Court Opinion

ID: 4383393
Source: CourtListenerOpinion
Date Created: 2019-04-02 22:48:58.428694+00
Date Added: 2024-06-11T14:22:45.888448
License: Public Domain

Affirmed and Opinion filed April 2, 2019.

                                    In The

                   Fourteenth Court of Appeals

                             NO. 14-18-00480-CV

   SANJAR NADERI, D.D.S. AND ANTOINE DENTAL CENTER, LLC,
                           Appellants
                                      V.

         KANGASABAPATHY “RIKKI” RATNARAJAH, Appellee

                   On Appeal from the 164th District Court
                           Harris County, Texas
                     Trial Court Cause No. 2017-83384

                                  OPINION

      Appellee Kangasabapathy “Rikki” Ratnarajah brings a health care liability
claim against appellants Sanjar Naderi, D.D.S. and Antoine Dental Center, LLC.
The trial court denied appellants’ Chapter 74 motion to dismiss based on alleged
deficiencies in Ratnarajah’s expert report. See Tex. Civ. Prac. & Rem.
Code § 74.351. We affirm.
                      I. FACTUAL AND PROCEDURAL BACKGROUND1

A.    Factual Background

      On July 25, 2016, Ratnarajah went to the Antoine Dental Center seeking
treatment for an upper left wisdom tooth abscess. Dr. Naderi or his staff recorded
Ratnarajah’s medical history, blood pressure, pulse, and weight. They also took
several types of X-rays of Ratnarajah’s teeth. Dr. Naderi charted various operative
and restorative dental procedures Ratnarajah needed. Dr. Naderi’s charting showed
that teeth numbers 1, 16, 17, and 32 were circled and labeled “SE,” presumably
indicating surgical extraction. Dr. Naderi extracted tooth #16 that day without
complications. Although an abscess on tooth #17 was clearly visible on a
panoramic X-ray, Dr. Naderi did not extract tooth #17 or prescribe any antibiotics
for Ratnarajah.

      Ratnarajah returned to Antoine Dental Center for his post-operative follow-
up visit on August 1, 2016. Dr. Naderi determined that Ratnarajah was healing
well and advised him to resume his regular activities. Dr. Naderi did not diagnose
the abscess on tooth #17 or prescribe antibiotics for Ratnarajah at that time, and
there is no evidence that Dr. Naderi suggested to Ratnarajah that tooth #17 be
removed.

      Ratnarajah returned to Antoine Dental Center and Dr. Naderi on November
9, 2016, complaining of “left sided tenderness.” Dr. Naderi’s notes reflect “no
signs of abscess or inflammation” and “to consult OMFS if problem persists,”2
even though no new X-rays were taken and there was evidence of an abscess
around tooth #17 on the X-rays taken forty-five days earlier. Despite recording that
there were no signs of an abscess or inflammation, Dr. Naderi prescribed
      1
          The background facts of this case are taken from Ratnarajah’s expert report.
      2
          “OMFS” is an initialism for “oral and maxillofacial surgeon.”

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Amoxicillin 500 mg without explanation or recording a diagnosis.

      Ratnarajah returned to Antoine Dental Center and Dr. Naderi on November
30, 2016, still in pain. The only documentation of this visit is a note that “Pt left
office without being seen by a doctor.”

      Ratnarajah again returned to Antoine Dental Center and Dr. Naderi on
February 28, 2017, still complaining of pain and discomfort on the left side. Dr.
Naderi’s notes reflect that Ratnarajah had “left sided discomfort and swelling,
[and] intraoral left sided swelling in lower left area.” Dr. Naderi referred
Ratnarajah to an oral surgeon for “further evaluation and possible systemic issues
contributory to swelling and inflammation” rather than for extraction of a wisdom
tooth he was unable or unwilling to perform. No more X-rays were taken, and no
antibiotics were prescribed despite the diagnosis of swelling and inflammation.
There is no documentation that Dr. Naderi or anyone at Antoine Dental Center had
a conversation with Ratnarajah to discuss his issues and possible treatment options.
Dr. Naderi did not record anywhere that tooth #17 needed to be extracted.

      Ratnarajah saw a medical provider on April 26, 2017, when he had an
extraction of tooth #17 and incision and drainage of a large infection that Dr.
Naderi failed to identify. Ratnarajah went on to develop osteomyelitis and other
large infections that eventually required a resection of his lower left mandible.

