                             In The
                       Court of Appeals
         Sixth Appellate District of Texas at Texarkana
                 ______________________________

                       No. 06-11-00120-CV
                 ______________________________


JOSEPH MORRIS MCKELLAR, M.D., D/B/A O. B. ASSOCIATES, CARTER J.
     MOORE, M.D., AND CARTER J. MOORE, M.D., P.A., Appellants

                                   V.

MARIA CERVANTES, INDIVIDUALLY AND AS NEXT FRIEND OF ALEK
               GONZALEZ, ET AL., Appellees




            On Appeal from the 276th Judicial District Court
                         Titus County, Texas
                        Trial Court No. 35,429




              Before Morriss, C.J., Carter and Moseley, JJ.
                      Opinion by Justice Carter
                                                  OPINION

            In this medical negligence case, Joseph Morris McKellar, M.D., d/b/a O. B. Associates,

Carter J. Moore, M.D., and Carter J. Moore, M.D., P.A., appeal the trial court’s order denying their

motion to dismiss the health care claims of Maria Cervantes and Omar Gonzalez, Individually and

as Next Friend of Alek Gonzalez, for failure to file an expert report compliant with Section

74.351(r)(6) of the Texas Civil Practice and Remedies Code. See TEX. CIV. PRAC. & REM. CODE

ANN. § 74.351(r)(6) (West 2011). We affirm the judgment of the trial court as to McKellar. We

reverse and remand for the trial court’s assessment of whether to grant a thirty-day extension to

cure expert report deficiencies as to Moore.

I.          Factual and Procedural Background

            Cervantes was a patient of Dr. Moore and Dr. McKellar and saw them regularly for

prenatal care of her high risk twin pregnancy. McKellar admitted Cervantes to Titus Regional

Medical Center during the course of her pregnancy in August 2008 with suspicion of

preeclampsia.1 When the babies were delivered via Caesarean section the day after Cervantes’

admission, the twin Alek was diagnosed with encephalopathy.2 Cervantes3 filed suit, asserting

health care liability claims against her obstetricians, McKellar and Moore. Pursuant to Section

1
 Preeclampsia is “a serious condition developing in late pregnancy that is characterized by a sudden rise in blood
pressure, excessive weight gain, generalized edema, proteinuria, severe headache, and visual disturbances and that
may result in eclampsia if untreated.” http://www.merriam-webster.com/dictionary/preeclampsia.
2
  Encephalopathy is “a disease of the brain; especially: one involving alterations of brain structure.”
http://www.merriam-webster.com/dictionary/encephalopathy.
3
    Appellants will be identified as Cervantes.

                                                        2
74.351 of the Texas Civil Practice and Remedies Code, Cervantes timely served the expert reports

and curricula vitae of Paul Douglas Gatewood, M.D., and Robert Atlas, M.D. McKellar and

Moore timely filed their objections to the expert reports, as well as a motion to dismiss and for

sanctions. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(b) (West 2011). The motion

alleged that the expert reports failed to comply with Section 74.351(r)(6) of the Texas Civil

Practice and Remedies Code because they did not include opinions regarding any negligent acts on

the part of Moore and failed to provide sufficient opinions directly establishing that McKellar’s

alleged negligent acts proximately caused Alek’s injuries. The qualifications of both physicians

to render opinions on the issue of causation were challenged.

       Cervantes filed her response to McKellar and Moore’s motion to dismiss and, following a

hearing, the trial court overruled the physicians’ objections to the expert reports, as well as their

motion to dismiss.

       McKellar and Moore appropriately appeal this interlocutory order denying the motion to

dismiss. TEX. CIV. PRAC. & REM. CODE ANN. § 51.014(a)(9) (West Supp. 2011) (appeal of

interlocutory order from district court that “denies all or part of the relief sought by a motion”

seeking to dismiss plaintiff’s claim for failure to meet expert report requirements); see Lewis v.

