                                                                               ACCEPTED
                                                                           12-15-00189-CV
                                                              TWELFTH COURT OF APPEALS
                                                                            TYLER, TEXAS
                                                                      9/16/2015 5:22:49 PM
                                                                                 Pam Estes
                                                                                    CLERK

                 CAUSE NO. 12-15-00189-CV        ORAL ARGUMENT
                                                     REQUESTED
                                                  FILED IN
                                           12th COURT OF APPEALS
                         IN THE                 TYLER, TEXAS
               COURT OF APPEALS FOR THE 9/16/2015 5:22:49 PM
  TWELFTH   DISTRICT OF TEXAS SITTING IN TYLER, TEXAS
                                                  PAM ESTES
                                                    Clerk



 GARRISON NURSING HOME AND REHABILITATION CENTER
         AND GARRISON NURSING HOME, INC.,

                                                      APPELLANTS,
                              VS.

                    LEGATHA DEMINGS,

                                                           APPELLEE.


        On Appeal from the 145th Judicial District Court
         of Nacogdoches, Nacogdoches County, Texas


APPELLANTS GARRISON NURSING HOME AND REHABILITATION
     CENTERAND GARRISON NURSING HOME, INC. BRIEF


                             KENT, ANDERSON, BUSH, FROST &
                             METCALF, P.C.
                             DAVID W. FROST
                             1121 E.S.E. LOOP 323, SUITE 200
                             TYLER, TEXAS 75701
                             (903) 579-7507
                             (903) 581-3701 (FAX)

                             ATTORNEYS FOR APPELLANTS
                             GARRISON NURSING HOME AND
                             REHABILITATION CENTER AND
                             GARRISON NURSING HOME, INC.
                  IDENTITY OF PARTIES AND COUNSEL

      The following is a complete list of all parties to the trial court’s judgment or

order appealed from and the names and addresses of all trial and appellate counsel:

      Plaintiffs/Appellee:
             Legatha Demings
             Trial Counsel and Appellate Counsel:
                    W. Stephen Shires
                    Law Office of Stephen Shires, PLLC
                    123 San Augustine Street
                    Center, Texas 75935
                    (936) 598-3052
                    (936) 598-3031 facsimile
                    stephen@shireslawfirm.com

      Defendant/Appellant:
           Garrison Nursing Home and Rehabilitation Center and Garrison Nursing
           Home, Inc.
           Trial Counsel and Appellate Counsel:
                  David W. Frost
                  Kent, Anderson, Bush, Frost & Metcalf, P.C.
                  1121 E.S.E. Loop 323, Suite 200
                  Tyler, Texas 75701
                  (903) 579-7500
                  (903) 581-3701 Facsimile
                  dfrost@tyler.net




                                         - ii -
                                      TABLE OF CONTENTS


IDENTITY OF PARTIES AND COUNSEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

INDEX OF AUTHORITIES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

STATEMENT OF THE CASE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

ISSUE PRESENTED.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

STATEMENT OF FACTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

SUMMARY OF ARGUMENT.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ISSUE PRESENTED (RESTATED). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ARGUMENT AND AUTHORITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

I.      Standard of Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

II.     In an Alleged Medical Malpractice Case, the Plaintiff Must Provide
        an Expert Report to the Defendant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

III.    Dr. Miller is not qualified to address causal relationship between
        alleged failure to administer Xarelto and an alleged stroke.. . . . . . . . . . 8

        A.      Qualification to express causation opinions.. . . . . . . . . . . . . . . . . . 8

        B.      The causal relationship between the alleged stroke and the alleged
                failure to administer Xarelto is the very matter at issue. . . . . . . . 9

        C.      Appellee fails to establish that Dr. Miller is qualified to address
                causation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

                1.       Dr. Miller provides no information regarding
                         Xeralto and his experience with Xeralto. . . . . . . . . . . . . . . 10

                                                       - iii -
IV.      Keith E. Miller M.D.’s Report is conclusory regarding causation. . . . 13

         A.       An expert report that is conclusory fails to satisfy
                  the statutory requirements.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

         B.       Dr. Miller’s causation opinions are impermissibly conclusory. . 14

                  1.       Opinions that alleged violations of administrative rules
                           caused stroke are conclusory.. . . . . . . . . . . . . . . . . . . . . . . . 14

                  2.       Opinion that Alleged failure to administer Xarelto caused
                           stroke is conclusory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

                           a.        Dr. Miller provides no more than a “bare assertion”
                                     of causation, and he fails to link his
                                     conclusions to the facts. . . . . . . . . . . . . . . . . . . . . . . . 18

                           b.        The court cannot infer that, because Xarelto was
                                     not given, Ms. Demings suffered a stroke. . . . . . . . . 20

V.       Res Ipsa Loquitur does not excuse production of expert report. . . . . . . 22

PRAYER.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

CERTIFICATE OF COMPLIANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

CERTIFICATE OF SERVICE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

APPENDICES

Order Denying Defendant’s Objections to Plaintiff’s Supplemental
Expert Report and Motion to Dismiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A

Expert Report of Keith E. Miller, M.D.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B

Tex. Civ. Prac. & Rem. Code Ann. §74.351. . . . . . . . . . . . . . . . . . . . . . . . . . . . C

                                                          - iv -
                                  INDEX OF AUTHORITIES

CASES                                                                                               PAGE

Am. Transitional Care Ctrs. of Tex. v. Palacios,
     46 S.W.3d 873 (Tex.2001). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 7, 13, 14

Bogar v. Esparza,
     257 S.W.3d 354 (Tex. App.–Austin 2008, no pet.). . . . . . . . . . . . . . . 22, 23

Bowie Mem'l Hosp. v. Wright,
     79 S.W.3d 48 (Tex. 2002) (per curiam). . . . . . . . . . . . . . . . . . . . . . . . . . 6, 7

Broders v. Heise,
     924 S.W.2d 148 (Tex. 1996). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8, 9

Castillo v. August,
       248 S.W.3d 874 (Tex. App.–El Paso 2008, no pet.). . . . . . . . . . . . . . . . . . 8

Collini v. Pustejovsky,
      280 S.W.3d 456 (Tex. App.–Fort Worth 2009, no pet.). . . . . 8, 11, 13, 20

Conboy v. Lindale Health Care, LLC,
     2013 WL 4680516 (Tex. App.–Tyler August 29, 2013, no pet.). . . 14, 20

Downer v. Aquamarine Operators, Inc.,
    701 S.W.2d 238 (Tex. 1985). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Earle v. Ratliff,
      998 S.W.2d 882 (Tex.1999). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 19

Flores v. Fourth Court of Appeals,
      777 S.W.2d 38 (Tex.1989). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Garcia v. Marichalar,
     198 S.W.3d 250 (Tex. App.–San Antonio 2006, no pet.). . . . . . . . . . 22, 23



                                                    -v-
Gingrich v. Scarborough,
     2010 WL 1711067 (Tex. App.–Beaumont April 29, 2010, no pet.).. . . . 21

HEB Grocery Co. v. Galloway,
    2014 WL 2152128 (Tex. App.–Beaumont May 22, 2014, no pet.)1.1, 12, 13


Ibrahim v. Gilbride, 2010 WL 5064430
      (Tex. App.–Houston [14th Dist.] December 9, 2010, no pet.).. . . . . . 19, 20

Jelinek v. Casas,
      328 S.W.3d 526 (Tex. 2010). . . . . . . . . . . . . . . . . . . . . . . . . . . 16, 17, 18, 2

Shaw v. BMW Healthcare, Inc.,
     100 S.W.3d 8 (Tex. App.-Tyler 2002, pet. denied). . . . . . . . . . . . . . . . . . . 5

Sherman v. HealthSouth Specialty Hosp. Inc.,
     397 S.W.3d 869 (Tex. App.–Dallas 2013, pet. denied). . . . . . . . . . . . 22, 23

Thomas v. Alford,
    230 S.W.3d 83 (Tex. App.–Houston [14th Dist.] 2008, no pet.). . . . . . . . . 8

STATUTES                                                                                   PAGE

TEX. CIV. PRAC. & REM. CODE §74.201.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

TEX. CIV. PRAC. & REM. CODE §74.351.. . . . . . . . . . . . . . . . . . . . . . . . . 22, 23, 24

TEX. CIV. PRAC. & REM. CODE §74.351 (a). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

TEX. CIV. PRAC. & REM. CODE §74.351 (b).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

TEX. CIV. PRAC. & REM. CODE §74.351 (r)(5)(C).. . . . . . . . . . . . . . . . . . . . . . . . 8

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




                                                - vi -
                         STATEMENT OF THE CASE

      On August 21, 2014, Appellee filed an Original Petition alleging a health care

liability claim against Garrison Nursing Home and Rehabilitation Center and

Garrison Nursing Home, Inc. (collectively “Garrison”). (CR 5 ). On September 12,

2014, Garrison filed its Original Answer. (CR 19). On January 10, 2015, Appellee

filed an expert report and curriculum vitae from Pauline Kaper, R.N., (CR 25). On

January 29, 2015, Garrison filed its Objections to Expert Report and Motion to

Dismiss. (CR 33). On April 7, 2015, the trial court entered an Order Denying

Defendant’s Motion to Dismiss and Granting Plaintiff a 30 Day Extension to Cure a

Deficient Expert Report having found the report of Pauline Kaper, R.N. deficient.

(CR 49). After the Appellee produced a Supplemental Expert report from Keith E.

Miller, M.D. on May 5, 2015 (CR 50), Garrison filed its Objections to Plaintiff’s

Supplemental Expert Report and Motion to Dismiss on May 22, 2015. (CR 78).

Appellee filed the Response to Garrison’s motion on June 19, 2015. (CR 115). On

June 29, 2015, the trial court issued its Order Denying Defendant’s Objections to

Plaintiff’s Supplemental Expert Report and Second Motion to Dismiss. (CR 164).

On July 17, 2015, Garrison filed a notice of interlocutory appeal (CR 165).




                                       - vii -
                             ISSUE PRESENTED

(1)   Whether the trial court abused its discretion in overruling Garrison’s
      objections to Appellee’s supplement expert report from Dr. Keith E.
      Miller for the failure to show he was qualified to provide opinions
      regarding the element of causation and denying Garrison’s motion to
      dismiss pursuant to section 74.351 of the Texas Civil Practice and
      Remedies Code.

(2)   Whether the trial court abused it’s discretion in overruling Garrison’s
      objections to Appellee’s supplemental expert report from Dr. Keith E.
      Miller for failure to adequately address the element of causation and
      denying its motion to dismiss those claims pursuant to section 74.351 of the
      Texas Civil Practice and Remedies Code.




                                      - viii -
                           CAUSE NO. 12-15-00189-CV             ORAL ARGUMENT
                                                                    REQUESTED


                           IN THE
                 COURT OF APPEALS FOR THE
      TWELFTH DISTRICT OF TEXAS SITTING IN TYLER, TEXAS



    GARRISON NURSING HOME AND REHABILITATION CENTER
            AND GARRISON NURSING HOME, INC.,

                                                                       APPELLANT,
                                          VS.

                              LEGATHA DEMINGS,

                                                                         APPELLEE.



                On Appeal from the 145th Judicial District Court
                 of Nacogdoches, Nacogdoches County, Texas


 APPELLANTS GARRISON NURSING HOME AND REHABILITATION
      CENTERAND GARRISON NURSING HOME, INC. BRIEF


      COMES         NOW,        GARRISON            NURSING          HOME        AND

REHABILITATION CENTER AND GARRISON NURSING HOME, INC.,

Appellants in the above-entitled and numbered cause and files the following

Appellants’ brief asking the court of appeals to reverse the trial court’s ruling on its

                                          -1-
motion to dismiss and in support thereof would respectfully show the court the

following:

                               STATEMENT OF FACTS

       This suit involves a health care liability claim related to alleged care and

treatment rendered to Legatha Demings by Appellants. The care and treatment at

issue occurred between May 25, 2012 and June 8, 2012. (CR 55) On June 8, 2012,

Appellee alleges that Ms. Demings suffered a cerebral vascular accident or stroke

(collectively “stroke”). (CR 55)

       Legatha Demings was born April 28, 1945.1 Ms. Demings was diagnosed with

the condition atrial fibrillation in the Fall of 2010, for which Ms. Demings began

taking medication. (CR 64; RR page 5, lines 9-14) One of the risks related to atrial

fibrillation is stroke. (RR page 5, lines 13-14).

