuse-of-discretion standard. Palacios, 46 S.W.3d
                                                             Application of Standard of Care section)
at 878. However, “if an expert report contains only
conclusions about the statutory elements, the trial          *4 • “In my expert opinion, the Defendant viol-
court has ‘no discretion but to conclude ... that the        ated the applicable standard of care for physi-
report does not represent a good-faith effort’ to sat-       cian's [sic] operating in the State of Texas based
isfy the statute.” Smith v. Wilson, 368 S.W.3d 574,          on the reasons mentioned above. Based on her ac-
577 (Tex.App.-Austin 2012, no pet.) (quoting Pala-           tions or failures to act, Mr. Colby suffered and
cios, 46 S.W.3d at 877, 880). To perform its re-             her actions or failures to act were a direct cause
view, the trial court must look only to the four             of worsening pain and numbness to Mr. Colby.
corners of the report itself. Palacios, 46 S.W.3d at         Her violations of the standard of care resulted in
878.                                                         a delay of Mr. Colby receiving appropriate care
                                                             for his injuries, and the worsening of his symp-
    Devere's eight-page report contains a paragraph
                                                             toms.” (from the Conclusion section)
on his qualifications, lists the issues he is reviewing
and the materials used in that review, and states the        • “Based on these worsening injuries, Mr. Colby
background facts. The report then turns to a discus-         has endured and will continue to endure signific-
sion of the standards of care for Kocurek's treat-           ant pain, numbness and incapacity until he can
ment of Colby and a discussion applying those                receive the appropriate treatment to correct these
standards of care to the facts presented. Finally, it        conditions.” (from the Conclusion section)
contains a conclusion section. The report contains
some detail of Colby's complaints, the standards of            The issue is whether these statements, which

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                                                                                                         Page 4
Not Reported in S.W.3d, 2014 WL 4179454 (Tex.App.-Austin)
(Cite as: 2014 WL 4179454 (Tex.App.-Austin))

appear to be the only attempts made at establishing        in Colby's condition—“treatment or therapy that
causation in Devere's report, are sufficient to meet       might have been recommended by a specialist, if
the requirements of section 74.351. We conclude            that referral had been made”—amounts to nothing
they are not.                                              more than speculation. See id. at 539 (concluding
                                                           that statement in expert report that breach of stand-
     The problem with Devere's report is that it fails     ard of care “in reasonable medical probability res-
to show, within its four corners, what specific ac-        ulted in [injury]” was insufficient). The report does
tions Kocurek did or did not take, or could have           not explain what treatment or therapy a specialist
taken, that would have prevented Colby's symptoms          would have provided had Colby been referred earli-
or injuries. See Tex. Civ. Prac. & Rem.Code §              er or how such treatment or therapy would have
74.351(r)(5) (expert report must include “fair sum-        prevented Colby's injuries. As a result, the state-
mary” or expert's opinion as to “causal relation-          ments in Devere's report regarding causation
ship” between medical defendant's failure to meet          amount to “no more than a bare assertion that
standard of care and injury). Nowhere in the report        [Kocurek's] breach resulted in increased pain and
does Devere actually state what specific violation         suffering.” See id. at 540.
of which standard of care led to a particular health
problem of Colby's. The report lists five standards             *5 This Court has consistently required more
of care that Kocurek allegedly violated in her treat-      than what Devere has provided in terms of expert
ment of Colby and the specific ways Devere be-             testimony on causation in the context of section
lieves Kocurek violated those standards of care.           74.351. See Smith, 368 S.W.3d at 577–78 (holding
Devere, however, did not provide facts that would          that expert report failed to show how doctor's al-
explain a causal link between any of those alleged         leged breach of standard of care caused patient to
breaches of the standards of care to any one of            commit suicide); Constancio v. Bray, 266 S.W.3d
Colby's injuries.                                          149, 157–58 (Tex.App.-Austin 2008, no pet.)
                                                           (holding that expert report that alleged that breach
     An expert report must explain, to a reasonable        of standard of care by doctor caused patient's death
degree, how and why the alleged breach caused the          is insufficient when report did not explain how in-
injury based on the facts presented. See Jelinek v.        creased monitoring of patient, detection of hypox-
Casas, 328 S.W.3d 526, 539–40 (Tex.2010). The              emia, and other actions would have prevented pa-
closest Devere's report comes to providing a causal        tient's death); Perez v. Daughters of Charity Health
link is in his statement that “[b]ased on [Kocurek's]      Servs. of Austin, No. 03–08–00200–CV, 2008 WL
actions or failures to act, Mr. Colby suffered and         4531558, at *4 (Tex.App.-Austin Oct. 10, 2008, no
[Kocurek's] actions or failures to act were a direct       pet.) (mem.op.) (concluding expert report insuffi-
cause of worsening pain and numbness to Mr.                cient on causation because it did not link hospital's
Colby. Her violations of the standard of care resul-       actions to patient's death or any cause of death and
ted in a delay of Mr. Colby receiving appropriate          did not identify any specific injury that would have
care for his injuries, and the worsening of his symp-      been prevented had hospital complied with standard
toms.” This statement, however, never identifies           of care). To find Devere's report sufficient on caus-
which breach of which standard of care by Kocurek          ation, we would have to make inferences from bey-
led to a worsening of Colby's pain and numbness.           ond the four corners of his report; this we are not
Further, the statement fails to identify how any spe-      allowed to do.
cific injury sustained by Colby would have been
prevented or lessened had he received “appropriate             Based on the record before us and the four
care” sooner. Devere's statement that referring            corners of the expert report, we are left with no
Colby to a specialist might have made a difference         choice but to conclude that the report does not

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Not Reported in S.W.3d, 2014 WL 4179454 (Tex.App.-Austin)
(Cite as: 2014 WL 4179454 (Tex.App.-Austin))

provide an adequate causal link between Kocurek's
alleged shortcomings and Colby's symptoms or in-
juries. Because the report is insufficient as to Ko-
curek, it is also insufficient as to Texas MedClinic,
which Colby sued solely on the basis of its alleged
vicarious liability for Kocurek's actions. See Smith,
368 S.W.3d at 579. Accordingly, we sustain the ap-
                                    FN4
pellants' second issue on appeal.

         FN4. Because appellants' second issue is
         dispositive of this appeal, we need not
         reach appellants' first appellate issue chal-
         lenging the trial court's conclusion that the
         expert report adequately demonstrated
         Devere's qualifications as an expert.

                    CONCLUSION
     We reverse the trial court's order denying ap-
pellants' motion to dismiss. We remand the cause to
the trial court for a determination of attorneys' fees,
see Tex. Civ. Prac. & Rem.Code § 74.351(b), and
for entry of a final order dismissing Colby's claims
against appellants.

Tex.App.-Austin,2014.
Kocurek v. Colby
Not Reported in S.W.3d, 2014 WL 4179454
(Tex.App.-Austin)

END OF DOCUMENT

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                                                                                                           Page 1
296 S.W.3d 193
(Cite as: 296 S.W.3d 193)

                                                                       198Hk804 k. Affidavits of merit or merit-
                                                             orious defense; expert affidavits. Most Cited Cases
           Court of Appeals of Texas,                             In providing the required expert report for a
             Houston (14th Dist.).                           health care liability claim, the claimant need not
   The METHODIST HOSPITAL, Appellant                         marshal his evidence or present sufficient evidence
                      v.                                     to avoid summary judgment. V.T.C.A., Civil Prac-
  Beverley SHEPHERD–SHERMAN, Appellee.                       tice & Remedies Code § 74.351.

                No. 14–08–01090–CV.                          [2] Health 198H       804
                    Aug. 20, 2009.
                                                             198H Health
Background: Marfan syndrome patient brought                       198HV Malpractice, Negligence, or Breach of
negligence action against hospital arising from              Duty
heart surgery by surgeons who were not patient's                     198HV(G) Actions and Proceedings
normal surgeon who was a Marfan syndrome spe-                           198Hk804 k. Affidavits of merit or merit-
cialist, alleging that stent was misplaced and that          orious defense; expert affidavits. Most Cited Cases
hospital's doctors and employees did not honor her                The required expert report for a health care li-
request to have her surgeon treat her. The 113th             ability claim must provide enough information to
District Court, Harris County, 2008 WL 6654897,              fulfill two purposes: (1) to inform the defendant of
Patricia Ann Hancock, J., denied the hospital's mo-          the specific conduct the plaintiff has called into
tion to dismiss based on patient's alleged failure to        question, and (2) to provide a basis for the trial
meet the expert report requirement. Hospital ap-             court to conclude the claims have merit. V.T.C.A.,
pealed.                                                      Civil Practice & Remedies Code § 74.351.

Holdings: The Court of Appeals, Leslie B. Yates,             [3] Appeal and Error 30        960(1)
J., held that:
(1) expert was qualified to render standard of care          30 Appeal and Error
opinion regarding hospital admissions procedures                 30XVI Review
for patients requesting a specific doctor;                          30XVI(H) Discretion of Lower Court
(2) expert report was sufficient as to the standard of                    30k960 Rulings on Motions Relating to
care and breach;                                             Pleadings
(3) expert report was sufficient as to causation; and                         30k960(1) k. In general. Most Cited
(4) hospital was not subject to sanction for frivol-         Cases
ous appeal.                                                       The appellate court reviews for an abuse of dis-
                                                             cretion a trial court's ruling on the adequacy of an
    Affirmed.                                                expert report and a motion to dismiss based on a
                                                             failure to meet the expert report requirement in a
                  West Headnotes
                                                             health care liability case. V.T.C.A., Civil Practice
[1] Health 198H        804                                   & Remedies Code § 74.351.

198H Health                                                  [4] Health 198H       804
    198HV Malpractice, Negligence, or Breach of
                                                             198H Health
Duty
                                                                 198HV Malpractice, Negligence, or Breach of
     198HV(G) Actions and Proceedings
                                                             Duty

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296 S.W.3d 193
(Cite as: 296 S.W.3d 193)

       198HV(G) Actions and Proceedings                      viders based on experience working with or super-
           198Hk804 k. Affidavits of merit or merit-         vising them, then he can be qualified to render an
orious defense; expert affidavits. Most Cited Cases          opinion in the form of the required expert report.
     In determining the qualifications of an expert          V.T.C.A., Civil Practice & Remedies Code §
to provide an expert report in a health care liability       74.402(b)(3), (c)(1).
case, the court must analyze the expert's training
and experience regarding the specific issue before           [7] Health 198H       804
the court to ensure the expert is qualified to give an
                                                             198H Health
opinion on that issue. V.T.C.A., Civil Practice &
                                                                 198HV Malpractice, Negligence, or Breach of
Remedies Code § 74.402(b)(3), (c)(1).
                                                             Duty
[5] Health 198H        804                                          198HV(G) Actions and Proceedings
                                                                        198Hk804 k. Affidavits of merit or merit-
198H Health                                                  orious defense; expert affidavits. Most Cited Cases
     198HV Malpractice, Negligence, or Breach of                 Physician's expert report was sufficient as to
Duty                                                         standard of care and breach even if report did not
       198HV(G) Actions and Proceedings                      identify the specific conduct called into question by
          198Hk804 k. Affidavits of merit or merit-          each type of hospital employee involved, namely
orious defense; expert affidavits. Most Cited Cases          doctors, nurses, or admissions staff, in patient's
     Physician was qualified to render standard of           negligence action against hospital arising from
care opinion regarding hospital admissions proced-           heart surgery performed by surgeons other than the
ures for patients requesting a specific doctor in pa-        Marfan syndrome specialist requested by patient;
tient's negligence action against hospital arising           report explained that the standard of care was the
from surgery performed by surgeons other than one            same for doctors and hospital staff when a patient
requested by patient, where physician had experi-            requested a specific doctor and report opined that
ence with all aspects of the admissions process,             the doctors and hospital staff all breached that
having been involved in numerous admissions                  standard. V.T.C.A., Civil Practice & Remedies
where either a patient had requested him as a doctor         Code § 74.351.
or a patient he was involved with requested another
doctor. V.T.C.A., Civil Practice & Remedies Code             [8] Health 198H       804
§ 74.402(b)(3), (c)(1).
                                                             198H Health
[6] Health 198H        804                                        198HV Malpractice, Negligence, or Breach of
                                                             Duty
198H Health                                                         198HV(G) Actions and Proceedings
     198HV Malpractice, Negligence, or Breach of                        198Hk804 k. Affidavits of merit or merit-
Duty                                                         orious defense; expert affidavits. Most Cited Cases
        198HV(G) Actions and Proceedings                         Expert report in health care liability case may
           198Hk804 k. Affidavits of merit or merit-         not state a global standard of care without explain-
orious defense; expert affidavits. Most Cited Cases          ing how that standard of care applies to the health
     A doctor serving as an expert in a health care          care providers at issue and how they breached it.
liability case is not automatically disqualified from        V.T.C.A., Civil Practice & Remedies Code §
giving opinions regarding other types of health care         74.351.
providers, even though the standard of care may be
different for those providers; if doctor is familiar         [9] Pretrial Procedure 307A        680
with the standard of care for other health care pro-

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296 S.W.3d 193
(Cite as: 296 S.W.3d 193)

307A Pretrial Procedure                                     tion; rather, the expert must explain the basis for
   307AIII Dismissal                                        his statements and link his conclusions to the facts.
       307AIII(B) Involuntary Dismissal                     V.T.C.A., Civil Practice & Remedies Code §
           307AIII(B)6 Proceedings and Effect               74.351.
                   307Ak680 k. Fact questions. Most
Cited Cases                                                 [12] Health 198H         804
     Whether an expert's opinions in the required
                                                            198H Health
expert report in a health care liability case are cor-
                                                                198HV Malpractice, Negligence, or Breach of
rect is an issue for summary judgment, not a motion
                                                            Duty
to dismiss. V.T.C.A., Civil Practice & Remedies
                                                                   198HV(G) Actions and Proceedings
Code § 74.351.
                                                                      198Hk804 k. Affidavits of merit or merit-
[10] Health 198H        804                                 orious defense; expert affidavits. Most Cited Cases
                                                                Expert report in health care liability case must
198H Health                                                 provide supported opinions that are sufficient to
     198HV Malpractice, Negligence, or Breach of            give the trial court assurance that the claim has
Duty                                                        merit. V.T.C.A., Civil Practice & Remedies Code §
       198HV(G) Actions and Proceedings                     74.351.
           198Hk804 k. Affidavits of merit or merit-
orious defense; expert affidavits. Most Cited Cases         [13] Costs 102         260(1)
     Physician's expert report was sufficient as to
                                                            102 Costs
causation in patient's negligence action against hos-
                                                               102X On Appeal or Error
pital arising from heart surgery performed by sur-
                                                                   102k259 Damages and Penalties for Frivol-
geons other than the Marfan syndrome specialist re-
                                                            ous Appeal and Delay
quested by patient, even though chain of events
                                                                     102k260 Right and Grounds
leading from hospital's actions to patient's injuries
                                                                         102k260(1) k. In general. Most Cited
had many links; report described Marfan syndrome
                                                            Cases
and explained why the use of a stent was contra-
dicted for Marfan syndrome patients, report opined          Costs 102        261
that stent should not have been used on patient, and
report repeatedly stated that no reasonable doctor,         102 Costs
which presumably included the Marfan syndrome                  102X On Appeal or Error
expert, would have performed stent surgery under                     102k259 Damages and Penalties for Frivol-
such circumstances. V.T.C.A., Civil Practice &              ous Appeal and Delay
Remedies Code § 74.351.                                                   102k261 k. Discretion of court. Most
                                                            Cited Cases
[11] Health 198H        804                                     Whether to grant sanctions for a frivolous ap-
                                                            peal is a matter of discretion that the appellate court
198H Health
                                                            exercises with prudence and caution and only after
    198HV Malpractice, Negligence, or Breach of
                                                            careful deliberation in truly egregious circum-
Duty
                                                            stances. Rules App.Proc., Rule 45.
      198HV(G) Actions and Proceedings
          198Hk804 k. Affidavits of merit or merit-         [14] Costs 102         260(4)
orious defense; expert affidavits. Most Cited Cases
    An expert report in a health care liability case        102 Costs
cannot be based on mere conclusions or specula-                102X On Appeal or Error

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296 S.W.3d 193
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        102k259 Damages and Penalties for Frivol-           claims of appellee Beverley Shepherd–Sherman
ous Appeal and Delay                                        (“Sherman”) based on her failure to meet the expert
          102k260 Right and Grounds                         *196 report requirements of chapter 74 of the Texas
              102k260(4) k. What constitutes frivol-        Civil Practice and Remedies Code. Methodist
ous appeal or delay. Most Cited Cases                       claims in four issues that the motion to dismiss
    If an appellant's argument on appeal fails to           should have been granted because Sherman's expert
convince the appellate court but has a reasonable           was not qualified and because the report was insuf-
basis in law and constitutes an informed, good-faith        ficient regarding the standard of care, breach of the
challenge to the trial court's judgment, sanctions for      standard of care, and causation. We conclude that
a frivolous appeal are not appropriate. Rules               the trial court did not abuse its discretion in deny-
App.Proc., Rule 45.                                         ing Methodists's motion to dismiss, and thus we af-
                                                            firm.
[15] Costs 102       260(5)
                                                                              BACKGROUND
102 Costs                                                        Sherman suffers from Marfan syndrome, which
   102X On Appeal or Error                                  is a condition that damages connective tissue in the
        102k259 Damages and Penalties for Frivol-           body and can affect many bodily systems, including
ous Appeal and Delay                                        the cardiovascular system. Sherman was a long-
          102k260 Right and Grounds                         term patient of Dr. Neal Kleiman, and he told her
                 102k260(5) k. Nature and form of           that if she ever had chest pains, she should call him
judgment, action, or proceedings for review. Most           and go to an emergency room. Dr. Kleiman would
Cited Cases                                                 then ensure that she was treated by Dr. Joseph
    Hospital's interlocutory appeal of denial of its        Coselli, a surgeon and Marfan syndrome specialist.
motion to dismiss patient's health care liability           In 2001, this scenario happened—Sherman experi-
claims based on her alleged failure to meet expert          enced chest pains and called Dr. Kleiman on the
report requirements was not frivolous, and therefore        way to the Methodist emergency room, and Dr.
sanctions were not warranted, even though the ap-           Kleiman contacted Dr. Coselli, who met her at the
peal lacked merit. Rules App.Proc., Rule 45.                hospital and performed heart surgery.

*195 Dwight Willis Scott Jr., Stephanie Laird                   In February 2006, Sherman again experienced
Tolson, Houston, TX, Michael H. Rubin, Baton                chest pains and called Dr. Kleiman on her way to
Rouge, LA, for appellants.                                  the Methodist emergency room. According to Sher-
                                                            man, this time Dr. Kleiman refused to call Dr.
Jimmy Williamson, Oscar Luis Delarosa, Kenneth
                                                            Coselli, despite her repeated requests. Dr. Kleiman
E. Broughton, Thomas P. Sartwelle, James R. Bo-
                                                            contacted Dr. Alan Lumsden instead. Sherman con-
ston, Cindy M. Rusnak, Houston, TX, for appellees.
                                                            tinued to insist to various doctors and hospital em-
                                                            ployees that Dr. Coselli was her doctor and that she
Panel consists of Chief Justice HEDGES and                  wanted him to be contacted, but she was told that
Justices YATES and FROST.                                   Dr. Coselli no longer worked for Methodist and that
                                                            Dr. Lumsden had taken his place. Two days after
                                                            being admitted to Methodist, Dr. Lumsden and Dr.
                    OPINION
                                                            Michael Reardon performed aortic stent graft sur-
LESLIE B. YATES, Justice.
                                                            gery on Sherman. After the surgery, Sherman
     This is an interlocutory appeal of the trial
                                                            tracked down Dr. Coselli, who transferred her to
court's order denying appellant The Methodist Hos-
                                                            another hospital and removed the stent. Sherman
pital's motion to dismiss the health care liability

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296 S.W.3d 193
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suffered complications from the stent surgery,              Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873,
which required many subsequent surgeries and left           878–79 (Tex.2001). In providing the expert's opin-
her unable to work or care for herself alone.               ions on these elements, the claimant need not mar-
                                                            shal his evidence or present sufficient evidence to
     Sherman sued Methodist and Drs. Kleiman,               avoid summary judgment. Palacios, 46 S.W.3d at
Lumsden, and Reardon. She alleged, inter alia, that         878; Patel v. Williams, 237 S.W.3d 901, 904
the doctors were negligent because they misplaced           (Tex.App.-Houston [14th Dist.] 2007, no pet.).
the stent and because a stent is contraindicated for a      Rather, the report must provide enough information
Marfan syndrome patient. Sherman alleged that               to fulfill two purposes: (1) to inform the defendant
Methodist is liable because its doctors and employ-         of the specific conduct the plaintiff has called into
ees did not honor her requests to have Dr. Coselli          question and (2) to provide a basis for the trial
treat her and Dr. Coselli would not have inserted a         court to conclude the claims have merit. Palacios,
stent, thereby preventing all of her subsequent 46 S.W.3d at 879; Patel, 237 S.W.3d at 904.
problems.
                                                                 [3] We review a trial court's ruling on the ad-
     Pursuant to chapter 74 of the Civil Practice and       equacy of an expert report and a motion to dismiss
Remedies Code, Sherman filed the expert report              based on a failure to meet the expert report require-
and curriculum vitae of Dr. Phillip Adams. The de-          ment for an abuse of discretion. Palacios, 46
fendants all objected, and Sherman was given an             S.W.3d at 877; San Jacinto Methodist Hosp. v. Ben-
opportunity to file a supplemental report. The de-          nett, 256 S.W.3d 806, 811 (Tex.App.-Houston
fendants again objected to Sherman's supplemental           [14th Dist.] 2008, no pet.). A trial court abuses its
report and filed a motion to dismiss, which the trial       discretion if it acts in an arbitrary or unreasonable
court denied. Methodist is the only defendant ap-           manner or without reference to any guiding rules or
pealing the trial court's ruling. We consider the ini-      principles. Bowie Mem'l Hosp. v. Wright, 79
tial and supplemental reports together in assessing         S.W.3d 48, 52 (Tex.2002). Though we may not
Sherman's compliance with chapter 74.                       substitute our judgment for that of the trial court,
                                                            the trial court has no discretion in determining what
                    ANALYSIS
                                                            the law is or applying the law to the facts. Id.; San-
A. Legal Framework
                                                            jar v. Turner, 252 S.W.3d 460, 463
     [1][2] Section 74.351 of the Civil Practice and
                                                            (Tex.App.-Houston [14th Dist.] 2008, no pet.).
Remedies Code requires a health care liability
claimant to provide the defendant with an expert re-        B. Qualifications
port within 120 days after filing the petition. TEX.             [4] In its first issue, Methodist challenges Dr.
CIV. PRAC. & REM.CODE ANN. § 74.351(a)                      Adams's qualifications to render an opinion as to
(Vernon Supp. 2008). A defendant may then file a            the allegations against it. To be qualified to provide
motion challenging the adequacy of the expert's             an expert report under chapter 74, an expert must,
*197 report, and the trial court “shall grant” the          among other things, be “qualified on the basis of
motion if it appears that the report does not repres-       training or experience” to offer an opinion in the
ent a good faith effort to comply with the statutory        relevant area of health care. TEX. CIV. PRAC. &
requirements. Id. § 74.351(a), (l ). A sufficient ex-       REM.CODE ANN. § 74.402(b)(3), (c)(1) (Vernon
pert report must provide a fair summary of the ex-          2005). We must analyze the expert's training and
pert's opinions regarding the applicable standard of        experience regarding the “specific issue” before the
care, the manner in which the care provided failed          court to ensure the expert is qualified to give an
to meet that standard, and the causal relationship          opinion on that issue. Thomas v. Alford, 230
between that breach and the injury, harm, or dam-           S.W.3d 853, 857 (Tex.App.-Houston [14th Dist.]
ages claimed. Id. § 74.351(r)(6); Am. Transitional

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296 S.W.3d 193
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2007, no pet.); see also In re Windisch, 138 S.W.3d         Bennett, 256 S.W.3d at 813–14; Ragan, 187 S.W.3d
507, 512–13 (Tex.App.-Amarillo 2004, no pet.).              at 563. Based on Dr. Adams's experience in hospit-
                                                            al admissions and working with hospital personnel
    [5] Unlike her claims against the defendant             in carrying out patient requests for specific doctors,
doctors, Sherman's claims against Methodist are not         we conclude Dr. Adams is qualified to render opin-
based on the surgery itself but on Methodist's em-                                                           FN1
                                                            ions regarding the claims against Methodist.
ployees denying her access to her doctor of choice.         See Wallace, 278 S.W.3d at 558–59 (concluding
Thus, the specific issue before the court involves          doctor qualified to provide standard of care for
hospital admissions procedures when a patient re-           medical center based on work with nurses, nurse
quests a specific doctor. Methodist argues that al-         practitioners, physician's assistants, and other doc-
though Dr. Adams may be qualified to give opin-             tors); Bennett, 256 S.W.3d at 814 (finding doctor
ions regarding Sherman's medical treatment, that            qualified to state standard of care for professional
does not establish his qualifications regarding the         nurse in preventing bed sores based on previous
standard of care for hospital admissions procedures         work with nurses in such situations); Ragan, 187
and the conduct of non-physician hospital person-           S.W.3d at 564 (stating that doctor was qualified to
nel when a patient requests a specific doctor.              provide standard of care for nurses based on experi-
                                                            ence working with nursing staff on the exact situ-
     [6] According to Dr. Adams's report, he has ex-
                                                            ation at issue in the case). Accordingly, we determ-
perience with all aspects of the admissions process,
                                                            ine the trial court did not abuse its discretion in
having been involved in numerous admissions
                                                            denying Methodist's motion to dismiss based on Dr.
where either a patient has requested him as a doctor
                                                            Adams's purported lack of qualifications, and we
or a patient he was involved with requested another
                                                            overrule its first issue.
doctor. He further states that he is familiar with the
standard of care for *198 hospital personnel based                   FN1. It is this fact that distinguishes this
on his work with admissions personnel and other                      case from Methodist's authority, in which
hospital staff responsible for following hospital                    the doctor either never stated the standard
policy. Methodist contends that this experience                      of care for the non-physician health care
does not qualify Dr. Adams to opine on the stand-                    providers at issue or did not explain the
ard of care applicable to non-physicians because his                 basis for any such knowledge. See, e.g.,
experience is based on his perspective as a doctor,                  Christus Health SE Tex. v. Broussard, 267
not, for example, as a nurse or admissions clerk.                    S.W.3d 531, 535–36 (Tex.App.-Beaumont
We disagree. A doctor is not automatically disqual-                  2008, no pet.); Simonson v. Keppard, 225
ified from giving opinions regarding other types of                  S.W.3d 868, 872–73 (Tex.App.-Dallas
health care providers, even though the standard of                   2007, no pet.); Methodist Health Care Sys.
care may be different for those providers. See                       of San Antonio, Ltd. v. Rangel, No.
Baylor Med. Ctr. at Waxahachie v. Wallace, 278                       04–05–00500–CV, 2005 WL 3445994, at
S.W.3d 552, 558 (Tex.App.-Dallas 2009, no pet.);                     *2–3 (Tex.App.-San Antonio Dec. 14,
Bennett, 256 S.W.3d at 814; Manor Care Health                        2005, pet. denied) (mem. op.); cf. Bennett,
Servs., Inc. v. Ragan, 187 S.W.3d 556, 562 256 S.W.3d at 814 (distinguishing Simon-
(Tex.App.-Houston [14th Dist.] 2006, pet. granted,                   son ).
judgm't vacated, remanded by agr.). If the doctor is
familiar with the standard of care for other health         C. Standard of Care and Breach
care providers based on experience working with or              [7] In its second and third issues, Methodist ar-
supervising them, then he can be qualified to render        gues that Sherman's expert report does not ad-
an opinion. See Wallace, 278 S.W.3d at 558–59;              equately identify and apply the standard of care and

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296 S.W.3d 193
(Cite as: 296 S.W.3d 193)

breach of the standard of care as to Methodist. Dr.         type of breach, and analyzed causation in the same
Adams states repeatedly in his report that when a           way does not render his opinion inadequate.”); San-
patient requests a specific doctor, the standard of         jar, 252 S.W.3d at 466–67 (affirming trial court's
care requires doctors and hospital employees to loc-        refusal to dismiss based on expert report that ap-
ate and contact that doctor and request his instruc-        plied same standard of care to multiple defendants).
tions for the care and treatment of that patient. Ac-       We conclude that Dr. Adams's report sufficiently
cording to Dr. Adams, Methodist's employees                 explained why the standard of care and breach ele-
breached the standard of care because, despite              ments were the same as to all the relevant health
Sherman's repeated requests, no one attempted to            care providers. Therefore, the trial court did not ab-
locate or contact Dr. Coselli and request his instruc-      use its discretion in denying Methodist's motion to
tions for her care.                                         dismiss on this basis, and we overrule Methodist's
                                                            second and third issues.
     [8][9] Methodist contends that the report is in-
adequate as to the standard of care and breach be-                   FN2. Dr. Adams may be, as Methodist
cause it does not identify the specific conduct                      suggests, incorrect in this conclusion, but
called into question by each type of hospital em-                    whether an expert's opinions are correct is
ployee involved, such as doctors, nurses, or admis-                  an issue for summary judgment, not a mo-
sions staff. Methodist argues that a global standard                 tion to dismiss under chapter 74. See, e.g.,
*199 of care and assertion of breach for all actors is               Sanjar, 252 S.W.3d at 467 n. 6
insufficient as a matter of law. Methodist is correct                (concluding that doctor's arguments that he
that an expert report may not state a global standard                did not owe duty to patient as described in
of care without explaining how that standard of                      expert report was an issue for summary
care applies to the health care providers at issue and               judgment rather than a motion to dismiss);
how they breached it. See, e.g., Haddad v. Mar-                      Wissa v. Voosen, 243 S.W.3d 165, 169–70
roquin, No. 13–07–014–CV, 2007 WL 2429183, at                        (Tex.App.-San Antonio 2007, pet. denied)
*4 (Tex.App.-Corpus Christi Aug. 29, 2007, pets.                     (same).
denied) (mem. op.); Doades v. Syed, 94 S.W.3d
664, 671–72 (Tex.App.-San Antonio 2002, no pet.).           D. Causation
However, that is not what Dr. Adams's report does.               [10] In its fourth issue, Methodist argues that
Rather, in his report, Dr. Adams explains that in the       Sherman's expert report is also insufficient as to
context of this specific area of practice—that is,          causation. Dr. Adams opines that the stent is the ul-
when a patient requests a specific doctor—the               timate cause of all Sherman's injuries and that Dr.
standard of care is the same for doctors and hospital       Coselli would not have performed stent surgery.
staff. He then opines that the doctors and hospital         Thus, if Methodist had followed the standard of
staff in this case all breached the standard of care        care and contacted Dr. Coselli, Sherman would
by failing to attempt to locate and contact Dr.             never have received a stent, thereby avoiding her
Coselli in response to Sherman's requests. There is         injuries. Methodist asserts that this opinion is spec-
nothing inherently impermissible about concluding           ulative and conclusory because there is no basis for
that different health care providers owed the same          concluding what Dr. Coselli would have actually
standard of care to Sherman and breached that duty          done and that, at most, any negligence by Method-
                   FN2                                      ist merely created a condition that allowed another's
in the same way.         See Bennett, 256 S.W.3d at
817 (“Although [the expert]'s opinion for each de-          negligence to cause an injury. Methodist stresses
fendant is identical, he unquestionably provided an         that its actions were administrative rather than
opinion for each hospital. That he held each defend-        treatment-oriented and that it was the allegedly de-
ant to the same standard of care, found the same            fective treatment that caused Sherman's injuries.

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     [11][12] An expert report cannot be based on                    REM.CODE ANN. § 74.351(s), (u)
mere conclusions or speculation. See Bowie, 79                       (Vernon Supp. 2008); In re Jorden, 249
S.W.3d at 52; Mosely v. Mundine, 249 S.W.3d 775,                     S.W.3d 416, 418, 420–24 (Tex.2008) (orig.
781 (Tex.App.-Dallas 2008, no pet.). Rather, the                     proceeding); In re Lumsden, 291 S.W.3d
expert must explain the basis for his statements and                 456, 461 (Tex.App.-Houston [14th Dist.]
link his conclusions to the facts. Bowie, 79 S.W.3d 2009, orig. proceeding); In re Huag, 175
at 52; Sanjar, 252 S.W.3d at 465, 467–68. Dr.                        S.W.3d 449, 456 (Tex.App.-Houston [1st
Adams does just that. He describes Marfan syn-                       Dist.] 2005, no pet.).
drome and explains why the use of a stent is con-
traindicated for Marfan syndrome patients and *200          E. Sanctions
should not have been used on Sherman. Dr. Adams                  [13][14][15] In her cross-issue, Sherman re-
repeatedly states that no reasonable doctor, which          quests this court to sanction Methodist for a frivol-
presumably includes Dr. Coselli, would have per-            ous appeal under Texas Rule of Appellate Proced-
formed stent surgery under such circumstances.              ure 45. Whether to grant sanctions for a frivolous
That the chain of events leading from Methodist's           appeal is a matter of discretion that this court exer-
actions to Sherman's injuries has many links does           cises with prudence and caution and only after care-
not render Dr. Adams's opinion insufficient because         ful deliberation in truly egregious circumstances.
he explains and supports each step. See Patel, 237          See Goss v. Houston Cmty. Newspapers, 252
S.W.3d at 905–06; Farishta v. Tenet Healthsystem            S.W.3d 652, 657 (Tex.App.-Houston [14th Dist.]
Hosps. Dallas, Inc., 224 S.W.3d 448, 454–55                 2008, no pet.). If an appellant's argument on appeal
(Tex.App.-Fort Worth 2007, no pet.). Methodist              fails to convince us but has a reasonable basis in
complains that Dr. Adams's opinion is not based on          law and constitutes an informed, good-faith chal-
evidence, such as an affidavit or deposition from           lenge to the trial court's judgment, sanctions are not
Dr. Coselli, stating exactly what he would have             appropriate. Id. Although Methodist's appeal lacks
done had he been called when Sherman was admit-             merit, we conclude that it is not frivolous, and we
ted. Methodist cites no authority that discovery            overrule Sherman's cross-issue.
from a fact witness is required to support an initial
                                FN3                                           CONCLUSION
expert report under chapter 74.      The report must
                                                                The trial court did not abuse its discretion in
provide supported opinions that are sufficient to
                                                            denying Methodist's motion to dismiss based on its
give the trial court assurance that the claim has
                                                            objections to Sherman's expert's qualifications and
merit. See Palacios, 46 S.W.3d at 879; Patel, 237
                                                            report. Having overruled all of Methodist's issues,
S.W.3d at 904. Dr. Adams's well-supported conclu-
                                                            we affirm the trial court's judgment.
sions about how a reasonably prudent doctor would
have acted under the circumstances are sufficient to        Tex.App.–Houston [14 Dist.],2009.
have given the trial court such assurances at this          Methodist Hosp. v. Shepherd-Sherman
stage in the case. That discovery could later prove         296 S.W.3d 193
Dr. Adams wrong is not a basis for holding that his
report is insufficient under chapter 74. See Sanjar,        END OF DOCUMENT
252 S.W.3d at 467 n. 6; Wissa v. Voosen, 243
S.W.3d 165, 169–70 (Tex.App.-San Antonio 2007,
pet. denied). We overrule Methodist's fourth issue.

        FN3. Indeed, discovery is severely limited
        before the chapter 74 expert report require-
        ment is met. See TEX. CIV. PRAC. &

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                                                          (“TMLA”). See TEX. CIV. PRAC. & REM. CODE
Only the Westlaw citation is currently available.         ANNN. § 74.351(b) (West 2011). Now, Nexion ap-
                                                          peals from the trial court's denial of that motion to
SEE TX R RAP RULE 47.2 FOR DESIGNATION
                                                          dismiss. Reliant is not a party to this appeal.
AND SIGNING OF OPINIONS.
                                                               In four issues, Nexion argues the trial court ab-
MEMORANDUM OPINION
                                                          used its discretion when it denied the motion to dis-
            Court of Appeals of Texas,                    miss. Specifically, Nexion contends the trial court
                      Dallas.                             erred because (1) the expert report “does not identi-
 Nexion Health at Garland, Inc. d/b/a Pleasant Val-       fy the standard of care applicable to Nexion or the
ley Healthcare and Rehabilitation Center, Appellant       actions that Nexion should have taken,” (2) the ex-
                        v.                                pert report “failed to establish a causal relationship
          Temperance Treybig, Appellee                    between Nexion's alleged negligence and Mr. Trey-
                                                          big's injury,” (3) Treybig failed to serve Nexion
              No. 05–14–00498–CV                          with a report from a “qualified expert,” and (4) the
         Opinion Filed December 31, 2014                  trial court failed to award Nexion its attorney's fees
                                                          and costs. We decide Nexion's third issue in its fa-
On Appeal from the 14th Judicial District Court,          vor. The expert report and curriculum vitae sup-
Dallas County, Texas, Trial Court Cause No.               plied by Treybig do not provide sufficient informa-
dc–13–12286. Eric Moye, Judge.                            tion regarding the knowledge and experience of the
Jason A. Burris, J. Edward Johnson III, Weston M.         medical expert, as indicated below. Accordingly,
Davis, Gregory N. Ziegler, Dallas, TX, for Appel-         we reverse the order of the trial court and remand
lant.                                                     the case for a determination of whether to grant
                                                          Treybig a thirty-day extension to cure the deficien-
Dawn M. Smith, Rachel Shackelford, Curtis
                                                          cies in the report. TEX. CIV. PRAC. & REM.
Clinesmith, Dallas, TX, for Appellee.
                                                          CODE ANN.. § 74.351(c).

Before Justices Bridges, Lang, and Evans                     I. FACTUAL AND PROCEDURAL BACK-
                                                                               GROUND
                                                               From March 1, 2010, through January 14,
           MEMORANDUM OPINION                             2013, Mr. Treybig, Treybig's father, was a resident
Opinion by Justice Lang                                   at Pleasant Valley Healthcare and Rehabilitation
    *1 This interlocutory appeal involves a medical       Center (“Pleasant Valley”), which is a nursing
malpractice action brought by the appellee, Tem-          home owned by Nexion. According to Treybig,
perance Treybig (“Treybig”), as Representative of         “Nexion provided what [she] believed and under-
the Estate of William Treybig (“Mr.Treybig”),             stood was skilled nursing care and ongoing assess-
against Nexion Health at Garland d/b/a Pleasant           ments of Mr. Treybig,” whose medical history in-
Valley Healthcare and Rehabilitation Center               cluded, among other things, double below the knee
(“Nexion”) and Reliant Pro Rehab, LLC                     amputations and two bilateral hip replacements.
(“Reliant”). Nexion, the appellant, filed a motion to     Treybig alleges Nexion “engaged, contracted with,
dismiss pursuant to section 74.351(b) of the Texas        and/or hired” Reliant, a physical therapy provider,
Civil Practices and Remedies Code, alleging Trey-         “to provide medical care and/or therapy to Mr.
big failed to comply with the medical expert report       Treybig while [he was] a resident at the facility.”
requirement of the Texas Medical Liability Act            Treybig's factual theory is that during a therapy ses-

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sion at Nexion's facility on October 4, 2011, two of                          1. Applicable Law
Reliant's therapists stretched Mr. Treybig and                   “A valid expert report has three elements: it
leaned their combined weight on him while ignor-            must fairly summarize the applicable standard of
ing his cries of pain. On or about October 11, 2011,        care; it must explain how a physician or health care
Mr. Treybig “was diagnosed as having a compres-             provider failed to meet that standard; and it must
sion fracture to his L4 vertebrae.”                         establish the causal relationship between the failure
                                                            and the harm alleged.” Certified EMS, Inc. v. Potts,
     On October 11, 2013, Treybig filed a medical           392 S.W.3d 625, 630 (Tex.2013) (citing TEX. CIV.
malpractice lawsuit against Nexion and later                PRAC. & REM. CODEE § 74.351(r)(6) (West
amended her petition to include Reliant as a de-            2011)). “A report need not marshal all the plaintiff's
fendant. Treybig alleged that the back fracture in-         proof, but it must include the expert's opinion on
jury, “among others, was caused by [Nexion and              each of the elements identified in the statute.” Am.
Reliant's] failure to design and/or implement care          Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46
plans that adequately addressed Mr. Treybig's con-          S.W.3d 873, 878 (Tex.2001) (decided under section
ditions and failure to provide the care he required.”       13.01 of the predecessor statute, the Medical Liab-
On March 7, 2014, Treybig served Nexion and Re-             ility and Insurance Improvement Act, previously
liant with the expert report and curriculum vitae of        codified at article 4590i of the Texas Revised Civil
Dr. Lige B. Rushing (“Dr.Rushing”). Nexion and              Statutes); see Loaisiga v. Cerda, 379 S.W.3d 248,
Reliant each filed a motion to dismiss under the            257–58 (Tex.2012) (applying Palacios 's expert re-
TMLA challenging the adequacy of Dr. Rushing's              port analysis to the TMLA). “The report can be in-
expert report. After a hearing, the trial court denied      formal in that the information in the report does not
both motions, and Nexion filed this appeal.                 have to meet the same requirements as the evidence
                                                            offered in a summary-judgment proceeding or at
       II. MEDICAL EXPERT'S REPORT
                                                            trial.” Id. at 879. “In determining a report's suffi-
                A. Standard of Review
                                                            ciency, the court may not look beyond the report it-
     *2 “Generally, an appellate court reviews a tri-
                                                            self because all information relevant to the inquiry
al judge's decision on a motion to dismiss a claim
                                                            should be contained [within] the document's four
under section 74.351 of the Texas Civil Practice
                                                            corners.” Christian Care Ctrs., Inc. v. Golenko, 328
and Remedies Code for an abuse of discretion.”
                                                            S.W.3d 637, 641 (Tex.App.–Dallas 2010, pet.
Baylor Med. Ctr. at Waxahachie v. Wallace, 278
                                                            denied) (citing Palacios, 46 S.W.3d at 878).
S.W.3d 552, 555 (Tex.App.–Dallas 2009, no pet.).
“A trial court abuses its discretion if it acts in an ar-       “The report serves two functions. ‘First, the re-
bitrary or unreasonable manner without reference to         port must inform the defendant of the specific con-
guiding rules or principles.” Id. “When reviewing           duct the plaintiff has called into question. Second,
matters committed to the trial court's discretion, an       and equally important, the report must provide a
appellate court may not substitute its judgment for         basis for the trial court to conclude that the claims
that of the trial court.” Cayton v. Moore, 224              have merit.’ ” Potts, 392 S.W.3d at 630 (quoting
S.W.3d 440, 444 (Tex.App.–Dallas 2007, no pet.).            Palacios, 46 S.W.3d at 879). “A report need not
“A trial court has no discretion when determining           cover every alleged liability theory to make the de-
what the law is or in applying the law to the facts.        fendant aware of the conduct that is at issue.” Id.
A clear failure by the trial court to analyze or apply      “The expert report requirement is a threshold mech-
the law correctly will constitute an abuse of discre-       anism to dispose of claims lacking merit,” and “[i]f
tion.” Wallace, 278 S.W.3d at 555–56 (internal              a health care liability claim contains at least one vi-
citations omitted).                                         able liability theory, as evidenced by an expert re-
                                                            port meeting the statutory requirements, the claim
          B. Standard of Care and Breach

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cannot be frivolous.” Id. at 631.                          ulted in Mr. Treybig's back fracture. Dr. Rushing
                                                           identifies the standard of care applicable to Nexion
     “When, as here, a plaintiff sues more than one        as follows:
defendant, the expert report must set forth the
standard of care for each defendant. If the standard         “In order to meet the standard of care, the facility
of care is the same for each defendant, then the re-         must provide a safe environment for its patients.
port must state so.” Tenet Hosps. Ltd. v. Love, 347          This standard encompasses a range of duties re-
S.W.3d 743, 753 (Tex.App.–El Paso 2011, no pet.)             lating to the patient's stay with the nursing home,
(internal citations omitted). “While a ‘fair sum-            which the facility owes to the patient, such as se-
mary’ is something less than a full statement of the         curing qualified personnel to administer the ser-
applicable standard of care and how it was                   vices provided, adequately supervising any ther-
breached, even a fair summary must set out what              apy sessions, providing proper equipment and fa-
care was expected, but not given.” Palacios, 46              cilities for all treatments necessary to meet the
S.W.3d at 880. “In other words, one must be able to          patient's needs, and following up with the patient
determine from the report what the standard of care          to verify the success of all procedures and treat-
required to be done. This requires ‘specific inform-         ments.... The standard of care is not met when a
ation about what the defendant should have done              nursing home fails to properly investigate, treat
differently.’ ” Russ v. Titus Hosp. Dist., 128               and document the patient's pain complaints over
S.W.3d 332, 342 (Tex.App.–Texarkana 2004, pet.               the course of time. The most obvious and egre-
denied) (quoting id.).                                       gious instance of Defendant's failure to investig-
                                                             ate and treat the patient's back pain was during
            2. Application of Law to Facts                   the therapy session when the therapists ignored
     *3 As to issue one, where Nexion claims the             Mr. Treybig's cries of pain and requests to stop
expert report “does not identify the standard of care        the session, continuing to push and pull using
applicable to Nexion or the actions that Nexion              their combined bodyweight.... Reasonable invest-
should have taken,” Nexion contends Dr. Rushing's            igation, documentation and treatment would have
reference to “Defendants,” apparently meaning both           signified the danger in forceful hamstring
Nexion and Reliant, renders his expert report defi-          stretches on a double below the knee amputee,
cient. Specifically, Nexion argues Dr. Rushing's             and prevented fracture.
“collective referral to Nexion and Reliant prevents
the report from (A) adequately stating the standard             Dr. Rushing sets forth what care was expected
of care as applied to Nexion and (B) identifying           from Nexion and how Nexion failed to provide it.
Nexion's allegedly negligent actions in violation of       The quoted statements provide a “fair summary” of
that standard.” Treybig responds that the report           the standard of care applicable to Nexion. See Pala-
“does not need to identify separate standards of           cios, (“[A] fair summary must set out what care
care when one standard applies to both [Nexion and         was expected, but not given.”); Columbia N. Hills
Reliant] through [Treybig's] vicarious liability and       Hosp.     Subsidiary,    L.P.    v.   Bowen,    No.
direct liability claims.” Treybig contends Dr. Rush-       02–13–00286–CV, 2014 WL 345658, at *4–5
ing's report provides “a fair summarization of the         (Tex.App.–Fort Worth Jan. 30, 2014, pet. denied)
standard of care” and “makes Nexion ‘aware of the          (mem.op.) (concluding an expert report that stated
conduct that is at issue.’ ”                               various duties owed by a hospital and detailed how
                                                           the hospital failed to properly perform those duties
     Treybig's health care liability claim arises out      “fairly summarized the applicable standard of care
of the care received by Mr. Treybig while he was a         for Hospital and explained how Hospital failed to
resident at Pleasant Valley, particularly, the physic-     meet that standard”); Russ, 128 S.W.3d at 342
al therapy and other related care that allegedly res-