Funderburk, 253 S.W.3d 204, 208 (Tex. 2008).




                                                 3
II.    Analysis

       As a medical negligence case, this matter is governed by Chapter 74 of the Texas Civil

Practice and Remedies Code. Section 74.351(a) provides that the plaintiff must “serve on each

party or the party’s attorney one or more expert reports” not later than 120 days “after the date the

original petition was filed. . . .” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a) (West 2011).

The report must provide “a fair summary of the expert’s opinions as of the date of the report

regarding 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.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6).

If the claimant’s report is timely filed but allegedly deficient, the trial court may grant a single,

thirty-day extension to cure that deficiency. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c)

(West 2011). Here, the trial court declined to find the expert reports deficient, and thus denied the

physicians’ motion to dismiss.

       McKellar and Moore complain that neither report met the statutory definition of an expert

report. A trial court must grant a motion to dismiss if it appears the report does not amount to an

objective good faith effort to comply with the statutory definition. Bowie Mem’l Hosp. v. Wright,

79 S.W.3d 48, 51 (Tex. 2002) (per curiam); Longino v. Crosswhite, 183 S.W.3d 913, 916 (Tex.

App.—Texarkana 2006, no pet.). A trial court’s decision regarding the adequacy of an expert

report is reviewed for an abuse of discretion. Wright, 79 S.W.3d at 51; Longino, 183 S.W.3d at



                                                 4
916. In order to reverse the trial court, we must find the court acted arbitrarily or unreasonably

without reference to guiding rules or principles.       Wright, 79 S.W.3d at 52. We may not,

however, substitute our opinion for that of the trial court. Id. Nevertheless, “a clear failure by

the trial court to analyze or apply the law correctly will constitute an abuse of discretion . . . .”

Walker v. Packer, 827 S.W.2d 833, 840 (Tex. 1992).

       A trial court must grant a motion to dismiss under Section 74.351 if it appears that the

report does not represent a good faith effort to comply with subsection (r)(6) or is not sufficiently

specific “to provide a basis for the trial court to conclude that the claims have merit.” Am.

Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001); see TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351(r)(6). A good faith effort further requires that the report

discuss the standard of care and breach of that standard with sufficient specificity to inform each

defendant of the conduct the plaintiff has called into question and to provide a basis for the trial

court to conclude the claims have merit. Jernigan v. Langley, 195 S.W.3d 91, 94 (Tex. 2006) (per

curiam). Here, the reports must provide notice of what conduct forms the basis of Cervantes’

complaints and provide a basis for the trial court to conclude that the claims have merit. Longino,

183 S.W.3d at 917. A report that merely states an expert’s conclusions about the standard of care,

breach, and causation does not meet the statutory requirements. Id.; Wright, 79 S.W.3d at 52.

Rather, the expert must explain the basis of his or her statements to link the expert’s conclusions to

the facts. Wright, 79 S.W.3d at 52.



                                                  5
        A.       The Gatewood Report

                 (1)      Inadequate as to Moore

        The report of Paul Douglas Gatewood4 indicates that Cervantes was diagnosed with a twin

monochorionic-diamnioctic pregnancy. According to Gatewood, Cervantes was admitted to the

hospital for possible preeclampsia due to excessive edema and proteinuria at a fetal gestation age

of thirty-four weeks. No nonstress test, fetal ultrasound, or biophysical profile was performed

after admission until a nonstress test was started the following day. Gatewood indicates:

        The fetal monitoring tracings demonstrate a reactive strip for one twin and a
        non-reassuring strip for the other by 17:54 (call A reactive, B non-reassuring).

        . . . . No mention of the variable is noted by OB Nurse Cook until 18:05. She also
        states average variability (6-25) throughout. Twin B has persistent, recurring
        variable decelerations with absent long-term variability.

