REVERSE and RENDER; and Opinion Filed July 25, 2016.




                                         S   In The
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                      No. 05-16-00018-CV

NEXION HEALTH AT LANCASTER, INC. D/B/A MILLBROOK HEALTHCARE AND
       REHABILITATION CENTER AND NANCY LAWSON, Appellants
                                V.
GURTHA WELLS, INDIVIDUALLY AND ON BEHALF OF THE ESTATE OF WILLIE
   WELLS, DECEASED, STEVE M. WELLS AND TAMMIE J. WELLS, Appellees

                       On Appeal from the 14th Judicial District Court
                                   Dallas County, Texas
                            Trial Court Cause No. DC-15-02533

                             MEMORANDUM OPINION
                         Before Justices Francis, Fillmore, and Schenck
                                  Opinion by Justice Schenck
       This is an interlocutory appeal of the denial of a motion to dismiss appellees’ health care

liability claims for failure to serve expert reports that comply with section 74.351 of the Texas

Civil Practice and Remedies Code filed by appellants Nexion Health at Lancaster, Inc. d/b/a

Millbrook Healthcare and Rehabilitation Center (“Nexion”) and Nexion’s Director of Nursing,

Nancy Lawson, (“Lawson”). TEX. CIV. PRAC. & REM. CODE ANN. § 74.351 (West Supp. 2015).

Appellants urge that the trial court erred by denying their motion and by failing to award them

attorney’s fees. For the reasons outlined in this opinion, we reverse the trial court’s December

18, 2015 order denying appellants’ motion to dismiss, render judgment dismissing appellees’

claims against appellants with prejudice, and remand this case to the trial court to determine the

reasonable attorney’s fees and costs to be awarded to appellants pursuant to section 74.351(b)(1)
of the civil practice and remedies code. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(b)(1);

TEX. R. APP. P. 43.2. Because all issues are settled in law, we issue this memorandum opinion.

TEX. R. APP. P. 47.4.

                                                               BACKGROUND

           Willie Wells resided at Nexion’s healthcare and rehabilitation facility in Lancaster, Texas

at various times between July and September 2013 after undergoing bowel surgery at University

General Hospital.               On September 19, 2013, at an unspecified time, nurse Tracee Rainey

examined Mr. Wells. She noted that Mr. Wells’ abdomen was semi-firm and mildly distended,

and that his bowel sounds were present but sluggish. She contacted medical management for

gastrointestinal concerns and indicated he would have an esophagram in the morning. On

September 20, 2013, Nexion transferred Mr. Wells to University General Hospital with

complaints of stomach pain and gas. He later died from complications arising from a bowel

obstruction.

           Gurtha Wells, individually and as the representative of the estate of Willie Wells,

Deceased, Steve M. Wells, and Tammie J. Wells’ (collectively the “Wells”) sued Nexion and

Lawson for negligence related to their care of Mr. Wells. More particularly, Wells alleged

Nexion and Lawson (1) failed to evaluate timely Mr. Wells’ bowel condition, (2) failed to

prevent Mr. Wells from failing on two occasions, and (3) failed to address adequately his

symptoms of bowel dysfunction on September 19, 2013. 1

           Prior to the expiration of Wells’ 120 day expert report deadline under section 74.351 of

the civil practice and remedies code, Wells served appellants with the initial expert reports of Dr.

Manuel A. Eskildsen regarding the conduct of Nexion and Lawson. Appellants objected to the

sufficiency of the reports arguing neither report sufficiently linked the alleged breaches of

   1
       Appellants’ alleged negligence in failing to prevent Mr. Wells’ falls is not included as a causative event of his death.



                                                                       –2–
Nexion’s and Lawson’s respective standards of care to Mr. Wells’ injuries. After hearing

appellants’ motion, the trial court found the reports were deficient and granted Wells a 30-day

extension to cure the deficiencies. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c).             Wells

served two amended expert reports within the allotted time.

       Appellants objected to the amended reports as failing to sufficiently set forth a causal link

between their conduct and Mr. Wells’ death, and moved for dismissal of Wells’ claims with

prejudice and requested attorney’s fees and costs.         After hearing, the trial court denied

appellants’ motion and appellants timely filed this interlocutory appeal.

