AFFIRM; Opinion Filed October 25, 2013.




                                         S    In The
                                Court of Appeals
                         Fifth District of Texas at Dallas
                                      No. 05-13-00365-CV

   TENA PATTERSON, M.D. AND THE FAMILY MEDICAL CENTER AT NORTH
                     GARLAND CLINIC, Appellants
                                 V.
  GENEVA ORTIZ, INDIVIDUALLY AND FOR THE BENEFIT OF MARIO ORTIZ,
            MARISELA ORTIZ AND MARITZA ORTIZ, Appellee

                      On Appeal from the 193rd Judicial District Court
                                   Dallas County, Texas
                           Trial Court Cause No. DC-09-14738

                                          OPINION
                         Before Justices FitzGerald, Francis, and Myers
                                   Opinion by Justice Myers
       Tena Patterson, M.D. and the Family Medical Center at North Garland Clinic bring this

interlocutory appeal of the trial court’s denial of their motion to dismiss the claims for medical

malpractice brought by Geneva Ortiz, individually and for the benefit of Mario Ortiz, Marisela

Ortiz, and Maritza Ortiz. See TEX. CIV. PRAC. & REM. CODE ANN. § 51.014(a)(9) (West. Supp.

2012). Appellants contend the trial court abused its discretion by denying their motion to

dismiss the claims because the expert report served by Ortiz was deficient under section 74.351

of the Texas Civil Practice & Remedies Code. On appeal, appellants assert the expert report

failed to establish causation. We affirm the trial court’s order denying the motion to dismiss.
                                        BACKGROUND

       On March, 4, 2008, Raul Ortiz went to the Family Medical Center with an upper

respiratory complaint. Raul was seen by various employees of the Family Medical Center,

including Dr. Patterson. Dr. Patterson did not admit Raul to the hospital. The next day, Raul

was admitted to Baylor Medical Center where he died. An autopsy the following day revealed

Raul had bilateral pneumonitis and pulmonary edema.

       Geneva Ortiz, Raul’s wife, brought a wrongful death and survivorship action against

appellants. Ortiz alleged appellants were negligent for failing: (1) to diagnose Raul’s condition

as pneumonia; (2) to perform tests that would disclose Raul’s conditions; and (3) to refer Raul to

an emergency health care facility for immediate treatment. She alleged these failures were a

proximate cause of Raul’s death.

       Ortiz timely served appellants with a letter from Leigh S. Galatzan, M.D., purporting to

meet the requirements for an expert report under section 74.351(r)(6) of the Texas Civil Practice

& Remedies Code. Appellants filed objections to the report and filed a motion to dismiss.

Appellants argued the report was deficient because it failed to show Dr. Galatzan was qualified

to render an expert opinion, it failed to show how Dr. Patterson caused the alleged harm, it was

speculative and conclusory concerning causation, and it failed to set forth any negligence by the

Family Medical Center. Ortiz v. Patterson, 378 S.W.3d 667, 670–71 (Tex. App.—Dallas 2012,

no pet.). The trial court granted the motion dismiss. See id. at 672.

       On appeal, we concluded the trial court abused its discretion by determining Dr. Galatzan

was not qualified to render an opinion. See id. at 673–74. However, we agreed with the trial

court that the report was defective as to causation. See id. at 674–75. We also concluded the

report failed to present any claims of direct negligence by the Family Medical Center but that a

report was not necessary for the vicarious liability of the Family Medical Center. See id. at 675–


                                               –2–
76. We also determined the trial court erred by denying Ortiz an extension of time to supplement

the report. See id. at 677. We remanded the cause to the trial court for further proceedings. Id.

at 678.

          Back in the trial court, appellee served appellants with a supplemental expert report from

Dr. Galatzan. Appellants objected to the new report as failing to meet the requirement of

presenting opinions regarding the causal relationship between Dr. Patterson’s omissions and the

harm or injury to Raul. Appellants asked the court to dismiss the cause due to the inadequacy of

the expert report. The trial court denied the motion to dismiss.