       On May 22, 2012, Ms. Demings suffered a cerebral vascular accident (“CVA”)

for which she was hospitalized initially in Carthage, Texas, and subsequently at

Nacogdoches Medical Center in Nacogdoches, Texas. (CR 55) On May 25, 2012,

Ms. Demings was discharged from Nacogdoches Medical Center and transferred to

Garrison. (CR 55) One of the discharge medications ordered by Ms. Demings’

       1
         It is Appellant’s understanding that Ms. Demings passed away during the summer of 2015
during the pendency of this lawsuit.


                                             -2-
physician was Xarelto, a blood thinning medication. (CR 63)

      On June 8, 2012, Ms. Demings was transferred from Garrison back to

Nacogdoches Medical Center for evaluation after exhibiting signs of confusion,

combativeness and inability to communicate. (CR 55) Appellee alleges that while at

Nacogdoches Medical Center Ms. Demings was diagnosed with a stroke. (CR 55)

Appellee alleges that Ms. Demings suffered the stroke due to Garrison’s alleged

failure to administer Xarelto to Ms. Demings. (CR 115) Ms. Demings was

hospitalized in Nacogdoches medical Center until June 20, 2012, when she was

transferred back to Garrison. (CR 55)

                          SUMMARY OF ARGUMENT

      This is an appeal of the trial court’s review of an expert report. To comply with

Chapter 74 of the Texas Civil Practice and Remedies Code, the expert must make a

“good faith attempt” to inform the defendants what they did wrong and how that

caused damages to the plaintiffs. The expert is required under the case law to apply

his conclusions on causation to the underlying facts of the case. In this case, the

Appellee relies upon a report authored by Dr. Keith Miller in an effort to comply with

causation requirements of Chapter 74.

      The trial court abused its discretion in denying Garrison’s Motion to Dismiss.




                                         -3-
First, Dr. Miller has failed to show that he is qualified to provide opinions regarding

the causal relationship between the alleged failure to administer Xarelto and the

stroke allegedly suffered by Ms. Demings.

      Second, the trial court abused its discretion in denying Garrison’s motion to

dismiss based on grounds that Dr. Miller’s opinion regarding causation is

impermissibly conclusory because he fails to provide any explanation whatsoever

linking an alleged failure to provide the medication Xarelto to Ms. Demings to the

stroke allegedly suffered by Ms. Demings. Since the report fails to satisfy the legal

requirements of an expert report, the trial court clearly abused its discretion in

denying the motion to dismiss. This court should reverse and render.

                       ISSUE PRESENTED (RESTATED)

(1)   Whether the trial court abused its discretion in overruling Garrison’s
      objections to Appellee’s supplement expert report from Dr. Keith E.
      Miller for the failure to show he was qualified to provide opinions
      regarding the element of causation and denying Garrison’s motion to
      dismiss pursuant to section 74.351 of the Texas Civil Practice and
      Remedies Code.

(2)   Whether the trial court abused it’s discretion in overruling Garrison’s
      objections to Appellee’s supplemental expert report from Dr. Keith E.
      Miller for failure to adequately address the element of causation and
      denying its motion to dismiss those claims pursuant to section 74.351 of the
      Texas Civil Practice and Remedies Code.




                                         -4-
                       ARGUMENT AND AUTHORITIES

I.    Standard of Review

      The standard of review in this case is abuse of discretion. Am. Transitional

Care Ctrs. of Tex. v. Palacios, 46 S.W.3d 873, 877 (Tex.2001); Shaw v. BMW

Healthcare, Inc., 100 S.W.3d 8, 12 (Tex. App.-Tyler 2002, pet. denied). Under an

abuse of discretion standard, appellate courts defer to a trial court's factual

determinations, but review questions of law de novo. Shaw, 100 S.W.3d at 12. A trial

court abuses its discretion if it acts in an arbitrary or unreasonable manner without

reference to any guiding rules or principles. Downer v. Aquamarine Operators, Inc.,

701 S.W.2d 238, 241-42 (Tex.1985). When reviewing matters committed to the trial

court's discretion, a court of appeals may not substitute its own judgment for the trial

court's judgment. Flores v. Fourth Court of Appeals, 777 S.W.2d 38, 41 (Tex.1989).

If a trial court fails to apply the law correctly to the case, the trial court has clearly

abused its discretion requiring correction by the court of appeals.

II.   In an Alleged Medical Malpractice Case, the Appellees Must
      Provide an Expert Report to the Defendant.

      Chapter 74 of the Texas Civil Practice and Remedies Code states the following:

      (a) In a health care liability claim, a claimant shall, not later than the
      120th day after the date each defendant’s original answer is filed, serve
      on that party or the party's attorney one or more expert reports, with a



                                           -5-
      curriculum vitae of each expert listed in the report for each physician or
      health care provider against whom a liability claim is asserted. The date
      for serving the report may be extended by written agreement of the
      affected parties. Each defendant physician or health care provider whose
      conduct is implicated in a report must file and serve any objection to the
      sufficiency of the report not later than the later of 21st day after the date
      the report is served or the 21st day after the date the defendant’s answer
      is filed, failing which all objections are waived.

See TEX. CIV. PRAC. & REM. CODE art. §74.351 (a). The statute defines “expert

report” as:

      (6) "Expert report" means 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. at §74.351 (r) (6).

      Therefore, to satisfy the requirements of the statue, a plaintiff in an alleged

medical malpractice case must provide an expert report to the defendants. The report

must provide a fair summary of the expert’s opinions, must set out what the expert

alleges the defendant did wrong and how those actions allegedly caused injury to the

plaintiffs. In Wright, the Supreme Court of Texas stated, "[i]f a plaintiff timely files

an expert report and the defendant moves to dismiss because of the report's

inadequacy, the trial court must grant the motion only if it appears to the court, after




                                          -6-
hearing, that the report does not represent a good faith effort to comply with the

definition of an expert report in Subsection (r)(6) of this section.” Bowie Mem'l Hosp.

v. Wright, 79 S.W.3d 48, 51-52 (Tex.2002) (per curiam).

       The Supreme Court of Texas has defined a "good-faith effort" as one that

provides information sufficient to (1) inform the defendant of the specific conduct the

plaintiff has called into question, and (2) provide a basis for the trial court to conclude

that the claims have merit. Id. at 52 (citing Palacios, 46 S.W.3d at 879). The trial

court’s review is limited to the four corners of the expert report, which need not

"marshal all the plaintiff's proof" but must include the expert's opinion on each of the

three main elements: standard of care, breach, and causation. Id.

       If a report fails to comply with the requirements of chapter 74 of the Texas

Civil Practice and Remedies Code, the trial court is required to dismiss the case

because of the defendants failure to serve an adequate expert report. Tex. Civ. Prac.

& Rem. Code § 74.351 (b). The dismissal also carries mandatory sanctions, requiring

an award to the defendant of his costs and attorney's fees against the plaintiff or the

plaintiff's attorney. Id.; see Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46

S.W.3d 873, 877 (Tex.2001).




                                           -7-
III.   Dr. Miller is not Qualified to Address Causal Relationship between
       alleged Failure to administer Xarelto and an alleged stroke

       A.    Qualification to express causation opinions

       “A report authored by a person who is not qualified to testify cannot constitute

an expert report.” Castillo v. August, 248 S.W.3d 874, 879 (Tex. App.–El Paso 2008,

no pet). A physician is qualified to submit an expert report on the causal relationship

between a departure from a standard of care and an injury when he would otherwise

be qualified to address causation under rule 702 of the Texas Rules of Evidence. Tex.

Civ. Prac. & Rem. Code §74.351 (r)(5)(C). To be so qualified, “an expert must have

knowledge, skill, experience, training, or education regarding the specific issue

before the court that would qualify the expert to give an opinion on that particular

subject.” Thomas v. Alford, 230 S.W.3d 83, 857 (Tex. App.–Houston [14th Dist.]

2007, no pet.). The party offering a witness as an expert on causation must establish

that the witness is qualified under rule 702. Collini v. Pustejovsky, 280 S.W.3d 456,

466 (Tex. App.– Fort Worth 2009, no pet.). Further, not every licensed doctor is

automatically qualified to testify as an expert on every medical question. Broders v.

Heise, 924 S.W.2d 148, 152 (Tex. 1996). In deciding whether an expert is qualified,

the trial court “must ensure that those who purport to be experts truly have expertise

concerning the actual subject about which they are offering an opinion.” Id. at 151.



                                          -8-
Therefore, the focus is on the very matter on which the expert is to give an opinion.

Id.

      B.     The causal relationship between the alleged stroke and the alleged
             failure to administer Xarelto is the very matter at issue

      The Appellee alleges that Ms. Demings suffered a stroke as a result of Garrison

allegedly failing to administer Xarelto. While not very explicit in his report, it

appears that Dr. Miller is of the opinion that Plaintiff suffered a stroke because

Defendant allegedly did not administer to her the medication Xarelto from May 25,

2012 through June 8, 2012. So, the actual subject upon which Dr. Miller is offering

an opinion is the relationship between an alleged stroke and the alleged failure to

administer the medication Xarelto.

      C.     Appellee fails to establish that Dr. Miller is qualified to address
             causation

      Given that Dr. Miller is attempting to offer opinions on the causal connection

between the alleged failure to administer Xarelto to Ms. Demings and her alleged

stroke, it is Appellee’s burden to establish that Dr. Miller truly has expertise as to

Xarelto, strokes, and the relationship between Xarelto and strokes. However, Dr.

Miller has failed to establish this expertise.

      Dr. Miller indicates that he is a medical doctor licensed in Texas with 25 years




                                          -9-
experience practicing medicine in office settings, hospitals, nursing homes,

rehabilitation centers and emergency departments. (CR 52, 54) He indicates that he

is board certified in Family Medicine. (CR 54) He also indicates that he practices in

nursing homes similar to Garrison and that he has numerous patients similar to Ms.

Demings. (CR 52) Dr. Miller writes

      I am familiar with the diagnosis and treatment of patients with cerebral
      vascular accidents (strokes), hypertension, related illnesses and their
      complications, along with any other conditions experienced by Ms.
      Legatha Demings.

(CR 53)

      As set forth below, Dr. Miller does not establish that he is qualified to render

an opinion regarding the causal relationship between a stroke and Xarelto.

      1.     Dr. Miller provides no information regarding Xarelto and his
             experience with Xarelto

      Dr. Miller fails to provide any information in his report regarding his

familiarity with the drug Xarelto; whether he has ever prescribed Xarelto; or whether

he has ever seen a patient suffer a stroke because of the failure to administer Xarelto.

In fact, he does not even describe how Xarelto works or its purpose. The lack of such

information regarding a physician’s experience and familiarity with the medication

at issue has led several appellate courts to find an expert unqualified to provide




                                         - 10 -
causation opinions related to other medications.

      In Collini v. Pustejovsky, the Fort Worth Court of Appeals addressed the

qualifications of an expert to express causation opinions regarding negligent

administration of a medication. 280 S.W.3d 456, 465 (Tex. App.– Fort Worth 2009,

no pet.). In Collini, the plaintiff alleged the defendant had negligently prescribed the

drug Reglan, which caused her to suffer tardive dyskinesia. Id. at 460. In finding the

plaintiff’s chapter 74 expert unqualified to opine on causation, the Collini court wrote

that the expert does

      not indicate that he has any specific knowledge, experience, education,
      or training in assessing the causal relationship between the prolonged
      use of Reglan and tardive dyskenesia. In fact, his report does not state
      that he has any experience or training regarding Reglan or tardive
      dyskinesia at all; rather, it only generally states that he has knowledge
      applicable to ‘primary care and family medicine.’

Id. at 465-66.

