Court Opinion

ID: 4372237
Source: CourtListenerOpinion
Date Created: 2019-02-28 16:42:56.182235+00
Date Added: 2024-06-11T14:49:37.180121
License: Public Domain

NUMBER 13-18-00231-CV

                             COURT OF APPEALS

                  THIRTEENTH DISTRICT OF TEXAS

                     CORPUS CHRISTI - EDINBURG

MARIA ZAMARRIPA, AS GUARDIAN
OF THE ESTATES OF R.F.R. AND
R.J.R., MINORS,                                                                    Appellant,

                                              v.

COLUMBIA VALLEY HEALTH CARE
SYSTEM, L.P., D/B/A VALLEY
REGIONAL MEDICAL CENTER,                                                            Appellee.

                    On appeal from the 445th District Court
                         of Cameron County, Texas.

                          MEMORANDUM OPINION
Before Chief Justice Contreras and Justices Benavides and Longoria
         Memorandum Opinion by Chief Justice Contreras

      This is an appeal of the trial court’s dismissal of a health care liability suit for failure

to comply with the expert report requirement of chapter 74 of the civil practice and
remedies code, the Texas Medical Liability Act (TMLA). See TEX. CIV. PRAC. & REM. CODE

ANN. § 74.351 (West, Westlaw through 2017 1st C.S.). Appellant Maria Zamarripa, as

guardian of the estates of R.F.R. and R.J.R., minors, argues by a single issue that the

trial court erred in granting the motion to dismiss filed by appellee, Columbia Valley Health

Care System, L.P., d/b/a Valley Regional Medical Center (VRMC), on the basis that

Zamarripa’s supplemental expert reports were insufficient on the issue of causation. We

reverse and remand.

                                           I. BACKGROUND

        The underlying suit arose from the tragic death of 36-year-old Yolanda Flores and

her unborn child. According to the pleadings, Flores was admitted to VRMC on March 6,

2012, for assessment of her pregnancy. At that time, she complained of back pain and

suprapubic pressure.          An ultrasound was performed, the results of which were

“suggestive of a complete placental previa.”1 On May 15, when Flores was around 32

weeks pregnant, she began vomiting and was taken by ambulance to VRMC, where she

was assessed and treated by obstetrician/gynecologist Patrick Ellis. An MRI showed

placenta accreta2 but no placental abruption.3 Dr. Ellis ordered Flores’s transfer from

        1 Placenta previa “occurs when a baby’s placenta partially or totally covers the mother’s cervix—
the outlet for the uterus. Placenta previa can cause severe bleeding during pregnancy and delivery.”
Placenta previa, MAYO CLINIC, https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-
causes/syc-20352768 (last visited Feb. 25, 2019).
        2  Placenta accreta is “a serious pregnancy condition that occurs when the placenta grows too
deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With
placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after
delivery.”    Placenta accreta, MAYO CLINIC, https://www.mayoclinic.org/diseases-conditions/placenta-
accreta/symptoms-causes/syc-20376431 (last visited Feb. 25, 2019).
        3 Placental abruption “occurs when the placenta partially or completely separates from the inner
wall of the uterus before delivery. This can decrease or block the baby’s supply of oxygen and nutrients
and cause heavy bleeding in the mother.” Placental abruption, MAYO CLINIC, https://www.mayoclinic.org/
diseases-conditions/placental-abruption/symptoms-causes/syc-20376458 (last visited Feb. 25, 2019).

                                                    2
VRMC in Brownsville to Bay Area Hospital (BAH) in Corpus Christi, over 150 miles away.

According to records, the transfer was ordered for a “medical necessity upgrade in care.”

BAH obstetrician/gynecologist Whitney Gonsoulin approved the transfer. While en route

to BAH, Flores suffered a placental abruption, causing severe bleeding. At BAH, an

emergency caesarian section and hysterectomy were performed. However, Flores and

her unborn child died that night.

        Zamarripa alleged in a petition in intervention4 that VRMC was negligent because

its nurses allowed Flores to be discharged on May 12, 2012, and because it allowed

Flores to be transferred to Corpus Christi.5 To comply with the TMLA’s expert report

requirement, Zamarripa filed reports by Frederick Harlass, M.D., and Grace Spears, a

registered nurse.        VRMC objected to the reports and moved to dismiss the suit,

contending that the reports were insufficient. The trial court overruled the objections and

denied the motion to dismiss, and we affirmed. Columbia Valley Healthcare Sys. L.P. v.

