Court Opinion

ID: 4661781
Source: CourtListenerOpinion
Date Created: 2021-02-22 08:15:12.647877+00
Date Added: 2024-06-11T08:02:16.060533
License: Public Domain

Affirmed and Memorandum Opinion filed February 18, 2021.

                                      In The

                    Fourteenth Court of Appeals

                              NO. 14-19-00751-CV

                         ANIL SINHA, MD, Appellant

                                          V.

                         ROGER NIEBUHR, Appellee

                    On Appeal from the 149th District Court
                           Brazoria County, Texas
                       Trial Court Cause No. 91026-CV

                  MEMORANDUM OPINION

      In his second appeal in this case, appellant Dr. Anil Sinha argues that the
trial court abused its discretion when it denied his motion to dismiss appellee
Roger Niebuhr’s health care liability claims against him based on Niebuhr’s failure
to file an expert report in compliance with section 74.351 of the Civil Practice and
Remedies Code. Dr. Sinha contends that Niebuhr’s amended expert report fails to
show a causal relationship between Dr. Sinha’s alleged breach of the standard of
care and Niebuhr’s injuries. We affirm.
                    I. FACTUAL AND PROCEDURAL BACKGROUND

       Dr. Sinha performed a laparoscopic appendectomy on Niebuhr and later the
same day, July 16, 2015, 1 Dr. Sinha released Niebuhr to go home. After
experiencing pain, Niebuhr returned the next day. A computed tomography (CT)
scan revealed three collection areas of air, blood, and fluid.            Dr. Sinha gave
Niebuhr pain medication and again released him to go home.

       Niebuhr returned the next day and remained under Dr. Sinha’s observation
and care under a regimen of intravenously administered antibiotics until July 20,
when Dr. Sinha again released Niebuhr to go home. Niebuhr claims Dr. Sinha
breached the standard of care during the period beginning the day after his
appendectomy (July 17, 2015) up to his discharge on July 20, 2015, (“the Post-
Appendectomy Care Period”). From the date of his appendectomy through the
penultimate day of the Post-Appendectomy Care Period, Niebuhr’s white blood
cell count continued to elevate. Niebuhr spent the next three days at home in
continued discomfort.

       When Niebuhr returned to Dr. Sinha on July 23, 2015, Dr. Sinha discovered
Niebuhr’s white-blood-cell count had elevated significantly, and the same night,
Niebuhr was transferred to Memorial Hermann Hospital. The day after he arrived
at Memorial Hermann, doctors performed an exploratory laparoscopy and installed
a drain. Despite these measures, Niebuhr’s condition continued to decline, and
three days later, on July 28, 2015, Niebuhr underwent open abdominal exploration
surgery, which revealed a “necrotic appendiceal base with leakage of fecal matter
from the cecum into the peritoneum” — a condition that could not be resolved
without major surgical intervention. He required “a right hemicolectomy (removal

       1
         All facts regarding the treatment discussed here derive from what is provided in the
expert report at issue.

                                             2
of the right colon) and an end ileostomy, leaving him in intestinal discontinuity.”

       Niebuhr remained at Memorial Hermann until he was discharged on August
3. His path to recovery required use of an ostomy bag for six months before “re-
attachment” surgery.

                                 Lawsuit and First Appeal

       Niebuhr sued Dr. Sinha, alleging that Dr. Sinha acted negligently during the
Post Appendectomy Care Period and his alleged actions and omissions resulted in
the necrotic condition that required life-changing surgery.

       Dr. Sinha moved to dismiss Niebuhr’s claims, asserting the expert report of
Dr. Paul J. Chestovich fell short in explaining the standard of care at issue in the
case and in explaining the causation theory. The trial court denied the motion, Dr.
Sinha appealed that ruling to this court, and we reversed, finding the report
deficient on the element of causation. In the opinion in the first appeal, the court
noted Dr. Chestovich’s expert report suffered from three deficiencies as to the
causation element because it lacked the following essentials:

       (1) an identifiable location of the intestinal leak; 2
       (2) information about when the necrosis developed or when the
       persistent leakage process began that led to necrosis; 3 and
       (3) an explanation “free from inconsistency” how an earlier surgery
       (performed by Dr. Sinha during the Post Appendectomy Period)
       would have made any difference in the outcome of Niebuhr’s

       2
          “Dr. Chestovich has not clearly shown that the leak location was ever identified.
Though he seems to make general observations about the location of the leak, he does not reveal
precisely the area that would have needed to be addressed.” Sinha v. Niebuhr, No. 14-17-00937-
CV, 2018 WL 6836930, at *5 (Tex. App.—Houston [14th Dist.] Dec. 28, 2018, no pet.) (mem.
op.)(“Sinha I”).
       3
          The Court stated “that while [Dr. Chestovich] states that the persistent leakage of
intestinal contents initiated the process that caused necrosis, he does not identify when that
process began or when necrosis developed.” Sinha, 2018 WL 6836930, at *5.

