REVERSE and REMAND; and Opinion Filed July 21, 2017.




                                          S   In The
                                Court of Appeals
                         Fifth District of Texas at Dallas
                                       No. 05-16-01124-CV

              STEPHEN COURTNEY, M.D. AND PLANO ORTHOPEDICS
              SPORTS MEDICINE AND SPINE CENTER, P.A., Appellants
                                    V.
                    CHRISTEL PENNINGTON, INDIVIDUALLY
             AND AS AN HEIR AND REPRESENTATIVE OF THE ESTATE
               OF STEVEN PAUL PENNINGTON, DECEASED, Appellee

                      On Appeal from the 162nd Judicial District Court
                                   Dallas County, Texas
                           Trial Court Cause No. DC-16-03386

                             MEMORANDUM OPINION
                           Before Justices Francis, Brown, and Schenck
                                    Opinion by Justice Brown
       In this interlocutory appeal, Stephen Courtney, M.D. and Plano Orthopedics Sports

Medicine and Spine Center, P.A. appeal the trial court’s order denying their objections to

Christel Pennington’s Chapter 74 expert reports and denying their motion to dismiss

Pennington’s wrongful death case for failure to serve adequate expert reports. We reverse and

remand to the trial court for further proceedings.

       Dr. Courtney performed spinal surgery on Pennington’s husband Steven Pennington

twice, once in March 2012, and once in July 2015. During the July 2015 procedure, Steven

suffered cardiac arrest and died. In March 2016, Pennington, individually and as an heir and

representative of Steven’s estate, sued Dr. Courtney and his professional association (collectively
“Dr. Courtney”) for negligence and gross negligence that allegedly occurred in connection with

the 2012 surgery.              On behalf of Steven’s estate, Pennington sought survival damages for

Steven’s mental anguish and pain and suffering, among other damage elements, following the

2012 surgery until his death. Pennington also sought wrongful death damages for the loss of her

husband, as well as exemplary damages.

          Pursuant to Chapter 74 of the civil practice and remedies code, Pennington served Dr.

Courtney with the expert report of Dr. George Wharton. Dr. Courtney objected to the expert

report for various reasons. Pennington then served Dr. Courtney with a supplemental expert

report from Dr. Wharton and a new expert report from Dr. Mark Entman. Dr. Courtney objected

to these new reports and moved to dismiss Pennington’s claims with prejudice for failure to

serve sufficient expert reports. After a hearing, the trial court overruled Courtney’s objections to

the reports and denied the motion to dismiss. This appeal followed. See TEX. CIV. PRAC. &

REM. CODE ANN. § 51.014(a)(9) (West Supp. 2016) (permitting appeal from interlocutory order

that denies relief sought by motion under section 74.351(b)).

          In this appeal, Dr. Courtney contends the trial court abused its discretion in overruling the

objections to the expert reports and in denying the motion to dismiss Pennington’s wrongful

death claim. 1 Dr. Courtney maintains that Pennington’s expert reports were insufficient because

they fail to (1) articulate the standards of care for the 2015 surgery; (2) articulate any breach of

the standard of care for the 2015 surgery; and (3) sufficiently address causation. Pennington

responds that the first two complaints about her expert reports are irrelevant because she has not

alleged that any negligence during the 2015 surgery caused her husband’s death. Her theory is

that her husband underwent a second surgery, during which he died, only because Dr. Courtney

was negligent in performing the first surgery. We agree with Pennington that the sole issue in

   1
       Dr. Courtney does not complain about the trial court’s actions regarding Pennington’s survival claim.



                                                                     –2–
this appeal is whether her expert reports adequately address whether negligence during the 2012

surgery caused her husband’s death in 2015.

        When asserting a health care liability claim, a claimant must comply with Chapter 74.

Stockton v. Offenbach, 336 S.W.3d 610, 614 (Tex. 2011). Section 74.351(a) provides that a

claimant shall serve, within 120 days after the defendant’s original answer is filed, an expert

report. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a) (West Supp. 2016). An expert report is

defined 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 the applicable standards of care, the manner
        in which the care rendered by the physician or health care provider failed to meet
        the standards, and the causal relationship between that failure and the injury,
        harm, or damages claimed.

Id. § 74.351(r)(6). A trial court shall grant a motion challenging the adequacy of an expert report

only if it appears to the court, after a hearing, that the report does not represent an objective good

faith effort to comply with this definition. Id. § 74.351(l). A claimant may use multiple expert

reports to address the different issues that may arise in a health care liability claim, such as

liability and causation. Id. § 74.351(i).