                                        APPLICABLE LAW

          Chapter 74 of the civil practice and remedies code requires a claimant pursuing a health

care liability claim to serve on each party one or more expert reports for each physician or health

care provider against whom a health care liability claim is asserted. CIV. PRAC. § 74.351(a)

(West 2011). An “expert report” is defined as follows:

          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.

Id. § 74.351(r)(6). An expert report must provide enough information to fulfill two purposes: it

must inform the defendant of the specific conduct the plaintiff has called into question, and it

must provide a basis for the trial judge to conclude that the claims have merit. Ortiz, 378 S.W.3d

at 671; Bakhtari v. Estate of Dumas, 317 S.W.3d 486, 496 (Tex. App.—Dallas 2010, no pet.). A

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

and causation. Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 879 (Tex.

2001). The report must explain the basis for the expert’s statements to link the conclusions to the

facts. Bowie Mem. Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). We may not “fill gaps” in a


                                                  –3–
report drawing inferences or guessing what the expert meant or intended. Hollingsworth v.

Springs, 353 S.W.3d 506, 513 (Tex. App.—Dallas 2011, no pet.) (citing Wright, 79 S.W.3d at

53). However, the report need not contain all the plaintiff’s proof, and the report does not need

to meet the same requirements as evidence submitted in a summary judgment proceeding or trial.

Bakhtari, 317 S.W.3d at 496. We determine whether a causation opinion is sufficient by

considering it in the context of the entire report. Id.

                                    STANDARD OF REVIEW

       We review a trial court’s ruling on a motion to dismiss for an abuse of discretion.

Palacios, 46 S.W.3d at 875. A trial court abuses its discretion when it acts in an arbitrary or

unreasonable manner or without reference to any guiding rules or principles.            Downer v.

Aquamarine Operators, Inc., 701 S.W.2d 238, 241–42 (Tex. 1985). In other words, the trial

court abuses its discretion when its actions are arbitrary or unreasonable. Id. “The mere fact that

a trial judge may decide a matter within his discretionary authority in a different manner than an

appellate judge in a similar circumstance does not demonstrate that an abuse of discretion has

occurred.” Id. However, a trial court has no discretion in determining what the law is or in

applying the law to the facts. Walker v. Packer, 827 S.W.2d 833, 840 (Tex. 1992) (orig.

proceeding); Children’s Med. Ctr. of Dall. v. Durham, 402 S.W.3d 391, 395 (Tex. App.—Dallas

2013, no pet.).

                                             ANALYSIS

       In their sole issue on appeal, appellants contend the trial court abused its discretion by

denying their motion to dismiss because Dr. Galatzan’s supplemental report does not establish

causation.   Causation is established in medical malpractice cases through evidence of a

“reasonable medical probability” or “reasonable probability” that the injuries were caused by the

defendant’s negligence; in other words, the plaintiff must present evidence “that it is ‘more likely


                                                 –4–
than not’ that the ultimate harm or condition resulted from such negligence.” Jelinek v. Casas,

328 S.W.3d 526, 532–33 (Tex. 2010) (quoting Kramer v. Lewisville Mem. Hosp., 858 S.W.2d

397, 399–400 (Tex. 1993)).

           In the original expert report, Dr. Galatzan described Raul’s symptoms and Dr. Patterson’s

notes contradicting those symptoms. Dr. Galatzan then stated,

           A patient presenting as Mr. Ortiz did on March 3, 20008, should have had a pulse
           oximetry assessment, and a chest x-ray. 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 the 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. This Court concluded that the trial court did not abuse its discretion

by determining that the report failed to meet the requirements of an expert report concerning

causation.         We stated that the two italicized sentences “merely state a conclusion about

causation; they are equivalent to the conclusory opinion that ‘the violations of the standard of

care were a proximate cause of this patient’s injury.’” Id. at 674. Distinguishing the report

before us from those in two other cases, 1 we stated that Dr. Galatzan’s report “failed to explain

how Raul’s condition worsened from ‘very ill’ to death from pneumonia and pulmonary edema

in a short time as a result of failing to conduct certain tests and admit him to a hospital without

relying on impermissible inferences.” Id. at 675. We concluded the trial court did not abuse its

discretion by determining the expert report was deficient as to causation. Id.