      In HEB Grocery Co. v. Galloway, 2014 WL 2152128 (Tex. App.–Beaumont

2014, no pet.), the plaintiff sued the defendant pharmacy for allegedly mixing the

wrong medication (an anti-fungal medication, Ketoconaxole) with her blood pressure

medication, Coreg. Id. at *1. The plaintiff alleged that the mis-filled prescription led

to her suffering uncontrolled blood pressure, neurologic symptoms and pain. Id. The

defendant challenged the qualifications of plaintiff’s expert, Jerry Keepers, M.D. Id.



                                         - 11 -
The trial court denied the challenge and motion to dismiss. Id. On appeal, the

Beaumont Court of Appeals found that Dr. Keepers was not qualified to opine that

the alleged mistake in the filling of the prescription caused the condition in question.

Id. at *6. The court noted that Dr. Keepers’ report and CV lacked the specific detail

necessary to establish he was qualified to render causation opinions. In relevant part,

the Galloway court noted that Dr. Keepers’ report failed to state

      that he has treated patients with high blood pressure or similar
      conditions; that he has prescribed blood pressure medication to patients
      or that he has actually prescribed Coreg; that he is familiar with what
      happens generally to patients who fail to take their blood pressure
      medications; that he has treated patients with, or read peer-reviewed
      articles about, and has personal knowledge or experience or training
      regarding, the side effects and symptoms of failing to take Coreg as
      prescribed; or that he is familiar with the pharmacology of Coreg and
      Ketoconaxole.

      In the present case, the very matter about which Dr. Miller is attempting to

provide opinions is the alleged failure to administer Xarelto causing Ms. Demings to

allegedly suffer a stroke. Yet, Dr. Miller provides no information regarding his

experience or training with Xarelto. He does not indicate that he has ever prescribed

Xarelto; he does not set forth that he is familiar with what happens to patients who

do not take Xarelto; and he does not identify any peer-reviewed articles regarding the

side effects and symptoms of failing to take Xarelto. This is the very type of




                                          - 12 -
information that was missing from the expert reports in the Collini and Galloway

cases.

         Dr. Miller provides no information as to his specific knowledge, experience,

education, or training in assessing the causal relationship between the alleged failure

to administer Xarelto and a stroke. Dr. Miller fails to provide any information to

show that he is qualified to provide opinions on the topic at issue. Therefore, Dr.

Miller’s report is deficient with regard to showing he is qualified to provide opinions

on the causal relationship between the alleged departures from the standard of care

and any injury or damage alleged by Appellee.

         Because Dr. Miller is not qualified to provide the causation opinions in this

case, Garrison filed a motion to dismiss. The trial court clearly abused its discretion

in denying the motion to dismiss.

IV.      Keith E. Miller, M.D.’s Report is Conclusory Regarding Causation

         A.    An Expert Report That is Conclusory Fails to Satisfy
               the Statutory Requirements

         The Supreme Court of Texas has held that the expert “report cannot merely

state the expert's conclusions about [the elements required in an expert report],” but

“‘the expert must explain the basis of his statements to link his conclusions to the

facts.’” Palacios, 46 S.W.3d at 877 (Tex.2001) (quoting Earle v. Ratliff, 998 S.W.2d



                                          - 13 -
882, 890 (Tex.1999)). “A report that merely states the expert's conclusions about the

standard of care, breach, and causation" does not fulfill the two purposes of a

good-faith effort.” Palacios, 46 S.W.3d at 879.

      This court has written that

      [a] causal relationship is established by proof that the negligent act or
      omission was a substantial factor in bringing about the harm and that
      absent this act or omission, the harm would not have occurred. Merely
      providing some insight into the plaintiff's claims does not adequately
      address causation. Accordingly, causation cannot be inferred; it must be
      clearly stated. The court may not fill in gaps in a report by drawing
      inferences or guessing what the expert meant or intended.

Conboy v. Lindale Health Care, LLC, 2013 WL 4680516, *2 (Tex. App.–Tyler 2013,

August 29, 2013, no pet.) Further, statements concerning causation cannot be

inferred, speculative, or conclusory. Id. at *4.

      B.     Dr. Miller’s Causation Opinions are impermissibly conclusory

      Dr. Miller’s report addresses causation in a conclusory fashion and is therefore

insufficient. He merely asserts that violations of the standard of care caused Ms.

Demings to suffer a stroke without providing any medical detail at all on how any

alleged violations of the standard of care caused the alleged stroke.

      1.     Opinions that alleged violations of administrative rules caused
             stroke are conclusory

      In his report, Dr. Miller sets forth a dizzying array of administrative rules



                                         - 14 -
which he believes Garrison violated in its care and treatment of Ms. Demings. (CR

59-62) He then, in conclusory fashion, writes that

      [t]he failure to comply with these standards caused, within a reasonable
      degree of medical and nursing, probability and certainty, Ms. Demings
      to suffer a stroke, extensive hospitalization, rehabilitation, and related
      complications, . . . .

(CR 65)

      Dr. Miller’s causation opinion provides absolutely no link between these

alleged violations and the stroke which Plaintiff alleges she suffered. For example,

Dr. Miller alleges that Garrison violated

      2. TAC Chapter 217 Rule 217.11 Standards of Nursing Practice (1)
      Standards Applicable to All Nurses. All vocational nurses, registered
      nurses and registered nurses with advanced practice authorization shall
      (B) implement measures to promote a safe environment for clients and
      others.

(CR 60) Dr. Miller simply writes that the violation of this Rule caused Ms. Demings

to suffer a stroke. He provides no information at all on the connection of how failing

to “implement measures to promote a safe environment for clients and others” was

a substantial factor in causing Ms. Demings to suffer a stroke. This example is

applicable to all 20 administrative rules which Dr. Miller alleges were violated.




                                         - 15 -
      2.     Opinion that Alleged failure to administer Xarelto caused stroke is
             conclusory

      Appellee has alleged that Ms. Demings suffered a stroke because of the failure

to administer Xarelto. Dr. Miller never explicitly states this opinion in his report.

However, to the extent Dr. Miller is attempting to provide the opinion that Ms.

Demings suffered a stroke because Garrison allegedly did not administer Xarelto to

Ms. Demings, this opinion is impermissibly conclusory because Dr. Miller fails to

provide any explanation whatsoever on how an alleged failure to provide the

medication Xarelto caused Ms. Demings to suffer a stroke.

      In Jelinek v. Casas, the Texas Supreme Court addressed conclusory reports.

328 S.W.3d 526 (Tex. 2010). In Jelinek, the patient was admitted to the hospital with

abdominal pain for which she was placed on antibiotics to treat and prevent intra-

abdominal infections. Id. at 529. Following an intra-abdominal surgery, the hospital

inadvertently failed to renew the antibiotics prescriptions resulting in a four-and-a-

half day period during which the patient did not receive the antibiotics. Id. at 530.

The plaintiff filed suit against the hospital and the patient’s treating physicians.

      The plaintiff produced an expert report alleging that the patient’s physicians

were negligent in failing to discovery that the antibiotics were not being administered

and “in ‘reasonable medical probability, resulted in a prolonged hospital course and



                                         - 16 -
increased pain and suffering experienced by Ms. Casas.’” Id. at 539. Defendant Dr.

Jelinek challenged the expert report and sought a dismissal, but his challenge was

overruled by the trial court and affirmed by the appellate court. Id. at 531. On appeal

to the Texas Supreme Court, Dr. Jelinek argued that the report was deficient because

it failed to state the applicable standard of care and because it only provided

conclusory statements of causation. Id. at 538-39.

      The Supreme Court reviewed the report and agreed with Dr. Jelinek with

regard to causation. Id. The Jelinek Court wrote:

      An expert cannot simply opine that the breach caused the injury. Stated
      so briefly, the report fails the second Palacios element — it does not
      give the trial court any reasonable basis for concluding that the lawsuit
      has merit. An expert’s conclusion that “in medical probability” one
      event caused another differs little, without an explanation tying the
      conclusion to the facts, from an ipse dixit, which we have consistently
      criticized. . . . Instead, the expert must go further and explain, to a
      reasonable degree, how and why the breach caused the injury based on
      the facts presented.

Id. at 539 (citations omitted). The court went on to write that the plaintiff’s expert

report offered

      no more than a bare assertion that Dr. Jelinek’s breach resulted in
      increased pain and suffering and a prolonged hospital stay. Beyond that
      statement, the report offers no explanation of how the breach caused the
      injury.

Id. at 540 (emphasis added). The Jelinek Court held the report insufficient because



                                         - 17 -
the report “lacked any explanation linking the experts conclusion to the relevant

facts.” Id.

      Therefore, a report that is conclusory and fails to link the expert’s opinions on

causation to the facts of the case is not a “good faith attempt” and the trial court is

required to sustain objections to such a report.

      a.      Dr. Miller provides no more than a “bare assertion” of causation,
              and he fails to link his conclusions to the facts

      In the present case, Dr. Miller’s report is very similar to the report in Jelinek.

Dr. Miller provides nothing more than the “bare assertion” that failing to meet the

standards of care

      within a reasonable degree of medical and nursing, probability and
      certainty, Ms. Demings to suffer a stroke, extensive hospitalization,
      rehabilitation, and related complications, . . .

(CR 14) This is the very ipse dixit the Jelinek Court held was not permissible. Dr.

Miller is simply stating one event (alleged failure to give Xarelto) caused another

(alleged stroke) “without an explanation tying the conclusion to the facts.” Jelinek,

328 S.W.3d at 539.

      Assuming for argument that Ms. Demings did suffer a stroke on June 8, 2012,

Dr. Miller provides no explanation as to how the administration of the Xarelto

between May 25 and June 8, 2012, would have prevented Ms. Demings’ stroke. Dr.



                                         - 18 -
Miller fails to explain how Xarelto works, the efficacy of Xarelto, his experience with

Xarelto, or studies about the effectiveness of Xarelto in preventing strokes, or specific

types of strokes. He basically asks the court to believe and agree that Xarelto

prevents all strokes. Dr. Miller has not explained the basis of his statements in order

to link his conclusions to the facts. See Earle v. Ratliff, 998 S.W.2d 882, 890 (Tex.

1999). He simply opines that Xarelto was not administered and, therefore, Ms.

Demings had a stroke. This does not meet the expert requirements for causation.

      The issues in this case are also similar to Ibrahim v. Gilbride, 2010 WL

5064430 (Tex. App.–Houston [14th Dist.], December 9, 2010, no pet.). In Ibrahim,

the plaintiff alleged that the defendant had failed to prescribe anti-seizure medications

and as a result, the plaintiff suffered a grand mal seizure, struck her head during the

seizure causing brain hemorrhages and other sustained injuries. Id. at *1. The

plaintiff produced an expert report which the defendant challenged as insufficient.

With regard to causation, the plaintiff’s expert opined that as a direct and proximate

result of the defendant failing to prescribe appropriate anti-seizure medications, the

plaintiff suffered a grand mal seizure and resulting brain injuries. Id. at *10. In

finding the report deficient on causation, the Ibrahim court wrote the following:

      Dr. Smith fails to identify the seizure disorder suffered by Mrs. Gilbride
      and its pathology and thus show that medication was a necessary and



                                          - 19 -
       potentially effective treatment . . . . Therefore, although “anti-seizure
       medications” are indubitably intended to prevent seizures. Dr. Smith
       does not sufficiently inform Dr. Ibrahim and the trial court why such
       medication would necessarily have prevented Mrs. Gilbride’s seizure.

Id. at *11. Similarly, in the present case, Dr. Miller has not identified anything

regarding the nature of the alleged stroke which Ms. Demings suffered, or show how

the medication Xarelto was necessary and potentially effective treatment. While he

identifies Xarelto as a blood thinning medication, Dr. Miller does not provide any

information as to why the Xarelto would necessarily have prevented Ms. Demings’

alleged stroke.2 He fails to identify any specifics about the stroke that Ms. Demings

allegedly suffered which would have allegedly been prevented by Xarelto.

       b.     The court cannot infer that, because Xarelto was not given, Ms.
              Demings suffered a stroke

       A court cannot infer causation. Conboy, 2013 WL 4680516 at *2. Dr. Miller

is attempting to have the court infer that had Xarelto been given to Ms. Demings, she

would not have suffered a stroke. This is not permitted.

