Court Opinion

ID: 9660534
Source: CourtListenerOpinion
Date Created: 2023-08-23 22:15:23.426214+00
Date Added: 2024-06-11T18:14:20.309446
License: Public Domain

SUE WALKER, J.,
dissenting.
I. INTRODUCTION
I respectfully dissent. The analytical framework utilized by the majority is contrary to the plain language of article 4590i, section 13.01(Z) and ignores controlling supreme court case law. I believe that Dr. Jones’s report, properly examined against the benchmark, guiding principles of good faith — that the report contain information sufficient to apprise the defendant of the claims against him and to permit the trial *52court to conclude the claims have merit — is clearly adequate.1 Consequently, I would hold that the trial court abused its discretion by dismissing the Windsors’ health care liability claim against Dr. Maxwell and would reverse the trial court’s order of dismissal.
II. An Expert Report Need not Correlate to Pleaded Acts of Negligence to Constitute a Good Faith Effort
The Windsors pleaded:

Cause of Action

Defendants [sic] failed to meet the minimum standard of care and provided substandard medical care and was negligent to Plaintiffs [sic] as follows:
(A) failing to select an appropriate technique to perform the arteriogram and failing to obtain an informed consent;
(B) failing to select an appropriate catheter;
(C) improperly positioning the catheter;
(D) injecting the catheter through the cerebral artery into plaintiffs brain;
(E) failing to acknowledge and honor the plaintiffs withdrawal of her consent; and
(F) failing to assure proper placement of the catheter;
Each of the above stated negligent acts was the direct and proximate cause of Plaintiffs damages.
The majority, instead of looking to the four corners of Dr. Jones’s report to determine whether it constitutes a good faith effort at compliance with article 4590i, section 13.01(r)(6)’s definition of an expert report, inexplicably, sua sponte, juxtaposes the Windsors’ pleaded acts of negligence with Dr. Jones’s report. Cf. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 53 (Tex.2002) (explaining, “We have held that the only information relevant to whether a report represents a good-faith effort to comply with the statutory requirements is the report itself.”); Am. Transitional Care Ctrs., Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex.2001) (interpreting the statute as requiring courts to look only to the report to determine adequacy — “Because the statute focuses on what the report discusses, the only information relevant to the inquiry is within the four corners of the document.”). The majority looks to specific negligent acts pleaded by the Windsors and then reviews Dr. Jones’s report to see if the Windsors have come forward with a causation opinion from Dr. Jones on the pleaded acts of negligence. Concluding that Dr. Jones’s report contains no causal link between Mrs. Windsor’s injury and the negligent acts pleaded by the Windsors, the majority then holds that Dr. Jones’s report does not constitute a good faith effort at compliance with section 13.01(r)(6)’s definition of an expert report. See Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(£), (r)(6) (Vernon Supp.2003).
The majority’s analysis of section 13.01’s good faith requirement is flawed. First, the majority’s use of the Windsors’ pleadings to measure whether Dr. Jones’s report constitutes a good faith effort turns Texas pleading practice on its head. The Windsors pleaded a single health care liability negligence claim against Dr. Maxwell — alleging that he negligently performed Mrs. Windsor's January 14, 1998 arteriogram. See, e.g., Lampasas v. Spring Ctr., Inc., 988 S.W.2d 428, 436 (Tex.App-Houston [14th Dist.] 1999, no pet.) (recognizing that amended pleadings simply adding factual variations of negligence claim did not preclude no-evidence summary judgment because amendment did not constitute new theory of recovery). *53The Windsors did not need to plead any specific acts of negligence by Dr. Maxwell in the absence of special exceptions. See Tex.R. Civ. P. 45(b), 47(a), 48; see also Boyles v. Kerr, 855 S.W.2d 593, 601 (Tex.1993) (op. on reh’g) (recognizing that the actual cause of action and the elements do not have to be pleaded with specificity; it is sufficient if a cause of action can be reasonably inferred). The Windsors could simply have pleaded that Dr. Maxwell negligently performed the arteriogram on Mrs. Windsor on January 14, 1998 and that his negligence in performing the ar-teriogram proximately caused Mrs. Windsor to suffer a brain injury leaving her with permanent physical impairment and other damages. See Roark v. Allen, 633 S.W.2d 804, 809 (Tex.1982) (rejecting argument that plaintiff must specifically plead negligent use of forceps and upholding judgment based on simple negligence pleading).