        We review the trial court’s decision regarding the adequacy of an expert report under an

abuse of discretion standard. Methodist Hosps. of Dallas v. Winn, 496 S.W.3d 148, 150 (Tex.

App.—Dallas 2016, no pet.). A trial court abuses its discretion if it acts in an arbitrary or

unreasonable manner without reference to any guiding rules or principles. Id. A trial court also

abuses its discretion if it fails to analyze or apply the law correctly. Id.

        In his expert reports, Dr. Wharton, an orthopedic surgeon, provided a history of Steven’s

spinal problems and treatment by Dr. Courtney, which began in 1997. Dr. Wharton described

the March 2012 surgery as “lumbar spine surgery” and “a 2 level lumbar interbody

instrumentation with Eminent Peek cages . . . performed at L3-4 and L4-5.” His supplemental


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report stated that during the 2015 surgery, Dr. Courtney implanted pedicle screws at several

levels, and the report indicates that over two hours into the surgery Steven suffered a cardiac

arrest and was declared dead.

       Dr. Wharton opined about the standards of care for the 2012 surgery and several breaches

of those standards. For example, Dr. Wharton opined that the standard of care required Dr.

Courtney to offer Steven a simple decompression at L3-4 only, which would have, within

reasonable medical probability, alleviated his symptoms. The decompression was a minimally

invasive outpatient procedure with a higher likelihood of success. Also, Dr. Wharton determined

that even if the standard of care supported the decision to place implants into the intervertebral

disc spaces, Dr. Courtney failed to select implants appropriate for the condition of Steven’s bone,

which caused Steven to suffer an end plate fracture. According to Dr. Wharton, these and other

named violations of the standards of care were a proximate cause of Steven’s continued pain and

suffering and his need for the July 2015 surgery. Dr. Wharton stated in his supplemental report,

“In my opinion, within reasonable medical probability, Mr. Pennington would have avoided the

need for the second surgical procedure on 07/22/2015 if Dr. Courtney had not performed a

needless procedure and had . . . [done] a simple decompression.”

       Pennington also served a report from Dr. Entman, a board-certified cardiologist. Dr.

Entman reviewed Steven’s medical records for the decade before his death, as well as the

autopsy report. Dr. Entman stated that Steven was a fifty-seven-year-old man with several health

issues, including diabetes and reactive lung disease, that were “uncommonly well managed.”

The doctor noted that Steven had a normal stress test in 2005 and had several evaluations of

cardiac function thereafter which were basically normal. Physical examinations were done

frequently during follow-ups without any obvious abnormalities.           In discussing Steven’s

cardiovascular disease risk factors, Dr. Entman observed that Steven had very little additional

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risk of heart disease from his diabetes diagnosis. Steven’s post-mortem examination showed that

he had a larger-than-normal heart, which apparently worked well, and one 60% lesion in his

coronary arteries, which was unlikely to be picked up in an exercise test.

       According to Dr. Entman, the data suggested that a coronary event or coronary death

would have been very unlikely. Nothing in Steven’s health history or post-mortem examination

suggested emergent cardiovascular or pulmonary death had the surgery in 2015 not occurred.

Dr. Entman stated that, in all reasonable medical probability, Steven would still be alive had the

2015 surgery not occurred. Dr. Entman further stated he read Dr. Wharton’s report which stated

that negligence in the patient’s care led to his 2015 surgery. Dr. Entman opined that the

negligence and breaches set out in Dr. Wharton’s report would more than likely be the proximal

cause of Steven’s death.

       To satisfy the requirements of Chapter 74, an expert must explain, based on facts set out

in the report, how and why a health care provider’s breach caused the injury. Columbia Valley

Healthcare Sys., L.P. v. Zamarripa, No. 15-0909, 2017 WL 2492003, at *4 (Tex. June 9, 2017).

An expert report must make a good-faith effort to explain how proximate cause is going to be

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

For a negligent act or omission to have been a cause-in-fact of the harm, the act or omission must

have been a substantial factor in bringing about the harm, and absent the act or omission – i.e.,

but for the act or omission – the harm would not have occurred. Id. This is the causal

relationship between the breach and injury that an expert report must explain to satisfy Chapter

74. Id. at *5. An expert’s simple ipse dixit — an assertion without proof — is insufficient to

establish a matter; rather the expert must explain the basis of his statements to link his

conclusions to the facts. Id. at *4; Hendricks v. Perales, No. 05-16-01258-CV, 2017 WL

1075637, at *6 (Tex. App.—Dallas Mar. 21, 2017, no pet.) (mem. op.). Statements based on

                                               –5–
reasonable medical probability, without explanation and without tying conclusions to facts, are

not sufficient. Hendricks, 2017 WL 1075637, at *6.

