                           NUMBER 13-10-00309-CV

                          COURT OF APPEALS

                THIRTEENTH DISTRICT OF TEXAS

                   CORPUS CHRISTI - EDINBURG

CHRISTUS SPOHN HEALTH SYSTEM
CORPORATION D/B/A CHRISTUS SPOHN
HOSPITAL CORPUS CHRISTI - SOUTH,                                        Appellant,

                                         v.

JESSE J. CERVANTES, INDIVIDUALLY AND
ON BEHALF OF THE ESTATE OF ELENA F.
CERVANTES, DECEASED, AND JOANN
ESCOBAR, AND NELDA VELA, INDIVIDUALLY,                                  Appellees.


                  On appeal from the 319th District Court
                        of Nueces County, Texas.


                       MEMORANDUM OPINION
               Before Justices Garza, Benavides, and Vela
                Memorandum Opinion by Justice Garza
      In this interlocutory appeal, appellant Christus Spohn Health System Corporation

d/b/a Christus Spohn Hospital Corpus Christi-South (―Christus‖) challenges the trial
court‘s order denying its motion to dismiss a health care liability claim brought by

appellees Jesse J. Cervantes, individually and on behalf of the estate of Elena F.

Cervantes, Joann Escobar, and Nelda Vela. By a single issue, Christus contends that

the trial court erred in concluding that appellees‘ expert reports complied with section

74.351 of the civil practice and remedies code. See TEX. CIV. PRAC. & REM. CODE ANN. §

74.351 (Vernon Supp. 2010). We affirm.

                                        I. BACKGROUND

       Elena Cervantes, a 51-year-old woman, was admitted to Christus on November

24, 2006, complaining of shortness of breath, chest pain, cough, and fever. Nicole

Ewing, M.D., an emergency room physician, examined Elena and noted that she was

―toxic appearing,‖ had a rapid heart rate and difficulty breathing. Dr. Ewing also noted

that Elena had highly elevated blood sugar and low oxygen saturation in her blood. After

further examination, Dr. Ewing diagnosed Elena with community-acquired pneumonia.

Elena was then admitted to Christus‘s intensive care unit (―ICU‖), where she was treated

by Sunil K. Gupta, M.D.        On Dr. Gupta‘s orders, Elena began taking Levaquin, an

antibiotic. Several hours later, a nurse reported that Elena was aphasic, or unable to

speak. After undergoing a CT scan, Elena went into respiratory arrest at around 2:00

a.m. the following morning. At around 9:00 a.m., another physician, Pradyumma C.

Mummady, M.D., examined Elena. Elena died at 9:56 a.m. Blood cultures taken after

Elena‘s death revealed the presence of Staphylococcus bacteria.

       Appellees1 filed suit against Christus and Drs. Ewing, Gupta, and Mummady on


       1
            Appellee Jesse Cervantes is Elena‘s surviving husband. The record does not reflect what
relation, if any, appellees Escobar and Vela had to Elena.

                                                2
November 17, 2008. 2 The lawsuit alleged in part that Christus, by and through its

nursing staff, (1) improperly assessed Elena‘s medical condition, (2) failed to notify the

physicians of changes in Elena‘s medical condition, (3) improperly responded to Elena‘s

changes in condition, and (4) improperly administered medical and nursing care and

treatment to Elena.         In support of their original petition, appellees attached expert

medical reports authored by John J. Stern, M.D., a clinical professor of medicine at the

University of Pennsylvania, and Beatriz C. Smith, a registered nurse.               See id. §

74.351(a).

       Christus timely responded to the lawsuit and filed objections to the sufficiency of

the expert reports. After a hearing on January 20, 2010, the trial court agreed with

Christus that the reports were insufficient. The trial court specifically found that, with

respect to Christus, ―the reports together are sufficient to detail the conduct the plaintiff

calls into question. However, the Court finds that the reports, taken together, do not

adequately address the standard of care required of the nurses and do not adequately

address the issue of causation.‖              The trial court granted appellees one thirty-day

extension to cure the deficiency. See id. § 74.351(c).