           Dr. Galatzan’s supplemental report 2 added more details of the diagnostic tests Dr.

Patterson should have run. The report stated a patient reporting the symptoms and medical


     1
     See Adeyemi v. Guerrero, 329 S.W.3d 241, 245 (Tex. App.—Dallas 2010, no pet.); Mosely v. Mundine, 249 S.W.3d 775, 780 (Tex.
App.—Dallas 2008, no pet.).
     2
        Hereafter, references to Dr. Galatzan’s “report” are to the supplemental report dated January 4, 2013. The portions of the report setting
forth the standard of care, breach of the standard, and causation were as follows:



                                                                     –5–
I have reviewed the medical records from Dr. Tena Patterson and the Family Medical Center at Garland concerning the
diagnosis and treatment of Mr. Raul Ortiz on the date of service March 4, 2008, as well as the medical records from Baylor
Medical Center at Garland for the date of service March 5, 2008. In addition, I reviewed the autopsy report of Mr. Raul
Ortiz, dated March 6, 2008.

The standard of care for a patient presenting with Mr. Ortiz’s symptoms, vital signs, and, his history of diabetes would
dictate that he receive the following care and treatment:

     1.    A thorough evaluation of the patient’s complaints and vital signs, including an assessment of pulse oximetry.

     2.    A thorough physical examination.

     3.    A chest X-ray.

     4.    Complete lab work, including a metabolic profile and blood cultures.

     5.    Hospital admission.

In my opinion, the standard of care for a practicing physician was not met on March 4, 2008, when Mr. Ortiz presented for
evaluation and treatment. Considering that Mr. Ortiz described symptoms of cough, congestion, and fever for one week,
that he had been vomiting and presented with a heart rate of 145 beats per minute, and that he was a diabetic, the
examining physician should have recognized that the patient was very ill. This clinical presentation contradicts the
statement in the record that the patient was “in no acute distress.” In fact, the normal exam that was documented is not at
all consistent with the patient’s complaints, his vital signs, and especially with the autopsy findings of bilateral pneumonitis
and pulmonary edema.

Given his symptoms, vital signs, and the history of diabetes, Mr. Ortiz should have promptly received the following care
and treatment:

     1.    A thorough evaluation of the patient’s complaints and vital signs, including an assessment of pulse oximetry.
           This evaluation likely would have revealed that patient was septic and unstable. Based on his post-mortem
           findings, the pulse oximetry would have shown that the patient was hypoxic.

     2.    A thorough physical examination would have likely revealed decreased and abnormal breath sounds, suggesting
           pneumonia, and requiring additional evaluation and consideration for admission.

     3.    A chest X-ray would likely have documented that Mr. Ortiz had pneumonia.

     4.    Complete lab work, including a metabolic profile and blood cultures. These tests would have alerted the
           physician of any abnormalities in his metabolic status, such as electrolyte abnormalities, acidosis, dehydration,
           and hyperglycemia.

     5.    Mr. Ortiz should have been promptly admitted to the hospital because, by all indicators, he was very ill. Based
           on his symptoms, his vital signs, his history of diabetes, his subsequent rapid demise, and the findings at
           autopsy, early, aggressive treatment, more likely than not, would have saved his life.