Although the factual acts of negligence pleaded by a plaintiff — especially in an original petition before discovery — are not in any way binding or limiting on the plaintiff, the majority for no apparent reason fixates on the Windsors’ pleaded acts of negligence in measuring the adequacy of Dr. Jones’s report. Via this analysis, the majority departs from the statutory requisites for a good faith effort at compliance with section 13.01(r)(6)’s definition of an expert report and from controlling supreme court case law. Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(Z), (r)(6); Palac-ios, 46 S.W.3d at 878. Utilizing this unconventional procedure, akin to a trial court’s consideration of a no-evidence motion for summary judgment, the majority then concludes that the Windsors did not come forward with a report addressing causation concerning their specifically pleaded negligent acts so the trial court did not abuse its discretion in dismissing with prejudice the Windsors’ suit against Dr. Maxwell.
The plain language of article 4590i, section 13, however, nowhere requires an expert’s report to correlate with or support factual negligent acts pleaded by a claimant in a single health care liability claim. The focus of the statute is on claims, not on the variety of factual negligent acts asserted within a single claim. Tex.Rev. Crv. Stat. Ann. art. 4590i, § 13.01(d), (r)(2). Moreover, one purpose of the expert-report requirement is to deter frivolous claims, not to supplant current pleading practice. Accord Palacios, 46 S.W.3d at 877-78 (explaining purpose of expert-report requirement is to deter frivolous claims). Thus, a claimant may simply plead that a health care provider was negligent in the performance of some procedure, that his negligence proximately caused injuries to the claimant, and that as a result the claimant has suffered damages in excess of the jurisdictional limits of the court. See Tex.R. Civ. P. 45, 47, 48. The claimant’s expert report would then necessarily be more specific than the claimant’s general pleading. Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(r)(6). Or, a plaintiff may, as the Windsors, plead specific, sometimes alternative factual negligent acts within a single negligence cause of action. See Tex.R. Civ. P. 45, 47, 48. That a claimant’s expert report or reports may or may not address every or any of the specifically pleaded acts of negligence set forth in the petition is simply of no import. Instead, courts are to look solely to the four corners of the report to determine whether it constitutes a good faith effort at compliance. Palacios, 46 S.W.3d at 878 (holding that “a trial court should look no further than the report in conducting a section 13.01(Z) inquiry”). The claimant’s pleadings are relevant to a determination of the adequacy of an expert report only to the extent that the defendant must be sued *54to trigger a report due-date, and the plaintiff must be asserting a health care liability claim to necessitate a report. Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(a), (d) (setting report due-dates); Rogers v. Crossroads Nursing Serv., Inc., 13 S.W.3d 417, 418-19 (Tex.App.-Corpus Christi 1999, no pet.) (recognizing article 4590i applies only to health care liability claims). I cannot agree with the majority that anything in the statute or in existing case law authorizes the analysis the majority engages in today — a comparison between pleaded factual acts of negligence and causation expressed within an expert report concerning those pleaded acts of negligence to determine the adequacy of an expert report.2
III. DR. Jones’s RepoRT, Under the Statute and Guiding Principles, Constitutes a Good Faith Effort
Dr. Maxwell challenged only the causation element of Dr. Jones’s report. Article 4590i, section 13.01(r)(6) requires that an expert report provide a fair summary of the causal relationship between the defendant health care provider’s negligence and the injury, harm, or damages claimed. Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(r)(6). A court may dismiss a claim based on the inadequacy of an expert report concerning causation only if the report does not constitute a good faith effort to provide a fair summary of the expert’s causation opinions. Id. § 13.01(e)(3), (l), (r)(6); see Borne Mem’l Hosp., 79 S.W.3d at 52; Palacios, 46 S.W.3d at 878. An expert report constitutes a good faith effort if it provides enough information to inform the defendant of the specific conduct the plaintiff has called into question and provides a basis for the trial court to conclude that the claims have merit. Pa-lacios, 46 S.W.3d at 879. Moreover, a plaintiff need not present evidence in the report as if it were actually litigating the merits. Id. The report can be informal in that the information in the report does not have to meet the same requirements as the evidence offered in a summary judgment proceeding or at trial. Id.
Here, Dr. Jones’s report is two and one-half pages, single spaced. The report indicates that Dr. Jones reviewed specific past and present medical records of Mrs. Windsor. Dr. Jones’s report also specifically states that he reviewed an affidavit made by Mrs. Windsor.3 Mrs. Windsor underwent a MRI on January 12, 1998, and Dr. Jones reviewed that report. The procedure at issue, a cerebral angiogram, was performed by Dr. Maxwell on Mrs. Windsor on January 14, 1998. Dr. Jones’s report factually notes the problems with the January 14,1998 procedure:
