                                  In The
                             Court of Appeals
                    Seventh District of Texas at Amarillo
                            ________________________

                                 No. 07-12-00030-CV
                            ________________________

        SENAIDA “CINDY” ALONZO AND VICTOR ALONZO, APPELLANTS

                                          V.

          DOUGLAS LAMPKIN, M.D. AND COVENANT HEALTH SYSTEM
                 D/B/A COVENANT LAKESIDE, APPELLEES



                          On Appeal from the 72nd District Court
                                 Lubbock County, Texas
             Trial Court No. 2009-548,605, Honorable Ruben Reyes, Presiding


                                 November 13, 2013

                           MEMORANDUM OPINION
                  Before QUINN, C.J., and HANCOCK and PIRTLE, JJ.


      Appellants, Senaida “Cindy” Alonzo and Victor Alonzo, appeal from an order

striking their medical experts and granting summary judgment in favor of Appellees,

Douglas Lampkin, M.D., and Covenant Health System d/b/a Covenant Lakeside

(Covenant) with respect to the Alonzos’ health care liability claims. Summary judgment

was granted because, without the testimony of the Alonzos’ medical experts, there was
no evidence to satisfy the causation element of their claim. In three issues, the Alonzos

assert the trial court erred by (1) excluding Dr. Harold Miller’s and (2) Dr. Todd Swick’s

expert testimony on the issue of causation; and (3) granting Covenant’s “no evidence”

motion for summary judgment. We affirm.


                                      BACKGROUND


      This is a medical malpractice action. On August 7, 2007, Dr. Lampkin performed

a hysterectomy on Cindy Alonzo, pricking her bowel in the process. The following day,

her white blood cell count was 13.6 when the normal range was 4.8 to 10.8. Early in the

morning on August 9, her oxygen saturation level dropped to 87% and was brought

back up to 93% using a nasal cannula. Later that morning, her oxygen saturation was

96%. The night of August 9, her oxygen saturation dropped to 86% and was brought

back up to 96% with treatment. On the morning of August 10, she was walking in the

hallway. Her oxygen saturation level was 95% on room air, her temperature was good,

respiration was good, and her pulse rate was 120. She was subsequently discharged

after being on room air at least three hours and her oxygen saturation level was 95%.

The next day, her family brought her back to the hospital where her bowel was repaired

and she underwent treatment to fend off an infection.        When re-admitted, Cindy’s

oxygen saturation was 74% and she was obtunded.


      More than a year later in October 2008, Dr. Duke Meyer diagnosed Cindy with a

new onset of cognitive decline possibly due to normal-pressure hydrocephalus, metastic

disease, vasculitus, an unwitnessed fall with subdural hematoma, dementing illness

such as Pick’s disease, premature Alzheimer’s, or psychiatric illness. Meyer referred


                                            2
her to a neurologist, Dr. Ahmad Sabouni. In November, she was seen by Sabouni who

described Alonzo as a person with a “history of hypoxic encephalopathy with mild

cognitive impairment secondary to depressed mood, with chronic migraine.”


         In October 2010, the Alonzos filed their First Amended Petition asserting Cindy

was prematurely discharged from the hospital in 2007 because neither Lampkin nor

Covenant appreciated the seriousness of her medical condition. Due to the premature

discharge, they alleged she suffered a hypoxic event (lack of oxygen) causing brain

damage and, as a result, suffers from a variety of symptoms including personality

changes, disabling headaches, memory loss, and difficulty concentrating.                       In two

scheduling orders, the parties agreed the expert designation deadline would be May 7,

2010, for the Alonzos and June 25, 2010, for Covenant.1 The Alonzos designated two

experts: Dr. Harold Miller, an obstetrician and gynecologist, and Dr. Richard Fulbright,

a neuropsychologist. In August 2011, the Alonzos designated a third expert, Dr. Todd

Swick.


         After deposing Miller and Fulbright, Covenant moved to strike their expert

designations for lack of qualifications, reliability, and relevance. Covenant also moved

for summary judgment based on lack of causation and subsequently moved to strike

Swick’s out-of-time designation.         After a hearing, the trial court granted Covenant’s

objections regarding Miller, Fulbright, and Swick.                The trial court also granted

Covenant’s no evidence motion for summary judgment based on a lack of evidence as

to causation. This appeal followed.