B.    Procedural Background

      Ratnarajah sued Dr. Naderi and Antoine Dental Center (collectively,
Appellants) in late 2017. Ratnarajah alleged that Appellants’ negligent evaluation,
treatment, and management of his care resulted in permanent, disabling injuries,
including the development of osteomyelitis and other severe infections; the
compete loss of his lower left mandible; permanent facial disfigurement and loss of

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function; permanent loss of many teeth in his lower jaw; and at least three
subsequent surgical procedures that would not have been necessary but for
Appellants’ negligence. Ratnarajah alleged that Antoine Dental Center was liable
for Dr. Naderi’s actions based on vicarious liability theories.

      Because Ratnarajah alleged health care liability claims against Appellants,
he timely served Appellants with a Chapter 74 expert report and curriculum vitae
of Andrew Hood, D.D.S. See Tex. Prac. & Rem. Code § 74.351(a); see also
id. § 74.001(13) (defining “health care liability claim”). Antoine Dental Center
filed objections to Dr. Hood’s qualifications. Ratnarajah responded by filing an
amended expert report of Dr. Hood. In the meantime, Dr. Naderi had filed
objections to Dr. Hood’s original expert report. Shortly thereafter, Dr. Naderi filed
objections to Dr. Hood’s amended expert report that were substantively similar to
the objections previously filed in response to Dr. Hood’s original expert report. On
the same day, Ratnarajah filed a second amended expert report of Dr. Hood, which
is the subject of this appeal.

      In his report, Dr. Hood set out the following opinions on the applicable
standard of care and Dr. Naderi’s breach of those standards:

      1.     Making the right diagnosis based on the oral and
             radiographic examination
             a.     Dr. Naderi failed to make a proper diagnosis of a dental
                    infection on tooth #17 that was clearly visible on the
                    panoramic radiograph o[n] his initial examination on July
                    25, 2016, therefore breaching the standard of care.
                    i.     Dr. Naderi failed to make this diagnosis on several
                           occasions. Specifically, when the initial
                           examination was done on July 25, 2016 as well as
                           on September 9, 2016 when Mr. Ratnarajah
                           complained of pain and left sided tenderness.
                    ii.    Dr. Naderi made the wrong diagnosis again on

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                 February 28, 2017 when he contributed the
                 swelling and inflammation to “possible systemic
                 issues[.]”
     b.    Dr. Naderi makes no record of any infection present in
           the bone around #17 anywhere in his records.
     c.    The panoramic radiograph from July 25, 2016 shows a
           diagnosis that #17 is necrotic and that infection from the
           tooth has spread into the bone surrounding #17.
     d.    The standard of care would require Dr. Naderi to
           properly recognize and diagnose the infection in the bone
           present around the panoramic radiograph taken on July
           25, 2016 from the necrotic tooth #17. A necrotic tooth
           #17 should have been treated by extraction of the tooth,
           remove the source of the infection to the surrounding
           bone. Failing to extract the tooth will foreseeably lead to
           continued growth and diffusion of the infection into the
           surrounding bone and tissues.
     e.    Dr. Naderi breached the standard of care by failing to
           properly diagnose Mr. Ratnarajah’s infection[.]

2.   Referring Mr. Ratnarajah to the appropriate dental
     specialist, such as an oral surgeon, for dental treatment he
     was unable to diagnose or unwilling to perform
     a.    There are many dentists who do not feel comfortable or
           willing to extract teeth. The standard of care is to
           diagnose and inform patients of their conditions and to
           either perform the treatment, or refer the patient to
           another dentist or specialist such as an oral surgeon who
           is able and willing to diagnose and provide the treatment.
     b.    Dr. Naderi breached the standard of care by failing to
           refer Mr. Ratnarajah to an oral surgeon for treatment he
           could not diagnose. If Dr. Naderi was unable to diagnose
           or unwilling to provide the treatment that Mr. Ratnarajah
           needed, he should have immediately referred him to
           another doctor that could.

3.   Treating an oral infection with antibiotics

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            a.     Dr. Naderi failed to treat an oral infection with
                   antibiotics.
                   i.     Dr. Naderi’s notes indicate that there was
                          “swelling and inflammation” in the area of #17 on
                          February 28, 2017. However, there is no record of
                          any prescription for antibiotics to stop or quell the
                          infection.
            b.     Dr. Naderi should have prescribed antibiotics when it
                   was obvious that there was “swelling and inflammation”
                   as he notated, in the area around #17. This would have
                   reduced the infection until an oral surgeon could remove
                   the tooth[.]
            c.     Dr. Naderi breached the standard of care by not
                   providing antibiotics to Mr. Ratnarajah when he recorded
                   swelling and inflammation.