The left vertebral artery was reportedly accessed but the catheter was reportedly removed following onset of nausea and vomiting, findings suggestive of vertebral artery distribution [ijschemia. The report [Dr. Maxwell’s operative re*55port] states that “multiple catheter exchanges were made to access the left vertebral anteriogram” [sic]. Intravas-cular heparin and “anti-vasospasm” therapy was begun, and a left subclavian arteriogram demonstrated a small inti-mal injury near the vertebral origin. Reduced flow was subsequently noted in the left vertebral artery.
Dr. Jones’s report then goes on to explain:
An additional MRI brain dated 1/26/98, consisting of sagittal and axial Tl-weighted, axial proton density and T2-weighted and MR angiography of the carotid bifurcation again shows [the same findings as the 1/12/98 MRI]. There are smaller areas of abnormally increased T2 signal in the left posterior cerebellar white matter and medial left cerebellar cortex, consistent with cerebellar infarct which appears new from the prior MR brain of 1/12/98. [Emphasis added.]
Under the “Opinions” heading of his report, Dr. Jones explains, “The patient has suffered the complication of an intimal injury to the left vertebral artery origin during a cerebral angiogram on l/H/98. A subsequent MRI confirms the presence of additional cerebellar infarction ... on the left corresponding to the left vertebral artery injury.” [Emphasis added.]
Thus, Dr. Jones’s report makes it clear that he compared a January 12, 1998 MRI of Mrs. Windsor’s brain and a January 26, 1998 MRI of Mrs. Windsor’s brain and saw a “new” intimal injury to the left vertebral artery and cerebellar infarction corresponding to the vertebral artery injury on the January 26th MRI that did not appear on the January 12th MRI. Dr. Jones even opined that these injuries occurred “during a cerebral angiogram on 1/14/98,” i.e., the procedure performed by Dr. Maxwell. Thus, the report clearly outlines physical tests documenting and confirming the “claimed injury,” i.e., an intimal injury to the left vertebral artery and a cerebellar infarction corresponding to the vertebral artery injury, occurring during the procedure performed by Dr. Maxwell.
Dr. Jones’s report explained that Mrs. Windsor developed nausea and vomiting during the procedure, a sign of vertebral ischemia.4 Mrs. Windsor swore in her affidavit that at this point she withdrew consent for the procedure and told Dr. Maxwell to stop. Mrs. Windsor swore that nevertheless Dr. Maxwell did not stop and continued on with the procedure until she was vomiting uncontrollably and lost control of her bowels. Dr. Jones’s report opines:
The patient has reported that consent was -withdrawn to the procedure and that the procedure continued despite such withdrawal of consent, with subsequent infarction5 documented above. The fact that the patient withdrew consent and the procedure continued with subsequent complications, is indicative that the actions by Dr. Maxwell did indeed fall below the standard of care.
Accordingly, Dr. Jones’s report summarizes: that during the January 14, 1998 cerebral arteriogram Mrs. Windsor suffered an intimal injury — here a puncture wound — to her left vertebral artery, the artery Dr. Maxwell had the catheter in*56serted into;6 that Mrs. Windsor began suffering an inadequate blood flow, ische-mia, through that artery, and as a result experienced nausea and vomiting; that Mrs. Windsor asked Dr. Maxwell to stop the procedure; that the standard of care is to stop the procedure immediately when the patient experiences nausea or vomiting or requests that the procedure be stopped; that Dr. Maxwell failed to stop the procedure when Mrs. Windsor experienced nausea and vomiting and requested that it be stopped; and that because Dr. Maxwell refused to stop the procedure the inadequate blood flow to Mrs. Windsor’s cerebellum through the vertebral artery continued and she suffered a “cerebellar infarction,” i.e., tissue damage, “corresponding to the left vertebral artery injury.” I would hold that this information, conveyed in Dr. Jones’s report, provides a fair summary of the causal relationship between Dr. Maxwell’s negligence — failing to stop the procedure upon withdrawal of consent and upon nausea and vomiting, both signs of intimal injury induced vertebral ischemia, i.e., reduced blood flow through the vertebral artery — and the injury claimed by Mrs. Windsor — a “cerebellar infarction” “corresponding to the left vertebral artery injury” and “subsequent infarction documented above,” i.e., MRI-documented cerebral brain tissue death. This information is sufficient to inform Dr. Maxwell, or any other medical professional reading the report, of the specific claims against Dr. Maxwell and is certainly sufficient to permit the trial court to conclude that the Windsors’ claims have merit.7 Consequently, Dr. Jones’s report constitutes a good faith effort at compliance with article 4590i, section 13.01(r)(6). Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(r)(6).
Dr. Jones’s report does not simply recite, as the majority contends, that Mrs. Windsor’s cerebral infarction merely followed Dr. Maxwell’s procedure but was not “caused” by the procedure. Dr. Jones’s report utilizes specific causative words, explaining that Mrs. Windsor suffered a “cerebellar infarction ... on the left corresponding to the left vertebral artery injury.” He explains that “The patient has reported that consent was withdrawn to the procedure and that the procedure continued despite such withdrawal of consent, with subsequent infarction documented above.” The adequacy of Dr. Jones’s report does not depend on whether he expressed causation using particular magic causation words. See Bowie Mem’l Hosp., 79 S.W.3d at 53. The causation words Dr. Jones chose are common to the medical field, are sufficient to apprise Dr. Maxwell of the causation element of the Windsors’ claim8 and to allow the trial court to conclude that the Windsors’ claim has merit.