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(concluding that statements in an expert report that       “provides a sufficient basis for the trial court to
a hospital “deviated from the standard of care,”           conclude that the claims have merit.” See Russ, 128
which required the hospital to lock windows or se-         S.W.3d at 342. The trial court did not abuse its dis-
cure them with metal screens, by “placing patient          cretion in denying the motion to dismiss on grounds
with potential suicidal ideation and recent suicidal       that the report failed to summarize the standard of
behavior in a fourth floor room with unlocked win-         care and explain how Nexion breached that stand-
dows” constituted a “specific allegation which             ard. See Bowen, 2014 WL 345658, at *5; id. Ac-
provide[d] the Hospital with notice of the conduct         cordingly, we decide Nexion's first issue against it.
complained of by [the plaintiff]”).
                                                                                C. Causation
     Although other statements in Dr. Rushing's re-             *4 In issue two, Nexion contends Dr. Rushing's
port describe the duties and failings of “the Defend-      report “fails to adequately address causation for the
ants,” referring to both Nexion and Reliant, the par-      same reason that it fails to address Nexion's stand-
ticular statements identified above, which are con-        ard of care—the report's collective description of
tained within the four corners of the report, are spe-     the events and defendants prevents it from ad-
cific to Nexion and are sufficient to inform Nexion        equately addressing Nexion's conduct.” Treybig re-
of its conduct that Treybig calls into question. See       sponds that the report “properly sets forth Dr.
Presbyterian Cmty. Hosp. of Denton v. Smith, 314           Rushing's opinions on causation as to Nexion” be-
S.W.3d 508, 514 (Tex.App.–Fort Worth 2010, no              cause “both Reliant and Nexion owed Mr. Treybig
pet.) (citing TEX. CIV. PRAC. & REM. CODE                  the same duty to properly supervise,” and the report
ANN.. § 74.351(r)(6) (defining “expert report”))           is “a good faith effort to articulate the causal rela-
(rejecting a hospital's argument that “several indi-       tionship between Nexion's failure to supervise and
vidual statements in [the expert's] report [were] in-      the harm to Mr. Treybig.” As discussed above, Dr.
sufficient” because the “report, as a whole,               Rushing's report does adequately identify Nexion's
provide[d] a ‘fair summary’ of [the expert's] opin-        allegedly negligent conduct, despite “the report's
ions”). It is clear from his report that in Dr. Rush-      collective description of the events and defend-
ing's opinion, Nexion's compliance with the stand-         ants.” See Fortner v. Hosp. of the Sw., LLP, 399
ard of care, by conducting “[r]easonable investiga-        S.W.3d 373, 383–84 (Tex.App.–Dallas 2013, no
tion, documentation and treatment” of Mr. Trey-            pet.) (concluding expert reports “represent[ed] a
big's pain complaints, “would have signified the           good faith effort to provide a fair summary of the
danger in forceful hamstring stretches on a double         experts' opinions about ... the causal relationship
below the knee amputee, and prevented fracture.”           between the failure and the claimed injury” because
Cf. Texarkana Nursing & Healthcare Ctr., LLC v.            the reports “identif[ied] each physician and health
Lyle, 388 S.W.3d 314, 320 (Tex.App.–Texarkana              care provider against which direct liability claims
2012, no pet.) (concluding an expert report, which         [were] asserted, including [the appellant, a hospit-
indicated that a nursing home breached the standard        al], and discuss[ed] how the provider breached the
of care by “allowing the documented assault of [the        applicable standard of care and caused or contrib-
patient] by one of its own employees,” did not suf-        uted to causation of [the patient's] injury”); Chris-
ficiently articulate the standard of care and breach       tus Spohn Health Sys. Corp. v. Sanchez, 299
because the report did not “advise [the nursing            S.W.3d 868, 877–78 (Tex.App.–Corpus Christi
home] of what should have been done in order to            2009, pet. denied) (concluding expert reports
prevent its employee from assaulting [the pa-              “sufficiently linked [the patient's] assault to [the
tient]”). We conclude the substance of Dr. Rush-           hospital's] failure to protect her from the assaultive
ing's report “gives fair notice” to Nexion of its neg-     conduct of [its employees]” when the reports stated
ligent conduct on which Treybig relies and                 the hospital “had duty to provide a safe recovery

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Not Reported in S.W.3d, 2014 WL 7499373 (Tex.App.-Dallas)
(Cite as: 2014 WL 7499373 (Tex.App.-Dallas))

environment,” described the alleged conduct of the         standards of care apply to physicians and health
employees, and concluded “[t]he fact that [the pa-         care providers.” Wallace, 278 S.W.3d at 558 (citing
tient] was vulnerable, unable to protect herself, and      Simonson v. Keppard, 225 S.W.3d 868, 872
felt as if her person was violated has caused her to       (Tex.App.–Dallas 2007, no pet.)).
now have symptoms of Major Depression and Post
Traumatic Stress Disorder”). So, for the same reas-          When a physician fails to state in his expert re-
ons discussed above, we decide Nexion's second is-           port or affidavit that he has knowledge of the
sue against it.                                              standard of care applicable to the specific types
                                                             of health care providers involved in the claim, or
          D. Medical Expert's Qualifications                 that he has ever worked with or supervised the
     In issue three, Nexion contends Dr. Rushing is          specific types of health care providers involved in
not a “qualified expert” because his report and cur-         the claim, the physician is not qualified on the is-
riculum vitae (1) “do not show that he is actively           sue of whether the health care provider departed
practicing in nursing home health care” and (2) do           from the accepted standards of care for health
not “demonstrate that he has knowledge of the                care providers.
standard of care for nurses or physical therapists
working in nursing homes like Nexion.”                          Id. “ ‘[E]xpert qualifications should not be too
                                                           narrowly drawn.’ ” Golenko, 328 S.W.3d at 643
                  1. Applicable Law                        (quoting Larson v. Downing, 197 S.W.3d 303, 305
    For purposes of the expert report, “a person           (Tex.2006) (per curiam)). “Rather, the trial court
giving opinion testimony regarding whether a               should determine whether the proffered expert has
health care provider departed from accepted stand-         ‘knowledge, skill, experience, training, or educa-
ards of health care” must be qualified to testify.         tion regarding the specific issue before the court
TEX. CIV. PRAC. & REM. CODEE §                             which would qualify the expert to give an opinion
74.351(r)(5)(B). Section 74.402(b) provides that a         on that particular subject.’ ” Id. (quoting Broders v.
person is qualified to testify only if the person:         Heise, 924 S.W.2d 148, 153–54 (Tex.1996)). “The
                                                           focus is on whether the expert's expertise goes to
  (1) is practicing health care in a field of practice     the very matter on which he is to give an opinion.”
  that involves the same type of care or treatment         Id. “Therefore, a medical expert from one specialty
  as that delivered by the defendant health care           may be qualified to testify if he has practical know-
  provider, if the defendant health care provider is       ledge of what is customarily done by practitioners
  an individual, at the time the testimony is given        of a different specialty under circumstances similar
  or was practicing that type of health care at the        to those at issue in the case.” Tenet Hosps. Ltd. v.
  time the claim arose;                                    Love, 347 S.W.3d 743, 750 (Tex.App.–El Paso
                                                           2011, no pet.); see also Broders, 924 S.W.2d at 153
  (2) has knowledge of accepted standards of care
                                                           (“Our holding does not mean that only a neurosur-
  for health care providers for the diagnosis, care,
                                                           geon can testify about the cause in fact of death
  or treatment of the illness, injury, or condition in-
                                                           from an injury to the brain, or even that an emer-
  volved in the claim; and
                                                           gency room physician could never so testify. What
  (3) is qualified on the basis of training or experi-     is required is that the offering party establish that
  ence to offer an expert opinion regarding those          the expert has ‘knowledge, skill, experience, train-
  accepted standards of health care.                       ing, or education’ regarding the specific issue be-
                                                           fore the court which would qualify the expert to
    Id.§ 74.402(b).                                        give an opinion on that particular subject.”).
                                                           However, “it is not enough to summarily state such
    “Section 74.402(b) makes it clear that different

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Not Reported in S.W.3d, 2014 WL 7499373 (Tex.App.-Dallas)
(Cite as: 2014 WL 7499373 (Tex.App.-Dallas))

‘knowledge’ when the reports and curricula vitae           care for such patients,” was qualified to testify to
fail to demonstrate how the experts gained the re-         the standard of care applicable in a claim against a
quisite experience or training,” and “the proffered        nursing home for failure to monitor a resident's eye
medical expert's expertise must be evident from the        injury). Accordingly, we disagree with Nexion to
four corners of his report and curriculum vitae.” Id.      the extent that it argues Dr. Rushing is not qualified
                                                           merely because he does not work in a nursing
            2. Application of Law to Facts                 home. Golenko, 328 S.W.3d at 644; IHS Acquisi-
     *5 As to its third issue, Nexion's first conten-      tion, 2008 WL 1822780, at *4 (“The statute, reas-
tion is that Dr. Rushing is not qualified to render an     onably construed, does not require that the expert
opinion on the applicable standard of care because         be involved in the exact same field as the health-
“he is not actively practicing health care in a nurs-      care-provider defendant.”) (citing Roberts v. Willi-
ing home.” Treybig responds that “Dr. Rushing              amson, 111 S.W.3d 113, 121 (Tex.2003)).
need not be employed at a nursing home to offer
opinions on a fracture to the spine of an elderly pa-           Second, Nexion contends Dr. Rushing is not
tient.”                                                    qualified because “[n]either Dr. Rushing's report
                                                           nor his [curriculum vitae] demonstrate that he has
     The “essential claim” in this case involves the       knowledge of the standard of care for nurses or
standard of care that should be applied in a nursing       physical therapists working in nursing homes like
home when it contracts with another healthcare pro-        Nexion.” In response, Treybig argues that Dr.
vider to provide a resident with physical therapy          Rushing has “ample experience treating patients
and other care on the premises of the nursing home.        with spinal injuries, including writing orders to
See Golenko, 328 S.W.3d at 644 (concluding that            treat and care for spinal injuries and supervising the
the “essential claim” against a nursing home in-           execution of the orders.”
volved the assessment and care of individuals with
Alzheimer's disease, so a doctor, who was board                 According to the record, Dr. Rushing is li-
certified in geriatrics and internal medicine, had         censed to practice medicine in Texas and is board
treated patients with similar conditions, was in-          certified in internal medicine, rheumatology, and
volved in the assessment of those patients, and had        geriatrics. He is actively engaged in the practice of
supervised nurses in the care and assessment of            these three specialties and is an attending physician
those patients, was qualified to testify to the applic-    at Presbyterian Hospital of Dallas, Texas. In his ex-
able standard of care, despite his lack of “nursing        pert report, Dr. Rushing more specifically identifies
home experience”). So, the relevant question is not        his qualifications regarding this case as follows:
the narrow issue of whether Dr. Rushing has
worked in a nursing home. Rather, it is the broader             In the regular course of my medical practice I
issue of whether Dr. Rushing is knowledgeable                have occasion to diagnose and treat patients with
about the standard of care applicable to the treat-          conditions similar to or identical with Mr. Trey-
ment of patients like Mr. Treybig and the relevant           big. [D]uring the course of my career I have
care provided by Nexion. See id ; IHS Acquisition            provided primary medical care to more than
No. 140, Inc. v. Travis, No. 13–07–481–CV, 2008              10,000 patients in hospitals, nursing homes and
WL 1822780, at *5 (Tex.App.–Corpus Christi Apr.              assisted living facilities. I have provided care to
24, 2008, pet. denied) (mem.op.) (concluding a               patients who, like Mr. Treybig, were suffering
doctor, who was board certified in geriatrics and            from diabetes, hip replacement therapy, complic-
“knowledgeable about the types of people who                 ations from infections, amputations, and spinal
reside in nursing homes, their afflictions, and most         injuries. I have written orders for the care and
importantly, the relevant treatment and standard of          treatment of these patients and have supervised
                                                             the execution of these orders by RNs LVN's and

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Not Reported in S.W.3d, 2014 WL 7499373 (Tex.App.-Dallas)
(Cite as: 2014 WL 7499373 (Tex.App.-Dallas))

  CNA's who were assigned to provide the hands-           “provided primary medical care” to patients in
  on care to my patients. These orders included or-       nursing homes with “conditions similar or identical
  ders for the treatment for hip pain as well as the      with Mr. Treybig” does not adequately establish
  treatment of spinal injuries. I am therefore intim-     how Dr. Rushing is “intimately familiar” with the
  ately familiar with the standards of care for the       standard of care owed by a nursing home under
  facilities involved in this claim as well as the        these circumstances. See id.; Simonson, 225 S.W.3d
  RNs, LVN's and CNA's who provid[ed] care to             at 872–73 (“Section 74.402(b)(2) requires that the
  Mr. Treybig.                                            expert have knowledge of the accepted standard of
                                                          care for health care providers, i.e. nurse practition-
     *6 While Dr. Rushing states that he is               ers, for the diagnosis involved in the claim.”
“intimately familiar with the standards of care for       (emphasis in original)). Because the four corners of
the facilities involved as well as the RNs, LVN's         Dr. Rushing's report and curriculum vitae do not
and CNA's who provid[ed] care to Mr. Treybig,” he         adequately articulate how Dr. Rushing is qualified
does not state that he is familiar with the standards     to opine on the standard of care applicable to a
of care that would be applicable to Nexion's super-       nursing home when it contracts with another health-
vision of Reliant's physical therapists who provided      care provider to provide a resident with physical
the relevant care or treatment to Mr. Treybig at          therapy care or treatment, we conclude the trial
Pleasant Valley, nor does his report and curriculum       court abused its discretion in denying the motion to
vitae identify any experience supervising, man-           dismiss on this basis. We decide in favor of Nexion
aging, or overseeing physical therapists or physical      on its third issue. See Love, 347 S.W.3d at 750–51.
therapy treatment. Compare Golenko, 328 S.W.3d
at 644 (concluding a doctor was qualified to testify          E. Thirty-day Extension to Cure Deficiencies
to the standard of care applicable to the assessment           In its fourth issue, Nexion contends the trial
of a patient with Alzheimer's disease for admission       court abused its discretion when it denied Nexion's
to a nursing home when the doctor was certified in        motion to dismiss and failed to award Nexion its at-
geriatrics and internal medicine, treated patients        torney's fees and costs. Treybig responds that if Dr.
with Alzheimer's disease, and supervised nurses in        Rushing's report is “inadequate, the case should be
the care and assessment of those patients), with Si-      remanded to receive a 30–day extension to cure the
monson, 225 S.W.3d at 872–73 (holding an expert           deficiencies.” In response, Nexion argues Treybig
report inadequate because the expert, a doctor, did       is not entitled to “a chance to get a thirty-day exten-
not “state that he either ha[d] knowledge of the          sion” because Dr. Rushing's report “did not implic-
standard of care applicable to nurse practitioners or     ate Nexion's conduct,” and Dr. Rushing “was not
that he ha[d] ever worked with or supervised nurse        qualified to offer the report.”
practitioners”). Further, Dr. Rushing's report and
curriculum vitae “fail to demonstrate how [he]                              1. Applicable Law
gained the requisite experience or training” to offer          When an expert report is timely served and
an opinion on the standard of care applicable in a        properly challenged, the trial court “shall grant a
nursing home when it contracts with another health-       motion challenging the adequacy of an expert re-
care provider to provide a resident with physical         port only if it appears to the court, after hearing,
therapy care on the premises of the nursing home.         that the report does not represent an objective good
See Love, 347 S.W.3d at 750 (“[I]t is not enough to       faith effort to comply with the definition of an ex-
summarily state [the expert's] ‘knowledge’ when           pert report in Subsection (r)(6).” TEX. CIV. PRAC.
the reports and curricula vitae fail to demonstrate       & REM. CODE ANN.. § 74.351(l); Potts, 392
how the experts gained the requisite experience or        S.W.3d at 630. The TMLA “also authorizes the trial
training.”). The statement that Dr. Rushing has           court to give a plaintiff who meets the 120–day

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Not Reported in S.W.3d, 2014 WL 7499373 (Tex.App.-Dallas)
(Cite as: 2014 WL 7499373 (Tex.App.-Dallas))

deadline an additional thirty days in which to cure a     dicating that the trial court may grant Treybig an
‘deficiency’ in the elements of the report.”              opportunity to cure the deficiencies. See Scoresby,
Scoresby v. Santillan, 346 S.W.3d 546, 549 346 S.W.3d at 557. Dr. Rushing's report was served
(Tex.2011) (citing TEX. CIV. PRAC. & REM.                 by the statutory deadline, and it “implicates” Nex-
CODE ANN.. § 74.351(c)). “The trial court should          ion's conduct, stating “[r]easonable investigation,
err on the side of granting the additional time and       documentation and treatment [of Mr. Treybig's pain
must grant it if the deficiencies are curable.” Id.       complaints] would have ... prevented fracture” and
(internal citations omitted). “The purpose of the ex-     “the events and failures set forth in [the] report
pert report requirement is to deter frivolous claims,     proximately caused Mr. Treybig's injuries.” See id.
not to dispose of claims regardless of their merits.”     While we have concluded that Dr. Rushing's report
Leland v. Brandal, 257 S.W.3d 204, 554                    and curriculum vitae did not adequately articulate
(Tex.2008) (citing Palacios, 46 S.W.3d at 878). “A        how Dr. Rushing is qualified to opine on the applic-
court may not provide opportunities to cure,              able standard of care in this case, it does not neces-
however, when an expert report is ‘absent’ as op-         sarily follow that Dr. Rushing is not “an individual
posed to deficient,” such as when a report “fails to      with expertise,” such that the report was “ ‘absent’
address all required elements of a claim.” Hollings-      as opposed to deficient.” See Hollingsworth, 353
worth v. Springs, 353 S.W.3d 506, 524                     S.W.3d at 524. Dr. Rushing's expertise, as a li-
(Tex.App.–Dallas 2011, no pet.) (denying a health         censed medical doctor, who is board certified in in-
care liability claimant an opportunity to cure when       ternal medicine, rheumatology, and geriatrics, “is
the expert report “omitted any discussion of the ele-     relevant in explaining the connection between” the
ment of causation,” so the “report could not qualify      physical therapists' alleged use of “excessive force”
as a good faith effort to meet Chapter 74's require-      and the back fracture Mr. Treybig suffered. See
ments”).                                                  Scoresby, 346 S.W.3d at 557 (“The Act requires
                                                          that [the expert's] knowledge, training or experi-
     “[A] thirty-day extension to cure deficiencies       ence, and practice be ‘relevant’ to [the plaintiff's]
in an expert report may be granted if the report is       claim.”). We agree with Treybig's contention that
served by the statutory deadline, if it contains the      this case should be remanded to the trial court for
opinion of an individual with expertise that the          consideration of a thirty-day extension to cure the
claim has merit, and if the defendant's conduct is        deficiencies. See Leland, 257 S.W.3d at 208. Ac-
implicated.” Scoresby, 346 S.W.3d at 557. The Su-         cordingly, we decide against Nexion on its fourth
preme Court has “recognize[d] that this is a minim-       issue.
al standard.” Id. “An individual's lack of relevant
qualifications and an opinion's inadequacies are de-                       III. CONCLUSION
ficiencies the plaintiff should be given an opportun-          The trial court abused its discretion in denying
ity to cure if it is possible to do so.” Id. at 549.      the motion to dismiss because Dr. Rushing's expert
When a court of appeals finds an expert report to be      report and curriculum vitae do not adequately artic-
deficient after the trial court concluded it was ad-      ulate how Dr. Rushing is qualified to opine on the
equate, the court of appeals “has the discretion to       standard of care applicable in a nursing home when
remand the case for consideration of a thirty-day         it contracts with another healthcare provider to
extension to cure the deficiency.” Leland, 257            provide a resident with physical therapy care on the
S.W.3d at 208.                                            premises of the nursing home. Accordingly, we re-
                                                          verse the trial court's order denying the motion to
          2. Application of Law to Facts                  dismiss and remand the cause to the trial court to
    *7 We now address whether Dr. Rushing's re-           consider whether to grant Treybig a thirty-day ex-
port meets the standard identified in Scoresby, in-       tension to cure the deficiencies in Dr. Rushing's re-

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                                                                                   Page 9
Not Reported in S.W.3d, 2014 WL 7499373 (Tex.App.-Dallas)
(Cite as: 2014 WL 7499373 (Tex.App.-Dallas))

port.

Tex.App.-Dallas, 2014
Nexion Health at Garland, Inc. v. Treybig
Not Reported in S.W.3d, 2014 WL 7499373
(Tex.App.-Dallas)

END OF DOCUMENT

                        © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                             Page 1
314 S.W.3d 508
(Cite as: 314 S.W.3d 508)

                                                            Pleadings
                                                                            30k960(1) k. In general. Most Cited
            Court of Appeals of Texas,                      Cases
                    Fort Worth.                                  A trial court's ruling concerning an expert re-
PRESBYTERIAN COMMUNITY HOSPITAL OF                          port under the Medical Liability and Insurance Act
 DENTON d/b/a Presbyterian Hospital of Denton               is reviewable under the abuse of discretion stand-
     and Chad Hammonds, R.N., Appellants,                   ard. V.T.C.A., Civil Practice & Remedies Code §
                          v.                                74.351.
Connie SMITH, Individually and as Personal Rep-
resentative of the Estate of Thomas Edward Smith,           [2] Health 198H         804
Deceased, and as Next Friend for Thomas Anthony
Smith, a Minor, and Douglas Smith and Stephanie             198H Health
                 Smith, Appellees.                               198HV Malpractice, Negligence, or Breach of
                                                            Duty
                No. 2–09–288–CV.                                   198HV(G) Actions and Proceedings
                  May 20, 2010.                                         198Hk804 k. Affidavits of merit or merit-
                                                            orious defense; expert affidavits. Most Cited Cases
Background: Survivors of deceased patient filed                  To constitute a good faith effort to comply with
negligence suit against hospital, based on post-            the definition of an expert report under the Medical
operative care provided by three employee-nurses.           Liability and Insurance Act the report must discuss
Hospital filed motion to dismiss based on alleged           the standards of care, breach, and causation with
insufficiency of survivors' expert reports. The             sufficient specificity (1) to inform the defendant of
393rd District Court, Denton County, Douglas M.             the conduct the plaintiff has called into question
Robison, J., denied motions. Hospital appealed.             and (2) to provide the trial court with a basis to
                                                            conclude that the claims have merit; a report does
Holdings: The Court of Appeals, Anne Gardner, J.,
                                                            not fulfill this requirement if it merely states the ex-
held that:
                                                            pert's conclusions or if it omits any of the statutory
(1) reports sufficiently described the standard of
                                                            requirements. V.T.C.A., Civil Practice & Remedies
care applicable to hospital's nurse-employees and
                                                            Code § 74.351.
how they allegedly breached the standard of care,
and                                                         [3] Health 198H         804
(2) second report sufficiently linked causation opin-
ions to facts and adequately described chain of             198H Health
events allegedly leading to patient's death.                     198HV Malpractice, Negligence, or Breach of
                                                            Duty
    Affirmed.                                                      198HV(G) Actions and Proceedings
                                                                       198Hk804 k. Affidavits of merit or merit-
                  West Headnotes
                                                            orious defense; expert affidavits. Most Cited Cases
[1] Appeal and Error 30         960(1)                           When reviewing the adequacy of a expert med-
                                                            ical report, the only information relevant to the in-
30 Appeal and Error                                         quiry of whether it complies with the definition of
   30XVI Review                                             an expert report under the Medical Liability and In-
     30XVI(H) Discretion of Lower Court                     surance Act is the information contained within the
           30k960 Rulings on Motions Relating to            four corners of the document; this requirement pre-

                            © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                            Page 2
314 S.W.3d 508
(Cite as: 314 S.W.3d 508)

cludes a court from filling gaps in a report by draw-       ical Liability and Insurance Act; report provided
ing inferences or guessing as to what the expert            that nurse had a duty to monitor patient's post-
likely meant or intended, but does not prohibit ex-         operative mental and physical conditions, a duty to
perts, as opposed to courts, from making inferences         either question or clarify doctor's order before ad-
based on medical history. V.T.C.A., Civil Practice          ministering both morphine and hydrocodone to pa-
& Remedies Code § 74.351.                                   tient but failed to do either, and failed to assess or
                                                            appreciate patient's altered level of consciousness,
[4] Health 198H       804                                   restrain patient, provide sufficient observation of
                                                            patient, and recognize that patient's catheter had
198H Health
                                                            been removed from his jugular vein. V.T.C.A.,
     198HV Malpractice, Negligence, or Breach of
                                                            Civil Practice & Remedies Code § 74.351.
Duty
       198HV(G) Actions and Proceedings                     [6] Health 198H        804
           198Hk804 k. Affidavits of merit or merit-
orious defense; expert affidavits. Most Cited Cases         198H Health
     In negligence suit against hospital, based on               198HV Malpractice, Negligence, or Breach of
acts of employee-nurse, medical doctor's expert re-         Duty
port sufficiently described the standard of care ap-                198HV(G) Actions and Proceedings
plicable to hospital's nurse-employee and how                           198Hk804 k. Affidavits of merit or merit-
nurse allegedly breached the standard of care, as re-       orious defense; expert affidavits. Most Cited Cases
quired by Medical Liability and Insurance Act; re-               In negligence suit against hospital, based on
port stated that nurse had a duty to assist doctor          acts of employee-nurse, nurse's expert report suffi-
with patient's post-operative anticoagulation ther-         ciently described the standard of care applicable to
apy, should have known incidence of thrombus fol-           second nurse-employee of hospital and how that
lowing mechanical valve replacement surgery,                nurse allegedly breached the standard of care, as re-
should have monitored patient's anticoagulant ther-         quired by Medical Liability and Insurance Act; re-
apy, should have known doctor made incorrect as-            port provided that nurse had a duty to monitor pa-
sessment, failed to report doctor's incorrect assess-       tient's post-operative mental and physical condi-
ment, and failed to recognize or report patient's ex-       tions, but failed to assess or appreciate patient's
cessive anticoagulation blood condition to doctors.         altered level of consciousness, failed to restrain pa-
V.T.C.A., Civil Practice & Remedies Code §                  tient, failed to provide sufficient surveillance of pa-
74.351.                                                     tient, failed to timely discover patient's removal of
                                                            catheter from jugular vein, and failed to monitor
[5] Health 198H       804                                   and document physiologic monitoring system with
                                                            appropriate alarm limits. V.T.C.A., Civil Practice &
198H Health
                                                            Remedies Code § 74.351.
     198HV Malpractice, Negligence, or Breach of
Duty                                                        [7] Health 198H        804
       198HV(G) Actions and Proceedings
           198Hk804 k. Affidavits of merit or merit-        198H Health
orious defense; expert affidavits. Most Cited Cases             198HV Malpractice, Negligence, or Breach of
     In negligence suit against hospital, based on          Duty
acts of employee-nurse, nurse's expert report suffi-              198HV(G) Actions and Proceedings
ciently described the standard of care applicable to                  198Hk804 k. Affidavits of merit or merit-
hospital's nurse-employee and how nurse allegedly           orious defense; expert affidavits. Most Cited Cases
breached the standard of care, as required by Med-              In negligence suit against hospital, based on

                            © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                           Page 3
314 S.W.3d 508
(Cite as: 314 S.W.3d 508)

acts of employee-nurses, medical doctor's expert re-        ment of Thomas Edward Smith. On December 31,
port sufficiently linked causation opinions to the          2008, the Smiths served the Hospital with expert re-
facts and adequately described the chain of events          ports by Dr. Michael E. Halkos, a cardiothoracic
allegedly leading to patient's death by nurse-              surgeon, and Dean W. Hayman, R.N., a registered
employees' alleged breaches of standard of care, as         nurse specializing in cardiac and critical care nurs-
required by Medical Liability and Insurance Act;            ing. The Hospital filed a motion to dismiss and ar-
report stated that nurses' failures to properly and         gued Dr. Halkos's and Nurse Hayman's expert re-
adequately monitor patient's activities and condi-          ports do not meet the statutory requirements be-
tions resulted in their failures to timely and prop-        cause they do not constitute “an objective good
erly recognize patient's removal of catheter that had       faith effort to provide a fair summary of the alleged
been sutured in his internal jugular vein, and bleed-       experts' opinions on the standard of care, alleged
ing from catheter site before patient experienced           breach thereof, and how any alleged breach by [the
hemorrhagic cardiopulmonary arrest, which prob-             Hospital] caused [the Smiths'] damages.”
ably led to his death. V.T.C.A., Civil Practice &
Remedies Code § 74.351.                                          After a hearing, the trial court denied the Hos-
                                                            pital's motion as to Dr. Halkos's report. The trial
*510 Jones Carr McGoldrick, LLP and Jeffrey F.              court partially denied and partially granted the Hos-
Wood, James J. McGoldrick and Heather J. Forgey,            pital's motion as to Nurse Hayman's report and
Dallas, for appellants.                                     granted the Smiths an extension to supplement
                                                                                                             FN1
                                                            Nurse Hayman's report if they chose to do so.
Keith Law Firm, PC and Darrell L. Keith, Fort               The Smiths then served the Hospital *511 with a
Worth, for appellees.                                       supplemental report from Nurse Hayman, and the
                                                            Hospital again objected. After a hearing, the trial
PANEL: LIVINGSTON, C.J.; GARDNER and                        court overruled the Hospital's objections to the sup-
WALKER, JJ.                                                 plemental report. This interlocutory appeal fol-
                                                            lowed. See Tex. Civ. Prac. & Rem.Code Ann. §
                                                            51.014(a)(9) (Vernon 2008); Lewis v. Funderburk,
                       OPINION                              253 S.W.3d 204, 208 (Tex.2008) (authorizing ap-
ANNE GARDNER, Justice.                                      peal from trial court order determining that expert
                    I. Introduction                         report was adequate and denying motion to dis-
     In this interlocutory appeal, Appellants Presby-       miss).
terian Hospital of Denton d/b/a Presbyterian Hos-
pital of Denton and Chad Hammonds, R.N.                             FN1. The trial court stated, “While [Nurse
(collectively, the Hospital) argue that the trial court             Hayman's report] was deficient in part, I
abused its discretion by denying the Hospital's mo-                 find that the Halkos report was sufficient
tion to dismiss. We affirm the trial court's order.                 to create a basis for asserting a claim that
                                                                    fairly put the Hospital on notice of the type
           II. Procedural Background                                of claims that are being asserted against it
    Appellees Connie Smith, Individually, and as                    by and through the nurses.” The trial court
Personal Representative of the Estate of Thomas                     also stated that its partial grant of the Hos-
Edward Smith, Deceased, and as Next Friend for                      pital's objection to Nurse Hayman's report
Thomas Anthony Smith, a Minor, and Douglas and                      is “kind of irrelevant because I find that it's
Stephanie Smith (collectively, the Smiths) sued the                 [otherwise] sufficient.”
Hospital on September 2, 2008. The Smiths asser-
ted that the Hospital, by and through its nurse-                       III. Factual Background
employees, acted negligently in its care and treat-             The Smiths' fourth amended petition, their live

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pleading at the time of the second hearing on the                Over the next few days, Mr. Smith continued
Hospital's motion to dismiss, contains the following        receiving blood pressure medications and received
allegations relevant to their claims against the Hos-       a new Quinton catheter. He received dialysis ther-
pital.                                                      apy, but by July 8, 2006, his “blood pressure con-
                                                            tinued to drop despite increasing ... his blood pres-
     On June 21, 2006, Mr. Smith presented to the           sure medications” and other treatments. Mr. Smith
emergency department at the Hospital with inter-            also had “continuous oozing of blood from his
mittent headaches, feverishness, increasing malaise         mouth, nose, hemodialysis catheter, and scrotal
and shortness of breath, minimal cough, shoulder            area.” On July 9, 2006, Dr. Mario Ruiz informed
and back pain, and leg swelling. He was admitted to         Mr. Smith's wife, Connie, that Mr. Smith was
the Hospital for further evaluation and treatment.          “slowly dying.” On July 10, 2006, “a medical de-
Tests revealed “the presence of bilateral pneumonia         cision was made to withdraw life support measures
and moderate renal compromise” and “severe tri-             from Mr. Smith due to his severely [sic] brain dam-
cuspid regurgitation with vegetations present.” Mr.         aged [sic] and other conditions, such life support
Smith's blood cultures were also positive for methi-        measures were withdrawn from Mr. Smith, and he
cillin-sensitive Staphylococcus aureus, and he was          was pronounced dead” on the evening *512 of July
treated with intravenous antibiotics.                       10, 2006. An autopsy by Dr. Juan Zamora
                                                            “revealed pathological findings of a status post re-
    Because of his diagnosis of tricuspid valve en-
                                                            cent tricuspid valve prosthesis implant showing no
docarditis, Mr. Smith “underwent a tricuspid valve
                                                            complications, hypertrophy of the heart (500g) with
debridement and excision with tricuspid valve re-
                                                            organizing fibrinoid percarditis, bilateral granulo-
placement” on June 30, 2006. A transesophageal
                                                            mata of the lungs, edema of the brain with acute
echocardiogram at the end of the operative proced-
                                                            hepatitis, and other findings.”
ure “revealed good seating of the valve with no
evidence of perivalvular leak, good function of the                       IV. Standard of Review
valve leaflets and ... no evidence of an atrial-                 [1] A trial court's ruling concerning an expert
ventricular block.” Mr. Smith then returned to the          report under section 74.351 (formerly article 4590i,
intensive care unit (the ICU) for further treatment         section 13.01) of the Medical Liability and Insur-
and recovery.                                               ance Act is reviewable under the abuse of discre-
                                                            tion standard. See Tex. Civ. Prac. & Rem.Code
     On July 4, 2006, Mr. Smith had a Quinton
                                                            Ann. § 74.351; Bowie Mem'l Hosp. v. Wright, 79
catheter sutured into place in his left internal jugu-
                                                            S.W.3d 48, 52 (Tex.2002); Am. Transitional Care
lar vein. He tolerated the procedure well, and all
                                                            Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875
catheters in his body were “noted to be free of
                                                            (Tex.2001). To determine whether a trial court ab-
reddness [sic] or edema.” However, Nurse Ham-
                                                            used its discretion, we must decide whether the trial
monds entered Mr. Smith's room on July 5, 2006,
                                                            court acted without reference to any guiding rules
and found that Mr. Smith “was experiencing agonal
                                                            or principles; in other words, we must decide
respirations,” that “the Quintan [sic] catheter was
                                                            whether the act was arbitrary or unreasonable. Cire
no longer in its proper place,” and that Mr. Smith
                                                            v. Cummings, 134 S.W.3d 835, 838–39 (Tex.2004).
“was and had been experiencing significant bleed-
                                                            An appellate court cannot conclude that a trial court
ing.” The medical staff successfully resuscitated
                                                            abused its discretion merely because the appellate
Mr. Smith, and he remained in the ICU. Later that
                                                            court would have ruled differently in the same cir-
day, however, Mr. Smith “was medically assessed
                                                            cumstances. Bowie Mem'l, 79 S.W.3d at 52; E.I. du
that he was not able to follow simple commands,
                                                            Pont de Nemours & Co. v. Robinson, 923 S.W.2d
except to open his eyes when his name was called.”
                                                            549, 558 (Tex.1995).

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             V. Statutory Requirements                      228 S.W.3d 276, 279 (Tex.App.-Austin 2007, no
     A health care liability claimant must serve an         pet.). However, section 74.351 does not prohibit ex-
expert report on each defendant no later than the           perts, as opposed to courts, from making inferences
120th day after the claim is filed. See Tex. Civ.           based on medical history. *513Marvin v. Fithian,
Prac. & Rem.Code Ann. § 74.351(a). A defendant              No. 14–07– 00996–CV, 2008 WL 2579824, at *4
may challenge the adequacy of a report by filing a          (Tex.App.-Houston [14th Dist.] July 1, 2008, no
motion to dismiss, and the trial court must grant the       pet.) (mem. op.); see also Tex.R. Evid. 703
motion to dismiss if it finds, after a hearing, that        (providing that an expert may draw inferences from
“the report does not represent an objective good            the facts or data in a particular case); Tex.R. Evid.
faith effort to comply with the definition of an ex-        705 (providing that expert may testify in terms of
pert report” in the statute. Id. § 74.351(l ). While        opinions and inferences).
the expert report “need not marshal all of the
plaintiff's proof,” it must provide a fair summary of                           VI. Analysis
the expert's opinions as to the “applicable standard             The Hospital argues in its sole issue that the
of care, the manner in which the care rendered by           expert reports by Dr. Halkos and Nurse Hayman are
the physician or health care provider failed to meet        insufficient and that the trial court abused its dis-
the standards, and the causal relationship between          cretion by denying the Hospital's motion to dismiss.
that failure and the injury, harm, or damages               See Tex. Civ. Prac. & Rem.Code Ann. § 74.351(l ).
claimed.” Id. § 74.351(r)(6); Palacios, 46 S.W.3d at        Dr. Halkos's and Nurse Hayman's expert reports
878 (construing former article 4590i, § 13.01).             discuss the acts and omissions of three of the Hos-
                                                            pital's nurse-employees: Donna L. McElravy, R.N.;
      [2] To constitute a good faith effort, the report     Chad Hammonds, R.N.; and Garland Gill, R.N. We
must discuss the standards of care, breach, and             address the allegations against each of these nurse-
causation with sufficient specificity (1) to inform         employees in turn.
the defendant of the conduct the plaintiff has called
into question and (2) to provide the trial court with       A. Duty and Alleged Breach by Nurse McElravy
a basis to conclude that the claims have merit. See              The Hospital contends Dr. Halkos's report is in-
Bowie Mem'l, 79 S.W.3d at 52; Palacios, 46                  sufficient because it does not adequately describe
S.W.3d at 879. A report does not fulfill this require-      the standard of care applicable to Nurse McElravy
ment if it merely states the expert's conclusions or        or how Nurse McElravy allegedly breached the
if it omits any of the statutory requirements. Bowie        standard of care.
Mem'l, 79 S.W.3d at 52; Palacios, 46 S.W.3d at
                                                                Relevant portions of Dr. Halkos's report
879. But the information in the report “does not
                                                            provide:
have to meet the same requirements as the evidence
offered in a summary-judgment proceeding or at                McElravy was responsible for assisting Dr.
trial.” Palacios, 46 S.W.3d at 879.                           Bolton in managing the post-operative anticoagu-
                                                              lation therapy of Mr. Smith to prevent thrombus
     [3] When reviewing the adequacy of a report,
                                                              formation as a result of the mechanical valve re-
the only information relevant to the inquiry is the
                                                              placement surgery performed on the patient. At
information contained within the four corners of the
                                                              that time, the incidence of thrombus (blood clot)
document. Bowie Mem'l, 79 S.W.3d at 52; Pala-
                                                              complications of following mechanical valve re-
cios, 46 S.W.3d at 878. This requirement precludes
                                                              placement surgery was or should have been a
a court from filling gaps in a report by drawing in-
                                                              matter of common knowledge to reasonably
ferences or guessing as to what the expert likely
                                                              prudent registered nurses specializing in cardi-
meant or intended. See Austin Heart, P.A. v. Webb,
                                                              ovascular and thoracic surgery.

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     McElravy should have properly monitored anti-          post-operative anticoagulation therapy; (2) should
  coagulant therapy for Mr. Smith in a manner that          have known the incidence of thrombus following
  would maintain an INR (International Normal-              mechanical valve replacement surgery; (3) should
  ized Ratio) of 2.5 to 3.5; or a PTT (Partial              have monitored Mr. Smith's anticoagulant therapy
  Thromboplastin Time) of 1.5 to 2.5 times the              so as to maintain an INR of 2.5 to 3.5 or a PTT of
  control.... On the morning of July 4, 2006, at            1.5 to 2.5 times the control; (4) should have known
  about 9:00 a.m., Dr. Bolton noted an INR greater          Dr. Bolton incorrectly recorded the INR as greater
  than 3 in Mr. Smith, and recorded in the progress         than 3; (5) failed to report Dr. Bolton's incorrect as-
  notes that Mr. Smith's INR was greater than 3             sessment of Mr. Smith's INR; and (6) failed to re-
  and noted to hold the administration of coumadin          cognize or report Mr. Smith's excessive anticoagu-
  that night. [The Hospital] laboratory reported            lation blood condition to Dr. Bolton, Dr. Russell, or
  critically abnormal results of Mr. Smith's PT (           PA Dizney. These statements, all contained within
  protime) at about 9:34 a.m., as being greater than        the four corners of Dr. Halkos's report, are suffi-
  120 seconds[,] and the laboratory was unable to           cient to inform the Hospital of the specific conduct
  calculate the INR. The protime greater than 120           by Nurse McElravy that the Smiths have called into
  seconds value reflected an excessive and poten-           question and provide a basis for the trial court to
  tially dangerous state of anticoagulation in Mr.          conclude that the Smiths' claim has merit. See
  Smith's blood.                                            Bowie Mem'l Hosp., 79 S.W.3d at 52; Palacios, 46
S.W.3d at 879.
    When the critically abnormal PT results and
  lack of a calculable INR were reported, McElravy               The Hospital also argues that several individual
  should have become aware of this information,             statements in Dr. Halkos's report are insufficient.
                                                            FN2
  and reported such values to Dr. Bolton, Dr. Rus-                We do not address these specific arguments by
  sell, or PA Dizney and cause repeat testing of a          the Hospital, however, because Dr. Halkos's report,
  new blood specimen from Mr. Smith to verify the           as a whole, provides a “fair summary” of his opin-
  previously noted and reported critical results....        ions; it (1) sufficiently informs the Hospital of the
  Therefore, when McElravy discovered or should             conduct the Smiths question and (2) provides the
  have discovered that Dr. Bolton improperly re-            trial court with a basis to conclude the Smiths'
  corded Mr. Smith's INR as greater than 3, she             claim has merit. See Tex. Civ. Prac. & Rem.Code
  failed to meet the applicable standard of reason-         Ann. § 74.351(r)(6); Bowie Mem'l, 79 S.W.3d at
  able and prudent nursing care in that she failed to       52; Palacios, 46 S.W.3d at 879; Benavides v. Gar-
  bring to Dr. Bolton or PA Dizney's attention Dr.          cia, 278 S.W.3d 794, 799 (Tex.App.-San Antonio
  Bolton's improper assessment of Mr. Smith's INR           2009, pet. denied) (stating that opinion in expert re-
  on the morning of July 4, 2006[;] she also failed         port, read in isolation, appeared conclusory, but
  to meet the standard of reasonable nursing care in        holding that opinion was sufficiently described in
  failing to recognize Mr. Smith's excessive antico-        context of entire report). The trial court did not ab-
  agulation blood condition, report such condition          use its discretion by finding that Dr. Halkos's report
  to Dr. Bolton, Dr. Russell *514 or PA Dizney and          adequately address Nurse McElravy's alleged duties
  bring about appropriate intervention to correct           and breaches of those duties.
  this dangerous condition for Mr. Smith.
                                                                     FN2. For example, the Hospital argues Dr.
    [4] Dr. Halkos's report adequately describes                     Halkos's report states that Nurse McElravy
Nurse McElravy's duties and alleged breaches of                      “should have properly monitored antico-
those duties. The report states that McElravy: (1)                   agulant therapy for Mr. Smith” but does
had a duty to assist Dr. Bolton with Mr. Smith's                     not explain how Nurse McElravy improp-

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        erly monitored anticoagulant therapy or               Dr. Bolton and question the orders.
        how Nurse McElravy should have mon-
        itored it and does not state how McElravy                Nurse Hammonds failed to perform sufficient
        was negligent in not having information               surveillance to discover the removal of the IJ
        about “critically abnormal PT ... results             catheter in time to prevent Mr. Smith's hemor-
        and lack of calculable INR” as alleged in             rhagic arrest. A reasonably prudent critical care
        the report.                                           nurse ... should have known that continuous
                                                              bleeding for approximately 30—45 minutes
B. Duty and Alleged Breach by Nurse Ham-                      would lead to hemorrhagic cardiac arrest. There-
monds                                                         fore, it is reasonable to conclude, in reasonable
    The Hospital also contends Nurse Hayman's re-             nursing probability, that Defendant Hammonds
port and supplemental report are insufficient be-             failed to see and assess Mr. Smith for at least 30
cause they do not adequately describe the standard            minutes prior to his arrest. According to the hos-
of care applicable to Nurse Hammonds or how                   pital records, Hammonds recorded Mr. Smith's
Nurse Hammonds allegedly breached the standard                vital signs at a time prior to his arrest when the
of care.                                                      Quinton catheter must have been out and there-
                                                              fore significant bleeding would and should have
    Relevant portions of Nurse Hayman's report                been obvious to a critical care nurse, including
provide:                                                      Hammonds, performing duties according to the
                                                              standards for reasonable and prudent nurses in
     Nurse Hammonds was responsible for provid-
                                                              ICU settings. The hospital ICU records indicate
  ing reasonable and prudent nursing diagnosis, as-
                                                              that Hammonds either failed to properly observe
  sessment, care and treatment for Mr. Smith's
                                                              Mr. Smith, or he did not accurately and com-
  post-operative conditions and well-being in the
                                                              pletely record his nursing actions in the hospital
  [Hospital] ICU, and this responsibility included
                                                              record, and both such failures would be a viola-
  careful and frequent monitoring of his physical
                                                              tion of the applicable standard of nursing care for
  and mental conditions, the plan of care from mul-
                                                              Hammonds.
  tiple consultants, and the delivery of ongoing in-
  tensive nursing care in the ICU and interventions              Nurse Hammonds failed to set alarm limits on
  as prescribed by attending and consulting physi-            the physiologic monitors that reflected the pa-
  cians as well as reasonable nursing practices.              tient's baseline vital signs and thereby failed to
                                                              discover when various parameters were in alarm
  *515 Nurse Hammonds administered 4 mg of
                                                              condition.... Hammonds either failed to transduce
  morphine sulfate by IV and 15 mg of hydro-
                                                              the IJ catheter to the alarm system or he failed to
  codone by mouth at 2000 (8:00 PM) on 7/04/06.
                                                              respond to the alarm condition caused by the re-
  Nurse Hammonds failed to properly administer
                                                              moval of the device. In either situation, Ham-
  the PRN (as necessary) pain control orders be-
                                                              monds failed to meet the applicable standard of
  cause he should have known that both medica-
                                                              nursing care for Mr. Smith.... In violation of the
  tions should not have been administered to Mr.
                                                              standards for reasonable and prudent critical care
  Smith in one dose. If Nurse Hammonds believed
                                                              nursing, Nurse Hammonds failed to document
  such orders allowed the choice to administer both
                                                              alarm conditions, rhythm strips, oxygen de-
  medications at one time, then Hammonds failed
                                                              saturation or his nursing responses to any of the
  to question or clarify Dr. Bolton's orders. It was a
                                                              abnormalities that occurred before Mr. Smith ex-
  violation of the reasonable and prudent standards
                                                              sanguinated (bled out) into arrest.
  of nursing care for a critical care nurse to admin-
  ister the medications in that manner or not to call         The hospital code record reflects that ECG mon-