       In Collini, the court addressed causation inferences. The defendant doctor had

challenged the causation opinion of the plaintiff’s expert that prolonged use of the

medication Reglan had caused tardive dyskinesia. 280 S.W.3d at 467. The Collini

       2
        Appellee’s first expert Pauline Kaper, R.N. acknowledges that Ms. Demings suffered a
transient ischemic attack (“TIA”) while on Xarelto on March 3, 2014. (CR 45)


                                           - 20 -
court agreed with the defendant doctor noting that the expert report did “not provide

any detail as to how Reglan caused [the plaintiff’s] conditions, or, more importantly,

how Dr. Collini’s specific prescriptions of Reglan attributed to the harm.” The court

noted that while the manufacturer’s warning regarding prolonged use of Reglan and

other causation opinions by doctors “may create a reasonable inference” that Dr.

Collini’s prolonged prescription of Reglan caused the plaintiff’s condition, the court

wrote that it was “not permitted to rely on that inference in reviewing [the

expert’s] report.” Id. (emphasis added); see also Gingrich v. Scarborough, 2010

WL 1711067, *2-3 (Tex. App.–Beaumont April 29, 2010, no pet.) (Report was

insufficient on causation where it stated that the cause of death was combined drug

toxicity and pulmonary edema, but it failed to explain why combined drug toxicity

occurred, how the combined drug toxicity related to pulmonary edema, or why it was

fatal.)

          In his report, Dr. Miller is asking the court to infer that failing to give Xarelto

caused Ms. Deming to suffer a stroke. He has provided no specifics about Ms.

Demings situation to show she suffered a stroke because Xarelto was not

administered. Dr. Miller is essentially asking the court infer that all stokes are

prevented by Xarelto. Causation cannot be inferred, and, therefore, Dr. Miller’s




                                             - 21 -
report is insufficient as to causation.

      In the present case, Dr. Miller has simply opined that an alleged breach caused

an injury, instead of explaining how and why the alleged breach caused the specific

injuries and damages claimed. Jelinek, 328 S.W.3d at 539. Accordingly, Dr. Miller’s

report is inadequate and conclusory, and the trial court abused its discretion in

denying Garrison’s motion to dismiss.

V.    Res Ipsa Loquitur does not excuse production of expert report

      Based upon Appellee’s arguments at the hearing on Appellant’s motion to

dismiss, it is anticipated that Appellee will argue that the doctrine of res ipsa loquitur

applies to this case, therefore, excusing Appellee from the expert report requirements

set forth in section 74.351. However, appellate decisions on this issue are quite clear

in that even if res ipsa loquitur were to be applicable as an evidentiary rule at time

of trial, it does not excuse the procedural requirement of providing an expert report

pursuant to section 74.351. See Sherman v. HealthSouth Specialty Hosp. Inc., 397

S.W.3d 869, 875-876 (Tex. App.–Dallas 2013, pet. denied); Bogar v. Esparza, 257

S.W.3d 354, 369 (Tex. App.–Austin 2008, no pet.); Garcia v. Marichalar, 198

S.W.3d 250 (Tex. App.–San Antonio 2006, no pet.).

      Res ipsa loquitur is an evidentiary rule by which negligence may be inferred




                                          - 22 -
by a jury, it is not a cause of action separate and apart from negligence. Garcia, 198

S.W.3d at 255. It applies in situations in which (1) the character of the accident is

such that it would not ordinarily occur in the absence of negligence, and (2) the

instrumentality causing the injury is shown to have been under the management and

control of the defendant. Id. Further, it applies only when “the nature of the alleged

malpractice and injuries are plainly within the common knowledge of laymen,

requiring no expert testimony.” Sherman, 397 S.W.3d at 875.3

       “In contrast, section 74.351's expert requirement establishes a threshold over

which claimant must proceed to continue in a lawsuit; it does not establish a

requirement for recovery.” Id. Res ipsa loquitur does not eliminate the procedural

requirement of an expert report at the commencement of litigation. See Sherman v.

HealthSouth Specialty Hosp. Inc., 397 S.W.3d 869, 875-876 (Tex. App.–Dallas 2013,

pet. denied); Bogar v. Esparza, 257 S.W.3d 354, 369 (Tex. App.–2008, no pet.);

Garcia v. Marichalar, 198 S.W.3d 250 (Tex. App.–San Antonio 2006, no pet.).

       Whether res ipsa loquitur is applicable to this case or not at time of trial is

       3
          The legislature has limited the applicability of res ipsa loquitur in health care claims only
to those cases in which the doctrine had been applied by Texas appellate courts as of August 29,
1977. See Tex. Civ. Prac. & Rem. Code Ann. §74.201. These categories have been limited to (1)
negligence in the use of mechanical instruments, (2) operating on the wrong portion of the body, and
(3) leaving surgical instruments or sponges within the body. Sherman, 397 S.W.3d at 875; Garcia,
198 S.W.3d at 256. In the present case, none of these categories apply, so even at any evidentiary
stage of this case, the doctrine of res ipsa loquitur does not apply.


                                                 - 23 -
irrelevant to the issue of the sufficiency of Appellee’s expert report from Dr. Miller.

Appellee’s were required to produce a sufficient expert report and res ipsa loquitur

does not excuse section 74.351's expert report requirements.

      Since Dr. Miller's report is inadequate and conclusory, Garrison filed a motion

to dismiss. The trial court denied the motion. The trial court clearly abused its

discretion in doing so and this court should reverse and render dismissal of the case.

                                      PRAYER

      WHEREFORE, PREMISES CONSIDERED, GARRISON NURSING

HOME AND REHABILITATION CENTER AND GARRISON NURSING HOME,

INC., Appellants in the above referenced appeal, asks the court of appeals to reverse

the trial court’s denial of Appellant’s motion to dismiss and render the judgment in

favor of Appellants dismissing the Appellees case against it and for such other and

further relief either at law or in equity to which Appellants may show just entitlement.




                                         - 24 -
         Respectfully submitted,

         KENT, ANDERSON, BUSH,
         FROST & METCALF, P.C.
         Woodgate I
         1121 E.S.E. Loop 323, Suite 200
         Tyler, Texas 75701
         (903) 581-5588
         (903) 581-3701 (Fax)



         By: /s/ David W. Frost
                David W. Frost
                State Bar No. 24002111
                dfrost@tyler.net

         ATTORNEYS FOR APPELLANT




- 25 -
                      CERTIFICATE OF COMPLIANCE

      The undersigned certifies this brief complies with the typed-volume limitations
of Texas Rule of Appellate Procedure 9. This brief contains 6,696 words and has
been prepared in proportionately spaced typeface using Word Perfect X6 in 14 point
Times New Roman font.

Dated: September 16, 2015

                                                    /s/ David W. Frost

                                                    David W. Frost




                          CERTIFICATE OF SERVICE

      I hereby certify that the foregoing document was electronically transmitted to

the following counsel on this 16th day of September, 2015.

      Mr. W. Stephen Shires
      Law Office of Stephen Shires, PLLC
      123 San Augustine Street
      Center, Texas 75935
      (936) 598-3031 - FAX



                                                    /s/ David W. Frost
                                                    David W. Frost




                                           - 26 -
APPENDICES

Order Denying Defendant’s Objections to Plaintiff’s Supplemental
Expert Report and Motion to Dismiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A

Expert Report of Keith E. Miller, M.D.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B

Tex. Civ. Prac. & Rem. Code Ann. §74.351. . . . . . . . . . . . . . . . . . . . . . . . . . . . C
     APPENDIX ''A''

Order Denying Defendants'
  Objections to Plaintiffs
Supplemental Expert Report
  and Motion to Dismiss
                                                                              F~D
                                                                       ~:             -P--M.
                                                                           JUN 2 9 2015
                                       NO. C-14-30319
                                                                           DISTRICT CLERK
LEGATHA DEMINGS                               §    IN THE DISTRICT C()UifrjJOCHES COUNTY, TX
Plaintiff,                                    §
                                              §
v.                                            §    145 1h JUDICIAL DISTRICT
                                             §
GARRISON NURSING HOME AND                    §
REHABILITATION CENTER AND                    §
GARRISON NURSING HOME, INC.                   §
Defendants.                                   §    OFNACOGDOCHESCOUNTY,TEXAS

          ORDER DENYING DEFENDANTS' OB.JECTION TO PLAINTIFF'S
     SUPPLEMENTAL EXPERT REPORT AND SECOND MOTION TO DISMISS

       On June 22, 2015, came before the Court Defendants' Objection to Plaintiffs

Supplemental Expert Report and Motion lo Dismiss (hereinafter the "Motion").          Having

considered the Motion, Plaintiff's Response to same, the pleadings, the evidence, and the

arguments of counsel, the Court hereby finds that the Motion should be, and is in all things,

DENIED.




                                                   DISTRICT JUDGE PRESIDING




                                             164
    APPENDIX ''B''

Expert Report of Keith E.
     Miller, M .D.
                                      May 4, 2015




Mr. W. Stephen Shires, Attorney at Law
The Law Offices of Stephen Shires, P.L.l.C.
123 San Augustine Street
Center, Texas 75935

                                      Re: Ms. Legatha Demings

Dear Mr. Shires:

        Thank you for allowing me to review this case on behalf of Ms. Legatha
Demings. My opinions in this report are based on the information I have
reviewed to date and my education, training, and direct experience in the
diagnosis and treatment of patients with conditions similar to those of Ms.
Legatha Demings as described in the materials I have reviewed and discussed in
this report.   Each opinion is based on reasonable medical and nursing,
probability and certainty.

                                 BACKGROUND
        My name is Keith E. Miller, M.D., and I give this report for the purpose of
complying with any applicable provisions or codes. As my attached curriculum
vitae demonstrates and which is incorporated into this report by reference, I am a
Medical Doctor currently licensed to practice in the State of Texas and formerly
licensed in the States of Louisiana and Arkansas. I currently practice in nursing
homes similar to Garrison Nursing Home and Rehabilitation Center in Garrison,
Texas. I have had numerous patients similar to Ms. Legatha Demings. I am
board-certified in Family Medicine and I have been in practice for more than 25
years. By virtue of my education, training, and direct experience, I am qualified
to render opinions regarding the standards of care as they apply to this particular
case.
       I am over the age of 18, of sound mind, and capable of preparing this
expert medical report. My opinions in this report are based on the information I
have reviewed to date, as well as my education, training, knowledge, and direct
experience in the diagnosis and treatment of patients with conditions similar to
those of Ms. Legatha Demings, as described in the materials I have reviewed
and discussed in this report. My opinions are based on reasonable medical and
nursing, probability and certainty. My opinions concern the care and treatment
received by Ms. Legatha Demings, or lack thereof, in regard to the applicable
standards of care and the manner, ir'l which the care rendered to Ms. Legatha
Demings by the healthcare facility in this case, fell below the standards of care
and caused the illnesses of Ms. Legatha Demings.

       It is impossible in an expert medical report to marshal all of the proof
regarding the standard of care, breach, and causation and include it within my
expert opinions in this case. My report represents a good faith effort to inform
the health-care facility of the specific conduct that I am calling into question and
to provide a basis for anyone to conclude that the claims in this matter have
merit. Obviously, any defendant in a medical malpractice case has medical
knowledge of medical terms which, when read in context with my opinions, will
be clear to any competent healthcare facility.

       This report will provide a summary of my opinions, as of this date,
regarding: 1) the applicable standards of care at issue in this case; 2) how the
applicable standards of care were violated and breached; 3) how the violations
and breaches of the applicable standards of care resulted in the illnesses of Ms.
Legatha Demings; and 4) what the health-care facility in this case should have
done differently to prevent the illnesses of Ms. Demings. I reserve the right to
amend, or add to, my opinions upon review of new records, testimony, or facts,
as they become available, or upon further review of existing materials.