Moreover, the majority’s holding that Dr. Jones’s report fails to explain “how *57continuance of the procedure caused the infarction,” overlooks the causative medical aspect inherent in an infarction. An infarction, tissue death, is by definition always physically caused by ischemia, an insufficient quantity of oxygenated blood reaching an organ or tissue until tissue death results, just as a broken arm is by definition always physically caused by excessive forces brought to bear on the arm bone. Here Dr. Jones explained the “cause” of Mrs. Windsor’s continued ische-mia: Dr. Maxwell’s failure to stop the procedure despite the increasingly severe symptoms of ischemia Mrs. Windsor was experiencing. He explained that the standard of care is to immediately stop the procedure upon the occurrence of these symptoms of ischemia, and noted that Dr. Maxwell did not stop, “with subsequent infarction documented above.” Any physician reading the report would have no doubt that Mrs. Windsor suffered an inti-mal injury to the left vertebral artery (here, a puncture wound to the artery being catheterized); she began suffering vertebral ischemia (reduced blood flow through the artery being catheterized) during the procedure;9 that no action (i.e., termination of the procedure and removal of the catheter) was taken to alleviate the ischemia; and that as a result a full-blown cerebral infarction (inadequate blood flow and resultant tissue death documented by a subsequent MRI) in the area served by the artery occurred. Continuation of the cerebral angiogram in light of increasingly severe symptoms of ischemia caused the subsequent infarction just as increasing physical force on an arm bone will cause it to break. Based on the medical facts here, it is unnecessary to require, as the majority does, Dr. Jones to state “how continuation of the procedure caused the infarction” just as it would be unnecessary to require a doctor to state how continued application of force to an arm bone caused it to break. Bones break when exposed to excessive force. Tissue dies when deprived of adequate oxygenated blood. Dr. Maxwell failed, even when Mrs. Maxwell suffered increasingly severe symptoms of oxygen deprivation to her brain, to halt the procedure and alleviate the oxygen deprivation, causing tissue death in Mrs. Windsor’s brain. The causation facts and opinion in Dr. Jones’s report render it a good faith effort at compliance with section 13.01(r)(6)’s expert report requirement concerning causation.
Finally, I cannot agree with the majority’s analysis of Dr. Jones’s statement, “The patient has reported that consent was withdrawn to the procedure and that the procedure continued despite such withdrawal of consent, with subsequent infarction documented above.” The majority asserts that it is possible to give two different meanings to this statement: it may simply be a factual statement reported by Mrs. Windsor to Dr. Jones that the infarction occurred after she withdrew her consent, or it may be Dr. Jones’s opinion that the infarction occurred after Mrs. Windsor withdrew her consent. The issue is settled, however, in the very next sentence of Dr. Jones’s report where he states, “The fact that the patient withdrew consent and the procedure continued with subsequent complications, is indicative that the actions by Dr. Maxwell did indeed fall below the standard of care.” Although this statement addresses the standard of care issue, it also clarifies Dr. Jones’s meaning in the prior sentence. It clarifies that it is Dr. Jones’s opinion that the procedure continued with subsequent complications. A sentence in an expert *58report may address both causation and standard of care. No one-element-per-sentence rule exists. Dr. Jones could have simply stated that continuance of the procedure after the patient withdrew consent violated the standard of care. But he didn’t. He incorporated and adopted as his opinion that the “procedure continued with subsequent complications.”
A trial court abuses its discretion when it misapplies the law to the facts. Walker v. Packer, 827 S.W.2d 833, 840 (Tex.1992) (orig.proceeding) (holding, “A trial court has no ‘discretion’ in determining what the law is or applying the law to the facts.”). A trial court also abuses its discretion when it makes a choice that is legally unreasonable in the factual-legal context in which it is made. W. Wendall Hall, Standards of Review in Texas, 34 St. Mary’s L.J. 1, 15-16 (2002). The trial court is required under section 13.01(i), Bowie Memorial Hospital, and Palacios to view the entire report in assessing its adequacy. Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(1) (requiring trial court to examine report to see if it represents good faith effort to comply with the definition of an expert report); Bowie Mem’l Hosp., 79 S.W.3d at 53 (explaining trial court should review information within four corners of report); Palacios, 46 S.W.3d at 878 (holding trial court should look to four corners of report in conducting 13.01(1) inquiry).