                                              3
       condition. 4
       This court denied Niebuhr’s motion for en banc reconsideration, and
Niebuhr did not file a petition for review in the Supreme Court of Texas.

       Because this court found that it was not “impossible for the deficiencies in
the report to be cured,” we reversed the trial court’s order and remanded the case to
give the trial court an opportunity to consider whether to grant Niebuhr a thirty-day
extension to cure the deficiencies. See Sinha v. Niebuhr, No. 14-17-00937-CV,
2018 WL 6836930, at *6 (Tex. App.—Houston [14th Dist.] Dec. 28, 2018, no pet.)
(mem. op.).

                           The Amended Report and this Appeal

       Niebuhr requested and the trial court allowed him an opportunity to cure the
deficiencies in the expert report. After Niebuhr filed his amended expert report, Dr.
Sinha filed another motion to dismiss alleging that the amended report remained
deficient as to causation. Dr. Chestovich’s amended report includes nearly
everything in the first report, plus facts set out in medical records not previously
mentioned (including some facts that our opinion suggested would be useful). The
amended report supplements the standard of care described in the “Medical
Opinion” section and adds significant content to the “Results” section. The new
parts aid Dr. Chestovich’s explanation of the causation theory. The trial court
denied Dr. Sinha’s motion and that ruling is the basis of Dr. Sinha’s current appeal.

       4
         “Dr. Chestovich provides no explanation why the laparoscopic surgery performed eight
days after the appendectomy — if performed earlier — would have yielded clear results in
identifying the source of the leak, and in addressing the problems. Accordingly, in the absence of
such an explanation, the report fails to offer a reason free from inconsistency that but for Dr.
Sinha’s failure to perform the exploratory laparoscopic surgery, the outcome would have been
any different.” Sinha, 2018 WL 6836930, at *6.

                                                4
                              III. ISSUE AND ANALYSIS

       In his sole issue, Dr. Sinha asserts the trial court abused its discretion in
denying his motion to dismiss because the amended expert report was inadequate
for failing to establish a causal link between Dr. Sinha’s conduct and Niebuhr’s
injuries.

       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.).

       Under his sole issue, Dr. Sinha complains that Dr. Chestovich’s amended
report fails to correct the deficiencies we outlined in the first appeal and argues that
certain statements made in the amended report are conclusory and factually
unsupported. We address these arguments in the context of the overarching issue
of whether the trial court abused its discretion in finding the amended expert report
on causation amounted to an objective good-faith effort to comply with the
definition of an expert report provided in section 74.351(r)(6).

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

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      [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). A trial court’s inquiry is limited to the four corners of the report. Jelinek v.
Casas, 328 S.W.3d 526, 539 (Tex. 2010).

      The report must provide 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 plaintiff’s claims have merit. See id. at 539. Omission
of any of the statutory elements prevents the report from being a good-faith effort.
See id. A report that merely states the expert’s conclusions about the standard of
care, breach, and causation does not meet the statutory requirements. See id. In
providing the expert’s opinions on these elements, the claimant need not marshal
evidence as if actually litigating the merits at trial or present sufficient evidence to
avoid summary judgment. See id.

      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. Chestovich must explain “how and why” the alleged negligence

                                           6
during Post-Appendectomy Care Period caused the development of necrosis that
resulted in significant removal of Niebuhr’s intestines, 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). Thus, for the amended report
to survive the challenge, Dr. Chestovich would have to explain how the allegedly
negligent conduct caused Niebuhr’s injuries. See id. at 226.