                                     STANDARD OF REVIEW

       We review a trial court’s denial of a motion to dismiss a health care liability claim based

on the sufficiency of an expert’s report for an abuse of discretion. Van Ness v. ETMC First

Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam); Nexion Health at Terrell Manor v.

Taylor, 294 S.W.3d 787, 791 (Tex. App.—Dallas 2009, no pet.). 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 must defer to the trial

court’s factual determinations if they are supported by the evidence, but review its legal

determinations de novo. Van Ness, 461 S.W.3d at 142. A trial court has no discretion, however,

in determining what the law is or in applying the law to the established facts. Sanchez v. Martin,

378 S.W.3d 581, 587 (Tex. App.—Dallas 2012, no pet.). With these standards in mind, we turn

to appellants’ issues.

                                           DISCUSSION

       In appellants’ first and second issues, appellants argue the trial court abused its discretion

in denying their motion to dismiss because Wells’ expert reports fail to identify a basis for




                                                –3–
requisite causation in that they do not state how appellants’ alleged breaches of the standard of

care caused Mr. Wells’ death.

I.     Applicable Law

       Chapter 74 of the civil practice and remedies code governs health care liability claims.

Brewster v. Columbia Med. Ctr. of Mckinney Subsidiary, L.P., 269 S.W.3d 314, 316 n.3 (Tex.

App.—Dallas 2008, no pet.). Under that chapter, any person who brings suit asserting a health

care liability claim must, within 120 days of the filing of the defendant’s answer, provide an

expert report for each physician or health care provider against whom a health care liability

claim is asserted. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a). An “expert report” is

defined as a written report that provides a fair summary of the expert’s opinions as of the date of

the report regarding (1) applicable standards of care, (2) the manner in which the care rendered

by the 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. Id. § 74.351(r)(6). A

report is deficient if it states only the expert’s conclusions about the standard of care, breach of

the standard of care, or causation. See Ortiz v. Patterson, 378 S.W.3d 667, 671 (Tex. App.—

Dallas 2012, no pet.).

       A trial court must grant a motion challenging the adequacy of an expert report only if it

appears, after hearing, that the report does not represent an objective good faith effort to comply

with the definition of “expert report” in section 74.351(r)(6). TEX. CIV. PRAC. & REM. CODE

ANN. § 74.351(l). In determining whether the expert report represents a good faith effort to

comply with the statutory requirements, the court’s inquiry is limited to the four corners of the

report. Sanchez, 378 S.W.3d at 588. A court may not “fill gaps” in an expert report by drawing

inferences or guessing what the expert likely meant or intended. Hollingsworth v. Springs, 353

S.W.3d 506, 513 (Tex. App.—Dallas 2011, no pet.). If a report omits any of the statutory

                                                –4–
elements of section 74.351(r)(6), it cannot be a good faith effort. Am. Transitional Care Ctrs. of

Tex., Inc. v. Palacios, 46 S.W.3d 873, 879 (Tex. 2001). As noted, one of the mandatory

elements of a good faith report is an explanation of the causal relationship between a failure to

meet the applicable standard of care and the injury, harm, or damages claimed.

       A causal relationship is established by proof that the negligent act or omission was a

substantial factor in bringing about the harm and that, absent this act or omission, the harm

would not have occurred. Mitchell v. Satyu, 05–14–00479–CV, 2015 WL 3765771, at *4 (Tex.

App.—Dallas June 17, 2015, no pet.) (mem. op.) (citing Costello v. Christus Santa Rosa Health

Care Corp., 141 S.W.3d 245, 249 (Tex. App.—San Antonio 2004, no pet.)). An expert report

must explain “to a reasonable degree, how and why the breach [of the standard of care] caused

the injury based on the facts presented.” Jelinek, 328 S.W.3d at 539–40. The report “must

explain the basis of [the expert’s] statements to link his conclusions to the facts.” Bowie Mem’l

Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002); see also Taylor v. Fossett, 320 S.W.3d 570, 575

(Tex. App.—Dallas 2010, no pet.). An expert’s mere conclusion that “in medical probability”

one event caused another differs little, without an explanation tying the conclusion to the facts,

from an ipse dixit, which the supreme court has consistently criticized. Jelinek, 328 S.W.3d at

539.