Zamarripa, 520 S.W.3d 62 (Tex. App.—Corpus Christi 2015), rev’d, 526 S.W.3d 453, 460

(Tex. 2017). On VRMC’s petition for review, the Texas Supreme Court reversed, holding

in part that “[i]n showing how and why a breach of the standard of care caused injury, the

expert report must make a good-faith effort to explain, factually, how proximate cause is

        4  Flores’s husband, Reynaldo Ramirez, initially filed suit in his personal capacity, as representative
of Flores’s estate, and as next friend of their minor children R.F.R. and R.J.R. Olga Flores and Zamarripa
later jointly filed a petition in intervention noting that, as temporary administrator of Flores’s estate and
temporary guardian for the minor children, respectively, they were the proper party representatives.
         Although Olga Flores and Zamarripa are both named plaintiffs in the final judgment and are
represented by the same counsel, only Zamarripa filed a notice of appeal. Accordingly, Olga Flores is not
a party to this appeal.
        5  Ramirez’s suit also named BAH, Ricardo Lemus, M.D., Ellis, Gonsoulin, and Hidalgo County
Emergency Medical Service Foundation as defendants. Zamarripa sought to intervene in the suit as to all
defendants. The causes of action against the non-VRMC defendants were severed from this case and are
not at issue in this appeal.

                                                      3
going to be proven.” 526 S.W.3d at 460. The Court noted that, though Spears stated in

her report that VRMC’s nurses breached their applicable standards of care, Spears could

not opine on causation.            Id. at 461 (citing TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(r)(5)(C) (providing that only a physician may provide expert testimony on the

causal relationship between a breach of the standard of care and injury)). And while

Harlass stated that VRMC caused Flores to be in an ambulance by “permitting and

facilitating the transfer” to BAH, he noted that it was Dr. Ellis—not VRMC or its nurses—

that actually ordered the transfer. Id. Because neither report explained how VRMC “had

either the right or the means to persuade Dr. Ellis not to order the transfer or to stop it

when he did,” the reports were insufficient to show that VRMC proximately caused

Flores’s injury and death. Id.

        On remand, the trial court granted Zamarripa a 30-day extension to file a compliant

report. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c). Zamarripa filed supplemental

expert reports, one by Spears and one by Steven Edmondson, M.D. Again, VRMC

objected to the reports and filed a motion to dismiss under chapter 74. This time, the trial

court sustained the objections and granted the motion. This appeal followed.6

                                             II. DISCUSSION

A.      Applicable Law and Standard of Review

        Under the TMLA, a plaintiff in a health care liability suit must serve the defendant

with a compliant expert report accompanied by the expert’s curriculum vitae.                             Id.

§ 74.351(a). If a plaintiff fails to do so within 120 days of filing suit, the trial court must

        6The parties refer to this appeal as an accelerated interlocutory appeal. However, the trial court
ordered all claims other than those against VRMC severed into a different cause number. Therefore, the
judgment on appeal is not interlocutory, and this appeal is not accelerated under the rules. Cf. TEX. R. APP.
P. 28.1.

                                                     4
dismiss the claim with prejudice on the defendant’s motion. Id. § 74.351(b)(2). The goal

of the statute is “to deter frivolous lawsuits by requiring a claimant early in litigation to

produce the opinion of a suitable expert that his claim has merit.” Zamarripa, 526 S.W.3d
453, 460 (Tex. 2017) (quoting Scoresby v. Santillan, 346 S.W.3d 546, 552 (Tex. 2011)).

Therefore, “[a]n expert report . . . is a low threshold a person [bringing a claim] against a

health care provider must cross merely to show that his claim is not frivolous.” Loaisiga

v. Cerda, 379 S.W.3d 248, 264 (Tex. 2012).

       To comply with the statute, an expert report must

       provide[] 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). A court must grant a motion challenging

the adequacy of an expert report only if it appears to the court, after hearing, that the

report does not represent an objective good-faith effort to comply with the definition of an

expert report set forth above. Id. § 74.351(l). A good-faith effort must provide enough

information to (1) inform the defendant of the specific conduct the plaintiff has called into

question, and (2) provide a basis for the trial court to conclude that the claims have merit.

Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d 510, 513 (Tex. 2017); Bowie

Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002) (per curiam). All information needed

for this inquiry is found within the four corners of the expert report, which need not marshal

all of the plaintiff’s proof. Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010)

       Notwithstanding the fact that chapter 74 speaks only of a “causal relationship” and

does not refer to “proximate cause,” the Texas Supreme Court has held that an expert

report must explain how and why the defendant’s breach proximately caused the plaintiff’s
                                              5
injury. Zamarripa, 526 S.W.3d at 460 (“[A] plaintiff asserting a health care liability claim

based on negligence, who cannot prove that her injury was proximately caused by the

defendant’s failure to meet applicable standards of care, does not have a meritorious

claim.”). Proximate cause has two components: (1) foreseeability and (2) cause-in-fact.

Rodriguez-Escobar v. Goss, 392 S.W.3d 109, 113 (Tex. 2013). For a negligent act or

omission to have been a cause-in-fact of the harm, it 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. If a negligent act or omission “merely

creat[es] the condition that makes the harm possible,” it is not a substantial factor in

causing the harm as a matter of law. Stanfield v. Neubaum, 494 S.W.3d 90, 97 (Tex.

2016). Foreseeability is shown by establishing that “a person of ordinary intelligence

should have anticipated the danger created by a negligent act or omission.”                Id.

Conjecture, guess, and speculation are insufficient to prove cause-in-fact and

foreseeability. Id.

       To satisfy chapter 74 with respect to proximate causation, the expert need not use

any particular words, such as “proximate cause,” “foreseeability,” or “cause in fact”;

however, the expert’s explanation of the plaintiff’s injuries must be more than a mere

conclusory assertion. Zamarripa, 526 S.W.3d at 460. The expert must “explain the basis

of his statements to link his conclusions to the facts.” Id.; Jelinek, 328 S.W.3d at 539

       We review a trial court’s decision on the sufficiency of an expert report for abuse

of discretion. Jelinek, 328 S.W.3d at 539. A court abuses its discretion if it acts in an

arbitrary or unreasonable manner and without reference to any guiding rules or principles.

Crawford v. XTO Energy, Inc., 509 S.W.3d 906, 911 (Tex. 2017). In our inquiry, we are

                                             6
precluded from filling gaps in a report by drawing inferences or guessing as to what the

expert likely meant or intended. Fulp v. Miller, 286 S.W.3d 501, 509 (Tex. App.—Corpus

Christi 2009, no pet.).

B.     Supplemental Expert Reports

       In her second report, Spears opined that the nurses at VRMC breached their

standard of care on May 15, 2012 by “failing to report labs related to low fibrinogen levels

to the physician caring for the patient.” Spears noted that “[l]ow fibrinogen levels in

patients with placenta accreta can lead to disseminated intravascular coagulation (DIC).”

Spears also stated that the nurses breached their standard of care by “not advocating for

further investigation of [Flores]’s continued abdominal pain/pressure” and by “allowing

[Flores] to be transferred [to] another facility many miles away while she was clearly in

[pre-term labor].” Again, pursuant to the statute’s restrictions on non-physician experts,

Spears did not opine as to causation.          See TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(r)(5)(C).

       Edmondson opined in his report that VRMC nurses breached their standard of care

by: (1) failing to “communicate the results of abnormal laboratory tests (blood count,

fibrinogen, and bilirubin) to Dr. Ellis and to request additional testing”; (2) failing to

“communicate the persistence of [Flores]’s contractions to Dr. Ellis”; (3) failing to “utilize

the chain of command when Dr. Ellis decided to transfer a patient who was 32 weeks

pregnant with a placenta previa and placenta accreta who was actively contracting and

no treatment had been ordered or given”; (4) failing “to provide treatment prior to the

transfer to minimize the risk of deterioration of [Flores]’s medical condition and to

                                              7
minimize the risk to her fetus”; and (5) “transferr[ing] an unstable patient nonemergently

by ground ambulance to a facility more than 150 miles away.”

      In a section of his report entitled “Causation,” Edmondson stated in part as follows:

      [Flores] had two prior cesarean sections and was diagnosed with a placenta
      previa. The presence of a placenta previa in a patient who has had previous
      cesarean sections is the most significant risk factor for a morbidly adherent
      placenta. Dr. Ellis was aware of [Flores]’s cesarean section history and the
      presence of a placenta previa at least as early as her 22[nd] week of
      pregnancy.

      ....