Dr. Hood also opined that due to the above breaches of the standard of care,
Ratnarajah would have more probably than not, within all medical/dental
probability, not have experienced any of the subsequent surgeries or lost any of his
mandible. Dr. Hood then detailed how each breach of the standard of care
proximately caused Ratnarajah’s injuries. Finally, Dr. Hood summarized his
causation opinions as follows:

      Specifically, if Dr. Naderi had correctly diagnosed the infection in the
      bone around #17 in his initial oral and radiographic examination on
      July 25, 2016, he would have been able to offer the appropriate
      treatment of extraction of the tooth, and/or referral to an oral surgeon
      for removal accompanied with an antibiotic regimen to stop the
      infection in the bone from growing. However, Dr. Naderi breached
      the standard of care by incorrectly diagnosing no infection around
      #17, gave no referral to an oral surgeon, or any antibiotic regimen. He
      offered no treatment at all. Leaving the infection untreated allowed it
      to continue to destroy tissue and bone foreseeably causing him to lose
      a portion of his mandible. This breach of the standard of care was the
      proximate cause and the substantial factor in bringing about the loss
      of Mr. Ratnarajah[’s] mandible. If the correct diagnosis had been
      made, the tooth could have been extracted and the source of the

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        infection would have been removed. Removing the source of the
        infection before it continued to grow and destroy tissue and bone
        would have certainly avoided the loss of a portion of Mr. Ratnarajah’s
        mandible. The loss of his mandible was certainly foreseeable because
        universally known scientific and medical knowledge of infection lead
        me to the conclusion that what did happen was what should and could
        have been predicted to happen.

        Dr. Naderi and Antoine Dental Center both objected to the second amended
report, complaining that the report failed to address the required statutory elements
and thus failed to demonstrate a good faith effort to provide them with notice of the
basis of Ratnarajah’s claims. Ratnarajah responded to Appellants’ cumulative
objections and set the matter for oral hearing on May 21, 2018. After hearing the
parties’ arguments, the trial court signed an order overruling all of Appellants’
objections to Dr. Hood’s second amended expert report and finding that the report
was sufficient for purposes of Chapter 74. This interlocutory appeal followed. See
Tex. Civ. Prac. & Rem. Code § 51.014(a)(9).

                    II.   The Sufficiency of the Expert Report

        On appeal, Appellants raise two issues. First, Appellants contend that
Ratnarajah’s expert report fails to provide a sufficient opinion of the applicable
standard of care and breach of that standard. Second, Appellants contend that
Ratnarajah’s expert report fails to adequately set forth a causal chain linking any
alleged harm actually suffered to a specific breach of an applicable standard of
care.

A.      Overview of Standard of Review and Applicable Law

        The Texas Medical Liability Act requires that plaintiffs alleging a health
care liability claim must serve each defendant with an adequate expert report or
face dismissal of their claim. Miller v. JSC Lake Highlands Ops., 536 S.W.3d 510,
511–12 (Tex. 2017) (per curiam) (citing Tex. Civ. Prac. & Rem. Code § 74.351(l)).
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The expert report must provide a “fair summary” of the expert’s opinions
regarding the (1) applicable standards of care, (2) manner in which the care
rendered by the physician or health care provider failed to meet the standards, and
(3) causal relationship between that failure and the injury, harm, or damages
claimed. Tex. Civ. Prac. & Rem. Code § 74.351(r)(6).

      We review a trial court’s decision to grant or deny a motion to dismiss based
on the adequacy of an expert report for an abuse of discretion. Abshire v. Christus
Health Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018) (per curiam). Under that
standard, appellate courts defer to the trial court’s factual determinations if they are
supported by evidence but review its legal determinations de novo. Van Ness v.
ETMC First Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam). A trial
court abuses its discretion if it rules without reference to guiding rules or
principles. Id.

      An expert report is adequate if the trial court finds that it constitutes a “good
faith effort” to comply with the statutory requirements. Abshire, 563 S.W.3d at 223
(citing Tex. Civ. Prac. & Rem. Code § 74.351(l)). An expert report demonstrates a
good faith effort when it contains sufficient information within the four corners of
the document to (1) inform the defendant of the specific conduct called into
question and (2) provide a basis for the trial court to conclude the claims have
merit. Id. “No particular words or formality are required, but bare conclusions will
not suffice.” Scoresby v. Santillan, 346 S.W.3d 546, 556 (Tex. 2011) (footnotes
omitted).