       On March 19, 2010, appellees filed supplemental reports by Smith and Dr. Stern.

In her supplemental report, Smith stated that the standard of care applicable to the

nursing staff was to:

       1.        Perform comprehensive nursing assessments regarding the health
                 status of the patient, and in the case of Elena Cervantes, note in
                 particular her medical history of staphylococcus infection and clearly
                 observable symptoms of sepsis.

       2.        Make nursing diagnoses that serve as the basis for the strategy of
       2
           The individual physician defendants are not parties to this appeal.
                                                      3
                 care, and in the case of Elena Cervantes, note in particular her
                 medical history of staphylococcus infection, consequent
                 susceptibility to same, and symptoms of acute sepsis.

       3.        Develop a plan of care based on the assessment and nursing
                 diagnosis.

       4.        Implement appropriate nursing care.

       5.        Evaluate the patient‘s responses to nursing interventions, and in the
                 case of Elena Cervantes, notify treating physicians and emergency
                 room and ICU physicians of the non-efficacy of measures to control
                 blood glucose and infection.

Smith then identified the following breaches of the standard of care:

       1.        In emergency room triage, the nursing staff failed to perform a proper
                 assessment that would have alerted hospital staff to Elena
                 Cervantes‘[s] clearly observable symptoms of sepsis and allow
                 notification of treating physicians and emergency room and ICU
                 physicians.

       2.        The emergency room nursing staff failed to notify Elena
                 Cervantes‘[s] physicians of the dire nature of her condition—namely
                 uncontrolled blood sugar and symptoms of acute sepsis.

       3.        In the emergency room, L. Guarneri, R.N., failed to perform a
                 comprehensive assessment of the health status of Elena Cervantes
                 and failed timely to assess and implement interventions on Elena
                 Cervantes‘[s] behalf, including control of blood glucose by insulin
                 administration and treatment of infection via antibiotic
                 administration. . . .

       4.        Nurse Guarneri also failed to evaluate Elena Cervantes‘[s] response
                 to the administered therapies and communicate the non-efficacy of
                 efforts to control infection. . . . .[3]

In his supplemental report, Dr. Stern stated that the ICU nursing staff breached the

applicable standard of care by ―fail[ing] to accurately note the clinical symptoms and

presentation of Elena Cervantes so that those symptoms could be conveyed to her

treating physicians‖ and by ―fail[ing] to convey to Elena Cervantes‘[s] physicians the dire
       3
           Smith did not address the issue of causation in her report.
                                                      4
nature of her condition and to insist that she have prompt physician evaluation.‖ Dr.

Stern then offered the following opinion as to how these breaches caused the damages

suffered by Elena:

       1.     Accurately noting the patient‘s symptoms and presentation. Had
              the nursing staff properly observed and reported Elena Cervantes‘[s]
              symptoms, presentation, and medical history, in reasonable medical
              probability her acute sepsis would have been diagnosed and treated
              earlier and within the window of opportunity when such treatment
              would have been much more likely to be effective. The failure of the
              nursing staff to impress upon Elena Cervantes‘[s] physicians the dire
              nature of her condition contributed to the failure to treat her properly
              and, ultimately, her death.

       2.     Communication of the patient‘s condition to her physicians. Had the
              nursing staff demanded earlier physician involvement, Ms.
              Cervantes‘[s] care probably would have, at a minimum, included
              additional appropriate antibiotic therapy.       A reasonable ICU
              physician, upon being presented with a realistic account of Ms.
              Cervantes‘[s] condition[,] would have prescribed a broad-based
              course of antibiotic therapy.         Given that her death was
              unquestionably secondary to the relentless effect of a
              Staphylococcal aureus sepsis, earlier physician involvement would
              certainly have had a saluterious [sic] effect on her health and in
              reasonable probability saved her life.