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  itoring and pulse oximetry were in progress at the        tients, including Mr. Smith, who demonstrate a de-
  time of the arrest event. Defendant Hammonds              creased level of consciousness, disorientation, and/
  either failed to establish that monitoring or he ig-      or sedation in order to prevent the patient from
  nored the alarm conditions that would have oc-            causing injury to himself.” Nurse Hayman's supple-
  curred in the setting of “agonal breathing.” Mr.          mental report states that Nurse Hammonds failed to
  Smith's agonal breathing would have caused                appreciate the potential side effects of simultaneous
  alarm conditions in the rate of respirations and          doses of morphine sulphate and hydrocodone,
  oxygen saturation on the alarm system.... Defend-         failed to assess, from a nursing perspective, Mr.
  ant Hammonds failed to recognize, intervene in,           Smith's resulting neurological impairment and de-
  or document and report any such alarm condi-              creased levels of consciousness, disorientation,
  tions for Mr. Smith at that time. Further, Ham-           and/or sedation, and failed to utilize wrist restraints
  monds had an obligation to be in audible or visu-         to prevent Mr. Smith from causing injury to him-
  al proximity to promptly and adequately respond           self.
  to any such clinical or physiological alarm condi-
  tions.                                                         [5] Nurse Hayman's report and supplemental
                                                            report provide that Nurse Hammonds: (1) had a
  Using the physiologic monitoring system, Nurse            duty to monitor Mr. Smith's post-operative mental
  Hammonds should have established and mon-                 and physical conditions; (2) had a duty to either
  itored clinical alarms/limits based on [Mr.               question or clarify Dr. Bolton's order before admin-
  Smith's] condition.... All central venous lines or        istering both morphine and hydrocodone to Mr.
  *516 catheters, like the left internal jugular cath-      Smith but failed to do either; (3) failed to assess,
  eter, should have been transduced to the                  from a nursing perspective, or appreciate Mr.
  physiological monitoring system such that the             Smith's altered level of consciousness; (4) failed to
  monitoring system would alarm when a central              use bilateral soft wrist restraints or obtain orders
  line became disconnected.                                 from Dr. Bolton or Dr. Russell for wrist restraints;
                                                            (5) failed to provide sufficient observations and
    Defendant Hammonds failed to perform suffi-             surveillance of Mr. Smith; (6) failed to recognize
  cient surveillance to discover the removal of the         that Mr. Smith's Quinton catheter had been re-
  IJ catheter in time to prevent Mr. Smith's hemor-         moved while recording Mr. Smith's vital signs; (7)
  rhagic arrest. A reasonably prudent critical care         failed to timely discover the removal of Mr. Smith's
  nurse, would have known that continuous bleed-            Quinton catheter; and (8) either failed to establish a
  ing for approximately 30—45 minutes would                 physiologic monitoring system and set the appro-
  lead to hemorrhagic cardiac arrest. Therefore, in         priate alarm limits on the monitoring system or
  reasonable medical probability, Hammonds failed           failed to monitor and document the alarms from the
  to observe Mr. Smith for 30—45 minutes prior to           monitoring system. These statements, all contained
  the arrest event.                                         within the four corners of Nurse Hayman's report,
                                                            are sufficient to inform the Hospital of the specific
    In addition, Nurse Hayman's supplemental re-
                                                            conduct by Nurse Hammonds that the Smiths have
port provides that the standard of care applicable to
                                                            called into question and provide a basis for the trial
Nurse Hammonds requires him to have basic know-
                                                            court to conclude that the claim has merit. See
ledge of all medications he administers to a patient,
                                                            Bowie Mem'l, 79 S.W.3d at 52; Palacios, 46
including the potential side effect of the medica-
                                                            S.W.3d at 879. The trial court did not abuse its dis-
tions to assess, from a nursing perspective,
                                                            cretion in finding that Nurse Hayman's report and
“decreased levels of consciousness, disorientation,
                                                            supplemental report sufficiently address duty and
and/or sedation in patients” similar to Mr. Smith,
                                                            alleged breach of duty as to Nurse Hammonds.
and to “utilize wrist restraints in the care of pa-

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C. Duty and Alleged Breach by Nurse Gill                      Using the physiologic monitoring system, Nurse
    [6] The Hospital next contends Nurse Hay-                 Gill should have established and monitored clin-
man's report and supplemental report are insuffi-             ical alarms/limits based on [Mr. Smith's] condi-
cient because they do not adequately describe the             tion.... All central venous lines or catheters, like
standard of care applicable to Nurse Gill or how              the left internal jugular catheter, should have
Nurse Gill allegedly breached the standard of care.           been transduced to the physiological monitoring
                                                              system such that the monitoring system would
     *517 Relevant portions of Nurse Hayman's re-             alarm when a central line became disconnected.
port provide:
                                                                 Furthermore, Nurse Hayman's supplemental re-
     Nurse Gill was responsible for providing reas-         port states that the standard of care applicable to
  onable and prudent nursing diagnosis, assess-             Nurse Gill requires him to have basic knowledge of
  ment, care and treatment for Mr. Smith's post-            all medications he administers to a patient, includ-
  operative conditions and well-being in the                ing the potential side effect of the medications to
  [Hospital] ICU, and this responsibility included          assess, from a nursing perspective, “decreased
  careful and frequent monitoring of his physical           levels of consciousness, disorientation, and/or seda-
  and mental conditions, the plan of care from mul-         tion in patients” similar to Mr. Smith, and to
  tiple consultants, and the delivery of ongoing in-        “utilize wrist restraints in the care of patients, in-
  tensive nursing care in the ICU and interventions         cluding Mr. Smith, who demonstrate a decreased
  as prescribed by attending and consulting physi-          level of consciousness, disorientation, and/or seda-
  cians as well as reasonable nursing practices.            tion in order to prevent the patient from causing in-
                                                            jury to him [self].” Nurse Hayman's supplemental
    Nurse Gill failed to perform sufficient surveil-
                                                            report states that Nurse Gill failed to appreciate the
  lance to discover the removal of the IJ catheter in
                                                            potential side effects of simultaneous doses of
  time to prevent Mr. Smith's hemorrhagic arrest. A
                                                            morphine sulphate and hydrocodone, failed to as-
  reasonably prudent critical care nurse, should
                                                            sess, from a nursing perspective, Mr. Smith's result-
  have known that continuous bleeding for approx-
                                                            ing neurological impairment and decreased levels
  imately 30—45 minutes would lead to hemor-
                                                            of consciousness, disorientation, and/or sedation,
  rhagic cardiac arrest. Therefore, it is reasonable
                                                            and failed to utilize wrist restraints to prevent Mr.
  to conclude, in reasonable nursing probability,
                                                            Smith from causing injury to himself.
  that Defendant Gill failed to see and assess Mr.
  Smith for at least 30 minutes prior to his arrest.             Nurse Hayman's report and supplemental report
  The hospital ICU records indicate that Gill either        adequately describe Nurse Gill's duties and alleged
  failed to properly observe Mr. Smith, or he did           breaches of those duties. The report and supple-
  not accurately and completely record his nursing          mental report provide that Nurse Gill: (1) had a
  actions in the hospital record, and both such fail-       duty to monitor Mr. Smith's post-operative mental
  ures would be a violation of the applicable stand-        and physical conditions; (2) failed to, from a nurs-
  ard of nursing care for Gill.                             ing perspective, assess or appreciate Mr. Smith's
                                                            altered level of consciousness; (3) failed to use bi-
  Defendant Gill failed to recognize, intervene in,
                                                            lateral soft wrist restraints or obtain orders from Dr.
  or document and report any such alarm condi-
                                                            Bolton or Dr. Russell for wrist restraints; (4) failed
  tions for Mr. Smith at that time. Further, Gill had
                                                            to provide sufficient surveillance of Mr. Smith; (5)
  an obligation to be in audible or visual proximity
                                                            failed to timely discover *518 the removal of Mr.
  to promptly and adequately respond to any such
                                                            Smith's Quinton catheter; and (6) failed to establish
  clinical or physiological alarm conditions.
                                                            or monitor and document a physiologic monitoring

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system with the appropriate alarm limits. These               If Dr. Suominen, PA Dizney or Nurse McElravy
statements, all contained within the four corners of          had properly evaluated Mr. Smith's conditions
Nurse Hayman's reports, are sufficient to inform the          and notified Dr. Bolton and Dr. Russell of such
Hospital of the specific conduct by Nurse Gill that           conditions, then in all probability, Mr. Smith's
the Smiths have called into question and provide a            state of excessive anticoagulation would have
basis for the trial court to conclude that the Smiths'        been recognized and corrected because the ap-
claim has merit. See Bowie Mem'l, 79 S.W.3d at 52;            plicable standards of medical care for Dr. Bolton
Palacios, 46 S.W.3d at 879. The trial court acted             and Dr. Russell would have required them to take
within its discretion in finding that Nurse Hayman's          such action under the circumstances. Unfortu-
report and supplemental report sufficiently address           nately, Mr. Smith's state of excessive anticoagu-
duty and alleged breach of duty as to Nurse Gill.             lation continued and the administration of large
                                                              doses of narcotic pain medications administered
D. Causation                                                  by Nurse Hammonds to Mr. Smith on the evening
     [7] Finally, the Hospital argues the Smiths' ex-         of July 4, 2006, in all probability led to disorient-
pert reports are insufficient because they do not suf-        ation and neurological impairment in Mr. Smith
ficiently describe how the alleged breaches of the            such that he was able to self-remove the left in-
standard of care by the Hospital's three nurse-               ternal jugular Quinton catheter causing massive
employees caused any harm to Mr. Smith.                       hemorrhage leading to exsanguinating cardiopul-
                                                              monary arrest. Although the sequence of events
    Relevant portions of Dr. Halkos's report
                                                              leading up to Mr. Smith's hemorrhagic arrest is
provide:
                                                              not accurately or completely documented in the
  It is my opinion that each of the above-described           [Hospital] medical record, it is likely that Mr.
  failures of Dr. Bolton, Dr. Russell, Dr. Suominen,          Smith's neurological impairment, caused by the
  PA Dizney, Nurse McElravy, Nurse Hammonds,                  large doses of narcotic pain medications for the
  and Nurse Gill to meet the reasonable, prudent,             above-discussed reasons, allowed him to avoid
  and accepted standards of medical, nursing and              suffering the significant pain of self-removal of
  health care in the diagnosis, assessment, care and          the Quinton catheter from his neck and not be
  treatment of [Mr.] Smith's post-operative and               alarmed by the subsequent massive hemorrhage
  clinical conditions, separately and collectively,           he experienced and summon the [Hospital] nurs-
  probably caused Mr. Smith to experience a                   ing staff for help.
  worsening of his physical and mental conditions
                                                              *519 Dr. Suominen's failure to adequately secure
  leading to his pulling out the Quinton catheter
                                                              the Quinton catheter to Mr. Smith's neck and
  resulting in significant and severe bleeding that
                                                              Nurse McElravy's failure to cause to be ordered[
  led to his hemorrhagic cardiopulmonary arrest
                                                              ] soft wrist restraints in the setting of Mr. Smith's
  with pulseless electrical activity, resuscitation,
                                                              altered level of consciousness allowed this series
  additional deterioration, and his death....
                                                              of events to occur where Mr. Smith was able to
  Dr. Bolton and Dr. Russell's failures to be noti-           pull out the Quinton catheter and experience
  fied [by Nurse McElravy] of Mr. Smith's severe              massive bleeding. If Dr. Suominen had ad-
  abnormal anticoagulation condition, as demon-               equately secured the Quinton catheter in Mr.
  strated by his incalculable and undetermined INR            Smith's neck and if Nurse McElravy had caused
  as of July 4, 2006, due to his abnormally high              to be ordered[ ] soft wrist restraints in the setting
  protime (greater than 120 seconds), allowed his             of Mr. Smith's altered level of consciousness this
  excessive anticoagulation condition to continue             series of events where Mr. Smith was able to pull
  unrecognized and uncorrected.                               out the Quinton catheter and experience massive

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314 S.W.3d 508
(Cite as: 314 S.W.3d 508)

  bleeding in all lilklihood [sic] would not have oc-               FN3. The Hospital also argues that Nurse
  curred and would not have progressed to cardiop-                  Hayman is not qualified to render causa-
  ulmonary arrest.                                                  tion opinions. We need not address this ar-
                                                                    gument, however, because Dr. Halkos's re-
  Nurses Hammonds['] and Gill's failures to prop-                   port, without reference to Nurse Hayman's
  erly and adequately monitor Mr. Smith's above-                    report, sufficiently addresses the causation
  described activities and conditions resulted in                   element in the Smiths' claim against the
  their failures to timely and properly recognize his               Hospital. See Tex.R.App. P. 47.1.
  removal of the Quinton catheter and the bleeding
  from the catheter site before he experienced hem-             We overrule the Hospital's sole issue.
  orrhagic cardiopulmonary arrest.... Nurses Ham-
  monds and Gill failed to closely monitor Mr.                                 VII. Conclusion
  Smith's conditions for a period of at least 30 to 45           Having overruled the Hospital's sole issue, we
  minutes before Hammonds['s] discovery of Mr.              affirm the trial court's order.
  Smith's hemorrhagic arrest. If Nurses Hammonds
                                                            Tex.App.–Fort Worth,2010.
  and Gill had timely discovered Mr. Smith's self-
                                                            Presbyterian Community Hosp. of Denton v. Smith
  removal of the Quinton catheter within 30 to 45
                                                            314 S.W.3d 508
  minutes before arrest, and implemented proper
  interventional procedures, it is likely that Mr.          END OF DOCUMENT
  Smith's significant bleeding condition could have
  been stopped and would not have progressed to
  cardiopulmonary arrest. Although Mr. Smith's
  clinical condition had a mortality of about twenty
  percent prior to the arrest, the above-discussed
  failures of Dr. Bolton, Dr. Russell, Dr. Suominen,
  PA Dizney, McElravy, Hammonds, and Gill
  probably led to the arrest and the sequelae that
  probably ensued and in reasonable probability led
  to his progressive weakness, increasing renal dys-
  function, and multi-system organ failure and his
  death.

     These statements, all contained within the four
corners of Dr. Halkos's report, sufficiently link Dr.
Halkos's causation opinions to the facts and ad-
equately describe the chain of events allegedly
leading to Mr. Smith's death. See Patel v. Williams,
237 S.W.3d 901, 905–06 (Tex.App.-Houston [14th
Dist.] 2007, no pet.) (holding expert report suffi-
ciently set forth causation when it presented a chain
of events beginning with a contraindicated prescrip-
tion and ending with the patient's death). The trial
court acted within its discretion in finding that Dr.
Halkos's report sufficiently address the element of
           FN3
causation.

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

                                                          ing their motion to dismiss Penny Jean's healthcare
Only the Westlaw citation is currently available.         liability claim for failure to serve an adequate ex-
                                                          pert report. See TEX. CIV. PRAC. & REM.CODE
SEE TX R RAP RULE 47.2 FOR DESIGNATION                    ANN. § 74.351(a) (West 2011). Penny's mother,
AND SIGNING OF OPINIONS.                                  Willie Ann Jean, died approximately three weeks
                                                          after gallbladder surgery as a result of hypoxic en-
MEMORANDUM OPINION
                                                          cephalopathy. Dr. Zuniga performed the surgery.
            Court of Appeals of Texas,                    Dr. Shenoy, a cardiologist, cleared Jean for the sur-
               Houston (1st Dist.).                       gery.
 Vasudev SHENOY and Dario Zuniga, Appellant
                                                                     FN1. See TEX. CIV. PRAC. &
                         v.
                                                                     REM.CODE ANN. § 51.014(a)(9) (West
Penny JEAN, Individually, and as Wrongful Death
                                                                     2011).
Beneficiary of Willie Ann Jean, Deceased, and on
Behalf of the Estate of Willie Ann Jean, Deceased,             In two issues, Shenoy contends that the trial
and on Behalf of all Wrongful Death Beneficiaries         court abused its discretion in denying his motion to
     of Willie Ann Jean, Deceased, Appellee.              dismiss because Jean's expert, Dr. Mazzei, an anes-
                                                          thesiologist, is not qualified to opine on the applic-
              No. 01–10–01116–CV.
                                                          able standard of care for a cardiologist, breach of
                  Dec. 29, 2011.
                                                          that standard or causation, and his report does not
On Appeal from the 151st District Court, Harris           adequately address standard of care, breach, or
County, Texas, Trial Court Case No.2010–28302.            causation. In his sole issue, Zuniga contends that
John G. Myers, Dee L. Dawson, Myers Doyle,                the trial court abused its discretion because (1)
Houston, for Appellant Vasudev Shenoy.                    Mazzei is not qualified to offer an opinion on the
                                                          applicable standard of care for a surgeon, (2) the re-
Robert G. Smith, David O. Cluck, Scott B. Novak,          port does not address how Zuniga caused Willie
Lorance & Thompson, P.C., Houston, for Appellant          Ann's death beyond mere conclusions, and (3) it is
Dario Zuniga.                                             “impermissibly cumulative”—that is, it does not
                                                          adequately identify the particular breaches of the
Monica C. Vaughan, for Penny Jean, Individually,          standard of care or causation with respect to each
and as Wrongful Death Beneficiary of Willie Ann           separate defendant. We reverse and render an order
Jean, Deceased, and on Behalf of the Estate of Wil-       dismissing the claims against Shenoy and Zuniga.
lie Ann Jean, Deceased, and on Behalf of all
Wrongful Death Beneficiaries of Willie Ann Jean,                              Background
Deceased.                                                      Mazzei's expert report provides the background
                                                          facts in this case. The medical records are not be-
                                                          fore us, and we accept the factual statements for the
Panel consists of Chief Justice RADACK and                                                FN2
                                                          limited purpose of this appeal.
Justices SHARP and BROWN.
                                                                     FN2. See Bowie Mem'l Hosp. v. Wright, 79
          MEMORANDUM OPINION                                         S.W.3d 48, 53 (Tex.2002) (review of
HARVEY BROWN, Justice.                                               Chapter 74 report is limited to four corners
                                     FN1                             of report).
    *1 In this interlocutory appeal,     Dr. Shenoy
and Dr. Zuniga appeal the trial court's orders deny-

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

    Willie Ann Jean, age 57, was taken by ambu-           plained. Shenoy cleared Willie Ann for the gall-
lance to the emergency room of Doctor's Hospital          bladder surgery.
on February 15,2008, complaining of abdominal
pain, vomiting, chest pain of three hours' duration,           Dr. Amin–Sankar, an anesthesiologist, per-
and difficulty breathing. As part of her admission,       formed a preoperative anesthesia assessment on
Willie Ann gave an extensive medical history that         February 19. He noted Willie Ann's past medical
included diabetes, hypertension, angina, surgery for      history, including her acute myocardial infarction
a brain aneurysm, coronary artery disease, chronic        and abnormal EKG. Amin–Sankar cleared Willie
obstructive pulmonary disease, hypercholester-            Ann for surgery.
olemia, and a prior myocardial infarction. Willie
                                                               On February 19, 2008, Zuniga performed the
Ann reported she had experienced abdominal and
                                                          surgery. The surgery was an “uneventful” proced-
chest pain for years without treatment. Based on a
                                                          ure. After leaving the post-anesthesia careunit
physical examination and ultrasound, the emer-
                                                          (PACU), Willie Ann was to be sent to the intensive
gency room physician, Dr. Mireles, determined that
                                                          care unit because she had fluctuating oxygen satur-
she had polyps and diagnosed symptomatic gall-
                                                          ation levels, inadequate ventilation, and shallow-
stones in her gallbladder. He recommended that she
                                                          ness of breath. Shortly thereafter, she was transpor-
undergo surgery to remove her gallbladder. He
                                                          ted back to the PACU and was placed on a ventilat-
ordered a surgical consultation and a cardiology
                                                          or. According to Mazzei's report, Amin–Sankar
consultation.
                                                          prematurely extubated Willie Ann ten minutes
     Shenoy, a cardiologist, saw her that same day,       later.Within a few minutes, Willie Ann was in res-
and noted that Willie Ann had a two- to three-year        piratory arrest. She received CPR and medications,
history of epigastric and right upper quadrant ab-        and Amin–Sankarreintubated her.
dominal pain as well as a history of a previous
                                                               Thirty minutes later, Willie Ann was returned
myocardial infarction and a cereberovascular acci-
                                                          to the ICU. According to Mazzei's report, Jean be-
dent (i.e., a stroke). Shenoy noted that Willie Ann
                                                          came “agitated” and had trouble with the ventilator.
had suffered chest pain, accompanied by shortness
                                                          She extubated herself and suffered a second respir-
of breath and sweating for four to six hours earlier
                                                          atory arrest. She was re-intubated and given medic-
that day. Willie Ann also had an abnormal electro-
                                                          ations. An EEG the following day showed possible
cardiogram (EKG). Shenoy's diagnosis was that
                                                          hypoxic encephalopathy —brain damage caused by
Willie Ann had sufferedan acute myocardial infarc-
                                                          lack of oxygen. A follow-up EEG the next day also
tion, symptomatic gallstones, hypertension, and
                                                          indicated hypoxic encephalopathy. Mazzei's report
diabetes.
                                                          does not discuss whether the EEGs differentiate
    *2 Zuniga, a surgeon, performed the surgical          between any damage caused by the first extubation
consultation three days after her initial admission,      and arrest and the second extubation and arrest.
on February 18, 2008. Zuniga confirmed the pres-          Willie Ann was unresponsive to stimuli, including
ence of gallstones, diagnosed inflammation of the         painful stimuli. On February 25, Willie Ann was
gallbladder, and cleared Willie Ann for surgery to        transferred to another facility for long-term care.
remove her gallbladder the next day, February 19,         She died on March 5, 2008 due to the hypoxic en-
subject to a cardiology assessment. Dr. Shenoy saw        cephalopathy.
Willie Ann again on February 18. A nuclear test
                                                              Penny filed a wrongful death medical malprac-
was negative for ischemia. Shenoy also ordered an
                                                          tice suit against Doctor's Hospital, Mireles,
EKG, the results of which are included in Mazzei's                                          FN3
                                                          Amin–Sankar, Shenoy, and Zuniga.        Penny al-
report but the significance of which are not ex-
                                                          leged that Shenoy and Zuniga were negligent in

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

clearing her mother for surgery. Specifically, Penny        who had recently suffered a MI, it should have
alleged that there was no emergency or urgent reas-         been expected that it would take her a significant
on to remove her mother's gallbladder and that her          period of time before she was capable of being
mother had experienced abdominal and chest pain             extubated to breathe on her own. This was not
for years without treatment. In addition, Willie Ann        taken into account nor was her clinical picture
had suffered an acute myocardial infarction before          when she was untimely extubated [by the anes-
the gallbladder surgery and had a history of numer-         thesiologist]. This caused her to suffer a respirat-
ous health problems. Although she was stable, her           ory arrest which further stressed Ms. Jean's abil-
history created additional risks that made her a poor       ity to recover from surgery and lead to another
candidate for surgery, and therefore Shenoy and             respiratory arrest with anoxic encephalopathy and
Zuniga negligently cleared Willie Ann for the sur-          death.... When Ms. Jean extubated herself, the
gery.                                                       failure to address her increasing respiratory dis-
                                                            tress resulted in a subsequent respiratory arrest
        FN3. Only Shenoy and Zuniga are parties             causing the anoxic encephalopathy which lead to
        to this appeal.                                     her death.

    *3 Penny timely served an expert report from               Shenoy and Zuniga moved to dismiss, asserting
                                FN4
Mazzei, an anesthesiologist.         Mazzei's report      that the report was inadequate to them. The trial
focused primarily on the anesthesiologist,                court granted Penny an opportunity to amend the
Amin–Sankar. Concerning Shenoy and Zuniga,                report. After receiving the amended report, Shenoy
Mazzei stated that if Willie Ann “had not under-          and Zuniga again moved to dismiss due to inad-
gone elective surgery on February 19, 2008, she           equacies in the report. The trial court denied the
would not have experienced the respiratory arrests        motions to dismiss, and this interlocutory appeal
that resulted from her extubation and she would           followed.
have, in all probability, survived.”
                                                                          Standard of Review
        FN4. See TEX. CIV. PRAC.                   &           We review a trial court's ruling on a motion to
        REM.CODE ANN. § 74.351(a).                        dismiss a healthcare liability lawsuit pursuant to
                                                          Chapter 74 of the Texas Civil Practice and Remed-
     Concerning Amin–Sankar, Mazzei's report
                                                          ies Code under an abuse of discretion standard. See
states, “In reasonable medical probability, if Ms.
                                                          Am. Transitional Care Ctrs. of Tex., Inc. v. Pala-
Jean had not been prematurely extubated, she
                                                          cios, 46 S.W.3d 873, 875 (Tex.2001) (reviewing
would not have had the increased demands placed
                                                          dismissal under predecessor statute, section 13(e)
on her body which caused her subsequent respirat-
                                                          of article 4590i); Runcie v. Foley, 274 S.W.3d 232,
ory arrest, anoxic brain injury and death.” He fur-
                                                          233 (Tex.App.-Houston [1st Dist.] 2008, no pet.). A
ther explained in his general discussion of causa-
                                                          trial court abuses its discretion if it acts in an arbit-
tion that the anesthesiologist should have been
                                                          rary or unreasonable manner without reference to
aware of the risks of premature extubation. A fair
                                                          guiding rules or principles or if it clearly fails to
reading of Mazzei's report is that the premature ex-
                                                          analyze or apply the law correctly. Runcie, 274
tubation was the immediate cause of death:
                                                          S.W.3d at 232. In reviewing whether an expert re-
  The time it takes for a patient's anesthesia effect     port complies with Chapter 74, we evaluate whether
  to lessen enough for them to be able to breathe         the report “represents a good-faith effort” to com-
  independently varies from patient to patient and        ply with the statute. Strom v. Mem'l Hermann Hosp.
  is affected by a patient's physiology and underly-      Sys., 110 S.W.3d 216, 221 (Tex.App.-Houston [1st
  ing disease processes. For a patient like Ms. Jean      Dist.] 2003, pet. denied). In making this evaluation,

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

we must look only at the information contained             have merit. Scoresby v. Santillan, 346 S.W.3d 546,
within the four corners of the report. Bowie Mem'l         556 (Tex.2011) (citing Palacios, 46 S.W.3d at
Hosp. v. Wright, 79 S.W.3d 48, 53 (Tex.2002).              879). A report that merely states the expert's con-
                                                           clusions as to the standard of care, breach, and
        Adequacy of Dr. Mazzei's report                    causation does not fulfill these two purposes. Id. “
    *4 In their respective appeals, Shenoy and             ‘[T]he expert must explain the basis of his state-
Zuniga attack various aspects of the adequacy of           ments and link his conclusions to the facts.’ “
Mazzei's report, asserting it fails to meet the re-        Wright, 79 S.W.3d at 52 (quoting Earle v. Ratliff,
quirements of section 74.351 of the Texas Civil            998 S.W.2d 882, 890 (Tex.1999)). Furthermore, in
Practice and Remedies Code. See TEX. CIV.                  assessing the report's sufficiency, the trial court
PRAC. & REM.CODE § 74.351(a).                              may not draw any inferences, and instead must rely
                                                           exclusively on the information contained within the
I. Chapter 74 expert report requirements
                                                           report's four corners. See Scoresby, 346 S.W.3d at
     Pursuant to section 74.351, medical-mal-
                                                           556 (citing Palacios, 46 S.W.3d at 878).
practice plaintiffs must provide each defendant
physician and health care provider with an expert          II. Adequacy of report concerning causation
report or voluntarily nonsuit the action. Id. If a              Within his second issue, Shenoy contends that
claimant timely furnishes an expert report, a de-          Mazzei's report does not adequately address causa-
fendant may file a motion challenging the report's         tion of Jean's injuries as a result of any negligence
adequacy. Id. The trial court shall grant the motion       by Shenoy. As part of his sole issue, Zuniga simil-
only if it appears, after hearing, that the report does    arly argues that the report is inadequate in its state-
not represent a good faith effort to comply with the       ment of causation for his alleged malpractice.
statutory definition of an expert report. See id. §
74.351(l ). The statute defines an expert report as a           *5 An expert report must include a fair sum-
written report by an expert that provides, as to each      mary of the causal relationship between the defend-
defendant, a fair summary of the expert's opinions,        ant's failure to meet the appropriate standard of care
as of the date of the report, regarding: (1) the ap-       and the injury, harm, or damages claimed. TEX.
plicable standards of care; (2) the manner in which        CIV. PRAC. & REM.CODE ANN. § 74.351(r)(6).
the care provided failed to meet the standards; and        An expert cannot merely state his conclusions or
(3) the causal relationship between that failure and       “provide insight” about the plaintiffs' claims, but
the injury, harm, or damages claimed. See id. §            must instead “explain the basis of his statements to
74.351(r)(6); Gray v. CHCA Bayshore, L.P., 189             link his conclusions to the facts.” Wright, 79
S.W.3d 855, 85859 (Tex.App.-Houston [1st Dist .]           S.W.3d at 52.In explaining causation, the report
2006, no pet.).                                            must explain how the physician's conduct caused
                                                           the plaintiff's injuries. Id. at 53.
     Although the report need not marshal all the
plaintiff's proof, it must include the expert's opin-      A. Assertions in Mazzei's expert report regard-
ions on the three statutory elements—standard of           ing causation
care, breach, and causation. See Palacios, 46                   Mazzei's report asserts that the applicable
S.W.3d at 878; Gray, 189 S.W.3d at 859. In detail-         standard of care breached by Shenoy included the
ing these elements, the report must provide enough         responsibility to consider all of Willie Ann's co-
information to fulfill two purposes if it is to consti-    morbidities because these conditions placed Willie
tute a good faith effort: first, it must inform the de-    Ann “at an unacceptably high risk for complica-
fendant of the specific conduct the plaintiff has          tions from surgery and anesthesia.” The report
called into question, and, second, it must provide a       identifies two risks from the surgery and anesthesia
basis for the trial court to conclude that the claims      : (1) the stresses placed upon the cardiovascular and

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

respiratory system during surgery and anesthesia                *6 Mazzei's report states that the medical con-
and (2) the depression of the central nervous system       ditions that rendered Willie Ann unfit for surgery
and the resulting risk of “experiencing cardiovascu-       caused the complications that arose when she was
lar and respiratory problems.” It also generally           extubated (“these complications occurred because
states that a patient's medical history may increase       of the medical conditions”). What he fails to do is
these risks. It does not, however, quantify or other-      provide a factual underpinning for that conclusion
wise describe the magnitude of risk for respiratory        explaining why or how this occurred and whether it
problems for a person undergoing this surgery with         was all her medical conditions listed in his report or
normal health or compare that risk to the risk for a       her myocardial infarction in particular that made
person with pre-existing medical conditions like           the risk unacceptable and caused her respiratory ar-
Willie Ann's. According to the report, these risks         rest. These omissions make the report conclusory
are addressed by intubating the patient “so the anes-      and deficient for purposes of section 74.351.
thesiologist can ventilate the patients while their
central nervous system is depressed” and that intub-       1. Expert reports cannot be conclusory to satisfy
ation normally continues “until the patient is able to     section 74.351.
again breathe on [his] own.” The report continues:              An opinion on causation stated without the un-
                                                           derlying facts is conclusory. Jelinek v. Casas, 328
  .... Although complications arose as Ms. Jean was        S.W.3d 526, 536 (Tex.2010); Arkoma Basin Ex-
  extubated following surgery, these complications         ploration Co., Inc. v. FMF Assocs. 1990–A, Ltd.,
  occurred because of the medical conditions that          249 S.W.3d 380, 389 n. 32 (Tex.2008). A conclus-
  should have lead Dr. Shenoy to conclude that Ms.         ory opinion is not probative. City of San Antonio v.
  Jean was not an appropriate surgical candidate. If       Pollock, 284 S.W.3d 809, 818 (Tex.2009); see
  Ms. Jean had not undergone elective surgery on           Zamecnik v. Indian Prairie Sch. Dist. No. 204, 636
  February 19, 2008, she would not have experi-            F.3d 874, 881 (7th Cir.2011) (stating that mere con-
  enced the respiratory arrests that resulted from         clusions are useless to the court).
  her extubation and she would have, in all probab-
  ility, survived.                                              This rule is not a mere procedural hurdle. Jur-
                                                           ies—or in the case of expert reports, judges—are
     In the “Causation” section, the report further        often confronted with conflicting expert testimony.
states:                                                    One expert may testify that X caused the plaintiff's
                                                           injuries while a different expert may testify that X
  Ms. Jean was a patient who was still recovering          did not cause the plaintiff's injuries. The factfinder
  from her MI who never should have undergone              typically lacks the expertise necessary to form an
  elective surgery. By continuing to recommend             opinion without expert assistance—this is why ex-
  the gallbladder removal surgery, clearing her for        pert testimony is admitted in the first place. See
  surgery and performing surgery, Ms. Jean's               TEX.R. EVID. 702. It is the expert's explanation of
  healthcare providers breached and violated the           “how” and “why” causation exists that allows the
  standards of care as set forth above and proxim-         factfinder to weigh the credibility of the expert's
  ately caused her death.                                  opinion and, when expert opinions conflict, to de-
                                                           cide which testimony to disregard. Cf. In re Chris-
    Finally, Mazzei states for a patient like Willie
                                                           tus Spohn Hosp. Kleberg, 222 S.W.3d 434, 440
Ann “it should have been expected that it would
                                                           (Tex.2007) (detailing reasons why it is essential
take her a significant period of time before she was
                                                           that the jury have access to the facts and data un-
capable of being extubated to breathe on her own .”
                                                           derlying an expert's testimony in order “to accur-
B. Adequacy of the report concerning Shenoy                ately assess the testimony's worth.”). With respect

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to expert reports in healthcare liability claims, the      precisely the information missing here: the how and
expert's explanation is what allows the trial court to     the why.
determine whether the claim has merit. See Jelinek,
328 S.W.3d at 539; see also Scoresby, 346 S.W.3d                In Gray, this court held that the expert report
at 552 (observing that Legislature enacted expert          contained a conclusory statement concerning causa-
report requirement to elicit expert opinions at an         tion. 189 S.W.3d at 860. The report stated that
early stage of the litigation to allow the trial court     “[t]he failure to monitor and detect the malposi-
to determine that a basis exists for concluding that       tioned left knee resulted in a dislocated left patella,
the claims have merit). Expert testimony that              severe pain and suffering, and subsequent medical
merely states a final conclusion on an essential ele-      treatment.” Id . at 858. Like the Supreme Court in
ment of a cause of action—such as causa-                   Jelinek, this court faulted the causation opinion for
tion—without providing a factual basis for that con-       failing to “convincingly tie the alleged departure
clusion does not aid the jury in its role as factfinder    from the standard of care to specific facts of the
but, rather, supplants it. This, an expert may not do.     case.” Id. at 860.
See Greenberg Traurig of N.Y., P.C.v. Moody, 161
                                                           2. Mazzei's report was conclusory on the issue of
S.W.3d 56, 97 (Tex.App.-Houston [14th Dist.]
                                                           causation
2004, no pet.) (“Expert testimony is admissible to
                                                                Mazzei's causation opinion regarding Shenoy's
aid the jury in its decision, but it may not supplant
                                                           decision to clear Willie Ann for surgery was con-
the jury's decision.”). Similarly, an expert report
                                                           clusory. Although Mazzei's report states that anes-
that merely asserts that a defendant physician's
                                                           thesia depresses the respiratory system and places
breach caused the plaintiff's injury without provid-
                                                           stress on the heart, the report does not state that
ing a factual basis does not provide the trial court
                                                           Willie Ann's history of heart problems or other con-
with the information necessary to evaluate the mer-
                                                           ditions somehow made her more likely to suffer
its of the plaintiff's claim. See Jelinek, 328 S.W.3d
                                                           respiratory arrest after premature extubation than a
at 529.
                                                           person without those medical conditions. It does
     *7 The requirement that the expert's opinion          not state that her risks for the complications that
must not be conclusory applies not only to trial           she experienced—respiratory arrest—were en-
testimony, but to expert reports required by section       hanced because of her medical conditions. The re-
74.351(a). See Jelinek, 328 S.W.3d at 539–40;              port does generally discuss why Willie Ann's other
Wright, 79 S.W.3d at 53.In Jelinek, the Texas Su-          conditions affected her suitability for surgery, but
preme Court found the trial court abused its discre-       does not link her medical conditions to the complic-
tion in denying a motion to dismiss because the ex-        ation she experienced, respiratory arrest. It recog-
pert's opinion on causation was conclusory. 328            nizes that a depressed central nervous system and
S.W.3d at 539–40. The expert's report stated that          the resulting risk of respiratory problems are nor-
“[the defendant's] breach of the appropriate stand-        mal byproducts of anesthesia for even a person with
ard of care in ‘reasonable medical probability, res-       normal health. In other words, Mazzei's report
ulted in a prolonged hospital course and increased         shows that the surgery itself created the risk and
pain and suffering being experienced by [the               does not state how or why Willie Ann's pre-existing
plaintiff].’ “ Id. at 539. The Court emphasized,           conditions changed those risks except in conclusory
“[T]he report says nothing more regarding causa-           terms. The report also states that those risks can be
tion.” Id. The Court faulted the report for offering       addressed by leaving her intubated for “a signific-
no explanation “tying the conclusion to the facts”         ant period of time” before extubation. Mazzei's re-
or of “how and why the breach caused the injury            port makes it clear that he believes that the prema-
based on the facts presented.” Id. at 539–40. This is      ture extubation was the immediate cause of her

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

death.                                                     side effect of the drug was restlessness, and the
                                                           restlessness caused Williams to become agitated
    *8 A report may be sufficient if it states a chain     and remove her feeding tube. Id . Willie Ann like-
of events that begin with a health care provider's         wise became agitated and removed her breathing
negligence and end in a personal injury. See Patel         tube. The report, however does not explain any
v.    Williams,    237 S.W.3d 901,     905      connection between clearing Willie Ann for surgery
(Tex.App.-Houston [14th Dist.] 2007, no pet.); see         or her medical history and her agitation. While the
also Engh v. Reardon, No. 01–09–00017–CV, 2010             report in Patel explained each step on the path of
WL 4484022, at *8 (Tex.App.-Houston [1st Dist.]                                                         FN5
                                                           causation, the report in this case does not.
Nov. 10, 2010, no pet.) (mem.op.). But neither case
involved an event as remote as that involved here.                   FN5. The report in this case is similarly
                                                                     distinguishable from the report in Engh. In
     In Patel, the Fourteenth Court of Appeals held                  Engh, the report identified the alleged
that an expert report sufficiently set forth causation               breach-placing a surgical clip on the ureter
when it presented a chain of events beginning with                   during surgery. 2010 WL 4484022 at *6.
an allegedly negligent prescription and ending with                  The report also explained the con-
the patient's death. Patel, 237 S.W.3d at 905–06.                    sequences of a clipped ureter. Specifically,
Patel prescribed Williams an anti-dementia drug.                     the report detailed how damage to and,
Id. at 903. The report explained that the drug was                   eventually, loss of the kidney would result
not FDA-approved for patients with Williams's ail-                   from clipped ureter. Id. Thus, this court
ment and that known side-effects of the drug in-                     found the report adequate, although Engh
cluded restlessness or a need to keep moving. Id.                    saw multiple other doctors and several
Williams's family withdrew consent for the drug,                     months passed after his surgery and before
but Patel continued to prescribe it. Id. Williams was                he lost his kidney. Id. at *10. The report
being fed via feeding tube, and allegedly due to the                 explained how the alleged breach caused
restlessness from the drug, she removed the tube.                    the loss of Engh's kidney, while the report
Id. The report identified nurses' notes that described               here contains no explanation of how clear-
Williams as agitated and stated that she kept pulling                ing a patient with a history like Willie
at her feeding tube. Id. The nursing staff improperly                Ann's causes premature extubation, self-
re-inserted the tube, causing a small cut, which be-                 extubation, or the eventual death of the pa-
came infected because of the contents of the feed-                   tient.
ing tube entering the cut. Id. The cut developed into
an abscess requiring multiple surgeries. Id. The re-           There were “many links in the chain of events”
port concluded that Williams's death was caused by         that began with the pre-surgical clearance and
the infection from the improperly re-inserted feed-        ended with her death, but Mazzei failed to explain
ing tube. Id. at 904. The Fourteenth Court held that       and support each link. While Mazzei explains how
the trial court did not abuse its discretion in determ-    Willie Ann's premature extubation prevented her
ining the report was not conclusory or speculative         from “maintain[ing] the oxygenation in the blood,”
concerning causation. Id. at 905–06.                       increasing her risk for respiratory arrest, he fails to
                                                           explain what role her pre-existing medical condi-
     The report in this case is distinguishable. The       tions played in her respiratory arrest. It is here that
report identifies the alleged breach—clearing Willie       we part company with the trial court and find that it
Ann for surgery with her medical history—as did            abused its discretion. Mazzei does not link the al-
the report in Patel—prescribing an unapproved drug         leged negligence—clearing Jean for surgery—with
without consent. See id. But there the similarities        the premature extubation except that one occurred
end. In Patel, the report explained that a known

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

before the other. That is not enough; it is only a              A causal link can be too attenuated to satisfy
statement of “but for” causation. If that is all that      the causation requirement for an expert report. See
section 74.351 requires to demonstrate causation,          Gonzalez v. Sebile, No. 09–09–00363–CV, 2009
almost any prior action taken by a health care pro-        WL 4668892, at *4 (Tex.App.-Beaumont Dec. 10,
vider could be said to cause the ultimate outcome.         2009, pet. denied) (mem.op.). In Gonzalez, the
For example, the referral by the emergency room            physician was sued for clearing the patient for sur-
physician for the surgical consultation with Dr.           gery without obtaining a cardiologist consultation
Shenoy also was a cause of Willie Ann's death if all       despite an earlier open heart surgery. 2009 WL
that is necessary is for an event to have preceded         4668892at *2. According to the plaintiffs, the de-
the injury.                                                fendant anesthesiologist fell below the standard of
                                                           care by failing to disqualify the plaintiff as not fit
     *9 To establish cause in fact, Mazzei had to          for surgery in part because of the risks of general
discuss why the act or omission was a substantial          anesthesia. Id. The court held that the report's state-
factor in causing the injury and without which the         ment that the plaintiff would not have been injured
harm would not have occurred. W. Invs., Inc. v.            if he had not undergone surgery in the first place
Urena, 162 S.W.3d 547, 551 (Tex.2005); see also            was “too attenuated to set forth evidence of causa-
Transcon. Ins. Co. v. Crump, 330 S.W.3d 211, 214           tion with sufficient specificity to inform” the physi-
(Tex.2010) (stating that plaintiff must prove “cause       cian of the alleged misconduct and to allow the trial
in fact (or substantial factor)”); Ford Motor Co. v.       court to conclude that the plaintiff's claims had
Ledesma, 242 S.W.3d 32, 46 (Tex.2007) (stating             merit. Id . at *3. Mazzei's report suffers from the
that producing cause requires that (1) the cause           same defect.
must be a substantial cause of the event in issue and
(2) it must be a but-for cause, namely one without              While Mazzei's report “provides insight” con-
which the event would not have occurred). The re-          cerning the claims surrounding Jean's death, it does
port does not do so. Mazzei's report does not link         not link the facts of the decision to clear her for sur-
facts from the alleged negligence in clearing her for      gery to the conclusion that Shenoy's alleged breach
surgery to Willie Ann's death. Willie Ann did not          of the standard of care caused Jean's death. It does
suffer a cardiac arrest during or after the surgery;       not, therefore, provide a basis for the trial court to
she suffered respiratory arrest and only after a pre-      have concluded that causation was demonstrated for
mature extubation. Mazzei does not state that Wil-         Shenoy's decision to clear Willie Ann for surgery.
lie Ann suffered any unusual respiratory issue dur-        See Palaciois, 46 S.W.3d at 879 (report must
ing the surgery itself; the surgical procedure was         provide basis for concluding that claims have mer-
“uneventful.” And based on Mazzei's report, it ap-         it). We conclude, therefore, that the report is con-
pears that any patient—healthy or with a history of        clusory and inadequate with respect to Shenoy. See
medical conditions—who is prematurely extubated            Gray, 189 S.W.3d at 860; see also Jelinek, 328
will not sufficiently “maintain the oxygenation in         S.W.3d at 539–40 (finding report inadequate con-
the blood” and therefore is at risk for respiratory ar-    cerning causation because it did not explain “how
rest. The mere fact that Willie Ann was cleared for        and why the breach caused the injury based on the
surgery before her death does not mean that the            facts presented”).
clearance for surgery caused her death. Jelinek, 328
S.W.3d at 533 (cautioning against the post hoc ergo            *10 We sustain this portion of Shenoy's second
propter hoc fallacy, that is, reasoning that an earlier    issue.
event caused a later event simply because it oc-
                                                           B. Adequacy of the report concerning Zuniga
curred first).
                                                               Penny has not alleged, and Mazzei's report
                                                           does not assert, that Zuniga negligently performed

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Not Reported in S.W.3d, 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.))
(Cite as: 2011 WL 6938538 (Tex.App.-Hous. (1 Dist.)))

surgery; rather, the surgery is described as
“uneventful.” For the same reasons that the report
is inadequate as to causation for Shenoy, we con-
clude that, with respect to Zuniga, the report fails to
explain how and why Zuniga's clearing of Willie
Ann for surgery caused her death, fails to demon-
strate the causal link necessary to have a meritori-
ous claim, and is conclusory and inadequate. See
Gray, 189 S.W.3d at 860; Jelinek, 328 S.W.3d at
539–40.

   We sustain this portion of Zuniga's sole issue.
FN6

         FN6. Because we have sustained Shenoy's
         second issue in part and Zuniga's sole issue
         in part, we do not address the other argu-
         ments raised by the parties. See
         TEX.R.APP. P. 47.1.

                   Conclusion
    We reverse and render an order dismissing the
claims against Shenoy and Zuniga.

SHARP, J., dissenting. Dissent to follow.

Tex.App.-Houston [1 Dist.],2011.
Shenoy v. Jean
Not Reported in S.W.3d, 2011 WL 6938538
(Tex.App.-Hous. (1 Dist.))