The construction of the sentence, “The patient has reported that consent was withdrawn to the procedure and that the procedure continued despite such withdrawal of consent, with the subsequent infarction documented above” to mean only that Mrs. Windsor told Dr. Jones the infarction occurred subsequent to her withdrawal of consent is incompatible with the next sentence of Dr. Jones’s report. Such a construction of this sentence, in light of the report as a whole, is a misapplication of the law, arbitrary, and legally unreasonable in the factual-legal context in which it is made. To the extent the trial court utilized this possible alternative construction of a single sentence in Dr. Jones’s two and one-half page report to negate the report’s overall expression of Dr. Jones’s causation opinion that Mrs. Windsor’s prolonged ischemia was due to Dr. Maxwell’s refusal to stop the procedure and resulted in a subsequent infarction corresponding to the vertebral artery puncture wound injury, the trial court abused its discretion.
Moreover, viewing this sentence in Dr. Jones’s report in conjunction with the sentence that follows it, is not “reviewing the evidence in the light most favorable to the non-prevailing party” as the majority contends. The trial court’s focus in making a section 13.01(() adequacy determination is supposed to be upon whether the expert report constitutes a good faith effort at compliance with section 13.01(r)(6) by informing the defendant of the specific conduct called into question and providing a basis for the trial court to conclude that the claims have merit. See Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(0, (r)(6); Bowie Mem’l Hosp., 79 S.W.3d at 53; Palacios, 46 S.W.3d at 878. Dr. Jones’s report accomplishes these purposes. The trial court does not have the discretion, as the majority apparently believes, to generate ambiguities in expert reports by viewing single sentences in isolation and giving them alternative meanings incompatible with the report as a whole. Accord, e.g., Columbia Gas Transmission Corp. v. New Ulm Gas, Ltd., 940 S.W.2d 587, 589 (Tex.1996) (recognizing that no ambiguity exists when one of two possible interpretations of sentence is not reasonable in light of construction of document as a whole). The fact that one sentence in Dr. Jones’s report, when considered in isolation, may be construed as having two meanings does not render his report not a good faith *59effort at compliance with section 13.01(r)(6).
Lastly, the majority attempts to analogize Dr. Jones’s report to the Wrights’ expert report in Bowie Memorial Hospital v. Wright. 79 S.W.3d at 52-53. Dr. Jones’s report is vastly different from the Wrights’ expert report opining that “if the x-rays [of Mrs. Wright’s foot] would have been correctly read and the appropriate medical personnel acted upon those findings then [Mrs. Wright] would have had the possibility of a better outcome." Id. (emphasis added.) The Wrights’ expert opined only that if the x-rays had been correctly read and if medical personnel acted on those x-rays, then possibly Wright could have had a better outcome. Id. Here, Dr. Jones’s opinion is not an if-this-and-if-that-then-a-possibility-of-a-better-outeome-exists opinion. Dr. Jones’s opinion is that Dr. Maxwell’s negligence in refusing to halt the procedure caused a “subsequent infarction,” “corresponding to the left vertebral artery injury,” i.e., a this-negligence-caused-that-injury opinion.
IV. Conclusion
For all of the above reasons, I dissent. Under the statutory language and controlling case law, Dr. Jones’s report constitutes a good faith effort at compliance with the statutory definition of an expert report. See Tex.Rev.Civ. Stat. Ann. art. 4590i, § 13.01(Z). Consequently, the trial court abused its discretion by dismissing the Windsors’ health care liability claim. I would sustain the Windsors’ first issue and reverse the trial court’s dismissal order.
APPENDIX
David A. Schiller
101 E. Park Blvd.
Suite 471
Plano, TX 75074
April 27, 2001.
Dear Mr. Schiller:
My name is Kendall M. Jones, M.D. I am a board-certified radiologist with a certificate of added qualification in neurora-diology. I am licensed to practice medicine in the state of Texas, where I have been in private practice for the past 7 years.
I have been asked to render opinion in the case of Beverly Windsor. I have been provided the following records: hospital records from HCA Denton Community Hospital; medical records from Gary Tu-nell, M.D.; Southridge Family Medicine; Family Radiology; Drs. David Cook, John Maxwell and Jayamaran Ravindra; Texas Neurology, P.A.; and Lewisville Neurology, P.A.
In addition, I have reviewed a head CT on patient Beverly Allison (6/11/92) and the following studies on Beverly Windsor: a head CT dated 1/11/98 (HCA Denton Community Hospital); an MRI of the brain dated 1/12/98, a cerebral angiogram dated 1/14/98, an MRI brain dated 1/26/98, and an Affidavit of Beverly Windsor.