         1
        In an e-mail exchange, the parties’ attorneys subsequently agreed to a one week extension until
May 14 for the designation of the Alonzos’ experts.

                                                  3
                                        DISCUSSION


       By their first two issues, the Alonzos assert (1) Miller was sufficiently qualified to

render an opinion on causation; (2) Swick’s late designation did not prejudice Covenant

and, by striking both Miller and Swick, the trial court improperly issued a “death penalty”

sanction because its ruling eliminated the Alonzos’ only causation evidence.           Logic

dictates that we address the Alonzos’ second issue first.


       DR. TODD SWICK


       The Alonzos assert the trial court erred by excluding Swick’s expert testimony

because the exclusion amounted to a “death penalty” sanction under Rule 215 of the

Texas Rules of Civil Procedure. In support, the Alonzos contend the exclusion fails to

meet the requirements established by the Texas Supreme Court in TransAmerican

Natural Gas Corp. v. Powell, 811 S.W.2d 913, 917-18 (Tex. 1991).


       We review a trial court’s decision to exclude testimony under an abuse of

discretion standard. Horizon/CMS Healthcare Corp. v. Auld, 34 S.W.3d 887, 906 (Tex.

2000). See Perez v. Embree Constr. Group, Inc., 228 S.W.3d 875, 883 (Tex. App.—

Austin 2007, pet. denied) (exclusion of expert witness due to untimely designation

reviewed under an abuse of discretion standard). The test for abuse of discretion is not

whether, in the opinion of the reviewing court, the facts present an appropriate case for

the trial court’s action, but “whether the trial court acted without reference to any guiding

rules and principles.” Cire v. Cummings, 134 S.W.3d 835, 838-39 (Tex. 2004) (quoting

Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 241 (Tex. 1986). In other

words, we must decide whether the trial court’s decision was arbitrary or unreasonable

                                             4
and we must uphold an evidentiary ruling if there is any legitimate basis for it. Owens-

Corning Fiberglass Corp. v. Malone, 972 S.W.2d 35, 43 (Tex. 1998).


        Here, the parties entered into agreed scheduling orders in January and

November 2010 requiring the Alonzos designate their expert witnesses in May 2010.

The orders were signed by the attorneys for all parties and by the judge, and filed with

the trial court’s papers as part of the record.              The agreed orders satisfied all the

requirements necessary to establish a Rule 11 agreement. TEX. R. CIV. P. 11.2 See

Trevino v. Houston Orthopedic Center, 831 S.W.2d 341, 344 (Tex. App.—Houston [14th

Dist.] 1992, writ denied). As the parties’ agreement was valid under Rule 11, the trial

court had a duty to enforce its terms. Fortis Benefits v. Cantu, 234 S.W.3d 642, 651

(Tex. 2007). See also EZ Pawn Corp. v. Mancias, 934 S.W.2d 87, 91 (Tex. 1996) (orig.

proceeding) (noting that trial courts should not consider evidence outside the bounds of

a valid Rule 11 agreement); Scott-Richter v. Taffarello, 186 S.W.3d 182, 189 (Tex.

App.—Fort Worth 2006, pet. denied) (holding that a trial court has a ministerial duty to

enforce a valid Rule 11 agreement).


        The Alonzos do not dispute that Swick was designated as an expert witness

months after the May 2010 deadline had passed. Thus, on filing of Covenant’s motion

to strike Swick’s untimely expert designation, the trial court had “a ministerial duty to

render judgment in strict accordance with the parties’ agreement.” Trevino, 831 S.W.2d

at 344.     The trial court did not err because its ruling complied with the parties’

agreement.

        2
         “Unless otherwise provided in these rules, no agreement between attorneys or parties touching
any suit pending will be enforced unless it be in writing, signed and filed with the papers as part of the
record, or unless it be made in open court and entered of record.” TEX. R. CIV. P. 11.

                                                    5
        The Alonzos assert their agreement was not intended to exclude a later

designation of experts who were intended to rebut the opinions of another party’s

experts. We disagree. A Rule 11 agreement is considered contractual in nature; Coale

v. Scott, 331 S.W.3d 829, 832 (Tex. App.—Amarillo 2011, no pet.), and, as such, is

interpreted in the same manner as are contracts in general.                    Golden Spread Elec.