If the treating physician had properly assessed Mr. Ortiz, she would have noted that his tachycardia was out of proportion
to his low grade fever, suggesting that the patient was septic and/or dehydrated. In addition, a patient with a history of
diabetes and cough, fever, vomiting, and tachycardia should prompt a prudent physician to more thoroughly evaluate that
patient with laboratory tests, a chest X-ray, IV fluid resuscitation, and admission to a hospital. Mr. Ortiz’s autopsy
findings, just forty eight hours after his office visit, showed that he had extensive pneumonitis and pulmonary edema. The
abnormal vital signs, the patient’s vomiting, the notes stating that he was “in no acute distress,” that his “respiratory rate
was unlabored,” and that his lungs were “clear to auscultation,” are inconsistent with a thorough and accurate physical
examination and assessment of the patient. The results were an inaccurate diagnosis, and the patient’s death.

In my opinion, the proximate cause of death in this case was due to the treating physician’s failure to follow the standard of
care in that:

     1.    There was no thorough evaluation of the patient’s complaints and vital signs, including an assessment of pulse
           oximetry.

     2.    There was no thorough physical examination.

     3.    There was a failure to perform a chest X-ray.


                                                             –6–
history of Raul should have been evaluated with a thorough evaluation of his complaints and

vital signs, including his pulse oximetry, which would have shown he was a hypoxic; a thorough

physical evaluation, which would have shown decreased and abnormal breath sounds suggesting

pneumonia; a chest x-ray, which would have shown whether he had pneumonia, and the autopsy

results showed that in fact Raul had pneumonia; complete lab work, which would have alerted

Dr. Patterson to any abnormalities in his metabolic status. Dr. Patterson should then have

admitted Raul to the hospital where “early, aggressive treatment, more likely than not, would

have saved his life.” The report stated that Dr. Patterson’s failure to proceed in this manner

resulted in “an inaccurate diagnosis, and the patient’s death.” The report stated that “[t]he

opinion with respect to proximate cause is based on a reasonable degree of medical probability.”

          Appellants assert that Dr. Galatzan’s report fails to meet the requirement we set forth in

Hollingsworth that an expert’s opinions adequately link the conduct identified as necessary with

the claimant’s injuries. See Hollingsworth v. Springs, 353 S.W.3d 506, 520–21 (Tex. App.—

Dallas 2011, no pet.) (“The question is whether Groudine’s opinions have adequately linked the

conduct he has identified as necessary—properly checking the workings of the anesthesia

circuit—with Spring’s injuries.”).                      Appellants argue that Galatzan’s report “is deficient on

causation because absent from the report is any discussion or explanation about how and why the

failure to conduct certain tests, certain examinations and admit Decedent to a hospital caused his

death.”      We disagree.             The report stated that Dr. Patterson’s failure to perform the tests,

               4.    There was a failure to perform complete lab work, including a metabolic profile and blood cultures.

               5.    There was a failure to refer Mr. Ortiz for a hospital admission.

          The failure to do a thorough evaluation of the patient, order the appropriate tests as indicated above, the failure to make the
          correct diagnosis of pneumonia, pulmonary edema, and respiratory failure, and, the failure to recognize the clinical
          severity, risks, and potential complications involved in not referring Mr. Ortiz for hospital admission were all a proximate
          cause of his death. If Mr. Ortiz had been properly evaluated and treated in accordance with the standard of care as outlined
          above, it is more likely than not, that Mr. Ortiz would have survived this illness. This opinion with respect to proximate
          cause is based on a reasonable degree of medical probability.




                                                                      –7–
examinations, and assessments resulted in “an inaccurate diagnosis, and the patient’s death,”

which the report (relying on the autopsy report) showed was from pneumonia. The report stated

that if Dr. Patterson had performed the tests, diagnosed Raul as suffering from pneumonia, and

determined Raul required hospitalization, Raul could have then received “early, aggressive

treatment [that], more likely than not, would have saved his life.” These statements explain why

Dr. Patterson’s conduct caused Raul’s death.