Gatewood’s report further states that Cook called McKellar to inform him of the nonreassuring

tracings at 18:20. Cook called again at 18:25 to inform McKellar that the patient had been

transferred to labor and delivery with oxygen and intravenous fluids. McKellar then contacted a

perinatologist for a consult, who recommended delivery by Caesarean section. At this point:

        9)       Dr. McKellar did not contact L&D to prepare for a Caesarean section.

        10)      Dr. McKellar arrived at L&D at 18:50 and called for the Caesarean section.

4
 Gatewood is a board-certified obstetrician-gynecologist. During his active practice since 1974, Gatewood
primarily practiced obstetrics with a sub-special interest in infertility/microsurgery from 1974–2004. Since June
2004, Gatewood has continued an active locum tenens obstetrics and gynecological practice in several communities in
Ohio, as well as hospitals in Tahlequah, Oklahoma, with the Cherokee Indian tribe, and Rosebud, South Dakota, with
the Sioux Indian tribe through 2010. Gatewood has also served as an instructor and clinical assistant professor of
obstetrics and gynecology at the Northeastern Ohio University College of Medicine.

                                                        6
       11)    Ms. Cervantes was not taken to the OR until 19:05 – awaited anesthesia
              arrival. Surgery began with anesthesia at 19:05, incision was at 19:23 with
              deliveries at 19:28.

              ....

       15)    The depressed twin was treated in the NICU for multiple problems,
              including encephalopathy.

Gatewood further opines that McKellar failed to meet the applicable standard of care in his

treatment of Cervantes due to his

       a)     Failure to order continuous fetal heart rate monitoring upon admission of
              Ms. Cervantes to the hospital.

       b)     Failure to order an ultrasound evaluation of the twins for discordance and
              biophysical profile.

       c)     Failure to notify labor and delivery of the decision to proceed with
              emergency Caesarean section at 18:35 after the consult with Dr. Gore.

       d)     Upon arrival failed to expedite rapid response for the Caesarean section.
              The patient wasn’t taken to the OR for 15 minutes (18:50–19:05) and delay
              in delivery from anesthesia at 19:05 until incision at 19:23.

The report also sets forth the alleged breach of the standard of care by Cook and the nurse

anesthetist. Gatewood concludes,

       In summary, the deviations in acceptable standards of care more likely than not
       represent the proximate cause of the injuries to the baby. In addition, but for these
       deviations, the baby more likely than not would have been born as healthy as the
       sibling twin, who was neurologically and physiologically intact.




                                                7
            Moore complains that because the Gatewood report does not mention Moore or any

negligent acts allegedly committed by Moore, the report does not represent a good faith effort to

comply with subsection (r)(6) of Section 74.351. We agree. In the complete absence of any

alleged negligent acts or omissions by Moore, the report fails to provide notice of what conduct

allegedly committed by Moore forms the basis of Cervantes’ complaints against him. 5 This

report thus fails to provide a basis for the trial court to conclude that the claims have merit as

against Moore.6 See Longino, 183 S.W.3d at 917. Accordingly, to the extent the trial court




5
 Moore’s briefing vaguely argues in a single sentence that “in the absence of any description of the injuries to the child
. . . it is impossible to determine if either Dr. Gatewood or Dr. Atlas are even qualified to render any opinions on the
nature and scope of the injuries to the child . . . .” While counsel for appellants argued to the trial court that Gatewood
and Atlas were not qualified to provide Chapter 74 reports because they are obstetrician/gynecologists and not
pediatric neurologists, no such argument has been advanced on appeal. The Texas Rules of Appellate Procedure
require an appellant to provide “a clear and concise argument for the contentions made, with appropriate citations to
authorities and to the record.” See TEX. R. APP. P. 38.1(i). Bare assertions of error, without argument or authority,
waive error. Enbridge Pipeline (East Tex.) L.P. v. Avinger Timber, L.L.C., 326 S.W.3d 390, 414 (Tex.
App.––Texarkana 2010, pet. granted). Because appellants’ briefing on the issue of expert qualification is inadequate,
the argument, if indeed it was intended to be seriously advanced, is waived. See Fredonia State Bank v. Gen. Am. Life
Ins. Co., 881 S.W.2d 279, 284–85 (Tex. 1994) (discussing “long-standing rule” that point may be waived due to
inadequate briefing).
6
    Cervantes contends the Gatewood report is adequate to support her claims against Moore because Atlas’ report states:

            Dr. McKellar and Dr. Moore were responsible for putting together a plan for this patient. They
            failed to provide the appropriate minimal standard of care by not monitoring this high risk
            pregnancy properly.

Cervantes maintains that because the same standard of care applies to both Moore and McKellar, the fact that Moore’s
name is only mentioned in the Atlas report is of no import. Because Moore’s name is never mentioned in the
Gatewood report, we cannot conclude this report in any way applies to Moore.


                                                            8
found Gatewood’s report adequate to comply with Section 74.351(r)(6) as against Moore, it

abused its discretion.7

                     (2)       Adequate as to McKellar

            With respect to McKellar, it is not asserted that Gatewood’s report is deficient with regard

to setting forth the applicable standard of care or the manner in which McKellar failed to meet that

standard. Rather, McKellar contends Gatewood’s report is deficient because it fails to set forth

the causal relationship between McKellar’s alleged failures and the injury, harm, or damages

claimed. The report states that “the deviations in acceptable standards of care more likely than

not represent the proximate cause of the injuries to the baby. In addition, but for these deviations,

the baby more likely than not would have been born as healthy as the sibling twin, who was

neurologically and physiologically intact.” Earlier in the report, the injuries to the baby are

described as “multiple problems, including encephalopathy.”

            The Texas Supreme Court has held that an expert cannot simply opine that the breach

caused the injury. Jelinek v. Casas, 328 S.W.3d 526 (Tex. 2010). In that case, the expert

testified that “the Hospital’s negligence ‘in medical probability’ caused Casas additional pain and

7
    The trial court’s order provides:

                     After considering DEFENDANTS’ OBJECTIONS TO PLAINTIFFS’ C.P.R.C.
            SECTION 74.351(a) EXPERT REPORTS OF PAUL D. GATEWOOD, M.D. AND ROBERT
            ATLAS, M.D. AND MOTION TO DISMISS AND FOR SANCTIONS, the Court hereby DENIES
            the motion.

                    IT IS HEREBY ORDERED that Defendants’ Objections to Plaintiffs’ C.P.R.C. Section
            74.351(a) timely Expert Reports of Paul D. Gatewood, M.D. and Robert Atlas, M.D. and Motion to
            Dismiss and for Sanctions Pursuant to C.P.R.C. § 74.351 is DENIED.

                                                          9
suffering.” Id. at 535. The expert based this opinion on the presence of an intra-abdominal

infection that could have been treated with certain antibiotics. Circumstantial evidence of

infection existed, but there was no direct evidence of an infection. The expert conceded the

circumstantial evidence on which he relied to form the opinion the patient suffered from an

infection were equally consistent with two other infections cultured from the patient’s incision and

blood—neither of which were treatable by the antibiotics in question. Id. The court held that

“[w]hen the only evidence of a vital fact is circumstantial, the expert cannot merely draw possible

inferences from the evidence and state that ‘in medical probability’ the injury was caused by the

defendant’s negligence.” Id. at 536.

       Here, we are not dealing with circumstantial evidence of a vital fact. Nevertheless, an

expert report must include a fair summary of the causal relationship between the defendant’s

failure to meet the appropriate standard of care and the injury, harm, or damages claimed. TEX.

CIV. PRAC. & REM. CODE ANN. § 74.352(r)(6). An expert must “explain the basis of his

statements to link his conclusions to the facts.” Wright, 79 S.W.3d at 52. Moreover, a report

may be sufficient if it states a chain of events that begin with a health care provider’s negligence

and end in a personal injury. See Patel v. Williams, 237 S.W.3d 901, 905 (Tex. App.—Houston

[14th Dist.] 2007, no pet.).

