Court Opinion

ID: 6499017
Source: CourtListenerOpinion
Date Created: 2022-07-11 00:12:20.670233+00
Date Added: 2024-06-11T09:10:06.649141
License: Public Domain

Affirmed and Memorandum Opinion filed July 7, 2022.

                                     In The

                    Fourteenth Court of Appeals

                             NO. 14-20-00698-CV

NORTH HOUSTON TRMC, LLC D/B/A HCA HOUSTON HEALTHCARE
                 TOMBALL, Appellant
                                       V.
    RANDI POTEET, RHONDA POTEET, AND REBA POTEET AS
   WRONGFUL DEATH BENEFICIARIES OF MEDALLION POTEET,
                    DECEASED, Appellee

                   On Appeal from the 133rd District Court
                            Harris County, Texas
                      Trial Court Cause No. 2020-02559

                         MEMORANDUM OPINION

      In this health care liability case, the defendant-appellant North Houston
TRMC, LLC (the “Hospital”) appeals the trial court’s overruling of objections it
filed to the Chapter 74 expert report served on it by the Plaintiff-appellees. We
affirm.
                    I. FACTUAL AND PROCEDURAL BACKGROUND

       Plaintiff-appellees, Randi, Rhonda, and Reba Poteet, the three adult children
surviving Medallion Poteet (the “Poteet Family”), sought wrongful death and
survival claims against the Hospital arising from alleged substandard post-
operative care resulting in their mother’s death. The Poteet Family served their
Chapter 74 expert report, authored by W. Owen Cramer, M.D., a local board
certified general surgeon, along with his curriculum vitae. The Hospital timely
objected to the report, and the Poteet Family served Dr. Cramer’s amended report.
As is common in such reports, before setting expert opinions, the report recites the
essential facts upon which the opinions are based.

            Medallion’s treatment at Tomball Regional Medical Center.1

       On October 11, 2018, eighty-two-year-old Medallion Poteet went to the
office of Dr. Brian Harkins complaining of abdominal discomfort and bloating.
She was diagnosed with cholecystitis (inflammation of the gallbladder), and
gastrointestinal reflux. Four days later, on October 15, 2018, at Tomball Regional
Hospital, Dr. Harkin performed gallbladder surgery on Ms. Poteet (“a robotically
assisted laparoscopic cholecystectomy and fundoplication”).

       During the immediate postoperative period Ms. Poteet “was noted to have
pain of a significant nature which was not being taken care of by pain medication
that had been prescribed in an adequate fashion.” Later that evening “[Poteet] was
noted to be hyposensitive when her normal blood pressure and state was that of an
[sic] hypertensive patient.” The next day, October 16, 2018, the Hospital’s nursing
staff alerted the on-call surgeon to her symptoms. The on-call surgeon discovered
Poteet was suffering from an “acute abdomen” and decided she needed immediate
1
  The facts regarding the treatment discussed here derive from what is provided in the expert
report at issue.

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surgery. During this surgery the on-call surgeon discovered and repaired “a small
bowel perforation that had likely occurred during” the original surgery.

         Plaintiffs’ expert, Dr. Cramer, states that “although the bowel was repaired
and her abdomen adequately washed out, she remained extremely ill and in septic
shock. She subsequently died two days later.”

                   Chapter 74 expert report objections and proceedings.
         The Hospital’s subsequent objections to the amended report were the subject
of the trial court’s order now appealed from.                 Among other contentions, the
Hospital’s objections set out the following argument:

         [Dr. Cramer’s] deficient opinions directly contradict the medical
         records. Dr. Cramer claims the nurses should have notified the
         physician of Ms. Poteet’s supposed hypotension on the evening of the
         15th. See Exhibit A at 2.2 However, the records establish that Ms.
         Poteet did not become hypotensive until the morning of the 16th,
         promptly after which the nurses notified the on-call physician. Her
         blood pressure was well within the parameters set out by her attending
         physician on the 15th. That is, instead of acknowledging and
         addressing the facts of this case, Dr. Cramer suggests she had a
         medical condition that did not yet exist and criticizes the nursing staff
         for failing to notify the physician of that non-existent condition.
         The Hospital did not attach the medical records alleged to contradict the
factual recitations in Dr. Cramer’s report.              Neither party included any of the
medical records in any of the papers on file with the trial court. In their written
objections to the amended report, the Hospital primarily sought to attack the
report’s causation opinion as deficient.

                           Motion for reconsideration and appeal.

         The trial court overruled the Hospital’s objections on September 20, 2020.

