                                       IN THE
                               TENTH COURT OF APPEALS

                                       No. 10-09-00297-CV

GRANBURY HOSPITAL CORPORATION
D/B/A LAKE GRANBURY MEDICAL CENTER,
                                                                            Appellant
    v.

DONNA HOSACK AS REPRESENTATIVE
OF THE ESTATE OF TEMPLE HALL,
                                                                            Appellee



                                 From the 18th District Court
                                   Johnson County, Texas
                                 Trial Court No. C200900041


                               MEMORANDUM OPINION


         Donna Hosack, as Representative of the Estate of Temple Hall, sued Granbury

Hospital Corporation d/b/a Lake Granbury Medical Center (“LGMC”) for negligence,

gross negligence, and wrongful death.1 After receiving Hosack’s expert reports, LGMC

filed a motion to dismiss Hosack’s lawsuit pursuant to section 74.351 of the Civil

Practice and Remedies Code. The trial court denied the motion. On appeal, LGMC


1
         Hosack sued other defendants who are not parties to this appeal.
challenges the denial of its motion to dismiss, arguing that Hosack’s expert reports are

insufficient as to causation. We reverse and remand.

                  STANDARD OF REVIEW AND APPLICABLE LAW

       When considering a motion to dismiss under section 74.351, the issue for the trial

court is whether the report represents a good-faith effort to comply with the statutory

definition of an expert report. See Bowie Mem'l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.

2002); see also Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex.

2001). An “expert report” is:

       A written report by an expert that provides a fair summary of the
       expert’s opinions as of the date of the report regarding the applicable
       standards of care, the manner in which the care rendered by the physician
       or health care provider failed to meet the standards and the causal
       relationship between that failure and the injury, harm, or damages
       claimed.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6) (Vernon Supp. 2009). To constitute a

“good-faith effort,” the report must discuss the standard of care, breach, and causation

with sufficient specificity 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, 79 S.W.3d at 52; 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, 79 S.W.3d at 52; Palacios, 46 S.W.3d at 878. Although an expert report need not

marshal all the plaintiff’s proof, the expert may not merely state conclusions about the

required elements of standard of care, breach, and causation. Bowie, 79 S.W.3d at 52.



Granbury Hospital Corp. v. Hosack                                                        Page 2
The report must include the expert’s opinion on each of the three elements. Id.; Palacios,

46 S.W.3d at 878. The expert must explain the basis of his statements to link his

conclusions to the facts. Earle v. Ratliff, 998 S.W.2d 882, 890 (Tex. 1999).

       We review a trial court’s order on a motion to dismiss a claim for failure to

comply with the expert report requirements under an abuse-of-discretion standard.

Bowie, 79 S.W.3d at 52; Palacios, 46 S.W.3d at 878. When reviewing matters committed

to the trial court’s discretion, we may not substitute our own judgment for the trial

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

                                    EXPERT REPORTS

       Dr. Lige B. Rushing explained that Hall, born in 1935, had a lengthy history of

medical conditions. After suffering from a fall, Hall was admitted at LGMC. Shortly

thereafter, Hall developed pressure ulcers.

       Rushing explained that the standard of care required LGMC and its staff to

provide: (1) “that level of care and treatment that a reasonable, prudent, similar facility

would provide under the same or similar circumstances;” (2) “that level of care,

treatment, and supervision to prevent accidents;” and (3) “the necessary care, treatment,

and supervision to prevent the development of pressure ulcers.” He explained that the

standard of care for preventing and/or treating pressure ulcers requires: (1)

“assessment of the residents [sic] risks for skin breakdown and if the resident is at risk

for skin breakdown, [] implement a plan of care to address that risk;” (2) “proper

pressure relieving strategies, i.e. turning and repositioning at least every two hours,




Granbury Hospital Corp. v. Hosack                                                       Page 3
adequate nutrition and hydration;” and (3) “proper hygiene such as keeping the

residents clean and their environment free of urine, feces, and sweat as is possible.”

       Rushing opined that LGMC knew of Hall’s “increased risk for development of

pressure ulcers because of her advanced age, her diabetes, and her limited mobility.”

He explained that LGMC breached the standard of care by leaving Hall on a bedpan too

long, resulting in the development of pressure ulcers and “set[ting] in motion a

connected series of events resulting in the pressure ulcer photographed on 03/12/07

and which persisted until her death on 04/11/07.” Rushing concluded:

       As a result of these pressure ulcers, Mrs. Hall experienced decreased
       mobility, increased metabolic requirements, worsening of the ulcer, and
       the pressure ulcer was a source of infection and toxins, all of which
       contributed to her death.

Absent these failures, “Hall would not have died when she did.”