This patient developed headache and ataxia in 5/92, and was seen at Harris Methodist for a right cerebellar hemorrhage, treated with posterior craniotomy. On 1/9/98, the patient reported difficulty reading. She was seen at Denton Community Hospital where a head CT without contrast on 1/11/98 demonstrated prior right posterior fossa eranieotomy with midline cerebellar clip, as well as a suba-cute, approximately 4x3 cm. left anterior parietal infarot, with focal effacement of sulci. Mild compression of the left occipital horn is noted, without bleed or shift evident. Basal ganglia calcifications are noted incidentally.
A subsequent MRI brain dated 1/12/98 using sagittal and axial T-l-weighted, axial proton-density and T2-weighted, and axial and coronal Tl-weighted images following contrast demonstrates a 4.2x2.8 cm. Left *60anterior/inferior parietal area of increased T2 signal consistent with infarction. There may be minimal superior temporal lobe involvement as well. There is a 2.8xl.O cm. Right cerebellar white matter infarct or area of encephalomalacia as well. This is likely in the posterior inferior cre-bellar artery distribution.
A subsequent cerebral angiogram dated 1/14-98, performed by John Maxwell, M.D., demonstrates an apparent feal origin (normal congenital varient) of the right posterior communicating artery. The carotid bifurications and intracranial circulation appear normal. The right vertebral artery appears normal.
The left verebral artery was reportedly accessed but the catheter was reportedly removed following onset of nausea and vomiting, findings suggestive of vertebral artery distribution Ischemia. The report states that “multiple catheter exchanges were made to access the left vertebral anteriogram” (sic). Intravascular heparin and “anti-vasospasm” therapy was begun, and a left subclavian anteriogram demonstrated a small intimal injury near the vertebral origin. Reduced flow was subsequently noted in the left vertebral artery.
An additional MRI brain dated 1/26/98, consisting of sagittal and axial Tl-weighted, axial proton density and T2-weighted and MR angiography of the eartotid bifurcation again shows a left anterior/inferior parietal infarct and an approximately 2.8x1 cm. right cerebellar white matter infarct. There are smaller areas of abnormally increased T2 signal in the left posterior cerebellar white matter and medial left cerebellar cortex, consistent with cerebellar infarct which appears new from the prior MR brain of 1/12/98.
OPINION: The patient has suffered the complication of an intimal injury to the left vertebral artery origin during a cerebral angiogram on 1/14/98. A subsequent MRI confirms the presence of additional cerebellar infarction (in addition to previously seen postoperative or post-hemorrhagic changes) on the left corresponding to the left vertebral artery injury.
There are several important issues raised be this case. Arterial injuries including intimal injury and more extensive arterial dissection are known complications of cerebral angiography. Arterial injury is not in and of itself an indication that the radiologist has fallen below the standard of care. However, there are additional elements in the standard of care which must be examined in this case. First, it is recorded both in the radiologist’s pre-angiog-raphy note, and in the post-angiography dictation that both verbal and written consent were obtained. However, there is no written consent in the records I have reviewed, and the specific risks given in the verbal consent are not delinerated.
Second, the post-angiography report states that “multiple catheter exchanges were made to access the left vertebral [artery].” However, the number of catheter exchanges is not given. The risk of vascular injury rises with each new attempt and with prolonged procedure time, particularly after one hour of catheter use. When the vertebral artery cannot be accessed, the subclavin artery can be safely injected.
Finally, it was stated that the patient developed nausea and vomiting, and that the catheter was subsequently removed from the vertebral artery. The patient reports a delay in the removal of the catheter. Removal in such eases should be immediate, since nausea and vomiting are clear warnings of vertebral ischemia. The delay in removing the catheter is below the standard of care. In addition, the patient withdrew consent and requested termination of the procedure, and in this case the procedure should have been terminat*61ed immediately. The patient has reported that consent was withdrawn to the procedure and that the procedure continued despite such withdrawal of consent, with subsequent infarction documented above. The fact that the patient withdrew consent and the procedure continued with subsequent complications, is indicative that the actions by Dr. Maxwell did indeed fall below the standard of care.
The appropriate standard of care for a cerebral angiogram would be to immediately remove a cerebral catheter at the onset of nausea and vomiting, which are indicative of vertebral ischemia. In addition, it is the standard of care to discontinue a procedure when the patient has verbally withdrawn consent. It is therefore, my opinion that Dr. Maxwell fell below the standard of care exercised by a reasonable and prudent radiologist in similar circumstances. I reserve the right to modify these opinions should additional evidence or records become available.
Sincerely,
/s/ K Jones
Kendall M. Jones, M.D.
Neuroradiologist