                                  MY EXPERTISE

       I am a medical doctor currently licensed to practice in the State of Texas
and formerly licensed in the States of Louisiana and Arkansas. I have been a
licensed medical doctor since 1985, have been practicing medicine continuously
since then, including during the time of this claim, and as part of my practice,
have been, and am currently, involved in the diagnosis, care, and treatment of
many patients similar to Ms. Legatha Demings. I am familiar with the diagnosis
and treatment of patients with cerebral vascular accidents (strokes),
hypertension, related illnesses and their complications, along with any other
conditions experienced by Ms. Legatha Demings. I am familiar with the
standards of care applicable to physicians, nurses, hospitals, nursing homes,
rehabilitation centers and their staffs that treat patients such as Ms. Demings.
Report of Keith E. Miller, M.D.                                             Page2




                                         131
My training is similar to the training of the physician, healthcare providers,
nurses, and facility staff in this case.

       After graduating from medical school in 1985 at the University of
Arkansas, I received additional training and experience in a family practice
residency program which t successfully completed in 1988. I have over 25 years'
experience practicing medicine in office settings, hospitals, nursing homes,
rehabilitation centers and emergency departme.nts. I am board-certified in
Family Medicine by the American Board of Family Medicine, and have been in
practice for more than 25 years. By virtue of my education, training, knowledge
and direct experience, I am qualified to render opinions regarding the standards
of care as they apply to this particular case, including the standards of care
applicable to physicians, nurses, hospitals, nursing homes, rehabilitation centers
and their staffs treating patients for strokes, hypertension, related illnesses and
their complications, along with any other conditions exhibited by Ms. Legatha
Demings, because I have treated many patients with these conditions.

                              A COPY OF MY CV IS ATT ACHED

              My attached curriculum vitae is incorporated herein as part of my report.
                                                            \
                                   MATERIALS REVIEWED

         The specific records and documents concerning Ms. Legatha Demings
which I have reviewed include the following:

                1) Medical Records of Ms. Legatha Demings from Nacogdoches
                   Medical Center in Nacogdoches, Texas;
                2) Garrison Nursing Home and Rehabilitation Center in Garrison,
                   Texas;
                3) Plaintiff's Original Petition; and
                4) Expert Nursing Report of Pauline Kaper, RN.

                                     SIGNIFICANT FACTS

        Ms. Legatha Demings is an adult female whose date of birth is April 28,
1945. In May 2012, Ms. Demings was 67 years-old. She had a past medical
history of hypertension, atrial fibrillation, congestive heart failure, emphysema,
and a previous transient ischemic attack (TIA).

         On May 22, 2012, Ms. Demings was living at home. She suddenly
developed slurred speech, weakness in her extremities, and she fell out of bed.
She was taken to a hospital in Carthage, Texas, and then subsequently
A~--•'W   '




Report of Keith E. Miller, M.D.                                                  Page3




                                                132
transferrecj to Nacogdoches Medical Center in Nacogdoches, Texas for further
evaluation and treatment.

           In the hospital, Ms. Demings was diagnosed as having had a
cerebrovascular accident (CVA) or stroke. Ms. Demings was discharged from
the hospital on May 25, 2012. In his discharge summary, Ms. Demings'
physician documented that this patient's stroke was of " ... ischemic origin, most
likely caused by her atrial fibrillation."

          In order to treat Ms. Demings' condition and prevent further strokes, her
physician discharged her from the hospital on a blood-thinning medication,
Xarelto. This physician stated in his discharge summary that Ms. Demings would
be "... started (on) Xarelto for her anticoagulation to avoid further strokes ... "

          On May 25, 2012, Ms. Demings was discharged from the hospital and
admitted to Garrison Nursing Home and Rehabilitation Center in Garrison, Texas
for further recovery and rehabilitation. According to Ms. Demings' physician, this
resident had begun to make some improvement as evidenced by improvement in
her speech and increased movement of her left side.

          After being in the care of Garrison Nursing Home and Rehabilitation
Center for less th~n two weeks, Ms. Demings became "confused, combative,
and unable to communicate". On June 8, 2012, she was taken by emergency
medical services back to Nacogdoches Medical Center for emergency
evaluation. There a computerized tomography (CT) scan of her head revealed
an ischemic infarction of her brain consistent with a stroke.

         One of Ms. Demings' consulting physicians, a neurological specialist,
documented in the medical record that Ms. Demings had suffered a
"Cerebrovascular accident extension with newly developed global aphasia,
aphasia and left-sided flaccid paralysis".

       Ms. Demings remained in the hospital for 12 days, and was discharged on
June 20, 2012. At the time of her discharge from the hospital, Ms. Demings'
physician noted in his discharge summary that this patient's overall medical
condition had deteriorated as a result of her stroke she suffered at Garrison
Nursing home and Rehabilitation Center, to the point that Ms. Demings was
made a do-not~resuscitate status such that if she experienced a cardiovascular
or respiratory failure, she would not be intubated or placed on a ventilator or
breathing machine.

     A "Medication Error Report" made by the nursing staff of Garrison Nursing
Home and Rehabilitation Center on June      2012, documented that from the
Report of Keith E. Miller, M.D.                                            Page4




                                         133
time Ms. Demings was first admitted to this facility on May 25, 2012 until the time
of her stroke and transfer on June 8, 2012, Ms. Demings was not given her
blood-thinning medication, Xarelto as ordered by her physician. This medication
had been ordered to be given in a dose of 20 milligrams (mgs) at bedtime daily.

         This same report stated that "res. (resident) arrived after 5:00 pm on a
Friday. This medication (Xarelto) was ordered along (with) all other meds from
nursing home pharmacy - nurse transcribing orders had to have all meds written
on pharmacy order sheets and faxed in to pharmacy by 6 pm so they could be
delivered that night".

          The Medication Error Report went on to document that a nurse at this
nursing home "failed to transcribe this med (medication) to MAR (Medication
Administration Record)" ... "an oversight". A question on this same form asked
"Could the error have endangered the life or welfare of the patient?" The·
responsible nurse completing the form answered the question with "Makes her a
higher risk for stroke in view of her diag (diagnosis) of atrial fibrillation."

           On a subsequent hospitalization on August 5, 2012, in his pre-operative
history and physical, one of Ms. Demings' physicians documented what had
happened to her during her stay at Garrison Nursing Home and Rehabilitation
Center from May 25, 2012 through June 8, 2012. This physician stated that prior
to her first admission to this nursing home, Ms. Demings "was found in atrial
fibrillation. She was started (on) Xarelto. Apparently ... did not follow-through in
the nursing home, and she had ... strokes, disabling, with severe __ . She was
rendered substantially disabled."

       This physician also documented in his discharge summary of this August
5, 2012 hospital stay, the importance of a patient such as Ms. Demings who
suffered with atrial fibrillation, to always remain on a blood-thinning medication
such as Xarelto. He stated that "She is to continue with Xarelto ... Instructions
were given to the family to make sure that this medication is never stopped."

                                                                                     .EAMILIARITY WITH THE STANDARD OF                          GAR~

       At the time of the care and treatment of Ms. Legatha Demings by Garrison
Nursing Home and Rehabilitation Center in Garrison, Texas, from May 2012
through June 2012, I was familiar with the minimum medical standards of care
applicable to the assessment, diagnosis and treatment of patients with strokes,
hypertension, and related illnesses, as well as their complications and other
medical conditions similar to those experienced by Ms. Legatha Demings and
described in the referenced medical records. I am familiar with the medical and
nursing standards of care for the above referenced conditions applicable to
  ---~~_..,.   ... ._ ... _ ............ ···•·   ····•••4••••   .-..-.-.-. ••---.-..-..-.~····----   .,. .•• ., ..... "'"'"""""""""~·-·



Report of Keith E. Miller, M.D.                                                                                                                        Pages




                                                                                                                                          134
Garrison Nursing Home and Rehabilitation Center in Garrison, Texas. The
minimum standards of care for treatment of patients with similar signs,
symptoms, and conditions as Ms. Legatha Demings that are the basis of this
report, are national standards of care and do not differ from community to
community.

            From the time of the medical treatment of Ms. Legatha Demings from
May 2012 through June 2012, and through the present, I have had an active
clinical practice as a family practitioner in Center, Texas that includes providing
care to adult patients in nursing homes and rehabilitation centers, such as Ms.
Legatha Demings. During my career as a family practitioner, I have worked with
and or supervised medical office staff, hospital staff, nursing home staff, and
rehabilitation center staff, including medical technologists and nurses, in the care
of my patients. I have also participated in the development and use of protocols,
policies and procedures for the care of patients with strokes, hypertension, and
related illnesses 1 as well as their causes and complications, including adults
such as Ms. Legatha Demings. In addition, based on my education, training,
knowledge, and direct experience, I am familiar with the accepted and expected,
standards of care, as listed below, for nursing home and rehabilitation center
facilities, who take care of patients with conditions such as strokes, hypertension,
related illnesses, and their complications, and can offer opinions on the
standards of care, the breaches of the standards of care and the causation of
the injuries from these breaches.

            In my medical practice, I routinely rely on medical records, nursing
records, lab reports, diagnostic tests and images, consulting physician reports
and other patient data. I consider materials of this type to be generally reliable,
unless evidenced otherwise, and they are the type of materials routinely relied
upon by physicians and clinical staff in providing care to patients.

                                                                                                    CASE SPECIFIC EXPERTISE

       At the time of the medical treatment of Ms. Legatha Demings, from May
2012 through June 2012, I was treating patients with symptoms similar to those
experienced by Ms. Demings. I am familiar with the accepted medical and
nursing standards of care applicable to the assessment, diagnosis, and
treatment of patients with strokes, hypertension, and related illnesses, as well as
any other medical conditions similar to those experienced by Ms. Legatha
Demings during that time as described in the referenced medical records. I am
familiar with the standards of care for physicians, nurses, and nursing home and
rehabilitation center staff treating patients such as Ms. Demings. I am familiar
with the medical and nursing standards of care for the above referenced medical
conditions, including strokes, hypertension, related illnesses, and their
'   , " ..~~""   ""'c-'~'••••-'••"   •   '   • •   m   •-~••••••••   '   "'"'••••--'••••,.••••·•• ••••••••••••   • • ••'-•• '-••• •••"""'"''•'•-   -'"'"' •••••••••••   • ••••••••••••••••••.,•••••••,.   ••••••••,.•••••••••••••••"'•••••• ••••••••••••••"•"•••••,.   ••-'-'"'   '-'•·•'·"~'·~'"'"   ~·-~""'-"'"''W•A•••   ••~"•••••••~'-"''"'""••m<o••"••••••••




    Report of Keith E. Miller, M.D.                                                                                                                                                                                                                                                                                            Page 6




                                                                                                                                                               135
complications, as they apply to Garrison Nursing Home and Rehabilitation
Center in Garrison, Texas. The accepted and applicable standards of care for
the treatment of patients with similar signs, symptoms, and conditions as Ms.
Legatha Demings, that are the basis of this report, are national standards of care
and do not differ from community to community, and also apply to the specific
medical care provided to Ms. Demings in this case. The accepted medical and
nursing standards of care for the assessment, diagnosis, and treatment of
medical conditions similar to those of Ms. Legatha Demings apply to all nursing
home and rehabilitation center facilities. I know the accepted standards of care,
the breaches and violations of the standards of care, and the causation link
between the breaches and violations of the standards of care and the illnesses,
of Ms. Legatha Demings, as they apply to Garrison Nursing Home and
Rehabilitation Center in Garrison, Texas, on the basis of my education,
knowledge, training, and direct experience.