       In that case, the court held that an expert report sufficiently set forth causation when it

presented a chain of events beginning with an allegedly negligent prescription and ending with the



                                                10
patient’s death. Id. at 905–06. Patel prescribed the patient a drug for help in her dementia which

was not FDA-approved for patients with the patient’s condition. Restlessness was a known side

effect of the drug. Id. Allegedly due to restlessness caused by the drug, the patient removed her

feeding tube, resulting in improper re-insertion of the tube, causing a cut which became infected.

Id. The cut developed into an abscess requiring multiple surgeries. Id. The report concluded

that death was caused by infection from the improperly re-inserted feeding tube, and was held not

to be conclusory or speculative regarding causation. Id.; see also Presbyterian Cmty. Hosp. of

Denton v. Smith, 314 S.W.3d 508, 519 (Tex. App.—Fort Worth 2010, no pet.) (statements

contained within four corners of report sufficiently link causation opinions to facts and adequately

describe chain of events leading to patient’s death).

            It is clear from Gatewood’s report that Alek suffered from encephalopathy.

Encephalopathy is a disease of the brain involving alteration of the brain structures.8 We are told

that Alek’s altered brain structure was probably caused by McKellar’s failure to order continuous

heart rate monitoring upon Cervantes’ admission to the hospital; failure to order an ultrasound for

discordance and a biophysical profile; and failure to notify labor and delivery of the decision to

proceed with emergency Caesarean section at 18:35 after the consult with Dr. Gore. Finally,

upon his arrival at the hospital, McKellar failed to expedite rapid response for the Caesarean

section.



8
    See supra, footnote 2.

                                                 11
       A fair reading of Gatewood’s report is that the failure to expeditiously discover and address

the recurring variable decelerations with absent long-term variability in Alek’s heart rate resulted

in Alek’s brain damage. Thus, the report sets forth a chain of events beginning with Cervantes’

admission to the hospital when McKellar allegedly negligently failed to monitor the twins’ heart

rates, when he knew Cervantes was at risk for preeclampsia due to excessive edema and

proteinuria, and at a time when he was aware that repeated consultations for serial ultrasounds

were necessary from April through July 24. Even though such ultrasounds were routinely utilized

to monitor the twins’ condition due to this high -risk pregnancy prior to Cervantes’ hospitalization,

no such ultrasounds were ordered at a critical time when she was hospitalized. Next, McKellar

failed to expedite his decision to perform an emergency Caesarean section, delaying the twins’

delivery, all of which resulted in brain damage to Alek. The trial court was permitted to read the

causation section in the context of the entire report. Benavides v. Garcia, 278 S.W.3d 794 (Tex.

App.—San Antonio 2009, pet. denied).

       The trial court abuses its discretion only when it acts in an arbitrary or unreasonable

manner without reference to any guiding rules or principles. Wright, 79 S.W.3d at 52. Given

this standard, we cannot conclude the trial court abused its discretion in finding that Gatewood’s

report represents an objective, good faith effort to comply with the definition of an expert report

provided in subsection (r)(6). TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6). The report

discusses the standard of care, breach, and causation with sufficient specificity to inform McKellar



                                                 12
of the conduct Cervantes has alleged and to provide a basis for the trial court to conclude that the

claims have merit. See Scoresby v. Santillan, 346 S.W.3d 546, 556 (Tex. 2011) (citing Palacios,

46 S.W.3d at 879).

        B.       The Atlas Report

                 (1)      Inadequate as to Moore

        The report of Dr. Robert Atlas 9 indicates that Cervantes was twenty-eight years old

carrying a thirty-four-week twin gestation when she was hospitalized for a twenty-four-hour urine

collection in connection with elevated blood pressure and proteinuria. Atlas further indicates,

        The next day upon placing the twins on the fetal monitor revealed an abnormal fetal
        heart rate tracing of twin B. The patient was eventually delivered via C/S.