II.    Application of the Law

       The question presented in appellants’ first and second issues is whether Dr. Eskildsen’s

reports provide enough explanation to render his causation opinions adequate; that is, whether

Dr. Eskildsen’s reports supply the “how and why” of a causal relationship between appellants’

purported breaches of the applicable standards of care and Mr. Wells’ death.




                                               –5–
           A.         Summary of the Facts Reported

           Both of Dr. Eskildsen’s reports contain the following summary of facts. On March 23,

2013, Mr. Wells was admitted to University General Hospital due to a history of volvulus, 2

uncontrolled hypertension, bipedal edema, and malnutrition. He was treated and discharged on

April 2, 2013. On July 1, 2013, Mr. Wells was again admitted to University General Hospital,

this time with abdominal pain, nausea and vomiting. He was diagnosed as having a sigmoid

volvulus with perforation. A resection was performed and Mr. Wells was discharged to Nexion

on July 11, 2013. On July 15, 2013, at the request of Mr. Wells’ wife, Mr. Wells was transported

back to University General Hospital. He was found to be hypotensive, hypovolemic, and had

developed a urinary tract infection. He was treated and transferred back to Nexion on July 19,

2013. On September 10, 2013, Nexion documented Mr. Wells had one fall in the last 30 days

and a total of four falls in the last 90 days. On September 19, 2013, nurse Rainey examined Mr.

Wells. The time of the examination is not noted. Nurse Rainey noted that Mr. Wells’ abdomen

was semi-firm and mildly distended, and his bowel sounds were present but sluggish. She

contacted medical management for gastrointestinal concerns and indicated Mr. Wells would have

an esophagram in the morning. On September 20, 2013, Mr. Wells was transferred back to

University General Hospital by ambulance due to his report of a stomach ache and gas. The time

of transport is not noted. A computed tomography scan of the abdomen and pelvis showed

extensive pneumoperitoneum with associated ascites 3 and subcutaneous air.                                                     The hospital

admitted Mr. Wells with acute abdomen, sepsis, shock, and hypokalemia. The record and Dr.

Eskildsen’s reports do not indicate whether additional tests were performed after Mr. Wells was

     2
        A volvulus occurs when part of the large intestine is twisted on itself and the mesentery. The mesentery is a supportive tissue that anchors
the intestines to the back wall of the abdomen. The twisted intestine creates a bowel obstruction that cuts off the blood supply and affects bowel
function. The Medical Center of Plano, http://www.themedicalcenterofplano.com.
     3
       Ascites is the build-up of fluid in the space between the lining of the abdomen and the abdominal organs. University of Maryland Medical
Center, http://www.umm.edu/health/medical/ency/articles/ascites.



                                                                       –6–
admitted or how Mr. Wells was treated after admittance. On September 28, 2013, Mr. Wells

died. The noted cause of death was bowel obstruction.

       B.     Nexion - Standard of Care

       Dr. Eskildsen’s report concerning Nexion states Nexion was required to:

       1.     Properly evaluate Mr. Wells upon his admission into the facility for signs
              or symptoms of bowel abnormalities and/or constipation;

       2.     Institute a system for monitoring Mr. Wells for abdominal pain and
              swelling, as well as for constipation;

       3.     Communicate abnormal findings regarding Mr. Wells’ abdomen to his
              physician and family; and

       4.     Properly treat Mr. Wells if he exhibited signs and symptoms of
              constipation, bowel obstruction, or emerging infection.

       C.     Nexion - Claimed Breaches of the Standard of Care

       Dr. Eskildsen states Nexion breached the standards of care by:

       1.     Failing to evaluate properly Mr. Wells for signs and symptoms of bowel
              abnormalities and/or constipation; and

       2.     Failing to report Mr. Wells’ developing bowel obstruction to his treating
              physician or family.

Dr. Eskildsen further elucidated that Nexion’s failure to recognize that Mr. Wells’ symptoms on

September 19, 2013 necessitated immediate evaluation and failure to notify Mr. Wells’ family

and physician on September 19, 2013 were breaches of the standard of care.

