                             Fourth Court of Appeals
                                    San Antonio, Texas
                                MEMORANDUM OPINION

                                       No. 04-17-00728-CV

     METHODIST HEALTHCARE SYSTEM OF SAN ANTONIO, LTD., L.L.P. d/b/a
       Northeast Methodist Hospital, Sarah I. Back, R.N., and Ismael Tres Sosa, M.D.,
                                        Appellants

                                                 v.

 Rita REMINGTON, Individually and as Independent Executor of the Estate of Alvin Charles
                    Hall, Deceased, and Karl Hall, Individually,
                                     Appellees

                     From the 57th Judicial District Court, Bexar County, Texas
                                  Trial Court No. 2016-CI-11703
                            Honorable Karen H. Pozza, Judge Presiding

Opinion by:      Marialyn Barnard, Justice

Sitting:         Sandee Bryan Marion, Chief Justice
                 Marialyn Barnard, Justice
                 Rebeca C. Martinez, Justice

Delivered and Filed: August 15, 2018

REVERSED AND REMANDED

           This is an accelerated appeal in which the trial court denied appellants, Methodist

Healthcare System of San Antonio, Ltd., L.L.P. d/b/a Northeast Methodist Hospital, Sarah I. Back,

R.N., and Ismael Tres Sosa, M.D.’s motions to dismiss health care liability claims filed by

appellees, Rita Remington, Individually and as Independent Executrix of the Estate of Alvin

Charles Hall, Deceased, and Karl Hall, Individually. On appeal, appellants contend the trial court

abused its discretion in denying the motions to dismiss because the expert report submitted by Rita
                                                                                     04-17-00728-CV


and Karl is conclusory and speculative as to the causation element of their health care liability

claims. We reverse the trial court’s orders denying the motions to dismiss and remand the cause

for further proceedings consistent with this opinion.

                                           BACKGROUND

       Alvin Charles Hall went to the emergency room at Northeast Methodist Hospital

complaining of nausea and vomiting. After the emergency room staff conducted an initial

examination, Dr. Sosa was contacted to provide medical care and treatment. The record reflects

that throughout the night and early morning hours, Alvin continued to experience distress and

discomfort. A naso-gastric tube was ultimately ordered and inserted into Alvin’s stomach to drain

gastric fluid; however, Alvin did not experience any relief. The next morning, Alvin’s cannister

of accumulated fluid was changed by Nurse Back. Approximately thirty minutes later, Alvin

“coded” and ultimately passed away without ever being examined by Dr. Sosa. It was ultimately

determined Alvin died of cardiac arrest.

       After his death, Alvin’s children, Rita and Karl, sued Northeast Medical Hospital, Nurse

Back, and Dr. Sosa for the care Alvin received at the hospital. According to Rita and Karl, Nurse

Back was negligent in her treatment of Alvin because at no point did she perform a comprehensive

nursing assessment, make an accurate nursing diagnosis, develop a plan of care, or implement

nursing care. Rita and Karl further alleged Northeast Medical Hospital was vicariously liable for

Nurse Back’s actions. With respect to Dr. Sosa, Rita and Karl asserted Dr. Sosa was negligent in

failing to timely examine Alvin and provide proper medical care and treatment.

       Rita and Karl then served an initial expert report prepared by Lige B. Rushing, Jr., M.D.

on the hospital, Nurse Back, and Dr. Sosa pursuant to section 74.351(a) of the Texas Civil Practice

and Remedies Code (“the Code”). See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a) (West

2017). Dr. Rushing’s report included his qualifications as an expert, provided a timeline of Alvin’s

                                                -2-
                                                                                       04-17-00728-CV


care at the hospital, and included sections discussing the standards of care, alleged breaches, and

causation elements of the theories of liability alleged in Rita and Karl’s petition. The hospital,

Nurse Back, and Dr. Sosa filed objections to Dr. Rushing’s report and motions to dismiss. See id.

§ 74.351(a), (b). The trial court found Dr. Rushing’s report insufficient as to the element of

causation, but granted Rita and Karl a thirty-day extension to cure the deficiency. See id.

