Court Opinion

ID: 9961952
Source: CourtListenerOpinion
Date Created: 2024-04-22 08:10:39.393275+00
Date Added: 2024-06-11T08:19:26.198270
License: Public Domain

Opinion issued April 16, 2024

                                       In The

                               Court of Appeals
                                      For The

                           First District of Texas
                             ————————————
                               NO. 01-23-00602-CV
                            ———————————
                     GARY HORNDESKI M.D., Appellant
                                         V.
                           CHERYL PRICE, Appellee

                    On Appeal from the 239th District Court
                           Brazoria County, Texas
                       Trial Court Case No. 111019-CV

                          MEMORANDUM OPINION

      This is an interlocutory appeal from the denial of a motion to dismiss pursuant

to Chapter 74 of the Texas Practice and Remedies Code in a health care liability suit.

Appellee Cheryl Price sued Appellant Gary Horndeski M.D. for negliegnce arising

from the breast reconstruction surgery he performed on her.          On appeal, Dr.
Horndeski argues the trial court abused its discretion by denying his motion to

dismiss because (1) Price’s expert report fails to provide a sufficient opinion on the

applicable standard of care and breach of that standard, and (2) her expert report

does not causally link Price’s damages to any specific breach of an applicable

standard of care. Dr. Horndeski argues that because Price is not entitled to an

opportunity to cure these deficiencies, we must reverse and remand the matter to the

trial court to award him his reasonable attorney’s fees and costs.

      We affirm the trial court’s order.

                                    Background1

      Appellee Cheryl Price suffered from left breast cancer in 1995. She had

“bilateral mastectomies followed by delayed breast cancer reconstruction with

implants in 1999.” She subsequently “developed an exposure and had the bilateral

implants removed.” She alleges in her petition that in 2019, she “presented to Dr.

Horndeski for care and treatment to remove excess skin under each arm after [her]

breast cancer surgery . . . .” On March 5, 2019, Dr. Horndeski performed a

“Bellasoma” breast reconstruction surgery on Price to remove the excess skin. Price

alleges that shortly after the surgical procedure, she developed bilateral blisters and

1
      This is the second interlocutory appeal in this suit. The background facts are taken
      directly from our prior opinion in Horndeski v. Price, No. 01-21-00577-CV, 2022
      WL 3363951, at *1 (Tex. App.—Houston [1st Dist.] Aug. 16, 2022, no pet.) (mem.
      op.).

                                           2
pustules on her skin and infections that required three operative debridements of her

breasts, wound care, and oral antibiotic therapy. Price also alleges that following

the surgical procedure, there was “evidence of unauthorized complete bilateral

breast reconstruction and infection.”

                              Procedural Background

      On January 4, 2021, Price filed a health care liability suit against Dr.

Horndeski alleging he “was negligent in providing appropriate and timely medical

care and treatment to [her] while she was his patient and breached his duty to provide

the standard of care in restoring and treating [her].” Price alleged Dr. Horndeski was

negligent in failing to (1) obtain her consent to perform the subject procedure,

(2) meet the standard of care in performing the unauthorized breast reconstruction,

(3) make a reasonable attempt to address her high-risk surgical candidacy for breast

reconstruction, (4) recognize that his skills, knowledge, or facilities were inadequate

to properly treat Price under the circumstances as they then existed, (5) adhere to the

acceptable standards for care in the medical profession by performing a “Bellasoma”

procedure for breast reconstruction when it was inappropriate, and (6) protect her

from possible infection after performing the procedure.

                   Original and Supplemental Expert Reports

      Price filed and served upon Dr. Horndeski an original expert report authored

by Leo Lapuerta, M.D., F.A.C.S., a board-certified plastic surgeon and Chief of

                                          3
Plastic Surgery at St. Joseph Hospital (“Dr. Lapuerta”), which she attached as

Exhibit A to her petition. On March 8, 2021, Dr. Horndeski objected to Dr.

Lapuerta’s report arguing it failed to satisfy the requirements of Chapter 74 of the

Texas Civil Practice and Remedies Code. See TEX. CIV. PRAC. & REM. CODE

§ 74.351(a), (r)(6) (requiring plaintiff asserting health care liability claim to serve

health care defendant with expert report providing fair summary of expert’s opinions

regarding applicable standards of care, breach, and causation).

      On June 11, 2021, Price served Dr. Horndeski with a supplemental expert

report authored by Dr. Lapuerta. In his Supplemental Report, Dr. Lapuerta discusses

his physical examination of Price, including Price’s medical history, and he offers

the following opinions:

              ACCEPTED STANDARD OF CARE FOR MS. PRICE

      In my opinion, Mrs. Price has an extensive and complicated medical
      and surgical history with a history of healing problems and she was not
      a candidate for any type of breast reconstruction. She had some type of
      procedure performed by Dr. Horndeski in March 2019 complicated by
      multiple infested pustules and required three operative debridements
      and wound care with oral antibiotic therapy to eventually heal.

           DEPARTURE FROM ACCEPTED STANDARD OF CARE
                       BY DR. HORNDESKI

      In my opinion, the procedure recommended and carried out by Dr.
      Horndeski on March 5, 2019 departed from and was below the accepted
      standard of care in the following respects:

      1.     Mrs. Price was and remains a very high risk surgical candidate
             which precludes any breast reconstruction.

                                          4
      2.     The procedure performed consisting of a “bellasoma”
             reconstruction and explained at www.horndeski.com is not the
             standard of care in breast reconstruction in the community and
             led to pustule formation and retained foreign bodies in the breasts
             which required several more operations by myself, Dr. Kovacev
             and Dr. Wegge to control.

      I have reviewed the aforesaid medical records and based upon my
      experience and training, it was below the standard of care for the
      defendant plastic surgeon, Dr. Horndeski, to perform the surgery on
      Ms. Price. Under reasonable medical probability had he simply
      refrained from performing the procedure, Ms. Price would not have
      sustained the disfigurement she complains of and all of the subsequent
      procedures would have been avoided.