      Dr. Chestovich’s amended report includes two standards of care that call for
exploratory laparoscopic surgery at different points and for different purposes
during the Post-Appendectomy Care Period:

         • First, the report explains that the day after the appendectomy
           when presented with a patient in Niebuhr’s condition—with
           increasing pain, significant post-operative bleeding in various
           places—the standard of care called for Dr. Sinha to perform
           exploratory laparoscopic surgery “to determine the source of
           the bleeding and evacuate the hematoma, verify there was not
           continued bleeding from the appendiceal artery, and verify the
           integrity of the appendiceal stump.”
         • Second, the report summarizes Niebuhr’s elevating white-
           blood-cell count from the time of the appendectomy to the
           penultimate day of the Post Appendectomy Care Period, and
           provides that on that day (July 19), given Niebuhr’s elevating or
           abnormal white blood count, “the standard of care in Niebuhr’s
           case called for Dr. Sinha to perform exploratory laparoscopic
           surgery to investigate the source of infection.”
      The amended report includes explanations of how and why Dr. Sinha’s
failure to perform an exploratory laparoscopic surgery on or about July 17 and July
19 caused the development of necrosis that resulted in significant removal of
Niebuhr’s intestines:

      The CT scan performed at BRH on 7/17/15 showed evidence of early
      post-operative bleeding. Based upon the findings at surgery on
      7/28/15, in reasonable medical probability, the appendiceal artery

                                         7
which Dr. Sinha clipped in surgery was the source of internal bleeding
Niebuhr was experiencing on 7/17/15. Had Dr. Sinha performed
exploratory laparoscopic surgery, in reasonable medical probability he
would have identified and controlled the source of bleeding and
simultaneously identified any intestinal perforation.
Niebuhr’s WBC count was increasing despite the removal of
appendix. After Niebuhr’s readmission to the hospital and the WBC
had increased to 16.4, Niebuhr’s WBC increased further to 16.9
despite administration of intravenous antibiotics. In reasonable
medical probability the cecum was leaking intestinal contents at this
point and was the source of Niebuhr’s increasing WBC. Had Dr.
Sinha performed an exploratory laparoscopic surgery on or about
7/19/15 as the standard of care called for him to do, he would have
identified and repaired the leakage in the cecum, while simultaneously
identifying any bleeding.
                                  ...
Necrosis is a process of degradation of living tissues that takes place
over time. The necrosis in Niebuhr’s cecum was caused by exposure
of his tissue to constant leakage of intestinal contents into his
peritoneum through the appendix wound at his cecum. The presence
of blood creates a medium in which bacteria thrive, allowing the
infection to continue. While it is impossible to precisely identify when
the tissue became necrotic, in reasonable medical probability there
was no necrotic tissue that had developed within 3-4 days after the
appendectomy surgery performed by Dr. Sinha. If Dr. Sinha had met
the standard of care and performed exploratory laparoscopic surgery
during the July 17, 2015 timeframe, the bleeding and intestinal
leakage would have been identified and Niebuhr would not have
developed necrosis.
                                  ...
. . .Had Dr. Sinha performed exploratory laparoscopic surgery on July
19, 2015 after it was apparent that Niebuhr had a worsening infection,
as the standard of care called for, in reasonable medical probability
the resulting surgeries at Memorial Hermann hospital would not have
been necessary. Thus, Roger Niebuhr would not have developed life-
threatening peritonitis and required a colon resection and ileostomy.
As a result, Mr. Niebuhr required additional procedures, and required
an ostomy bag for 7 months, as well as the other potential lifelong

                                   8
      complications associated with such surgeries. These operations and
      the associated morbidity would not have been necessary had the
      standard of care been followed.
Dr. Chestovich’s explanation in the amended report provides a straightforward link
between Dr. Sinha’s alleged breaches of the standard of care, and the respective
consequences, which ultimately led to Niebuhr’s injury.           The report is not
conclusory, and fairly addresses the three deficiencies we noted in our previous
opinion.

   (1) The amended report provides factual support for the presumed ability to
       pinpoint the location of the intestinal leak.

      In the first appeal, the panel was concerned that none of the medical records
available to Dr. Chestovich revealed that the leakage site could be located, and the
inability to locate the leakage was inconsistent with Niebuhr’s causation theory
that depends on Dr. Sinha locating and fixing the leakage site during the Post-
Appendectomy period. In his amended report Dr. Chestovich addresses that
concern, as he identifies the leakage location in an area near the appendectomy
staple line. Specifically, the report includes content from medical records not
included in the original report—it supplies notes from the post-operative pathology
report that the defect located in “the cecum [was] immediately adjacent to a 3.5cm
in length stapled line (probable appendectomy site), measuring 3.0 x 2.5 cm.”