END OF DOCUMENT

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368 S.W.3d 574
(Cite as: 368 S.W.3d 574)

                                                            not have committed suicide, was not good faith at-
                                                            tempt to comply with medical expert report require-
          Court of Appeals of Texas,                        ments in malpractice action against prescribing
                    Austin.                                 physician and clinic, where report did not indicate
  Ted SMITH, D.O.; and Austin Regional Clinic,              how failure to take complete history was cause of
               P.A., Appellants,                            patient's suicide, and it did not include information
                      v.                                    that physician should have gleaned from patient's
        Janet Lynn WILSON, Appellee.                        past or symptoms that would have stopped physi-
                                                            cian from prescribing anti-depressant. V.T.C.A.,
             No. 03–10–00387–CV.
                                                            Civil Practice & Remedies Code § 74.351(r)(6).
                 Jan. 11, 2012.
        Rehearing Overruled May 7, 2012.                    [2] Health 198H        804

Background: Medical malpractice action was                  198H Health
brought against physician and clinic, after patient              198HV Malpractice, Negligence, or Breach of
who had been prescribed anti-depressant committed           Duty
suicide. The 53rd Judicial District Court, Travis                  198HV(G) Actions and Proceedings
County, Suzanne Covington, J., denied defendants'                      198Hk804 k. Affidavits of merit or merit-
motion to dismiss due to deficient expert report,           orious defense; expert affidavits. Most Cited Cases
and defendants appealed.                                         In determining whether a proffered medical ex-
                                                            pert report represents a good faith effort to comply
Holding: The Court of Appeals, David Puryear, J.,
                                                            with the statutory requirements for the same, in a
held that expert's medical report was not good faith
                                                            medical malpractice action, the trial court should
attempt to comply with medical expert report re-
                                                            confine its inquiry to the four corners of the report,
quirements.
                                                            which must include the expert's opinion on all three
    Reversed and remanded.                                  statutory elements and must explain the basis of the
                                                            expert's statements to link his conclusions to the
                  West Headnotes                            facts. V.T.C.A., Civil Practice & Remedies Code §
                                                            74.351(r)(6).
[1] Health 198H       804
                                                            [3] Health 198H        804
198H Health
     198HV Malpractice, Negligence, or Breach of            198H Health
Duty                                                             198HV Malpractice, Negligence, or Breach of
      198HV(G) Actions and Proceedings                      Duty
          198Hk804 k. Affidavits of merit or merit-                198HV(G) Actions and Proceedings
orious defense; expert affidavits. Most Cited Cases                   198Hk804 k. Affidavits of merit or merit-
     Amended medical expert report stating that ap-         orious defense; expert affidavits. Most Cited Cases
plicable standard of care for prescribing anti-                  A medical expert report submitted in support of
depressant was to take full psychiatric history of          a medical malpractice claim need not marshal all
mental health patient complaining of depression             the plaintiff's proof, but to be considered a good-
and stress, that patient was suicide-vulnerable, that       faith effort to satisfy the expert report statute, it
there was connection between anti-depressant and            must do more than simply provide the expert's con-
suicide, and that, but for medication, patient would        clusions as to standard of care, breach, and causa-

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368 S.W.3d 574
(Cite as: 368 S.W.3d 574)

tion, and it must discuss the standard of care,              determination of attorney's fees.
breach, and causation with sufficient specificity to
inform the defendant of the conduct the plaintiff                   Factual and Procedural Background
has called into question and to provide a basis for               On August 6, 2007, Wilson's son, Keith Mi-
the trial court to conclude that the claims have mer-        chael Harris, went to see Dr. Smith, complaining of
it. V.T.C.A., Civil Practice & Remedies Code §               depression and stress. Harris was twenty-three
74.351(l ), (r)(6).                                          years old and had recently broken up with his girl-
                                                                                                       FN1
                                                             friend. Smith prescribed fluoxetine            with
[4] Health 198H        804                                   twelve refills and did not schedule a follow-up vis-
                                                             it. On September 5, 2007, Harris committed sui-
198H Health                                                  cide.
     198HV Malpractice, Negligence, or Breach of
Duty                                                                  FN1. Fluoxetine is the generic name for
       198HV(G) Actions and Proceedings                               Prozac, an anti-depressant. We will refer to
           198Hk804 k. Affidavits of merit or merit-                  the drug as fluoxetine except when quoting
orious defense; expert affidavits. Most Cited Cases                   the record, in which the terms seem to be
     If a medical expert report submitted in support                  used interchangeably.
of a medical malpractice suit contains only conclu-
sions about the statutory elements, the trial court               Wilson sued appellants, alleging that Smith
has “no discretion but to conclude that the report           was negligent in prescribing fluoxetine and in not
does not represent a good-faith effort” to satisfy the       scheduling a follow-up visit with Harris, that ARC
statute governing the expert report requirements.            was vicariously liable as Smith's employer, and that
V.T.C.A., Civil Practice & Remedies Code §                   their negligence was a proximate cause of Harris's
74.351(l ), (r)(6).                                          death. Wilson timely served an expert report by Dr.
                                                             John T. Maltsberger. See Tex. Civ. Prac. &
*575 Diana L. Faust, R. Brent Cooper, Richard C.             Rem.Code Ann. § 74.351 (West 2011). In his re-
Harrist, Cooper & Scully, PC, Dallas, TX, for Ap-            port, Maltsberger stated that the accepted standard
pellant.                                                     of care that should be employed when prescribing
                                                             fluoxetine required a doctor to obtain a description
Dan Ballard, Stacey J. Simmons, Ballard & Sim-               of the patient's “anxious and depressive symptoms”
mons, LLP, Austin, TX.                                       and a full psychiatric history. He opined that Smith
                                                             breached that standard of care because he did not
Jay Harvey, Winckler & Harvey, LLP, Austin, TX,
                                                             “obtain and record” Harris's symptoms of anxiety
for Appellee.
                                                             and depression or his full psychiatric history.
                                                             Maltsberger stated that there was a generally recog-
Before Chief Justice JONES, Justices PURYEAR                 nized relationship between fluoxetine and suicide in
and PEMBERTON.                                               adolescents and young adults and that “adolescents
                                                             with psychiatric disorders” had a greater risk of sui-
                                                             cidal thoughts and behavior in “the first few months
                      OPINION
                                                             of treatment” when prescribed fluoxetine. Maltsber-
DAVID PURYEAR, Justice.
                                                             ger*576 concluded by stating, “[I]t is my opinion
     Appellants Ted Smith, D.O., and Austin Re-
                                                             that more likely than not, had Keith Harris not been
gional Clinic (“ARC”) appeal from the denial of
                                                             prescribed fluoxetine, he would not have committed
their motion to dismiss appellee Janet Lynn
                                                             suicide.”
Wilson's suit for medical malpractice. We reverse
the trial court's order and remand for dismissal and             Appellants objected to the report, asserting it

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368 S.W.3d 574
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was deficient because it was conclusory with regard           opinion that more likely than not, fluoxetine was
to causation. Appellants also noted that the report           a significant cause that worsened the emotional
did not mention ARC at all, much less level any cri-          burden of Mr. Harris's illness and that without it
ticism against it, and argued that it therefore               he would not have committed suicide.
amounted to no expert report at all as to ARC. The
trial court found that Maltsberger's report qualified            Appellants filed another motion to dismiss, as-
as a report but was inadequate, denied appellants'          serting that the new report was deficient because
motion to dismiss, and gave Wilson thirty days to           Maltsberger “never connects the dots and says that
remedy the report's deficiencies. Wilson filed an           based on the history or presentation that existed had
amended report providing essentially the same               Dr. Smith obtained an adequate history, he should
opinions, but adding more detail to the causation           not have prescribed Prozac.” Appellants further as-
            FN2                                             serted:
paragraph.      Maltsberger changed his statements
about the relationship between fluoxetine and sui-
                                                              [Maltsberger] never states that based on the in-
cidal thinking and behavior to refer only to adoles-
                                                              formation available to Dr. Smith at the time that
cents, removing his prior inclusion of “young
         FN3                                                  he was treating Mr. Harris, Dr. Smith should
adults.”      Maltsberger concluded:
                                                              have concluded that Mr. Harris was suicide-
        FN2. The amended report is two and one-               vulnerable. As an expert, he is supposed to ana-
        half pages long, and the actual summaries             lyze Dr. Smith's actions based on the information
        of the standard of care, breach, and causa-           that was available to him at the time. His failure
        tion are covered in slightly over one page.           to do so renders his opinions conclusory, and
                                                              therefore, not adequate.
        FN3. This is a noteworthy omission, since
        Harris, as a twenty-three-year-old man,                 Appellants also reasserted that because Malts-
        was not what is generally considered an             berger's report made no reference to or criticism of
        adolescent. See Webster's Third New Int'l           ARC, it did not qualify as an expert report on those
        Dictionary 28 (2002) (defining adoles-              claims. The trial court denied appellants' motion to
        cence as “the period of life from puberty to        dismiss, and appellants filed this appeal. See id. §
        maturity terminating legally at the age of          51.014(a)(9) (West 2008).
        majority”); see also medical-diction-
                                                                                     Analysis
        ary.thefreedictionary.com/adolescence
                                                                 [1] Within 120 days of the date a plaintiff files
        (last visited January 5, 2012, citing
                                                            a health-care-liability claim, she must serve each
        Mosby's     Med.      Dictionary    (2009),
                                                            physician or health care provider against whom
        Miller–Keane Encyclopedia & Dictionary
                                                            claims are asserted (“medical defendant”) with at
        of Med., Nursing, & Allied Health (2003))
                                                            least one expert report that summarizes the expert's
        (defining adolescence as time between pu-
                                                            opinions “regarding applicable standards *577 of
        berty and adulthood, usually running from
                                                            care, the manner in which the care rendered by the
        between eleven and thirteen and between
                                                            physician or health care provider failed to meet the
        eighteen and twenty).
                                                            standards, and the causal relationship between that
  Based on the information provided to me to date,          failure and the injury, harm, or damages claimed.”
  it is my opinion that Keith Harris was a suicide-         Id. § 74.351(a), (r)(6). After an expert report is
  vulnerable, depressed young man. As outlined in           filed, a medical defendant may file an objection to
  the studies described above, fluoxetine worsened          the report's sufficiency and a motion to dismiss the
  his depression and agitated this patient, driving         plaintiff's liability claims. See id. § 74.351(a), (b).
  him beyond his capacity for endurance. It is my

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368 S.W.3d 574
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     [2] When the adequacy of a report is chal-             Wilson the opportunity to provide an amended re-
lenged, the trial court should only sustain the objec-      port. The new report, however, added very little to
tions if it determines “that the report does not rep-       Maltsberger's statements related to Smith's alleged
resent an objective good faith effort to comply with        breach of the standard of care and causation, in-
the definition of an expert report.” Id. § 74.351(l );      cluding only one additional paragraph that stated
see American Transitional Care Ctrs. of Tex., Inc.          that Harris was “a suicide-vulnerable, depressed
v. Palacios, 46 S.W.3d 873, 878 (Tex.2001). The             young man” and that fluoxetine worsened his de-
                                                                                             FN4
trial court should confine its inquiry to the four          pression and led to his suicide.       Wilson asserts
corners of the report, which must include the ex-           that this report “provides, in its four corners, that
pert's opinion on all three statutory elements and “        but for prescribing the medication the patient would
‘must explain the basis of [the expert's] statements        not have committed suicide.” That may be true, but
to link his conclusions to the facts.’ ” Bowie Mem'l        despite Maltsberger's opinion that fluoxetine
Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.2002)                worsened Harris's mental state and “without it he
(quoting Earle v. Ratliff, 998 S.W.2d 882, 890              would not have committed suicide,” the report does
(Tex.1999)). If the trial court finds a report defi-        not explain how taking more complete medical re-
cient, the plaintiff's claims against the medical de-       cords from Harris would have made Smith aware
fendant are subject to dismissal unless the court           that fluoxetine would put Harris at risk for suicidal
grants “one 30–day extension to the claimant in or-         thoughts or action and *578 would have dissuaded
der to cure the deficiency.” Tex. Civ. Prac. &              Smith from prescribing fluoxetine. In other words,
Rem.Code Ann. § 74.351(c), (l ). If an expert report        the report does not show how Smith's alleged
is not timely served, the trial court must dismiss the      breach of the standard of care caused the tragic res-
claims against the medical defendant if the defend-         ult. See Taylor v. Fossett, 320 S.W.3d 570, 577–78
ant files a motion to dismiss. Id. § 74.351(b).             (Tex.App.-Dallas 2010, no pet.) (report did not
                                                            provide a factual explanation of how doctor's delay
     [3][4] “A report need not marshal all the              in diagnosis or treatment caused complications);
plaintiff's proof,” but to be considered a good-faith       Estorque v. Schafer, 302 S.W.3d 19, 28–29
effort to satisfy the statute, it must do more than         (Tex.App.-Fort Worth 2009, no pet.) (expert report
simply provide the expert's conclusions as to stand-        left “gaps by not explaining how or why the physi-
ard of care, breach, and causation. Palacios, 46            cians' failure to consult a urologist or gynecologist
S.W.3d at 878–79. Instead, the report “must discuss         caused worsening or progression of Shirley's listed
the standard of care, breach, and causation with suf-       conditions” and did not explain how plaintiff would
ficient specificity to inform the defendant of the          not have been injured had defendants obtained con-
conduct the plaintiff has called into question and to       sults from specialists); Johnson v. Willens, 286
provide a basis for the trial court to conclude that        S.W.3d 560, 565 (Tex.App.-Beaumont 2009, pet.
the claims have merit.” Id. at 875. We review a trial       denied) (report did not explain what “normal dose”
court's denial of a motion to dismiss under section         would have been, why prescribed dose was excess-
74.351 for an abuse of discretion, but if an expert         ive, what patient complained of, or what proper
report contains only conclusions about the statutory        treatment would have been); see also Wright, 79
elements, the trial court has “no discretion but to         S.W.3d at 53 (affirming trial court's determination
conclude ... that the report does not represent a           that report was insufficient because it lacked
good-faith effort” to satisfy the statute. Id. at 877,      “information linking the expert's conclusion ... to
880.                                                        Bowie's alleged breach”); Gray v. CHCA Bayshore
                                                            L.P., 189 S.W.3d 855, 859–60 (Tex.App.-Houston
    After appellants objected to the sufficiency of
                                                            [1st Dist.] 2006, no pet.) (affirming trial court's
Maltsberger's original report, the trial court gave
                                                            finding that report was insufficient because it did

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368 S.W.3d 574
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not provide any specific information about what de-                 presented here. The Bakhtari report ex-
fendants should have done or “convincingly tie the                  plained that the medication in question
alleged departure from the standard of care to spe-                 should only have been prescribed for very
cific facts of the case”).                                          short-term use, no refills should have been
                                                                    given, the patient should have been warned
        FN4. Although Wilson alleged in her peti-                   of possible side-effects, the doctor should
        tion that Smith breached the standard of                    have consulted with or referred the patient
        care by not scheduling a follow-up visit                    to a mental-health professional, and the
        with Harris, neither of Maltsberger's re-                   doctor should have provided or arranged
        ports discusses follow-up visits or states                  for “on-going assessment and monitoring”
        whether a follow-up should have been                        of the patient's condition. Id. at 496–97 nn.
        scheduled, when such a visit would have                     9, 10. Maltsberger's cursory report bears
        been appropriate, or whether it would have                  very little similarity to the specificity and
        made a difference in this case.                             explanations provided in the Bakhtari re-
                                                                    port.
     Maltsberger's report essentially states that (1)
the applicable standard of care required Smith to                Further, Maltsberger states that studies have
obtain and record a description of Harris's symp-           shown a relationship between fluoxetine and sui-
toms and a complete psychiatric history, (2) Smith          cide in adolescents and that fluoxetine increases the
neglected to get a description of the symptoms or a         risk of suicidal thoughts and behavior in adoles-
complete psychiatric history in deciding to pre-            cents with psychiatric disorders. He does not,
scribe fluoxetine, and (3) fluoxetine worsened Har-         however, state that fluoxetine should never be pre-
ris's emotional state to the point where he commit-         scribed to adolescents, nor does he explain whether
ted suicide. Maltsberger does not, however, provide         fluoxetine is always inappropriate*579 for all ad-
even the roughest summary of the information                olescents, whether some adolescents can safely take
Smith should have gleaned from Harris's psychiat-           it, or, more importantly, whether the findings re-
ric past or symptoms that would have stopped                lated to adolescents could even be applied to Har-
Smith from prescribing fluoxetine or whether Har-           ris, who at twenty-three was not an adolescent.
ris's symptoms or history actually contained in-            Without more, Maltsberger's statement that a cor-
formation that would have indicated that fluoxetine         relation exists between fluoxetine and suicide in ad-
                                       FN5
was not an appropriate prescription.         He does        olescents does not supply a causal link between the
not provide facts to explain the causal link between        prescribing of fluoxetine and Harris's suicide.
Smith's alleged breach and Harris's suicide, one of
the required statutory elements of an expert report.             To be sure, Maltsberger was not required to
See Tex. Civ. Prac. & Rem.Code Ann. §                       provide an exhaustive, lengthy summary of how
74.351(r)(6) (expert report must include “fair sum-         Smith's omissions caused Harris's suicide or what
mary” of expert's opinion as to “causal relation-           aspects of Harris's medical records led Maltsberger
ship” between medical defendant's failure to meet           to conclude that fluoxetine was an inappropriate
standard of care and injury).                               and dangerous prescription, but he provides liter-
                                                            ally no summary of such information. We are left
        FN5. Wilson cites to Bakhtari v. Estate of          with no choice but to conclude that the report does
        Dumas, 317 S.W.3d 486 (Tex.App.-Dallas              not provide a fair summary of the causal link
        2010, no pet.), stating Bakhtari is a               between Smith's alleged shortcomings and Harris's
        “strikingly similar case.” The expert report        death. See Taylor, 320 S.W.3d at 577–78; Estorque,
        in Bakhtari, however, provided substan- 302 S.W.3d at 28–29; Johnson, 286 S.W.3d at 565.
        tially more information than the report

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368 S.W.3d 574
(Cite as: 368 S.W.3d 574)

Because the report is insufficient as to Smith, it is
also insufficient as to ARC, which Wilson sued
solely for vicarious liability for Smith's conduct.
See Kettle v. Baylor Med. Ctr., 232 S.W.3d 832,
842–43 (Tex.App.-Dallas 2007, pet. denied)
(affirming dismissal of suit against professional as-
sociation due to deficiencies in report about doc-
tor's conduct, stating that whether association was
directly or vicariously liable, “liability still depends
on conduct” of doctor).

     We reverse the trial court's order denying ap-
pellants' motion to dismiss. We remand the cause to
the trial court for the determination of attorney's
fees, see Tex. Civ. Prac. & Rem.Code Ann. §
74.351(b), and for entry of a final order dismissing
Wilson's claims against appellants.

Tex.App.–Austin,2012.
Smith v. Wilson
368 S.W.3d 574

END OF DOCUMENT

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                                                                                                            Page 1
388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

                                                                       198Hk804 k. Affidavits of merit or merit-
                                                             orious defense; expert affidavits. Most Cited Cases
         Court of Appeals of Texas,                               A motion to dismiss a health care liability
                 Texarkana.                                  claim is properly granted if it appears that the ex-
  TEXARKANA NURSING & HEALTHCARE                             pert report does not represent a good-faith effort to
         CENTER, LLC, Appellant                              comply with expert report requirements of the Med-
                      v.                                     ical Liability Act or is not sufficiently specific to
Susan LYLE, Independent Guardian of Betty Ruth               provide a basis for the trial court to conclude that
               Vest, Appellee.                               the claims have merit. V.T.C.A., Civil Practice &
                                                             Remedies Code § 74.351(a, l, r).
              No. 06–12–00067–CV.
             Submitted: Nov. 20, 2012.                       [2] Health 198H        804
              Decided: Dec. 14, 2012.
                                                             198H Health
Background: Resident's daughter brought action                    198HV Malpractice, Negligence, or Breach of
against nursing home, alleging negligent hiring, su-         Duty
pervision, and failure to provide a safe environ-                  198HV(G) Actions and Proceedings
ment, as well as vicarious liability for assault of                    198Hk804 k. Affidavits of merit or merit-
resident by home's employee. The 202nd Judicial              orious defense; expert affidavits. Most Cited Cases
District Court, Bowie County, Leon F. Pesek Jr., J.,             A report that merely states the expert's conclu-
trial court denied nursing home's motion to dismiss.         sions about the standard of care, breach, and causa-
Nursing home appealed.                                       tion does not constitute a good-faith effort under
                                                             the Medical Liability Act; rather, the expert must
Holdings: The Court of Appeals, Carter, J., held
                                                             explain the basis of his statements to link his con-
that:
                                                             clusions to the facts. V.T.C.A., Civil Practice &
(1) expert report provided by daughter was defi-
                                                             Remedies Code § 74.351(a, r).
cient with respect to her direct liability claim;
(2) remand was required to allow trial court to con-         [3] Health 198H        804
sider whether to grant extension to allow expert to
cure the deficiency;                                         198H Health
(3) expert report was also deficient with respect to              198HV Malpractice, Negligence, or Breach of
daughter's vicarious liability claims; and                   Duty
(4) the deficiency with respect to the vicarious liab-              198HV(G) Actions and Proceedings
ility claims was not curable.                                           198Hk804 k. Affidavits of merit or merit-
                                                             orious defense; expert affidavits. Most Cited Cases
    Remanded.                                                     A “good-faith effort” to comply with statutory
                                                             definition of an expert report, pursuant to the Med-
                  West Headnotes
                                                             ical Liability Act, is one that (1) provides informa-
[1] Health 198H        804                                   tion sufficient to inform the defendant of the specif-
                                                             ic conduct called into question and (2) enables the
198H Health                                                  trial court to conclude the claims have merit.
    198HV Malpractice, Negligence, or Breach of              V.T.C.A., Civil Practice & Remedies Code §
Duty                                                         74.351(l ).
     198HV(G) Actions and Proceedings

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                                                                                                              Page 2
388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

[4] Appeal and Error 30          962                                30XVII(D) Reversal
                                                                       30k1177 Necessity of New Trial
30 Appeal and Error                                                        30k1177(6) k. Issues not passed on be-
    30XVI Review                                             low. Most Cited Cases
       30XVI(H) Discretion of Lower Court                         The Court of Appeals would remand health
           30k962 k. Dismissal or nonsuit before tri-        care liability case against nursing home to trial
al. Most Cited Cases                                         court to consider whether to grant a 30-day exten-
     Trial court's ruling on a motion to dismiss is re-      sion to cure deficiencies in expert report to allow
viewed for an abuse of discretion.                           expert to address standard of care and how standard
                                                             was breached when resident was assaulted by
[5] Appeal and Error 30          946
                                                             home's employee, where only direct negligence
30 Appeal and Error                                          claim addressed in report was that home failed to
   30XVI Review                                              provide resident with safe and secure environment;
      30XVI(H) Discretion of Lower Court                     although report did not address plaintiff's claim that
          30k944 Power to Review                             home had a duty to assist resident in maintaining
              30k946 k. Abuse of discretion. Most            highest practicable level of physical, mental, and
Cited Cases                                                  psychosocial well being, implicit in such duty was
    A trial court abuses its discretion, as would            provision of safe and secure environment, and at
warrant reversal, when it acts arbitrarily or unreas-        least three of plaintiff's direct liability claims neces-
onably or without reference to any guiding rules or          sarily related to provision of safe environment.
principles.                                                  V.T.C.A., Civil Practice & Remedies Code §
                                                             74.351(a, c, r).
[6] Health 198H        804
                                                             [8] Health 198H         804
198H Health
     198HV Malpractice, Negligence, or Breach of             198H Health
Duty                                                              198HV Malpractice, Negligence, or Breach of
       198HV(G) Actions and Proceedings                      Duty
           198Hk804 k. Affidavits of merit or merit-                198HV(G) Actions and Proceedings
orious defense; expert affidavits. Most Cited Cases                    198Hk804 k. Affidavits of merit or merit-
     Medical expert's report did not adequately set          orious defense; expert affidavits. Most Cited Cases
forth the applicable standard of care and how the                 When a defendant's alleged health care liability
standards were breached, as required by expert re-           is purely vicarious, a medical expert report that ad-
port statute, in suit alleging that nursing home was         equately implicates the actions of that party's agents
directly negligent for assault of resident by home's         or employees is sufficient. V.T.C.A., Civil Practice
employee; only direct negligence claim addressed             & Remedies Code § 74.351(a).
in report was that of failing to provide resident with
                                                             [9] Health 198H         804
a safe and secure environment, but report failed to
articulate what nursing home should have done dif-           198H Health
ferently to prevent the assault. V.T.C.A., Civil                 198HV Malpractice, Negligence, or Breach of
Practice & Remedies Code § 74.351(a, l, r).                  Duty
                                                                   198HV(G) Actions and Proceedings
[7] Appeal and Error 30          1177(6)
                                                                       198Hk804 k. Affidavits of merit or merit-
30 Appeal and Error                                          orious defense; expert affidavits. Most Cited Cases
   30XVII Determination and Disposition of Cause                 Medical expert report, in health care liability

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388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

suit alleging that nursing home was vicariously li-         Nursing & Healthcare Center, L.L.C. (Texarkana
able for its employee's assault of resident, failed to      Nursing) from 2003 until September 2011, when
                                                                                    FN1
demonstrate good-faith effort to provide fair sum-          she passed *316 away.        From the time of her
mary of expert's opinions regarding standard of             admission, Vest was dependent on the nursing
care applicable to home's employees, breach of              home staff for all of her care. It is alleged that on
standard of care, and causation, as required by             July 31, 2009, while under the care of the Tex-
Medical Liability Act; report stated that standard of       arkana Nursing staff and while receiving hospice
care for home and its staff required the facility to        care, Vest was assaulted by Mary Bean, an L.V.N.
provide level of care and treatment that a reason-          employed by Texarkana Nursing. The assault al-
able, prudent, similar facility would provide, but          legedly left scratches on Vest's forehead, cuts on
failed to identify the standard of care applicable to       her left leg, knots on the sides of her head, and
the staff, or address breach and causation.                 caused bruising and swelling of her left eye. Vest
                                                                                        FN2
V.T.C.A., Civil Practice & Remedies Code §                  recovered from the assault.       Bean was arrested
74.351(a, l, r).                                            and charged with assault.

[10] Health 198H        804                                          FN1. Lyle died in September 2011, after
                                                                     the petition was filed in July 2011.
198H Health
     198HV Malpractice, Negligence, or Breach of                     FN2. While Lyle does not claim Vest died
Duty                                                                 as a result of the assault, the prayer for re-
       198HV(G) Actions and Proceedings                              lief is phrased in terms of the “wrongful
           198Hk804 k. Affidavits of merit or merit-                 death beneficiaries of BETTY RUTH
orious defense; expert affidavits. Most Cited Cases                  VEST.”
     Deficiencies in expert report, in health care li-
ability suit alleging that nursing home was vicari-              In July 2011, Susan Lyle, Vest's daughter and
ously liable for its employee's assault of resident,        independent guardian, sued Texarkana Nursing
                                                            FN3
were not curable, where report failed to identify the             alleging Vest was assaulted by Bean in July
standard of care applicable to the nursing home's           2009 and was injured as a result. Lyle pleads that
staff, and did not address breach and causation.            the claims “by Plaintiff against Defendants fall
V.T.C.A., Civil Practice & Remedies Code §                  within the scope of Chapter 74 of the Texas Civil
74.351(a, l, r).                                            Practice and Remedies Code.” This assertion is in-
                                                            corporated into each theory of liability thereafter
*315 David W. Frost, Kent, Anderson & Bush, PC,             set forth in the petition. Lyle claims Texarkana
Tyler, TX, for appellant.                                   Nursing is vicariously liable for the alleged negli-
                                                            gence of its employees. Lyle further alleges Tex-
J.T. Borah, Dawn W. Smith, Curtis E. Clinesmith,            arkana Nursing was directly responsible for the as-
The Clinesmith Firm, Dallas, TX, for appellee.              sault due to negligent supervision, negligent hiring,
                                                            failure to hire and provide sufficient staff, and fail-
Before MORRISS, C.J., CARTER and MOSELEY,                   ure to allocate sufficient financial resources to the
JJ.                                                         facility. The petition also alleges a direct negli-
                                                            gence claim against Texarkana Nursing based on
                                                            the failure to provide a safe environment for its res-
                    OPINION                                 idents.
Opinion by Justice CARTER.
I. Background                                                        FN3. Ann Yeager Ellisor (the nursing
    Betty Ruth Vest was a resident of Texarkana                      home administrator) was also a named de-

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388 S.W.3d 314
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         fendant in the lawsuit. The claim against            ages claimed.
         Ellisor was nonsuited.
                                                                 TEX. CIV. PRAC. & REM.CODE ANN. §
     Lyle provided an expert report from Milton D.          74.351(r)(6) (West 2011). A motion to dismiss is
                        FN4
Shaw, M.D., C.M.D.            In response, Texarkana        properly granted if it appears that the report does
Nursing filed a motion to dismiss for failure to            not represent a good-faith effort to comply with
provide an adequate expert report in accordance             subsection (r)(6) or is not sufficiently specific “to
with Section 74.351(a) and (b) of the Texas Civil           provide a basis for the trial court to conclude that
Practice and Remedies Code. TEX. CIV. PRAC. &               the claims have merit.” Am. Transitional Care Ctrs.
REM.CODE ANN. § 74.351(a), (b) (West 2011).                 of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875
The trial court denied the motion to dismiss. On ap-        (Tex.2001); see TEX. CIV. PRAC. & REM.CODE
peal of this interlocutory order, Texarkana Nursing         ANN. § 74.351(r)(6). A report that merely states
alleges that (1) the trial court erred in denying its       the expert's conclusions regarding the standard of
motion to dismiss Lyle's direct liability claims, and       care, breach, and causation is deficient. See Pala-
(2) the trial court erred in denying its motion to dis-     cios, 46 S.W.3d at 879. “[T]he expert must explain
miss Lyle's vicarious liability claims.                     the basis of his statements to link his conclusions to
                                                            the facts.” Bowie Mem'l Hosp. v. Wright, 79 S.W.3d
         FN4. Shaw is board certified in internal           48, 52 (Tex.2002) (per curiam). A motion challen-
         medicine and is certified by the American          ging the adequacy of an expert report shall be gran-
         Medical Directors Association as a medic-          ted if the report “does not represent an objective
         al director. Shaw is the medical director of       good faith effort to comply” with the statutory
         the geriatrics and extended care program at        definition of an expert report. TEX. CIV. PRAC. &
         the Veterans Administration (VA) Hospital          REM.CODE ANN. § 74.351(l ) (West 2011). A
         in Kerrville and is assistant clinical pro-        “good faith effort” is one that (1) provides informa-
         fessor of medicine at the University of            tion sufficient to inform the defendant of the specif-
         Texas Medical School at San Antonio.               ic conduct called into question and (2) enables the
         Shaw is the medical director of two private        trial court to conclude the claims have merit.
         community nursing homes in Kerrville,              Wright, 79 S.W.3d at 52.
         separate from his VA practice.
                                                                 [4][5] We review a trial court's ruling on a mo-
II. Applicable Law and Standard of Review                   tion to dismiss for an abuse of discretion. Id.; Go-
     [1][2][3] Chapter 74 of the Texas Civil Practice       forth v. Bradshaw, 296 S.W.3d 849, 851
and Remedies Code requires a health care liability          (Tex.App.-Texarkana 2009, no pet.). A trial court
claimant to serve on each party one or more expert          abuses its discretion when it acts arbitrarily or un-
reports, together with a curriculum vitae of each ex-       reasonably or without reference to any guiding
pert, no later than 120 days after the original peti-       rules or principles. Walker v. Gutierrez, 111
tion is filed. TEX. CIV. PRAC. & REM.CODE                   S.W.3d 56, 62 (Tex.2003). A trial court has no dis-
ANN. § 74.351(a). An expert report is                       cretion, however, in correctly analyzing and apply-
                                                            ing the law. Walker v. Packer, 827 S.W.2d 833, 840
  a written report by an expert that provides a fair
                                                            (Tex.1992).
  summary of the expert's opinions as of the date of
  the report regarding applicable standards of care,        III. Analysis
  the manner in which the care rendered by the
  physician or health care provider failed to meet          A. Shaw's Report is Deficient, but Not Silent,
  the standards, and the *317 causal relationship           with Respect to Direct Liability Claims
  between that failure and the injury, harm, or dam-

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388 S.W.3d 314
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     Texarkana Nursing argues that Shaw's report is                  FN6. Ecchymosis is “[t]he passage of
silent with respect to the pled claims of direct liab-               blood from ruptured blood vessels into
ility. Texarkana Nursing characterizes the categor-                  subcutaneous tissue, marked by a purple
ies of direct negligence listed in the petition as neg-              discoloration of the skin.” Ecchymosis
ligence in hiring, staffing levels, supervision of per-              Definition, TheFreeDictionary.com, ht-
sonnel, provision of financial resources, and failing                tp://www.thefreedictionary.com/ecchymosi
to comply with the Code of Federal Regulations.                      s (last visited Dec. 10, 2012).
FN5
                                                                 The report includes one paragraph addressing
         FN5. The allegations fall variously under          the standard of care, as follows:
         the categories listed in the petition as
         “Negligence,” “Negligence Resulting in               The standard of care for a long term care facility
         Health       Care     Liability      Claims,”        and its staff requires that the facility in question
         “Negligence Per Se,” and “Violation of               provide that level of care and treatment that a
         Penal Code § 22.04.” Pled claims include:            reasonable, prudent, similar facility would
         the failure to allocate sufficient financial         provide under the same or similar circumstances.
         resources to Texarkana Nursing for resid-            The facility must provide the necessary care and
         ents' needs to be met, resulting in the mis-         services to attain or maintain the highest practic-
         treatment, abuse, and neglect of Vest; the           able physical, mental, and psychosocial well-
         failure to use reasonable care in treating           being possible. To do so also requires that the
         residents with the degree of skill and learn-        nursing facility provide a safe environment for its
         ing ordinarily possessed and used by nurs-           residents, insofar as it is possible.
         ing home facilities in the same or similar
                                                                 Shaw further opines:
         locality; the failure to assist all residents,
                                                              In the case of Ms. Vest, Texarkana Nursing and
         including Vest, in attaining and maintain-
                                                              Healthcare Center clearly did not provide a safe
         ing the highest practicable level of physic-
                                                              and secure environment for its residents, allowing
         al, mental, and psychosocial well-being;
                                                              the documented assault of Ms. Vest by one of its
         the failure to properly supervise nurses and
                                                              own employees. In this regard, Texarkana Nurs-
         aides; the failure to provide sufficient
                                                              ing and Healthcare Center breached its responsib-
         nurses and aides; the failure to ensure that
                                                              ility to Ms. Vest and her family, resulting in in-
         Vest received timely and accurate care as-
                                                              jury to the resident.
         sessments and necessary supervision; vari-
         ous violations of the Code of Federal Reg-              Shaw concludes that “Texarkana Nursing and
         ulations; and violation of Section 22.04 of        Healthcare Center failed to provide a safe environ-
         the Texas Penal Code (injury to elderly in-        ment for Ms. Vest, resulting in her assault and in-
         dividual). TEX. PENAL CODE ANN. §                  jury at the hands of an employee of the facility.”
         22.04 (West Supp.2012).
                                                                     (1) Standard of Care and Breach
     Shaw's report states that Vest “was assaulted              Even though our analysis is confined to the
by Mary Ann Bean, an L.V.N. at the nursing facil-           four corners of the report, the report must be read in
ity, resulting in injuries to Mrs. Vest, including a 1      conjunction with the pleadings to determine if it
inch scratch to the forehead, bilateral contusions          provides a basis for Lyle's claims. See Palacios, 46
with swelling to the forehead, left periorbital ec-         S.W.3d at 878. The report states that the applicable
chymosis,*318 and contusion with ecchymosis to              standard of care requires Texarkana Nursing to
                     FN6
the left lower leg.”                                        “provide the necessary care and services to attain or

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maintain the highest practicable physical, mental,                   suicidal patient from injuring herself. In
and psychosocial wellbeing possible.” This stand-                    that case, the patient sustained injuries
ard includes, insofar as it is possible, the duty to                 from a fall out of a hospital window. This
“provide a safe environment for ... residents.” Shaw                 Court held that the statement “that win-
opines that Texarkana Nursing breached the stand-                    dows [must] either be secured with metal
ard of care by allowing the “documented assault on                   screens that only staff can open, or be
Ms. Vest by one of its own employees.” The result-                   locked” or, “[i]f the patient has access to
ing injuries are listed in the report.                               the window, a special difficult to break
                                                                     glass or Plexiglass should be used” was
     Texarkana Nursing initially takes issue with                    sufficient to apprise the hospital of what it
Shaw's opinion addressing the need to provide Vest                   should have done differently in light of the
with a “safe environment” because it is not a pled                   fact that the hospital placed the patient in a
claim. Even though not pled in this precise lan-                     fourth-floor room with unlocked windows.
guage, the petition alleges a breach of the                          Russ, 128 S.W.3d at 342.
nondelegable duty to assist Vest in attaining and
maintaining “the highest practicable level of phys-              Conversely, Lyle contends that the report meets
ical, mental, and psychosocial well being.” As              the criteria set out in Chapter 74. According to
Shaw opines, the provision of a safe environment is         Lyle, the report sets forth the standard of care, re-
required in order to fulfill this duty. See Harris          quiring the facility to provide the level of care and
Methodist Fort Worth v. Ollie, 342 S.W.3d 525,              services necessary for Vest to maintain and attain
527 (Tex.2011) (per curiam) (“services a [health            the highest level of well-being possible, thus neces-
care provider] provides its patients necessarily in-        sitating the provision of an environment safe for
clude those services required to meet the patients'         residents. Lyle defends the breach and causation
fundamental needs such as ... safety”).                     sections of the report in reliance on UHS of Timber-
                                                            lawn, Inc. v. S.B. ex rel. A.B., 281 S.W.3d 207
     Texarkana Nursing further complains of the in-         (Tex.App.-Dallas 2009, pet. denied). In that case, a
adequacy of the stated standard of care, because it         thirteen-year-old patient at Timberlawn's psychiat-
does not indicate what Texarkana Nursing should             ric treatment facility was placed in a ward with
have done differently, citing Russ v. Titus Hospital        male patients, where one of them allegedly raped
District,     128 S.W.3d 332,     341–42         her. The patient claimed her injuries were proxim-
(Tex.App.-Texarkana         2004,    pet.    denied)        ately caused by the negligence of Timberlawn's em-
(“[w]hether a defendant breached his or her duty to         ployees and submitted an expert report in support
a patient cannot be determined absent specific in-          of her claims. Timberlawn claimed the report was
formation about what the defendant should have              inadequate and conclusory on the issue of causa-
done differently”) (quoting Palacios, 46 S.W.3d at          tion. This complaint was based on the premise that
      FN7
880).      In other words, one must be able to de-          the expert did not opine that the patient was actu-
termine from the report what was required by the            ally raped, and, thus, could not identify the alleged
standard of care. This requires “specific informa-          causal relationship between Timberlawn's alleged
tion about what the defendant should have done dif-         negligence and the patient's injury. In rejecting this
ferently.” Palacios, 46 S.W.3d at 880. Here, we             premise, the court distinguished health care liability
have a generic statement that the nursing facility          claims in which “the ‘injury, harm, or damages
must provide a safe environment. Texarkana Nurs-            claimed’ flow from the existence of a medical con-
ing maintains this is insufficient.                         dition that itself resulted from the breach of the ap-
                                                            plicable standard of care.” Id. at 212. In such a
        FN7. Russ involved an allegedly deficient
                                                            case,
        report regarding a hospital's duty to keep a

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388 S.W.3d 314
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  [I]dentifying the causal relationship between the                 the following records in conjunction with
  alleged breach of the standard of care and the res-               issuing his report:
  ulting harm involves not only an explanation as
  to how the standard of care was breached, but                        1) Nursing Home Records from Tex-
  also how the breach gave rise to the new, deleter-                   arkana Nursing and Healthcare Center
  ious medical condition. Similarly, other health-
                                                                       2) Affidavit from the Texas Board of
  care liability claims may allege that a breach of
                                                                       Nursing
  the applicable standard of care exacerbated a pre-
  existing medical condition, or hindered or pre-                      3) Offense Report by Officer Steven G.
  vented the effective treatment of such a condi-                      Womack
  tion. Identifying the “breach/injury” causal rela-
  tionship in these cases may well require an expert                   4) Pictures of Mrs. Vest taken by her
  to opine as to the existence, extent, and prognosis                  daughter
  of the pre-existing medical condition, as well as
  how the alleged breach of the standard of care ag-                   5) Arrest Report of Mary Elliott Bean.
  gravated such a condition, impeded or prohibited
                                                              in the male unit exposed [the patient] to harm
  its treatment, and otherwise affected the patient's
                                                              which resulted in her self reported rape. Had
  prognosis.
                                                              [S.B.] been housed in a safe and appropriate man-
  However, S.B.'s claim is different. S.B. alleges            ner, given her propensity for sexual victimiza-
  that, as a result of Timberlawn's failure to meet           tion, she would not have been placed in a male
  the applicable standards of care relevant to its            unit. By being housed in a male unit it was fore-
  treatment of her, she was raped. Rape is not a              seeable that [S.B.] would be exposed to and was
  medical condition. It is an assault. Moreover,              at higher risk for the exact self reported harm
  rape may—or may not—be accompanied by med-                  which she suffered....
  ically ascertainable evidence of physical trauma,           Id. at 214. The report made clear the specific con-
  or even physical evidence that it occurred.                 duct called into question and provided a suffi-
                                                              cient basis for the trial court to conclude that the
     *320 Id. The court, therefore, declined to hold          claim had merit. Id. at 215.
that the causation element of the report was re-
quired to include an opinion that the patient was in            In this case, however, the report indicates that
fact raped. Id.                                             Texarkana Nursing failed to provide “a safe and se-
                                                            cure environment for its residents, allowing the
    This case is different from Timberlawn inas-            documented assault of Ms. Vest by one if its own
much as Texarkana Nursing is not claiming that the          employees.” In other words, the assault itself is the
report fails to state that Vest was, in fact, assaulted.    breach of the standard of care, which requires the
There is no dispute that Vest was assaulted; the as-        provision of a safe and secure environment for
                                               FN8
sault was photographically documented.               In-    nursing home residents. This statement does not,
stead, Texarkana Nursing claims the mere state-             however, advise Texarkana Nursing of what should
ment that it failed to provide a safe environment is        have been done in order to prevent its employee
an insufficient statement of the breach of the stand-       from assaulting Vest.
ard of care, because it does not indicate what
should have been done differently. In contrast, the             The question boils down to one of how much
Timberlawn report stated that housing the patient           detail is needed in order for an expert report to
                                                            withstand Chapter 74 scrutiny when the harm al-
         FN8. Shaw's report indicates he reviewed           leged arises from assaultive conduct. Lyle points to

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388 S.W.3d 314
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Christus Spohn Health System Corp. v. Sanchez,              the [certified nurse's assistant] and the [registered
299 S.W.3d 868 (Tex.App.-Corpus Christi 2009,               nurse],” “[f]ailed to protect Ms. Sanchez from sexu-
pet. denied), in support of her contention that the         al harassment and sexual abuse,” and “[f]ailed to
report is sufficient. Sanchez involved an action            provide safety to Ms. Sanchez in her immediate
against a hospital and hospital employees in their          post operative [sic] when the [certified nurse's as-
individual capacities for assault and intentional in-       sistant] lifted Ms. Sanchez up and began dancing
fliction of emotional distress. Sanchez was an              with her.” Id. The court found that this report put
I.C.U. patient when a registered nurse and a certi-         the hospital on notice of the specific, complained-of
fied nurse's assistant allegedly entered her room           conduct. Id.
and made unwanted sexual advances toward her.
Sanchez alleged that one of the men undressed her                In this case, unlike Sanchez, the report simply
and exposed her body for the other to see. She fur-         states that Texarkana Nursing failed to provide a
ther claimed that they turned her over using their          safe and secure environment for Vest. In Sanchez,
hands instead of a turning pad and, while they were         however, the report stated that the hospital was re-
moving her from the bed to a chair in her room,             quired to provide adequate supervision of its certi-
they danced with her. Sanchez alleged that during           fied nursing assistants and licensed nursing person-
these physical contacts, the nurse and nurse's assist-      nel, to protect its patient from sexual harassment
ant made sexual overtures and comments and that             and abuse, and to keep the patient safe. Granted,
the improper conduct continued until she was dis-           this is not much more detail than we have in this
charged from the hospital a few days later. Id. at          case, but Sanchez may be close to the line of what
872.                                                        is permissible.

     *321 Sanchez sued the hospital for negligent                For example, Baylor All Saints Medical Center
hiring, supervision, training, and retention of its         v. Martin, 340 S.W.3d 529 (Tex.App.-Fort Worth
employees and vicarious liability for the conduct of        2011, no pet.), involved an alleged sexual assault
                                                                                                FN9
its employees. Relevant to this case, Sanchez's ex-         on a patient in her hospital room.       The hospital
pert report was attacked on the basis that it did not       objected to the sufficiency of the patient's expert re-
adequately set forth the standard of care and/or            port. The report in question articulates the standard
safety and breach because the report was alleged to         of care as follows:
be conclusive and speculative. Id. at 877. Spohn
                                                                     FN9. The Martin opinion does not indicate
further argued that the report failed to provide spe-
                                                                     whether the assault was committed by a
cific information about what it should have done
                                                                     hospital employee, another patient, or
differently. The report stated, in relevant part, that
                                                                     some other third party.
the “standard of care requires that the hospital and
its nursing staff provide adequate supervision to             A hospital such as Baylor All Saints Medical
their certified nursing assistants and licensed nurs-         [C]enter is expected to adhere to specific stand-
ing personnel.” The report further stated that the            ards of care in regard to all of its patients. A bed-
“standard of care requires that the hospital and its          rock principal [sic] in providing care to its pa-
nursing staff protect their patients from sexual har-         tients is the understanding that all of a hospital's
assment and abuse.” Id.                                       patients by nature of their disease or injury are
                                                              potentially vulnerable and necessarily need to re-
     The court concluded that the report identified
                                                              ceive treatment in a safe and secure environment.
the care that was expected, but not rendered under
                                                              The Joint Commission on Accreditation of Health
the applicable standard of care, because it states the
                                                              Care Organizations (JCAHO) has established in
hospital “[f]ailed to provide adequate supervision to
                                                              its Hospital Standards that all healthcare organiz-

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388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

  ations must have in place policies which safe-                     misreading of the discovery allowed under
  guard patients from assault by hospital staff and                  Section 74.351(s). Because assaults in
  by strangers that enter the hospital. The JCAHO                    health care settings are covered by Section
  requires that hospitals adequately implement                       74.351, said the court (Martin, 340 S.W.3d
  these standards, and monitor this implementation.                  at 534 (citing Diversicare Gen. Partner,
  The JCAHO patient security and safety expecta-                     Inc. v. Rubio, 185 S.W.3d 842, 851
  tions would require at a minimum that hospitals                    (Tex.2005))), logically, discovery of the
  should employ a sufficient number of security                      hospital's policies and procedures regard-
  personal [sic] to insure that no unauthorized per-                 ing the protection of patients from assault
  sons enter patients ['] rooms and physically as-                   must be covered by Section 74.351(s).
  sault their patients. Additionally, the JCAHO                      Martin, 340 S.W.3d at 534.
  standards would expect that all hospital staff
  should be trained to identify *322 persons that                Kingwood Pines Hospital, LLC v. Gomez, 362
  are not authorized to enter patients['] rooms and         S.W.3d 740 (Tex.App.-Houston [14th Dist.] 2011,
  should monitor and prevent unauthorized persons           no pet.), further illustrates the need for detail when
  from having access to patients receiving treat-           an expert offers opinions regarding patient safety.
  ment at the hospital.                                     In that case, a patient of Kingwood Pines Hospital
  Id. at 533–34. The court determined this to be an         was sexually assaulted by another patient. Gomez
  insufficient statement of the standard of care. For       offered an expert report indicating a failure “to en-
  example, the report stated that there must be             sure that there were appropriately trained and ad-
  policies in place to safeguard patients from as-          equate staffing and millieu structure such that a
  sault, including employing a sufficient number of         young girl ... would not be sexually molested.” The
  security personnel. The court wrote that this             report stated that the standard of care was breached
  statement failed to indicate what specific policies       when the physician failed to insure her patient's
  and safeguards should have been in place. Fur-            safety using “any of the number of measures avail-
  ther, the “ ‘policies in place to safeguard patients'     able,” by failing to “provide additional supervision”
  are not identified.” Id. at 534. The number of se-        and not affording the patient “the most basic super-
  curity personnel needed and the training the staff        vision.” Id. at 750. The report further indicated that
  should have received is not described. Id. This re-       (the physician) was required “to insure her patients
  port failed in light of the required standard, i.e.,      are being treated in a safe and secure environment
  “what an ordinary prudent hospital would do un-           by being aware of the environment, patient popula-
  der the same or similar circumstances,” and               tion, and safety measures taken by the hospital.” Id.
  “even a fair summary must set out what care was           at 749. In concluding the report was conclusory, the
  expected.” Id. (citing Palacios, 46 S.W.3d at             court noted that it did not provide information
        FN10                                                about how the physician was to insure that the hos-
  880).
                                                            pital was adequately staffed and that staff members
        FN10. The court also addressed Martin's             were appropriately trained or what measures were
        claim that the report was all that could be         available to insure the patient's safety. Further, the
        done at the time in light of the fact that          report did not indicate what kind of supervision by
        Section 74.351(s) only allows discovery of          the hospital was sufficient to provide a secure en-
        medical records and billing records, which          vironment for the patient. Id. at 750.
        do not contain the circumstances surround-
        ing the assault and hence provide no dis-               [6] In this case, the only direct negligence
        covery as to whether security standards             claim addressed in Shaw's report is that of failing to
        were met. The court wrote that this was a           provide Vest with a safe and secure environment.