Dr. Horndeski objected to Dr. Lapuerta’s Supplemental Report and argued the report

failed to satisfy the requirements of Chapter 74 because the report did not provide a

fair summary of Dr. Lapuerta’s opinions regarding the applicable standards of care,

Dr. Horndeski’s breach of that standard, and how Dr. Horndeski’s breach caused

Price’s harm. Dr. Horndeski also filed a motion to dismiss with prejudice Price’s

negligence claim on the same grounds, and he asked the trial court to award him his

attorney’s fees and costs pursuant to Section 74.351(b) of the Texas Civil Practice

and Remedies Code. See TEX. CIV. PRAC. & REM. CODE § 74.351(b) (requiring trial

court to dismiss plaintiff’s health care liability claims with prejudice and award

defendant health care provider its attorney’s fees and costs when plaintiff fails to

timely serve compliant expert report). The trial court denied Dr. Horndeski’s motion

to dismiss and Dr. Horndeski filed an interlocutory appeal challenging the trial

court’s ruling.

                                          5
      On August 16, 2022, this Court issued an opinion concluding that Dr.

Lapuerta’s Supplemental Report failed to provide a fair summary of his opinions

regarding the applicable standard of care, Dr. Horndski’s breach of that standard,

and causation. Horndeski v. Price, No. 01-21-00577-CV, 2022 WL 3363951, at *6–

7 (Tex. App.—Houston [1st Dist.] Aug. 16, 2022) (mem. op.) (“Horndeski I”). We

remanded the matter to the trial court to determine whether Price should be afforded

a thirty-day extension to cure the defects identified in Dr. Lapuerta’s report. Id. at

*7; TEX. CIV. PRAC. & REM. CODE § 74.351(c) (authorizing trial court to grant

plaintiff thirty-day extension to cure expert report’s deficiencies).

                                  Amended Report

      On remand, the trial court granted Price a thirty-day extension to cure her

report. On October 10, 2022, Price served Dr. Horndeski with an Amended Report,

where Dr. Lapuerta provides the following opinions:2

             ACCEPTED STANDARD OF CARE FOR MRS. PRICE

      In my opinion, Mrs. Price has an extensive and complicated medical
      and surgical history with a history of severe healing problems and she
      was not a candidate for any type of breast reconstruction. Her past
      surgical history includes a failed attempt at implant reconstruction,
      which is one of the standard operations performed in high risk patients

2
      The “Personal Examination” section of the Amended Report is identical to the same
      section in the Supplemental Report with two exceptions. The Amended Report also
      states Price “developed severe complications of abscess formation, bilateral open
      breast wounds and required operative debridements on 3/18/19 and 3/28/19” and it
      states Dr. Lapuerta observed “evidence of attempted bilateral breast reconstruction
      and infections” when he examined Price on May 28, 2019. (Emphasis added).

                                           6
who desire breast reconstruction. Her past surgical history also includes
severe complications after colon surgery leading to wound care issues
and hernia formation. These complications reduce other autologous
tissue options for Mrs. Price such as a TRAM or DIEP flap. She had a
procedure performed by Dr. Horndeski in March of 2019 consisting of
what he refers to as “bellasoma procedure” which was complicated by
multiple infected pustules and required five to six subsequent operative
debridements by three other surgeons and wound care with oral
antibiotic therapy to eventually heal. Based upon my experience,
training, practice and review of literature, the accepted standard of care
for a plastic surgeon presented with the history and examination of
Cheryl Price as set forth within Dr. Horndeski’s records is to perform
no reconstructive procedure whatsoever. Additionally, the procedure
performed by Dr. Horndeski consisted of a “Bellasoma” reconstruction
and is explained at www.horndeski.com. The standard of care
operations in breast reconstruction would include implant
reconstruction, TRAM flaps or DIEP flaps and latissimus muscle flaps.
The “Bellasoma” reconstruction varies from the standard of care and
ordinary breast reconstructive surgery and, even if a plastic surgeon was
to ignore the standard of care to do nothing, the procedure described
and performed by Dr. Horndeski breached the standard of care.

    DEPARTURE FROM ACCEPTED STANDARD OF CARE
                BY DR. HORNDESKI

In my opinion, the procedure recommended and carried out by Dr.
Horndeski on March 5, 2019 departed from and was below the accepted
standard of care in the following respect; Mrs. Price was a very high
risk surgical candidate which, under the aforesaid standard of care for
plastic surgeons, precludes any elective breast reconstruction. Any
breast reconstruction under her presentation would be a violation of the
standard of care of a plastic surgeon. She had already failed multiple
attempts at bilateral breast reconstruction and has a history of severe
wound problems after other operations on her body. Mrs. Price stated
to me that all she wanted was her dog ears removed from the
mastectomies and this was never performed. The standard of care for
patients with multiple failed reconstructive attempts, as indicated in the
records of Cheryl Price is to do nothing. Additionally, Dr. Horndeski
breached the standard of care by performing a “bellasoma” procedure
which is an unknown procedure, experimental at best, and not the

                                    7
      standard of care in any community. Dr. Horndeski actually refers to
      the operation in question as the “ultimate” breast lift in his progress
      notes on 3/18/2019.

                                   CAUSATION

      The ill-advised “Bellasoma” reconstructive breast surgery performed
      by Dr. Horndeski on Cheryl Price led to foreseeable and inevitable
      multiple infected pustule formation, fat necrosis and retained foreign
      bodies in the breasts which required two operative debridements by Dr.
      Horndeski and several more operations by myself, Dr. Kovacev and Dr.
      Wegge to control. Based upon aforesaid medical records and based
      upon my experience and training, it was below the standard of care for
      the defendant plastic surgeon, Dr. Horndeski, to perform the
      “Bellasoma” surgery on Mrs. Price. Under reasonable medical
      probability had he simply refrained from performing the procedure,
      Mrs. Price would not have sustained the disfigurement she complains
      of and all five of the subsequent procedures would have been avoided.

      Dr. Horndeski objected to the Amended Report arguing the report was

inadequate as to standard of care, breach, and causation. He filed a motion to dismiss

with prejudice Price’s negligence claim on the same grounds, and he asked the trial

court to award him his attorney’s fees and costs. See TEX. CIV. PRAC. & REM. CODE

§ 74.351(b).    The trial court denied his motion and this interlocutory appeal

followed.

                                     Discussion

      On appeal, Dr. Horndeski challenges the trial court’s order denying his motion

to dismiss Price’s health care liability claim against him. He argues Dr. Lapuerta’s

Amended Report is deficient because Dr. Lapuerta does not provide a fair summary

of his opinions regarding (1) the applicable standard of care, (2) how Dr. Horndeski

                                          8
breached that standard, and (3) the causal relationship between Dr. Horndeski’s

alleged breach of the standard of care and the harm to Price.