      The VRMC nursing staff, nurses Hedrick and Rivera[,] should have
      communicated the results of the low hemoglobin and the low fibrinogen
      levels to Dr. Ellis. They should have requested additional testing such as
      repeating the blood count and fibrinogen levels, as well as blood tests to
      assess [Flores]’s clotting. Communication of these results and requests for
      additional tests would have revealed [Flores]’s concealed bleeding and
      developing coagulopathy (DIC). These breaches resulted in a failure to
      diagnose [Flores]’s bleeding and coagulopathy and a failure to appreciate
      the severity of [Flores]’s medical condition. Nurse Hedrick’s and Nurse
      Rivera’s failure to report the lab results and failure to request additional lab
      tests and Nurse Rivera’s failure to communicate the persistent contractions
      to Dr. Ellis or to convey the presence of persistent contractions without
      treatment via her chain of command deprived [Flores] of the evaluation and
      treatment that was necessary to minimize the risk of transfer to her and her
      fetus. In addition, these breaches deprived Dr. Ellis of information
      necessary to considering the risks of transfer. With this information, Dr. Ellis
      would have known that [Flores] was not stable for transfer and that she
      needed to be delivered, or if she must be transferred, that the transfer
      should have been emergently to a closer facility, avoiding any undue delay
      in treatment.

      ....

      Notwithstanding Dr. Ellis’s physician certification on the memorandum [of]
      transfer, VRMC needed to provide treatment to stabilize her medical
      condition and minimize the risk of transfer; however this obligation of VRMC
      was not discussed with her prior to her consent. Delivery was a key
      component of the treatment and was required to stabilize [Flores]’s medical
      condition. Assuming arguendo that Dr. Ellis was not capable of performing
      a cesarean hysterectomy on [Flores] and that she must be transferred, an
      appropriate transfer required treatment to minimize the risk of the transfer
      such that no material deterioration is likely to occur during the transfer.

                                             8
       [Flores] only received IV fluids and IV antibiotics. She did not receive any
       treatment for her contractions or any evaluation of her anemia or low
       fibrinogen level. She should have received medication to stop the
       contractions as well as additional blood tests (repeat blood count to check
       for a falling hemoglobin and/or platelets, repeat fibrinogen level) and tests
       of her coagulation (prothrombin time and partial thromboplastin time).
       Appropriate blood and blood products should have been given. As a result
       of the failure to provide the necessary treatment prior to transfer her
       hemorrhaging continues and the coagulopathy continues to evolve,
       facilitating continued hemorrhage and worsening coagulopathy as
       described above.

       If transfer was necessary, VRMC should have transferred [Flores]
       emergently to a closer facility. There were hospitals within 50 miles of
       VRMC with capacity and capability to provide the care that [Flores] needed.
       More specifically, Doctors Hospital at Renaissance in Edinburg, Texas had
       a level III NICU, was a level II trauma center (higher level designation than
       VRMC), and had perinatologists on staff at that facility. The consequence
       of this breach is that treatment for [Flores]’s·medical condition was delayed.
       The delay in treatment, as noted above, allowed the hemorrhage to
       continue, the coagulopathy to evolve facilitating more hemorrhage and
       shock, and worsening shock leading to end organ damage and
       cardiovascular collapse.

C.     Analysis

       Citing the Texas Supreme Court’s 2017 opinion, VRMC’s motion to dismiss argued

that the new reports by Edmondson and Spears “still do not explain how [VRMC] allegedly

permitted or facilitated Ms. Flores’s transfer, or whether [VRMC] had any say in the matter

once Dr. Ellis ordered the transfer.”     Specifically, VRMC contended that, although

Edmondson’s report suggested that the nurses’ failure to provide certain information to

Ellis proximately caused Flores’s injury and death, it is “pure speculation” to suggest that

Ellis was not already aware of that information at the time he ordered the transfer. It also

argued that it is “pure speculation” to suggest that, had the nurses “advocated for

additional treatment or against transfer (medical decisions they could not lawfully make),”

Ellis would have provided additional treatment or transferred Flores to a closer facility.

                                             9
       In response to the motion to dismiss, Zamarripa pointed to Edmondson’s

statement that Ellis “would have known that [Flores] was not stable for transfer” if the

nurses had reported the low hemoglobin and low fibrinogen levels to Ellis; his statement

that, had the nurses requested additional testing, that testing would have “revealed”

Flores’s “concealed bleeding and developing coagulopathy”; and his statement that

Flores, a patient with placenta previa who had previous cesarean sections, had “the most

significant risk factor for a morbidly adherent placenta.” Zamarripa argued that these

statements satisfy the supreme court’s proximate cause requirement.