       In her expert report, registered nurse Suzanne Frederick explained the standard

of care for the LGMC nurses, opined that Hall was “at risk for skin breakdown,” and

concluded that Hall was “left on the bedpan too long, which was substandard” and that

this “breach of the standard of care proximately caused a linear pressure ulcer around

Ms. Hall’s buttocks and upper thighs.” She concluded that “based on a reasonable

degree of nursing certainty, [] this pressure ulcer would not have occurred had the

nurses removed Ms. Hall from the bedpan timely.”

                                        ANALYSIS

       LGMC challenges both Frederick’s report and Rushing’s report on the basis that

neither is sufficient as to the element of causation.



Granbury Hospital Corp. v. Hosack                                                    Page 4
       First, LGMC correctly argues that Frederick is not qualified as an expert on

causation. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.403(a) (Vernon 2005); see also TEX.

CIV. PRAC. & REM. CODE ANN. § 74.351(r)(5)(C). She may, however, testify as to the

standard of care and breach of that standard. See HealthSouth Corp. v. Searcy, 228 S.W.3d

907, 909 (Tex. App.—Dallas 2007, no pet.).

       Second, LGMC argues that Dr. Rushing’s report is “conclusory, speculative, and

requires the trial court to infer a causal link between the alleged wrong-doing and the

patient’s death over six weeks later.” We agree.

       In his report, Rushing concludes that LGMC’s conduct violated the standard of

care by allowing Hall to remain on a bedpan too long, resulting in the development of

pressure ulcers, which released infection and toxins into Hall’s system, and launching a

series of events that eventually contributed to her death. However, his report indicates

that Hall died of cardiorespiratory arrest.      Rushing does not explain how Hall’s

development of pressure ulcers resulted in her cardiorespiratory arrest.          Because

Rushing’s report fails to connect the occurrence of pressure ulcers to Hall’s death, his

report is insufficient on the element of causation. See Regent Health Care Ctr. of El Paso,

L.P. v. Wallace, 271 S.W.3d 434, 441 (Tex. App.—El Paso 2008, no pet.) (“[W]hile the

report indicates that the breach of the standard of care resulted in worsening of the

described skin conditions, there is no linkage to the cause of death, aside from the

assertion of a close temporal proximity between the conditions and the premature

death.”); see also Nexion Health at Southwood, Inc. v. Judalet, No. 12-08-00464-CV, 2009

Tex. App. LEXIS 7404, at *11 (Tex. App.—Tyler Sept. 23, 2009, no pet.) (mem. op.)


Granbury Hospital Corp. v. Hosack                                                    Page 5
(Expert report was deficient on causation because “[expert] failed to explain the causal

relationship between the decedent’s leg fracture and her death;” i.e., “how a fractured

leg caused her to experience congestive heart failure.”).

        Nevertheless, Hosack conditionally argues that she is entitled to remand of this

cause to the trial court to consider granting a thirty-day extension.2

        If an adequate 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. TEX. CIV. PRAC. &

REM. CODE ANN. § 74.351(c). Where a report is not “so deficient as to constitute no

report at all,” a plaintiff is entitled to remand of the case to the trial court to consider

granting an extension to cure. Gardner v. U.S. Imaging, Inc., 274 S.W.3d 669, 670-71 (Tex.

2008) (citing Ogletree v. Matthews, 262 S.W.3d 316, 323 (Tex. 2007) (Willett, J., concurring)

and Lewis v. Funderburk, 253 S.W.3d 204, 211 (Tex. 2008) (Willett, J., concurring)).

        We cannot say that Rushing’s report is “so deficient as to constitute no report at

all.” Gardner, 274 S.W.3d at 670; see Leland v. Brandal, 257 S.W.3d 204, 207-08 (Tex. 2008).

The report identifies the standard of care and the manner in which the standard of care

was not met. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6). It is deficient with

respect to the element of causation. Under these circumstances, Hosack is entitled to

remand. See Gardner, 274 S.W.3d at 670; see also Leland, 257 S.W.3d at 207-08; Wallace,

271 S.W.3d at 441; Judalet, 2009 Tex. App. LEXIS 7404, at *14.


2       In her response to LGMC’s motion to dismiss, Hosack requested an additional thirty days to cure
in the event her reports were found to be deficient. The trial court denied the motion to dismiss; thus, it
did not rule on Hosack’s request.


Granbury Hospital Corp. v. Hosack                                                                   Page 6
       In summary, we sustain LGMC’s sole issue, reverse the trial court’s order

denying LGMC’s motion to dismiss, and remand this cause for further proceedings

consistent with this opinion.




                                                 FELIPE REYNA
                                                 Justice
Before Chief Justice Gray,
       Justice Reyna, and
       Justice Davis
Reversed and remanded
Opinion delivered and filed April 28, 2010
[CV06]




Granbury Hospital Corp. v. Hosack                                          Page 7