A.    Standard of Review

      We review a trial court’s decision on a motion to dismiss a health care liability

claim for abuse of discretion. See Am. Transitional Care Ctrs. of Tex., Inc. v.

Palacios, 46 S.W.3d 873, 875 (Tex. 2001). When reviewing matters committed to

a trial court’s discretion, we may not substitute our own judgment for that of the trial

court. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). A trial court

does not abuse its discretion merely because it decides a discretionary matter

differently than an appellate court would in a similar circumstance. Harris Cnty.

Hosp. Dist. v. Garrett, 232 S.W.3d 170, 176 (Tex. App.—Houston [1st Dist.] 2007,

no pet.). But a trial court has no discretion in determining what the law is or in

applying the law to the facts. See Walker v. Packer, 827 S.W.2d 833, 840 (Tex.

1992). A trial court abuses its discretion if it acts in an arbitrary or unreasonable

manner without reference to guiding rules or principles. Jelinek v. Casas, 328

S.W.3d 526, 539 (Tex. 2010). We conduct our review keeping in mind that Chapter

74 expert reports are required to deter baseless claims, not to block earnest ones.

Scoresby v. Santillan, 346 S.W.3d 546, 554 (Tex. 2011) (“The purpose of the expert

report requirement is to deter frivolous claims, not to dispose of claims regardless of

                                           9
their merit.”). When reviewing decisions for abuse of discretion, “[c]lose calls must

go to the trial court.” Larson v. Downing, 197 S.W.3d 303, 305 (Tex. 2006).

B.    Applicable Law

      Under the Texas Medical Liability Act, a health care liability claimant must

“serve on [each defendant] or the [defendant’s] attorney one or more expert reports,

with a curriculum vitae of each expert listed in the report for each physician or health

care provider against whom a liability claim is asserted” to substantiate her claims.

TEX. CIV. PRAC. & REM. CODE § 74.351(a); see E.D. by & through B.O. v. Tex.

Health Care, P.L.L.C., 644 S.W.3d 660, 662 (Tex. 2022); Abshire v. Christus Health

Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018). 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 (1) the applicable standards of care, (2) the

manner in which the care rendered by the defendant physician or health care provider

failed to meet the standards, and (3) the causal relationship between that failure and

the injury, harm, or damages claimed by the plaintiff. TEX. CIV. PRAC. & REM. CODE

§ 74.351(r)(6); see E.D. by & through B.O., 644 S.W.3d at 662 (citing TEX. CIV.

PRAC. & REM. CODE § 74.351(l), (r)(6)).

      A “fair summary” of the expert’s opinions means the report must state more

than the expert’s mere conclusions on the standard of care, breach, and causation.

The report must explain the basis of the expert’s opinion so as to link the conclusions

                                          10
to the facts of the case. See Jelinek, 328 S.W.3d at 539; Wright, 79 S.W.3d at 52.

“The fair summary benchmark is not an evidentiary standard, and at this early stage

of the litigation, we do not require a claimant to present evidence in the report as if

it were actually litigating the merits.” E.D. by & through B.O., 644 S.W.3d at 667

(internal quote marks omitted) (quoting Abshire, 563 S.W.3d at 226). “Rather, [t]he

ultimate evidentiary value of the opinions proffered—that is, whether there actually

is a breach and causal connection—is a matter to be determined at summary

judgment and beyond. E.D. by & through B.O., 644 S.W.3d at 667 (internal quote

marks omitted) (quoting Abshire, 563 S.W.3d at 226) (alteration in original).

      In assessing the report’s sufficiency, the trial court may not draw any

inferences; the only information relevant to the inquiry is within the four corners of

the document. In re McAllen Med. Ctr., Inc., 275 S.W.3d 458, 463 & n.14 (Tex.

2008); Palacios, 46 S.W.3d at 878–79. Although the report need not marshal all the

plaintiff’s proof, it must include the expert’s opinions on the three statutory

elements: standard of care, breach, and causation. Abshire, 563 S.W.3d at 223

(citing Palacios, 46 S.W.3d at 878–79); Gray v. CHCA Bayshore L.P., 189 S.W.3d

855, 859 (Tex. App.—Houston [1st Dist.] 2006, no pet.). Courts must view the

report in its entirety, rather than isolating specific portions or sections, to determine

whether it is sufficient. See Baty v. Futrell, 543 S.W.3d 689, 694 (Tex. 2018)

(stating when reviewing sufficiency of expert reports, courts must view report in its

                                           11
entirety); see also Ortiz v. Patterson, 378 S.W.3d 667, 671 (Tex. App.—Dallas 2012,

no pet.) (“We determine whether a causation opinion is sufficient by considering it

in the context of the entire report.”); Austin Heart, P.A. v. Webb, 228 S.W.3d 276,

282 (Tex. App.—Austin 2007, no pet.) (“The form of the report and the location of

the information in the report are not dispositive.”).

      An expert report must be served “not later than the 120th day after the date

each defendant’s original answer is filed.”        TEX. CIV. PRAC. & REM. CODE

§ 74.351(a). To avoid dismissal, the report must provide enough information as to

each required element to constitute an “objective good faith effort to comply with

the definition of an expert report.” Id. § 74.351(l). First, the report must inform the

defendant health care provider of the specific conduct the plaintiff questions or about

which the plaintiff complains. E.D. by and through B.O., 644 S.W.3d at 664.

Second, the report must provide a basis for the trial court to conclude that the

plaintiff’s health care claims have merit. Id. A report that merely states the expert’s

conclusions as to the standard of care, breach, and causation does not fulfill these

two purposes. See Scoresby, 346 S.W.3d at 556. While the expert report need not

use any particular words and may be informal, “bare conclusions will not suffice.”

Id.

      In reviewing the adequacy of an expert report, a trial court may not consider

an expert’s credibility, the data relied on by the expert, or the documents the expert

                                          12
failed to consider at the pre-discovery stage of the litigation. See Mettauer v. Noble,

326 S.W.3d 685, 691–92 (Tex. App.—Houston [1st Dist.] 2010, no pet.); Gonzalez,

485 S.W.3d at 245; Gonzalez v. Padilla, 485 S.W.3d 236, 245 (Tex. App.—El Paso

2016, no pet.). It is not the trial court’s job to weigh the report’s credibility; that is,

the court’s disagreement with the expert’s opinion does not render the expert report

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

      If the plaintiff serves a timely expert report and the defendant physician or

health care provider files a motion challenging the report’s adequacy, the trial court

“shall grant [the] 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 in Subsection

(r)(6).”3 TEX. CIV. PRAC. & REM. CODE § 74.351(l); see Palacios, 46 S.W.3d at 877.