        There were multiple lapses in the standard of care regarding the management of
        Ms. Cervantes. First, when a patient is admitted with the above conditions the
        standard mandates the fetal well being be assessed upon the admission.
        Ms. Cervantes was not placed on an external fetal monitor until more than 28 hours
        after admission. Nor was a NST/BPP ordered for her. Because of her condition,
        the fetuses were at a higher risk of complications. Not ordering a Non Stress
        Test/Biophysical Profile (NST/BPP) on this patient is below the standard of care.

        Second, regarding the timing of the response of Dr. McKellar, by my evaluation the
        patient was noted to have an abnormal fetal heart rate tracing no later than 1800. It
        was not recognized by the nursing staff until 1820. Dr. McKellar is noted to be in
        the hospital at 1850 by the nursing notes. Further, once in the hospital it took 33
        minutes to begin the surgical procedure. The standards published by The
        American Congress of Ob/GYN and American Academy of Pediatrics state the

9
 Atlas is the Chairman of the Department of Obstetrics and Gynecology and head of Maternal Fetal Medicine at Mercy
Medical Center in Baltimore, Maryland. Atlas is also an assistant professor of Obstetrics, Gynecology, and
Reproductive Sciences at the University of Maryland School of Medicine. Atlas is board-certified in Obstetrics and
Gynecology and Maternal Fetal Medicine and has been treating patients for seventeen years with a diagnosis of twin
gestation, preeclampsia on a daily basis.

                                                       13
        decision to incision time should be 30 minutes. This is the community standard
        throughout the United States.

        Dr. McKellar and Dr. Moore were responsible for putting together a plan for this
        patient. They failed to provide the appropriate minimal standard of care by not
        monitoring this high risk pregnancy properly. They failed to order a NST/BPP.
        Patients with preeclampsia are at a marked increased risk of placental insufficiency,
        placental abruption, fetal death and further complications.

                ....

        In reasonable medical probability each of the above failures were a proximate
        cause of the injuries suffered by this child.

                ....

        By not following these standards, Ms. Cervantes was not afforded the care needed
        to ensure the safety of her unborn fetuses and are the proximate cause of this child’s
        problems. . . .

        Moore maintains this report is inadequate as to him because the alleged negligent acts set

forth in the report cannot be attributed to him merely by a “passing mention” of his name. The

Atlas report states that the failure to place Cervantes on an external monitor upon her admission to

the hospital, the failure to perform a nonstress test/biophysical profile earlier than twenty-eight

hours after admission, and the failure to perform surgical intervention in a timely fashion after

McKellar’s arrival at the hospital were lapses in the standard of care. However, there is no

reference or mention that Moore was involved with the hospital admission, the care provided in the

hospital, or the delivery of the twins. The Atlas report mentions Moore in a single reference in

which it is stated:



                                                 14
       Dr. McKellar and Dr. Moore were responsible for putting together a plan for this
       patient. They failed to provide the appropriate minimal standard of care by not
       monitoring this high risk pregnancy properly. They failed to order a NST/BPP.

       The only explanation of the plan is a failure to monitor the status of the twins with a

nonstress test/biophysical profile. This involves a treatment subsequent to admission to the

hospital.   There is nothing in the report or the record to indicate Moore was involved in

Cervantes’ hospital admission or subsequent treatment. Even though the Atlas report mentions

Moore, a “passing mention” to a defendant and a failure to state how that defendant breached the

standard of care or how the alleged breach caused injury is insufficient to constitute a report

compliant with the statute. Jernigan, 195 S.W.3d at 93–94.