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388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

Because the report fails to articulate what Tex-            S.W.3d at 527. The report, albeit in a conclusory
arkana Nursing should have done differently to pre-         manner, addresses this claim.
vent the assault, it is deficient with respect to artic-
ulation of the standard of care and its breach.                  Because the report is deficient with respect to
                                                            Lyle's direct liability claim regarding the failure to
                   (2) Causation                            provide a safe and secure environment for Vest, the
     Texarkana Nursing further contends that                trial court should be permitted the opportunity to
Shaw's report is deficient in that it *323 fails to set     consider whether to grant a thirty-day extension to
forth the causal relationship between Texarkana             cure the deficiencies. See TEX. CIV. PRAC. &
                                                                                                            FN11
Nursing's alleged deviations from the standard of           REM.CODE ANN. § 74.351(c) (West 2011);
care and Vest's injuries. The report does, however,         Leland v. Brandal, 257 S.W.3d 204, 207
indicate that Texarkana Nursing breached its re-            (Tex.2008); Longino v. Crosswhite, 183 S.W.3d
sponsibility to Vest in allowing the documented as-         913, 918 n. 2 (Tex.App.-Texarkana 2006, no pet.);
sault of Vest by one of its own employees, resulting        see also Scoresby v. Santillan, 346 S.W.3d 546, 549
in injury to Vest. The resulting injuries are de-           (Tex.2011) (trial court should err on side of grant-
scribed. Lyle maintains that this is a sufficient           ing additional time and must grant it if deficiencies
                                                                           FN12
statement of causation under Timberlawn. After all,         are curable).         Because at least three of Lyle's
assault is not a medical condition. Conversely, if          direct liability claims necessarily relate to the pro-
the report is not sufficiently detailed in its state-       vision of a safe environment, they are not com-
ment of the standard of care and breach, and, thus,         pletely unaddressed, and we decline to find that
                                                                                                 FN13
fails to advise Texarkana Nursing of what it should         such claims should be dismissed.            See *324
have done differently to provide a safe and secure          Querry v. Sanders, No. 06–08–00099–CV, 2009
environment for Vest, then it logically follows that        WL 1097904, at *7 (Tex.App.-Texarkana Apr. 24,
causation should be described in terms of the spe-          2009, no pet.) (mem. op.) (report which wholly
cific shortcomings that created a situation in which        failed to address alleged negligence in failing to
assault could occur.                                        properly identify and isolate main bile duct before
                                                            initiating main procedure not curable deficiency).
B. Deficiencies Regarding Direct Liability Are
Curable                                                              FN11. Section 74.351 of the Texas Civil
     [7] Texarkana Nursing contends that because                     Practice and Remedies Code states, “If an
the report does not address the pleaded cause of ac-                 expert report has not been served within
tion, it does not constitute a good-faith effort to                  the period specified by Subsection (a) be-
comply with the statutory requirements and should,                   cause elements of the report are found de-
therefore, be dismissed in reliance on Windsor v.                    ficient, the Court may grant one 30–day
Maxwell, 121 S.W.3d 42, 51 (Tex.App.-Fort Worth                      extension to the claimant in order to cure
2003, pet. denied) (to inform defendant of specific                  the deficiency.” TEX. CIV. PRAC. &
conduct plaintiff has called into question, report                   REM.CODE ANN. § 74.351(c).
must support cause of action alleged by plaintiff in
its pleadings). Here, as previously discussed, the re-               FN12. Scoresby involved a letter report
port does address the claim that Texarkana Nursing                   that failed to state the standard of care but
had a duty to assist Vest in attaining and maintain-                 implied that it was inconsistent with the
ing “the highest practicable level of physical, men-                 physicians' conduct. Even so, the report
tal, and psychosocial well being.” Implicit in this                  contained the opinion of an individual with
duty is the provision of a safe and secure environ-                  expertise that the claim had merit and im-
ment. See Harris Methodist Fort Worth, 342                           plicated the defendants' conduct. This min-
                                                                     imal standard is met here as well. The re-

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388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

         port is written by an individual with ex-          similar locality; failed to assist residents (including
         pertise, implicates the conduct of Tex-            Vest) in attaining and maintaining the highest prac-
         arkana Nursing, and indicates that the             ticable level of physical, mental, and psychosocial
         claim has merit. Scoresby, 346 S.W.3d at           well-being; failed to meet the applicable standards
         557.                                               of care; violated their duty of care to Vest through
                                                            mistreatment, abuse and neglect; and violated Sec-
         FN13. Lyle alleges that Texarkana Nursing          tion 22.04 of the Texas Penal Code (injury to eld-
         was negligent in terms of hiring, staffing         erly individual). Shaw's report is silent with respect
         levels, supervision of personnel, provision        to each of these claims, with the exception of as-
         of financial resources, and in failing to          saultive conduct and mistreatment. The report iden-
         comply with the Code of Federal Regula-            tifies conduct by Texarkana Nursing's employ-
         tions.                                             ee—the alleged assault on Vest. The report fails,
                                                            however, to identify the standard of care, breach of
C. Shaw's Report Fails to Address Vicarious Li-
                                                            the standard of care, or causation.
ability Claims
     [8] Lyle's petition alleges that Texarkana Nurs-            [9] The only statement regarding the standard
ing has “vicarious liability for the acts and omis-         of care in the entire report regarding the staff is:
sions of all persons or entities under their control,       “The standard of care for a long term care facility
either directly or indirectly, including employees,         and its staff requires that the facility in question
agents, consultants, and independent contractors,           provide that level of care and treatment that a reas-
whether in-house or outside entities, individuals,          onable, prudent, similar facility would provide un-
agencies, or pools causing or contributing to the in-       der the same or similar circumstances.” (Emphasis
juries of BETTY RUTH VEST.” “When a party's                 added.) The report says nothing regarding the
alleged health care liability is purely vicarious, a re-    breach of the standard of care by the staff or how
port that adequately implicates the actions of that         that breach caused Vest's injuries. While the under-
party's agents or employees is sufficient.” Gardner         lying nature of the vicarious liability claim rests in
v. U.S. Imaging, Inc., 274 S.W.3d 669, 671–72               the intentional acts of Bean, which appear to be un-
(Tex.2008) (per curiam). Thus, if the report identi-        related to the rendition of health care, Lyle's plead-
fies conduct by Texarkana Nursing's employee,               ing alleges her claims fall within the purview of
Texarkana Nursing is implicated. As long as the re-                      FN14
                                                            Chapter 74.        We must, therefore, analyze *326
port adequately addresses the standard of care ap-          them as such. See Giron v. Baylor Univ. Med. Ctr.,
plicable to the employee, how the employee                  No. 05–09–00825–CV, 2011 WL 149981, at *2
breached the standard of care, and that the breach          (Tex.App.-Dallas Jan. 19, 2011, pet. denied) (mem.
caused the plaintiff's injury, it is sufficient as          op.) (when Giron chose to proceed under Chapter
against Texarkana Nursing to satisfy the expert re-         74 and plead her cause of action as health care liab-
port requirement for the vicarious liability claims.        ility claim, she bound herself to statutory require-
See RGV Healthcare Assocs., Inc. v. Estevis, 294            ments).
S.W.3d 264, 273 (Tex.App.-Corpus Christi 2009,
pet. denied).                                                        FN14. Recently, the Texas Supreme Court
                                                                     decided Loaisiga v. Cerda, 379 S.W.3d
    Lyle pled that the staff of Texarkana Nursing                    248 (Tex.2012). Loaisiga was not decided
did not provide Vest with timely and accurate care                   until after the appellant's brief was filed
assessments and necessary supervision; failed to                     here and well after the hearing in the trial
use reasonable care in treating residents with the                   court. In Loaisiga, two female patients
degree of skill and learning ordinarily possessed                    sued a medical doctor, the professional as-
and used by nursing home facilities in the same or

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388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

        sociation bearing his name, and a clinic al-                  [W]e fail to see how the Legislature
        leging the doctor assaulted them by grop-                     could have intended the requirement of
        ing their breasts while examining them for                    an expert report to apply under circum-
        sinus and flu symptoms. Id. at 253. The pa-                   stances where the conduct of which a
        tients served the doctor and professional                     plaintiff complains is wholly and con-
        association with reports from a physician                     clusively inconsistent with, and thus sep-
        who, based on the assumption that the al-                     arable from, the rendition of “medical
        legations in the plaintiffs' pleadings were                   care, or health care, or safety or profes-
        true, opined that the doctor's alleged ac-                    sional or administrative services directly
        tions did not fall within any appropriate                     related to health care” even though the
        standard of care. The defendants argued                       conduct occurred in a health care con-
        that the claims were health care liability                    text. See TEX. CIV. PRAC. &
        claims and moved for dismissal on the                         REM.CODE ANN. § 74.001(a)(13); see
        basis that the reports were deficient. The                    also TEX. GOV'T CODE ANN. §
        trial court denied the motions. The court of                  311.021 (“In enacting a statute, it is pre-
        appeals held that the claims were not                         sumed that ... a just and reasonable result
        health care liability claims and that expert                  is intended....”).
        reports were not required and affirmed the
        trial court's order without considering the                   Id. at 257.
        report's adequacy. Id. at 254. The high
                                                                      The court then listed three factors that
        court recognized a presumption:
                                                                      must be reflected in the record in order
          The breadth of the statute's text essen-                    for an assault claim against a medical or
          tially creates a presumption that a claim                   health care provider not to be considered
          is an HCLC if it is against a physician or                  a health care liability claim:
          health care provider and is based on
                                                                      [A] claim against a medical or health
          facts implicating the defendant's conduct
                                                                      care provider for assault is not an HCLC
          during the course of a patient's care,
                                                                      if the record conclusively shows that (1)
          treatment, or confinement. See [Marks v.
                                                                      there is no complaint about any act of
          St. Luke's Episcopal Hosp., 319 S.W.3d
                                                                      the provider related to medical or health
          658, 662 (Tex.2010) ]. But the presump-
                                                                      care services other than the alleged of-
          tion is necessarily rebuttable. In some in-
                                                                      fensive contact, (2) the alleged offensive
          stances the only possible relationship
                                                                      contact was not pursuant to actual or im-
          between the conduct underlying a claim
                                                                      plied consent by the plaintiff, and (3) the
          and the rendition of medical services or
                                                                      only possible relationship between the
          healthcare will be the healthcare setting
                                                                      alleged offensive contact and the rendi-
          (i.e., the physical location of the conduct
                                                                      tion of medical services or healthcare
          in a health care facility), the defendant's
                                                                      was the setting in which the act took
          status as a doctor or health care provider,
                                                                      place.
          or both.
                                                                      Id.
          Id. at 256. Following a discussion of the
          statute's requirement that claimants in                     In determining whether a claim is sub-
          health care liability claims file expert re-                ject to the Texas Medical Liability Act's
          ports, the high court wrote:                                (TMLA) expert report requirements, the

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388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

          trial court is not limited to the four                       determination of whether her claims are
          corners of the expert report; instead, the                   subject to the TMLA's expert report re-
          trial court should consider the entire re-                   quirements.
          cord, including pleadings, motions and
          responses, and relevant evidence prop-                 [10] The lone statement regarding the standard
          erly admitted. Id. at 258. In Loaisiga, the       of care applicable to the staff of Texarkana Nursing
          court noted a lack of information to give         fails to specify what is required of a reasonable and
          context to the physician's actions during         prudent staff under the same or similar circum-
          the examinations, such as medical re-             stances. This statement is not a fair summary of
          cords, reports, and other information re-         Shaw's opinions regarding the standard of care for
          garding the plaintiffs' symptoms and              the Texarkana Nursing staff. The mere recitation of
          complaints to the physician. This lack of         a legal standard, in the absence of specific facts ap-
          information prevented the plaintiffs from         plicable to this case, is not a good-faith effort to ar-
          conclusively showing that “the only rela-         ticulate the standard of care. See Lira v. Cerna, No.
          tionship between the alleged touching of          08–01–00250–CV, 2002 WL 1767569, at *6
          their breasts and Dr. Loaisiga's rendition        (Tex.App.-El Paso Aug. 1, 2002, no pet.) (not des-
          of medical services was the physical loc-         ignated for publication) (The statement that “[t]he
          ation of the examination....” Id. at 259.         standard of care requires that a physician provide
          The court went on to say that                     that level of care which a reasonable prudent physi-
                                                            cian would provide in the same or similar circum-
          because we are clarifying the standard            stances” does not demonstrate good-faith effort to
          for whether claims are subject to the             provide fair summary of expert's opinions and does
          TMLA's expert report requirements and             not identify standard of care.); see also Hood v.
          the plaintiffs maintain that theirs are not,      Phillips, 554 S.W.2d 160, 165 (Tex.1977) (holding
          we conclude it is appropriate to remand           that legal standard for medical profession is
          the case to the trial court for further pro-      “reasonable and prudent” physician “under the
          ceedings regarding that issue. See Low v.         same or similar circumstances”). Moreover, the re-
          Henry, 221 S.W.3d 609, 621 (Tex.2007)             port is silent regarding the breach of the standard of
          (remanding “to allow the parties to               care and causation. Because the standard of care ap-
          present evidence responsive to our                plicable to the staff is not identified, and because
          guidelines”).                                     breach and causation are not addressed, these defi-
                                                            ciencies are not curable. Lyle's vicarious liability
          Id. at 260.                                       claims should, therefore, have been dismissed by
                                                            the trial court.
          In light of Loaisiga, this Court ques-
          tioned whether to remand the case to the          IV. Conclusion
          trial court for a determination of whether            Because the report is deficient with respect to
          or not Lyle's claim is, in fact, a health         Lyle's direct liability claim regarding the failure to
          care liability claim. However, in                 provide a safe and secure environment for Vest, we
          Loaisiga, the plaintiffs maintained that          remand this claim to the trial court to consider
          their claims were not health care liability       whether to grant a thirty-day extension to cure these
          claims. Here, Lyle has represented to             deficiencies.
          this Court that her claims are health care
          liability claims, and, in oral argument,              Shaw's report is silent with respect to the stand-
          Lyle's counsel stated it was not her wish         ard of care, breach, and causation regarding her vi-
          to remand the case to the trial court for a       carious liability claims. Because these deficiencies

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388 S.W.3d 314
(Cite as: 388 S.W.3d 314)

are not curable, Lyle's vicarious liability claims are
dismissed.

Tex.App.–Texarkana,2012.
Texarkana Nursing & Healthcare Center, LLC v.
Lyle
388 S.W.3d 314

END OF DOCUMENT

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                                                                                                        Page 1
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

                                                              was a nonsubscriber to workers' compensation insur-
                                                              ance; and
           Supreme Court of Texas.                            (6) aside from claims alleging negligent medical care or
TEXAS WEST OAKS HOSPITAL, LP and Texas Hos-                   health care, a claim need not involve a patient-physician
       pital Holdings, LLC, Petitioners,                      relationship for it to be an HCLC.
                       v.
      Frederick WILLIAMS, Respondent.                            Judgment of Court of Appeals reversed; case re-
                                                              manded with instructions.
                    No. 10–0603.
                Argued Nov. 8, 2011.
                Decided June 29, 2012.                           Lehrmann, J., filed a dissenting opinion, in which
                                                              Medina and Willett, JJ., joined.
Background: Estate of psychiatric patient brought
health care liability claim (HCLC) against hospital and                           West Headnotes
hospital's employee who was involved in physical alter-
                                                              [1] Health 198H        800
cation with patient that resulted in patient's death and
injuries to employee. Employee brought cross-claim of         198H Health
negligence against hospital, which was a nonsubscriber           198HV Malpractice, Negligence, or Breach of Duty
to workers' compensation scheme. The 234th District                 198HV(G) Actions and Proceedings
Court, Harris County, Reese Rondon, J., denied hospit-                 198Hk800 k. In general. Most Cited Cases
al's motion to dismiss employee's cross-claim as an               Causes of action that are health care liability claims
HCLC subject to expert-report requirements. Hospital          (HCLCs) cannot be transmuted to avoid the strictures of
brought interlocutory appeal. The Court of Appeals, 322       the medical liability statute. V.T.C.A., Civil Practice &
S.W.3d 349,Leslie B. Yates, J., affirmed. Hospital filed      Remedies Code § 74.001 et seq.
petition for review.
                                                              [2] Appeal and Error 30         893(1)
Holdings: The Supreme Court, Wainwright, J., held
that:                                                         30 Appeal and Error
(1) employee was a “claimant” under the Texas Medical            30XVI Review
Liability Act (TMLA);                                               30XVI(F) Trial De Novo
(2) negligence claim was based on alleged departures                  30k892 Trial De Novo
from accepted standards of health care and of safety and                  30k893 Cases Triable in Appellate Court
was therefore an HCLC;                                                          30k893(1) k. In general. Most Cited
(3) if expert medical or health care testimony is neces-      Cases
sary to prove or refute the merits of claim against a
physician or health care provider, claim is an HCLC;          Health 198H        800
(4) to qualify as an HCLC, a claim that is based on de-
                                                              198H Health
partures from accepted standards of safety need not be
                                                                 198HV Malpractice, Negligence, or Breach of Duty
directly related to health care, abrogating St. David's
                                                                     198HV(G) Actions and Proceedings
Healthcare P'ship, L.P. v. Esparza, 315 S.W.3d 601;
                                                                        198Hk800 k. In general. Most Cited Cases
Appell v. Muguerza, 329 S.W.3d 104;
                                                                   The nature of health care liability claims (HCLCs)
(5) interpreting hospital employee's action as an HCLC
                                                              that the Legislature intended to include under the um-
did not conflict with exclusive-remedy provisions of
                                                              brella of the Texas Medical Liability Act (TMLA) is a
Texas Workers' Compensation Act (TWCA), as hospital

                              © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                         Page 2
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

matter of statutory construction, a legal question that                    198Hk804 k. Affidavits of merit or meritori-
appellate court reviews de novo. V.T.C.A., Civil Prac-         ous defense; expert affidavits. Most Cited Cases
tice & Remedies Code § 74.001(a)(13).                               Though not a patient, psychiatric technician and
                                                               professional caregiver who was employed at private
[3] Statutes 361      1072                                     mental health hospital was a “claimant” under Texas
                                                               Medical Liability Act (TMLA) in context of determin-
361 Statutes
                                                               ing whether negligence claim he asserted against hospit-
   361III Construction
                                                               al for injuries sustained in physical altercation with pa-
      361III(A) In General
                                                               tient was a health care liability claim (HCLC) subject to
         361k1071 Intent
                                                               TMLA's expert-report requirements. V.T.C.A., Civil
             361k1072 k. In general. Most Cited Cases
                                                               Practice & Remedies Code §§ 74.001(a)(2, 13),
   (Formerly 361k181(1))
                                                               74.351(a, b).
Statutes 361       1091
                                                               [6] Health 198H        800
361 Statutes
                                                               198H Health
   361III Construction
                                                                  198HV Malpractice, Negligence, or Breach of Duty
         361III(B) Plain Language; Plain, Ordinary, or
                                                                      198HV(G) Actions and Proceedings
Common Meaning
                                                                         198Hk800 k. In general. Most Cited Cases
          361k1091 k. In general. Most Cited Cases
                                                                    A health care liability claim (HCLC) under the
   (Formerly 361k188)
                                                               Texas Medical Liability Act (TMLA) contains three ba-
    In construing a statute, court's aim is to determine
                                                               sic elements: (1) a physician or health care provider
and give effect to the legislature's intent, and court be-
                                                               must be a defendant; (2) the claim or claims at issue
gins with the plain and common meaning of the statute's
                                                               must concern treatment, lack of treatment, or a depar-
words.
                                                               ture from accepted standards of medical care, or health
[4] Health 198H        804                                     care, or safety or professional or administrative services
                                                               directly related to health care; and (3) the defendant's
198H Health                                                    act or omission complained of must proximately cause
   198HV Malpractice, Negligence, or Breach of Duty            the injury to the claimant. V.T.C.A., Civil Practice &
      198HV(G) Actions and Proceedings                         Remedies Code § 74.001(a)(13).
           198Hk804 k. Affidavits of merit or meritori-
ous defense; expert affidavits. Most Cited Cases               [7] Health 198H        804
    With the exception of medical care and health care
                                                               198H Health
claims, court's focus in determining whether claims are
                                                                  198HV Malpractice, Negligence, or Breach of Duty
health care liability claims (HCLCs) falling under Texas
                                                                     198HV(G) Actions and Proceedings
Medical Liability Act (TMLA) and its expert-report re-
                                                                          198Hk804 k. Affidavits of merit or meritori-
quirements is not the status of the claimant, but the
                                                               ous defense; expert affidavits. Most Cited Cases
gravamen of the claim or claims against the health care
                                                                   Negligence claim that was brought against private
provider. V.T.C.A., Civil Practice & Remedies Code §§
                                                               mental health hospital by its employee, a mental health
74.001(a)(10, 13, 19), 74.351(a, b).
                                                               professional, to recover for injuries from altercation
[5] Health 198H        804                                     with psychiatric patient was based on alleged departures
                                                               from accepted standards of health care and, therefore,
198H Health                                                    was a “health care liability claim” (“HCLC”) subject to
   198HV Malpractice, Negligence, or Breach of Duty            expert-report requirements of Texas Medical Liability
      198HV(G) Actions and Proceedings                         Act (TMLA); employee alleged he was acting on pro-

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                                                                                                        Page 3
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

fessional judgments of a physician about patient's care              198HV(G) Actions and Proceedings
and treatment, and that the physician's judgments and                   198Hk815 Evidence
the hospital's additional professional judgments about                     198Hk821 Necessity of Expert Testimony
safety protocols departed from accepted standards of                            198Hk821(5) k. Particular procedures.
care and caused employee's injury. V.T.C.A., Civil            Most Cited Cases
Practice & Remedies Code §§ 74.001(a)(13), 74.351(a,               Expert testimony was required to support negli-
b).                                                           gence claim by hospital employee, a mental health pro-
                                                              fessional, against hospital in connection with injuries
[8] Health 198H       804                                     sustained in altercation with psychiatric patient, thus
                                                              making claim a “health care liability claim” (“HCLC”)
198H Health
                                                              under the Texas Medical Liability Act (TMLA); at its
   198HV Malpractice, Negligence, or Breach of Duty
                                                              core, caregiver's dispute with hospital was over the ap-
       198HV(G) Actions and Proceedings
                                                              propriate standards of care owed to employee in treating
            198Hk804 k. Affidavits of merit or meritori-
                                                              and supervising a psychiatric patient at the mental hos-
ous defense; expert affidavits. Most Cited Cases
                                                              pital, what services, protocols, supervision, monitoring
    In order for a claim based on departures from ac-
                                                              and equipment were necessary to satisfy the standard,
cepted standards of health care to constitute a health
                                                              and whether such specialized standards were breached.
care liability claim (HCLC) subject to expert-report re-
                                                              V.T.C.A., Civil Practice & Remedies Code §
quirements of Texas Medical Liability Act (TMLA),
                                                              74.001(a)(13).
there must a nexus between the standard departed from
and the alleged injury. V.T.C.A., Civil Practice & Rem-       [11] Health 198H        804
edies Code §§ 74.001(a)(13), 74.351(a, b).
                                                              198H Health
[9] Health 198H       800                                         198HV Malpractice, Negligence, or Breach of Duty
                                                                     198HV(G) Actions and Proceedings
198H Health
                                                                          198Hk804 k. Affidavits of merit or meritori-
   198HV Malpractice, Negligence, or Breach of Duty
                                                              ous defense; expert affidavits. Most Cited Cases
       198HV(G) Actions and Proceedings
                                                                   Negligence claim by hospital employee, a mental
          198Hk800 k. In general. Most Cited Cases
                                                              health professional, against hospital in connection with
    If expert medical or health care testimony is neces-
                                                              injuries sustained in altercation with psychiatric patient
sary to prove or refute the merits of claim against a
                                                              would not be considered a health care liability claim
physician or health care provider, the claim is a “health
                                                              (HCLC) subject to expert-report requirements of Texas
care liability claim” (“HCLC”) under the Texas Medical
                                                              Medical Liability Act (TMLA) on bare basis that claim
Liability Act (TMLA). V.T.C.A., Civil Practice & Rem-
                                                              mirrored HCLC claims of patient's estate against hospit-
edies Code § 74.001(a)(13).
                                                              al that stemmed from same fact pattern, though employ-
[10] Health 198H       800                                    ee's claim qualified as an HCLC on other grounds; em-
                                                              ployee and patient's estate stood as separate claimants.
198H Health                                                   V.T.C.A., Civil Practice & Remedies Code §§
   198HV Malpractice, Negligence, or Breach of Duty           74.001(a)(2, 13), 74.351(a, b).
      198HV(G) Actions and Proceedings
         198Hk800 k. In general. Most Cited Cases             [12] Health 198H        804

Health 198H        821(5)                                     198H Health
                                                                 198HV Malpractice, Negligence, or Breach of Duty
198H Health                                                         198HV(G) Actions and Proceedings
   198HV Malpractice, Negligence, or Breach of Duty                     198Hk804 k. Affidavits of merit or meritori-

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                                                                                                           Page 4
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

ous defense; expert affidavits. Most Cited Cases               198H Health
     Negligence claim asserted by hospital employee, a            198HV Malpractice, Negligence, or Breach of Duty
mental health professional, against hospital in connec-              198HV(G) Actions and Proceedings
tion with injuries sustained in altercation with psychiat-                198Hk804 k. Affidavits of merit or meritori-
ric patient implicated alleged departures from accepted        ous defense; expert affidavits. Most Cited Cases
standards of safety and therefore qualified as a health
care liability claim (HCLC) subject to the expert-report       Workers' Compensation 413            2084
requirements of the Texas Medical Liability Act
                                                               413 Workers' Compensation
(TMLA); claim was predicated on the monitoring and
                                                                     413XX Effect of Act on Other Statutory or Com-
restraint of violent, schizophrenic patients. V.T.C.A.,
                                                               mon-Law Rights of Action and Defenses
Civil Practice & Remedies Code §§ 74.001(a)(2, 13),
                                                                      413XX(A) Between Employer and Employee
74.351(a, b).
                                                                            413XX(A)1 Exclusiveness of Remedies Af-
[13] Health 198H        804                                    forded by Acts
                                                                             413k2084 k. In general. Most Cited Cases
198H Health                                                         Interpreting hospital employee's negligence claim
    198HV Malpractice, Negligence, or Breach of Duty           against hospital, brought to recover for on-the-job injur-
       198HV(G) Actions and Proceedings                        ies sustained in altercation with psychiatric patient, as a
           198Hk804 k. Affidavits of merit or meritori-        health care liability claim (HCLC) subject to the expert-
ous defense; expert affidavits. Most Cited Cases               report requirements of the Texas Medical Liability Act
     To qualify as a health care liability claim (HCLC)        (TMLA) did not conflict with exclusive-remedy provi-
subject to expert-report requirements of Texas Medical         sions of Texas Workers' Compensation Act (TWCA),
Liability Act (TMLA), a claim that is based on depar-          where hospital was a nonsubscriber to workers' com-
tures from accepted standards of safety need not be dir-       pensation insurance. V.T.C.A., Labor Code §§ 406.002,
ectly related to health care; abrogating St. David's           406.031(a), 406.033, 408.001(a); V.T.C.A., Civil Prac-
Healthcare P'ship, L.P. v. Esparza, 315 S.W.3d 601;            tice & Remedies Code §§ 74.001(a)(13), 74.351(a, b).
Appell v. Muguerza, 329 S.W.3d 104. V.T.C.A., Civil
Practice & Remedies Code §§ 74.001(a)(13), 74.351(a,           [16] Workers' Compensation 413            11
b).
                                                               413 Workers' Compensation
[14] Statutes 361      1161                                        413I Nature and Grounds of Employer's Liability
                                                                          413k11 k. Purpose of legislation. Most Cited
361 Statutes                                                   Cases
    361III Construction                                             In providing the worker a form of prompt remuner-
       361III(E) Statute as a Whole; Relation of Parts to      ation for loss of earning capacity, the statutory workers'
Whole and to One Another                                       compensation scheme is in lieu of common law liability
          361k1161 k. Relative and qualifying terms and        based on negligence. V.T.C.A., Labor Code § 406.001
provisions, and their relation to antecedents. Most Cited      et seq.
Cases
    (Formerly 361k196)                                         [17] Health 198H        804
     Under the “last antecedent doctrine” of statutory in-
                                                               198H Health
terpretation, a qualifying phrase should be applied only
                                                                  198HV Malpractice, Negligence, or Breach of Duty
to the portion of the sentence immediately preceding it.
                                                                     198HV(G) Actions and Proceedings
[15] Health 198H        804                                               198Hk804 k. Affidavits of merit or meritori-
                                                               ous defense; expert affidavits. Most Cited Cases

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                                                                                                        Page 5
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

    Aside from claims alleging negligent medical care          a “claimant” under the Act and his allegations against
or health care, a claim need not involve a patient-            his nonsubscribing employer are health care and safety
physician relationship for it to be a health care liability    claims under the TMLA's definition of HCLCs, requir-
claim (HCLC) subject to expert-report requirements of          ing an expert report to maintain his lawsuit. We further
Texas Medical Liability Act (TMLA). V.T.C.A., Civil            hold that the Act does not conflict with the Texas Work-
Practice & Remedies Code §§ 74.001(a)(13), 74.351(a,           ers' Compensation Act (TWCA). We therefore reverse
b).                                                            the judgment of the court of appeals.

[18] Health 198H        807                                                         I. Background
                                                                    Texas West Oaks Hospital, LP and Texas Hospital
198H Health                                                    Holdings, LLC operate Texas West Oaks Hospital
    198HV Malpractice, Negligence, or Breach of Duty           (West Oaks), a state-licensed, private mental health hos-
       198HV(G) Actions and Proceedings                        pital located in Houston, Texas. Frederick*175 Willi-
          198Hk807 k. Notice. Most Cited Cases                 ams, a psychiatric technician and professional caregiver
     Purpose of the notice-of-suit and medical-re-             at West Oaks, was injured on the job while supervising
cords-release provisions of the Texas Medical Liability        a patient, Mario Vidaurre. Vidaurre was admitted to
Act (TMLA) is to encourage the parties to negotiate and        West Oaks on June 11, 2007. Due to his history of para-
settle disputes prior to suit. V.T.C.A., Civil Practice &      noid schizophrenia, including manic outbursts and viol-
Remedies Code §§ 74.051(a, d), 74.052.                         ent behavior directed at family members and profes-
                                                               sional staff, Vidaurre was placed by his admitting phys-
*174 Ryan Lee Clement, Wesson H. Tribble, Tribble,
                                                               ician on one-to-one observation, an elevated level of su-
Ross & Wagner, Houston, TX, for Texas West Oaks
                                                               pervised care in the psychiatric unit. Vidaurre was also
Hospital, LP.
                                                               put on “unit restriction,” meaning he could only be
Charles M. Hessel, Marks Balette & Giessel, P.C.,              taken out of the psychiatric unit by direct order of a
Robert Steven Kwok, William Wade Hoke, Robert                  physician. A few days after Vidaurre's admission, while
Kwok & Associates, Leah Rush Easterby, Houston, TX,            Williams was supervising him, Vidaurre became agit-
for Frederick Williams.                                        ated. To calm him, Williams took Vidaurre to an out-
                                                               door enclosed smoking area, in violation of the unit-
                                                               restriction policy. The door to the enclosure locked be-
Justice WAINWRIGHT delivered the opinion of the                hind them and the unsupervised area contained no cam-
Court, in which Chief Justice JEFFERSON, Justice               eras, audio supervision, mirrors, or other monitoring ap-
HECHT, Justice GREEN, Justice JOHNSON, and                     paratus. Although Williams previously had taken
Justice GUZMAN joined.                                         Vidaurre to the smoking area without incident, a physic-
     At issue in this interlocutory appeal is whether the      al altercation occurred on this occasion, resulting in
claims of an employee against his employer, both of            Vidaurre's death and injuries to Williams.
whom are health care providers, alleging injuries arising
out of inadequate training, supervision, risk-mitigation,          Vidaurre's estate sued West Oaks, and later Willi-
and safety in a mental health facility, constitute health      ams, asserting HCLCs under the TMLA, codified in
care liability claims (HCLCs) under the Texas Medical          Chapter 74 of the Texas Civil Practice and Remedies
Liability Act (TMLA or Act). See TEX. CIV. PRAC. &             Code. TEX. CIV. PRAC. & REM.CODE §§ 74.001 –
REM.CODE ch. 74 et seq. We conclude that the TMLA              74.507. Williams later asserted cross claims of negli-
does not require that the claimant be a patient of the         gence against West Oaks pursuant to section 406.033 of
health care provider for his claims to fall under the Act,     the Texas Labor Code, a statutory provision governing
so long as the Act's other requirements are met. We            employee common law claims against employers not
hold that the employee here is properly characterized as       subscribed to workers' compensation. See TEX.

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                                                                                                          Page 6
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

LAB.CODE § 406.033. West Oaks' status as a nonsub-                      law is applicable to his claims. Act of June 2,
scriber to workers' compensation is uncontroverted, and                 2003, 78th Leg., R.S., ch. 204, § 10.09, 2003
therefore, Williams' claims against his employer are not                Tex. Gen. Laws 847, amended by Act of July
barred by the Texas Workers' Compensation Act. See                      19, 2011, 82nd Leg., 1st C.S., ch. 7, § 4.02,
id.; Port Elevator–Brownsville, L.L.C. v. Casados, 358                  2011 Tex. Gen. Laws 5445 (amending section
S.W.3d 238, 241 (Tex.2012) (discussing the “exclusive                   74.001(a), adding subsection (a)(12)(A)(viii)
remedy” doctrine).                                                      (including a health care collaborative as a
                                                                        “health care provider”) and making nonsub-
    Williams alleged that West Oaks was negligent in:                   stantive changes).

  (a) Failing to properly train Williams to work at West            The court of appeals affirmed the trial court's order.
  Oaks' premises, including warning him of the inherent        322 S.W.3d 349, 354. The court analyzed Williams'
  dangers of working with patients with the conditions         claims as breaches of West Oaks' duty of safety to its
  and tendencies that Mario Vidaurre possessed; (b)            employee. Id. at 352. The court of appeals began its
  Failing to adequately supervise West Oaks' employ-           analysis from the premise that the phrase “directly re-
  ees, including Williams, while working with patients         lated to health care” in section 74.001(a)(13) modifies
  with conditions and tendencies that Mario Vidaurre           not only “professional or administrative services,” but
  possessed; (c) Failing to provide adequate protocol to       also the term “safety.” Id. It concluded that a safety
  avoid and/or decrease the severity of altercations           claim “must be directly related to and inseparable from
  between its employees, such as Williams, and pa-             health care.” Id. It is not disputed here that Vidaurre's
  tients; (d) Failing to provide its employees, including      claims against West Oaks are HCLCs, but Williams ar-
  Williams, with adequate emergency notification               gues his claims against West Oaks are not. The court of
  devices to alert other employees of altercations in          appeals noted the related nature of the two parties' cases
  which assistance is needed; (e) Failing to warn Willi-       but concluded, based in part on our withdrawn opinion
  ams of the dangers that West Oaks knew or should             in Marks v. St. Luke's Episcopal Hospital, 52
  have known were associated with working with pa-             Tex.Sup.Ct.J. 1184, withdrawn and superseded on re-
  tients such as Mr. Vidaurre; and (f) Failing to provide      hearing, 319 S.W.3d 658 (Tex.2010), that Williams'
  a safe workplace for its employees, including Willi-         claims against West Oaks are separable from health care
  ams.                                                         and are not HCLCs. 322 S.W.3d at 353. Reasoning that
                                                               the source of West Oaks' duty to Williams is the em-
     West Oaks filed a motion to dismiss on the grounds
                                                               ployer-employee relationship and that the nature of
that Williams' claims constituted HCLCs under the
                                                               Vidaurre's relationship with West Oaks—patient to
TMLA and that Williams had not served an expert re-
                                                               health care provider—is different from Williams', the
port on West Oaks, as required under the Act. See TEX.
                                                               court of appeals concluded that the safety claims “flow
CIV. PRAC. & REM.CODE § 74.001(a)(13) (defining
                                                               from the employment relationship” between Williams
health care liability claims), and § 74.351(a), (b)
                                                               and West Oaks and are not “directly related” to health
(requiring a trial court to dismiss a health care liability
                                                               care, as required by the statute. 322 S.W.3d at 352–53;
claim if an expert report is not served within 120 days
                 FN1                                           TEX. CIV. PRAC. & REM.CODE § 74.001(a)(13).
of filing suit).      Williams *176 responded that his
                                                               West Oaks filed a petition for review in this Court.
claims sound in ordinary negligence rather than health
care liability. Following a hearing, the trial court denied                          II. Discussion
West Oaks' motion. West Oaks then filed this inter-                 [1] In seeking to distinguish ordinary negligence
locutory appeal. See id. § 51.014(a)(9).                       claims from HCLCs, the heart of these cases lies in the
                                                               nature of the acts or omissions causing claimants' injur-
         FN1. The HCLC definition was amended after
                                                               ies and whether the events are within the ambit of the
         Williams' cause of action accrued, and the prior

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                                                                                                          Page 7
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

legislated scope of the TMLA. Causes of action that are        “aris[ing] in other settings, such as jails and prisons”).
HCLCs cannot be transmuted to avoid the strictures of          In essence, Williams argues that the hospital is the mere
the medical liability statute. Omaha Healthcare Ctr.,          situs of his claims, that his role as psychiatric technician
LLC v. Johnson, 344 S.W.3d 392, 394 (Tex.2011); Di-            overseeing a mental patient has no bearing on the char-
versicare Gen. Ptr., Inc. v. Rubio, 185 S.W.3d 842, 851        acter of his claims, and the fact that his claims arose in
(Tex.2005). We recognize that the Legislature intended         a mental health facility has little or no bearing on their
the Texas Medical Liability Insurance Improvement Act          character.
(TMLIIA), the TMLA's predecessor, to be broad, and it
broadened that scope further in 2003 with its repeal and       A. Standard of Review
amendments resulting in the TMLA. Act of May 30,                   [2][3] West Oaks' and Williams' arguments both
1977, 65th Leg., R.S., ch. 817, § 1.02(6), 1977 Tex.           implicate the scope of claims reached by the TMLA.
Gen. Laws 2039, 2040 (former TEX.REV.CIV. STAT.                The nature of the claims the Legislature intended to in-
art. 4590i, § 1.02(6)), repealed by Act of June 2, 2003,       clude under the TMLA's umbrella is a matter of stat-
78th Leg., R.S., ch. 204, § 10.09, 2003 Tex. Gen. Laws         utory construction, a legal question we review de novo.
847, 884. After the 2003 amendments, the breadth of            Marks, 319 S.W.3d at 663 (interpreting the TMLIIA);
HCLCs include causes of action against physicians and          see also MCI Sales & Serv., Inc. v. Hinton, 329 S.W.3d
health care providers for negligence in the provision of       475, 500 (Tex.2010) (observing that questions of stat-
“medical care, or health care, or safety or professional       utory construction are generally reviewed de novo). In
or administrative services directly related to health          construing a statute, our aim “ ‘is to determine and give
care.” TEX. CIV. PRAC. & REM.CODE §                            effect to the Legislature's intent,’ ” and we begin with
74.001(a)(13).                                                 the “ ‘plain and common meaning of the statute's
                                                               words.’ ” McIntyre v. Ramirez, 109 S.W.3d 741, 745
     West Oaks argues that Williams' claims, mirroring         (Tex.2003) (quoting Tex. Dep't of Transp. v. Needham,
the same facts as Vidaurre's HCLCs, are HCLCs and              82 S.W.3d 314, 318 (Tex.2002); State Dep't of High-
therefore implicate the requirement to serve an expert         ways & Pub. Transp. v. Gonzalez, 82 S.W.3d 322, 327
report. Such a conclusion would mandate *177 a dis-            (Tex.2002) (further citations omitted)).
missal because Williams did not serve a report on West
Oaks. TEX. CIV. PRAC. & REM.CODE § 74.351(a),                  B. Relationship Between the Parties Under the Act
(b). West Oaks also urges that Williams' status as a               Williams argues that the lack of a patient-physician
health care provider at the hospital—as opposed to a pa-       or patient-health-care-provider relationship between
tient—does not remove Williams from the requirement            him and West Oaks is a clear barrier to inclusion of his
that he pursue his allegations as HCLCs. On the other          claims within the Legislature's definition of HCLCs. He
hand, Williams characterizes his allegations as ordinary       asserts that such a relationship is necessary to HCLCs.
negligence claims against a nonsubscriber to the work-         At one point in the past, Williams may have had a good
ers' compensation scheme. Williams contends that the           argument. However, modifications over time to the
court of appeals was correct in concluding that his            TMLA and its predecessor indicate a different scope for
claims fall outside the HCLC definition and therefore an       HCLCs under current law.
expert report is not required for his suit to proceed. See
                                                                    The TMLIIA was enacted in 1977 to relieve a med-
322 S.W.3d 349, 353–54. Williams also echoes the
                                                               ical “crisis [having] a material adverse effect on the de-
court of appeals in asserting that West Oaks' alleged
                                                               livery of medical and health care in Texas.” Act of May
safety and security breaches do not require expert med-
                                                               30, 1977, 65th Leg., R.S., ch. 817, § 1.02(6), 1977 Tex.
ical testimony and are interchangeable with safety and
                                                               Gen. Laws 2039, 2040 (repealed 2003). In 2003, facing
security issues arising in non-medical settings such as
                                                               another “medical malpractice insurance crisis” and a
corrections facilities. See id. at 353 (opining that Willi-
                                                               corresponding “inordinate[ ]” increase in the frequency
ams' safety and security claims involve issues also
                                                               of HCLCs filed since 1995, the Legislature repealed the

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                                                                                                         Page 8
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

TMLIIA, amending parts of the previous article 4590i             breadth of HCLCs beyond the patient population.
and recodifying it as Chapter 74 of the Texas Civil              This in turn necessarily widened the reach of the ex-
Practice and Remedies Code. Act of June 2, 2003, 78th            pert report requirement, unless otherwise limited by
Leg., R.S., ch. 204, § 10.11(a), 2003 Tex. Gen. Laws             other statutory provisions.
847, 884.
                                                                    However, “health care” and “medical care” HCLCs
     The 2003 legislation featured a significant modific-      are separately defined in the Act and reference treat-
ation to the existing law; it changed the HCLC defini-         ment furnished “for, to, or on behalf of a patient.” Id. §
                                                                                       FN3
tion:                                                          74.001(a)(10), (a)(19).      As discussed more fully be-
                                                               low, “medical care” and “health care” HCLCs require
  *178 ‘Health care liability claim’ means a cause of          that the claimant be a patient. See Part II.D.1, infra.
  action against a health care provider or physician for
  treatment, lack of treatment, or other claimed depar-                FN3. This conclusion is in harmony with the
  ture from accepted standards of medical care, or                     Legislature's stated intent to “reduce [the] ex-
  health care, or safety or professional or administrative             cessive frequency ... of health care liability
  services directly related to health care, which proxim-              claims through reasonable improvements and
  ately results in injury to or death of a claimant,                   modifications in the Texas insurance, tort, and
  whether the claimant's claim or cause of action                      medical malpractice systems....” Act of June 2,
  sounds in tort or contract.                                          2003, 78th Leg., R.S., ch. 204, § 10.11(b)(1),
                                                                       2003 Tex. Gen. Laws 847, 884.
     TEX. CIV. PRAC. & REM.CODE § 74.001(a)(13)
(emphases added). The Legislature replaced the term                 [4] With the exception of medical care and health
“patient” with “claimant” in the definition of an HCLC.        care claims, our focus in determining whether claims
FN2
      Compare TEX. CIV. PRAC. & REM.CODE §                     come under the TMLA is not the status of the claimant,
74.001(a)(13), with TEX.REV.CIV. STAT. art. 4590i, §           but the gravamen of the claim or claims against the
1.03(a)(4) (repealed 2003). The Legislature also defined       health care provider. See Diversicare, 185 S.W.3d at
the new term in the Act:                                       854.