       On appeal, Zamarripa cites the Texas Supreme Court’s recent opinion in Abshire

v. Christus Health Southeast Texas, 563 S.W.3d 219, 221 (Tex. 2018) (per curiam). In

that case, the plaintiff Abshire was admitted to the defendant hospital Christus five

different times over the course of two weeks, complaining of shortness of breath, difficulty

walking, and pain in her chest, back, and shoulders. Id. Chest x-rays and physical

therapy were ordered. Id. But hospital records showed that, for at least two of Abshire’s

five visits to Christus, the nurses failed to record that Abshire suffers from osteogenesis

imperfecta (OI), or brittle-bone disease. Id. at 221–22. Subsequently, Abshire was

transferred to a different hospital, where a spine MRI was performed, revealing that

Abshire had a compression fracture in one of her thoracic vertebrae. Id. at 222. Despite

surgery, the fracture ultimately rendered Abshire paraplegic and incontinent. Id.

       Abshire sued Christus, alleging that its nurses were negligent by “fail[ing] to

recognize the signs and symptoms of a spinal compression fracture resulting in a delay

in treatment” and by “miss[ing] the history of [OI] that predisposes one to fractures.” Id.

She filed an expert report stating in part:

                                              10
       Failure of the nursing staff to document a complete and accurate
       assessment resulted in a delay in proper medical care (ie. [sic] the ordering
       of imaging studies and protection of the spine.) . . . . [H]ad the
       symptomology that Ms. Abshire was experiencing been appropriately linked
       to the [OI] diagnosis then the proper course of care would have been to
       admit the patient to the hospital on absolute bed rest, order imaging studies
       such as a CT or MRI of her back, then treat the injury to the spine. . . . The
       hospital staff clearly ignored signs and symptoms of spinal injury and kept
       investigating the same areas over and over with no relief to the
       patient. . . . This failure on the part of the hospital staff allowed the spinal
       injury to progress to the point of paraplegia. . . . Had they had a complete
       medical history they would have known to examine other areas and that this
       patient had a high probability of a compression fracture.

Id. at 224–25.

       The Beaumont Court of Appeals found the report insufficient. HealthSouth Rehab.

Hosp. of Beaumont, LLC v. Abshire, 561 S.W.3d 193, 217 (Tex. App.—Beaumont 2017),

rev’d, 563 S.W.3d at 219. It observed that, even on the two hospital visits during which

Abshire’s history of OI was documented by the nurses, the treating physician did not order

tests or spinal treatment. Id. The report was therefore “conclusory” as to causation

because it “fail[ed] to explain how the nurses’ alleged failure to document OI was a

substantial factor in causing or exacerbating Abshire’s injuries . . . or that it would have

changed the outcome.” Id.

       The Texas Supreme Court reversed and held that the report was sufficient to

satisfy chapter 74 as to causation. Abshire, 563 S.W.3d at 225–26. The report “explained

how the nurses’ breach—failing to consistently document Abshire’s OI, particularly in light

of her continued complaints of back pain—caused a delay in diagnosis and proper

treatment and why that delay caused the issues that led to Abshire’s paraplegia.” Id. at

225. The Court rejected the court of appeals’ reasoning, characterizing its analysis as a

simple disagreement with the “merits” of the expert’s conclusion. Id. at 226. The Court

noted that, “with respect to causation, the [trial] court’s role is to determine whether the
                                             11
expert has explained how the negligent conduct caused the injury.” Id. “Whether this

explanation is believable should be litigated at a later stage of the proceedings.” Id.

        Zamarripa contend that the expert report in Abshire is akin to Edmondson’s report

in this case. They note that, in both cases, the expert explained that the nurses’ breaches

caused untimely diagnosis and treatment of the patient, which in turn caused the patient’s

injuries. In Abshire, the nurses’ breach was their failure to “document and assess,” see
563 S.W.3d at 227 n.11; here, the nurses’ alleged breach was their failure to assess

Flores’s condition and communicate it to Ellis.