2
    The Hospital’s “Exhibit A” is a copy of Dr. Cramer’s expert report.

                                                  3
Five days later, the Hospital moved for reconsideration at which time the Hospital
attached various medical records for the first time. With the support of these
medical records, the Hospital argued that Dr. Cramer’s report misstates the facts
and timing of Ms. Poteet’s condition while at the Hospital. On October 12, 2020,
the Hospital filed its notice of appeal of the trial court’s order of September 20,
2020. There is no indication in the clerk’s record that the trial judge was ever
made aware of or ruled on the motion for reconsideration. The Hospital’s appeal
relies in significant part on the medical records filed after the trial court’s ruling on
its objections.

                     II. CHAPTER 74 EXPERT REPORT MOTION

      In two issues the Hospital complains that the trial court abused its discretion,
first in its finding that Dr. Cramer’s report represents an objective good faith effort
to address the applicable standard of care and breach, and second, by finding his
report represents an objective good faith effort to address causation.

A. Standard of Review.

      We apply an abuse-of-discretion standard when reviewing a trial court’s
decision as to the adequacy of an expert report. See Van Ness v. ETMC First
Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam). The trial court abuses
its discretion if it acts arbitrarily, unreasonably, or without reference to guiding
rules or principles. See Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.
2002). Although we may not substitute our judgment for that of the trial court, the
trial court has no discretion in determining what the law is or applying the law to
the facts. Id.; Sanjar v. Turner, 252 S.W.3d 460, 463 (Tex. App.—Houston [14th
Dist.] 2008, no pet.).

B. Dr. Cramer’s Opinions

                                           4
      After briefly describing the sequence of events that led to Ms. Poteet’s death
(discussed above), Dr. Cramer’s report sets the standard of care applicable to her
post-operative treatment. The standard of care is described in the report as follows:

      The standard of care for nursing personnel when dealing with
      postoperative patients requires that they report any deviation of what
      is expected as a normal postoperative course, as well as a deviation of
      the vital signs, to the attending physician as soon as it is noted.
As applied to the particular facts of the case, the report restates the standard of care
and identifies the breach as follows:

          • In this case, the prolonged significant postoperative pain that
            was described by the patient from the laparoscopic procedure,
            as well as the significant hypotension that occurred late that
            afternoon and into the evening of the 15th represents a
            significant change in the status of the patient and should have
            been immediately passed on to the attending physician or their
            designated covered physician.        This was not done and
            represents substandard care on the part of the nursing staff at
            Tomball Regional.
The remainder of the opinion provides the various components of Dr. Cramer’s
proximate cause opinion. This includes a paragraph about the foreseeability of
harm resulting from such a breach, which discusses the level of knowledge
expected of hospital nurses, which includes knowledge of the probable results of
their inaction. It states, “[i]t is foreseeable to a nurse that if he/she does not notify
the attending physician of changes in the patient’s status, then the patient will not
get adequate medical intervention for their condition.” In this paragraph, the report
explains that nurses are charged with knowing the following:

      • that increased pain and hypotension are significant medical issues
        which warrant notification of the medical staff.
      • that increased pain and hypotension are potential signs of an acute
        abdomen and that the medical staff must be notified to address
        these signs and symptoms.
                                           5
      • that the failure to address an acute abdomen can lead to serious
        injury or death of the patient.
The paragraph concludes with the statement that “[t]herefore, it was foreseeable to
the nursing staff that failure to communicate the pain and hypotension to the
medical staff could lead to Ms. Poteet’s death.”

      The following paragraph sets out Dr. Cramer’s description of the causal
sequence:

      In this case, the delay in notifying the medical staff of the pain and
      hypotension direction led to Ms. Poteet’s death. On the evening of the
      15th, if the nursing staff had contacted the medical staff, then the
      diagnosis of acute abdomen would have been made and Ms. Poteet
      would have been immediately taken to surgery on the evening of the
      15th as compared to later in the morning on the 16th. Ms. Poteet was
      showing signs of sepsis on the evening of the 15th, but did not go into
      septic shock until later on the 16th. If Ms. Poteet had been taken to
      surgery on the evening of the 15th when the nursing staff noted the
      pain and hypotension, then the bowel could have been repaired and a
      washout performed before she went into septic shock. Unfortunately,
      the delay from the 15th to the 16th allowed Ms. Poteet’s sepsis to
      profess [sic] to the point where she would not recover despite surgery.
      Then, Dr. Cramer’s states his ultimate causation opinion, that “[i]f the nurses
had appropriately communicated with physicians with [sic] the changes and
appearance of the patient in the immediate postoperative care an earlier
intervention could have occurred which would, in all reasonable medical
probability, have saved Ms. Poteet’s life.”