                                 I acquired this education, knowledge, training and experience through:

        1) My attending, and successfully completing, medical school classes,
and residency, that teach the evaluation, diagnosis, care and treatment of
patients with the same or similar conditions as Ms. Legatha Demings, and for
illnesses related to strokes, hypertension, and their complications;

       2) Practical experience of diagnosing and treating patients with the same ·
or similar conditions as Ms. Legatha Demings, and for illnesses related to
strokes, hypertension, and their complications;

      3) Discussions with colleagues at yearly conferences, seminars and
meetings;

        4) Study of technical works routinely published in textbooks, journals and
literature concerning the evaluation, diagnosis, care and treatment of patients
with the same or similar conditions as Ms. Legatha Demings, and for illnesses
related to strokes, hypertension, and their complications;

       5) My routine discussions and consultations with other physicians who
also treat patients with the same or similar conditions as Ms. Legatha Demings,
and for illnesses related to strokes, hypertension, and their complications;

       6) My routine and regular contact with nursing horne nurses, staff and
residents who take care of patients with the same or similar conditions as Ms.
Legatha Demings, and for illnesses related to strokes, hypertension, and their
complications;

••••"•J••••"••••••'·• .. •••••••,••'•''""'""""""-'••'-•••   •   ••••••"••••'-• .. v"• .. vo•••<




Report of Keith E. Miller, M.D.                                                                         Page7




                                                                                                  136
                                     7) My knowledge
                            and experience                                                                                            giving   lectures   and    in-service
conferences to the nurses and staff;

                                      8) My experience serving on numerous hospital and nursing home
committees; and

                                      9) My observation of nurses and nurse conduct, supervising residents,
and instructing nurses and residents in the evaluation, diagnosis, care and
treatment of patients the same as, or similar to Ms. Legatha Demings, and for
illnesses related to strokes, hypertension, and their complications.

                                                                                                          FACILITY- PATIENT RELATIONSHIP

            Based upon the above facts, there was a facility-patient relationship
established between Ms. legatha Demings and Garrison Nursing Home and
Rehabilitation Center in Garrison, Texas.

                                                                                                                               DUTY

         There was a duty owed to Ms. Legatha Demings by Garrison Nursing
Home and Rehabilitation Center in Garrison, Texas, to do what a reasonable
nursing home or rehabilitation center would have done under the same or similar
circumstances, or not to do what a reasonable nursing home or rehabilitation
center would not have done under the same or similar circumstances.

                                                                                     RELEVANT STANDARDS OF CARE IN ISSUE

       This section addresses some of the principal applicable standards of care
that Garrison Nursing Home and Rehabilitation Center in Garrison, Texas and its
staff should have met for Ms. Legatha Demings, specifically how Garrison
Nursing Home and Rehabilitation Center and its staff breached the standards of
care and the causal relationship of the breach to Ms. Demings' illnesses and
related complications. These standards are based on my education, training,
and direct experience, and are reflected in the state and federal regulations that
govern nursing homes, rehabilitation centers, and skilled nursing facilities.

      The following standards, among others, are consistent with the standards
of care that were required to be followed by Garrison Nursing Horne and
Rehabilitation Center in Garrison, Texas, and its staff as it concerns Ms. Legatha
Demings:

1. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1) Stan-
dardsApplicable to All Nurses. AU vocational nurses, registered nurses and reg-
'""'··~.-.,.,.,,,,.,~.--•   - ~~;.. •• n"<"...• ,;;.-.-,,.;v."."•'"'~"'"''"'"""""";, - "   ~< ,,,,.,.,•• ,y   u   '~""""   m                                    "'""   ·~-'•""'"•"'~""~"•   ~n•w•   •



Report of Keith E. Miller, M.D.                                                                                                                                          Page 8




                                                                                                                                137
istered nurses with advanced practice authorization shall: (A) Know and conform
to the Texas Nursing Practice Act and the Board's rules and regulations as well
as all federal, state, or local laws, rules or regulations affecting the nurse's cur-
rent area of nursing practice;

2. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
registered nurses with advanced practice authorization shall: (B) Implement
measures to promote a safe environment for clients and others;

3. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice {1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
registered nurses with advanced practice authorization shall: (C) Know the ratio-
nale for and the effects of medications and treatments and shall correctly admin-
ister the same;

4. TAC Subchapter H Rule §19.701. A facility must care for its residents in a
manner and in an environment that promotes maintenance or enhancement of
each resident's quality of life. (5) Accommodation of needs. A resident has the
right to: (A) reside and receive services in the facility with reasonable
accommodation of individual needs and preferences, except when the health or
safety of the individual or other residents would be endangered;

5. TAC Subchapter B Rule §19.101 Neglect - A deprivation of life's
necessities of food, water, or shelter, or a failure of an individual to provide
services, treatment, or care to a resident which causes or could cause mental or
physical injury, or harm or death to the resident.

6. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
registered nurses with advanced practice authorization shall: (D) Accurately and
completely report and document: (iii) physician, dentist, or podiatrist orders; (iv)
administration of medications and treatments; (v) client responses(s); and (vi)
contacts with other health care team members concerning significant events
regarding client's status; (G) Obtain instruction and supervision as necessary
when implementing nursing procedures or practices; (N) Clarify any order or
treatment regimen that the nurse has reason to believe is inaccurate, non-
efficacious or contraindicated by consulting with the appropriate licensed
practitioner and notifying the ordering practitioner when the nurse makes the
decision not to administer the medication or treatment.

7. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
 .~v   "'•""'"-""""'',.   •   ••••   ---><•»•>'«•"•-••••••-'••••'-"•••••~·~-·   .. ••••-'"-""""'""""""~-   """""""'•••••••   -4•••••"""""""'""""•••••••••""""""""'°'"""""•••••"••"'"~.c.-.-••••••-'·~---·~"""""""'""   ""   0



Report of Keith E. Miller, M.D.                                                                                                                                                                                                 Page 9




                                                                                                                                                                  138
registered nurses with advanced practice authorization shall: (F) Promote and
participate in education and counseling to a client(s) and, where applicable, the
family/significant other(s) based on health needs;

8. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
registered nurses with advanced practice authorization shall: (G) Obtain
instruction and supervision as necessary when implementing nursing procedures
or practices;

9. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
registered nurses with advanced practice authorization shall: (M) Institute
appropriate nursing interventions that might be required to stabilize a client's
condition and/or prevent complications;

10. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
registered nurses with advanced practice authorization shall: (T) Accept only
those nursing assignments that take into consideration client safety and that are
commensurate with the nurse's educational preparation, experience, knowledge,
and physical and emotional ability;

11. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (1)
Standards Applicable to All Nurses. All vocational nurses, registered nurses and
registered nurses with advanced practice authorization shall: (U) Supervise
nursing care provided by others for whom the nurse is professionally
responsible;

12. TAC Chapter 217 Rule §217.11 Standards of Nursing Practice (3)
Standards Specific to Registered Nurses. The registered nurse shall assist in
the determination of healthcare needs of clients and shall: (A) Utilize a
systematic approach to provide individualized, goal-directed, nursing care by: (i)
performing comprehensive nursing assessments regarding the health status of
the client; (ii) making nursing diagnoses that serve as the basis for the strategy
of care; (iii) developing a plan of care based on the assessment and nursing
diagnosis; (iv) implementing nursing care; and (v) evaluating the client's
responses to nursing interventions;

13. TAC Chapter 217 Rule §217.12 Unprofessional Cond·uct (1) Unsafe
Practice - actions or conduct including, but not limited to: (A) Carelessly failing,
repeatedly failing, or exhibiting an inability to perform vocational, registered, or
advanced practice nursing in conformity with the standards of minimum
"••• •   ••••-•••-'-••••,_ • .-_, ••• 0ww "W""A;   ~-··   °'" •   '•••••• • •   •••••••-••••••••vvv"" •••v   •••••••' ••••••••'••• •••• •   •••vv••,••••V••••••"••   AVmvA~-''"'h'-""'w•vv.-;·<••"~·   "V"   -   vvv;.. ~-~v"v-   _v,,,_m_,m




Report of Keith E. Miller, M.D.                                                                                                                                                                                              Page 10




                                                                                                                                                        139
acceptable level of nursing practice set out in Rule 217.11.

14. TAC Chapter 217 Rule §217.12 Unprofessional Conduct (1) Unsafe
Practice - actions or conduct including, but not limited to: (B) Carelessly or
repeatedly failing to conform to generally accepted nursing standards in
applicable practice settings;

15. TAC Chapter 217 Rule §217.12 Unprofessional Conduct (4) Careless or
repetitive conduct that may endanger a client's life, health, or safety. Actual
injury to a client need not be established.

16. 42 CFR 483.20, 483.25-The facility must conduct initially a comprehensive,
accurate assessment of each resident's functional capacity, a plan of care,
based on a resident assessment, which will be used to provide care and
services to attain the highest practical physical, mental, and psychosocial well-
being;

17. 42 CFR 483.15- A facility must care for its residents in a manner that
promotes quality of life and dignity;

18. 42 CFR 483.30- The facility must have sufficient nursing staff to provide
nursing and related services to attain or maintain the highest practicable
physical, mental, and psychosocial well-being of each resident, as determined by
resident assessments and individual plans of care;

19. 42 CFR 483.13, F 224- "Neglect" means failure to provide goods and
services necessary to avoid physical harm, mental anguish, or mental illness.

20. 42 CFR 483.20 (k) (3) (I) - The services provided or arranged by the facility
must meet professional standards of quality;


    HQV\l THE STANDABDS QF C~Jil:: WERE BREA~HED AND CAUSED
                    INJURY.,. HARM, OR DAMAGES

       Illnesses Caused by Failing to Properly Administer Medications

         Ms. Legatha Demings is an adult female whose date of birth is April 28,
1945. In May 2012, Ms. Demings was 67 years-old. She had a past medical
history of hypertension, atrial fibrillation, congestive heart failure, emphysema,
and a previous transient ischemic attack (TIA).

      •'-•••••••••••••••   -•m••··•~--.,-,   ....   ,_~,"   .... _..-,,., ....."'-••-   »•••••·•·-~·•··"··••   •



Report of Keith E. Miller, M.D.                                                                                          Page 11




                                                                                                                   140
          On May 22, 2012, Ms. Demings was living at home. She suddenly
developed slurred speech, weakness in her extremities, and she fell out of bed.
She was taken to a hospital in Carthage, Texas, and then subsequently
transferred to Nacogdoches Medical Center in Nacogdoches, Texas for further
evaluation and treatment.

           In the hospital, Ms. Demings was diagnosed as having had a
cerebrovascular accident (CVA) or stroke. Ms. Demings was discharged from
the hospital on May 25, 2012. In his discharge summary, Ms. Demings'
physician documented that this patient's stroke was of "... ischemic origin, most
likely caused by her atrial fibrillation."

           In order to treat Ms. Demings' condition and prevent further strokes, her
physician discharged her from the hospital on a blood-thinning medication,
Xarelto. This physician stated in his discharge summary that Ms. Demings would
be "... started (on) Xarelto for her anticoagulation to avoid further strokes ... "

          On May 25, 2012, Ms. Demings was discharged from the hospital and
admitted to Garrison Nursing Home and Rehabilitation Center.in Garrison, Texas
for further recovery and rehabilitation. According to Ms. Demings' physician, this
resident had begun to make some improvement as evidenced by improvement in
her speech and increased movement of her left side.

          After being in the care of Garrison Nursing Home and Rehabilitation
Center for less than two weeks, Ms. Demings became "confused, combative,
and unable to communicate". On June 8, 2012, she was taken by emergency
medical services back to Nacogdoches Medical Center for emergency
evaluation. There a computerized tomography (CT) scan of her head revealed
an ischemic infarction of her brain consistent with a stroke.

         One of Ms. Demings' consulting physicians, a neurological specialist,
documented in the medical record that Ms. Demings had suffered a
"Cerebrovascular accident extension with newly developed global aphasia,
aphasia and left-sided flaccid paralysis".

         Ms. Demings remained in the hospital for 12 days, and was discharged
on June 20, 2012. At the time of her discharge from the hospital, Ms. Demings'
physician noted in his discharge summary that this patient's overall medical
condition had deteriorated as a result of her stroke she suffered at Garrison
Nursing home and Rehabilitation Center, to the point that Ms. Demings was
made a do-not-resuscitate status such that if she experienced a cardiovascular
or respiratory failure, she would not be intubated or placed on a venti.lator or
breathing machine .
•"."'"""   "~'''·"~'   , .....,   A•·.-.-•.•-,.-••W<c.   "•"•"•""""•" -.,-.-.·.-;."··..._""'·'····"·~w.v.·m·•~   '"""""""""   --,w~~--~•-."''"·'•"" .v;




Report of Keith E. Miller, M.D.                                                                                                                                 Page 12




                                                                                                                                                          141
       A "Medication Error Report" made by the nursing staff of Garrison Nursing
Home and Rehabilitation Center on June 8, 2012, documented that from the
time Ms. Demings was first admitted to this facility on May 25, 2012 until the time
of her stroke and transfer on June 8, 2012, Ms. Demings was not given her
blood-thinning medication, Xarelto as ordered by her physician. This medication
had been ordered to be given in a dose of 20 milligrams (mgs) at bedtime daily.