        FN2. The Legislature also broadened the sub-           C. Williams' Status as a “Claimant” Under the Act
        ject-matter scope of the activities constituting            [5] We next examine whether Williams is a
        HCLCs through the addition to the definition           “claimant” under the TMLA. Only claimants are oblig-
        of “professional or administrative services dir-       ated to serve expert reports on physicians or health care
        ectly related to health care.” Id. §                   providers. TEX. CIV. PRAC. & REM.CODE §
        74.001(a)(24).                                         74.351(a), (b). West Oaks argues that the language and
                                                               structure of the definition of “claimant” in the current
  ‘Claimant’ means a person, including a decedent's es-        statute, especially when compared to its predecessor, in-
  tate, seeking or who has sought recovery of damages          dicate that the term includes not only patients, but other
  in a health care liability claim. All persons claiming       persons as well. Williams asserts that he is not a
  to have sustained damages as the result of the bodily        “claimant” because his claims are not HCLCs, as they
  injury or death of a single person are considered a          do not involve the exercise of professional medical
  single claimant.                                             judgment. Williams also argues that the Legislature's
  TEX. CIV. PRAC. & REM.CODE § 74.001(a)(2).                   substitution of “patient” with “claimant” is meant only
  “Person” is not defined in the TMLA and therefore            to include derivative claims by the relatives and repres-
  must be given its common law meaning. Id. §                  entatives of deceased patients,*179 not employees of
  74.001(b). Changing the term “patient” to “claimant”         health care provider defendants.
  and defining “claimant” as a “person” expands the

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

     As observed above, a “claimant” is broadly defined        distinction). Neither the language of the TMLA nor the
as a “person,” including the estate of a person, bringing      logic of the amendments can support a narrow reading
an HCLC. TEX. CIV. PRAC. & REM.CODE §                          of the term “claimant.”
74.001(a)(2). A claimant is a person seeking damages
for an HCLC. See id. § 74.001(a)(2), (13). As noted            D. Character of Williams' Claims
above, the TMLIIA, by contrast, featured an HCLC                    In defining the types of claims against health care
definition predicated on injury to a “patient.”                providers constituting HCLCs, the question we face is
TEX.REV.CIV. STAT. art. 4590i, § 1.03(a)(4)                    not whether it seems that a claimed injury really arose
(repealed 2003). Neither “person” nor “patient” is a           from treatment commonly understood to be some type
defined term in the TMLA and therefore possesses such          of medical or health care; nor do we address whether
meaning as is consistent with the common law. TEX.             the incident causing the injury would have been a com-
CIV. PRAC. & REM.CODE § 74.001(b).                             mon law negligence claim. Instead, the issue posed is
                                                               whether the umbrella fashioned by the Legislature's pro-
     Although he likely would not have been a “patient”        mulgation of the TMLA includes the cause of action
under the TMLIIA, Williams is a “claimant” and a               brought by a claimant against physicians or health care
“person” under the textual change to the definition of         providers.
HCLCs in the TMLA. Not only is the term “patient” not
included within the definition of “claimant,” the Legis-            The foundations of our analysis are well estab-
lature used the term “including” to precede the refer-         lished. As in Diversicare and Marks, we determine
ence to a decedent's estate. This renders any compon-          whether the relevant allegations are negligence claims
ents of the definition nonexclusive. TEX. GOV'T                or are properly characterized as HCLCs under the Act.
CODE § 311.005(13); Entergy Gulf States, Inc. v. Sum-          Marks, 319 S.W.3d at 662 (construing the TMLIIA);
mers, 282 S.W.3d 433, 440–41 (Tex.2009) (noting that           Diversicare, 185 S.W.3d at 847.
the term “including” is a term of enlargement and cau-                                                               FN4
                                                                    [6] An HCLC contains three basic elements:
tioning against “circumventing Legislative intent” by
                                                               (1) a physician or health care *180 provider must be a
misapplying non-exhaustive lists in statutes); see also
                                                               defendant; (2) the claim or claims at issue must concern
In re Allcat Claims Serv., L.P., 356 S.W.3d 455, 468
                                                               treatment, lack of treatment, or a departure from accep-
(Tex.2011) (observing that the term “including” in that
                                                               ted standards of medical care, or health care, or safety
case was an explanatory term of enlargement).
                                                               or professional or administrative services directly re-
     The dissent argues that the 2003 amendment substi-        lated to health care; and (3) the defendant's act or omis-
tuting “claimant” in lieu of “patient” in the HCLC             sion complained of must proximately cause the injury to
definition merely clarifies that a patient's estate or oth-    the claimant. See TEX. CIV. PRAC. & REM.CODE §
ers acting in a representative capacity may bring an           74.001(a)(13); Marks, 319 S.W.3d at 662 (construing
HCLC. 371 S.W.3d at 194 (Lehrmann, J., dissenting).            the similar definition found in the TMLIIA).
But further belying the contention that a “claimant” may
                                                                       FN4. “ ‘Health care liability claim’ means a
be only a patient or her estate is the Act's definition of
                                                                       cause of action against a health care provider or
“representative.” The term “representative,” used in the
                                                                       physician for treatment, lack of treatment, or
Act's medical-records-disclosure provision, is defined
                                                                       other claimed departure from accepted stand-
as the “agent of the patient or claimant,” indicating that
                                                                       ards of medical care, or health care, or safety or
patient and claimant do not necessarily refer to the same
                                                                       professional or administrative services directly
category of persons. TEX. CIV. PRAC. & REM.CODE
                                                                       related to health care, which proximately res-
§ 74.001(a)(25) (emphasis added), 74.052; Wilson N.
                                                                       ults in injury to or death of a claimant, whether
Jones Mem'l Hosp. v. Ammons, 266 S.W.3d 51, 61–62
                                                                       the claimant's claim or cause of action sounds
(Tex.App.—Dallas 2008, pet. denied) (also drawing the
                                                                       in tort or contract.” TEX. CIV. PRAC. &

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

         REM.CODE § 74.001(a)(13).                               claims brought under this prong of the HCLC definition
                                                                 must involve a patient-physician relationship. See id. §
     The second element is at issue in this case: whether        74.001(a)(10). “Health care” is:
Williams' claims alleging West Oaks' failure to properly
train the facility's staff, warn of risks associated with vi-      ... any act or treatment performed or furnished, or that
olent psychiatric patients, provide adequate protocols             should have been performed or furnished, by any
and equipment to limit such risks, and provide a safe              health care provider for, to, or on behalf of a patient
work environment under such circumstances implicate                during the patient's medical care, treatment, or con-
one or more of the standards listed in the HCLC defini-            finement.
tion. There are several types of HCLCs set out in the
TMLA: in addition to claims involving treatment and                   Id. § 74.001(a)(10)(emphases added); see also, e.g.,
lack of treatment, the Act contemplates claims for al-           Omaha Healthcare Ctr., 344 S.W.3d at 395 (pointing to
leged “departure[s] from accepted standards of medical           the “any act” language in the “health care” definition as
care, or health care, or safety or professional or admin-        necessarily implicating more than acts of *181 physical
istrative services directly related to health care.” TEX.        care and medical diagnosis and treatment); Diversicare,
CIV. PRAC. & REM.CODE § 74.001(a)(13). All of 185 S.W.3d at 847 (noting the “broad[ ]” nature of the
these categories of claims, except safety, are defined           “health care” definition). While the “any act” language
terms in the Act. See, e.g., id. § 74.001(a)(10), (a)(19),       of the “health care” definition is certainly expansive, it
and (a)(24) (defining “health care,” “medical care,” and         is limited by the requirement that health care be
“professional or administrative services”). West Oaks            rendered “for, to, or on behalf of a patient during the
asserts that Williams' claims allege departures from ac-         patient's medical care, treatment, or confinement.”
cepted standards of either “health care” or “safety.”            TEX. CIV. PRAC. & REM.CODE § 74.001(a)(10)
Williams argues that neither of these categories of              (emphases added). Because a claim under the health
claims applies to his allegations, removing him from the         care prong of section 74.001(a)(13) incorporates the
Act's reach.                                                     definition of “health care,” such a claim must involve a
                                                                 patient-physician relationship.
1. Claimed Departures from Accepted Standards of
Health Care                                                           [7] The requirement that a claim arising under the
     We examine whether Williams' complaints are                 health care prong of section 74.001(a)(13) involve a pa-
“claimed departure[s] from accepted standards of ...             tient-physician relationship could be viewed as in ten-
health care.” TEX. CIV. PRAC. & REM.CODE §                       sion with the term “claimant,” defined in terms of a per-
74.001(a)(13). In Diversicare, we held that a claim al-          son. See id. § 74.001(a)(2). We consider all the relevant
leges a departure from accepted standards of health care         provisions of the TMLA together and follow the rule
if the act or omission complained of is an inseparable or        that specific statutory provisions prevail over more gen-
integral part of the rendition of health care. 185 S.W.3d        eral provisions. See Jackson v. State Office of Admin.
at 848, 850. “[T]raining and staffing policies and super-        Hearings, 351 S.W.3d 290, 297 (Tex.2011) (reiterating
vision and protection of [patients] ... are integral com-        the rule that “a specific statutory provision prevails as
ponents of a [health care facility's] rendition of health        an exception over a conflicting general provision”)
care services....” Id. at 850. Williams' claims are similar      (citing Tex. Lottery Comm'n v. First State Bank of
to the health care claims at issue in Diversicare.               DeQueen, 325 S.W.3d 628, 637 (Tex.2010)); see also
However, our analysis of health care claims in that case         TEX. GOV'T CODE § 311.026(b) (same). However, the
involved claims by a patient against a health care pro-          specific wording of the “health care” definition, that
vider, not, as in this case, claims brought by a non-            health care be an act involving treatment rendered for,
patient employee against his employer.                           to or on behalf of a patient, acts as a limitation on the
                                                                 general provision that an HCLC need only be pursued
    The definition for “health care” suggests that               by a “claimant.” While other categories of HCLCs need

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

only be pursued by claimants, by specific statutory dir-       577.005(b), 577.010(a).
ective health care claims must involve a patient-
physician relationship.                                             [9] The necessity of expert testimony to support or
                                                               refute the allegations at issue is a factor in assessing the
     [8] Claims based on departures from accepted              nature of a claim against a health care provider or phys-
standards of health care therefore involve a nexus             ician. Diversicare, 185 S.W.3d at 848. Here, the court
between the standard departed from and the alleged in-         of appeals considered the need for expert testimony in
jury. Such a nexus exists in this case. Williams, a health     Williams' case and concluded that “even if medical ex-
care provider for Vidaurre, was assaulted by Vidaurre,         pert testimony is necessary to establish Williams'
who was a West Oaks patient. See TEX. CIV. PRAC. &             claims, the need for expert testimony is not dispositive
REM.CODE § 74.001(a)(12) (defining “health care pro-           as to whether a claim is a health care liability claim.”
vider” to include employees of facilities licensed to 322 S.W.3d at 353. We have indicated that even when
provide health care). Williams was acting on orders to         expert medical testimony is not necessary, the claim
provide one-on-one supervision for Vidaurre. That dir-         may still be an HCLC. Murphy v. Russell, 167 S.W.3d
ective was made by a West Oaks physician exercising            835, 838 (Tex.2005) (“The fact that in the final analys-
professional judgment about the schizophrenic patient's        is, expert testimony may not be necessary to support a
care and treatment, including, specifically, heightened        verdict does not mean the claim is not a health care liab-
supervision in light of recent aggressive and violent be-      ility claim.”). We have not previously addressed the
havior. Additional professional judgments about the            court of appeals' reasoning, and we now hold that if ex-
safety protocols for such patients were put in place by        pert medical or health care testimony is necessary to
West Oaks to care for its mental patients. Williams al-        prove or refute the merits of the claim against a physi-
leges that these judgments, concerning his training and        cian or health care provider, the claim is a health care li-
psychiatric institutional protocols, departed from accep-      ability claim.
ted standards of care and caused his injury. We previ-
ously reasoned in Diversicare that the health care facil-           [10] Expert testimony in the health care field is ne-
ity's “training and staffing policies and supervision and      cessary to support Williams' claims. Those claims re-
protection of [a patient] and other residents are integral     quire evidence on proper training, supervision, and pro-
components of [the facility's] rendition of health care        tocols to prevent, control, and defuse aggressive behavi-
services.” 185 S.W.3d at 850. Williams' similar allega-        or and altercations in a mental hospital between psychi-
tions constitute HCLCs based on claimed departures             atric patients and employed professional counselors
from accepted standards of health care.                        who treat and supervise them. The provision of emer-
                                                               gency notification devices, warning of dangers associ-
     Texas mental health statutes and regulations bolster      ated with psychiatric patients, providing a safe work-
this conclusion. West Oaks is a state-licensed, private        place, and properly training the caregiver at a psychiat-
mental health facility. The law requires that an inpatient     ric facility are integral to the patient's care and confine-
mental health facility “provide adequate medical and           ment. Acts or treatment that are integral to a “patient's
psychiatric care and treatment to every patient in ac-         medical care, treatment, or confinement” constitute
cordance with the highest standards accepted in medical        “health care.” TEX. CIV. PRAC. & REM.CODE §
practice. ” TEXAS HEALTH AND SAFETY CODE §                     74.001(a)(10). Claims for injuries arising from depar-
576.022(a)(emphasis added). Mental health hospitals            tures from proper “treatment performed or furnished, or
may not operate in Texas *182 unless licensed by the           that should have been performed or furnished” are
Texas Department of Health and operated in accordance          health care claims. Id. § 74.001(a)(10). Contrary to Wil-
with the rules and standards of the Texas Board of Men-        liams' argument, this dispute concerns more than simply
tal Health and Mental Retardation to ensure the proper         determining whether a person should be protected from
care and treatment of patients. Id. § 577.001(a),              a known aggressive person. The dispute between Willi-

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

ams and West Oaks is, at its core, over the appropriate                 sional service a hospital is licensed and expec-
standards of care owed to this mental health profession-                ted to provide, for it is in the business of
al in treating and supervising a psychiatric patient at the             providing medical care to patients and protect-
mental hospital, what services, protocols, supervision,                 ing them from an unreasonable risk of harm
monitoring and equipment were necessary to satisfy the                  while receiving medical treatment.... [T]he
standard, and whether such specialized standards were                   competent performance of this responsibility is
breached. See Diversicare, 185 S.W.3d at 850. The al-                   ‘inextricably interwoven’ with delivering com-
legedly missing or insufficient protocols and standards                 petent quality medical care to hospital pa-
were for a mental patient in a mental hospital. It would                tients.”).
blink reality to conclude that no professional mental
health judgment is required to decide what those should              *183 Williams' argument that any security officer
be, and whether they were in place at the time of Willi-        could have performed the oversight and supervision of a
             FN5                                                psychiatric patient at the mental health hospital is
ams' injury.
                                                                overly simplistic. Perhaps a security officer could have
         FN5. As we discussed in Diversicare, a number          protected Williams, and Vidaurre himself, from harm,
         of other states also recognize that providing su-      or lessened the severity of the injuries suffered, but se-
         pervision and a safe environment at a health           curity is only one aspect of the matter. Williams' posi-
         care facility are matters of professional health       tion at West Oaks involved professional, health-
         care judgment. 185 S.W.3d at 852–54 (citing            care-related judgments different from the tasks typically
         Dorris v. Detroit Osteopathic Hosp., 460 Mich.         associated with a law enforcement officer, security
         26, 594 N.W.2d 455, 466 (1999) (concluding             guard, or bouncer. Treatment of a mental patient subject
         that claims for assault in a psychiatric hospital      to psychotic and aggressive outbursts requires health
         implicated medical or health care under                care, not simply protection from bodily harm, to con-
         Michigan's medical malpractice statute and             trol, defuse, or prevent mental processes leading to ag-
         noting that “[t]he ordinary layman does not            gression, and professional techniques to do so. Patients
         know the type of supervision or monitoring             at West Oaks are there not merely for shelter, but also
         that is required for psychiatric patients in a         for care and treatment. See Charrin v. Methodist Hosp.,
         psychiatric ward.”); Smith v. Four Corners             432 S.W.2d 572, 574 (Tex.Civ.App.—Houston [1st
         Mental Health Ctr., 70 P.3d 904, 914 (Utah             Dist.] 1968, no writ) (holding that the hospital-patient
         2003) (holding that an assaulted child's lawsuit       relationship is different from that of a landlord-tenant).
         against the outpatient mental health care pro-         Williams' self-described role at West Oaks was that of a
         vider was a health care malpractice claim be-          “counselor” and “caregiver,” not a security guard. One
         cause the plaintiff's “allegations arise out of the    of Vidaurre's experts characterizes psychiatric techni-
         fact that [a health care provider] provided men-       cians as a “valuable and indispensable part of psychiat-
         tal health services directly to him....”)); see        ric hospital care.” Vidaurre's expert also notes that the
         also D.P. v. Wrangell Gen. Hosp., 5 P.3d 225,          role of psychiatric technician involves appropriately ob-
         229 n. 17 (Alaska 2000) (“[I]n so far as               serving and evaluating potentially assaultive mentally
         [plaintiff] intends to argue issues that involve       ill patients and assessing the potential for violent erup-
         specialized medical decisions—such as the ap-          tions. Thus, the very deficiencies in training and proto-
         propriate level of physical restraints or medica-      cols Williams complains of underscore the health-re-
         tion—she can do so only through expert testi-          lated nature of his role.
         mony.”); Bell v. Sharp Cabrillo Hosp., 212
Cal. App. 3d 1034, 260 Cal. Rptr. 886, 896                     [11] We do not conclude, as West Oaks would have
         (1989) (“[T]he competent selection and review          us, that Williams' claims should be considered HCLCs
         of medical staff is precisely the type of profes-      on the bare basis that they mirror those of the patient

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

and stem from the same fact pattern. Williams and the          administrative services directly related to health care,
patient stand as separate claimants. We analyze the ap-        which proximately results in injury to or death of a
plicability of the TMLA and its attendant procedural re-       claimant....” TEX. CIV. PRAC. & REM.CODE §
quirements on the gist of the claimant's allegations. See      74.001(a)(13)(emphasis added). The dissent argues that
Diversicare, 185 S.W.3d at 847–48.                             the 2003 amendment was intended to narrow the exist-
                                                               ing scope of the safety prong of HCLCs by requiring
2. Claimed Departures from Accepted Standards of                                                                 FN6
                                                               that safety be “directly related to health care.”     See
Safety                                                         id. We disagree for several reasons.
    [12] We also examine whether Williams' claims
may be characterized as HCLCs under the definition's                   FN6. Texas appellate courts construing the
“safety” prong. We have not decided whether safety                     TMLA have diverged on whether “directly re-
claims must be “directly related to health care.” The                  lated” applies to safety claims or only to other
TMLA's HCLC definition includes, among the different                   claims in the definition's list of departures from
types of covered claims, “claimed departure[s] from ac-                accepted standards. Compare St. David's
cepted standards of ... safety....” TEX. CIV. PRAC. &                  Healthcare P'ship, L.P. v. Esparza, 315 S.W.3d
REM.CODE § 74.001(a)(13).                                              601, 604 (Tex.App.—Austin 2010), rev'd on
                                                                       other grounds, 348 S.W.3d 904 (Tex.2011)
     Williams was injured during an altercation with                   (“directly related to health care” modifies
Vidaurre in a smoking area at the hospital, and he con-                “safety”); Appell v. Muguerza, 329 S.W.3d
tends his injuries would have been avoided if West                     104, 115 (Tex.App.—Houston [14th Dist.]
Oaks had instituted proper safety protocols and monit-                 2010, pet. filed) (same); Dual D Healthcare
oring devices. Williams' claims, predicated upon the                   Operations, Inc. v. Kenyon, 291 S.W.3d 486,
monitoring and restraint*184 of violent, schizophrenic                 489–90 (Tex.App.—Dallas 2009, no pet.)
patients, implicate the safety, as commonly understood,                (same); Omaha Healthcare Ctr., L.L.C. v.
of employees and patients. Safety is not defined in the                Johnson,       246 S.W.3d 278,      284
TMLA. This Court has construed the term, under prin-                   (Tex.App.—Texarkana 2008), rev'd on other
ciples of statutory construction, according to its com-                grounds, 344 S.W.3d 392 (Tex.2011) (same);
monly understood meaning as the condition of being                     Harris Methodist Ft. Worth v. Ollie, 270
“untouched by danger; not exposed to danger; secure                    S.W.3d 720, 723 (Tex.App.—Fort Worth 2008)
from danger, harm or loss.” Diversicare, 185 S.W.3d at                 , rev'd on other grounds, 342 S.W.3d 525
855 (quoting the definition of “safe” in Black's Law                   (Tex.2011) (same); Christus Health v. Beal,
Dictionary (6th ed.1990) to construe the meaning of                    240 S.W.3d 282, 289 (Tex.App.—Houston [1st
“safety” under predecessor statute). Logically, the in-                Dist.] 2007, no pet.) (same); Valley Baptist
clusion of safety “expand[ed] the scope of the statute                 Med. Ctr. v. Stradley, 210 S.W.3d 770, 774–75
beyond what it would be if it only covered medical and                 (Tex.App.—Corpus Christi 2006, pet. denied)
health care” and included the claims in that case, and it              (same), with Holguin v. Laredo Reg'l Med.
was not necessary to define the precise boundaries of                  Ctr., L.P., 256 S.W.3d 349, 354–55
the safety prong. Diversicare, 185 S.W.3d at 855; see                  (Tex.App.—San Antonio 2008, no pet.) (safety
also Marks, 319 S.W.3d at 662–63.                                      claim need not be directly related to health
                                                                       care); Emeritus Corp. v. Highsmith, 211
     [13] In 2003, the Legislature modified the defini-
                                                                       S.W.3d 321, 328 (Tex.App.—San Antonio
tion of HCLCs. It changed “patient” to “claimant,” and
                                                                       2006, pet. denied) (“[A] claim may be a ‘health
also added the italicized phrase to the relevant portion
                                                                       care liability claim’ under the safety definition
of the pre–2003 definition: HCLC means a cause of ac-
                                                                       even if it does not ‘directly relate[ ] to health-
tion for a “claimed departure from accepted standards of
                                                                       care.’ ”).
medical care, or health care, or safety or professional or

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

     Safety was in the Act prior to the 2003 amendments        that “[p]rofessional supervision, monitoring, and protec-
and this Court construed it according to its common            tion of the patient population necessarily implicate the
meaning as being secure from danger, harm or loss. Di-         accepted standards of safety.” Diversicare, 185 S.W.3d
versicare, 185 S.W.3d at 855. The phrase “directly re-         at 855. Williams' similar complaints here concerning his
lated to health care” was added to the definition of           protection from danger at the hands of a mental patient
                                                                                      FN7
HCLCs in 2003 to modify “professional or administrat-          also implicate safety.
ive services.” Compare TEX.REV.CIV. STAT. art
4590i, § 1.03(a)(4) (repealed 2003), with Act of June 2,               FN7. We explained in Diversicare that the
2003, 78th Leg., R.S., ch. 204, § 10.01, 2003 Tex. Gen.                claimant's allegations of deficient monitoring
Laws 847, 865.                                                         and training are distinct from hypothetical
                                                                       claims for injuries arising out of an intruder as-
     [14] Scrutinizing grammar in interpreting statutes,               saulting a claimant due to an unlocked window
we are cognizant of the rule that “[m]odifiers should                  or a claimant falling from a rickety staircase.
come, if possible, next to the words they modify.” Wil- 185 S.W.3d at 854. These examples, however,
liam Strunk, Jr. & E.B. White, THE ELEMENTS OF                         did not concern our analysis of HCLCs that
STYLE R. 30 (4th ed. 2000); see also Bryan A. Garner,                  were alleged departures from accepted stand-
GARNER'S MODERN AMERICAN USAGE 523                                     ards of safety. They were instead provided as
(2003) (noting that “[w]hen modifying words are separ-                 examples of claims that would be separable
ated *185 from the words they modify, readers have a                   from health care under the health care prong of
hard time processing the information,” and adding that                 the HCLC definition. Id. (construing the TM-
“the true referent should generally be the closest appro-              LIIA). Diversicare 's only holding as to the
priate word.”). This rule is related to the last antecedent            scope of claims based on alleged departures
doctrine of statutory interpretation commonly applied to               from accepted standards of safety was that in-
ambiguous legislative texts. 82 C.J.S. STATUTES §                      clusion of the term safety in the HCLC defini-
443 (2011) (footnotes omitted). Under that tenet, a qual-              tion expanded the reach of the statute and that
ifying phrase should be applied only to the portion of                 it was broad enough to include the claimants'
the sentence “immediately preceding it.” City of Dallas                claim in that case. Marks v. St. Luke's Epis-
v. Stewart, 361 S.W.3d 562, 571 n. 14 (Tex.2012)                       copal Hosp., No. 07–0783, 52 Tex.Sup.Ct.J.
(applying the doctrine); Spradlin v. Jim Walter Homes,                 1184, 2009 WL 2667801, 2009 Lexis 636, at
Inc., 34 S.W.3d 578, 580 (Tex.2000) (same). Accord-                    *39 (Tex. August 28, 2009) (Wainwright, J.,
ingly, the phrase “directly related to health care” modi-              dissenting), opinion withdrawn and substituted
fies the terms immediately before it—“professional or                  on rehearing, 319 S.W.3d 658 (Tex.2010).
administrative services.” Under the dissent's logic, the
phrase “directly related to health care” should be ap-              Moreover, a majority of the members of this Court
plied to modify each term in the HCLC definition, in-          have opined in written opinions or joined written opin-
cluding professional or administrative services, safety,       ions reasoning that safety is not constricted by the sub-
health care, and medical care. This construction is non-       sequent addition to the statute of the phrase
sensical, as it would be entirely redundant as to health       “professional or administrative services directly related
care and medical care, unsupported by the text in the at-      to health care.” Concurring and dissenting in Diversi-
tempted application to safety, and render safety largely       care, Chief Justice Jefferson wrote that safety, un-
repetitive of health care. See Marks, 319 S.W.3d at 673        defined in the statute, is commonly understood to mean
(Johnson, J., concurring) (pointing out that safety and        protection from danger and that the “specific source of
health care are separate). We explained in Diversicare,        that danger ... is without limitation.” 185 S.W.3d at
a patient-assault case also involving training and staff-      860–61 (Jefferson, C.J., concurring and dissenting)
ing policies and monitoring and protection of patients,        (also noting that “[i]n defining health care liability

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

claims as it did, the Legislature created a statute with a     claim against his employer would not have constituted a
broad scope. Complaints about the breadth of [the TM-          medical malpractice claim prior to the enactment of the
LIIA] should be directed to the Legislature, not to this       medical liability statutes in 1977.
Court, for the courts must ‘take statutes as they find
them.’ ” (citation omitted)). Concurring in Marks,                  We see no conflict between the TMLA and the TW-
Justice Johnson agreed with Chief Justice Jefferson's          CA, whether the claim at issue is asserted against an
analysis of safety in his concurrence and dissent in Di-       employer subscribing to workers' compensation insur-
versicare. Justice Johnson reasoned that making safety         ance or, as here, against a nonsubscriber. The TWCA is
contingent on a direct connection between it *186 and          unique in permitting private Texas employers to elect to
health care would “effectively read [ ] safety out of the      subscribe to workers' compensation insurance. Id. §
statute instead of properly giving it meaning as an addi-      406.002(a); Lawrence v. CDB Servs., Inc., 44 S.W.3d
tional category of claims.” Marks, 319 S.W.3d at 673           544, 552 (Tex.2001); see also Casados, 358 S.W.3d at
(Johnson, J., concurring, joined by Justice Willett,           241. If they so elect, and their employees do not opt out
                                              FN8              of the workers' compensation coverage, then their em-
Justice Hecht, and Justice Wainwright).             Chief
Justice Jefferson wrote again in Marks, quoting his con-       ployees are generally precluded from filing suit against
currence and dissent in Diversicare, noting that a reas-       them and must instead pursue their claims through an
onable construction of “safety” is to give the term its        administrative agency against the employer's insurance
“common meaning,” which could therefore encompass              carrier for benefits provided for in the TWCA. See
premises liability claims. Id. at 674 (Jefferson, C.J.,        TEX. LAB.CODE § 406.031(a) (noting that an employ-
concurring and dissenting, joined by Justices Green,           er's insurance carrier is liable for compensation of an
Guzman and Lehrmann).                                          employee's injury if the employee is subject to the Act
                                                               and the injury arises out of the course and scope of the
        FN8. Justices Hecht and Wainwright joined              employment). But employees need not prove the em-
        Justice Johnson's concurrence in Marks, except         ployer's negligence for workers' compensation recovery,
        for the discussion of “safety.” 319 S.W.3d at          just that they were injured in the course and scope of
        667.                                                   employment. See id. (“An insurance carrier is liable for
                                                               compensation for an employee's injury without regard
     We agree with West Oaks that Williams' claims are         to fault or negligence....”); id. § 406.002(b) (stating that
indeed for departures from accepted standards of safety.       a subscribing employer is subject to the TWCA). As
We conclude that the safety component of HCLCs need            part of the legislated policy trade-off underlying the
not be directly related to the provision of health care        workers' compensation system, employees are also lim-
and that Williams' claims against West Oaks implicate          ited in their recovery to indemnity and medical ex-
this prong of HCLCs.                                           penses, absent intentional conduct. See id. § 408.001(a)
                                                               (“Recovery of workers' compensation benefits is the ex-
E. Relationship with the Texas Workers' Compensa-
                                                               clusive remedy of an employee covered by workers'
tion Act
                                                               compensation insurance coverage....”); but see id. §
    [15] Williams also contends that interpreting the
                                                               408.001(b) (allowing recovery of exemplary damages
TMLA to encompass his claims will conflict with the
                                                               for *187 death caused by an intentional act or omission
procedural and substantive litigation rights granted to
                                                               or the employer's gross negligence).
employee plaintiffs under the TWCA. See TEX.
LAB.CODE § 406.001 et seq. He argues that his per-                  However, if an employer forgoes workers' com-
sonal injury claims against his employer should not be         pensation coverage, and is a nonsubscriber to the work-
characterized as HCLCs because the Legislature did not         ers' compensation system, it is subject to suits at com-
intend for employee claims against a health care pro-          mon law for damages. With the exception of certain em-
vider employer to fall under the rubric of the Act. Willi-     ployer defenses abrogated by the statute, a suit by an
ams also contends that an employee's personal injury

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

employee of a nonsubscribing employer is largely out-          Other proceedings to recover against nonsubscribing
side the limitations imposed by the TWCA. See id. §            employers would similarly be governed by applicable
406.033(a), (d) (discussing limited defenses and em-           statutes and rules, e.g., proof of negligence and causa-
ployee burden of proof in establishing negligence). Em-        tion, notice requirements under the Texas Tort Claims
ployees of a nonsubscriber, injured on the job, must           Act, or the common pleading and service requirements
prove the elements of a common law negligence claim,           in the Texas Rules of Civil Procedure for all lawsuits.
absent intentional misconduct. Id. § 406.033(d). An em-
ployee may also elect to waive workers' compensation                Williams invites us to read into the TMLA an ex-
coverage and “retain the common-law right of action to         ception for claimants happening to be employees of
recover damages for personal injuries or death” if cer-        nonsubscriber health care provider employers who sue
tain notification requirements are met. Id. § 406.034(a),      their employers for claims that come under the TMLA
(b).                                                           umbrella. Williams' case is against a nonsubscriber, out-
                                                               side of the workers' compensation system, yet he im-
     [16] Thus, the workers' compensation construct            plores the Court to except him from the TMLA's re-
contemplates two systems, one in which covered em-             quirements without any express statutory exception. He
ployees may recover relatively quickly and without lit-        seeks a common law exemption from the TMLA's man-
igation from subscribing employers and the other in            date that we are not willing to create.
which nonsubscribing employers, or the employers of
employees who have opted not to accept workers' com-                As explained, the TWCA and the TMLA do not
pensation coverage, are subject to suit by injured em-         conflict in this case. But even if they did, the Legis-
ployees to recover for their on-the-job injuries. “In          lature has already designated the victor—the TMLA
providing the worker a form of prompt remuneration for         would prevail. Section 74.002(a) of the TMLA states:
loss of earning capacity, the statutory [workers' com-
                                                                 *188 In the event of a conflict between this chapter
pensation] scheme is in lieu of common law liability
                                                                 and another law, including a rule of procedure or
based on negligence.” Paradissis v. Royal Indem. Co.,
                                                                 evidence or court rule, this chapter controls to the ex-
507 S.W.2d 526, 529 (Tex.1974); see also Reed Tool
                                                                 tent of a conflict.
Co. v. Copelin, 689 S.W.2d 404, 407 (Tex.1985) (“The
system balances the advantage to employers of im-                   TEX. CIV. PRAC. & REM.CODE § 74.002(a).
munity from negligence and potentially larger recovery         This provision was added as part of the 2003 amend-
in common law actions against the advantage to em-             ments and replaced an earlier, more cabined conflicts
ployees of relatively swift and certain compensation           provision. See TEX.REV.CIV. STAT. art. 4590i, §
without proof of fault.”).                                     11.05 (repealed) (entitled “Subchapter's Application
                                                               Prevails Over Certain Other Laws” and stating that
     Just as the workers' compensation system treats em-
                                                               “[t]he provisions of this subchapter shall apply notwith-
ployees of subscribing versus nonsubscribing employ-
                                                               standing the provisions contained in Article 4671, Re-
ees differently, the treatment of those two differently
                                                               vised Civil Statutes of Texas, 1925, as amended, and the
situated employees under the TMLA for on-the-job in-
                                                               provisions of Article 5525, Revised Civil Statutes of
juries is also distinct. The employee of a subscriber that
                                                               Texas, 1925, as amended” (pertaining to injuries result-
is a health care provider must pursue an administrative
                                                               ing in death and survival of cause of action, respect-
remedy under the TWCA for on-the-job injuries.                          FN9
                                                               ively)).
However, the employee of a nonsubscribing employer
that is a health care provider must file suit against the              FN9. Articles 4671 and 5525 were both re-
nonsubscriber and follow the rules that govern that suit.              pealed prior to the 2003 amendments as part of
In this case, the governing rules include the TMLA's re-               the Legislature's 1985 adoption of the Texas
quirements for a claimant suing a health care provider.                Civil   Practice     and   Remedies     Code.

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

        TEX.REV.CIV. STAT. arts. 4671 and 5525, re-                 only those in which the defendant has a patient-phys-
        pealed by Act of June 16, 1985, 69th Leg.,                  ician or “patient-health-care-provider” relationship with
        R.S., ch. 959, § 9(1), 1985 Tex. Gen. Laws                  the plaintiff. In spite of the Act's words, the dissent
        3242, 3322.                                                 proffers that the Court strays from the language of the
                                                                    Act and undermines its purpose. See 371 S.W.3d at
Here, Williams must establish the medical negligence of             199–200 (Lehrmann, J., dissenting). The chart below
West Oaks to recover under the TMLA. The statute re-                vividly illustrates the Legislature's broad intention and
quires expert reports to support his claims.                        refutes the dissent's position.

                III. Response to Dissent
At base, the dissent's position is that, notwithstanding
the Legislature's substitution of the term “claimant” for
“patient” in the TMLA's HCLC definition, HCLCs are

             TEX.REV.CIV. STAT. art. 4590i,                                 TEX. CIV. PRAC. & REM.CODE
       § 1.03(a)(4) (repealed 2003) (emphases added)                § 74.001(a)(13) (amended 2003) (emphases added)
“Health care liability claim” means a cause of action           “Health care liability claim” means a cause of action
against a health care provider or physician for treatment,      against a health care provider or physician for treatment,
lack of treatment, or other claimed departure from accepted     lack of treatment, or other claimed departure from accepted
standards of medical care or health care or safety which        standards of medical care, or health care, or safety or pro-
proximately results in injury to or death of the patient,       fessional or administrative services directly related to
whether the patient's claim or cause of action sounds in tort   health care, which proximately results in injury to or death
or contract.                                                    of a claimant, whether the claimant's claim or cause of ac-
                                                                tion sounds in tort or contract.
                                                                    Jackson, 351 S.W.3d at 297 (holding that specific stat-
     As explained in Parts II.B and C above, in 2003 the            utory provisions override general provisions). However,
Legislature modified the scope of HCLCs when it de-                 that limitation does not apply to claims of safety, which
leted “patient” and inserted the broader term “claimant”                                                         FN11
                                                                    is not defined with reference to a patient.         TEX.
in the definition. Compare TEX. CIV. PRAC. &                        CIV. PRAC. & REM.CODE § 74.001(a)(13). Contend-
REM.CODE § 74.001(a)(13), with TEX.REV.CIV.                         ing that only patients' claims may be considered
STAT. art. 4590i, § 1.03(a)(4) (repealed 2003). A                   HCLCs, the dissent argues, in essence, that the 2003
claimant need not be the patient in all HCLCs.                      amendment is a nullity and seeks to have the Court re-
                                                                    write section 74.001(a)(13). We decline to do so.
     As discussed above, two of the different types of
HCLCs have specific definitions. The “medical care”                         FN10. There is a slight variance between the
and “health care” definitions both refer to services                        definitions for “health care” and “medical
rendered for, to, or on behalf of a patient during the pa-                  care.” The “health care” definition features the
               FN10
tient's care,          treatment, or confinement. *189                      word “medical” between the words “patient's”
TEX. CIV. PRAC. & REM.CODE § 74.001(a)(10),                                 and “care.” The “medical care” definition does
(a)(19); see id. at § 74.001(a)(13). Although HCLCs, as                     not feature this word. TEX. CIV. PRAC. &
defined, include causes of action against health care                       REM.CODE § 74.001(a)(10), (a)(19).
providers brought by “claimants,” the specific incorpor-
ation of the patient relationship for health care and med-                  FN11. The scope of claims for “professional or
ical care claims governs the HCLC for departures from                       administrative services directly related to
accepted standards of medical care and health care. See                     health care” in the HCLC definition is not at is-

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

         sue in this case.                                          The dissent contends that the parties' right to med-
                                                               ical records cannot be applied against a third-party pa-
     [17] This is a statutory construction case. Our role      tient, such as Vidaurre. Specifically, the dissent points
“is to determine and give effect to the Legislature's          out that medical-privacy laws may prevent the parties
[expressed] intent.” McIntyre, 109 S.W.3d at 745. Such         from compelling a person such as Vidaurre, who is not
cases may offer the temptation to shoehorn a desired le-       a party to this case *190 pursuing a claim under the
gislative result. But the Legislature changed “patient” to     TMLA, from supplying his medical records. 371
“claimant,” and “claimant” is broader than “patient.”          S.W.3d at 195 (Lehrmann, J., dissenting). JUSTICE
Aside from claims alleging negligent medical care or           LEHRMANN'S point is well taken, but not in this case.
health care, a claim need not involve a patient-physician      Williams is the claimant in this case and these require-
relationship for it to be an HCLC.                             ments should be applied to him. For purposes of his
                                                               own medical records, Williams would be the “patient”
    The dissent argues several other points which we
                                                               referenced in the authorization form. See TEX. CIV.
address briefly. The dissent contends that other provi-
                                                               PRAC. & REM.CODE § 74.052(c)(A). In alignment
sions of the TMLA should trump the definition of
                                                               with the broadly defined “claimant,” the notice provi-
HCLCs.
                                                               sion makes clear at the outset that it applies to “any per-
     [18] (1) Notice of suit and medical records release       son” asserting an HCLC, as opposed to a “patient” or
provisions. The dissent similarly notes that inclusion of      representative. Id. §§ 74.001(a)(2), .051(a). In turn, the
non-patients as claimants would render the notice of           disclosure requirements allow not only for the release of
suit to health care providers, and accompanying medic-         records of a patient-plaintiff, but also the pre- and post-
al-records releases, to health care providers, question-       injury records of non-patient plaintiffs seeking recovery
able. 371 S.W.3d at 195 (Lehrmann, J., dissenting)             for her post-injury damages. See id. § 74.052
(citing TEX. CIV. PRAC. & REM.CODE §§ 74.051,                  (predicating the disclosure requirements on the applic-
.052). The Act requires “any person” asserting an              ability of section 74.051(a)). Such records would bear
HCLC to provide notice to the defendant physician or           directly in assessing the extent of damages and would
health care provider. TEX. CIV. PRAC. & REM.CODE               streamline settlement negotiations, regardless of wheth-
§ 74.051(a). This notice must be accompanied by the            er the claimant was a patient of the health care provider
medical-records release form detailed in section 74.052.       being sued.
Id. § 74.052; Jose Carreras, M.D., P.A. v. Marroquin,
                                                                    (2) Expert report provisions. The dissent similarly
339 S.W.3d 68, 73 (Tex.2011). Further, all parties are
                                                               asserts that the Act's definition of “expert report” and
entitled to “complete and unaltered copies of the pa-
                                                               discussion of expert qualifications means that HCLCs
tient's medical records.” TEX. CIV. PRAC. &
                                                               must be based on a patient-physician relationship be-
REM.CODE § 74.051(d). The form of notice provides a
                                                               cause those provisions contain references to departures
release including the name of the “patient.” Id. §
                                                               from accepted standards by physicians or health care
74.052(c)(A), (B). As the dissent correctly observes, the
                                                               providers and knowledge of accepted standards for dia-
Legislature's purpose for the notice and disclosure re-
                                                               gnosing, caring, or treating the illness, injury, or condi-
quirements was to encourage the parties to negotiate
                                                               tion at issue in the claim. 371 S.W.3d at 195–96
and settle disputes prior to suit. 371 S.W.3d at 195
                                                               (Lehrmann, J., dissenting) (discussing TEX. CIV.
(Lehrmann, J., dissenting); Carreras, 339 S.W.3d at 73
                                                               PRAC. & REM.CODE §§ 74.351(r)(6), .401(a)(2),
(citing Garcia v. Gomez, 319 S.W.3d 638, 643
                                                               .402(a)(2)). The fact that experts submitting reports
(Tex.2010)). However, nothing in the language of the
                                                               have knowledge of the alleged standards at issue does
notice and disclosure provisions or in their purpose of
                                                               not logically lead to a conclusion that only a patient's
encouraging pre-suit negotiation and settlement indic-
                                                               suit against a health care provider can constitute an
ates a legislative intent that in all cases a claimant must
                                                               HCLC, especially when such a conclusion conflicts
be a patient or her representative.

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

with the Legislature's substitution of “claimant” for          visions to the more relevant HCLC definition meaning-
“patient” in the TMLA's definition of HCLCs. Simil-            less.
arly, the dissent's point that the “expert report” defini-
tion calls for a discussion of the manner in which the              (4) Re-interpretation of Diversicare. Our opinion
care rendered by the physician or health care provider         today is consistent with our earlier construction of the
failed to meet standards does not lead to the conclusion       HCLC definition in Diversicare, 185 S.W.3d at 847
that only the patient at the receiving end of that care can    (noting that “we examine the underlying nature of the
be a “claimant” under the Act. Id. § 74.351(r)(6); see         claim and are not bound by the form of the pleading”).
also id. § 74.001(a)(2). An expert report detailing the        The dissent contends that we stray from Diversicare and
departure from standards would still be relevant in a          its progeny by centering our analysis on the nature of
case, such as this, where a non-patient alleges that the       the claims at issue. 371 S.W.3d at 196–97 (Lehrmann,
health care provider's deviations from accepted stand-         J., dissenting). The dissent erroneously argues that Di-
ards led to his injury. As explained, expert testimony is      versicare requires courts to place equivalent emphasis
necessary to specify the departure from accepted stand-        on the relationship between the parties. Specifically, the
ards leading to the injury. Id. § 74.351(r)(6). The Act's      dissent contends that in Diversicare we attached
requirement that an expert be qualified to give an opin-       “equal” importance to the “claimant's status as a pa-
ion on the standards at issue does not, as the dissent         tient” at a health care facility. Id.; see Diversicare, 185
contends, indicate that the condition at issue must be         S.W.3d at 850. However, in Diversicare we discussed
sustained by a patient. The expert report requirement is       that relationship, not because it was determinative in the
intended to effectuate the TMLA's objective that only          scope of HCLCs generally, but because those were the
meritorious causes of action proceed, not define the           facts of the case we were deciding. Diversicare, 185
scope of HCLCs. See Samlowski v. Wooten, 332 S.W.3d            S.W.3d at 850. The standards for the conduct at issue,
404, 416 (Tex.2011) (Wainwright, J., dissenting in             rather than the form of pleadings or identity of parties,
part).                                                         are paramount in classifying HCLCs. See Yamada v.
                                                               Friend, 335 S.W.3d 192, 196 (Tex.2010) ( “Artful
     (3) Jury instructions. The dissent observes that one      pleading does not alter [the nature of the underlying
of the jury instructions required by the Act in jury trials    claim].”); Omaha Healthcare, 344 S.W.3d at 394
includes a caution that a finding of negligence may not        (similar).
be based solely on evidence of a “bad result” to the
claimant, but a bad result may be considered in determ-             (5) Importance of the 2003 amendments. Incredibly,
ining negligence. 371 S.W.3d at 196 (Lehrmann, J., dis-        the dissent contends that the Court places “undue im-
senting) (citing TEX. CIV. PRAC. & REM.CODE §                  portance” on the Legislature's modification of the
74.303(e)(2)). Drifting again from the statutory text dir-     HCLC definition in 2003, substituting the broader term
ectly at issue, the dissent argues that this instruction       “claimant” for “patient” in identifying who may bring a
“only *191 makes sense” in the context of a patient dis-       claim. 371 S.W.3d at 193–94 (Lehrmann, J., dissent-
satisfied with medical or health care services delivered       ing); TEX. CIV. PRAC. & REM.CODE § 74.001(a)(13)
by a health care provider. We fail to see the logic in this    . The dissent would interpret that modification as refer-
argument. “Bad result” is not defined, making it diffi-        ring to the estate or direct representatives of a patient-
cult to limit its meaning exclusively to health care or        plaintiff, parties that have always been permitted to
medical care, as the dissent would do. The Act indicates       make a claim, even prior to the 2003 amendment. See
that a “bad result” is merely a fact that may be con- 371 S.W.3d at 197 (Lehrmann, J., dissenting); see also
sidered in a negligence finding. To conclude from this         TEX.REV.CIV. STAT. art. 4590i, § 1.03(a)(9), 4.01
provision that the Legislature intended to include only        (repealed 2003). First, focusing on the language of the
patients under the Act, when it expressly broadened the        statutory definition at the center of this case does not
HCLC definition, is not logical and would render the re-       give it “undue importance.” Second, the dissent's con-

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

struction is contrary to established rules of statutory        workers' compensation insurance). However, the
construction. As we note in Parts II. B and C,                 plaintiff must prove the negligence of the nonsubscrib-
“claimant” is defined as “a person, including a de-            ing employer or the employer's agent. TEX.
cedent's estate, seeking or who has sought recovery of         LAB.CODE § 406.033(d). As part of the negligence
damages in a health care liability claim.” TEX. CIV.           claim against a health care provider employer, an em-
PRAC. & REM.CODE § 74.001(a)(2). Thus, aside from              ployee asserting a claim that is otherwise an HCLC
claims involving health care or medical care and claims        must adhere to the expert report requirements of the
based on treatment, a direct healthcare-pro-                   TMLA. The dissent also argues that our reasoning will
vider-to-patient relationship is not required for claims to    discourage small claims and implies that fewer employ-
constitute HCLCs.                                              ers will subscribe to workers' compensation insurance.
371 S.W.3d at 199 (Lehrmann, J., dissenting). However,
     (6) Construction of “safety.” The dissent argues          because no information concerning workers' compensa-
that this issue has not been properly raised. 371 S.W.3d       tion policies is in the record before us, the dissent's con-
at 198 (Lehrmann, J., dissenting). However, West Oaks          cerns are speculative at best. As described above, while
presents the safety-related nature of its claims in its        we see no conflict between the TMLA and TWCA, the
briefing, and the court of appeals analyzed Williams'          Legislature signaled its intent that the TMLA should
claims as safety claims. 322 S.W.3d 349, 352. Contrary         control over contradictory statutory provisions. See
to the dissent's assertions, our construction of “safety”      TEX. CIV. PRAC. & REM.CODE § 74.002(a).
is based not only on established canons of textual con-
struction,*192 but also on our interpretation of safety             (8) Legislative purpose of the TMLA. Noting that
based on its commonly understood meaning. See Diver-           one of the stated purposes of the Act is to reduce the
sicare, 185 S.W.3d at 855. Further, following principles       frequency and cost of medical malpractice claims, the
of statutory construction, our construction of “safety”        dissent concludes that our holding will result in a larger
prevents the term from becoming meaningless surplus-           number of total HCLC claims, contrary to the Legis-
age, subsumed into claims based on departures from ac-         lature's purpose. 371 S.W.3d at 199–200 (Lehrmann, J.,
cepted standards of “health care.” See TEX. CIV.               dissenting). Given the number of claims filed against
PRAC. & REM.CODE § 74.001(a)(13).                              health care providers, many will be HCLCs and some
                                                               may not be. The dissent would shift the balance so that
     (7) Balance between the TMLA and TWCA. Con-               many more are not HCLCs, which is contrary to the Le-
tending that our assessment of Williams' claims as             gislature's change of “patient” to “claimant.” We refuse
HCLCs “forc[es]” them into the HCLC “mold” and                 to trump explicit statutory language with the dissent's
“significantly disrupts the delicate balance between em-       view of the TMLA's purpose.
ployee and employer interests” motivating the TWCA,
the dissent argues that our reasoning alters the incentive          Finally, our conclusion that the Act covers claims
structure in the TWCA intended to penalize nonsub-             by non-patients against health care providers is not new
scribing employers. 371 S.W.3d at 199 (Lehrmann, J.,           territory. The Fifth Court of Appeals has concluded that
dissenting). However, contrary to the implication of the       a non-patient hospital visitor's personal injury claim res-
dissent, the TWCA does not create an especially punit-         ulting from an on-premises patient assault was an
ive litigation regime for nonsubscribing employers.            HCLC. Ammons, 266 S.W.3d at 64. The court, citing
Rather, as noted above, nonsubscribing employers are           Diversicare, concluded that the supervision and re-
divested of several common law defenses. See TEX.              straint of patients was at issue and constituted health
LAB.CODE § 406.033(a); see also Kroger Co. v. Keng,            care under the facts of that case. Id. The Ammons court
23 S.W.3d 347, 349–50 (Tex.2000) (describing the lim-          correctly reasoned that no language in the Act required
itation of defenses of nonsubscribers as a “penalty”           that a “claimant” also necessarily be a “patient.” Id. at
meant as an incentive for employers to subscribe to            60–62.