       In Hollingsworth, the patient went to a hospital for minor surgery, removal of a cyst on

his arm. Hollingsworth, 353 S.W.3d at 511. When the anesthesiologist was trying to anesthetize

the patient, the patient had difficulty breathing. Id. at 512. While the anesthesiologist attempted

to remedy the patient’s breathing problem, the patient suffered a cardiopulmonary arrest and was

resuscitated. However, the patient suffered a hypoxic brain injury, was nonresponsive to verbal

commands, and later died. Id. at 511, 518. The patient’s family sued the anesthesia technicians,

amongst others. The anesthesia equipment had alarms that should have, but failed, to go off

during the efforts to secure an airway for the patient. Id. at 520. The expert report on the

anesthesia technicians stated they had a duty to check the equipment to make sure the alarms

were not turned off or disabled. Id. The report stated that the failure to check the anesthesia

equipment was beneath the standard of care and “compromised the attempted failed induction

and the resuscitation effort.” Id. We stated that the report did not explain how the failure of the

alarms was linked to the patient’s brain injury. Id. at 521. We could not infer how working

alarms would have led to a better outcome for the patient. Id. Because the report did not explain

these causal links, we concluded the report was conclusory on causation. Id.

       In the case before us, however, Dr. Galatzan’s report showed that performing the tests

and examinations would have led to the diagnosis of pneumonia and Raul’s admission to the

hospital, where he would have received “early, aggressive treatment [that], more likely than not,

                                               –8–
would have saved his life.”        The report in Hollingsworth contained no such statement

demonstrating how working alarms would have prevented the patient’s brain injury.                We

conclude Hollingsworth is distinguishable.

       Appellants also assert Dr. Galatzan’s report is deficient because “it fails to discuss what

treatment should have been provided to Decedent and fails to discuss and explain how and why

some specific treatment would have prevented Decedent’s death.” The “treatment” the report

states Dr. Patterson should have provided was to admit Raul to a hospital. The report explains

how the action of admitting Raul to the hospital would have prevented his death by stating that at

the hospital, Raul would have received “early, aggressive treatment [that], more likely than not,

would have saved his life.”

       In support of their argument, appellants assert that six cases show that Dr. Galatzan’s

report was insufficient for failing to discuss what treatment Dr. Patterson should have provided.

These cases illustrate that mere observation, monitoring, testing, and evaluating, by themselves,

generally do not constitute the cause of a patient’s injury. Those activities do not alter the

outcome because they simply constitute watching and data gathering. They may provide the

information the doctors and health care providers need to take some action to alter the outcome.

If the action based on the observation, monitoring, testing, and evaluating would have avoided

the patient’s injury, then there is a causal relationship between the failure to observe, monitor,

test, and evaluate and the patient’s injury. However, if that action would not have avoided the

patient’s injury, then there is no causal relationship between the failure to observe, monitor, test,

and evaluate and the injury. Therefore, if the report states the breach of the standard of care by

the physician or health care provider is the failure to monitor, observe, test, or evaluate, the

report must explain what action the defendant physician or health care provider would have

taken in response to the data obtained from the monitoring, monitoring, testing, and evaluating

                                                –9–
that should have been performed, including passing that data to another physician or health care

provider who could take action that would have altered the patient’s outcome. The report must

explain why the action the defendant should have taken, either by itself or in coordination with

the actions of others, would have prevented the patient’s injury.

       In Ngo v. Lewis, No. 09-10-00140-CV, 2010 WL 3518225 (Tex. App.—Beaumont Sept.

9, 2010, no pet.) (mem. op.), a woman who was positive for Vaginal Group B Streptococcus

(GBS) was admitted to the hospital for delivery of her child. Id. at *1. The hospital was

incorrectly informed by her obstetrician that she was negative for GBS; in fact, she was positive

for GBS. During delivery, her child was exposed to the infection and became ill. The child

came under the care of the first defendant, Dr. Ngo, at 7:50 p.m., one and a half hours after

delivery. At 8:15 p.m., Dr. Ngo consulted with the second defendant, a neonatologist, Dr.