       D.     Nexion - Causation

       As to causation, Dr. Eskildsen states:

       As a direct result of [Nexion’s] breaches of the above standards of care, I
       conclude that Willie Wells’ death on September 28, 2013 was directly caused by a
       bowel obstruction that he developed while under the care and supervision of
       [Nexion]. More specifically, on September 19, 2013, the facility documented
       findings that Mr. Wells’ abdomen was abnormal. This condition went untreated.
       As a result of this untreated bowel obstruction, Mr. Wells developed a new
       perforation in his bowel at the site of his prior bowel surgery. This new
       perforation resulted in fecal peritonitis, which is a leakage of bowel fluid and
                                               –7–
        contents directly into his abdomen. By the following day, Mr. Well’s untreated
        bowel obstruction and fecal peritonitis had developed into sepsis. Which is an
        infection of the blood [sic]. Due to this, Mr. Wells subsequently went into septic
        shock, and ultimately died of his bowel obstruction. Thus, based on my
        education, training and education as a medical doctor, as well as my review of the
        relevant medical records in this case, I have concluded that Mr. Wells’ bowel
        obstruction, which he developed while under the care and supervision of [Nexion]
        was a substantial contributing factor to his death on September 28, 2013.

(emphasis added). This opinion is much like the opinions in the Ortiz, Jeffers, and Klovenski

cases, in that it identifies the manner of the injury but does not explain how it relates to an

identified breach in the standard of care or state why, but for the claimed breach, the injury or

death would not have resulted.

        In Ortiz, the patient sought treatment for respiratory complaints at a medical facility and

died the next day. In the subsequent malpractice lawsuit, the claimants relied on an expert report

that recited, in pertinent part:

              Failing to do the appropriate tests, make the correct diagnosis, and recognize
              the clinical severity and risks involved in not referring Mr. Ortiz for admission
              to a hospital did not meet the standard of care, and contributed to the
              premature death of this man. If Mr. Ortiz had received appropriate evaluation
              and treatment it is more likely than not that he would have survived this
              ordeal.
Ortiz, 378 S.W.3d at 673. In that case, we concluded that the expert failed to explain how

Ortiz’s death resulted from the breaches of the standard of care identified in the report, and

accordingly we concluded that the trial judge properly granted the defendants’ motion to dismiss.

Id. at 674.

        In Jeffers, the patient sought treatment for an upper respiratory infection at a hospital and

died the next morning from cardiac arrest. In the subsequent medical malpractice case, the

claimants relied on an expert report that recited, in relevant part:

              [Physician’s Assistant] Knightstep failed to timely examine Ms. Jeffers and
              appropriately intervene. As such, she failed to appreciate and address Ms.
              Jeffers’ clearly deteriorating condition. As a result, Ms. Jeffers’ worsening
              hypoxia ultimately led to profoundly inadequate oxygenation and associated

                                                   –8–
           cardiac arrest and death.

Debra Knightstep, P.A. v. Jeffers, No. 05–12–01067–CV, 2013 WL 3487933, at *3 (Tex. App.—

Dallas July 10, 2013, no pet.) (mem. op.). In that case, we concluded the expert failed to state an

opinion on the causal connection between the breaches of the standards of care and Ms. Jeffers’

death. Id. In doing so, we noted the expert did not state how Knightstep’s failing to physically

examine Jeffers caused her death or how performing appropriate additional testing would have

prevented her death. Id. Accordingly, we reversed the trial court’s order denying Knightstep’s

motion to dismiss and remanded the case for a determination of whether Jeffers should be

granted a 30-day extension to cure deficiencies in the report.