“The purpose of the expert report requirement is to deter frivolous claims, not to

dispose of claims regardless of their merit.” Scoresby, 346 S.W.3d at 554. Section

74.351 was designed to meet that purpose “by requiring a claimant early in litigation

to produce the opinion of a suitable expert that his claim has merit.” Columbia

3
      If an expert report is not served timely “because elements of the report are found
      deficient, the [trial] court may grant one 30-day extension to the claimant in order
      to cure the deficiency.” TEX. CIV. PRAC. & REM. CODE § 74.351(c). Following
      remand from this Court’s decision in Horndeski I, the trial court granted Price thirty
      days to cure the deficiencies in her report. This appeal stems from the trial court’s
      denial of Dr. Horndeski’s motion to dismiss filed after Price filed her Amended
      Report.

                                            13
Valley Healthcare Sys. L.P. v. Zamarripa, 526 S.W.3d 453, 460 (Tex. 2017)

(quoting Scoresby, 346 S.W.3d at 552). It is “a low threshold” a person asserting 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) (Hecht, J.,

concurring and dissenting). Accordingly, the Texas Supreme Court “has encouraged

trial courts to liberally construe expert reports in favor of plaintiffs.” Henry v. Kelly,

375 S.W.3d 531, 535 (Tex. App.—Houston [14th Dist.] 2012, pet. denied).

C.    Standard of Care and Breach

      The standard of care relevant to a healthcare provider is what an ordinarily

prudent healthcare provider would do under the same or similar circumstances.

Palacios, 46 S.W.3d at 880; Strom v. Mem’l Hermann Hosp. Sys., 110 S.W.3d 216,

222 (Tex. App.—Houston [1st Dist.] 2003, pet. denied). “Identifying the standard

of care is critical: Whether a defendant breached his or her duty to a patient cannot

be determined absent specific information about what the defendant should have

done differently.” Palacios, 46 S.W.3d at 880; Nw. EMS Consultants, P.A. v.

Guillory, No. 01-19-00668-CV, 2020 WL 4516872, at *7 (Tex. App.—Houston [1st

Dist.] Aug. 6, 2020, pet. denied) (mem. op.) (finding expert report conclusory with

respect to applicable standard of care where report failed to specifically describe

standard of care for transferring patient strapped to stretcher from ambulance to

hospital). The standard of care articulated in the expert report, however, “need not

                                           14
be complicated for it to be sufficient.” Keepers v. Smith, No. 01-20-00463-CV, 2022

WL 2347744, at *12 (Tex. App.—Houston [1st Dist.] June 30, 2022, pet. denied)

(mem. op.) (citing Baty, 543 S.W.3d at 697).

      For standard of care and breach, the expert report must explain what the

defendant physician should have done under the circumstances and what the

physician did instead. Abshire, 563 S.W.3d at 226 (noting that to identify standard

of care adequately expert report must set forth “specific information about what the

defendant should have done differently”); see also Palacios, 46 S.W.3d at 880 (“The

standard of care for a hospital is what an ordinarily prudent hospital would do under

the same or similar circumstances.”). A report that merely states the expert’s

conclusions about standard of care and breach is insufficient. See Palacios, 46

S.W.3d at 880.

      The report must identify the care that should have been given and it must do

so with such specificity that inferences are not needed to discern it. Guillory, 2020

WL 4516872, at *7; see Russ v. Titus Hosp. Dist., 128 S.W.3d 332, 342 (Tex.—App.

Texarkana, 2004, pet. denied) (“In other words, one must be able to determine from

the report what the standard of care required to be done.”). A trial court cannot fill

in missing gaps in an expert report, draw inferences, or guess what an expert likely

meant in his expert report. Tenet Hosps., Ltd. v. Garcia, 462 S.W.3d 299, 310 (Tex.

App.—El Paso 2015, no pet.); see also Collini v. Pustejovsky, 280 S.W.3d 456, 462

                                         15
(Tex. App.—Fort Worth 2009, no pet.) (“When reviewing the adequacy of a report,

the only information relevant to our inquiry is the information contained within the

four corners of the document. This requirement precludes a court from filling gaps

in a report by drawing inferences or guessing as to what the expert likely meant or

intended.” (internal citations and footnote omitted)).

      Dr. Horndeski argues Dr. Lapuerta’s opinions in his Amended Report are

“virtually identical to those found deficient by this Court in his Original and

Supplemental Reports.” According to Dr. Horndeski, Dr. Lapuerta’s Amended

Report fails to provide a fair summary of his opinions regarding the standard of care

applicable to Dr. Horndeski and the manner in which Dr. Horndeski failed to meet

that standard.   He argues Dr. Lapuerta’s opinions, as expressed in the report

concerning the applicable standard of care and breach, are conclusory and thus the

Amended Report fails to inform Dr. Horndeski of how he breached the standard of

care and what Dr. Lapuerta believes Dr. Horndeski should have done differently.

      We disagree with Dr. Horndeski’s characterization of the Amended Report as

“virtually identical” with respect to his opinions on standard of care and breach. In

Horndeski I, we concluded that Dr. Lapuerta’s Supplemental Report was inadequate

with regard to standard of care and breach, and we stated:

      In his supplemental expert report, Dr. Lapuerta states that in his
      opinion, “Mrs. Price has an extensive and complicated medical and
      surgical history with a history of healing problems and she was not a
      candidate for any type of breast reconstruction. She had some type of
                                          16
      procedure performed by Dr. Horndeski in March 2019 complicated by
      multiple infested pustules and required three operative debridements
      and wound care with oral antibiotic therapy to eventually heal.” Dr.
      Lapuerta then opines that “[t]he procedure performed consisting of a
      “bellasoma” reconstruction and explained at www.horndeski.com is
      not the standard of care in breast reconstruction in the community.”

      These opinions do not articulate a standard of care applicable to a
      plastic surgeon with respect to breast reconstruction surgery.

We further held Dr. Lapuerta’s opinion that “[t]he procedure performed consisting

of a ‘bellasoma’ reconstruction and explained at www.horndeski.com is not the

standard of care in breast reconstruction in the community” or that “Price has an

extensive and complicated medical and surgical history with a history of healing

problems and she was not a candidate for any type of breast reconstruction” “fails to

state how the Bellasoma procedure violated any particular standard of care or explain

with any level of specificity what Dr. Horndeski should have done differently.”