B.    Standard of Care and Breach

      Appellants first contend that Ratnarajah’s expert report fails to provide a
sufficient opinion on the applicable standard of care and breach of that standard.
Appellants argue that Dr. Hood’s three articulated standards of care and the alleged
                                           8
breaches of those standards are vague and not linked to the facts.

      The applicable standard of care is defined according to what an ordinarily
prudent physician or health care provider would have done under the same or
similar circumstances. See Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46
S.W.3d 873, 880 (Tex. 2001); Tovar v. Methodist Healthcare Sys. of San Antonio,
LTD., 185 S.W.3d 65, 68 (Tex. App.—San Antonio 2005, pet. denied). Identifying
the standard of care is critical because whether a physician or health care provider
breached a duty of care cannot be determined without specific information about
what the defendant should have done differently. Abshire, 563 S.W.3d at 226;
Palacios, 46 S.W.3d at 880. While a fair summary is something less than a full
statement of the applicable standard of care and how it was breached, it must set
out what care was expected but not given. Abshire, 563 S.W.3d at 226.

      Appellants complain that each of the three standards of care and breaches
identified by Dr. Hood are impermissibly vague and do not provide needed
information on what specifically should have happened differently. As to Dr.
Hood’s opinion that Dr. Naderi failed to make the correct diagnosis based on the
oral and radiographic examination, Appellants argue that while Dr. Hood suggests
that the radiographs and examinations performed should have led to a different
diagnosis (an infection) than the one given, this only asserts that there should have
been a different outcome. And, while Dr. Hood acknowledges that Dr. Naderi
diagnosed “possible systemic issues” on February 28, 2017, Appellants assert that
he does not explain why that diagnosis was wrong beyond the assertion that it was
incorrect. Appellants also assert that Dr. Hood failed to explain exactly what he
saw on the radiographs that led him to reach the conclusion that the radiographs
showed necrosis.

      Appellants raise similar complaints about Dr. Hood’s opinion that Dr.

                                         9
Naderi should have referred Ratnarajah to the appropriate dental specialist, such as
an oral surgeon, for dental treatment that Dr. Naderi was unable to diagnose or
unwilling to perform. According to Appellants, the report is vague because it does
not identify the specific kind of referral that would satisfy the standard of care or
explain the conduct that should have triggered such a referral, making it
“completely unclear why a referral was required.”

      We disagree that Dr. Hood’s opinions concerning the standard of care and
breach are vague and not linked to the facts. As shown above, Dr. Hood set out
three specific standards of care: (1) making a correct diagnosis based on the oral
and radiographic examination; (2) referring Ratnarajah to the appropriate dental
specialist, such as an oral surgeon, for dental treatment he was unable to diagnose
or unwilling to perform; and (3) treating an oral infection with antibiotics.
Although explained in greater detail in the report, Dr. Hood opined that Dr. Naderi
breached the standards of care when he failed to diagnose a dental infection on
tooth #17 that was “clearly visible” on an X-ray during the initial examination and
extract the tooth to remove the infection, failed to refer Ratnarajah to an
appropriate dental specialist or oral surgeon when he was unable to diagnose the
infection or unwilling to extract the tooth, and failed to prescribe antibiotics that
would have reduced the infection when—roughly six months after Ratnarajah’s
initial visit—Dr. Naderi observed swelling and inflammation around the area of
tooth #17.

      Appellants’ arguments focus on particular statements which, if viewed in
isolation, may appear conclusory. Viewing Dr. Hood’s report in its entirety,
however, places the statements in context and provides sufficient information
about what Dr. Naderi should have done differently. See Baty v. Futrell, 543
S.W.3d 689, 694 (Tex. 2018) (explaining that courts “must view the report in its

                                         10
entirety, rather than isolating specific portions or sections” to determine whether
the report is adequate (citing Van Ness, 461 S.W.3d at 144)); Miller, 536 S.W.3d at
515 (holding that expert’s opinion was sufficient when entirety of expert report
was credited and expert’s opinions were read in context).