        In Klovenski, the patient sought treatment from Dr. Kapoor, her primary care physician,

for a lump on her thigh. Dr. Kapoor failed to discover the lump was cancerous. Another

physician diagnosed Klovenski with cancer four months later. Klovenski died a year and two

months later. In the subsequent medical malpractice case, the claimants relied on an expert

report that recited, in relevant part:

        I find Dr. Kapoor’s failure to timely diagnose the cancer in the left thigh of his
        patient Margaret Klovenski of [sic] a four month period of time . . . directly
        resulted in the spread of this beyond therapeutic (surgical, radiation, and
        chemotheraphy, as provided) control, leading to Mrs. Klovenski’s ultimate
        debilitating and painful death, none of which, it is probable, would have occurred
        had Dr. Kapoor initially diagnosed the cancer in his patient’s leg successfully.

Kapoor v. Estate of Klovenski, No. 14–09–00963–CV, 2010 WL 3721866, at *4 (Tex. App.—

Houston [14th Dist.] Sept. 23, 2010 no pet.) (mem. op.).         In that case, the Houston court of

appeals concluded the expert failed to connect her conclusion to any specific facts regarding

whether Klovenski’s type of cancer was treatable, either before or after its eventual diagnosis.

Id. at *5. The court further concluded that the expert’s opinion required the court to infer that (1)

different, more effective treatment would have been available for Klovenski’s unidentified type

of cancer three months earlier, or (2) earlier treatment would have been more likely to improve
                                                –9–
Klovenski’s prognosis. The court recognized that such inferences are not permitted. Id. (citing

Wright, 79 S.W.3d at 53.

       In this case, Dr. Eskildsen states that had Nexion notified Mr. Wells’ family and

physician on September 19, 2013, Mr. Wells would have been evaluated in a hospital setting,

which would have allowed Mr. Wells to receive intravenous fluids, bowel rest, and if necessary

resection of the obstructed bowel.    Dr. Eskildsen does not state that had Mr. Wells been

evaluated in a hospital setting on September 19, 2013, his bowel would have been resected, or

opine that a specific identified intervention on September 19, 2013 would have prevented Mr.

Wells’ bowel obstruction causing his death. Instead, Dr. Eskildsen merely concludes, had Mr.

Wells been evaluated in a hospital setting on September 19, 2013, he would not have developed

a severe bowel obstruction, perforation, infection, and sepsis and would not have died. Dr.

Eskildsen fails to explain why evaluation and treatment on September 20, 2013 were insufficient

or how evaluation on September 19, 2013 would have remedied the situation or led to a different

outcome for Mr. Wells. We may not fill the gap and infer how evaluation and some potential

treatment on September 19, 2013 would have remedied the situation or would have led to a

better outcome for Mr. Wells. See Jeffers, 2013 WL 3487933, at *4. Like the causation

opinions in Ortiz, Jeffers, and Klovenski, we conclude Dr. Eskildsen’s causation opinion

concerning Nexion is conclusory.

       E.     Lawson - Standard of Care

       Dr. Eskildsen’s report concerning Lawson states that Lawson was required to ensure:

       1.     Nexion’s nursing program and staff met Mr. Wells medical needs; and

       2.     Mr. Wells was provided proper medical care and treatment.

       F.     Lawson - Breach of the Standard of Care

       Dr. Eskildsen states Lawson breached the standard of care by:

                                             –10–
       1.      Individually failing to properly evaluate Mr. Wells for signs and
               symptoms of bowel abnormalities and/or constipation and clearly
               documenting those evaluations; and

       2.      Failing to ensure that the facility’s nursing staff properly evaluated Mr.
               Wells for signs and symptoms of bowel abnormalities.

       G.      Lawson - Causation

       As to a causal connection between Lawson’s alleged breaches of the standards of care

and Mr. Wells’ death, Dr. Eskildsen reiterates his causation opinion concerning Nexion. For the

reasons stated supra, Dr. Eskildsen’s causation opinion concerning Lawson is conclusory.

       We additionally note that Wells’ claims against Lawson are based solely on her alleged

individual negligence. Lawson did not examine Mr. Wells on September 19, 2013 and was not

involved in the decision to transfer Mr. Wells to the hospital. Dr. Eskildsen indicates Lawson

signed a Minimum Data Set, a standardized assessment tool of health status, for Mr. Wells on

July 29, 2013. Dr. Eskildsen does not indicate what that assessment revealed and does not

causally connect Lawson’s assessment of Mr. Wells on July 29, 2013 to his death on September

28, 2013.