      Dr. Sinha concedes this new contribution addresses one of the court’s stated
concerns, but Dr. Sinha emphasizes that staples were also noted to be closed, and
argues that the amended report never explains why the stapled-up appendectomy
site and the leakage site are related. The pathologist’s interpretation of the CT scan
identifying the “full thickness defect” immediately adjacent to the “(probable
appendectomy site),” while not factually conclusive that the appendectomy caused
the defect, is relevant to show that the defect existed at all relevant times, and was

                                          9
capable of being observed and located. This court’s opinion in Marvin v. Fithian
is instructive on this point. 14-07-00996-CV, 2008 WL 2579824, at *4 (Tex.
App.—Houston [14th Dist.] July 1, 2008, no pet.).

      In Marvin, we considered whether a doctor’s report setting out that Dr.
Marvin breached the standard of care by failing to timely conduct a physical exam
after Fithian presented with evidence of an infection following laparoscopic gastric
band surgery. Id. On appeal, Dr. Marvin argued that the plaintiff’s expert’s
opinions on causation lacked factual support. The court addressed this concern,
describing each of the facts linking the expert’s causal conclusion:

      Dr. Martin [the plaintiff’s expert] explained that surgery could have
      been performed prior to deterioration of Fithian's organs if the source
      of her post-surgical infections had been discovered on February 3. In
      the report, Dr. Martin described a series of missed chances for an
      accurate diagnosis of the cause of Fithian's infections. Dr. Martin
      stated that Fithian would have been timely diagnosed with peritonitis,
      and surgery would have been performed to close the hole in her
      stomach if a qualified physician had performed a physical exam on
      February 3. Dr. Martin explained that surgery would have eliminated
      the source of the Fithian's peritonitis and “almost all of her subsequent
      problems.” Dr. Martin opined that Fithian would not have developed
      kidney failure and pulmonary insufficiency if this course of action had
      been followed. Dr. Martin stated that each day Dr. Marvin missed an
      opportunity to intervene, more of Fithian's tissues was destroyed by
      infection and her period of disability was increased. According to Dr.
      Martin, Fithian suffered from life-threatening peritonitis, secondary
      pulmonary insufficiency, pleural effusions with toxic cellular
      products, and secondary kidney failure because she was not timely
      diagnosed and treated.
      Id. at 3. We concluded that the above facts sufficed to support the causation
opinion.   Id. at *3.   We also addressed the defendant’s contention that the
plaintiff’s expert engaged in an impermissible inference that the pin hole in
Fithian’s stomach existed on the earlier date. Id. at *4. We concluded that Dr.

                                         10
Martin’s conclusion amounted to a permissible inference gleaned from the medical
records, that the source of the infection to be the same pinpoint as that referenced
as discovered as leaking by Dr. Martin during surgery four days later. Id. We
conclude that the amended report in this case similarly details missed opportunities
while similarly relying on permissible inferences gleaned from the medical
records.

      In short, the addition of the pathologist’s observation to the report adds some
factual basis for the proposition that the leakage site would have been located by
Dr. Sinha had he performed one of the proposed exploratory laparoscopic
surgeries. See id.

      (2) The report provides background information about the timing of the
      persistent leakage of intestinal contents that initiated the process that
      allegedly caused necrosis, when that process began, and permissible
      conclusions about when necrosis developed.

      Dr. Sinha complains that “the crucial questions posed by this Court—when
did the process of necrosis begin and when did it develop—remain unanswered.”

      In his amended report, Dr. Chestovich notes that it is impossible to know
precisely when the necrotic tissue developed but posits “in reasonable medical
probability there was no necrotic tissue that had developed within 3-4 days after
the appendectomy surgery performed by Dr. Sinha.” Dr. Sinha argues that this
statement equates to speculation. We disagree: these statements find support in the
report. See Naderi v. Ratnarajah, 572 S.W.3d 773, 780 (Tex. App.—Houston
[14th Dist.] 2019, no pet.). Specifically, Dr. Chestovich explains the necrotic
process—the degrading of living tissues over time, and how the presence of blood
on the tissue creates a medium in which bacteria thrive, allowing the infection to
continue. This explanation, coupled with other facts in the report about Niebuhr’s
treatment and condition—that he was on intravenously-administered antibiotics

                                         11
that would have offset (to some extent) the infection during that timeframe—
supports Dr. Chestovich’s conclusion that the necrotic tissue had not yet developed
within three to four days after the appendectomy. See id.

         Similarly, Dr. Chestovich’s statement that “[w]hen Niebuhr presented at
Memorial Hermann Hospital on 7/23/15 the necrosis had already developed” was a
conclusion fairly supported in the context of his explanation of the necrotic
process, the removal intravenously-administered antibiotics, and Niebuhr’s
doubled white-blood-cell count taken on that date. See id.

         (3) The report provides an explanation free from inconsistency that the
         failure to perform an earlier laparoscopy altered the outcome.