. A copy of Dr. Jones's report, in its entirety, is attached.

. The next step in the majority’s facts-pleaded-must-match-report’s-opinions analysis will be the reversal of a trial court’s dismissal order in part when a specific factual pleading is supported by a specific correlating opinion in an expert report, and an affirmance of a trial court's dismissal order in part as to those specific factual allegations lacking a correlating specific opinion in an expert report. Thus, application of the analytical framework used by the majority will lead to complicated and statutorily unintended results.

. The record from the motion to dismiss hearing indicates that Mrs. Windsor herself is a nurse, that she was awake during the procedure, and that because she had not yet been deposed at the time the expert report was due, she executed an affidavit setting forth the events that occurred during the procedure and provided that affidavit to Dr. Jones for him to rely upon in making his report.

. Ischemia is "a low oxygen state usually due to obstruction of the arterial blood supply or inadequate blood flow leading to hypoxia in the tissue." On Line Medical Dictionary, Dept, of Medical Oncology, University of Newcastle upon Tyne (2003), at http://cancer-web.ncl.ac.uk./cgi-bin/omd?ischemia.

. An infarct is "an area of tissue death due to local lack of oxygen." Id.at http://cancer-web.ncl.ac.uk./cgi-bin/omd?infarct.

. The majority fails to recognize that the puncture of the vertebral artery resulted in reduced blood flow through the artery. Dr. Jones's report even mentions that "[r]educed flow was subsequently noted in the left vertebral artery.”

. In light of the factual causation information provided in Dr. Jones’s report, I cannot agree with the majority that it is conclusory. Cf. Earle v. Ratliff, 998 S.W.2d 882, 890 (Tex. 1999) (holding defendant doctor’s summary judgment affidavit stating, "use of Steffe pedi-cle screws and plates met the standard of care” was conclusory because it "states only the conclusion that Earle met the applicable standard of care”). As outlined above, Dr. Jones's non-summary judgment expert report provides facts explaining the basis for his causation opinion.

.Recall that Dr. Maxwell did not challenge the adequacy of Dr. Jones's report on any other ground.

. Dr. Jones's report recognizes that reduced blood flow through Mrs. Windsor’s left vertebral artery was documented by the subsequent left subclavian arteriogram.