C. Chapter 74’s “Good-Faith” Requirements.

      Under section 74.351, a claimant, not later than the 120th day after the date a
health-care liability claim is filed, must serve on each party one or more expert
witness reports addressing liability and causation. Tex. Civ. Prac. & Rem. Code
Ann. § 74.351(a), (j) (West, Westlaw through 2017 R.S.); Lewis v. Funderburk,

                                          6
253 S.W.3d 204, 205 (Tex. 2008). The statute defines an “expert report” as

      [A] written report by an expert that provides a fair summary of the
      expert’s opinions as of the date of the report regarding applicable
      standards of care, the manner in which the care rendered by the
      physician or health care provider failed to meet the standards, and the
      causal relationship between that failure and the injury, harm, or
      damages claimed.

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6) (West, Westlaw through 2017
R.S.). A trial court shall grant a motion challenging the adequacy of the expert
report if the report is not an objective good-faith effort to comply with the
definition of an expert report provided in section 74.351(r)(6). Id. §§ 74.351(l),
(r)(6). The law limits the trial court’s inquiry to the four corners of the report.
Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010).

      A compliant report must include an explanation of the basis for the expert’s
statements and link the expert’s conclusions to the facts. Wright, 79 S.W.3d at 52;
Gannon v. Wyche, 321 S.W.3d 881, 897 (Tex. App.—Houston [14th Dist.] 2010,
pet. denied). A report that merely states the expert’s conclusions about the standard
of care, breach, and causation does not meet the statutory requirements. Am.
Transitional Care Centers of Tex., Inc. v. Palacios, 46 S.W.3d 873, 879 (Tex.
2001); see Wright, 79 S.W.3d at 53.

      To comply with these requirements, and constitute a “good-faith effort,” a
report must provide enough information to fulfill two purposes: (1) it must inform
the defendant of the specific conduct the plaintiff has called into question and (2) it
must provide a basis for the trial court to conclude that the claims have merit.
Palacios, 46 S.W.3d at 879; Gannon, 321 S.W.3d at 889. The report need not
marshal all of the plaintiff’s proof, but the report must include the expert’s opinion
on each of the elements identified in the statute: standard of care, breach, and

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causation. Palacios, 46 S.W.3d at 878–79.

D. Did the trial court abuse its discretion in concluding that the expert’s
opinions on standard of care and breach satisfied an objective good-faith
effort complying with section 74.351(r)(6)'s definition of an expert report?

      The Hospital’s first issue concerns the report’s standard of care and breach
opinions, but the Poteet family contends that the Hospital’s challenges to Dr.
Cramer’s standard of care and breach opinions are made for the first time on
appeal. We address both parties’ contentions.

      The Hospital’s objections in the trial court to Dr. Cramer’s amended report
set out the legal standards relevant to all required opinions in a Chapter 74’s expert
report; for standard of care, breach, and causation.       In the conclusion of its
argument the Hospital attacks, albeit generically, all statutory elements (including
standard of care and breach) in its statement: “Dr. Cramer’s report fails to satisfy
Chapter 74’s expert report requirements because it contains only conclusions about
the statutory elements in Section 74.351”. These facts tend to support that the
argument was preserved.

      But, to the Poteet Family’s preservation point, the analytical section of the
Hospital’s trial court objection primarily directed the court to review specific
complaints to Dr. Cramer’s causation opinions; not the standard of care or breach
opinions. And, at the hearing, the Hospital’s attorney focused on Dr. Cramer’s
causation opinion.    Moreover, on appeal, the Hospital’s standard of care and
breach arguments relate to the Hospital’s comparison of facts stated in the report
with selected medical records. The Hospital argues that the assumptions that
underlie Dr. Cramer’s expert report are belied by selected medical records. Though
the Hospital raised this extrinsic-evidence argument, it did not characterize it as an
attack on the report’s standard of care and breach opinions.

                                          8
      But even if we presume for the sake of argument that the court should have
been aware that these arguments were challenges to Dr. Cramer’s standard of care
and breach opinions, there are two problems with the Hospital’s arguments. First,
the Hospital’s extrinsic-evidence arguments (whether directed at the standard of
care, breach or causation) were not timely supported by the medical records at the
time of the court’s ruling on the objections, and therefore not preserved.3 The
medical records were not filed with the trial court until the Hospital filed its motion
for reconsideration which was never submitted nor ruled upon. Second, even if the
records had been filed with the trial court in the original objection to the expert
report, they would have fallen outside the trial court’s review, which was limited to
the four corners of the expert report. American Transitional Care Centers of Texas
v. Palacios, 46 S.W.3d 873, 878 (Tex. 2001); Loaisiga v. Cerda, 379 S.W.3d 248,
258 (Tex. 2012)(“In Palacios we held that the TMLA’s language requires a trial
court to determine a report’s adequacy from its four corners.”)