§ 74.351(c). Thereafter, Rita and Karl served the hospital, Nurse Back, and Dr. Sosa with a

supplemental expert report by Dr. Rushing. The hospital, Nurse Back, and Dr. Sosa again filed

objections to the supplemental report and moved to dismiss, asserting the supplemental report was

still deficient with regard to the element of causation. See id. § 74.351(a). The trial court overruled

the objections and denied the motions to dismiss.          Appellants subsequently perfected this

interlocutory, accelerated appeal. See id. § 51.014(a)(9) (stating person may appeal interlocutory

order that denies all or part of motion under Section 74.351(b), except appeal may not be taken

from order granting extension).

                                              ANALYSIS

       On appeal, appellants argue the trial court erred in denying the motions to dismiss, which

challenged the sufficiency of Dr. Rushing’s expert report. Specifically, appellants contend the

expert report is insufficient because it is conclusory and speculative as to the causation element of

the asserted health care liability claims.

                                         Standard of Review

       We review a trial court’s decision to grant or deny a motion to dismiss a health care liability

lawsuit brought under Chapter 74 of the Texas Civil Practice and Remedies Code for an abuse of

discretion. Hill Country San Antonio Mgmt. Servs., Inc. v. Trejo, 424 S.W.3d 203, 208 (Tex.

App.—San Antonio 2014, pet. dism’d) (citing Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52

(Tex. 2002); Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex.

                                                 -3-
                                                                                         04-17-00728-CV


2001)); Peterson Regional Med. Ctr. v. O’Connell, 387 S.W.3d 889, 892 (Tex. App.—San Antonio

2012, pet. denied). Under this standard, we may not substitute our judgment for that of the trial

court with regard to factual matters. See Bowie, 79 S.W.3d at 52. “An abuse of discretion occurs

when the trial court acts in an arbitrary or unreasonable manner and without reference to any

guiding rules or principles.” Peterson Regional Med. Ctr., 387 S.W.3d at 892; see also Bowie, 79

S.W.3d at 52. A trial court also abuses its discretion if it fails to analyze or apply the law correctly.

Bowie, 79 S.W.3d at 52; Peterson Regional Med. Ctr., 387 S.W.3d at 892.

                                           Applicable Law

                                     Expert Report Requirements

        Section 74.351(a) of the Code requires a plaintiff to serve each physician or health care

provider against whom a health care liability claim is asserted an expert report and curriculum

vitae of each expert within a specified time. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a). The

purpose of the report is: (1) to inform the defendant of the specific conduct called into question

and (2) to provide a basis for the trial court to determine if the plaintiff’s claims have merit. Bowie,

79 S.W.3d at 52; Palacios, 46 S.W.3d at 879. The statute defines a valid expert report 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 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);

see Bowie, 79 S.W.3d at 52; Palacios, 46 S.W.3d at 879.

        If the report does not constitute a good faith effort to comply with the statutory

requirements, then the trial court must grant the motion challenging the report and dismiss the

claim with prejudice. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(1); Jernigan v. Langley, 195

S.W.3d 91, 93 (Tex. 2006); Bowie, 79 S.W.3d at 52; Palacios, 46 S.W.3d at 879. To determine

                                                  -4-
                                                                                       04-17-00728-CV


whether a report constitutes a good faith effort, courts consider only the information within the

four corners of the report and is prohibited from filling gaps by making inferences or guessing

what the expert likely meant. Rodriguez v. Walgreen Co., No. 03-14-00765-CV, 2016 WL

368772, at *2 (Tex. App.—Austin Jan. 27, 2016, no pet.) (mem. op.). The report need not

encompass all of the plaintiff’s proof, but it must include an opinion on each of the three elements

identified by the statute: standard of care, breach and causal relationship. Bowie, 79 S.W.3d at 52;

Jones v. King, 255 S.W.3d 156, 159 (Tex. App.—San Antonio 2008, pet. denied). The report

cannot merely state the expert’s conclusions about these elements, but must contain explanations

of the basis of the expert’s statements and link the expert’s conclusions to the facts. Jelinek v.