       Christus again objected to the reports‘ sufficiency and moved to dismiss, asserting

that Smith‘s report ―improperly opines on causation‖ and that Dr. Stern‘s report ―is

conclusory on the issue of causation, and does not directly link actions or omissions by

the nurses to injuries suffered by the plaintiffs.‖ After a hearing, the trial court found the

reports to be adequate and denied Christus‘s motion to dismiss.            This accelerated

interlocutory appeal followed. See id. § 51.014(a)(9) (Vernon 2008) (permitting appeal

of interlocutory order denying all or part of a motion to dismiss for failure to serve an

expert report in a health care liability claim); TEX. R. APP. P. 28.1(a) (stating that appeals



                                              5
from interlocutory orders are accelerated).

                           II. STANDARD OF REVIEW AND APPLICABLE LAW

       We review a trial court‘s order denying a motion to dismiss for failure to comply

with the expert report requirement under an abuse of discretion standard. NCED Mental

Health, Inc. v. Kidd, 214 S.W.3d 28, 32 (Tex. App.–El Paso 2006, no pet.) (applying

abuse of discretion standard to trial court‘s denial of motion to dismiss); Kendrick v.

Garcia, 171 S.W.3d 698, 702 (Tex. App.–Eastland 2005, pet. denied) (same); see Am.

Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex. 2001) (applying

abuse of discretion standard to trial court‘s granting of motion to dismiss). A trial court

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

to any guiding rules or principles. Downer v. Aquamarine Operators, Inc., 701 S.W.2d

238, 241-42 (Tex. 1985). However, a trial court has no discretion in determining what

the law is or in applying the law to the facts. Walker v. Packer, 827 S.W.2d 833, 840

(Tex. 1992); Baylor Univ. Med. Ctr. v. Biggs, 237 S.W.3d 909, 916 (Tex. App.–Dallas

2007, pet. denied).          Therefore, when the issues are purely questions of law, we

effectively conduct a de novo review. See Pallares v. Magic Valley Elec. Coop., Inc., 267

S.W.3d 67, 69-70 (Tex. App.–Corpus Christi 2008, pet. ref‘d).

       Under chapter 74, a plaintiff asserting a health care liability claim must serve a

medical expert report upon each party‘s attorney no later than the 120th day after the date

the original petition was filed. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a).4 The


       4
           The statute defines ―health care liability claim‖ as:

       a cause of action against a health care provider or physician for treatment, lack of
       treatment, or other claimed departure from accepted standards of medical care, or health
       care, or safety or professional or administrative services directly related to health care,
                                                        6
report must ―provide[] a fair summary of the expert‘s opinions as of the date of the report

regarding applicable standards of care, the manner in which the care rendered by the

physician or health care provider failed to meet the standards, and the causal relationship

between that failure and the injury, harm, or damages claimed.‖ Id. § 74.351(r)(6). If it

appears to the court, after a 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),‖ then the

trial court must dismiss the claim. Id. § 74.351(l). To constitute a ―good faith effort,‖ the

report must provide enough information 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. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002);

see Palacios, 46 S.W.3d at 879.

       The trial court should look no further than the report itself, because all the

information relevant to the inquiry is contained within the document‘s four corners.

Bowie Mem’l Hosp., 79 S.W.3d at 52 (citing Palacios, 46 S.W.3d at 878). The report

need not marshal all the plaintiff‘s proof, but it must include the expert‘s opinion on each of

the three elements that the civil practice and remedies code identifies: standard of care,

breach, and causation. Id. Moreover, an expert cannot merely state conclusions about

these elements; the expert must explain the basis of his or her statements to link the

conclusions with the facts. Id. (citing Palacios, 46 S.W.3d at 878; Earle v. Ratliff, 998

S.W.2d 882, 890 (Tex. 1999)).



       which proximately results in injury to or death of a claimant, whether the claimant‘s claim or
       cause of action sounds in tort or contract.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(13) (Vernon 2005). It is undisputed that appellees‘ claims
fall under this definition.
                                                     7
                                                III. ANALYSIS

        Christus argues on appeal that Dr. Stern‘s opinion is inadequate under chapter 74

because it is conclusory and speculative as to causation.5 See id.