       In that case, Jernigan’s name appeared only in one line of the report, stating that “[a]t 4:30

p.m. [John Langley’s] case was discussed with Dr. Jernigan and at 4:50 p.m. a lactulose enema

was ordered.” Id. at 93. The Texas Supreme Court determined that this

       glancing statement that John’s case was “discussed” with Dr. Jernigan sheds no
       light whatsoever on what Dr. Jernigan allegedly did wrong, much less how his
       alleged error(s) proximately caused John’s death. Thus, we conclude that the
       reports omitted statutory elements of Marie Langley’s claim against Dr. Jernigan.

Id. at 94. Likewise, in this case, even though the report indicates Atlas’ opinion that the claim

against Moore had merit, the report fails to discuss the required elements of the standard of care,




                                                15
breach, and causation with sufficient specificity to inform Moore of the conduct called into

question.10

                     (2)      Adequate as to McKellar

            McKellar concedes the Atlas report adequately sets forth the applicable standards of care

and the manner in which the care rendered by McKellar failed to meet those standards. McKellar

confines his criticism of the Atlas report to the causation component, which states:

            In reasonable medical probability, each of the above failures were a proximate
            cause of the injuries suffered by this child.

McKellar complains that this brief statement fails to explain the nature of Alek’s injuries and does

not indicate the mechanism of injury or how the alleged negligent acts led to the allegedly

unspecified injuries.

            Cervantes maintains the causation component of the Atlas report is sufficient, inasmuch as

a single expert report need not address all liability and causation issues with respect to a health care

provider.        TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i) (West 2011). 11                             The statute

10
  Cervantes argues that the Atlas report is sufficient as to Moore because McKellar and Moore were jointly
responsible for Cervantes’ prenatal care, and they jointly failed to provide the appropriate minimal standard of care by
improperly monitoring her high-risk pregnancy. She maintains that the issue of whether or not Moore’s failure to
create a plan addressing the complications of a high-risk pregnancy was a breach of the standard of care that caused
Alek’s injuries is a question for the jury, citing Hayes v. Carroll, 314 S.W.3d 494, 507 (Tex. App.––Austin 2010, no
pet.). We disagree. In Hayes, the explanation of the applicable standard of care and the need to adhere to it provided
sufficient information to explain how breaching the standard caused the injury in question. Id. at 507. The Atlas
report, unlike the report in Hayes, fails to discuss the required elements of the standard of care, breach, and causation
with sufficient specificity to inform Moore of the conduct called into question.
11
     Section 74.351(i) provides:

            Notwithstanding any other provision of this section, a claimant may satisfy any requirement of this

                                                            16
specifically provides that “a claimant may satisfy any requirement of this section for an expert

report by serving reports of separate experts regarding . . . different issues arising from the conduct

of a physician.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i). The health care liability

statute thus does not require a single expert to address all liability and causation issues as to a

defendant, and the expert reports should be read together when determining whether they represent

a good faith effort to satisfy the statute. Packard v. Guerra, 252 S.W.3d 511, 526 (Tex.

App.—Houston [14th Dist.] 2008, pet. denied). We may therefore consider the Gatewood and

Atlas reports in the aggregate to determine whether the trial court abused its discretion when it

determined that these reports constituted an objective good faith effort to comply with the

definition of an expert report in subsection (r)(6). See TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(l) (West 2011).

         When considered in the aggregate, these reports indicate Alek suffered from

encephalopathy12 due to McKeller’s breach of the applicable standards of care. Again, the trial

court was permitted to read the causation section in the context of the entire report. Benavides,



         section for serving an expert report by serving reports of separate experts regarding different
         physicians or health care providers or regarding different issues arising from the conduct of a
         physician or health care provider, such as issues of liability and causation. Nothing in this section
         shall be construed to mean that a single expert must address all liability and causation issues with
         respect to all physicians or health care providers or with respect to both liability and causation issues
         for a physician or health care provider.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i).
12
  Even though the Atlas report indicates the child (Alek) suffered injuries, in looking at both reports in the aggregate,
it is apparent Alek’s primary injury was encephalopathy.