Horndeski I, 2022 WL 3363951, at *6. We further stated that “Dr. LaPuerta does

not explain or give a summary of what Dr. Horndeski should have done under the

circumstances or ‘what care was expected, but not given.’” Id. (quoting Palacios, 46

S.W.3d at 880).

      In his Amended Report, Dr. Lapuerta reiterates that Price “has an extensive

and complicated medical and surgical history with a history of severe healing

problems.” But, unlike in his Supplemental Report, Dr. Lapuerta adds and explains

in his Amended Report that:

                                         17
      [Price’s] past surgical history includes a failed attempt at implant
      reconstruction, which is one of the standard operations performed in
      high risk patients who desire breast reconstruction. Her past surgical
      history also includes severe complications after colon surgery leading
      to wound care issues and hernia formation. These complications reduce
      other autologous tissue options for Mrs. Price such as a TRAM or DIEP
      flap.

Dr. Lapuerta clarified that the “procedure performed by Dr. Horndeski in March of

2019” consisted “of what [Dr. Horndeski] refers to as ‘bellasoma procedure.’” He

also reiterated that the Bellasoma procedure was “complicated by multiple infected

pustules and required” surgery and “wound care with oral antibiotic therapy to

eventually heal,” and he stated that the complications from the Bellasoma procedure

required “five to six subsequent operative debridements by three other surgeons,”

rather than three surgeries he stated in his Supplemental Report. For the first time

in his Amended Report, Dr. Lapuerta further stated:

      Based upon my experience, training, practice and review of literature,
      the accepted standard of care for a plastic surgeon presented with the
      history and examination of Cheryl Price as set forth within Dr.
      Horndeski’s records is to perform no reconstructive procedure
      whatsoever. Additionally, the procedure performed by Dr. Horndeski
      consisted of a “Bellasoma” reconstruction and is explained at
      www.horndeski.com. The standard of care operations in breast
      reconstruction would include implant reconstruction, TRAM flaps or
      DIEP flaps and latissimus muscle flaps.             The “Bellasoma”
      reconstruction varies from the standard of care and ordinary breast
      reconstructive surgery and, even if a plastic surgeon was to ignore the
      standard of care to do nothing, the procedure described and performed
      by Dr. Horndeski breached the standard of care.

                                        18
In another section of the Amended Report, Dr. Lapuerta stated Price had undergone

“a latissimus flap,” and the Bellasoma procedure is “an unknown procedure,

experimental at best, and not the standard of care in any community,” which “Dr.

Horndeski actually refers to. . . as the ‘ultimate’ breast lift.”

      Unlike his Supplemental Report, when viewed in its entirety and liberally

construed in Price’s favor, Dr. Lapuerta’s Amended Report articulated two standards

of care applicable to Dr. Horndeski. According to Dr. Lapuerta, the applicable

standard of care for a plastic surgeon presented with a patient who has had multiple

unsuccessful breast reconstruction surgeries in the past, including a “failed attempt

at implant reconstruction,” and “a latissimus flap,” and has “a history of severe

healing problems” post-surgery which “reduce[d] other autologous tissue options for

Mrs. Price such as a TRAM or DIEP flap,” is “to perform no reconstructive

procedure whatsoever.” See Baty, 543 S.W.3d at 694 (stating courts should assess

sufficiency of expert report by considering entire report, not just discrete portions);

Henry, 375 S.W.3d at 535 (stating expert reports should be liberally construed in

favor of plaintiffs); see generally Keepers, 2022 WL 2347744, at *12 (“The stated

standard of care need not be complicated for it to be sufficient.”). According to Dr.

Lapuerta, Dr. Horndeski breached that standard of care by performing the Bellasoma

procedure on Price in light of her medical history, a procedure Dr. Lapuerta explains

“varies from the standard of care and ordinary breast reconstruction surgery.”

                                            19
      When viewed in its entirety and liberally construed in Price’s favor, Dr.

Lapuerta’s Amended Report also states the standard of care for a plastic surgeon

performing breast reconstruction surgery is to perform a known breast reconstruction

procedure, not an unknown or experimental procedure. Dr. Lapuerta opines Dr.

Horndeski breached that standard of care by performing the Bellasoma procedure on

Price because the Bellasoma procedure is “an unknown procedure” that is

“experimental at best” and “varies from an ordinary breast reconstruction surgery.”

See Baty, 543 S.W.3d at 694 (stating courts should consider entire expert report

when determining sufficiency); Henry, 375 S.W.3d at 535 (stating expert reports

should be liberally construed in favor of plaintiffs); see generally Keepers, 2022 WL

2347744, at *12 (recognizing uncomplicated standard of care may “be sufficient”

for purposes of Section 74.351).

      Having done so, Dr. Lapuerta has informed Dr. Horndeski that he should have

refrained from performing any breast reconstruction surgery on Price in light of her

prior medical history, including failed reconstructive surgeries, and in no event

should Dr. Horndeski have performed the Bellasoma procedure on Price because it

is an unknown and experimental procedure. See Abshire, 563 S.W.3d at 226 (stating

expert report must set forth “specific information about what the defendant should

have done differently”); see generally Grindstaff v. Michie, 242 S.W.3d 536, 543

(Tex. App.—El Paso 2007, no pet.) (“While these statements are written in the

                                         20
negative rather than the positive, the report provides specific information about what

Dr. Grindstaff should have done differently.”).

      According to Dr. Horndeski, Dr. Lapuerta’s Amended Report is conclusory

regarding the standard of care and breach because the Amended Report does not

provide a sufficient factual basis for Dr. Lapuerta’s assertion Price had “multiple

failed reconstructive attempts.” On the contrary, the Amended Report states Price

had “bilateral mastectomies followed by delayed breast cancer reconstruction with

implants in 1999,” “a latissimus flap in the past,” and “some other type of breast

procedure in 2000 as well.” Dr. Lapuerta further states that Price’s “past surgical

history includes a failed attempt at implant reconstruction, which is one of the

standard operations performed in high risk patients who desire breast

reconstruction.” According to Dr. Lapuerta, Price “had already failed multiple

attempts at bilateral breast reconstruction and has a history of severe wound

problems after other operations on her body.”