         Dr. Sinha complains that the report does not consistently explain how an
exploratory surgery in the specified timeframe—July 17 to July 20—would have
made any difference in the outcome of Niebuhr’s condition, when the July 24
exploratory surgery did not reveal the source of the intestinal leak. This argument,
a point made in our first opinion about the first report, relies in part on a
comparison to our sister court’s decision in Karkoutly v. Guerrero, involving
medical negligence claims based on allegations of a delayed exploratory
procedure.        13-17-00097-CV, 2017 WL 6379795, at *4 (Tex. App.—Corpus
Christi-Edinburg Dec. 14, 2017, no pet.).

         The Karkoutly case involved a situation where the expert “did not mention
any new information that was gleaned from the exploratory surgery, or whether the
exploratory yielded any progress toward resolving the patient’s condition.” Id. We
concluded the report in that case comparable to the first report because like the
report in that case, the first report did not describe the exploratory surgery as
yielding any clearer information about source of the infection. 5                  Sinha I, at *6.

5
    Though deficient, the deficiency of the first report in this case (the Sinha I report) was not so

                                                  12
And like the Karkoutly report, the first report in this case lacked any clear
reference to the medical records identifying the source of the infection. Though we
concluded the comparison to Karkoutly compelling under the first report, the
information and opinions in the amended report render it distinguishable from
Karkoutly.

       The amended report draws from the data available from the diagnostic tests,
the CT scans, blood tests, and pathology reports, and the moments during the Post-
Appendectomy Care Period where Dr. Sinha passed on opportunities to conduct
laparoscopic exploration, and supplies factual basis for Dr. Chestovich’s opinion
that such intervention would have revealed that the appendiceal artery which Dr.
Sinha clipped in surgery was the source of internal bleeding Niebuhr was
experiencing on July 17, the same source of what elevated his white blood cell
count on July 19.         The amended report chronologically illustrates Niebuhr’s
changing intestinal landscape as first consisting of a blood leak near the
appendectomy staple lines (July 17), then leaking intestinal contents prior to the
development of necrosis (July 19), then leaking intestinal contents from organs
deteriorating from necrosis (July 24). In short, Dr. Chestovich’s amended report
identifies the leak location with greater precision, educates the parties and court
about the complications associated with an intestinal leak and about the necrotic
process, and estimates the timeframe when the necrotic process began. The first
report did not. Understanding the necrotic process, the existence of the leak and

severe as the deficiency in Karkoutly. Whereas the Karkoutly expert report failed to note any
information gleaned or any progress toward patient-recovery from the exploratory surgery, the
Sinha I report notes that the exploratory surgery yielded the discovery of Niebuhr’s intestinal
leak. But beyond noting the discovery of its existence, the Sinha I report fell short of showing
that the leak’s source had then or ever been located. Thus, the circumstance described in the first
report begged the question: How could the leak be repaired if it could never be located? The
amended report, with clearer reference to the probable location of the leak, eliminates this
question.

                                                13
the progression of the leak, provided the basis for showing why an earlier
exploratory procedure would have avoided the same outcome for Niebuhr.

      Dr. Sinha’s arguments do not overcome the reality that, at worst, if an
exploratory surgery had occurred on the 17th or 19th and only yielded information
revealing the existence (but not the location) of an intestinal leak — that such a
discovery, simply made earlier than it was, would have prompted intervention at a
more expedited pace than actually occurred. Dr. Sinha seems to acknowledge that
Dr. Chestovich’s report illustrates a window in time wherein Dr. Sinha’s early
intervention could have avoided the unfavorable outcome, but calculates this to be
a comparable sliver in time. These concerns are better suited for a jury.

      The report draws a line directly from Dr. Sinha’s decision not to perform a
laparoscopic surgical intervention during the Post-Appendectomy Care Period, to a
delay in diagnosis (identifying the intestinal leak) and the alleged proper treatment,
to the ultimate injury (necrosis). See Abshire, at 225; see also Marvin, at * 4.

                                     III. CONCLUSION

       Dr. Chestovich’s amended expert report has cured the deficiencies
identified in the court’s opinion in the first appeal and meets the standards
applicable to causation opinions. See Tex. Civ. Prac. & Rem. Code § 74.351(r)(6).
We therefore overrule Dr. Sinha’s sole appellate point and affirm the trial court’s
order denying his motion to dismiss.

                                        /s/    Randy Wilson
                                               Justice

Panel consists of Justices Spain, Poissant and Wilson.

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