Casas, 328 S.W.3d 526, 539–40 (Tex. 2010) (citing Bowie, 79 S.W.3d at 52; Palacios, 46 S.W.3d

at 878).

                                      Causation Requirement

       The only element of Dr. Rushing’s expert report that appellants challenge on appeal is the

element of causation. According to appellants, Dr. Rushing’s opinion as to the causation element

of their claims is conclusory and speculative because none of Dr. Rushing’s statements explain

how or why Dr. Sosa or Nurse Back’s alleged breaches of the respective standards of care caused

Alvin’s death.

       Recently, the Texas Supreme Court addressed the issue of causation in section 74.351(a)

expert reports, stating: “Unquestionably, a plaintiff asserting a health care liability claim based on

negligence, who cannot prove that her injury was proximately caused by the defendant’s failure to

meet applicable standards of care, does not have a meritorious claim.”             Columbia Valley

Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 460 (Tex. 2017). As such, a plaintiff

asserting a health care liability claim must submit an expert report that sufficiently “explain[s],

based on facts set out in the report, how and why the breach caused the injury.” Van Ness v. ETMC

                                                 -5-
                                                                                    04-17-00728-CV


First Physicians, 461 S.W.3d 140, 142 (Tex. 2015); see Zamarripa, 526 S.W.3d at 460; Jelinek,

328 S.W.3d at 539. The report does not have to prove proximate cause, but the expert cannot

simply opine that the breach caused the injury. Zamarripa, 526 S.W.3d at 460; Van Ness, 461

S.W.3d at 142; Jelinek, 328 S.W.3d at 539. “Instead, the expert must go further and explain, to a

reasonable degree, how and why the breach caused the injury” by linking the defendant’s alleged

failures to the plaintiff’s injury. Jelinek, 328 S.W.3d at 539–40; see Costello v. Christus Santa

Rosa Health Care Corp., 141 S.W.3d 245, 249 (Tex. App.—San Antonio 2004, no pet.) (noting

expert report must explain causal connection between claimed omissions and injury). And

although there are no “magic words” to establish causation, “the expert report must make a good-

faith effort to explain, factually, how proximate cause is going to be proven.” Zamarripa, 526

S.W.3d at 460.

                                              Application

       Turning to Dr. Rushing’s supplemental report, the report begins by describing Alvin’s

condition when he arrived at the emergency room, stating that Alvin was vomiting. Dr. Rushing

highlights that Alvin “was morbidly obese [with] a history of hypertension, dyslipidemia, diabetes,

coronary artery disease with the placement of two stents and peripheral vascular disease.” Dr.

Rushing further opines that due to Alvin’s “morbidities,” Alvin should have been admitted to an

intensive care unit where he would have been placed on a cardiac monitor. According to Dr.

Rushing, Alvin “died from a cardiac rhythm disturbance,” such as ventricular fibrillation,

ventricular tachycardia, or cardiac arrest.

       When describing Dr. Sosa’s conduct and how it allegedly caused Alvin’s death, Dr.

Rushing’s report speaks only in terms of possibilities, failing to explain how and why Dr. Sosa’s

alleged breach of the applicable standards of care caused Alvin’s death. According to Dr. Rushing,

Dr. Sosa breached the applicable standards of care by: (1) failing to personally examine and assess

                                                 -6-
                                                                                      04-17-00728-CV


Alvin; (2) failing to ensure the correct placement and function of Alvin’s naso gastric tube; (3)

failing to confirm or eliminate abdominal distension or other abdominal abnormality; (4) failing

to monitor electrolytes in a timely manner; and (5) failing to admit Alvin to the intensive care unit.

When explaining these breaches, Dr. Rushing describes what he believed Dr. Sosa should have

done, concluding Alvin’s chances of survival would have been greater. For example, when

opining Alvin should have been admitted to the intensive care unit due to his “morbidities,” Dr.