         This same report stated that "res. (resident) arrived after 5:00 pm on a
Friday. This medication (Xarelto) was ordered along (with) all other meds from
nursing home pharmacy - nurse transcribing orders had to have all meds written
on pharmacy order sheets and faxed in to pharmacy by 6 pm so they could be
delivered that night".

          The Medication Error Report went on to document that a nurse at this
nursing home "failed to transcribe this med (medication) to MAR (Medication
Administration Record)" ... "an oversight". A question on this same form asked
11
   Could the error have endangered the life or welfare of the patient?" The
responsible nurse completing the form answered the question with "Makes her a
higher risk for stroke in view of her diag (diagnosis) of atrial fibrillation."

           On a subsequent hospitalization on August 5, 2012, in his pre-operative
history and physical, one of Ms. Demings' physicians documented what had
happened to her during her stay at Garrison Nursing Home and Rehabilitation
Center from May 25, 2012 through June 8, 2012. This physician stated that prior
to her first admission to this nursing home, Ms. Demings "was found in atrial
fibrillation. She was started (on) Xarelto. Apparently ... did not follow-through in
the nursing home, and she had ... strokes, disabling, with severe __ . She was
rendered substantially disabled."

       This physician also documented in his discharge summary of this August
5, 2012 hospital stay, the importance of a patient such as Ms. Demings who
suffered with atrial fibrillation, to always remain on a blood-thinning medication
such as Xarelto. He stated that "She is to continue with Xarelto ... lnstructions
were given to the family to make sure that this medication is never stopped."

      The staff of Garrison Nursing Home and Rehabilitation Center in Garrison,
Texas failed to appreciate that Ms. Legatha Demings was at the highest risk for
the development of future strokes due to her past medical history which included
hypertension, atrial fibrillation, a previous TIA, and a previous stroke.

       The nursing staff of Garrison Nursing Home and Rehabilitation Center ob-
viously needed better training in safe and systematic methods to properly trans-
fer medication orders to their MAR Ms. Demings arrived at this nursing home in
Report of Keith E. Miller, M.D.                                             Page 13




                                         142
the late evening on a Friday. The Medication Error Report indicated that the
staff of this nursing home was under a short deadline to get Ms. Demings' medi-
cation orders to the pharmacy in order to obtain her medications by that evening
otherwise they would not receive her medications until at least the following day
or perhaps even longer since the following day fell on a weekend. It is certain
that the nurse transcribing these pharmacy orders felt pressured to get this
process done quickly. Unfortunately there was no procedure in place at the time
of this incident to ensure that medication orders would always be accurately and
precisely transcribed by the nursing staff of this facility, even under stressful situ-
ations.

         After it was recognized by this nursing home staff that Ms. Demings had
failed to properly receive her medications, the nursing staff of this facility recog-
nized the need to improve their procedures for medication ordering from the
pharmacy. In the Medication Error Report, the nursing staff responded to a
question which asked, HWhat precautions can you take to prevent a similar
error?" The nurse completing this report answered by stating "always have two
nurses check orders on new admissions to make sure {orders are) transcribed
correctly".

         The specific steps of an appropriate procedure for Ms. Demings would
have been tailored to her and would have been determined by an extensive as-
sessment by the nursing staff. These measures would have included such
things as having in place an appropriate plan to ensure this resident's medication
orders were .properly transcribed to her MAR, ensure that her medications were
properly ordered and received from the pharmacy, and comparing her physi-
cian's orders with her MAR to ensure her original medication orders were always
being properly carried out.

         As a direct cause, this facility and its staff failed to comply with those
standards set forth in paragraph numbers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,
14, 15, 16, 17, 18, 19, and 20. It is my opinion, based upon my experience,
knowledge, qualifications and review of these records that these standards were
not followed and the result was that Ms. Legatha Demings was harmed and
injured. The failure to comply with these standards caused, within a reasonable
degree of medical and nursing, probability and certainty, Ms. Demings to suffer a
stroke, extensive hospitalization, rehabilitation, and related complications, which
compromised her overall health and well-being, and resulted in an overall
worsening of her condition, unnecessary and preventable pain, suffering, mental
anguish, and loss of dignity. These injuries and illnesses could have, within a
reasonable degree of medical and nursing, probability and certainty, been
prevented or detected/addressed earlier if these standards had been followed.

~    -··--~.   ~   , , ,__. , _ " - ' - '   , , , • --- '~'-·'-'-"'"~"·"~·   --~~' ~-"~   J, ' ' -   • •,.~   •   ·-'·-~"             '   ...   ~~~   ..
Report of Keith E. Miller, M.D.                                                                                                   Page 14




                                                                                                                            143
       To meet the standards, Garrison Nursing Home and Rehabilitation Center
in Garrison, Texas, and its staff were required to do among other things the fol-
lowing when caring for Ms. Legatha Demings:

       A Recognize and act on the fact that Ms. Legatha Demings was at high
         risk for illnesses due to a stroke and its related complications, by pre-
          paring and following a Care Plan based on an accurate assessment;

      B. Specifically implement an effective and accurate Care Plan by ensuring:

         1. That the Care Plan which included the method for safely and accu-
            rately administering Ms. Demings' medications was implemented and
            used at all times;

         2. That Ms. Demings had sufficient and knowledgeable personnel for
            properly administering her. medications safely;

      C. Ensure that a safe and appropriate system was in place to make sure
         that Ms. Demings' physician orders for medications were properly and
         accurately transcribed and transmitted to the pharmacy;

      D. Put in place a method to recheck Ms. Demings' physician mediation or-
         ders from time to time to ensure she was receiving all her necessary,
           prescribed medications; and

      E. Inform and Educate Ms. Demings' family and/or caretakers to the risk
         of suffering illnesses including strokes if she did not properly receive her
         medications.


                                    SUMMARY

I have been advised that "Negligence" means:

           Negligence, when used with respect to the conduct of a medical
facility means failure to use ordinary care, that is, failing to do that which a
medical facility of ordinary prudence would have done under the same or
similar circumstances or doing that which a medical facility of ordinary
prudence would not have done under the same or similar circumstances.




Report of Keith E. Miller, M.D.                                              Page 15




                                          144
 I have been advised "proximate cause" means:

        That cause which, in a natural and continuous sequence, produces an
event, and without cause such event would not have occurred. In order to
be a proximate cause, the act or omission complained of must be such
that a health care facility,        using ordinary care,       would have
foreseen that the event or some similar event might reasonably result there
from. There may be more than one proximate cause of an event.

         More likely than not, this failure on the part of Garrison Nursing Home and
Rehabilitation Center in Garrison, Texas, to practice in an acceptable manner
directly resulted in Ms. Legatha Demings' illnesses due to a stroke and its
complications, as well as overall worsening of her condition, unnecessary and
preventable pain, suffering, extensive hospitalization, mental anguish, and loss
of dignity. As more specifically set forth above, the actions and inactions of this
facility caused the conditions and complications described above.

            In summary, Garrison Nursing Home and Rehabilitation Center in
Garrison, Texas, did not meet the standard of care in their treatment of Ms.
Legatha Demings. It is my opiniqn, based on my medical education, experience,
and training and based upon a reasonable degree of medical and nursing,
probability and certainty, that these negligent acts and omissions as stated
above proximately caused Ms. Demings' illnesses due to a stroke, and their
complications, along with overall worsening of condition, as well as caused her
unnecessary and preventable pain, extensive hospitalization, suffering, mental
anguish, and loss of dignity. It is my opinion that Garrison Nursing Home and
Rehabilitation Center in Garrison, Texas, knew or should have known that their
failure to meet the standards of care would put Ms. Demings at extreme risk of
harm and knew or should have known that this failure to meet these standards
would likely cause complications or illnesses to Ms. Demings. Nevertheless,
Garrison Nursing Home and Rehabilitation Center still failed to follow the above
standards. Had the standards of care been followed by Garrison Nursing Home
and Rehabilitation Center, more likely than not and based upon a reasonable
degree of medical and nursing, probability and certainty, Ms. Demings would not
have suffered the illnesses due to a stroke, along with their complications, as
well as overall worsening of her condition, unnecessary and preventable pain,
suffering, extensive hospitalization, mental anguish, and loss of dignity.




Report of Keith E. Miller, M.D.                                             Page 16




                                         145
                                  Respectfully $Ubmitted,

                                  ljl/Jr:1t      iy
                                  J(~ l , /f/M'JI '
                                  Keith E. Miller, M.D,
                                  620 Tenaha Street
                                  Center, Texas 75935




Report of Keith E. Miller, M.D.                             Page 17




                                     146
CURRICULUM VITAE



 KEITH   ~.   MILLER, M.D.



   620 Tenaha Street

 Center, Texas 75935

    (936) 598-2716




               147
           KEITH E. MILLER, M.D.


                - EDUCATION -

           Chief Resident, 7/87 to 6/88
University of Arkansas Medical Sciences Campus
 Area Health Education Center, South Arkansas
               El Dorado, Arkansas

    Family Practice Residency, 7/86 to 6/88
University of Arkansas Medical Sciences Campus
 Area Health Education Center, South Arkansas
               El Dorado, Arkansas

      Family Practice Internship, 7/85 to 6/86
                University Hospital
              Little Rock, Arkansas

     Doctor of Medicine Degree, 8/81 to 5/85
    University of Arkansas College of Medicine
               Little Rock, Arkansas

               Attended, 8/80 to 5/81
University of Arkansas at Little Rock, School of Law
                Little Rock, Arkansas

           Bachelor of Arts, 8/76 to 5/79
             German and Chemistry
               Baylor of University
                  Waco, Texas

              Attended, 8/75 to 5/76
              Biology and Chemistry
            East Texas Baptist College
                  Marshall, Texas

       Shelbyville High School, 8/71 to 5/75
                 Shelbyville, Texas




                         2

                         148
                         KEITH E. MILLER, M.D.


                        -PRACTICE ACTIVITIES-

           Full Time Family Medicine Practice, July 1988 to Present

                         Commissioner, 9/03 to 9/07
        Texas State Board of Medical Examiners I Texas Medical Board
                   State Medical Licensing Board of Texas

         Physician Consultant for Physician Peer Review, 8/90 to 9/03
                   Texas State Board of Medical Examiners
                    State Medical Licensing Board of Texas

    Member, Texas Statewide Medical Advisory Committee, 8/95 to Present
                      Blue Cross/Blue Shield of Texas
Performs Physician Peer Review for All Blue Cross/Blue Shield Patients in Texas

                          President, 1990 to Present
                        Shelby County Medical Society

       Advisory Committee Member and Clinical Faculty, 8/90 to Present
                   School of Licensed Vocational Nursing
                               Panola College
                               Center, Texas

       Member, Board of Directors, and Medical Director, 8/90 to Present
                   Shelby County Child Advocacy Center
                                Center, Texas

                              2014 to Present
                      Family Medicine Service Privileges
                       Memorial Hospital San Augustine
                            San Augustine, Texas

                              2014 to Present
                      Family Medicine Service Privileges
                        Nacogdoches Medical Center
                            Nacogdoches, Texas

      Former Physician Reviewer, Texas Medical Foundation, 8/90 to 8/03
           Performs Physician Peer Review/Quality Assurance for
                All Medicare and Champus Patients in Texas

                                       3

                                      149
           KEITH E. MILLER, M.D.

  -PRACTICE ACTIVITIES (CONTINUED)-

  Former Clinical Faculty, Preceptor, 8/90 to 8/03
   University of Texas Health Sciences Center
      Family Practice Residency Program
                   Tyler, Texas