      Although explained in greater detail as set out above, Dr. Hood explained
that the standard of care required Dr. Naderi to recognize and diagnose the
infection in the bone that was “clearly seen” around tooth #17 on the panoramic X-
ray taken on July 25, 2016, and to treat the infection by extracting the tooth to
remove the source of the infection. Dr. Hood also opined that failing to extract the
tooth would foreseeably lead to continued growth and diffusing of the infection
into the surrounding bone and tissues. Contrary to Appellants’ argument, Dr. Hood
did not opine that Dr. Naderi was negligent merely because of a bad outcome. Dr.
Hood opined Dr. Naderi’s failure to diagnose the infection around tooth #17 and
extract the tooth at his initial examination is the primary conduct that fell below the
standard of care and allowed the infection to continue to grow.

      Dr. Hood’s opinions, in context, also demonstrate a basis for the conclusion
that Dr. Naderi’s diagnosis of “possible systemic issues” was incorrect—that is, the
diagnosis was incorrect because Dr. Naderi should have diagnosed the necrotic
tooth #17. Additionally, Dr. Hood’s opinion that the standard of care required Dr.
Naderi to refer Ratnarajah to a dental specialist is sufficiently specific because Dr.
Hood explained that the standard of care is to diagnose and inform patients of their
conditions and to either perform the treatment or refer the patient to “another
dentist or specialist, such as an oral surgeon, who is able and willing to diagnose
and provide the treatment”—but Dr. Naderi failed to do any of these things. See
Baty, 543 S.W.3d at 695–97 (holding expert report adequately stated applicable
standard of care and breach despite presence of some conclusory language when

                                          11
report, viewed in its entirety, explained the specific conduct called into question).

      Dr. Hood’s report adequately identifies the standards of care applicable to
Dr. Naderi and the specific actions Dr. Naderi should have taken but did not. See
Miller, 536 S.W.3d at 516–17; Palacios, 46 S.W.3d at 880. More detail is not
required at this stage of the proceedings. See Abshire, 563 S.W.3d at 226; Baty,
543 S.W.3d at 697. Because the report is sufficient as to the standards of care
identified and the breaches of those standards, we overrule Appellants’ first issue.

B.    Causation

      In their second issue, Appellants contend that the report fails to link the
damages sustained by Ratnarajah to any specific breach of an applicable standard
of care.

      To provide a fair summary of causation, the expert is required to explain
“how and why” the physician’s or health care provider’s breach caused the
plaintiff’s injury. Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d
453, 459–60 (Tex. 2017). A conclusory statement of causation is inadequate;
instead, the expert must explain the basis of his statements and link conclusions to
specific facts. Abshire, 563 S.W.3d at 224. To satisfy the “how and why”
requirement, the expert need not prove the entire case or account for every known
fact; the report is sufficient if it makes “a good-faith effort to explain, factually,
how proximate cause is going to be proven.” Id. (quoting Zamarripa, 526 S.W.3d
at 460).

      Appellants argue that Dr. Hood did not explain how the three standards of
care led to the relevant damages. Instead, according to Appellants, Dr. Hood
offered only statements that things would have been different, with little
information as to how they would be different. As an example, Appellants

                                          12
complain that Dr. Hood offered two incompatible statements about causation: he
suggested that the correct diagnosis would have led to removal of the tooth before
an infection spread, while at the same time he suggested that a consultation any
time before February 28, 2017, would have prevented the loss of the mandible.
Appellants contend that these statements are incompatible because either the
infection had to be treated on July 26, 2016, or it could be referred out at any of the
four appointments that occurred before February 28, 2017.

      Appellants’ contention is incorrect, however, because Dr. Hood opined that
if Dr. Naderi had not failed to diagnose the infection during Ratnarajah’s initial
visit or refer him to an oral surgeon “on any of his previous four visits before
February 28, 2017,” Ratnarajah would have discovered the infection and it could
have been treated before the infection spread. Dr. Hood also opined that if the
infection had been discovered and treated before it got “out of control,” within “all
medical/dental probability, Ratnarajah would have been able to avoid losing a
portion of his mandible.” Even if the report contained inconsistences, the trial court
had discretion to resolve any inconsistencies when deciding whether the report
demonstrated a good faith effort to show that Ratnarajah’s claim had merit. See
Van Ness, 461 S.W.3d at 144 (holding that trial court did not abuse its discretion
by determining that expert report containing conflicting statements about causation
was not conclusory but was a good faith effort to comply with Chapter 74’s
requirements).