       Although Pennington has not alleged any negligence in connection with the second

surgery, if her husband’s cardiac arrest did not result from that surgery, there can be no causal

link between the 2012 negligence and his death. Pennington’s expert reports were deficient on

causation because there is nothing in them to show why her husband suffered cardiac arrest and

died during the 2015 surgery. Dr. Wharton’s report addressed the alleged negligence during the

first surgery, which he asserted made the second surgery necessary. Dr. Wharton noted that

Steven suffered cardiac arrest during the second surgery. Dr. Entman does not describe the

cause of death in his report or use the term “cardiac arrest.” Dr. Entman’s report gave his

opinion that “[i]n all reasonable medical probability, Mr. Pennington would still be alive had the

surgery in 2015 not occurred.” His report also indicates that the negligence and breaches of the

standard of care set out in Wharton’s report would be “more likely than not,” the proximal cause

of death. But Dr. Entman provided no factual support for his conclusion that Steven would still

be alive but for the second surgery. Although the doctor explained his opinion that nothing in

Steven’s medical records made a coronary event likely, that is not the same as showing that the

cardiac arrest was brought on by the 2015 surgery. There is simply nothing in either expert’s

report to explain how or if the cardiac arrest was linked to the 2015 surgery. Without such

explanation, there is no showing of a causal link between the alleged negligence in the first

surgery and Steven’s death. The cases Pennington relies on are distinguishable. See, e.g., Kelly

v. Rendon, 255 S.W.3d 665, 671 & 678 n.10 (Tex. App.—Houston [14th Dist.] 2008, no pet.)

(although like this case, Kelly involves two surgeries, the procedures were days apart and cause

of death was directly related to first surgery — complications from necrotizing fasciitis, or

infection of wound from first surgery). Under the facts of this case, the trial court abused its

                                               –6–
discretion in overruling Dr. Courtney’s objections to the expert reports. We sustain that part of

Dr. Courtney’s sole issue in which he complains of the court’s error in overruling his objections.

       Dr. Courtney also asserts that we should dismiss Pennington’s wrongful death claim with

prejudice and remand for a determination of the doctor’s attorney’s fees and costs. But Chapter

74 allows the trial court to grant one thirty-day extension to cure a deficiency in an expert report,

and a court must grant an extension if the report’s deficiencies are curable. TEX. CIV. PRAC. &

REM. CODE ANN. § 74.351(c); Columbia Valley Healthcare, 2017 WL 2492003, at *5; see

Scoresby v. Santillan, 346 S.W.3d 546, 556–57 (Tex. 2011). In her response to Dr. Courtney’s

objections to the reports, Pennington requested the opportunity to cure any deficiencies. The

reports at issue are not so deficient as to constitute no report at all, and Pennington is entitled to

an opportunity to cure the deficiencies. See Hendricks, 2017 WL 1075637, at *7. We therefore

reverse and remand to the trial court to consider granting a thirty-day extension of time to allow

Pennington to attempt to cure the deficiencies in the experts’ reports regarding causation.




                                                       /Ada Brown/
                                                       ADA BROWN
                                                       JUSTICE



161124F.P05




                                                 –7–
                                        S
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                       JUDGMENT

STEPHEN COURTNEY, M.D. AND                            On Appeal from the 162nd Judicial District
PLANO ORTHOPEDICS SPORTS                              Court, Dallas County, Texas
MEDICINE AND SPINE CENTER, P.A.,                      Trial Court Cause No. DC-16-03386.
Appellants                                            Opinion delivered by Justice Brown, Justices
                                                      Francis and Schenck participating.
No. 05-16-01124-CV         V.

CHRISTEL PENNINGTON,
INDIVIDUALLY AND AS AN HEIR AND
REPRESENTATIVE OF THE ESTATE OF
STEVEN PAUL PENNINGTON,
DECEASED, Appellee

        In accordance with this Court’s opinion of this date, the trial court’s November 4, 2016
order is REVERSED and this cause is REMANDED to the trial court for further proceedings
consistent with this opinion.

       It is ORDERED that appellants STEPHEN COURTNEY, M.D. AND PLANO
ORTHOPEDICS SPORTS MEDICINE AND SPINE CENTER, P.A. recover their costs of this
appeal from appellee CHRISTEL PENNINGTON, INDIVIDUALLY AND AS AN HEIR AND
REPRESENTATIVE OF THE ESTATE OF STEVEN PAUL PENNINGTON, DECEASED.


Judgment entered this 21st day of July, 2017.




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