                                                           17
278 S.W.3d at 799. In that case, the court concluded the expert report linked the breach of the

standard of care by failing to diagnose preeclampsia and severe preeclampsia and by failing to

timely admit the mother to the hospital to the conclusion that such breaches resulted in severe

untreated preeclampsia and death from cardiorespiratory arrest, as well as the traumatic delivery

and injuries sustained by the infant. The report stated that if Benavides (the treating physician)

had not repeatedly breached the standard of care,

       [I]n all medical probability Mrs. Garcia would have survived and her infant would
       not have suffered prolonged anoxia and other injuries . . . , due to the
       cardiopulmonary arrest and resuscitation.

Id. at 801–02. When the causation section was examined in the context of the entire report, it was

sufficient, and permitted the trial court to conclude that Garcia’s claims against Benavides had

merit. Id. at 802.

       Likewise, when the causation section of the Atlas report is examined in the context of the

entire report, and is further considered together with the Gatewood report, it is apparent that the

failure to order an external fetal monitor for more than twenty-eight hours after Cervantes’

admission to the hospital on suspicion of preeclampsia, together with the failure, in this known,

high-risk pregnancy, to order a nonstress test/biophysical profile, together with McKellar’s failure

to conduct a Caesarean section delivery in a timely fashion, resulted in Alek’s encephalopathy.

Due to these failures, “Cervantes was not afforded the care needed to ensure the safety of her

unborn fetuses and are the proximate cause of the child’s problems.”



                                                18
       We conclude this report, considered together with the Gatewood report, was sufficient to

put McKellar on notice of the conduct about which Cervantes complains and further provides a

sufficient basis for the trial court to conclude Cervantes’ claim against McKellar has merit.

III.   Thirty-Day Extension

       The trial court may grant a thirty-day extension to supplement a timely-filed expert report,

even if the report is found to be deficient. The extension allows the claimant an opportunity to

cure the deficiencies. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c); Leland v. Brandal, 257

S.W.3d 204, 205 (Tex. 2008) (when elements of timely-filed report found deficient by trial or

appellate court, one thirty-day extension to cure may be granted).

       A document utterly devoid of substantive content does not qualify as an expert report and is

not eligible for an extension for an attempted cure. But a document qualifies as an expert report if

it contains a statement of opinion by an individual with expertise indicating that the claim asserted

by the plaintiff against the defendant has merit. Scoresby, 346 S.W.3d at 549. Even if such a

report is deficient in some respects, the plaintiff should be given an opportunity to cure, if it is

possible to do so. This lenient standard avoids the expense and delay of multiple interlocutory

appeals and assures a claimant a fair opportunity to demonstrate that his or her claim is not

frivolous. Id.

       In this instance, Gatewood’s report never mentions Moore and is devoid of any substantive

content concerning standard of care, breach, causal relationship, or harm as it pertains to Moore.



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It is, therefore, not subject to an extension. Whereas, the report of Atlas, while deficient, does

indicate that the claim against Moore has merit. Therefore, under the test established by the

Texas Supreme Court in Scoresby, we will remand to the trial court for its determination of

whether to grant a thirty-day extension to allow Cervantes to attempt to cure the deficiencies in the

Atlas report regarding Moore.

IV.    Conclusion

       We reverse in part and remand this case to the trial court to determine whether to grant a

thirty-day extension so that Cervantes might attempt to cure the deficiencies in the Atlas report as

to Moore. Because the Gatewood report contained no statements regarding the standard of care,

breach or causation as to Moore, there are no deficiencies to correct as to Moore; the report made

such evaluation only as to McKellar. Because the trial court acted within its discretion in refusing

to grant McKellar’s motion to dismiss, we affirm the judgment of the trial court as it relates to

McKellar.



                                              Jack Carter
                                              Justice

Date Submitted:        March 21, 2012
Date Decided:          April 18, 2012




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