Annavajjhala. At 9:00 p.m., the child was transferred to the neonatal intensive care unit. Id. At

that time, the child was in distress, and the child received its first dose of spectrum antibiotics at

9:37 p.m. Id. at *2. At 3:20 a.m., Dr. Annavajjhala ordered the patient moved to a hospital in

Houston. The child died six days later. Id. The expert report stated Dr. Ngo breached the

standard of care by failing to obtain blood work and order antibiotics in a timely fashion, failed

to order and evaluate blood gases in a timely fashion, and failed to consult a neonatologist in a

timely fashion. Id. at *3. The report stated that these actions and inactions of Dr. Ngo “more

likely than not proximately caused [the child’s] irreversible neurological damage and subsequent

death.” Id. The court of appeals concluded the report was deficient because it “fails to explain

how Dr. Ngo’s alleged delays were substantial factors in bringing about Ian’s death.” Id. at *4.

The report contained “analytical gaps with respect to the connecting the delays identified by the

report to having caused [the child’s] death.” Id. at *3. Concerning Dr. Annavajjhala, the report

stated she failed to act in a timely fashion to provide the child respiratory support, evaluate the

                                                –10–
child’s blood gases, and treat his hypertension. Id. at *4. On causation, the report stated the

doctor’s deviations from the standard of care “more likely than not proximately caused [the

child’s] irreversible neurological damage and subsequent death. Id. The court of appeals states

the report did not explain how the acts and omissions identified in the report affected the child’s

chance of survival. The report “fail[ed] to explain what additional treatment should have been

offered had the various procedures he describes been performed timely. . . . How delays in

providing [the child] adequate ventilation support, delays in obtaining blood gases or delays in

treating [the child’s] hypertension caused [the child’s] death is never explained the report.” Id.

The mere statement that the acts and omissions caused the child’s death was an insufficient

explanation of causation to comply with the requirements of section 74.351. Id.

       In Lewis v. Funderburk, No. 10-05-00197-CV, 2008 WL 5473043 (Tex. App.—Waco

Dec. 31, 2008, pet. denied) (mem. op.), the patient sought treatment for a fractured wrist. Id. at

*1. The fracture did not heal properly and required surgery. Id. at * 7. The doctor was sued for

malpractice. Id. at *1. The expert report stated the doctor deviated from the standard of care by

not taking x-rays at regular intervals to confirm proper healing and that “loss of position has not

occurred.” Id. at *6. The report concluded that “[t]hese deviations and breaches from the

standard care [sic] were the proximate causes of the malunited left distal radius fracture.” Id.

The court of appeals stated the expert “explained how [the doctor] failed to detect a

misalignment, which inferentially preceded the malunion, but he did not explain what [the

doctor] could or should have done about it upon making this discovery.” The court concluded

the report failed to provide a fair summary of the causal relationship between the doctor’s failure

to monitor the fracture as it healed and the malunited fracture. Id. at *8.

       In Craig v. Dearbonne, 259 S.W.3d 308 (Tex. App.—Beaumont 2008, no pet.), the

patient was admitted to the hospital with pneumonia on January 25, 2005. Id. at 310. The

                                                –11–
defendant doctor saw the patient on January 25, 27, and 28. Id. The patient was transferred to

another hospital on January 29 and died three days later. Id. at 311. The expert report stated the

doctor should have ordered daily x-rays to assess the patient’s pneumonia and that the doctor

breached the standard of care by not seeing the patient on January 26 because the standard of

care required daily examination and assessment. Id. at 312. The report stated that if the doctor

had properly examined and assessed the patient daily, then the worsening pneumonia would have

been recognized, and the patient “could have been effectively treated on 01/26/05, 01/27/05 and

01/28/05.” Id. The report also stated, “If proper assessment and treatment had been performed

by [the doctor] on 01/26, 01/27, or 01/28 then more likely than not, [the patient] could have been

successfully treated and would not have died when she did.” Id. The court of appeals concluded

these statements in the report were conclusory because they “do not explain precisely how [the

doctor’s] negligence proximately caused [the patient’s] death. . . . In addition, the report fails to

explain what treatment would have been effective, but was not provided or whether the treatment

Craig provided would have been effective if it had been started earlier.” Id. at 313 (citation

omitted).