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

                      IV. Conclusion                            age employers to become subscribers under the Workers
     Williams claims that West Oaks failed to properly          Compensation Act. For these reasons, I am compelled
train, warn and supervise him to *193 work with poten-          to respectfully express my dissent.
tially violent psychiatric patients and, as a result, failed
to provide a safe workplace. In 2003, the Legislature           I. The Medical Liability Act Contemplates a Patient/
broadened the definition of health care liability claims              Physician Relationship Between the Parties
under the Texas Medical Liability Act by adding new             A. The Act's plain language indicates that it applies
types of claims under the HCLC definition and expand-           to claims alleging a breach of a health care pro-
ing the scope of persons included within the Act's pur-         vider's duty to a patient.
view. Compare TEX. CIV. PRAC. & REM.CODE §                           Our primary objective in construing a statute “is to
74.001(a)(13), with TEX.REV.CIV. STAT. art. 4590i, §            ascertain and give effect to the Legislature's intent by
1.03(a)(4) (repealed 2003). We conclude that Williams'          first looking at the statute's plain and common mean-
claims against West Oaks are properly characterized as          ing.” Tex. Natural Res. Conservation Comm'n v.
health care liability claims based on claimed departures        Lakeshore Util. Co., 164 S.W.3d 368, 378 (Tex.2005).
from accepted standards of health care and safety. Wil-         We divine that intent by reading the statute as a whole,
liams failed to provide an expert report in accordance          and we interpret the legislation to give effect to the en-
with section 74.351(a). TEX. CIV. PRAC. &                       tire act. Id. (citing City of San Antonio v. City of Bo-
REM.CODE § 74.351(a). We therefore reverse the                  erne, 111 S.W.3d 22, 25 (Tex.2003)). Furthermore, we
judgment of the court of appeals affirming the trial            may look to the statutory context to determine a term's
court's order denying West Oaks' motion to dismiss all          meaning. City of Boerne, 111 S.W.3d at 25. All of those
of Williams' claims. Because West Oaks requested its            tools lead to the conclusion that Williams's claims are
attorney's fees and costs in the trial court pursuant to        not health care liability claims.
Texas Civil Practice and Remedies Code section 74.35
                                                                    Under the Medical Liability Act, § 74.001 et seq., a
1(b)(1), we remand to that court with instructions to dis-
                                                                health care liability claim is
miss Williams' claims against West Oaks and consider
West Oaks' request for attorney's fees and costs.                 a cause of action against a health care provider or
                                                                  physician for treatment, lack of treatment, or other
Justice LEHRMANN filed a dissenting opinion, in
                                                                  claimed departure from accepted standards of medical
which Justice MEDINA and Justice WILLETT joined.
                                                                  care, or health care, or safety or professional *194 or
Justice LEHRMANN, joined by Justice MEDINA and                    administrative services directly related to health care,
Justice WILLETT, dissenting.                                      which proximately results in injury to or death of a
     “A whole new world [of health care liability                 claimant, whether the claimant's claim or cause of ac-
claims], hinted by opinions in the last few years, is             tion sounds in tort or contract.
here.” In re McAllen Med. Ctr., Inc., 275 S.W.3d 458,
                                                                    TEX. CIV. PRAC. & REM.CODE § 74.001(a)(13).
470 (Tex.2008) (Wainwright, J. dissenting). Interpreting
                                                                The Court concludes that Williams's suit against his em-
a law designed to reduce the number of medical mal-
                                                                ployer for providing an unsafe workplace and inad-
practice suits, the Court holds that an employee's claims
                                                                equate training alleges health care liability claims, des-
against his employer for providing an unsafe workplace
                                                                pite the lack of any physician-patient relationship
and inadequate training are health care liability claims.
                                                                between the health care provider and the claimant. 371
The Court's strained reading of the statute runs counter
                                                                S.W.3d at 174. The Court first determines that Willi-
to express statutory language, the Legislature's stated
                                                                ams's claims are for a departure from health care stand-
purposes in enacting the current version of chapter 74,
                                                                ards because they “involve a patient-physician relation-
and common sense. Further, the Court's decision under-
                                                                ship.” 371 S.W.3d at 181. Although that determination
mines the balance struck by the Legislature to encour-
                                                                is more than enough to decide the case, the Court then

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

reaches out to further expand the Act's scope by decid-        claim. Instead, health care claims arise from “act[s] or
ing that a claim under the “safety” prong of the health        treatment furnished or that should have been furnished
care liability claim definition need not be directly re-       for, to, or on behalf of a patient during the patient's
lated to health care—even though Williams's claim is,          medical care, treatment, or confinement.” TEX. CIV.
in the Court's view—directly related to health care.           PRAC. & REM.CODE § 74.001(a)(10) (emphasis ad-
Both conclusions are inconsistent with plain statutory         ded). Williams's claims allege that West Oaks failed to
language and sound statutory construction. The Act is          provide him, not the patient, adequate training and a
replete with provisions indicating that a health care liab-    safe work place.
ility claim must be founded on a health care provider's
alleged breach of a professional duty towards a patient.            Section 74.051 of the Act highlights the Court's er-
See Diversicare Gen. Partner, Inc. v. Rubio, 185               ror in concluding that the mere peripheral involvement
S.W.3d 842, 851, 854 (Tex.2005). The Court's interpret-        of a patient transforms an ordinary negligence claim in-
ation renders some of those provisions meaningless or          to a health care claim. That section requires health care
nonsensical.                                                   liability claimants to provide *195 notice by certified
                                                               mail to any health care provider against whom the claim
1. Williams's claims are not “health care” claims, as          is asserted sixty days before the claim is filed. TEX.
the Court concludes.                                           CIV. PRAC. & REM.CODE § 74.051(a). The notice
     The Act defines “health care” as “any act or treat-       must be accompanied by a form authorizing the release
ment performed or furnished, or that should have been          of the medical records of “the patient ” whose treatment
performed or furnished, by any health care provider for,       is the subject of the claim. Id. §§ 74.051(d)( “All parties
to, or on behalf of a patient during the patient's medical     shall be entitled to obtain complete and unaltered copies
care, treatment, or confinement.” TEX. CIV. PRAC. &            of the patient's medical records....”); 74.052(c)A, B. Un-
REM.CODE § 74.001(a)(10) (emphasis added). Plainly,            der the Court's reading of the statute, Williams would
the Legislature contemplated that a health care liability      be required to authorize or obtain authorization for the
claim based upon a departure from standards of health          release of Vidaurre's medical records to pursue his suit
care would stem from medical treatment directed to-            against his employer. Obviously, medical privacy laws
ward a particular patient—“the patient” whose care,            prevent Williams from authorizing the release of
treatment, or confinement is the subject of the lawsuit.       Vidaurre's medical records. 45 C.F.R. § 164.502(f)
                                                               (providing that Health Insurance Privacy and Portability
     Based largely on the Legislature's use of the term        Act restrictions apply to deceased individuals). While
“claimant” rather than “patient” in the health care liabil-    the Legislature sought to reduce frivolous claims
ity claim definition, the Court determines that a claim        against health care providers, it sought to do so without
falls under the health care prong of the definition even       unduly restricting claims with merit. It is inconceivable
absent a physician-patient relationship so long as a           that the Legislature intended to require health care
physician-patient relationship is “involved.” 371              claimants with meritorious claims to be blocked by the
S.W.3d at 189. As set out in section I.B. below, the           refusal of third parties (the patients “involved”) to au-
Court's analysis of the significance of the Legislature's      thorize release of their medical records.
use of “claimant” in the definition flows from an erro-
neous premise and is deeply flawed; the Court's reliance            Moreover, even if Williams were somehow able to
on the change ignores the fact that the Legislature used       obtain authorization from Vidaurre's estate, the records
the term throughout the Act's predecessor, including in        would not serve the purpose sections 74.051 and 74.052
its statement of legislative purpose. More importantly,        were designed to serve: to “ ‘provide[ ] an opportunity
the Legislature did not say that a health care claim must      for health care providers to investigate claims and pos-
“involve” a patient. Indeed, the word is found nowhere         sibly settle those with merit at an early stage.’ ” Jose
in the definition of health care or health care liability      Carreras, M.D., P.A. v. Marroquin, 339 S.W.3d 68, 73

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

(Tex.2011) (quoting In re Collins, 286 S.W.3d 911,               or health care provider failed to meet the standards,
916–17 (Tex.2009)). Vidaurre's psychiatric diagnosis             and the causal relationship between that failure and
and violent tendencies are undisputed, and the records           the injury, harm, or damages claimed.
would have no bearing on the merits of Williams's
claims against West Oaks for allegedly providing an un-             TEX. CIV. PRAC. & REM.CODE § 74.351(r)(6)
safe workplace and inadequate training.                        (emphasis added). The emphasized language clearly
                                                               contemplates that the defendant health care provider has
    The Court discounts the import of these sections,          delivered health care services to a patient, who has al-
finding no language to suggest that employee/employer          legedly been injured by the provider's departure from
disputes like this case are not health care liability          applicable standards. The Court minimizes the defini-
claims. But section 74.052, which describes the stat-          tion's significance by noting that “[t]he fact that experts
utory authorization form that must accompany the stat-         submitting reports have knowledge of the alleged stand-
utory notice provides:                                         ards deviated from does not logically lead to a conclu-
                                                               sion that only a patient's suit against a health care pro-
  (c) The medical authorization required by this section       vider can constitute an HCLC....” 371 S.W.3d at 190.
  shall be in the following form[ ]:                           That suggestion, however, overlooks the provision's ref-
                                                               erence to the health care provider's rendition of care.
  (A) I, _______________ (name of patient [not
  claimant] or authorized representative), hereby au-               The sections of the Act governing the qualifications
  thorize _______________ (name of physician or oth-           of experts who may author reports similarly show that a
  er health care provider to whom the notice of health         health care liability claim arises only from a patient/
  care claim is directed) to obtain and disclose ... the       health care provider relationship. Section 74.041 estab-
  protected health information described below....             lishes the necessary qualifications for an expert in a suit
                                                               against a physician. Among other qualifications, the ex-
     Other provisions of the Act, which provide the rel-
                                                               pert must “ha[ve] knowledge of accepted standards of
evant statutory context, see City of Boerne, 111 S.W.3d
                                                               medical care for the diagnosis, care, or treatment of the
at 25, shore up the conclusion that health care liability
                                                               illness, injury, or condition involved in the claim. ”
claims arise from a health care provider's breach of a
                                                               TEX. CIV. PRAC. & REM.CODE § 74.401(a)(2)
duty toward a particular patient. I examine several be-
                                                               (emphasis added). The definitions thus contemplates
low.
                                                               that the lawsuit will center on a physician's treatment of
2. The Court's interpretation is inconsistent with             a patient's illness, injury, or condition, not on the ad-
provisions governing the expert reports and the                equacy of a workplace or the training provided to an
qualifications of experts.                                     employee.
     The Court reverses the court of appeals' judgment
                                                               3. The jury instruction mandated by the Legislature
and remands to the trial court, instructing it to dismiss
                                                               contemplates that the claim arises from a health care
because Williams failed to comply with the expert re-
                                                               provider's treatment of a patient.
port requirement of section 74.351. But the very defini-
                                                                    In section 74.303(e) of the Act, the Legislature
tion of “expert report” belies the Court's conclusion that
                                                               mandated the inclusion of two express jury instructions
Williams's allegations state claims for health care liabil-
                                                               “[i]n any action on a health care liability claim that is
ity. An “expert report” is defined as
                                                               tried by a jury in any court in this state.” The second of
  a written report by an expert that provides a fair sum-      those is:
  mary of the expert's opinions as of the date of the re-
                                                                 A finding of negligence may not be based solely on
  port regarding applicable standards of care, *196 the
                                                                 evidence of a bad result to the claimant in question,
  manner in which the care rendered by the physician
                                                                 but a bad result may be considered by you, along

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

  with other evidence, in determining the issue of negli-       care liability claim.” The Act's predecessor, the Medical
  gence. You are the sole judges of the weight, if any,         Liability and Insurance Improvement Act, former article
  to be given to this kind of evidence.                         4590i, defined the term as

     Id. § 74.303(e)(2). This instruction reflects the            a cause of action against a health care provider or
long-recognized principle that a physician who exer-              physician for treatment, lack of treatment, or other
cises ordinary care, within his school or specialty, is not       claimed departure from accepted standards of medical
liable to a patient for a bad outcome. See Bowles v.              care or health care or safety which proximately results
Bourdon, 148 Tex. 1, 219 S.W.2d 779, 782 (1949).                  in injury or death of the patient, whether the patient's
Clearly, the instruction only makes sense where a pa-             claim or cause of action sounds in tort or contract.
tient or the patient's proxy is dissatisfied by health care
services delivered by a health care provider. In the con-            Act of May 30, 1977, 65th Leg., R.S., ch. 817, §
text of the present case, in which the health care pro-         1.03(a)(4), 1997 Tex. Gen. Laws 2039, 2041, repealed
vider acted as an employer, the instruction becomes             by Act of June 2, 2003, 78th Leg., R.S., ch. 204, § 10.09
nonsensical.                                                    2003 Tex. Gen. Laws 847, 884 (emphasis added). In
                                                                2003, the Legislature replaced the word “patient” with
B. The Court's Interpretation Is Contrary to Our                the term “claimant.” TEX. CIV. PRAC. & REM.CODE
Prior Interpretations and Attaches Undue Import-                § 74.001(13). Without regard to the abundant indicia to
ance to the Alteration of the Definition of “Health             the contrary throughout the Act, the Court concludes
Care Liability Claim.”                                          that this change contemplated health care liability
     Noting that “our focus ... is not the status of the        claims that do not arise from the physician-patient rela-
claimant,” 371 S.W.3d at 178, the Court rejects out of          tionship.
hand Williams's contention that the lack of a patient-
physician relationship between him and West Oaks                     While claimant is a new term in the definition of
places his suit outside of the Act. It is true, as the Court    health care liability claim, the word was used
asserts, that in Diversicare we placed great importance         throughout the TMLIIA before the Legislature made
upon the essence of the claims, “the alleged wrongful           that change. In fact, the Legislature used the term in de-
conduct and the duties allegedly breached.” 185 S.W.3d          scribing the Act's very purpose: to alleviate a perceived
at 851. But in *197 rejecting Rubio's contention that her       health care crisis “in a manner that will not unduly re-
claim for a sexual assault by another patient should be         strict a claimant's rights any more than necessary to
treated as an ordinary premises liability claim, we at-         deal with the crisis.” Act of May 30, 1977, 65th Leg.,
tached equal importance to the claimant's status as a pa-       R.S., ch. 817, § 1.02(13)(3), 1977 Tex. Gen. Laws
tient between the parties: “There is an important distinc-      2039, 2040, repealed by Act of June 2, 2003, 78th Leg.,
tion in the relationship between premises owners and in-        R.S., ch 204, § 10.09 2003 Tex. Gen. Laws 847, 884
vitees on one hand and health care facilities and their         The term was also used and defined in section 13 of art-
patients on the other. The latter involves health care.”        icle 4590i. That section, the precursor of sections
Id. at 850. And we emphasized that, were we to agree            74.351 and 74.352 of the current act, among other
with Rubio's position, “our decision would have the ef-         things, required a claimant in a health care liability
fect of lowering the standard from professional to ordin-       claim to file an expert report within 180 days. Act of
ary care.” Id. at 854. The presence of a doctor-patient         May 1, 1995, 74th Leg., R.S., ch. 971, § 1, sec.
relationship was undeniably important to our determina-         13.01(d), (e), 1995 Tex. Gen. Laws 985, 985–986, re-
tion that Rubio's allegations amounted to health care li-       pealed by Act of June 2, 2003, 78th Leg., R.S., ch 204,
ability claims.                                                 § 10.09, 2003 Tex. Gen. Laws 847, 884. “Claimant”
                                                                was defined as
     The Court attaches much significance to the Legis-
lature's alteration in 2003 of the definition of “health          a party who files a pleading asserting a claim. All

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

  plaintiffs claiming to have sustained damages as the         must be directly related to health care. That issue isn't
  result of the bodily injury or death of a single person      presented because, at least in the Court's view, Willi-
  are considered to be a single claimant.                      ams's claim is directly related to health care. West Oaks
                               th                              itself argued that Willams's claims “are inextricably in-
     Act of May 1, 1995, 74 Leg., R.S., ch. 971, § 1,          terwoven with the rendition of health care services.”
sec. 13.01(d), (e), 1995 Tex. Gen Laws 985, 985–986,           Even if the question were properly before us, though, I
                                          th
repealed by Act of June 2, 2003, 78 Leg., R.S., ch             would reach a different conclusion than the Court. I
204, § 10.09 2003 Tex. Gen. Laws 847, 884. Accord-             would hold that a claim for safety under the Health Care
ingly, even though “health care liability claim” referred      Liability Act must arise from a breach of a health care
to injury to or the death of a patient, the statute contem-    provider's duty to adequately ensure a patient's safety in
plated that others could pursue claims under article           providing health care services.
4590i. And what parties could claim to have damages as
the result of the injury or death of a patient but spouses          The Court's conclusion that a health care liability
or relatives with their own claims for loss of support or      claim for breach of a safety standard depends entirely
*198 consortium or mental anguish, or others acting in a       on the last antecedent doctrine, 371 S.W.3d at 182, or
representative capacity, such as an estate or next friend?     the notion that “ ‘[m]odifiers should come, if possible,
In light of that history, it seems fairly obvious that the     next to the words they modify.’ ” 371 S.W.3d at 184
Legislature broadened the definition of “health care li-       (quoting William Strunk, Jr. & E.B. White, THE ELE-
ability claim” in 2003 to harmonize the definition with        MENTS OF STYLE R. 20 (4th ed. 2000)). In the
its previous recognition that parties other than patients      Court's view, then, the Legislature would have had to
might suffer injuries as the result of a health care pro-      frame the definition as “a cause of action against a
vider's departure from accepted standards in rendering         health care provider or physician for treatment, lack of
                                   FN1
health care services to a patient.                             treatment, or other claimed departure from accepted
                                                               standards of ... safety directly related to health care or
         FN1. The Court also makes much of the Act's           professional or administrative services directly related
         definition of “representative,” a term used in        to health care, which proximately results in injury to or
         the Act's medical records disclosure provision.       death of a claimant, whether the claimant's claim or
         TEX. CIV. PRAC. & REM.CODE §§                         cause of action sounds in tort or contract. Neither
         74.001(a)(25), .052. “Representative” is              Strunk and White's instructions nor the last antecedent
         defined as the “agent of the patient or               doctrine are so absolute as to require such redundancy.
         claimant.”     The     Court    concludes    this     See City of Dallas v. Stewart, 361 S.W.3d 562, 571 n.
         “indicat[es] that patient and claimant do not ne-     14 (Tex.2012). Instead, we should read the word in har-
         cessarily refer to the same category of per-          mony with the other provisions I have discussed, and in
         sons.” I agree, but my conclusion that                conjunction with the words surrounding “safety,” which
         “claimant” refers to parties with claims derived      all clearly implicate claims arising from a health care
         from a health care provider's breach of a duty        provider's delivery of medical care to a patient. See City
         toward a particular patient, such as guardians,       of Boerne, 111 S.W.3d at 29 (citing Cty. of Harris v.
         executors, survivors, and next friends, is far        Eaton, 573 S.W.2d 177, 179 (Tex.1978)).
         more consistent with other provisions of the
         Act than the Court's.                                      The     Court's     reading     of     the     term
                                                               “safety”—“untouched by danger, not exposed to
               II. Safety Under the Act                        danger; secure from danger, harm or loss”—is so broad
    Although its holding that Williams has asserted a          that almost any claim against a health care provider can
claim for breach of a health care standard is dispositive,     now be deemed a health care liability claim. If a hospit-
the Court reaches out to decide an issue that isn't even       al cook leaves an unlit gas burner on and causes an ex-
presented: whether a claim for safety under the Act

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371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

plosion, claims for any resulting injuries might be           tion insurance, the Court's decision increases the burden
health care liability*199 claims. If a nurse's deranged       and cost of pursuing negligence claims against nonsub-
spouse arrives at a clinic and shoots her, her claim that     scribers for employees of health care institutions. This
the facility provided inadequate security will also fall      will likely discourage healthcare workers from bringing
under the statute. Surely the Legislature did not intend      smaller claims.
to make professional liability insurers responsible for
such claims in order to solve an insurance availability            More importantly, the Act places strict limits on
crisis.                                                       damages that may be recovered from health care pro-
                                                              viders. TEX. CIV. PRAC. & REM CODE §§ 74.301
  III. The Court's Holding Undermines the Balance             –.303. By conferring the benefit of the Act's statutory
Struck by the Legislature in the Workers Compensa-            damages cap on nonsubscribing health care providers,
                         tion Act                             the Court gives health care provider nonsubscribers a
     I dissent also because, by forcing an employee's         benefit that is at odds with the measures the Legislature
negligence suit against his employer for on-the-job in-       implemented to penalize employers who opt not to par-
juries into the health-care-liability-claim mold, the         ticipate in the workers compensation system. “In enact-
Court significantly disrupts the delicate balance             ing section 406.033 and its predecessors, the Legislature
between employee and employer interests the Legis-            intended to delineate explicitly the structure of an em-
lature sought to implement when it enacted the Texas          ployee's personal-injury action against his or her non-
Workers Compensation Act (TWCA). The TWCA per-                subscribing employer.” Kroger v. Keng, 23 S.W.3d at
mits an employee to bring a negligence action against a       350–351. Today's decision redraws that delineation.
nonsubscriber like West Oaks. See TEX. LAB.CODE §
406.033. By making the common law defenses of as-                IV. The Court's Holding Undermines the Legis-
sumption of the risk, negligence of a fellow employee,                        lature's Stated Purposes
and contributory negligence unavailable to a nonsub-               In enacting chapter 74, the Legislature found that
scribing employer under the TWCA, id. at § 406.033(a),        “the number of health care liability claims [had] in-
it is clear that the Legislature intended to “penalize[ ]     creased since 1995 inordinately[,] caus[ing] a serious
nonsubscribers” and make it easier for their employees        public problem in availability and affordability of ad-
to recover. Kroger Co. v. Keng, 23 S.W.3d 347, 349,           equate medical professional liability insurance.” Act of
352 (Tex.2000) (noting that “[t]o encourage employers         June 2, 2003, 78th Leg., R.S., ch. 204, § 10.11(a)(1),
to obtain workers' compensation insurance, [the TWCA]         (4), 2003 Tex. Gen. Laws 847, 884. It adopted the Act
penalizes nonsubscribers by precluding them from as-          to reduce the frequency and decrease the *200 costs of
serting certain common-law defenses in their employ-          those claims. Id. at § 10.11(b)(1), (2). By sweeping a
ees' personal injury actions” and that the “Legislature       whole new class of claims—negligence claims of em-
intended that an employee's fault would neither defeat        ployees of health care institutions—into chapter 74, the
nor diminish his or her recovery”). Under the Court's         Court increases the number of health care liability
holding, employees of nonsubscribing healthcare pro-          claims and thwarts that purpose. Mystifyingly, the
viders will encounter procedural hurdles, such as the         Court proclaims that its decision is “in harmony” with
Act's notice and expert report requirements, that the         the Act's purposes because this new class of health care
TWCA does not contemplate. See TEX. CIV. PRAC. &              claimants will be required to file expert reports. 371
REM.CODE §§ 74.051, 74.351. Failure to comply with            S.W.3d at 182–83, n. 5. To be sure, Williams's claim
these special requirements can result in harsh con-           will be dismissed in the wake of today's decision—one
sequences, including dismissal of a claim with prejudice      claim will go away. But, in the future, employees in
and assessment of attorneys fees against the plaintiff.       Williams's position will be forewarned that they must
Id. § 74.351(b). Rather than the health care provider be-     provide an expert report and undoubtedly will do so.
ing penalized for not subscribing to workers' compensa-       The upshot of the Court's decision is that medical pro-

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                                                                                          Page 27
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033
(Cite as: 371 S.W.3d 171)

fessional liability insurers will be responsible for claims
that normally would have fallen under a health care em-
ployer's workers compensation or comprehensive liabil-
ity coverage.

     The Court has previously declined to construe pro-
visions of the Act in a way that would lead to absurd
results. Jose Carreras, M.D., P.A. v. Marroquin, 339
S.W.3d 68, 72–73 (Tex.2011). It should do so here.

                      V. Conclusion
     The Court's conclusion that Williams's claim
against his employer for providing inadequate training
and an unsafe workplace is a health care liability claim
is not only counterintuitive, it is inconsistent with the
Act's express language and its underlying purposes.
Furthermore, it alters the contours of employees' claims
against nonsubscribing health care providers established
in the Workers Compensation Act. For these reasons, I
respectfully dissent.

Tex.,2012.
Texas West Oaks Hosp., LP v. Williams
371 S.W.3d 171, 55 Tex. Sup. Ct. J. 1033

END OF DOCUMENT

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                                                                                                          Page 1
401 S.W.3d 41, 56 Tex. Sup. Ct. J. 467
(Cite as: 401 S.W.3d 41)

                                                            termining pediatric nephrologist's, obstetrician's,
                                                            and pediatric neurologist's reports were adequate to
             Supreme Court of Texas.                        satisfy the expert report requirement of the Texas
TTHR LIMITED PARTNERSHIP d/b/a Presbyteri-                  Medical Liability Act (TMLA) as to patient's claim
        an Hospital of Denton, Petitioner,                  that hospital was vicariously liable for the negli-
                        v.                                  gence of two physicians in connection with damage
Claudia MORENO, individually and as Next Friend             to patient's child's nervous system and kidneys dur-
          of F.C., a Minor, Respondent.                     ing childbirth, where obstetrician stated a standard
                                                            of care and opined that physicians breached the
                  No. 11–0630.
                                                            standard and thereby caused an extended labor and
              Argued Nov. 6, 2012.
                                                            birthing process, and the other two experts opined
             Decided April 5, 2013.
                                                            that the extended birthing process caused the dam-
          Rehearing Denied June 7, 2013.
                                                            age to the child's nervous system and kidneys.
Background: Mother, individually and as next                V.T.C.A., Civil Practice & Remedies Code §
friend of child, sued hospital and two physicians for       74.351(a), (r)(6).
injuries to child during birth. The 362nd District
                                                            [2] Health 198H       804
Court, Denton County, Robert Bruce McFarling, J.,
denied hospital's motion to dismiss under Texas             198H Health
Medical Liability Act (TMLA). Hospital appealed.                 198HV Malpractice, Negligence, or Breach of
The Fort Worth Court of Appeals affirmed, 2011              Duty
WL 2651813. Hospital appealed.                                     198HV(G) Actions and Proceedings
                                                                       198Hk804 k. Affidavits of merit or merit-
Holdings: The Supreme Court, Johnson, J., held
                                                            orious defense; expert affidavits. Most Cited Cases
that:
                                                                 Obstetrician/gynecologist's report was not im-
(1) combined conclusions of three experts were ad-
                                                            properly conclusory under the Texas Medical Liab-
equate to satisfy expert report requirement of
                                                            ility Act (TMLA), in stating that the standard of
TMLA, and
                                                            care for a doctor caring for a patient presenting
(2) TMLA did not require an expert report as to
                                                            with conditions such as the mother in the present
each liability theory alleged against hospital.
                                                            case was to immediately deliver the babies by
   Affirmed in part, reversed in part, and re-              cesarean section, that failing to do so was a breach
manded.                                                     of that standard, and that the physicians' failure to
                                                            perform a cesarean section resulted in the extended
                  West Headnotes                            labor and birthing process. V.T.C.A., Civil Practice
                                                            & Remedies Code § 74.351(r)(6).
[1] Health 198H       804
                                                            [3] Health 198H       804
198H Health
    198HV Malpractice, Negligence, or Breach of             198H Health
Duty                                                            198HV Malpractice, Negligence, or Breach of
      198HV(G) Actions and Proceedings                      Duty
          198Hk804 k. Affidavits of merit or merit-               198HV(G) Actions and Proceedings
orious defense; expert affidavits. Most Cited Cases                   198Hk804 k. Affidavits of merit or merit-
    Trial court did not abuse its discretion by de-         orious defense; expert affidavits. Most Cited Cases

                            © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                           Page 2
401 S.W.3d 41, 56 Tex. Sup. Ct. J. 467
(Cite as: 401 S.W.3d 41)

    The Texas Medical Liability Act (TMLA) re-             culties associated with the pregnancy. The hospit-
quires a claimant to timely file an adequate expert        al's nurses began having problems monitoring
report as to each defendant in a health care liability     Moreno and the twins, so they paged the physician
claim, but it does not require an expert report as to      on call, Dr. Lorie Gore–Green. Dr. Gore–*43 Green
each liability theory alleged against that defendant.      and Moreno's regular doctor, Dr. Marc Wilson, at-
V.T.C.A., Civil Practice & Remedies Code §                 tended to Moreno the next morning. Dr. Wilson in-
74.351.                                                    duced labor and used forceps and vacuum extrac-
                                                           tion to deliver the second baby, F.C. At some point
*42 J. Kevin Oncken, Roger A. Berger, Uzick On-            shortly before or during the birth process F.C.
cken, P.C., Houston, TX, for Petitioner.                   suffered blood loss and a hypoxic-ischemic insult.
                                                           It was later determined that his nervous system and
Craig T. Enoch, Enoch Kever PLLC, Austin, TX,
                                                           kidneys were damaged.
Lawrence R. Lassiter, Les Weisbrod, Max E. Free-
man II, Miller Weisbrod LLP, Dallas, TX, for Re-                Moreno, individually and as next friend of
spondent.                                                  F.C., sued the hospital, Dr. Wilson, and Dr.
                                                                         FN2
                                                           Gore–Green.         She alleged that the hospital was
Justice JOHNSON delivered the opinion of the               liable for the injuries to F.C. because of its own dir-
Court.                                                     ect negligence as well as its vicarious liability for
     Plaintiffs suing on health care liability claims      the negligence of its nurses and the two doctors.
must serve each defendant with an expert report
                                                                    FN2. Neither Dr. Wilson nor Dr.
meeting the requirements of the Texas Medical Li-
                                      FN1                           Gore–Green are parties to this appeal. We
ability Act (“TMLA” or “the Act”)         or face dis-
                                                                    will reference only the claims against the
missal of their claims. We recently held that an ex-
                                                                    hospital.
pert report satisfying the requirements of the
TMLA as to a defendant, even if it addresses only                Moreno timely served Presbyterian with a re-
one theory of liability alleged against that defend-       port by Dr. Samuel Tyuluman, an obstetrician and
ant, is sufficient for the entire suit to proceed          gynecologist. See TEX. CIV. PRAC. &
against the defendant. Certified EMS, Inc. v. Potts,       REM.CODE § 74.351(a) (requiring service of an
392 S.W.3d 625 (Tex.2013). In this case the                expert report not later than the 120th day after a
plaintiff's expert reports satisfy the TMLA require-       health care liability claim is filed). The hospital ob-
ments as to her claim that a hospital is vicariously       jected to Dr. Tyuluman's report on the basis that he
liable for the allegedly negligent actions of two          was not qualified to express opinions about the
doctors. Accordingly, the plaintiff's case against the     cause of F.C.'s neurological and kidney damage,
hospital may proceed.                                      and also because his opinions about the standards
                                                           of care, breach of the standards, and causation were
         FN1. TEX. CIV. PRAC. & REM.CODE §§
                                                           conclusory. In response to the objections, Moreno
         74.001–.507.
                                                           served a report by Dr. Billy Arant, a pediatric neph-
                                                                     FN3
     We affirm the judgment of the court of appeals        rologist.      See id. § 74.351(i) (authorizing ful-
in part, reverse in part, and remand the cause to the      filling the expert report requirements by serving
trial court for further proceedings.                       multiple reports). Presbyterian objected to Dr.
                                                           Arant's report on various grounds.
                 I. Background
    Claudia Moreno, pregnant with twins, was ad-                    FN3. Nephrology involves the study of
mitted to TTHR Ltd., d/b/a Presbyterian Hospital of                 functions and treatment of the kidneys.
Denton (“Presbyterian” or “the hospital”) for diffi-

                           © 2015 Thomson Reuters. No Claim to Orig. US Gov. Works.
                                                                                                            Page 3
401 S.W.3d 41, 56 Tex. Sup. Ct. J. 467
(Cite as: 401 S.W.3d 41)

     The trial court sustained only Presbyterian's         the nurses violated applicable standards of nursing
objection that the reports failed to show a causal re-     care and the reports of Drs. Arant and Seals did not
lationship between the alleged failures of the hos-        attempt to address either nursing standards of care
pital and its nurses to meet the applicable standards      or breaches of those standards. Id. at 170. The court
of care and F.C.'s neurological injury. The court          remanded the case to the trial court and instructed it
granted Moreno a thirty-day extension to cure the          to consider granting Moreno a thirty-day extension
reports. See id. § 74.351(c) (providing that if            to cure the deficiencies found on appeal. Id. at 170.
“elements of the report are found deficient, the
court may grant one thirty-day extension to the                Presbyterian appeals, arguing that the court of
claimant in order to cure the deficiency”). She then       appeals erred by concluding Moreno's reports were
filed a report by Dr. John Seals, a pediatric neurolo-     adequate as to causation, but even if the reports
gist. Presbyterian objected to Dr. Seals's report on       were adequate in that respect, the court erred by re-
the basis that it did not set out any acts of alleged      manding the case for the trial court to consider
negligence on the part of the hospital, nor did it set     granting another thirty-day extension to cure the
out a causal connection between any allegedly neg-         other deficiencies.
ligent act or omission of the hospital or its nurses
                                                                After we heard oral argument in this case we
and F.C.'s neurological injury. The trial court de-
                                                           held in Certified EMS that the TMLA does not re-
termined that when the reports of Drs. Tyuluman,
                                                           quire an expert report for each liability theory
Arant, and Seals were read in concert, Moreno had
                                                           pleaded against a defendant. Certified EMS, Inc.,
met the TMLA's requirements. It denied the hospit-
392 S.W.3d at 632. Our decision in that case con-
al's motion to dismiss, and this interlocutory appeal
                                                           trols the outcome here because we conclude that
followed. See id. § 51.014(a)(9).
                                                           Moreno's expert reports addressing the hospital's al-
     The court of appeals affirmed as to the ad-           leged liability for the actions of Drs. Wilson and
equacy of the reports regarding Moreno's claim that        Gore–Green are adequate. Given that determina-
Presbyterian is vicariously liable for the doctors'        tion, we do not address whether the court of appeals
negligence. 401 S.W.3d 163. In doing so, it determ-        erred by remanding the case for the trial court to
ined that Dr. Tyuluman's report specified several          consider granting a second extension of time for
standards of care, how the defendant doctors               Moreno to cure deficiencies in her reports.
breached them, and that Drs. Arant and Seals were
                                                             II. Vicarious Liability for the Doctors' Actions
qualified to and did opine on the causal connection
                                                                 [1] The court of appeals held that the trial court
between the breaches by the doctors and F.C.'s in-
                                                           did not abuse its discretion by determining
juries. Id. at 169. The appeals court also determined
                                                           Moreno's reports were adequate as to her claim that
that the reports adequately addressed a causal rela-
                                                           the hospital is vicariously liable for the negligence
tionship between the events at delivery and F.C.'s
                                                           of Drs. Wilson and Gore–Green. 401 S.W.3d at
neurological and kidney injuries. Id. at 170. But in
                                                           166. Its review of the trial court's ruling was under
addressing the direct liability claims, the court con-
                                                           the abuse of discretion standard. Am. Transitional
cluded that Dr. Tyuluman's report did not ad-
                                                           Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873,
equately address the applicable standards of care or
                                                           877 (Tex.2001). So is ours, and we reach the same
how Presbyterian breached those standards, and
                                                           conclusion as did the court of appeals.
neither *44 the report of Dr. Arant nor that of Dr.
Seals addressed any standard or breach by the hos-             [2] A valid expert report under the TMLA must
pital. Id. at 167. As to the vicarious liability claims    provide: (1) a fair summary of the applicable stand-
based on the nurses' actions, the court concluded          ards of care; (2) the manner in which the physician
that Dr. Tyuluman's report did not state how any of        or health care provider failed to meet those stand-

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                                                                                                           Page 4
401 S.W.3d 41, 56 Tex. Sup. Ct. J. 467
(Cite as: 401 S.W.3d 41)

ards; and (3) the causal relationship between that         nurses—may proceed. See id. at 632.
failure and the harm alleged. TEX. CIV. PRAC. &
REM.CODE § 74.351(r)(6). Dr. Tyuluman's report                                IV. Conclusion
set out applicable standards of care for doctors                We affirm the court of appeals' judgment as to
treating a patient with conditions similar to those        the adequacy of the reports regarding the claim that
with which Moreno presented. He opined that (1)            Presbyterian is vicariously liable for the doctors' ac-
the standard of care for a doctor caring for a patient     tions. We need not and do not consider whether the
presenting with conditions such as Moreno's was to         TMLA authorized the court of appeals to remand
immediately deliver the babies by cesarean section;        the case to the trial court for it to consider granting
(2) failing to do so was a breach of that standard;        a second extension of time for Moreno to cure her
and (3) the doctors' failing to perform a cesarean         reports. We reverse that part of the court of appeals'
section resulted in the extended labor and birthing        judgment by which it did so, but affirm its judg-
process. We agree with the court of appeals that as        ment remanding the entire suit to the trial court.
to the foregoing standard of care and breach, Dr.
                                                                The cause is remanded to the trial court for fur-
Tyuluman's report was not conclusory. Dr. Arant's
                                                           ther proceedings consistent with this opinion.
report explained that asphyxia during the birth pro-
cess caused F.C.'s kidney injury, and Dr. Seals's re-      Tex.,2013.
port stated his opinion that the hypoxic-ischemic          TTHR Ltd. Partnership v. Moreno
event during the labor and delivery process caused         401 S.W.3d 41, 56 Tex. Sup. Ct. J. 467
F.C.'s brain injury. Accordingly, we agree with the
court of appeals that the trial court did not abuse its    END OF DOCUMENT
discretion by finding Moreno's reports adequate as
to the claim that Presbyterian is vicariously liable
                            FN4
for actions of the doctors.

         FN4. Presbyterian does not concede that it
         can be held vicariously liable for the doc-
         tors' actions. But it acknowledges that
         whether it can be is not a question to be
         determined in this appeal.

 *45 III. Direct Liability and Vicarious Liability
                for Nurses' Negligence
     [3] As we articulated in Certified EMS, the
TMLA requires a claimant to timely file an ad-
equate expert report as to each defendant in a health
care liability claim, but it does not require an expert
report as to each liability theory alleged against that
defendant. Certified EMS, Inc., 392 S.W.3d at 632.
Here, because the trial court did not abuse its dis-
cretion in finding Moreno's reports adequate as to
her theory that Presbyterian is vicariously liable for
the doctors' actions, her suit against Presbyteri-
an—including her claims that the hospital has direct
liability and vicarious liability for actions of the

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                                                                                                            Page 1
281 S.W.3d 207
(Cite as: 281 S.W.3d 207)

                                                             port and curriculum vitae in determining whether
                                                             the witness is qualified as an expert under health
            Court of Appeals of Texas,                       care liability statute. V.T.C.A., Civil Practice &
                      Dallas.                                Remedies Code § 74.351(r)(5)(C).
   UHS OF TIMBERLAWN, INC., Appellant,
                         v.                                  [2] Health 198H        804
  S.B., a Minor, by and through her Next Friend,
                  A.B., Appellee.                            198H Health
                                                                  198HV Malpractice, Negligence, or Breach of
                No. 05–08–00222–CV.                          Duty
                    Feb. 24, 2009.                                   198HV(G) Actions and Proceedings
                                                                        198Hk804 k. Affidavits of Merit or Merit-
Background: Former patient brought action                    orious Defense; Expert Affidavits. Most Cited
against psychiatric treatment facility, alleging that        Cases
she was placed in a ward with male patients and                   Under health care liability statute, the expert
one of them raped her. The 160th Judicial District           report must represent a good-faith effort to provide
Court, Dallas County, Jim Jordan, J., denied facil-          a fair summary of the expert's opinions. V.T.C.A.,
ity's motion to dismiss, and facility appealed.              Civil Practice & Remedies Code § 74.351(l ),
                                                             (r)(6).
Holdings: The Court of Appeals, Moseley, J., held
that:                                                        [3] Health 198H        804
(1) in order to identify the causal relationship
between actions of treatment facility and patient's          198H Health
claimed injury, patient was not required, under                   198HV Malpractice, Negligence, or Breach of
health care liability statute, to proffer an expert re-      Duty
port opining that she was in fact raped; and                        198HV(G) Actions and Proceedings
(2) report of patient's expert contained adequate                      198Hk804 k. Affidavits of Merit or Merit-
statements regarding causation so as to satisfy ex-          orious Defense; Expert Affidavits. Most Cited
pert report requirement of health care liability stat-       Cases
ute.                                                              Health care liability statute's expert-report re-
                                                             quirement serves two purposes: (1) to inform the
    Affirmed.                                                defendant of the specific conduct the plaintiff has
                                                             called into question; and (2) to provide a basis for
                  West Headnotes
                                                             the trial court to conclude the claims have merit.
[1] Health 198H        804                                   V.T.C.A., Civil Practice & Remedies Code §
                                                             74.351(r)(6).
198H Health
    198HV Malpractice, Negligence, or Breach of              [4] Health 198H        804
Duty
                                                             198H Health
      198HV(G) Actions and Proceedings
                                                                 198HV Malpractice, Negligence, or Breach of
         198Hk804 k. Affidavits of Merit or Merit-
                                                             Duty
orious Defense; Expert Affidavits. Most Cited
                                                                   198HV(G) Actions and Proceedings
Cases
                                                                      198Hk804 k. Affidavits of Merit or Merit-
    Appellate courts consider only the expert's re-
                                                             orious Defense; Expert Affidavits. Most Cited

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                                                                                                              Page 2
281 S.W.3d 207
(Cite as: 281 S.W.3d 207)

Cases                                                             Traditionally, appellate courts apply an abuse
     Expert report does not comply with health care           of discretion standard in reviewing the trial court's
liability statute if it fails to address the standard of      decision to deny a motion to dismiss based on fail-
care, breach of the standard, and causation, or if it         ure to file an adequate expert report under health
only states the expert's conclusions regarding these          care liability statute. V.T.C.A., Civil Practice &
elements. V.T.C.A., Civil Practice & Remedies                 Remedies Code § 74.351(r)(6).
Code § 74.351(r)(6).
                                                              [8] Appeal and Error 30           946
[5] Health 198H         804
                                                              30 Appeal and Error
198H Health                                                       30XVI Review
     198HV Malpractice, Negligence, or Breach of                     30XVI(H) Discretion of Lower Court
Duty                                                                    30k944 Power to Review
      198HV(G) Actions and Proceedings                                       30k946 k. Abuse of Discretion. Most
          198Hk804 k. Affidavits of Merit or Merit-           Cited Cases
orious Defense; Expert Affidavits. Most Cited                      Trial court abuses its discretion if it acts in an
Cases                                                         arbitrary or unreasonable manner without reference
     Although the expert report need not marshal all          to any guiding rules or principles.
of the plaintiff's proof, it must include the expert's
opinion on each of the elements identified in the             [9] Appeal and Error 30           946
health care liability statute. V.T.C.A., Civil Practice
                                                              30 Appeal and Error
& Remedies Code § 74.351(r)(6).
                                                                 30XVI Review
[6] Health 198H         804                                         30XVI(H) Discretion of Lower Court
                                                                       30k944 Power to Review
198H Health                                                                30k946 k. Abuse of Discretion. Most
     198HV Malpractice, Negligence, or Breach of              Cited Cases
Duty
       198HV(G) Actions and Proceedings                       Appeal and Error 30            1008.1(3)
          198Hk804 k. Affidavits of Merit or Merit-
                                                              30 Appeal and Error
orious Defense; Expert Affidavits. Most Cited
                                                                 30XVI Review
Cases
                                                                       30XVI(I) Questions of Fact, Verdicts, and
     Under health care liability statute, expert's re-
                                                              Findings
port must explain the basis of his or her statements
                                                                        30XVI(I)3 Findings of Court
to link those conclusions to the facts. V.T.C.A.,
                                                                            30k1008 Conclusiveness in General
Civil Practice & Remedies Code § 74.351(r)(6).
                                                                               30k1008.1 In General
[7] Appeal and Error 30           960(1)                                           30k1008.1(3) k. Substituting Re-
                                                              viewing Court's Judgment. Most Cited Cases
30 Appeal and Error                                                Appellate court may not substitute its judgment
   30XVI Review                                               for the trial court's judgment, or find that the trial
      30XVI(H) Discretion of Lower Court                      court abused its discretion merely because appellate
           30k960 Rulings on Motions Relating to              court would have decided the matter differently.
Pleadings
              30k960(1) k. In General. Most Cited             [10] Health 198H         804
Cases
                                                              198H Health

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281 S.W.3d 207
(Cite as: 281 S.W.3d 207)

     198HV Malpractice, Negligence, or Breach of                     198Hk815 Evidence
Duty                                                                     198Hk821 Necessity of Expert Testi-
       198HV(G) Actions and Proceedings                     mony
          198Hk804 k. Affidavits of Merit or Merit-                            198Hk821(3) k. Proximate Cause.
orious Defense; Expert Affidavits. Most Cited               Most Cited Cases
Cases                                                            Some health care liability claims may allege
     In order to identify the causal relationship           that a breach of the applicable standard of care ex-
between actions of psychiatric treatment facility           acerbated a pre-existing medical condition, or
and patient's claimed injury, patient was not re-           hindered or prevented the effective treatment of
quired under health care liability statute to proffer       such     a    condition,    and    identifying   the
an expert report opining that she was in fact raped;        “breach/injury” causal relationship in these cases
patient alleged that, as result of facility's failure to    may require an expert to opine as to the existence,
meet the applicable standards of care relevant to its       extent, and prognosis of the pre-existing medical
treatment of her, she was raped, rape was not a             condition, as well as how the alleged breach of the
medical condition, and instead, it was an assault,          standard of care aggravated such a condition, im-
and medical evidence of an alleged sexual assault           peded or prohibited its treatment, and otherwise af-
was not required even in criminal prosecutions.             fected the patient's prognosis.
V.T.C.A., Civil Practice & Remedies Code §
74.351(r)(6).                                               [13] Rape 321       51(3)

[11] Health 198H         631                                321 Rape
                                                                321II Prosecution
198H Health                                                        321II(B) Evidence
     198HV Malpractice, Negligence, or Breach of                      321k50 Weight and Sufficiency
Duty                                                                      321k51 In General
      198HV(B) Duties and Liabilities in General                               321k51(3) k. Carnal Knowledge.
          198Hk630 Proximate Cause                          Most Cited Cases
               198Hk631 k. In General. Most Cited                Medical evidence of an alleged sexual assault
Cases                                                       is not required in criminal prosecutions; the rule in
    In some health care liability claims, the injury,       Texas is that penetration may be proven by circum-
harm, or damages claimed flow from existence of a           stantial evidence.
medical condition that itself resulted from the
breach of the applicable standard of care, and in           [14] Rape 321       54(1)
such cases, identifying the causal relationship
                                                            321 Rape
between the alleged breach of the standard of care
                                                               321II Prosecution
and the resulting harm involves not only explana-
                                                                   321II(B) Evidence
tion as to how standard of care was breached, but
                                                                      321k50 Weight and Sufficiency
also how the breach gave rise to the new, deleteri-
                                                                         321k54 Corroboration of Female
ous medical condition.
                                                                             321k54(1) k. Necessity. Most Cited
[12] Health 198H         821(3)                             Cases
                                                                The testimony of a sexual assault victim alone
198H Health                                                 is sufficient evidence of penetration to support a
    198HV Malpractice, Negligence, or Breach of             criminal conviction, even if the victim is a child.
Duty
     198HV(G) Actions and Proceedings                       [15] Health 198H        804

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                                                                                                           Page 4
281 S.W.3d 207
(Cite as: 281 S.W.3d 207)

198H Health                                                 Before Justices     MOSELEY,       RICHTER,       and
     198HV Malpractice, Negligence, or Breach of            FRANCIS.
Duty
      198HV(G) Actions and Proceedings
                                                                                 OPINION
          198Hk804 k. Affidavits of Merit or Merit-
                                                            Opinion by Justice MOSELEY.
orious Defense; Expert Affidavits. Most Cited
                                                                 Appellee S.B., acting through her next friend
Cases
                                                            A.B., sued appellant UHS of Timberlawn, Inc. She
     Under health care liability statute, an expert re-
                                                            alleges that while she was thirteen years old and a
port need not marshal the claimant's evidence, but it
                                                            patient at Timberlawn's psychiatric treatment facil-
should explain the basis of the expert's opinions and
                                                            ity, she was placed in a ward with male patients,
link his conclusions to the facts. V.T.C.A., Civil
                                                            where one of them raped her. She claims her injur-
Practice & Remedies Code § 74.351(r)(6).
                                                            ies were proximately caused by the negligence of
[16] Health 198H         804                                Timberlawn's employees.