        We agree that, under Abshire, Edmondson’s report is sufficient to establish

proximate causation for purposes of chapter 74.7 The report stated, not as a matter of

possibility but as a matter of fact, that the failure of the VRMC nurses to communicate

test results and observations to Ellis “deprived Dr. Ellis of information necessary to

considering the risks of transfer.” According to the report, the information which Ellis was

“deprived” of would have made apparent that Flores “was not stable for transfer and that

she needed to be delivered, or if she must be transferred, that the transfer should have

been emergently to a closer facility.” In this way, the report illustrated a direct, causal link

from the nurses’ breaches of the standard of care to the physician’s decision to order the

transfer, and in turn, to the fatal outcome in this case.

        It is not “pure speculation,” as VRMC argues, for Edmondson to suggest that Ellis

was unaware of the pertinent information at the time he ordered the transfer; instead, it

        7In its 2017 opinion, the supreme court did not disturb our holding on the sufficiency of the expert
reports as to the standard of care applicable to VRMC and its breach thereof. See Columbia Valley
Healthcare Sys. L.P. v. Zamarripa, 526 S.W.3d 453 (Tex. 2017). Accordingly, we only address whether
the reports were sufficient to establish proximate causation. See TEX. CIV. PRAC. & REM. CODE ANN.
§ 74.351(r)(6) (West, Westlaw through 2017 1st C.S.); TEX. R. APP. P. 47.1.

                                                    12
was Edmondson’s considered expert opinion, the credibility of which is not at issue at this

stage of the litigation. See Abshire, 563 S.W.3d at 226. Indeed, Edmondson has

elucidated the exact causal link that the supreme court envisioned in 2017 when it ordered

the trial court to consider granting Zamarripa a 30-day extension to file a compliant report.

See Zamarripa, 526 S.W.3d at 461 (noting that Spears’s first report “seems to suggest

that [VRMC] breached its standard of care in not providing Dr. Ellis information that would

have persuaded him to change his mind” about the transfer and that, “[w]hile the report

does not explain how that could have happened, we cannot say it would be impossible”).

It provided a basis for the trial court to conclude that VRMC’s nurses had the “means to

persuade” the physician to make a different decision regarding the transfer. See id.

       The causation opinion offered by Edmondson is, in fact, stronger that the one

considered in Abshire. In Abshire, the expert stated that the nurses’ failure “to document

a complete and accurate assessment” resulted in a delay in care, thereby allowing the

plaintiff’s “spinal injury to progress to the point of paraplegia.” Id. at 224–25. But the

expert did not state or imply that the treating physicians were unaware that the plaintiff

suffered from OI—the condition that made her predisposed to compression fractures.

Instead, there was no dispute that, on several occasions, the nurses accurately recorded

the plaintiff’s condition. See id. at 221, 222. The report was nevertheless held to be

sufficient as to causation, and not merely the expert’s ipse dixit, even though there was

no further explanation as to why or how a “complete and accurate assessment” would

have effectuated a different result. Here, on the other hand, the expert stated directly that

the nurses’ breaches “deprived” the physician of information that was “necessary” to his

decision on whether or not to order a non-emergency transfer. The causal link between

                                             13
the omissions of the hospital staff and the plaintiff’s injury has thus been made far more

explicit in this case than it was in Abshire. VRMC disputes whether Ellis was in fact

“deprived” of the necessary information, and a trier of fact may eventually find that he was

not, but again, the credibility of Edmondson’s opinion is not at issue at this stage. See

Abshire, 563 S.W.3d at 226.

        We conclude that Edmondson’s report constitutes a good faith effort to establish

the causal relationship between VRMC’s alleged breaches and the damages claimed.

See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6).                      Accordingly, we sustain

Zamarripa’s issue on appeal.

                                           III. CONCLUSION

        Because the supplemental expert reports satisfied the requirements of chapter 74

as to causation under Abshire, the trial court abused its discretion by dismissing

Zamarripa’s claims.8 We therefore reverse the trial court’s judgment as to those claims

and remand with instructions to deny VRMC’s motion to dismiss and for further

proceedings consistent with this opinion.

                                                                        DORI CONTRERAS
                                                                        Chief Justice

Delivered and filed the
28th day of February, 2019.

        8We note that the trial court did not have the benefit of Abshire at the time it made its ruling.
However, as a Texas Supreme Court opinion, Abshire is binding, and the trial court has no discretion in
determining what the law is or in applying the law to the facts. Walker v. Packer, 827 S.W.2d 833, 840
(Tex. 1992) (orig. proceeding); In re K.M.S., 91 S.W.3d 331, 331 (Tex. 2002).

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