       In Gray v. CHCA Bayshore, L.P., 189 S.W.3d 855 (Tex. App.—Houston [1st Dist.] 2006,

no pet.), the patient underwent sinus surgery at the hospital for chronic sinusitis and nasal septal

deformity. Id. at 856. When she awoke, she had pain in her left knee, later determined to be a

dislocated patella. Id. She sued the anesthesiologist and the hospital for the injury to her knee,

alleging the injury was caused by flexing of her leg during surgery and that the injury could have

been prevented by the anesthesiologist and nursing staff monitoring her extremities during the

surgery. Id. at 856–57. The trial court determined the expert report was deficient and dismissed

the patient’s suit. Id. at 858. In the report, the expert stated the doctor and nurses failed to

monitor the positioning of the patient’s left knee and monitor her extremities during surgery to

                                               –12–
prevent injury during surgery and post operatively. Id. at 857. On causation, the report stated

that if the anesthesiologist and nursing staff “had monitored and detected the flexing of [the

patient’s] arms and legs during general anesthesia in a timely fashion, then in reasonable medical

probability,” the injury would not have occurred. Id. The report also stated, “The failure to

monitor and detect the malpositioned left knee resulted in a dislocated left patella, severe pain

and suffering, and subsequent medical treatment.” Id. at 858. The court of appeals stated the

report did not set forth a breach of the standard of care because the report did not state what the

defendants should have done differently other than monitoring the patient. Id. at 859. Likewise,

the court of appeals stated the report did not satisfy the statutory elements of causation because it

did not state with any specificity how the failure to monitor caused the patient’s injury. Id. at

860. The court of appeals concluded the trial court did not abuse its discretion by dismissing the

patient’s claims. Id.

       In Costello v. Christus Santa Rosa Health Care Corp., 141 S.W.3d 245 (Tex. App.—San

Antonio 2004, no pet.), the patient went to the hospital emergency room complaining of chest

pain. Id. at 247. After being “triaged” by the nursing staff, the patient was instructed to wait in

the waiting room. Forty minutes later, the patient suffered a cardiac arrest and could not be

resuscitated. Id. The expert report stated patients in that situation “require immediate triage to

an examination room, placement on a telemetry monitor, and a ‘stat’ EKG followed by prompt

physician evaluation. . . . If this patient would have been appropriately triaged and evaluated,

then in all reasonable medical probability she would have survived.” Id. The trial court granted

the hospital’s motion to dismiss. Id. The court of appeals concluded the report was deficient as

to causation because it did not explain the causal relationship between the hospital’s omissions—

failure to triage and evaluate—and the patient’s death. Id. at 249. The court went on to state that

the report did not explain what medical information triage and evaluation would have revealed.

                                               –13–
The report also failed to state what would have been done if the omissions had not occurred,

what treatment would have been available, or that some “unknown treatment could have or

would have been effective.” Id. The court of appeals affirmed the trial court’s dismissal of the

case.

        In Gonzales v. Graves, No. 07-03-00268-CV, 2004 WL 510898 (Tex. App.—Amarillo

2004, no pet.) (mem. op.), the patient went to the emergency room complaining of back and

abdominal pain, slight wheezing, and shortness of breath. Id. at *3. The emergency room

physician prescribed medication and referred the patient to a urologist, Dr. Graves, because of

tumors in the patient’s scrotal sac. Dr. Graves performed an “intravenous pyelogram, which was

essentially unremarkable.” Id. Within fifty-two hours of first going to the emergency room, the

patient tried to return there; however, he suffered cardiac arrest in the car and could not be