Coop., Inc. v. Denver City Energy Assoc., L.P., 269 S.W.3d 183, 190-91 (Tex. App.—

Amarillo 2008, pet. denied). We look to the plain meaning of the words of a Rule 11

agreement to determine the extent of the parties’ agreement. Id. Here, the parties’

agreement requires that the Alonzos “shall list each expert’s name, . . .” by May 7, 2010.

The term “expert” is neither defined nor qualified. Hence, the Alonzos were required to

designate all their experts, rebuttal or otherwise, by the due date.


        The Alonzos also assert the trial court improperly issued a “death penalty”

sanction by striking Swick’s expert designation citing TransAmerica Natural Gas Corp.

v. Powell, 811 S.W.2d 913 (Tex. 1991). See TEX. R. CIV. P. 215. This assertion ignores

the fact that the Alonzos entered into and were bound by the specific language of their

Rule 11 agreement.3          In the absence of any modification of their agreement with

Covenant, the trial court was duty bound to grant Covenant’s motion.                        See Fortis

Benefits, 234 S.W.3d at 651. Accordingly, we find the trial court did not abuse its

discretion in granting Covenant’s motion to strike Swick’s expert designation.                       The

Alonzos’ second issue is overruled.



        3
        We note that, in any event, Rule 215 is inapplicable in this instance. Under Rule 193.6 the
testimony of a witness not timely identified is inadmissible as evidence. TEX. R. CIV. P. 193.6(a); Didur-
Jones v. Family Dollar, Inc., No. 02-09-00069-CV, 2009 Tex. App. LEXIS 8999, at *5, *8-9 (Tex. App.—
Fort Worth 2009, pet. denied) (mem. op.).

                                                    6
       DR. HAROLD J. MILLER


       1. EXPERT WITNESSES


       A witness qualified as an expert by knowledge, skill, experience, training, or

education may testify in the form of an opinion. TEX. R. EVID. 702. If a licensed doctor

has sufficient familiarity with the specific subject matter at issue in a medical malpractice

suit, he is qualified to testify as an expert. Broders v. Heise, 924 S.W.2d 148, 152-53

(Tex. 1996). See Cooper Tire & Rubber Co. v. Mendez, 204 S.W.3d 797, 800 (Tex.

2006) (the expert must truly have expertise concerning the “actual subject about which

they are offering an opinion”). Further, a medical expert from one specialty may be

qualified to testify if he has practical knowledge of what is customarily done by

practitioners of a different specialty under circumstances similar to those at issue in the

suit. Tenet Hospitals, Ltd. v. De La Riva, 351 S.W.3d 398, 406 (Tex. App.—El Paso

2011, no pet.). Accordingly, a trial court must measure the doctor’s expertise against

the opinion being offered to determine whether he or she is qualified.           SunBridge

Healthcare Corp. v. Penny, 160 S.W.3d 230, 237 (Tex. App.—Texarkana 2005, no

pet.); Marvelli v. Alston, 100 S.W.3d 460, 474 (Tex. App.—Fort Worth 2003, pet.

denied).


       When an expert testifies regarding causation, he or she must provide information

linking the defendant’s purported breach of the standard of care to the injury, harm, or

damages. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 53 (Tex. 2002). A causal

connection is established by proof that the negligent act or omission was a substantial

factor in bringing about the harm and that absent said act or omission the harm would


                                             7
not have occurred. Costello v. Christus Santa Rosa Health Care Corp., 141 S.W.3d

245, 249 (Tex. App.—San Antonio 2004, no pet.). See Wright, 79 S.W.3d at 53. A

causation opinion may not be conclusory; Estorque v. Schafer, 302 S.W.3d 19, 27 (Tex.

App.—Fort Worth 2009, no pet.), or merely provide some insight into plaintiff’s claims.

Wright, 79 S.W.3d at 53. Neither is the trial court required to admit opinion evidence

which is connected to existing data by the ipse dixit of the expert. Cooper Tire, 204

S.W.3d at 801. If the expert brings merely his credentials and subjective opinion, his

testimony is unsupported and cannot be of assistance to the jury. Id. Indeed, we may

not fill in gaps in an expert’s report or testimony by drawing inferences or guessing what

the expert likely meant or intended. Austin Heart, P.A. v. Webb, 228 S.W.3d 276, 279

(Tex. App.—Austin 2007, no pet.). “[C]ausation cannot be inferred; it must be clearly

stated.” Tenet Hospitals, Ltd. v. Love, 347 S.W.3d 743, 755 (Tex. App.—El Paso 2011,

no pet). See Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 876

(Tex. 2001) (expert testimony may not establish causation through mere conjecture,

speculation, or possibility).