Rushing speaks only in terms of possibilities, stating Alvin’s “chances of surviving a cardiac arrest

would have been greatly improved.” Opinions based on possibilities are insufficient. See, e.g.,

Bowie, 79 S.W.3d at 53 (holding expert’s opinion that plaintiffs “would have had the possibility

of a better outcome” did not meet standard); Hutchinson v. Montemayor, 144 S.W.3d 614, 617

(Tex. App.—San Antonio 2004, no pet.) (holding expert opinion that if arteriogram had been done,

there was “possibility” of correctable lesion such that amputation may have been avoided did not

meet standard).

       Dr. Rushing completely fails to link Dr. Sosa’s alleged failures to Alvin’s death. See

Jelinek, 328 S.W.3d at 539–40; Costello, 141 S.W.3d at 249. Rather, we are left to fill in gaps by

drawing inferences as to what Dr. Rushing might have meant. See Bowie, 79 S.W.3d at 53. For

instance, Dr. Rushing opines Alvin’s vomiting should have been documented; however, nowhere

in the report does Dr. Rushing explain how such documentation would have resulted in Dr. Sosa

taking different actions, thereby preventing Alvin’s death. See id. (highlighting causation opinion

that contains gaps in chain of causation fails to meet statute’s requirements); Tenet Hospitals, Ltd.

v. Love, 347 S.W.3d 743, 755 (Tex. App.—El Paso 2011, no pet.) (holding expert statement that

hospital’s failure to provide on-call pulmonologist caused death without explanation of how that

might have altered course of treatment rendered causation opinion insufficient); Estorque v.

Schafer, 302 S.W.3d 19, 28 (Tex. App.—Fort Worth 2009, no pet.) (holding expert’s failure to

                                                 -7-
                                                                                     04-17-00728-CV


explain how consult with urologist would have changed outcome rendered causation opinion

insufficient); Costello, 141 S.W.3d at 249 (holding expert’s claim that better monitoring of cardiac

patient would have prevented heart attack failed to explain how result would be different and was

therefore insufficient).   Later in the report, Dr. Rushing states Alvin’s persistent vomiting

suggested Alvin had an intestinal obstruction; but again, Dr. Rushing does not explain how or why

Alvin’s intestinal obstruction was linked to his cardiac rhythm disturbance — the ultimate reason

Dr. Rushing believed Alvin died — or what additional actions Dr. Sosa could have taken to prevent

the cardiac rhythmic disturbance. See Jelinek, 328 S.W.3d at 539–40; Bowie, 79 S.W.3d at 53.

       At another point in the report, Dr. Rushing states Alvin’s low magnesium levels left him

predisposed to ventricular arrhythmias, such as ventricular tachycardia or cardiac arrest. Dr.

Rushing opines that if Dr. Sosa would have ordered an immediate intravenous replacement of

magnesium, “it would have reduced [Alvin’s] risk for cardiac arrhythmia,” again, speaking in

terms of chances and leaving us to infer that Alvin’s risk for cardiac arrhythmia was linked to the

cardiac rhythm disturbance that caused his death. See Jelinek, 328 S.W.3d at 539–40; Bowie, 79

S.W.3d at 53. Finally, Dr. Rushing opines that Dr. Sosa should have examined Alvin for

abdominal distention, which he explains is one cause of cardiac arrest. According to Dr. Rushing,

if such an examination would have occurred, Dr. Sosa would have been able to reposition the naso

gastric tube, assuming it was not properly placed, and prevented abdominal distention, leaving us

to infer that the repositioning of the naso gastric tube would have prevented Alvin’s death. See

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

       Accordingly, we conclude Dr. Rushing’s report fails to clearly link how Dr. Sosa’s

omissions were a substantial factor in bringing about Alvin’s death. See Zamarripa, 526 S.W.3d

at 460; Jelinek, 328 S.W.3d at 539–40; Costello 141 S.W.3d at 249. Rather, the report speaks in

terms of chances and possibilities, leaving us to infer that absent Dr. Sosa’s omissions, Alvin’s

                                                -8-
                                                                                      04-17-00728-CV


death would not have occurred. See Zamarripa, 526 S.W.3d at 460; Bowie, 79 S.W.3d at 53.