      Dr. Horndeski also argues the Amended Report does not provide a sufficient

factual basis for Dr. Lapuerta’s assertion that Price was not a candidate for breast

reconstruction surgery or “set forth the preexisting condition such that made Price a

high-risk surgical candidate for the procedure in question.” In his Amended Report,

Dr. Lapuerta opines that the “standard of care operations in breast reconstruction

would include implant reconstruction, TRAM flaps or DIEP flaps and latissimus

                                         21
muscle flaps.” According to Dr. Lapuerta, when Dr. Horndeski operated on Price,

Price had already had a “failed attempt at implant reconstruction” and a latissimus

muscle flap, and her “past surgical history also includes severe complications . . .

[which] reduce other autologous tissue options for Mrs. Price such as a TRAM or

DIEP flap.” Dr. Lapuerta thus explained Price was not a good candidate for the

Bellasoma procedure, or any other breast reconstruction surgery, because the breast

reconstruction surgeries she had in the past were unsuccessful and TRAM flaps or

DIEP flaps, the other standard breast reconstruction surgeries, were not available

options given Price’s history of impaired wound healing and post-surgical

complications. Having done so, Dr. Lapuerta’s Amended Report provides sufficient

factual information supporting his opinions on the applicable standard of care. See

Windrum v. Kareh, 581 S.W.3d 761, 770 (Tex. 2019) (“The line determining

whether an expert opinion is conclusory is difficult to draw, and ‘[c]lose calls must

go to the trial court.’”) (quoting Larson, 197 S.W.3d at 304); see also Baty, 543

S.W.3d at 695 (stating conclusory statements in expert report context fail to “provide

the requisite ‘specific information about what the defendant should have done

differently’”) (quoting Palacios, 46 S.W.3d at 880)).

      The purpose of Section 74.351 is to deter frivolous health care liability claims

“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 at 460 (quoting Scoresby, 346

                                          22
S.W.3d at 552). Although Section 74.351’s expert report requirements are

mandatory with regard to all health care liability claims, the requirements to not

present an exacting or particularly burdensome standard. See also Loaisiga, 379

S.W.3d at 264 (stating expert report requirement creates “a low threshold a person

claiming against a health care provider must cross merely to show that his claim is

not frivolous”); see also Curnel v. Hous. Methodist Hosp.-Willowbrook, 562 S.W.3d

553, 562–63 (Tex. App.—Houston [1st Dist.] 2018, no pet.) (stating Section

74.351’s requirements “have been variously described as a ‘lenient standard,’ ‘low

threshold,’ and ‘relatively low bar’”) (footnotes omitted)).

      Liberally construing Dr. Lapuerta’s Amended Report in Price’s favor and

bearing in mind that Section 74.351’s limited purpose is to dispose of frivolous

claims, we conclude the trial court reasonably could have determined that Dr.

Lapuerta’s Amended Report represented a good-faith effort to inform Dr. Horndeski

of the applicable standard of care and manner in which Dr. Horndeski allegedly

breached that standard, as required by Section 74.351(r)(6). See Henry, 375 S.W.3d

at 535 (stating Texas Supreme Court “has encouraged trial courts to liberally

construe expert reports in favor of plaintiffs”). Although the Amended Report could

have provided a more robust discussion of Dr. Lapuerta’s opinions on standard of

care and breach, we nevertheless consider it sufficient, and to the extent the report’s

                                          23
adequacy is a close call, “[c]lose calls must go to the trial court.” Larson, 197

S.W.3d at 304.

D.    Causation

      An expert report must provide a “fair summary” of the expert’s opinion

regarding the causal relationship between the failure of a defendant health care

provider to provide care in accord with the applicable standard of care and the

plaintiff’s claimed injury, harm, or damages.        TEX. CIV. PRAC. & REM. CODE

§ 74.351(r)(6); E.D. by & through B.O., 644 S.W.3d at 663. An expert does not

fulfill the statutory requirements by generally opining that the defendant’s breach

caused an injury. Jelinek, 328 S.W.3d at 539 (citing Palacios, 46 S.W.3d at 879);

Guillory, 2020 WL 4516872 at *12; see also Abshire, 563 S.W.3d at 224 (“A

conclusory statement of causation is inadequate . . . .”). Such a statement is

conclusory and provides merely the expert’s ipse dixit. See Jelinek, 328 S.W.3d at

539. Instead, the expert report must explain how and why the defendant health care

provider’s breach proximately caused the plaintiff’s injury. Zamarripa, 526 S.W.3d

at 460 (stating expert report sufficient as to causation if it makes “a good-faith effort

to explain, factually, how proximate cause is going to be proven”). Although

“magical words” are not required, mere invocation of the phrases such as “proximate

cause,” “foreseeability,” or “cause in fact” does not ensure the report will be found

adequate. See id.

                                           24
      The “detail needed to establish a causal link generally is proportional to the

complexity of the negligent act giving rise to the claim.” Columbia Med. Ctr. of

Arlington Subsidiary L.P. v. L.M., No. 02-17-00147-CV, 2018 WL 1095746, at *7

(Tex. App.—Fort Worth Mar. 1, 2018, no pet.) (mem. op.). In other words, a

“causation opinion is not conclusory simply because it is not complex.” Id.

      Proximate cause has two components: cause-in-fact and foreseeability.

Zamarripa, 526 S.W.3d at 460; Gunn v. McCoy, 554 S.W.3d 645, 658 (Tex. 2018).

A defendant physician’s breach was a cause-in-fact of the plaintiff’s injury if the

breach was a substantial factor in bringing about the harm, and absent the breach the

harm would not have occurred. Gunn, 554 S.W.3d at 658. Even if the harm would

not have occurred absent the defendant physician’s breach, “the connection between

the defendant and the plaintiff’s injuries simply may be too attenuated” for the

breach to qualify as a substantial factor. Allways Auto Grp., Ltd. v. Walters, 530

S.W.3d 147, 149 (Tex. 2017) (internal quotations omitted); CHCA Clear Lake, L.P.

v. Stewart, No. 01-19-00874-CV, 2021 WL 3412461, at *10 (Tex. App.—Houston

[1st Dist.] Aug. 5, 2021, no pet.) (mem. op.). A breach is not a substantial factor if

it “does no more than furnish the condition that makes the plaintiff’s injury

possible.” Allways Auto Grp., 530 S.W.3d at 149. A defendant physician’s breach

is a foreseeable cause of the plaintiff’s injury if a physician of ordinary intelligence

would have anticipated the danger caused by the negligent act or omission. Puppala

                                          25
v. Perry, 564 S.W.3d 190, 197 (Tex. App.—Houston [1st Dist.] 2018, no pet.);

CHCA Clear Lake, 2021 WL 3412461, at *10. Dr. Horndeski argues Dr. Lapuerta’s

Amended Report does not provide a fair summary of Dr. Lapuerta’s opinion

regarding the causal relationship between Dr. Horndeski’s alleged breaches of the

standard of care and Price’s harm because Dr. Lapuerta does not explain how and

why Dr. Horndeski’s alleged breaches caused Price’s “complicated healing and

subsequent procedures,” and further that Dr. Lapuerta’s statements regarding the

causal relationship are conclusory. According to Dr. Horndeski, Dr. Lapuerta’s

Amended Report suffers from the same deficiencies as his Original and

Supplemental Reports, which we found were inadequate in Horndeski I, because Dr.