       The plaintiff has the burden to establish that their expert witness is qualified to

offer an opinion on causation; Gammill v. Jack Williams Chevrolet, Inc., 972 S.W.2d

713, 718 (Tex. 1998), and such opinion must establish causal nexuses between (1) the

defendant’s conduct and the event sued upon and (2) the event sued upon and the

plaintiff’s injuries. See Jelinek v. Casas, 328 S.W.3d 526, 532 (Tex. 2010). We review

the trial court’s decision to strike an expert’s testimony for abuse of discretion. Broders,

924 S.W.2d at 151.




                                             8
       2. ANALYSIS


       The critical causation issues presented by the Alonzos’ claim are (1) whether a

hypoxic event occurred between the time of Alonzo’s surgery on August 7, 2007, and

her re-admission on August 11, 2007, and (2) whether such an event caused her

symptoms more than a year later.


       Miller’s report indicates he is a board-certified obstetrician/gynecologist that is

basing his opinions on his training, experience, and education in the OB/GYN field.

Although his specialty does not focus on diseases of the nervous system, he has

performed hundreds of hysterectomies including post-operative care. His curriculum

vitae indicates he completed his residency in OB/GYN in 1964 and has since engaged

in a private OB/GYN practice as well as a teaching practice in various faculty positions.

He has written articles and received numerous awards in the OB/GYN field of medicine.

Nowhere, however, does his curriculum vitae indicate he has any experience, training or

education in the field of neurology or, more specifically, brain injuries. On deposition, he

indicated he has not evaluated Alonzo personally. He testified his opinions did not rely

on any medical literature; he has not practiced as a neurologist, psychologist, or

psychiatrist; he hasn’t treated brain injuries; doesn’t read brain EEGs, MRIs, or CT

scans; couldn’t recall the last time he sent a patient to a neurologist; didn’t use

neuropsychologists; didn’t evaluate patients to determine the extent of any nerve

damage due to hypoxia; couldn’t predict how much brain damage Alonzo suffered; and

couldn’t pinpoint the occurrence of a hypoxic event sufficient to cause brain damage to

Alonzo. If he had a problem with a brain injury, he indicated he would consult with a



                                             9
neurologist for his or her opinion whether a patient had a brain injury and the extent of

any damage.


      Here, there is nothing in the four corners of Miller’s report, his curriculum vitae, or

his deposition indicating he is qualified to opine on causation as to Alonzo’s injuries.

Thus, we cannot conclude the trial court abused its discretion in finding that Miller was

not qualified to render causation opinions regarding Alonzo’s injuries. See Broders, 924

S.W.2d at 153; Pediatrix Med. Servs. Inc. v. De La O, 368 S.W.3d 34, 40-41 (Tex.

App.—El Paso 2012, no pet.); De La Riva, 351 S.W.3d at 407.                 Cf. Roberts v.

Williamson, 111 S.W.3d 113, 122 (Tex. 2003) (board-certified pediatrician qualified as a

medical expert because his report showed that he “studied the effects of pediatric

neurological injuries,” had “extensive experience advising parents about the effects of

those injuries,” and relied on the interpretation of MRIs and CT scans by a pediatric

neurologist); Livingston v. Montgomery, 279 S.W.3d 868, 877 (Tex. App.—Dallas 2009,

no pet.) (medical expert’s report reflected that he had “knowledge and expertise to

recognize the perinatal progression of hypoxia due to inadequate oxygenation through a

compromised uteroplacental unit”).


      Alternatively, the expert opinion in Miller’s report is conclusory because he

“simply express[es] an inference without stating the underlying facts upon which the

inference was based;” Love, 347 S.W.3d at 755, i.e., Alonzo suffered a hypoxic event

that caused brain injury. Miller simply states in his report and deposition that Alonzo

first entered the hospital with no brain injury and, more than a year after her final

discharge, showed signs of brain injury.         He provides no analytical link between

Alonzo’s hospital stays at Covenant and her subsequent medical condition.               See

                                            10
Regent Health Care Ctr. of El Paso, L.P. v. Wallace, 271 S.W.3d 434, 441 (Tex. App.—

El Paso 2008, no pet.) (mere reference to general concepts regarding patient

assessment, monitoring, and interventions were insufficient as a matter of law to

establish causation). See Lo v. Gonzales., No. 01-12-00987-CV, 2013 Tex. App. LEXIS

4820, at *15-18 (Tex. App.—Houston [1st Dist.] April 18, 2013, no pet.) (mem. op.)