Because the report requires inferences or guesses as to what Dr. Rushing likely meant, we hold the

report is insufficient as to the issue of causation with respect to Dr. Sosa. See Rodriguez, 2016

WL 368772, at *2.

       With respect to Nurse Back, we hold Dr. Rushing’s report is likewise conclusory and

speculative because it fails to explain how Nurse Back’s alleged negligence caused Alvin’s death

or what Nurse Back could have done to prevent Alvin’s death. In his report, Dr. Rushing explains

Nurse Back failed to properly assess Alvin’s status, recognize Alvin’s cardiac arrest in a timely

manner, call a code blue in a timely manner, and keep an appropriate clinical record. Dr. Rushing

states that when Nurse Back began her assessment of Alvin, she reported he was “snoring audibly

and had deep regular respirations,” but by the time she listened to his heart, she could not hear his

heart beating and therefore called a code blue. According to the expert report, “there was a 30

minute time interval from the beginning of her assessment until the code blue was called.”

According to Dr. Rushing, “it should have been obvious when [Alvin] stopped breathing.” Dr.

Rushing continues, stating “there was an inordinate delay time wise between [Alvin’s]

cardiorespiratory arrest and the initiation of CPR.” At no point does Dr. Rushing link these facts

and explain how Nurse Back’s omissions caused Alvin’s death. Rather, Dr. Rushing’s report falls

short, speculating that if Nurse Back had called a code blue more timely, Alvin would have a better

chance of surviving. We are then left to infer that Nurse Back should have recognized when Alvin

stopped breathing and initiated CPR, and that by initiating CPR in a more timely manner, Alvin

would not have died. See Craig v. Dearbonne, 259 S.W.3d 308, 313 (Tex. App.—Beaumont 2008,

no pet.) (holding expert report deficient because it failed to explain how different treatment would

have been effective if it had been started earlier); Jones v. King, 255 S.W.3d 156, 158, 159 (Tex.

App.—San Antonio, 2008, pet. denied) (holding expert’s opinion as to causation was conclusory

                                                -9-
                                                                                                  04-17-00728-CV


because it failed to explain whether earlier treatment would have been effective). Accordingly,

because we conclude Dr. Rushing’s opinion as to causation is conclusory with respect to Nurse

Back, we hold the expert report is insufficient.

        With regard to the hospital, Rita and Karl asserted it was liable based on respondeat

superior, i.e., the hospital was vicariously liable for the allegedly negligent actions of Dr. Sosa and

Nurse Back. They did not allege any direct negligence claims against the hospital, and Dr.

Rushing’s report does not include separate opinions with regard to any direct negligence by the

hospital. When a party’s alleged health care liability is purely vicarious, a report that inadequately

implicates the actions of that party’s agent or employees is likewise insufficient as to the party

alleged to be vicariously liable. See Gardner v. U.S. Imaging, Inc., 274 S.W.3d 669, 671–72 (Tex.

2008). Thus, because Dr. Rushing’s report is inadequate as to causation with regard to Dr. Sosa

and Nurse Back, it is likewise insufficient with regard to the claims of respondeat superior asserted

against Northeast Medical Hospital. See id.

                                                 CONCLUSION

        Having determined Dr. Rushing’s report fails to sufficiently explain the causation element

with regard to any of Rita and Karl’s health care liability claims, we reverse the trial court’s orders

denying appellants’ motions to dismiss, and we remand the cause to the trial court for the

determination of attorney’s fees under section 74.251(b)(1) of the Code, and for entry of a final

order dismissing Rita and Karl’s claims against appellants. 1

                                                         Marialyn Barnard, Justice




1
  The plain language of section 74.351 permits one thirty-day extension to cure a specified deficiency in an expert
report. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c); see also Leland v. Brandal, 257 S.W.3d 204, 207 (Tex.
2008). Because Rita and Karl were previously granted a thirty-day extension to cure deficiencies in Dr. Rushing’s
report, we have no authority to grant them another extension. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(c);
see also Leland, 257 S.W.3d at 207.

                                                      - 10 -