198H Health                                                      Timberlawn asserts, among other things, that
     198HV Malpractice, Negligence, or Breach of            the report of S.B.'s expert, Dr. Michael Jay Levine,
Duty                                                        is deficient because he did not opine as to whether
       198HV(G) Actions and Proceedings                     S.B. was in fact raped; neither does the report in-
          198Hk804 k. Affidavits of Merit or Merit-         dicate Levine was qualified to render such an opin-
orious Defense; Expert Affidavits. Most Cited               ion. We affirm the trial court's order denying Tim-
Cases                                                       berlawn's motion to dismiss.
     Report of patient's expert contained adequate
                                                                  *210 PROCEDURAL BACKGROUND
statements regarding causation so as to satisfy ex-
                                                                 S.B. filed the curriculum vitae and report of Dr.
pert report requirement of health care liability stat-
                                                            Levine within 120 days of the filing of the petition.
ute with respect to patient's claim that, as result of
                                                            See TEX. CIV. P. & REM. C.. § 74.351 (Vernon
psychiatric treatment facility's failure to meet the
                                                            Supp.2008). Timberlawn successfully disputed the
applicable standards of care relevant to its treat-
                                                            adequacy of that report, and the trial court gave
ment of her, she was raped when she was placed in
                                                            S.B. an additional thirty days to cure any deficien-
ward with male patients; expert's report stated that,
                                                            cies in Levine's report. See id. § 74.351(c). There-
because patient had a history of past sexual victim-
                                                            after, S.B. filed another report and curriculum vitae
ization and risk factors of a co-morbid develop-
                                                            from Dr. Levine, entitled “Revised Expert Report.”
mental disability and a psychiatric disorder, the
                                                            Timberlawn also objected to adequacy of this re-
standard of care required facility to provide housing
                                                            port, and filed a motion to dismiss. However, the
where patient could not be accessed by unsuper-
                                                            trial court denied Timberlawn's motion. Timber-
vised males. V.T.C.A., Civil Practice & Remedies
                                                            lawn appealed. See id. §§ 51.014(a)(9); 74.351(b);
Code § 74.351.
                                                            Lewis v. Funderburk, 253 S.W.3d 204, 206–08
*209 Sidney L. Murphy, Steed Flagg, L.L.P., Rock-           (Tex.2008); Romero v. Lieberman, 232 S.W.3d
well, Cathy F. Bailey, Steed Flagg, LLP, Dallas, for        385, 388 (Tex.App.-Dallas 2007, no pet.).
Appellant.
                                                                           APPLICABLE LAW
Vicki Kathleen McCarthy, Duncanville, Kirk L.                    Within 120 days of filing suit, a plaintiff as-
Pittard, F. Leighton Durham, Cheyenne J.                    serting a healthcare liability claim must serve ex-
Robertson, Durham & Pittard, Dallas, for Appellee.          pert reports for each physician or health care pro-
                                                            vider against whom such a claim is asserted. TEX.

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281 S.W.3d 207
(Cite as: 281 S.W.3d 207)

CIV. PRAC. & REM.CODE § 74.351(a). These re-                proof, it must include the expert's opinion on each
ports must identify the “applicable standards of            of the elements identified in the statute. See id. at
care, the manner in which the care rendered by the          878. Moreover, the expert's report must explain the
physician or health care provider failed to meet the        basis of his or her statements to link those conclu-
standards, and the causal relationship between that         sions to the facts. Earle v. Ratliff, 998 S.W.2d 882,
failure and the injury, harm, or damages claimed.”          890 (Tex.1999); Mosely v. Mundine, 249 S.W.3d
Id. § 74.351(r)(6).                                         775, 780 (Tex.App.-Dallas 2008, no pet.).

     [1] As pertinent to this appeal, an “expert”                        STANDARD OF REVIEW
means “with respect to a person giving opinion                   [7][8][9] Traditionally we apply an abuse of
testimony about the causal relationship between the         discretion standard in reviewing the trial court's de-
injury, harm, or damages claimed and the alleged            cision to deny a motion to *211 dismiss based on
departure from the applicable standard of care in           failure to file an adequate expert report. See Walker
any health care liability claim, a physician who is         v. Gutierrez, 111 S.W.3d 56, 63 (Tex.2003)
                                                                                                              FN1
otherwise qualified to render opinions on such              (discussing predecessor statute to § 74.351(c)).
causal relationship under the Texas Rules of Evid-          The trial court abuses its discretion if it acts in an
ence.” TEX. CIV. PRAC. & REM.CODE ANN. §                    arbitrary or unreasonable manner without reference
74.351(r)(5)(C). To be so qualified under the Texas         to any guiding rules or principles. Bowie Mem'l
Rules of Evidence, an expert must have knowledge,           Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.2002) (per
skill, experience, training, or education regarding         curiam); Mosely, 249 S.W.3d at 778. We may not
the specific issue before the court that would quali-       substitute our judgment for the trial court's judg-
fy the expert to give an opinion on that particular         ment, or find that the trial court abused its discre-
subject. Broders v. Heise, 924 S.W.2d 148, 153              tion merely because we would have decided the
(Tex.1996) (citing rule of evidence 702). We con-           matter differently. Id. If, however, the trial court
sider only the expert's report and CV in determining        clearly failed to analyze and determine the law cor-
whether the witness is qualified as an expert under         rectly or applied the law incorrectly to the facts,
section 74.351. See Mem'l Hermann Healthcare                then it abused its discretion. Id.
Sys. v. Burrell, 230 S.W.3d 755, 758
(Tex.App.-Houston [14th Dist.] 2007, no pet).                        FN1. Timberlawn recognizes this; never-
                                                                     theless, citing discussions (but not rulings)
     [2][3][4][5][6] Under subsections 74.351(l )                    in two court of appeals' opinions, it con-
and (r)(6), the expert report or reports must repres-                tends we should apply a de novo standard.
ent a good-faith effort to provide a fair summary of                 Those two opinions are Kendrick v. Gar-
the expert's opinions. Am. Transitional Care Ctrs.                   cia,      171 S.W.3d 698,      702
of Tex., Inc. v. Palacios, 46 S.W.3d 873, 878                        (Tex.App.-Eastland 2005, pet. denied), and
(Tex.2001). The expert-report requirement serves                     Quint v. Alexander, No. 03–04–00819–CV,
two purposes: (1) to inform the defendant of the                     2005 WL 2805576 (Tex.App.-Austin 2005,
specific conduct the plaintiff has called into ques-                 pet denied.). However, Timberlawn
tion; and (2) to provide a basis for the trial court to              provides no additional briefing, or any ana-
conclude the claims have merit. Id. at 879. A report                 lysis or discussion as to how the two stand-
does not fulfill these purposes if it fails to address               ards might differ in the context of this ap-
the standard of care, breach of the standard, and                    peal. Thus we decline Timberlawn's invita-
causation, or if it only states the expert's conclu-                 tion.
sions regarding these elements. Id. at 879. Although
the report need not marshal all of the plaintiff's                          ANALYSIS
                                                                On appeal Timberlawn asserts several com-

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plaints about the revised expert report.                      raped. [S.B.'s] expert did not nor could not articu-
                                                              late facts to support any opinion that
A. “New” Report                                               [Timberlawn's] alleged breaches in the standard
     In its fourth issue Timberlawn argues the re-            *212 of care proximately caused [S.B.'s] alleged
vised report contains new opinions with regard to             sexual assault or rape. [S.B.'s] expert has not
the breach of the standard of care and causation,             shown himself to be qualified to render an opin-
and thus constitutes a “new report” that: (1) was             ion that [S.B.] was sexually assaulted or raped or
improperly filed after the time limitations provided          that the alleged breaches in the standard of care
by section 74.351; and (2) “exceeds the scope of §            proximately caused [S.B.'s] sexual assault or
74.351(c).” It argues the statute “does not allow a                 FN2
                                                              rape.
plaintiff to obtain and serve a new report.” As sole
support for its argument, Timberlawn cites the
court of appeals's opinion in Danos v. Rittger, 253                  FN2. Timberlawn's brief continues:
S.W.3d 294 (Tex.App.-Houston [1st Dist.] 2007),
                                                                       Accordingly, this case has no merit, and
rev'd 253 S.W.3d 215 (Tex.2008). As the Texas Su-
                                                                       there is no basis to continue to take up
preme Court reversed the court of appeals on that
                                                                       the time and resources of the Trial Court,
point, we overrule Timberlawn's fourth issue. See
                                                                       to expend the time, energy, and re-
Danos v. Rittger, 253 S.W.3d 215 (Tex.2008)
                                                                       sources of the litigants, or even to put
(citing Lewis v. Funderburk, 253 S.W.3d 204
                                                                       [S.B.] through what will undoubtedly be
(Tex.2008)).
                                                                       a traumatic experience of discovery, de-
B. Causation-related Complaints                                        position, and trial testimony, reliving her
     [10] In its remaining issues, Timberlawn as-                      past medical, psychiatric, and education-
serts Levine's revised report and curriculum vitae                     al history, not to mention her ‘past his-
do not establish he is qualified to render an opinion                  tory of sexual victimization’, and the
as to causation, and the revised report is inadequate                  matters alleged in this lawsuit. This case
and conclusory as to that issue. These arguments all                   is the very type of case that Chapter 74
flow from Timberlawn's position disputing whether                      was designed to require the Court to dis-
S.B. was, in fact, raped.                                              miss at an early stage

     Timberlawn contends that, absent a statement                Thus, the premise of Timberlawn's arguments
in Levine's revised report (presumably based on all         is that unless S.B. can present the report of a quali-
reasonable medical probability) that S.B. was in            fied expert opining that S.B. was actually raped, her
fact raped, Levine's revised report fails to identify       expert report(s) cannot identify the alleged causal
the “causal relationship between [Timberlawn's ac-          relationship between Timberlawn's actions or omis-
tions] and the injury, harm, or damages claimed.”           sions and S.B.'s alleged injuries, as required by sec-
See TEX. CIV. PRAC. & REM.CODE ANN. §                       tion 74.351(r)(6). We reject this premise.
74.351(r)(6). Timberlawn argues Levine did not
                                                                [11][12] In some healthcare liability claims, the
opine, nor did he show he was qualified to opine, as
                                                            “injury, harm, or damages claimed” flow from the
to whether S.B. had been raped. Timberlawn's argu-
                                                            existence of a medical condition that itself resulted
ments are best summarized in the conclusion and
                                                            from the breach of the applicable standard of care.
prayer set forth in its brief:
                                                            In such cases, identifying the causal relationship
  [Levine] did not and/or could not express an              between the alleged breach of the standard of care
  opinion, based on his education, training or ex-          and the resulting harm involves not only an explan-
  perience, that [S.B.] was sexually assaulted or           ation as to how the standard of care was breached,

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but also how the breach gave rise to the new, dele-         whether S.B. was in fact raped; and (2) because
terious medical condition. Similarly, other health-         Levine's report did not render an opinion on that is-
care liability claims may allege that a breach of the       sue.
applicable standard of care exacerbated a pre-
existing medical condition, or hindered or preven-          1. Levine's Qualifications
ted the effective treatment of such a condition.                 The standard of care relevant to S.B.'s claim is
Identifying the “breach/injury” causal relationship         the assessment, treatment, and housing of an ad-
in these cases may well require an expert to opine          olescent mental patient in a mental health facility.
as to the existence, extent, and prognosis of the pre-      Timberlawn does not dispute Levine's qualifica-
existing medical condition, as well as how the al-          tions to opine as to that standard or as to the breach
leged breach of the standard of care aggravated             of that standard. We agree the record shows the tri-
such a condition, impeded or prohibited its treat-          al court could have concluded S.B. met her burden
ment, and otherwise affected the patient's prognos-         to show Levine had the knowledge, skill, experi-
is.                                                         ence, training, or education necessary to opine
                                                            whether Timberlawn's conduct breached the applic-
                                                                                                          FN3
     However, S.B.'s claim is different. S.B. alleges       able standard of care and caused her injury.       See
that, as a result of Timberlawn's failure to meet the       Broders, 924 S.W.2d at 153; Mosely, 249 S.W.3d at
applicable standards of care relevant to its treat-         779. We conclude the trial court did not abuse its
ment of her, she was raped. Rape is not a medical           discretion in overruling Timberlawn's objection to
condition. It is an assault. Moreover, rape may—or          Levine's qualifications as an expert pursuant to sec-
may not—be accompanied by medically ascertain-              tion 74.351(r)(5). We overrule Timberlawn's issue
able evidence of physical trauma, or even physical          based on Levine's qualifications.
evidence that it occurred.
                                                                     FN3. Levine is a licensed medical doctor
    [13][14] Medical evidence of an alleged sexual                   and a clinical associate professor at the De-
assault is not required even in criminal prosecu-                    partment of Psychiatry and Behavioral Sci-
tions; the rule in Texas is that “penetration may be                 ences at the University of Texas–Houston
proven by circumstantial evidence.” See Villalon v.                  Medical School. He has worked at hospit-
State, 791 S.W.2d 130, 133 (Tex.Crim.App.1990).                      als in Texas and other states since complet-
Moreover, the testimony of a sexual assault victim                   ing his residency in 1972 in positions in-
alone is sufficient evidence of penetration to sup-                  volving child and adolescent neurodevel-
port a criminal conviction, even if the victim is a                  opmental diagnosis and treatment. He
child. Karnes v. State, 873 S.W.2d 92, 96                            trains and supervises medical students,
(Tex.App.-Dallas 1994, no pet.) (citing Garcia v.                    psychiatry residents, child psychiatry fel-
State, 563 S.W.2d 925, 928 (Tex.Crim.App. [Panel                     lows, and psychology interns and externs.
Op.] 1978)).                                                         Levine's curriculum vitae shows he has ex-
                                                                     tensive training and experience with the
     We decline to hold that in order to identify the                assessment, evaluation, and treatment of
causal relationship between Timberlawn's actions                     children and adolescents in a mental health
and S.B.'s claimed injury, see TEX. CIV. PRAC. &                     facility or hospital. See Mosely, 249
REM.CODE ANN. § 74.351(r)(6), she was required                       S.W.3d at 779–80 (emergency room physi-
to proffer an expert report opining that she was in                  cian qualified to opine about causation re-
fact raped. Thus we reject Timberlawn's arguments                    garding emergency room physician's abil-
that the trial court erred in not dismissing S.B.'s                  ity to interpret routine chest x-rays and
claim because: (1) Levine's*213 report did not                       identify abnormality in patient later dia-
show him to be qualified to render an opinion on

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281 S.W.3d 207
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         gnosed with cancer); Palafox v. Silvey, 247        Levine's report states in part that S.B.
         S.W.3d 310, 316 (Tex.App.-El Paso 2007,
         no pet.) (physician with training and exper-         was actually housed on the male side of the treat-
         ience working with elderly patients and              ment unit. Once housed on the male unit [S.B.]
         knowledge of “swallowing mechanism”                  should have been provided a room which could
         qualified to offer opinion on cause of pa-           not be accessed by unsupervised male patients.
         tient's aspiration and death after defendant         Instead her room was accessed by an unsuper-
         placed her on non-pureed diet).                      vised male, who, she reported, sexually assaulted
                                                              her. It is my best professional medical opinion
2. Adequacy of Report Regarding Causation                     from the available reviewed materials that Tim-
     [15][16] An expert report need not marshal the           berlawn failed to provide individualized assess-
claimant's evidence, but it should explain the basis          ment, and failed to provide particularly adequate
of the expert's opinions and link his conclusions to          protection from harm such as sexual victimiza-
the facts. Bowie Mem'l Hosp., 79 S.W.3d at 52.                tion. Specifically, that Timberlawn breached its
Thus, Levine's report should link Timberlawn's al-            duty by housing [S.B.] in such a manner that a
leged negligence with S.B.'s alleged harm or injur-           male patient was able to obtain access to her for
ies-her sexual assault by a male patient. See Bowie           sexual victimization.
Mem'l Hosp., 79 S.W.3d at 52; Costello v. Christus
Santa Rosa Health Care Corp., 141 S.W.3d 245,                    According to Levine, if Timberlawn had fol-
249 (Tex.App.-San Antonio 2004, no pet.)                    lowed the standard of care, S.B. would have been
(“[C]ausation is established by proof that the negli-       housed on the girls side of the treatment unit
gent act or omission was a substantial factor in            “where she would not have been exposed to harm
bringing about the harm and without which the               and/or victimization from male patients.” The re-
harm would not have occurred.”).                            port also indicates that housing S.B. in a male unit
                                                            “exposed her to harm which resulted in her self re-
     Levine's report states the applicable standard of      ported rape. Had [S.B.] been housed in a safe and
care required Timberlawn to “provide individual-            appropriate manner, given her propensity for sexual
ized assessment, and adequate medical treatment in          victimization, she would not have been placed in a
the least restrictive environment and access to ad-         male unit.”
vocacy services.” Specifically, because S.B. had a
history of past sexual victimization and “the risk               The report also addresses how the breach of the
factors of a co-morbid developmental disability and         standard of care caused S.B.'s injury. Specifically,
a psychiatric disorder, the standard of care required       the report states housing S.B.
Timberlawn to provide[ ] housing where [S.B.]
                                                              in the male unit exposed her to harm which resul-
could not be accessed by unsupervised males.” The
                                                              ted in her self reported rape. Had [S.B.] been
report also states: “If [S.B.] needed to be housed on
                                                              housed in a safe and appropriate manner, given
a unit where males would be located, the standard
                                                              her propensity for sexual victimization, she
of care would require Timberlawn to provide a
                                                              would not have been placed in a male unit. By
room which could not be accessed by an unsuper-
                                                              being housed in a male unit it was foreseeable
vised male.”
                                                              that [S.B.] would be exposed to and was at higher
     Levine stated Timberlawn breached the stand-             risk for the exact self reported harm which she
ard of care by failing to provide S.B. with individu-         suffered which was the assault she reported by a
                                                                                        FN4
alized assessment, adequate *214 medical treatment            16 year old male patient.
in the least restrictive environment, and an environ-
ment and housing where she would be kept safe.

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281 S.W.3d 207
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        FN4. Levine's report also states in part:                     thoughts. After being at home less than
                                                                      two [w]eeks she was readmitted to an-
          Had Timberlawn followed the applicable                      other facility, Green Oaks where she had
          standard of care discussed above, and                       to restart with a new therapy program.
          not breached the standard of care, as dis-
          cussed above, [S.B.] would have been                   We conclude Levine's report identified the spe-
          properly evaluated, and properly housed           cific conduct of Timberlawn called *215 into ques-
          on the girls side of the treatment Unit           tion by S.B. and provided a sufficient basis for the
          she would have been in the least restrict-        trial court to conclude the claim has merit. See
          ive environment, where she would not              Palacios, 46 S.W.3d at 879. Therefore, the trial
          have been exposed to harm and/or vic-             court did not abuse its discretion in denying the
          timization from male patients. Had Tim-           motion to dismiss. We overrule Timberlawn's is-
          berlawn carefully reviewed [S.B.'s] past          sues concerning the adequacy of the expert report.
          medical, psychiatric and educational
          database and made an adequate current                                CONCLUSION
          evaluation, they would have identified                 Having rejected all of Timberlawn's issues, we
          the past history of sexual victimization          affirm the trial court's order.
          and the risk factors of a co-morbid de-
                                                            Tex.App.–Dallas,2009.
          velopmental disability and psychiatric
                                                            UHS of Timberlawn, Inc. v. S.B. ex rel. A.B.
          disorder which made [S.B.] more sus-
                                                            281 S.W.3d 207
          ceptible to sexual victimization and
          which required an enhanced specific               END OF DOCUMENT
          treatment and protection....

          The Sexual Assault reported by [S.B.]
          resulted in a termination of her stay at
          Timberlawn, rape crises intervention,
          fear of pregnancy and due to deteriora-
          tion of her mental state the eventual re-
          admittance to another facility. As a dir-
          ect and proximate cause of the improper
          housing and security provided, [S.B.] re-
          ported a sexual assault which stopped
          her treatment at Timberlawn and re-
          quired her to be sent to Parkland Hospit-
          al for a rape exam. At the age of 13 she
          was prescribed and took the morning
          after pill to prevent a pregnancy. The re-
          cords show that she developed a fear of
          getting pregnant or catching a disease.
          She was unable to complete her therapy
          program at Timberlawn and went home.
          She continued to miss school and the
          home therapist reported that she contin-
          ued to be upset and had suicidal

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243 S.W.3d 165
(Cite as: 243 S.W.3d 165)

                                                            Code § 74.351(a), (r)(6).

          Court of Appeals of Texas,                        [2] Health 198H         804
                 San Antonio.
   Michael Fawzy WISSA, M.D., Appellant,                    198H Health
                      v.                                         198HV Malpractice, Negligence, or Breach of
 Mark VOOSEN, Karen Voosen, and Mary Eliza-                 Duty
      beth (“Emmy”) Voosen, Appellees.                             198HV(G) Actions and Proceedings
                                                                       198Hk804 k. Affidavits of Merit or Merit-
                No. 04–07–00386–CV.                         orious Defense; Expert Affidavits. Most Cited
                    Sept. 26, 2007.                         Cases
                                                                 In determining whether the expert report con-
Background: Patient brought action against doc-             stitutes a good faith attempt to comply with Medic-
tors and anesthesiologist for medical negligence, al-       al Liability and Insurance Improvement Act, courts
leging failure to properly diagnose and treat her           look no further than the report itself, and while the
wound infection resulting in unnecessary surgeries,         report need not marshal all of the plaintiff's proof, it
chronic infection, pain and suffering and impair-           must include the expert's opinion on each of the
ment to her ankle. The 45th Judicial District Court,        elements identified in the Act: standard of care,
Bexar County, Janet P. Littlejohn, J., denied anes-         breach, and causation. V.T.C.A., Civil Practice &
thesiologist's motion to dismiss, and he appealed.          Remedies Code § 74.351(l).

Holding: The Court of Appeals, Phylis J. Speedlin,          [3] Health 198H         804
J., held that doctor's expert report was adequate un-
der Medical Liability and Insurance Improvement             198H Health
Act.                                                            198HV Malpractice, Negligence, or Breach of
                                                            Duty
    Affirmed.                                                     198HV(G) Actions and Proceedings
                                                                      198Hk804 k. Affidavits of Merit or Merit-
                  West Headnotes
                                                            orious Defense; Expert Affidavits. Most Cited
[1] Health 198H       804                                   Cases
                                                                Expert report under Medical Liability and In-
198H Health                                                 surance Improvement Act need not present evid-
     198HV Malpractice, Negligence, or Breach of            ence as if the plaintiff were actually litigating the
Duty                                                        merits, but it must do more than merely state the
       198HV(G) Actions and Proceedings                     expert's conclusions about the statutory require-
          198Hk804 k. Affidavits of Merit or Merit-         ments. V.T.C.A., Civil Practice & Remedies Code
orious Defense; Expert Affidavits. Most Cited               § 74.351(r)(6).
Cases
    In order to comply with statutory requirements,         [4] Appeal and Error 30          960(1)
expert report in medical malpractice action must
                                                            30 Appeal and Error
both inform the defendant of the specific conduct
                                                               30XVI Review
the plaintiff has called into question, and provide a
                                                                  30XVI(H) Discretion of Lower Court
basis for the trial court to conclude that the claims
                                                                       30k960 Rulings on Motions Relating to
have merit. V.T.C.A., Civil Practice & Remedies
                                                            Pleadings

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243 S.W.3d 165
(Cite as: 243 S.W.3d 165)

               30k960(1) k. In General. Most Cited          inquiry at trial, or during a summary judgment pro-
Cases                                                       ceeding, it was simply not a determination contem-
     Appellate courts review a trial court's determ-        plated or required with respect to anesthesiologist's
ination about the adequacy of an expert report un-          motion to dismiss, challenging the adequacy of ex-
der Medical Liability and Insurance Improvement             pert report. V.T.C.A., Civil Practice & Remedies
Act for abuse of discretion. V.T.C.A., Civil Prac-          Code § 74.351(l).
tice & Remedies Code § 74.351(r)(6).
                                                            [7] Health 198H       804
[5] Health 198H       804
                                                            198H Health
198H Health                                                      198HV Malpractice, Negligence, or Breach of
    198HV Malpractice, Negligence, or Breach of             Duty
Duty                                                               198HV(G) Actions and Proceedings
      198HV(G) Actions and Proceedings                                198Hk804 k. Affidavits of Merit or Merit-
         198Hk804 k. Affidavits of Merit or Merit-          orious Defense; Expert Affidavits. Most Cited
orious Defense; Expert Affidavits. Most Cited               Cases
Cases                                                            Under Medical Liability and Insurance Im-
                                                            provement Act, a qualified expert in a similar field
Judgment 228        181(33)                                 may testify as to the accepted standards of care if
                                                            he can demonstrate within the expert report that he
228 Judgment
                                                            possesses knowledge about the care or treatment
   228V On Motion or Summary Proceeding
                                                            delivered by the defendant and the diagnosis, care
       228k181 Grounds for Summary Judgment
                                                            or treatment of the condition involved in the claim.'
          228k181(15) Particular Cases
                                                            V.T.C.A., Civil Practice & Remedies Code §
              228k181(33) k. Tort Cases in General.
                                                            74.402(b).
Most Cited Cases
    A motion to dismiss seeks to demonstrate that a         [8] Health 198H       804
plaintiff has not satisfied the procedural require-
ments with respect to expert report under Medical           198H Health
Liability and Insurance Improvement Act, while a                 198HV Malpractice, Negligence, or Breach of
motion for summary judgment seeks to demonstrate            Duty
that the substance of the claim lacks merit.                       198HV(G) Actions and Proceedings
V.T.C.A., Civil Practice & Remedies Code §                            198Hk804 k. Affidavits of Merit or Merit-
74.351(r)(6).                                               orious Defense; Expert Affidavits. Most Cited
                                                            Cases
[6] Health 198H       804                                       Doctor's expert report established that he was
                                                            practicing health care in field of practice that in-
198H Health
                                                            volved the same type of care or treatment as
     198HV Malpractice, Negligence, or Breach of
                                                            provided by anesthesiologist to patient, and further
Duty
                                                            established the necessary experience and know-
       198HV(G) Actions and Proceedings
                                                            ledge to render expert opinion, and thus, the expert
          198Hk804 k. Affidavits of Merit or Merit-
                                                            report was adequate under Medical Liability and In-
orious Defense; Expert Affidavits. Most Cited
                                                            surance Improvement Act; expert report set forth
Cases
                                                            applicable standards of care required of a licensed
     While anesthesiologist's challenge to the scope
                                                            physician, such as anesthesiologist, when complet-
of his legal duty to patient might indeed be a proper
                                                            ing a history and physical examination on pre-

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243 S.W.3d 165
(Cite as: 243 S.W.3d 165)

operative patient and when serving as supervising           the patient's required history and physical examina-
physician for podiatrist conducting a surgical pro-         tion. The history and physical form that Dr. Wissa
cedure. V.T.C.A., Civil Practice & Remedies Code            completed listed him as “Examining M.D. for Podi-
                                                                   FN1
§ 74.351(l), (r)(6).                                        atry.”        Dr. Wissa did not treat Emmy again
                                                            after her second surgery.
*166 Diana L. Faust, R. Brent Cooper, Michelle E.
Robberson, Cooper & Scully, P.C., Dallas, TX,                        FN1. A podiatrist is licensed to practice
Karen R. Roberts, Rosemary L. Hollan, Hollan Law                     podiatry. TEX. OCC.CODE ANN. §
Firm, P.C., San Antonio, TX, for Appellant.                          202.001(3)(A) (Vernon 2004). “Podiatry”
                                                                     means the treatment of or offer to treat any
Jon T. Powell, The Powell Law Firm, Brant S. Mit-                    disease, disorder, physical injury, deform-
tler, M.D., J.D., San Antonio, TX, for Appellees.                    ity, or ailment of the human foot by any
                                                                     system or method. Id. § 202.001(a)(4)
*167 Sitting: CATHERINE STONE, Justice,                              (Vernon 2004).
PHYLIS J. SPEEDLIN, Justice, STEVEN C. HIL-
                                                                 Emmy developed complications at the surgical
BIG, Justice.
                                                            site. She and her parents ultimately sued five de-
                                                            fendants, including Dr. Wissa, for medical negli-
                       OPINION                              gence, alleging failure to properly diagnose and
Opinion by PHYLIS J. SPEEDLIN, Justice.                     treat her wound infection resulting in unnecessary
     In this interlocutory appeal, we are asked to de-      surgeries, chronic infection, pain and suffering and
termine if the trial court abused its discretion when       impairment to her ankle. The Voosens timely
it denied Dr. Michael Wissa's motion to dismiss the         served the expert report of Marvin Brown, M.D. Dr.
underlying medical malpractice suit against him.            Wissa objected to Dr. Brown's report as it pertained
Finding no error, we affirm the trial court's order.        to him and filed a motion to dismiss under section
                                                            74.351(b) of the Texas Civil Practice and Remedies
    FACTUAL AND PROCEDURAL BACK-                            Code. TEX. CIV. PRAC. & REM.CODE ANN. §
                    GROUND                                  74.351(b) (Vernon Supp.2006). The trial court
    The facts relevant to this appeal are essentially       denied Dr. Wissa's motion and this interlocutory
undisputed. Mary Elizabeth Voosen (“Emmy”), a               appeal was perfected.
16 year old high school student, athlete, and cheer-
leader sought medical evaluation and treatment for               In one issue, Dr. Wissa maintains the trial court
chronic right ankle pain. Initially, Marque Allen,          abused its discretion in denying his motion to dis-
D.P.M., a podiatrist employed by Sports Medicine            miss the medical malpractice suit against him. Dr.
Associates of San Antonio, evaluated Emmy and               Wissa first argues the trial court failed to determine
determined that her ankle was unstable due to a lig-        as a matter of law that Dr. Wissa owed no legal
                                                                                                         FN2
ament injury. To correct the problem, Dr. Allen             duty to Emmy as a podiatrist or surgeon.          Spe-
performed a surgical procedure on Emmy's right              cifically, Dr. Wissa maintains the standard of care
ankle on October 29, 2004. Subsequently, on                 set forth in Dr. Brown's report does not apply to
November 29, 2004, Dr. Allen saw Emmy in follow             him in his limited role as an anesthesiologist. In a
up and scheduled a second surgery on Emmy's                 related argument, Dr. Wissa also maintains Dr.
ankle for the next day. Immediately prior to her            Brown's expert report fails to establish that he is
second surgery, Emmy met with the anesthesiolo-             qualified to render an opinion about the standards
gist for the procedure, Dr. Michael Wissa. Dr.              of care applicable to Dr. Wissa in his role as an an-
Wissa performed a pre-anesthesia evaluation prior           esthesiologist.*168 In response, the Voosens con-
to administering anesthesia and also documented             tend Dr. Brown's report meets the statutory require-

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ments necessary for an expert report under section          pert report in Subsection (r)(6).” TEX. CIV. PRAC.
74.351(b) of the Texas Civil Practice and Remedies          & REM.CODE ANN. § 74.351(l ) (Vernon
Code. TEX. CIV. PRAC. & REM.CODE ANN. §                     Supp.2006). In determining whether the expert re-
74.351(b).                                                  port constitutes a good faith attempt to comply with
                                                            the statute, we look no further than the report itself.
        FN2. Dr. Wissa also argues that “the trial          See Palacios, 46 S.W.3d at 878 (the only informa-
        court erroneously relied on expert testi-           tion relevant to the inquiry is within “the four
        mony about duty to impliedly find Dr.               corners” of the report). While the report need not
        Wissa owed the duties of a podiatrist or            marshal all of the plaintiff's proof, it must include
        surgeon even though Dr. Wissa only                  the expert's opinion on each of the elements identi-
        formed a physician-patient relationship for         fied in the statute: standard of care, breach, and
        the purposes of administering anesthesia to         causation. Id. at 878–79; Tovar, 185 S.W.3d at 68.
        Emmy....”                                           The report need not present evidence as if the
                                                            plaintiff were actually litigating the merits, but it
APPLICABLE LAW AND STANDARD OF RE-
                                                            must do more than merely state the expert's conclu-
                       VIEW
                                                            sions about the statutory requirements. Palacios, 46
     [1] In a medical malpractice lawsuit such as the
                                                            S.W.3d at 879. In addition to expressing a fair sum-
one before us, a claimant must timely provide each
                                                            mary of the expert's opinions on the three elements
defendant health care provider an expert report with
                                                            of an expert report, the report must be rendered by
the expert's curriculum vitae. TEX. CIV. PRAC. &
                                                            an expert qualified to testify under section 74.401.
REM.CODE         ANN.      §    74.351(a)    (Vernon
                                                            TEX. CIV. PRAC. & REM.CODE ANN. § 74.401
Supp.2006). The Chapter 74 expert report must
                                                            (Vernon 2005). We review a trial court's determina-
provide “a fair summary of the expert's opinions as
                                                            tion about the adequacy of an expert report under
of the date of the report regarding applicable stand-
                                                            an abuse of discretion standard. Bowie Mem'l Hosp.
ards of care, the manner in which the care rendered
                                                            v. Wright, 79 S.W.3d 48, 52 (Tex.2002). A trial
by the physician or health care provider failed to
                                                            court abuses its discretion when it acts in an arbit-
meet the standards, and the causal relationship
                                                            rary or unreasonable manner without reference to
between that failure and the injury, harm, or dam-
                                                            any guiding rules or principles. Id.
ages claimed.” TEX. CIV. PRAC. & REM.CODE
ANN. § 74.351(r)(6) (Vernon Supp.2006). In order                                DISCUSSION
to comply with the statutory requirements, the re-               [5] Dr. Wissa first argues the trial court erred
port must both inform the defendant of the specific         in failing to properly analyze and apply the law re-
conduct the plaintiff has called into question, and         garding legal duty. He maintains his duty to Emmy
provide a basis for the trial court to conclude that        was limited because he was only engaged to
the claims have merit. Am. Transitional Care Ctrs.          provide anesthesiology services; therefore, the trial
of Tex., Inc. v. Palacios, 46 S.W.3d 873, 879               court should have made a threshold determination
(Tex.2001); Tovar v. Methodist Healthcare Sys. of           that Dr. Wissa owed no legal duty to Emmy as a
San Antonio, Ltd., L.L.P., 185 S.W.3d 65, 67–68             podiatrist or surgeon. Dr. Wissa cites several cases
(Tex.App.-San Antonio 2005, pet. denied).                   for the legal proposition that the existence of duty
                                                            in a medical negligence case is a *169 question of
     [2][3][4] If the affected physician or health
                                                            law the trial court must make before it considers the
care provider challenges the report's adequacy by a
                                                            applicable standard of care. See, e.g., Praesel v.
motion to dismiss, the trial court must grant the mo-
                                                            Johnson, 967 S.W.2d 391, 394 (Tex.1998)
tion “only if it appears to the court, after hearing,
                                                            (threshold question for court is whether treating
that the report does not represent an objective good
                                                            physicians have legal duty to third parties to warn
faith effort to comply with the definition of an ex-

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epileptic patients not to drive); St. John v. Pope,         surgery, filled out her history and physical form,
901 S.W.2d 420, 423 (Tex.1995) (duty of on-call             and provided the anesthesia for her surgery. In-
physician consulted over telephone must be decided          stead, Dr. Wissa disputes that his duty to Emmy ex-
before issue of standard of care). None of the cases        tended beyond his role in providing anesthesia, or
cited by Dr. Wissa, however, involve a Chapter 74           that by completing a history and physical form pri-
expert report. Instead, each case cited by Dr. Wissa        or to the procedure he assumed “full responsibility
arises in the context of a summary judgment pro-            for Dr. Allen's conduct and all aspects of Emmy's
ceeding, which we find readily distinguishable from         care before, during and after the procedure.” He ar-
a motion to dismiss filed under section 74.351.             gues that the trial court should have determined, as
Compare TEX. CIV. PRAC. & REM.CODE ANN.                     a matter of law, that he did not have a duty to
§ 74.351(r)(6) (expert report must address each ele-        Emmy outside the administration of anesthesia,
ment identified in the statute-applicable standard of       and, accordingly, should have ignored Dr. Brown's
care, breach and causal relationship) with TEX.R.           report and criticisms to the contrary. As noted by
CIV. P. 166a(c) (summary judgment is proper                 the Supreme Court in Praesel, in deciding whether
where no genuine issue exists as to any material            a legal duty exists, among other factors, the court
fact). While the purposes of a motion to dismiss un-        “weigh[s] the risk, foreseeability and likelihood of
der section 74.351 and a motion for summary judg-           injury against the social utility of the actor's con-
ment are similar in some respects, their scope is           duct, the magnitude of the burden of guarding
clearly different. See Farishta v. Tenet Healthsys-         against the injury and the consequences of placing
tem Hospitals Dallas, Inc., 224 S.W.3d 448, 453             that burden on the defendant.” Praesel, 967 S.W.2d
(Tex.App.-Fort Worth 2007, no pet.) (noting that            at 397; Graff v. Beard, 858 S.W.2d 918, 920
both seek to eliminate frivolous claims). A motion          (Tex.1993) (decision to impose common law duty
to dismiss seeks to demonstrate that a plaintiff has        involves complex considerations of public policy
not satisfied the procedural requirements of                and their application to the particular facts of case).
Chapter 74, while a motion for summary judgment             While Dr. Wissa's challenge to the scope of his leg-
seeks to demonstrate that the substance of the claim        al duty to Emmy may indeed be a proper inquiry at
lacks merit. See Smalling v. Gardner, 203 S.W.3d            trial, or during a summary judgment proceeding, it
354, 367 (Tex.App.-Houston [14th Dist.] 2005, pet.          *170 is simply not a determination contemplated or
denied); see also Apodaca v. Russo, 228 S.W.3d              required under the statutory language of Chapter
252, 255 (Tex.App.-Austin 2007, no pet.) (expert            74. See TEX. CIV. PRAC. & REM.CODE ANN. §
report is not required to prove defendant's liability,      74.351(l ) (“[a] court shall grant a motion challen-
but rather to provide notice of what conduct forms          ging the adequacy of an expert report only if it ap-
the basis for plaintiff's complaints); see also Pala-       pears to the court, after hearing, that the report does
cios, 46 S.W.3d at 879 (“[t]o avoid dismissal, a            not represent an objective good faith effort to com-
plaintiff need not present evidence in the report as        ply with the definition of an expert report....”).
if it were actually litigating the merits. The report
can be informal in that the information in the report            [7] Dr. Wissa also challenges Dr. Brown's
does not have to meet the same requirements as the          qualifications to render an opinion on the standards
evidence offered in a summary-judgment proceed-             of care applicable to Dr. Wissa in his role as the an-
ing or at trial”).                                          esthesiologist for Emmy's surgery. Dr. Wissa points
                                                            out that Dr. Brown does not recite any education,
    [6] Furthermore, Dr. Wissa does not dispute             training or experience in the administration of anes-
that he had a physician-patient relationship with           thesia during a podiatric surgical procedure for
Emmy, and therefore, owed some duty to Emmy.                debridement and wound closure. We respectfully
He admits he physically examined her prior to her           disagree that only an expert in the same specialty

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field of practice can qualify as an expert for pur-                  Schmidt and Dr. Michael F. Wissa and is
poses of a Chapter 74 report. See TEX. CIV.                          over eighteen pages in length. It details Dr.
PRAC. & REM.CODE ANN. § 74.402(b) (Vernon                            Brown's credentials, documents reviewed,
2005). According to the statute, in order to testify                 and the patient's history, and devotes over
about the accepted standards of care, a person must:                 five pages to Dr. Wissa's care of Emmy.
(1) be practicing in “a field of practice that involves
the same type of care or treatment as that delivered          [I] am fully qualified to render opinions about the
by the defendant health care provider;” (2) possess           standard of care, breaches of the standard of care,
“knowledge of accepted standards of care ... for the          and causation with respect to the damages caused
diagnosis, care, or treatment of the illness, injury,         by those breaches to Ms. Voosen by virtue of the
or condition involved in the claim;” and (3) be               fact that the process of pre-operative evaluation
“qualified on the basis of training or experience to          as ‘Examining M.D. for Podiatry’ is the same for
offer an expert opinion regarding those accepted              orthopedic surgeons and any other medical doctor
standards of health care.” Id. Accordingly, a quali-          of any specialty who takes on that responsibility
fied expert in a similar field may testify as to the          or who fails to take on that responsibility. The
accepted standards of care if he can demonstrate              specific skills to perform a competent History
within the report that he possesses knowledge about           and Physical *171 Examination and Assessment
the “care or treatment ... delivered by the defend-           and Plan are taught to all medical students in all
ant” and “the diagnosis, care or treatment of the ...         specialty areas and contain common elements for
condition involved in the claim.” Id.                         all specialties, whether orthopedic surgery or an-
                                                              esthesiology.
     [8] Turning to the report, it is undisputed that         The report further details ten standards of care
Dr. Brown's report does not criticize Dr. Wissa's             “for Dr. Michael Wissa in treating patients with
actual administration of anesthesia, but instead, sets        conditions like or similar to those experienced by
forth the applicable standards of care required of a          Emmy Vossen” and the manner in which the care
licensed physician such as Dr. Wissa when com-                provided by Dr. Wissa failed to meet the enumer-
pleting a history and physical examination on a pre-          ated standards. For example, Dr. Brown opines
operative patient like Emmy and when serving as a             that when he performed a physical examination
supervising physician for a podiatrist conducting a           for purposes of filling out the history and physic-
surgical procedure like the procedure done on                 al form, Dr. Wissa was expected, as a medical
Emmy. Additionally, it is undisputed that the report          doctor, to diagnose a wound infection and to re-
adequately sets forth Dr. Brown's credentials and             cognize that it required hospitalization and
vast experience as a board certified orthopedic sur-          “urgent consultation with other specialists.”
geon and his familiarity with lower leg, foot and
                                             FN3                 Based on the record before us, Dr. Brown's re-
ankle problems, including wound infection.         Dr.
Brown's report states that he knows the accepted            port establishes that he is practicing health care in a
standard of care required of Dr. Wissa and details          field of practice that involves the same type of care
the manner in which he is familiar with the accep-          or treatment as provided by Dr. Wissa to Emmy,
ted standards of care for completing pre-operative          and further establishes the necessary experience
history and physical examinations and serving as a          and knowledge to render an expert opinion. Ac-
supervising physician for a podiatrist. For example,        cordingly, the trial court did not abuse its discretion
Dr. Brown affirmatively states:                             when it denied Dr. Wissa's motion to dismiss. We
                                                            affirm the trial court's order.
         FN3. Dr. Brown's report dated February
         19, 2007 is directed at both Dr. David R.          Tex.App.–San Antonio,2007.
                                                            Wissa v. Voosen

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243 S.W.3d 165

END OF DOCUMENT

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