        First, Christus asserts that the report is conclusory as to causation because it ―fails

to explain exactly what [Christus] nurses should have done, yet failed to do.‖ 6 Christus

specifically takes issue with Dr. Stern‘s statements that: (1) Elena‘s acute sepsis would

have been diagnosed earlier ―[h]ad the nursing staff properly observed and reported

[Elena‘s] symptoms, presentation, and medical history‖; and (2) the failure of the nurses

to ―impress upon‖ the physicians the ―dire nature‖ of Elena‘s condition contributed to her

death. Christus argues that ―[w]ords like ‗proper‘ and ‗impress upon‘ and ‗dire‘ are

subjective and do not inform [Christus] of exactly how the nurses‘ actions or omissions

allegedly caused [Elena‘s] injury and/or death.‖                    See Palacios, 46 S.W.3d at 880

(―Whether a defendant breached his or her duty to a patient cannot be determined absent

specific information about what the defendant should have done differently . . . a fair

summary must set out what care was expected, but not given.‖). However, Dr. Stern‘s
        5
           We note that Christus‘s arguments on appeal pertain entirely to Dr. Stern‘s report. Christus does
not argue on appeal that Smith‘s report was inadequate in any way, despite having previously asserted in
its objections and motion to dismiss in the trial court that Smith‘s report ―improperly opine[d] on causation.‖
The judgment on appeal—which merely stated that the trial court found ―the reports to be
adequate‖—arguably implied that each report is independently adequate to satisfy the chapter 74
requirement. If that were the case, then we would be bound to affirm the trial court‘s judgment regardless
of the adequacy of Dr. Stern‘s report. Nevertheless, the parties do not address this possibility. Moreover,
the parties appear to agree on appeal that Smith‘s report did not address the issue of causation at all.
Accordingly, we will affirm only if Dr. Stern‘s report was adequate as to the issue of causation.
        6
          As appellees note, this argument appears to challenge the adequacy of Dr. Stern‘s report with
respect to the standard of care element, rather than the causation element. However, Christus‘s
objections to Dr. Stern‘s report in the trial court complained only that the report ―is conclusory on the issue of
causation, and does not directly link actions or omissions by the nurses to injuries suffered by the plaintiffs.‖
Therefore, Christus has not preserved any issue regarding the adequacy of Dr. Stern‘s report with respect
to the standard of care element. See Barber v. Dean, 303 S.W.3d 819, 826 n.5 (Tex. App.–Fort Worth
2009, no pet.) (noting that grounds for insufficiency of an chapter 74 expert report not specifically raised by
timely objection are waived). We will address Christus‘s issue only insofar as it bears upon the adequacy
of the report as to the causation element.
                                                        8
statements regarding causation obviously referenced the explanation earlier in his report

that the nursing staff breached its standard of care by failing to note Elena‘s ―fever, poor

oxygen and CO2 processing‖ and ―her history of staphylococcal infection‖ and by failing to

communicate those facts to Elena‘s treating physicians. This statement explained what

the nurses should have done; the subsequent statement regarding causation then

explained why the nurses‘ failure to do those things led to the damages claimed by Elena.