       As to Lawson’s administrative duties, Dr. Eskildsen was required to link Lawson’s

alleged failed management responsibilities to Mr. Wells’ death. Dr. Eskildsen does link any

alleged administrative negligence to Mr. Wells’ death. See Hollingsworth, 353 S.W.3d at 518–

19 (alleged breaches of hospital administrators not causally linked to injury sustained).

       We conclude that Dr. Eskildsen’s reports concerning Nexion and Lawson fail to provide

a fair summary of the causal relationship between Nexion’s and Lawson’s purported failures to

meet the applicable standards of care and Mr. Well’s death. See TEX. CIV. PRAC. & REM. CODE

ANN. § 74.351(r)(6). Because Wells’ expert reports omit the statutory element of causation, they

do not fulfill the good faith effort requirement. Consequently, the trial court abused its discretion



                                               –11–
in denying appellants’ motion to dismiss Wells’ claims against them. We sustain appellants’

first and second issues.

C.     Attorney’s Fees Under Section 74.351

       In their third issue, appellants argue the trial court erred in failing to award appellants’

attorney’s fees because Dr. Eskildsen’s reports failed to satisfy section 74.351 of the civil

practice and remedies code. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351. Section 74.351(b)(1)

mandates that the trial court award the health care provider reasonable attorney’s fees and costs

of court if the claimant fails to serve an expert report that complies with section 74.351. Id.

§ 74.351(b)(1). Because we conclude Wells failed to serve expert reports that comply with

section 74.351, we sustain appellants’ third issue.

                                           CONCLUSION

       We reverse the trial court’s order denying appellants’ motion to dismiss, render judgment

dismissing appellees’ claims against appellants with prejudice, and remand this case to the trial

court to determine the reasonable attorney’s fees and costs to be awarded to appellants pursuant

to section 74.351(b)(1) of the civil practice and remedies code.




                                                      /DAVID J. SCHENCK/
                                                      DAVID J. SCHENCK




160018F.P05




                                               –12–
                                         S
                                Court of Appeals
                         Fifth District of Texas at Dallas
                                        JUDGMENT

NEXION HEALTH AT LANCASTER,                          On Appeal from the 14th Judicial District
INC. D/B/A MILLBROOK HEALTHCARE                      Court, Dallas County, Texas
AND REHABILITATION CENTER AND                        Trial Court Cause No. DC-15-02533.
NANCY LAWSON, Appellants                             Opinion delivered by Justice Schenck.
                                                     Justices Francis and Fillmore participating.
No. 05-16-00018-CV          V.

GURTHA WELLS, INDIVIDUALLY AND
ON BEHALF OF THE ESTATE OF
WILLIE WELLS, DECEASED, STEVE M.
WELLS AND TAMMIE J. WELLS,
Appellees

        In accordance with this Court’s opinion of this date, the trial court’s order denying
appellants NEXION HEALTH AT LANCASTER, INC. D/B/A MILLBROOK HEALTHCARE
AND REHABILITATION CENTER AND NANCY LAWSON’s motion to dismiss is
REVERSED and judgment is RENDERED that appellees’ claims against appellants are
dismissed with prejudice. The case is remanded to the trial court to determine the reasonable
attorney’s fees and costs to be awarded to appellants pursuant to section 74.351(b)(1) of the civil
practice and remedies code.

       It is ORDERED that appellants NEXION HEALTH AT LANCASTER, INC. D/B/A
MILLBROOK HEALTHCARE AND REHABILITATION CENTER AND NANCY LAWSON
recover their costs of this appeal from appellees GURTHA WELLS, INDIVIDUALLY AND
ON BEHALF OF THE ESTATE OF WILLIE WELLS, DECEASED, STEVE M. WELLS AND
TAMMIE J. WELLS.


Judgment entered July 25, 2016.




                                              –13–