      Appellants next argue that Dr. Hood does not say when the infection spread,
only that it did. Appellants assert that while Dr. Hood “clearly believes that there
was some sort of continuum where this issue might have been treated,” there is no
detail on when the damage complained of actually occurred, when a consultation
was required, and how much, if any, damage was caused by a failure to return to a

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provider between February 28, 2017, and April 26, 2017, when Ratnarajah was
ultimately treated. But the absence of an opinion stating with specificity at what
point in the continuum of disease progression became irreversible or when an
intervention would have proven timely does not cause an expert’s causation
opinion to be conclusory at this early stage of evaluation. Puppala v. Perry, 564
S.W.3d 190, 201 (Tex. App.—Houston [1st Dist.] 2018, no pet.).

      Appellants also argue that Dr. Hood does not explain how Dr. Naderi’s
failure to give Ratnarajah antibiotics in February 2017 proximately caused the
“downstream” surgeries and loss of a mandible. Appellants complain that Dr.
Hood does not identify what antibiotics should have been used, if it would have
made a difference which were used and the timing of use, or anything else that
would clarify the what, why, and when of antibiotics. However, an expert report is
not required to contain that level of detail at this early stage of the litigation. See
Abshire, 563 S.W.3d at 224. Moreover, it is not necessary that Dr. Hood specify
the type of antibiotic used. See Van Ness, 461 S.W.3d at 144 (stating that report
was adequate where it referred only to the need to treat the patient’s illness with
“antibiotics”); see also Lakshmikanth v. Leal, No. 13–08–00389–CV, 2009 WL
140741, at *3 (Tex. App.—Corpus Christi Jan. 22, 2009, pet. denied) (mem. op.)
(rejecting argument that expert report was conclusory because it did not mention
the specific antibiotics that should have been prescribed and whether such
antibiotics would have prevented the patient’s severe infection).

      Lastly, Appellants assert that a standard of care that “anytime there is
swelling and inflammation antibiotics should be given” is overly broad and lacking
an explanation as to why such a standard required antibiotics in lieu of other
treatment options based solely on swelling. But read in context, Dr. Hood opined
that at a time when swelling and inflammation was obvious, Dr. Naderi should

                                          14
have prescribed antibiotics to treat the infection around tooth #17—not to treat
swelling—because Dr. Hood expressly stated that Dr. Naderi breached the
standard of care when he “failed to treat an oral infection with antibiotics” and that
the failure to prescribe antibiotics is what allowed the infection to spread.

      To constitute a good faith effort, an expert must explain the basis of his
statements and link his conclusions to specific facts. Abshire, 563 S.W.3d at 224.
Here, Dr. Hood stated that Dr. Naderi failed to correctly diagnose the infection
around tooth #17, refer Ratnarajah to an oral surgeon, or prescribe antibiotics on
February 28, 2017, when it was obvious that there was swelling and inflammation,
and that these failures left the infection untreated and caused it to continue to
destroy tissue and bone, which foreseeably caused Ratnarajah to lose a portion of
his mandible. We conclude that Dr. Hood’s expert report sufficiently explains the
basis of his statements and links his conclusions to facts. See id. at 225 (holding
that expert report adequately linked alleged breach of standard of care to a delay in
diagnosis and ultimate injury); Van Ness, 461 S.W.3d at 144 (holding that expert
report alleging that physician’s failure to timely diagnose child’s pertussis and start
treatment with antibiotics and to continue that treatment as indicated by diagnostic
testing probably would have prevented child’s death); see also Mosely v. Mundine,
249 S.W.3d 775, 780–81 (Tex. App.—Dallas 2008, no pet.) (holding that expert
opinion on causation was not conclusory when expert linked physician’s failure to
detect cancer at an early stage to a delayed diagnosis requiring invasive and
aggressive treatment and significant reduction in patient’s life expectancy). We
overrule Appellants’ second issue.

                                  III. CONCLUSION

      Because Ratnarajah’s expert report provided a fair summary of the expert’s
opinions regarding the applicable standards of care, a statement identifying the

                                          15
manner in which the care rendered by Dr. Naderi failed to meet the standards, and
an explanation of the causal relationship between that failure and the injury, harm,
or damages claimed, the trial court did not abuse its discretion in denying
Appellants’ motion to dismiss. See Tex. Civ. Prac. & Rem. Code § 74.351(r)(6).
We overrule Appellants’ issues and affirm the trial court’s order.

                                       /s/    Ken Wise
                                              Justice

Panel consists of Justices Wise, Zimmerer, and Spain.

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