      Dr. Cramer’s opinions—which identify both the general standard of
postoperative care expected of the nurses, and in context, specific acts the nurses
were expected to but failed to perform to meet that general standard—were thus
not mere conclusions about the statutory elements. See, e.g., Baty v. Futrell, 543
S.W.3d 689, 695 (Tex. 2018) (report not conclusory where it did not require one to
infer what physician defendant should have done differently); Whitmire, 2020 WL
4983321, at *19 (expert’s report was not vague or conclusory because it identified
nurse’s specific negligent conduct—failure to recognize signs of preterm labor, and
adequately described what should have been done differently).

      We therefore overrule appellant’s first issue.

      3
          Tex. R. App. P. 33.1.

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E. Did the trial court abuse its discretion in concluding that the expert’s
opinions on causation satisfied an objective good-faith effort complying with
section 74.351(r)(6)'s definition of an expert report?

       The Hospital’s second issue concerns Dr. Cramer’s report’s causation
opinions. Proximate cause encompasses two components: (1) foreseeability and
(2) cause-in-fact.      Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526
S.W.3d 453, 460 (Tex. 2017). For a negligent act or omission to have been a
cause-in-fact of the harm, the act or omission must have been a substantial factor in
bringing about the harm, and absent the act or omission—i.e., but for the act or
omission—the harm would not have occurred. Id. For the amended report to
suffice as to causation, in it Dr. Cramer must explain “how and why” the alleged
negligence caused Ms. Poteet to go into septic shock that resulted her untimely
death, set forth the basis for his statements, and link his conclusions to specific
facts. See Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 224 (Tex. 2018).

       The report explains both how prompt communication from the nursing staff
would have prevented Poteet’s septic shock and subsequent death — by allowing
the treating physician to make an earlier diagnosis of the perforated bowel, and
why the delay ultimately caused Poteet’s death — because of the delay, she was
already in septic shock at the time of her second surgery. See Abshire, 563 S.W.3d
at 224.

       We disagree with the Hospital’s contention that Dr. Cramer’s report leaves
“gaps in the chain of causation” or is based on “impermissible assumptions” about
how Ms. Poteet’s treating physicians would respond.4 In two pages, Dr. Cramer’s
report:

       4
          Moreover, for the reasons already discussed, the extrinsic evidence relied on to support
the Hospital’s challenge to the facts Dr. Cramer has relied on in his report are unavailing at this
stage in the case.

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       (1) explains that the Hospital’s nurses were required to notify the
       attending physician of any worsening of Poteet’s condition;
       (2) details how the nurses failed to notify the attending physician of
       Poteet’s “prolonged significant postoperative pain” and “significant
       hypotension,”
       (3) sets out knowledge charged to hospital nurses, and the
       foreseeability of the harm that would follow from the nurses’ failure
       to notify and explains that the nurses should have been aware of these
       risks
       (4) provides the relevant conclusions concerning attending physican’s
       anticipated response and outcome of an earlier notification of Poteet’s
       symptoms,5 and
       (5) explains that this delayed reporting of Ms. Poteet’s worsening
       condition delayed the diagnosis of acute abdomen and ultimately led
       to her death.
       We conclude the trial court did not abuse its discretion in its implicit finding
that Dr. Cramer’s causation opinions satisfied an objective good-faith effort
complying with section 74.351(r)(6)'s definition of an expert report. See, e.g.,
Abshire, 563 S.W.3d at 225 (holding expert’s report provided a “straightforward
link” between nurses’ failure to properly document patient’s pain, to a delay in
diagnosis and proper treatment, and the ultimate injury); Tex. Children’s Hosp. v.
Knight, 604 S.W.3d 162, 180 (Tex. App.—Houston [14th Dist.] 2020, pet. filed)
(holding expert’s report satisfied TMLA where opinion explained the nursing
staff’s failure to notify the physicians of signs of circulatory distress caused a delay
in the physician’s diagnosis, which led to the plaintiff’s injury).

5
  In addition to the causation opinions discussed in section II.B above, the report provides the
conclusion that the on-call physician, if notified, would have acted:
       [I]f the attending physician or the physician’s designate had been made aware of the
       persistent significant pain, as well as hypotension, by the evening of the 15th that an
       evaluation would have occurred by the physicians monitoring the patient and they would
       have taken Ms. Poteet back to the operating room, resolved the injury to the small bowel,
       and she would in all reasonable medical probability, be alive today.

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      We therefore overrule appellant’s second issue.

                                 III. CONCLUSION

      Dr. Cramer’s report meets the applicable statutory standards for health care
liability case expert opinions. See Tex. Civ. Prac. & Rem. Code § 74.351(r). We
therefore overrule the Hospital’s issues and affirm the trial court’s order overruling
its objections.

                                       /s/    Randy Wilson
                                              Justice

Panel consists of Chief Justice Christopher, and Justices Zimmerer and Wilson.

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