Lapuerta “merely reorganized sentences he had in his previous reports and sprinkled

in additional words such as ‘foreseeable’ and ‘inevitable.’”

      We find the opinions in Grindstaff v. Michie, 242 S.W.3d 536 (Tex. App.—

El Paso 2007, no pet.) and Ranelle v. Beavers, No. 02-08-437-CV, 2009 WL

1176445 (Tex. App.—Fort Worth Apr. 30, 2009, no pet.) (mem. op.) to be

instructive to our analysis. We discuss them in turn.

      In Grindstaff, Sandra Michie filed a health care liability claim against her

former podiatrist, Dr. Grindstaff, alleging Dr. Grindstaff was negligent by among

other things, “performing a surgical procedure that was not indicated for her then

existing condition and diagnosis.” Id. at 539. She served Dr. Grindstaff with a report

                                         26
prepared by her expert, Dr. Cartwright. Id. Dr. Grindstaff objected to the adequacy

of Dr. Cartwright’s report and moved to dismiss with prejudice Michie’s negligence

claim against him. The trial court found Dr. Cartwright’s report complied with

Section 74.351 and denied Dr. Grindstaff’s motion to dismiss. Id.

          On appeal, Dr. Grindstaff argued Dr. Cartwright’s report did not satisfy the

requirements of Section 74.351 because it “fail[ed] to address causation or, in the

alternative, [was] merely conclusory.” Id. at 544. With respect to causation, Dr.

Cartwright’s report stated:

          The surgery is subsequently performed on both feet simultaneously and
          the patient ultimately achieves no benefit whatsoever and in fact feels
          that her condition is now worse. She is now unable to wear much of the
          footwear she states she was able to wear prior to surgery and that she is
          much less ambulatory than she was prior to surgery. She claims that her
          pain is much greater. I believe these complaints are a direct result of the
          surgery that was neither warranted or indicated.

Id. According to Dr. Cartwright, “Dr. Grindstaff’s recommendation for bilateral

surgery is generally not recommended and performing the surgery endoscopically

was contraindicated since Michie presented with symptoms suggesting nerve

compression.” Id. The court held the trial court had not abused its discretion by

finding Dr. Cartwright’s report complied with Section 74.351. Id. The opinion

states:

          According to Dr. Cartwright, Dr. Grindstaff breached the standard of
          care by recommending a surgical procedure that was contraindicated,
          controversial, had a high risk of complications, and should not have
          been performed bilaterally. Following surgery, Michie’s pain and

                                              27
      condition worsened. This was a “direct result of the surgery that was
      neither warranted or indicated.” Such is generally the case where the
      negligence claim arises from surgery gone awry. All of Dr.
      Cartwright’s opinions were “based on a reasonable degree of medical
      probability.”

Id.

      Similar, in Ranelle, Herschel Beavers filed negligence and medical battery

claims against his former surgeon, Dr. Ranelle, alleging Dr. Ranelle was negligent

by among other things, “[p]erform[ing         an] unnecessary surgery.”     2009 WL

1176445, at *1. According to Beavers, Dr. Ranelle misrepresented to him that he

needed back surgery to treat a non-existent medical condition, and Dr. Ranelle

negligently performed the unnecessary surgery. Id. Dr. Ranelle objected to the

adequacy of the report prepared by Beavers’ expert, Dr. McBride, and moved to

dismiss with prejudice Beavers’ claims against him. In his report, Dr. McBride

stated:

      [Beavers’] ongoing back problems and all of the consequences that
      naturally flow from performing a surgery that would not have been
      performed if Dr. Ranelle had been honest. These consequences include
      hospitalization, pain associated with recovery from the trauma of
      surgery, limitation in activities and additional medical care including in
      this case, physical therapy and additional surgery to remove the bone
      stimulator.

Id. at *4 (discussing medical battery claim).

      It is my opinion based on reasonable medical probability that the failure
      of Dr. Ranelle to observe the standards of care in Herschel Beavers’
      case was a proximate cause of the [sic] Mr. Beavers’ ongoing back
      problems and all of the consequences that naturally flow from

                                         28
      performing a surgery that would not have been performed if Dr. Ranelle
      had been honest.

Id. at *6 (discussing negligent claim based on unnecessary surgery) (emphasis in

original). The court held the trial court did not abuse its discretion by finding Dr.

McBride’s opinion was adequate with regard to the casual relationship between Dr.

Ranelle’s performance of the unnecessary surgery and Beavers’ harm. Id.

      In his Amended Report, Dr. Lapuerta states Price’s medical history includes

multiple failed breast reconstruction procedures and a history of severe post-surgical

complications and impaired wound healing. Dr. Lapuerta opines Dr. Horndeski

breached the standard of care by performing the Bellasoma procedure on Price, an

experimental elective breast reconstruction surgery that was contraindicated by

Price’s medical history and not standard for reconstructive surgery. According to

Dr. Lapuerta, Price “developed severe complications of abscess formation, bilateral

open breast wounds” after the Bellasoma surgery, which required five or six

surgeries over seventh months and oral antibiotics to treat. When viewed in its

entirety and liberally construed in Price’s favor, Dr. Lapuerta’s Amended Report

reflects Dr. Lapuerta’s opinion that had Dr. Horndeski refrained from performing

any breast reconstruction surgery, including the Bellasoma procedure, Price would

not have suffered severe post-surgical complications, as she had after prior surgeries,

that required multiple surgeries to treat. In other words, Price, who had a history of

severe post-surgical complications and impaired wound healing, suffered severe

                                          29
post-surgical complications and impaired wound healing after the Bellasoma

surgical procedure performed by Dr. Horndeski, and Price would not have suffered

such post-surgical injuries if Dr. Horndeski had not performed the surgery given his

knowledge of Price’s medical history.