resuscitated. The cause of death was “bronchopneumonia with left empyema.” The patient’s

surviving spouse sued Dr. Graves for failing to diagnose and treat the patient properly. Id. The

expert report stated Dr. Graves did not take the patient’s history and conduct a thorough physical

examination of him. Id. at *3, *4. The trial court dismissed the claim because the expert report

was deficient. The court of appeals agreed, and stated that the report failed to state “what, if

anything, should have been done to address [the patient’s] complaints.” Id. at *4. The court also

concluded the discussion of causation was inadequate: “It is not enough to merely state, as [the

expert] did here, that the failure to diagnose [the patient’s] pneumonia was the proximate cause

of his death.” Id. at *5.

        These cases are distinguishable from the case before us because the reports in those cases

stated the failure to examine, monitor, test, and evaluate the patients’ condition was the cause of

the patients’ injuries. Dr. Galatzan’s report goes beyond merely stating the failure to examine,

monitor, test, and evaluate caused Raul’s death. The report specified the action Dr. Patterson

                                              –14–
should have taken in response to the results of the examination and testing:                                                         prompt

hospitalization of Raul where he could receive early, aggressive treatment for his pneumonia.

The report states that hospitalization with the early, aggressive treatment would have saved

Raul’s life. To the extent appellants may be arguing that the report was deficient for not

specifying the precise treatment Raul would have received in the hospital, 3 appellants cite no

authority requiring the report to specify the actions that should or would have been taken by

anyone other than the defendant physicians and health care providers.

           In this case, the trial court acted within its broad discretion when it concluded the report

adequately identified the omissions of Dr. Patterson that breached the standard of conduct,

specified the actions Dr. Patterson should have taken, and explained “the causal relationship

between that failure and the injury, harm, or damages claimed.” See CIV. PRAC. § 74.351(r)(6).

Unlike the original report, the explanation of causation in Dr. Galatzan’s supplemental report is

not the equivalent of stating, “the violations of the standard of care were a proximate cause of

this patient’s injury.” See Ortiz, 378 S.W.3d at 674. Although the report’s explanation of

causation could have been more detailed, we cannot conclude the trial court’s denial of

appellants’ motion to dismiss was arbitrary or unreasonable or without reference to any guiding

rules or principals. We conclude the trial court did not err by denying appellants’ motion to

dismiss.

           We overrule appellants’ sole issue on appeal.




     3
       Appellants do not make this argument expressly. Except for the “Statement of Facts” section of their brief, appellants do not mention the
portion of Dr. Galatzan’s report stating that Raul’s admission to a hospital where he would receive “early, aggressive treatment” would have
saved his life.



                                                                    –15–
                                 CONCLUSION

We affirm the trial court’s order denying appellant’s motion to dismiss.




                                           /Lana Myers/
                                           LANA MYERS
                                           JUSTICE




                                       –16–
                                        S
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                       JUDGMENT

Dr. Tena Patterson and the Family Medical            On Appeal from the 193rd Judicial District
Center, Appellants                                   Court, Dallas County, Texas
                                                     Trial Court Cause No. DC-09-14738.
No. 05-13-00365-CV         V.                        Opinion delivered by Justice Myers.
                                                     Justices FitzGerald and Francis participating.
Geneva Ortiz, Individually and for the
Benefit of Mario Ortiz, Marisela Ortiz, and
Maritza Ortiz, Appellee

       In accordance with this Court’s opinion of this date, the order of the trial court is
AFFIRMED.
       It is ORDERED that appellee Geneva Ortiz, individually and for the benefit of Mario
Ortiz, Marisela Ortiz, and Maritza Ortiz, recover her costs of this appeal from appellants Dr.
Tena Patterson and the Family Medical Center.


Judgment entered this 25th day of October, 2013.




                                                   /Lana Myers/
                                                   LANA MYERS
                                                   JUSTICE




                                              –17–