       Christus further contends that Dr. Stern‘s report is speculative because ―it provides

no basis for his assumption that the nurses (as opposed to the independent actions of

[the] physician defendant[s]) affirmatively caused Ms. Cervantes harm.‖ In support of

this contention, Christus cites Costello v. Christus Santa Rosa Health Care Corp., in

which the plaintiff‘s expert opined merely that ―[i]f this patient would have been

appropriately triaged and evaluated, then in all medical probability she would have

survived.‖ 141 S.W.3d 245, 249 (Tex. App.–San Antonio 2004, no pet.). The San

Antonio Court of Appeals found this to be inadequate for purposes of chapter 74, noting

that ―[w]hile no particular term or phrase is required for an expert to establish causation,

the converse is also true,‖ and ―[w]ithout more, the magic words of ‗reasonable medical

probability‘ provide no evidence of causation.‖      Id.   Here, however, Dr. Stern has

provided more than just ―magic words‖; he has explained exactly what the nurses should

have done and why their failure to do it probably caused Elena to suffer harm.

Specifically, Dr. Stern noted that, had the nurses ―demanded earlier physician

involvement,‖ those physicians would have at least prescribed additional antibiotic

therapy, which probably would have saved Elena‘s life. Although Dr. Stern‘s causation



                                             9
theory with respect to the nurses is dependent on subsequent actions taken by a

physician, Dr. Stern also opines that ―[a] reasonable ICU physician, upon being presented

with a realistic account of Ms. Cervantes‘[s] condition[,] would have prescribed a

broad-based course of antibiotic therapy.‖           He has provided the necessary causal

link—from the nurses‘ omissions to the physicians‘ actions to the damages suffered by

Elena—thereby providing ―a basis for the trial court to conclude that the claims have

merit.‖ Bowie Mem’l Hosp., 79 S.W.3d at 52.

       Finally, Christus argues that ―Dr. Stern‘s choice of terminology‖—specifically, his

use of the word ―probably‖—―belies the speculative nature of his causation opinion.‖

Christus states as follows in its appellate brief:

       As explained by the Texas Supreme Court, words like ―probably,‖
       ―‗perhaps,‘ and ‗possibly‘ indicate conjecture, speculation, or mere
       possibility rather than a qualified opinion based on reasonable medical
       probability.‖ Columbia Med. Ctr. of Los Colinas, Inc. v. Hogue, 271 S.W.3d
       238, 246-47 (Tex. 2008) . . . .

This is a mischaracterization of the supreme court‘s holding in Hogue. In that case, the

Court found, in a legal sufficiency challenge to the evidence supporting the verdict in favor

of the plaintiff, the following expert testimony to be insufficient to raise a question of fact

on causation:

       Q:       And if you would have considered [a] cardiac cause higher on [your
                differential diagnosis], would that have meant you would have
                considered obtaining a consultation of a cardiologist?

       A:       Possibly.

       Q:       Would that have meant that you would have considered requesting
                an echocardiogram?

       A:       Possibly.


                                              10
Id. at 247. The Court then explained that ―‗[p]erhaps‘ and ‗possibly‘ indicate conjecture,

speculation or mere possibility rather than qualified opinions based on reasonable

medical probability.‖   Id.   Christus‘s attempt to add ―probably‖ to the list of words

indicating conjecture is obviously wrong. In fact, ―probability‖ with respect to causation is

precisely the standard for recovery in an action under chapter 74. See, e.g., Columbia

Rio Grande Healthcare v. Hawley, 284 S.W.3d 851, 860 (Tex. 2009) (―Recovery in a

medical malpractice case requires proof to a reasonable medical probability that the

injuries complained of were proximately caused by the negligence of a defendant.‖

(Emphasis added.)). Dr. Stern‘s well-supported opinion that certain additional action by

the nurses would have ―in reasonable probability saved [Elena‘s] life‖ was sufficient to

―provide a basis for the trial court to conclude that the claims have merit.‖ Bowie Mem’l

Hosp., 79 S.W.3d at 52.         Accordingly, the report complied with the chapter 74

requirement.

       We conclude that the trial court did not err by denying Christus‘s motion to dismiss.

Christus‘s sole issue is overruled.

                                      IV. CONCLUSION

       We affirm the judgment of the trial court.


                                                         ________________________
                                                         DORI CONTRERAS GARZA
                                                         Justice

Delivered and filed the
10th day of February, 2011.




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