Former Director of Emergency Services, 8/90 to 8/11
         Shelby Regional Medical Center
                   Center, Texas

               Former Chief of Staff
          Shelby Regional Medical Center
                  Center, Texas

                 July 1988 to 2013
     Full Time Active Family Practice Privileges
           Shelby Regional Medical Center
                    Center, Texas

            September 2010 to Present
                 Medical Director
             Legacy Hospice of Center
                  Center, Texas

              March 2011 to Present
            Assistant Medical Director
            The Hospice of East Texas
                  Tyler, Texas

                July 1988 to Present
     Full Time Active Family Practice Privileges
               Holiday Nursing Home
                    Center, Texas

                July 1988 to Present
     Full Time Active Family Practice Privileges
             Pine Grove Nursing Home
                    Center, Texas



                          4

                         150
         KEITH E. MILLER, M.D.

-PRACTICE ACTIVITIES (CONTINUED)-

             July 1988 to Present
  Full Time Active Family Practice Privileges
          Green Acres Nursing Home
                 Center, Texas

             July 1988 to Present
  Full Time Active Family Practice Privileges
          Twin Lakes Nursing Home
            San Augustine, Texas

             July 1988 to Present
  Full Time Active Family Practice Privileges
         Colonial Pines Nursing Home
            San Augustine 1 Texas

              July 1988 to Present
  Full Time Active Family Practice Privileges
   Trinity Nursing and Rehabilitation Center
             San Augustine, Texas

              July 1988 to Present
  Full Time Active Family Practice Privileges
        El Camino House Nursing Home
             San Augustine, Texas

          December 2013 to Present
  Full Time Active Family Practice Privileges
        Lakeside Village Assisted Living
                 Center1 Texas

          March 2012 to Present
              Medical Director
     Bethany Home Health Care Agency
             Carthage, Texas

         January 2014 to May 2015
      Medical Director, Jennings Place
   Day Care for Mentally Challenged Adults
                Center, Texas

                       5

                      151
             KEITH E. MILLER, M.D.


         - BOARD CERTIFICATIONS -

    American Board of Family Medicine, ID 53861

            Certification Date July 8, 1988

          Re-Certification Date July 14, 1995

          Re-Certification Date July 12, 2002

          Re-Certification Date July 15, 2010


    - PROFESSIONAL CERTIFICATIONS -

      Hospice Medical Director Certified (HMDC)
     Hospice Medical Director Certification Board
               July 8, 2014 to Present

             Certified Medical Review Officer
      Medical Review Officer Certification Council
       United States Department of Transportation
United States Department of Health and Human Services
               Certified February 21, 2006
              Re-certified March 24, 2012

               Certified Medical Examiner
       Federal Motor Carrier Safety Administration
       United States Department of Transportation
United States Department of Health and Human Services
               Certified February 11, 2014

          Fellow (AAFP), 1990 to Present
       American Academy of Family Physicians

             American Heart Association
                    CPR Instructor
       Advanced Cardiac Life Support Instructor
       Pediatric Advanced Life Support Provider



                           6

                           152
               KEITH E. MILLER, M.D.


       - PROFESSIONAL AFFILIATIONS ..

            American Medical Association

             Southern Medical Association

       American Academy of Family Physicians

              Texas Medical Association

            Shelby County Medical Society


          - VOLUNTEER ACTIVITIES -

                Texas State Legislature
         Physician of the Day, 1989 to Present

Coordinator, Free Physicals Programs, 1988 to Present
                Department of Athletics
  Center Independent School District, Center, Texas

          Team Physician, 1988 to Present
               Department of Athletics
          Center Independent School District

    Vice~President,
                  Board of Trustees, 1990 to 1999
   Center Independent School District, Center, Texas

              Preceptor, 1990 to Present
Texas Statewide Medical Student Preceptorship Program

            Member, Development Council
                 Baylor University

 Former Member, Committee on Rural Health Concerns
            Texas Medical Association

     Former Member1 Committee on Rural Health
        Texas Academy of Family Physicians


                           7
                          153
          KEITH E. MILLER, M.D.


                -LI CENSURE-

    State of Texas (H-2155), 8/87 to Present

 Formerly Licensed in Arkansas and Louisiana


                 -AWARDS-

    Texas Academy of Physician Assistants
    Supervising Physician of the Year - 2004

         American Medical Association
         Physician's Recognition Award

   American Academy of Family Physicians
Award for Clinical Instruction of Medical Students

    Center Independent School District
 Community Service Award for Contributions to
     Student Academics and Athletics

   Anderson County Educational Cooperative
   Service Award for Organizing Programs for
           Special Services Students

            Texas State Legislature
     Award of Appreciation for Serving as
    Physician to Legislators While in Session


             - PUBLICATIONS -

 "Use of Digoxin in the Family Practice Setting"
    Journal of the Arkansas Medical Society
                 February 1988




                        8

                        154
                            KEITH E. MILLER, M.D.


                                  -ARTICLES-

                 "More Doctors in Texas After Malpractice Caps"
                                New York Times
                                October 5, 2007
        Story of Texas Medical Board Responding to Increased Licensing
       Demands During My Tenure as Chairman of the Licensing Committee

                              "Dangerous Doctors"
                                Reader's Digest
                                    June 2004
               Background Story of Texas Medical Board Prior to My
                        Appointment as a Commissioner

                         "Dangerous Doctors - Follow-Up"
                                  Reader's Digest
                                   March 2005
                 Follow-up Story of Texas Medical Board After My
Appointment as a Commissioner Including Motion Made by Myself for the Largest Fine
                  Levied Against a Doctor by any State in History

                               "No Medicinal Jet Fuel"
                                   Texas Medicine
                                    August 2009
 Story of My Filing of Complaint Against a Physician for Non-Therapeutic Prescribing


                                 - PERSONAL ..

                       Married to Linda Gee Miller since 1975

    Interests Are Health-Care Reform and Finance Issues, in America and Abroad

                   Speaks Fluent German and Passable Spanish

                       Instrument-Rated Private Aircraft Pilot

                           Umpire, High School Baseball



                                          9

                                         155
     APPENDIX ''C''

Section 74.351, Texas Civil
Practice and Remedies Code
§ 74.351. Expert Report, TX CIV PRAC & REM§ 74.351




 !Vernon's Texas Statutes and Codes Annotated
   ICivil Practice and Remedies Code (Refs &Annas)
     ITitle 4. Liability in Tort
        IChapter 74. Medical Liability (Refs &Annas)
           ISubchapter H. Procedural Provisions (Refs &Annas)

                                     V.T.C.A., Civil Practice & Remedies Code§ 74.351

                                                   § 74.351. Expert Report

                                                Effective: September 1, 2013
                                                            Currentness




(a) In a health care liability claim, a claimant shall, not later than the 120th day after the date each defendant's original
answer is filed, serve on that party or the party's attorney one or more expert reports, with a curriculum vitae of each expert
listed in the report for each physician or health care provider against whom a liability claim is asserted. The date for serving
the report may be extended by written agreement of the affected parties. Each defendant physician or health care provider
whose conduct is implicated in a report must file and serve any objection to the sufficiency of the report not later than the
later of the 21st day after the date the report is served or the 21st day after the date the defendant's answer is filed, failing
which all objections are waived.



(b) If, as to a defendant physician or health care provider, an expert report has not been served within the period specified by
Subsection (a), the court, on the motion of the affected physician or health care provider, shall, subject to Subsection (c),
enter an order that:



  (1) awards to the affected physician or health care provider reasonable attorney's fees and costs of court incurred by the
  physician or health care provider; and



  (2) dismisses the claim with respect to the physician or health care provider, with prejudice to the refiling of the claim.



(c) If an expert report has not been served within the period specified by Subsection (a) because elements of the report are
found deficient, the court may grant one 30-day extension to the claimant in order to cure the deficiency. If the claimant does
not receive notice of the court's ruling granting the extension until after the 120-day deadline has passed, then the 30-day
extension shall run from the date the plaintiff first received the notice.



(d) to (h) [Subsections ( d)-(h) reserved]




         . Next © 2015 Thornson Reuters. No cl2irn to                     L.1. S. Governrnent ~t\/orks .
§ 74.351. Expert Report, TX CIV PRAG & REM§ 74.351



(i) Notwithstanding any other provision of this section, a claimant may satisfy any requirement of this 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.



G) Nothing in this section shall be construed to require the serving of an expert report regarding any issue other than an issue
relating to liability or causation.



(k) Subject to Subsection (t), an expert report served under this section:



  (1) is not admissible in evidence by any party;



  (2) shall not be used in a deposition, trial, or other proceeding; and



  (3) shall not be referred to by any party during the course of the action for any purpose.



(l) A court shall grant a motion challenging the adequacy of an expert report only if it appears to the court, after hearing, that
the report does not represent an objective good faith effort to comply with the definition of an expert report in Subsection
(r)(6).



(m) to (q) [Subsections (m)-(q) reserved]



(r) In this section:



  (1) "Affected parties" means the claimant and the physician or health care provider who are directly affected by an act or
  agreement required or permitted by this section and does not include other parties to an action who are not directly affected
  by that particular act or agreement.



   (2) "Claim" means a health care liability claim.



   (3) [reserved]


          Next © 2015 Thomson Reuters. No cl2im to                     U.S. Governrnent \/\/orks.                               2
§ 74.351. Expert Report, TX CIV PRAG & REM§ 74.351




  (4) "Defendant" means a physician or health care provider against whom a health care liability claim is asserted. The term
  includes a third-party defendant, cross-defendant, or counterdefendant.



  (5) "Expert" means:



    (A) with respect to a person giving opinion testimony regarding whether a physician departed from accepted standards
    of medical care, an expert qualified to testify under the requirements of Section 74.401;



    (B) with respect to a person giving opinion testimony regarding whether a health care provider departed from accepted
    standards of health care, an expert qualified to testify under the requirements of Section 74.402;



    (C) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or damages
    claimed and the alleged departure from the applicable standard of care in any health care liability claim, a physician who
    is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence;



    (D) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or
    damages claimed and the alleged departure from the applicable standard of care for a dentist, a dentist or physician who
    is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence; or



    (E) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or damages
    claimed and the alleged departure from the applicable standard of care for a podiatrist, a podiatrist or physician who is
    otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence.



  (6) "Expert report" means 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.



(s) Until a claimant has served the expert report and curriculum vitae as required by Subsection (a), all discovery in a health
care liability claim is stayed except for the acquisition by the claimant of information, including medical or hospital records
or other documents or tangible things, related to the patient's health care through:



  (1) written discovery as defined in Rule 192.7, Texas Rules of Civil Procedure;




                © 2 0 ~ 5 Tho1T~scd1 R.suters,
§ 74.351. Expert Report, TX CIV PRAC & REM§ 74.351



   (2) depositions on written questions under Rule 200, Texas Rules of Civil Procedure; and



   (3) discovery from nonparties under Rule 205, Texas Rules of Civil Procedure.



(t) If an expert report is used by the claimant in the course of the action for any purpose other than to meet the service
requirement of Subsection (a), the restrictions imposed by Subsection (k) on use of the expert report by any party are waived.



(u) Notwithstanding any other provision of this section, after a claim is filed all claimants, collectively, may take not more
than two depositions before the expert report is served as required by Subsection (a).



Credits

Added by Acts 2003, 78th Leg., ch. 204, § 10.01, eff. Sept. 1, 2003. Amended by Acts 2005, 79th Leg., ch. 635, § 1, eff
Sept. 1, 2005; Acts 2013, 83rd Leg., ch. 870 (H.B. 658), § 2, eff Sept. 1, 2013.



V. T. C. A., Civil Practice & Remedies Code§ 74.351, TX CIV PRAC & REM§ 74.351
g~~1..1.!!~()1:1g!?:th<'. <'.?.4?.f !!?:<'.~9!?~<'.g1:1l(;l~ §<'.~~i?.1..1.()f!h<'. ?~th!::<'.g~~l(;l~~<'.
End of Document                                                                CO 2015 Thomson Reuters. No claim to original U.S. Government Works.