(expert’s reliance on the passage of time without any underlying factual support

insufficient to establish delay itself actually caused any additional symptoms or

suffering). “An expert’s simple ipse dixit is insufficient to establish a matter; rather, the

expert must explain the basis of his statements to link his conclusions to the facts.”

Earle v. Ratliff, 998 S.W.2d 882, 890 (Tex. 1999). See Jelinek, 328 S.W.3d at 529.


       In addition, neither his report nor deposition explain how any failure to consult a

specialist during Alonzo’s first hospital stay caused any worsening or progression of her

listed conditions. Estorque, 302 S.W.3d at 28 (expert’s report insufficient to establish

causation where expert failed to explain how or why the physicians’ failure to consult a

urologist or gynecologist caused any worsening or progression of patient’s listed

conditions). Instead, on deposition, Miller testified he could not say whether a consult

with a pulmonologist or neurologist would have resulted in the discovery and treatment

of any infection from the bowel perforation—the purported genesis of Alonzo’s

oxygenation issues. See Costello, 141 S.W.3d at 249 (finding expert’s mere assertion

that the patient would have survived was conclusory when report did not explain the

causal connection between hospital’s claimed failure to appropriately triage and

evaluate the patient and the patient’s death, offered no explanation of what medical




                                             11
information a more timely triage and evaluation would have revealed, nor state what

would have been done had the hospital not failed to act).


      The Alonzos assert Miller appropriately relied on the reports of Matthew Lambert,

licensed psychologist, and Richard L. Fulbright, licensed neuropsychologist, to conclude

that Alonzo suffered brain damage from hypoxia after she was discharged from the

hospital and re-admitted the following day.4                  Lambert assessed Alonzo’s medical

condition as of January 2009. The conclusions in his report regarding the origin of her

symptoms were premised on an oral history provided by the Alonzos.                     Fulbright

assessed Alonzo’s condition as of March 2010. The conclusions in his report regarding

the origin of her symptoms similarly relied on an oral history provided by Alonzo’s

husband.        Neither Lambert nor Fulbright examined Alonzo prior to their initial

consultations in 2009 and 2010 respectively. While section 74.351(i), in part, permits a

claimant to utilize separate expert reports regarding different issues, such as liability

and causation, arising from the conduct of a physician; TEX. CIV. PRAC. & REM. CODE

ANN. § 74.351(i) (West 2011); Iqbal v. Rash, 346 S.W.3d 827, 832 (Tex. App.—El Paso

2011, no pet.), the experts must still meet the requirements of section 74.403(a) which

requires that only a physician who is otherwise qualified may render an opinion in a suit

against a physician or health care provider on causation. TEX. CIV. PRAC. & REM. CODE

ANN. § 74.403(a) (West 2011). See De La Riva, 351 S.W.3d at 405; Iqbal, 346 S.W.3d

at 832.

      In sum, due to Miller’s inadequate qualifications and, alternatively, the

inadequacies of the causation opinions expressed in his expert report and deposition,

      4
          Miller also relied on Swick’s expert report.


                                                         12
we cannot say the trial court acted unreasonably or in an arbitrary manner without

reference to guiding rules or principles when it struck Miller as an expert witness, i.e. the

trial court did not abuse its discretion in excluding Dr. Miller’s testimony. Accordingly,

Appellant’s first issue is overruled.


       SUMMARY JUDGMENT


       The Alonzos assert the trial court erred in granting summary judgment in favor of

Covenant because the expert affidavits and testimony of Miller and Swick created an

issue of fact on causation.       This contention overlooks that the trial court granted

summary judgment after striking Miller and Swick as expert witnesses. Having found

the trial court committed no error by striking their expert testimony, we also find the trial

court properly granted summary judgment because the Alonzos failed to produce any

evidence to establish the element of causation. See In re K.D.C., 78 S.W.3d 543, 551-

52 (Tex. App.—Amarillo 2002, no pet.). The Alonzos’ third issue is overruled.


                                        CONCLUSION


       The trial court’s judgment is affirmed.



                                                  Patrick A. Pirtle
                                                      Justice




                                             13