       As in Grindstaff and Ranelle, Dr. Lapuerta has thus established a relatively

simple causal relationship between an unnecessary surgery and the patient’s harm

which consists of “the consequences that naturally flow from performing a surgery

that [should] not have been performed.”         Ranelle, 2009 WL 1176445 at *4;

Columbia Med. Ctr., 2018 WL 1095746, at *7 (stating expert’s “causation opinion

is not conclusory simply because it is not complex”); Curnel v. Hous. Methodist

Willowbrook Hosp., No. 01-18-01054-CV, 2019 WL 7341669, at *8 (Tex. App.—

Houston [1st Dist.] Dec. 31, 2019, no pet.) (mem. op.) (“Expert reports must provide

a causal relationship between the breach and the injury, but case law rejects requiring

every single detail to satisfy the requirements of Section 74.351.”); cf. Power v.

Kelley, 70 S.W.3d 137, 143 (Tex. App.—San Antonio 2001, no pet.) (“Causation

may be proven by evidence showing that a surgical procedure was performed that

was contraindicated . . . .”).

       Citing to Standefer v. Brewer, 256 S.W.3d 889 (Tex. App.—Dallas 2008), Dr.

Horndeski argues that Dr. Lapuerta’s report is inadequate as to causation because

the report does not “connect beyond ipse dixit that had Dr. Horndeski simply

                                          30
refrained from performing the procedure, [Price] would not have sustained the

disfigurement she complains of and all of the subsequent procedures would have

been avoided.” Dr. Horndeski’s reliance on Standefer is misplaced.

      In Standefer, Rose Brewer asserted Dr. Standefer was negligent by failing to

obtain her informed consent before performing a cosmetic face-lift procedure. 256

S.W.3d at 890. Dr. Standefer argued that Brewer’s expert report was inadequate as

to causation because it did not contain a good faith effort to provide a fair summary

of the expert’s opinion on causation. Id. at 893. For a negligence claim based on

informed consent, proximate cause “requires proof that had the risk been disclosed,

a reasonable person in the same or similar circumstances would have refused the

treatment or procedure, and the injury complained of was caused in fact by the

undisclosed risk.” Id. at 892 (citing McKinley v. Stripling, 763 S.W.2d 407, 410

(Tex. 1989)). The court held that Brewer’s expert report did not “discuss whether a

reasonable person would have declined the procedure had they been fully informed

of the risks required to be disclosed,” and it thus failed to show how Dr. Standefer’s

failure to disclose “the risk of failure or possible need for further reconstructive

surgery caused Brewer’s injury or damage.” Id. at 893. The court held the expert’s

statements that Brewer “was not a surgical candidate for the procedure or that she

was harmed by being advised to undergo ‘a simple’ but failed face-lift are not

sufficient to show causation in a lack of informed consent case.” See id. Unlike the

                                         31
expert in Standefer, Dr. Lapuerta did not have to “discuss whether a reasonable

person would have declined the procedure had they been fully informed of the risks

required to be disclosed” in order to satisfy the proximate causation element for a

theory of negligence based on the performance of an unnecessary and

contraindicated surgery. See Power, 70 S.W.3d at 143 (“Because Earl’s claims are

for negligence based on the performance of unnecessary surgeries, Earl is not

required to meet the causation requirements for an informed consent claim.”).

Furthermore, the only theory of negligence in Standefer was based on the failure to

obtain consent. There is thus no indication in Standefer that Brewer’s report would

have been insufficient if rendered in support of a negligence claim based on

something other than the failure to obtain informed consent.

      Price need not marshal all of her evidence or prove her case against Dr.

Horndeski at this stage of the case. Section 74.351 only requires the plaintiff to serve

a report that constitutes a good-faith effort to provide a fair summary of the expert’s

opinions regarding causation. See TEX. CIV. PRAC. & REM. CODE § 74.351(l). This

good-faith effort is satisfied if the plaintiff’s report provides enough information to

(1) inform the defendant of the specific conduct the plaintiff calls into question and

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

Palacios, 46 S.W.3d at 879; see generally Henry, 375 S.W.3d at 535 (stating Texas

Supreme Court “has encouraged trial courts to liberally construe expert reports in

                                          32
favor of plaintiffs”). When viewed in its entirety and liberally construed in favor of

Price, Dr. Lapuerta’s Amended Report constitutes a good faith effort to provide Dr.

Horndeski with Dr. Lapuerta’s opinions regarding the causal relationship between

Dr. Horndeski’s breaches of the standard of care and Price’s harm. See Ortiz, 378

S.W.3d at 671 (“We determine whether a causation opinion is sufficient by

considering it in the context of the entire report.”); Austin Heart, P.A., 228 S.W.3d

at 282 (“The form of the report and the location of the information in the report are

not dispositive.”).

      Like our holding with respect to the adequacy of Dr. Lapuerta’s Amended

Report on standard of care and breach, in reaching our decision with respect to the

sufficiency of the Amended Report on the element of causation, we are mindful that

the expert report requirement is a low initial threshold intended to deter frivolous

claims, not to dispose of claims regardless of their merit. See Zamarripa, 526

S.W.3d at 460 (stating Section 74.351 intended to deter frivolous health care liability

claims “by requiring a claimant early in litigation to produce the opinion of a suitable

expert that his claim has merit”) (quoting Scoresby, 346 S.W.3d at 552); see also

Loaisiga, 379 S.W.3d at 264 (stating expert report requirement creates “a low

threshold a person claiming against a health care provider must cross merely to show

that his claim is not frivolous”). Although the Amended Report could have provided

a more robust discussion of Dr. Lapuerta’s opinion on the causal relationship

                                          33
between Dr. Horndeski’s breach and Price’s harm, we nevertheless consider it

sufficient, and to the extent the report’s adequacy is a close call with respect to

causation, “[c]lose calls must go to the trial court.” Larson, 197 S.W.3d at 304.

                                    Conclusion

      We affirm the trial court’s order denying Dr. Horndeski’s motion to dismiss

with prejudice Price’s negligence claim.

                                                Veronica Rivas-Molloy
                                                Justice

Panel consists of Chief Justice Adams and Justices Landau and Rivas-Molloy.

                                           34