                         COURT OF APPEALS
                         SECOND DISTRICT OF TEXAS
                              FORT WORTH

                              NO. 02-17-00147-CV


COLUMBIA MEDICAL CENTER OF                                          APPELLANT
ARLINGTON SUBSIDIARY L.P.
AKA/DBA MEDICAL CENTER OF
ARLINGTON

                                        V.

L.M.                                                                  APPELLEE

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           FROM THE 96TH DISTRICT COURT OF TARRANT COUNTY
                     TRIAL COURT NO. 096-284523-16

                                     ----------

                        MEMORANDUM OPINION1

                                     ----------

       In this case involving alleged sexual misconduct by a nurse against a

patient, Columbia Medical Center of Arlington Subsidiary L.P. d/b/a Medical

Center of Arlington (MCA) brings an interlocutory appeal from the trial court’s

April 11, 2017 order overruling its motion objecting to the patient L.M.’s revised
       1
       See Tex. R. App. P. 47.4.
expert report and seeking dismissal of L.M.’s claims. See Tex. Civ. Prac. & Rem.

Code Ann. § 51.014(a)(9) (West Supp. 2017), § 74.351(b)(2) (West 2017). MCA

contends in a single issue that the trial court erred (1) by granting L.M. an

extension to cure deficiencies in her original expert report because it was so

lacking in substance that it was no report at all, (2) by overruling its objections to

L.M.’s original report and a revised report that she timely filed after the extension,

and (3) by “denying [its] motions to dismiss.” Because we conclude that L.M.’s

original proffered report was deficient but curable and that L.M.’s revised expert

report is not deficient, we affirm the trial court’s denial of MCA’s second motion to

dismiss.

                 I. Background Facts And Procedural History

      L.M. sued nurse Gerald Thomas Cagle, Staff Quest Plus, his staffing

agency employer, and MCA for common law negligence and health care liability

under chapter 74 of the Texas Civil Practice and Remedies Code. L.M. alleged

that after she went to MCA’s emergency room complaining only of chest pain,

Cagle––without obtaining a doctor’s order and without following established

protocol or policy––performed an unnecessary invasive catheterization (an “in-

and-out” catheterization) and after doing so, performed an unnecessary and also

unordered digital vaginal examination.2 L.M. alleged that MCA was vicariously



      2
       L.M. also claimed that Cagle rubbed and patted her buttocks after giving
her an injection and massaged her shoulders and back while smelling her hair.

                                          2
liable for Cagle’s conduct and that it had negligently trained, instructed, and

supervised Cagle.

      L.M. timely filed documents purporting to constitute an expert report: a

transcript of sworn testimony during a Texas Board of Nursing hearing by nurse

Denise Benbow concerning Cagle’s conduct; Benbow’s curriculum vitae (CV); an

administrative law judge’s (ALJ) recommendation to the Board that Cagle’s

license be revoked; and an opinion and order of the Board revoking Cagle’s

license prepared by nurse Katherine A. Thomas.               MCA objected to the

documents on numerous grounds, including that the documents constituted

either no report at all or a deficient report, and filed a motion to dismiss alleging

the same grounds it raised in its objections. At a hearing on its objections and

motion, MCA’s counsel argued, “[A]ll they’ve done is they’ve pieced together

documents from Nurse Cagle’s Texas Board of Nursing ALJ hearing and have

attempted to repurpose same as an expert report.”          Instead of ruling at the

hearing, the trial court took the matter under advisement.

      Three weeks later, on October 26, 2016, the trial court signed an order

finding that “the expert report [was] deficient” and granting L.M. a thirty-day

extension to cure the deficiencies. See id. § 74.351(c), (r)(6). The order did not

expressly deny the motion to dismiss. MCA did not appeal from this order.

      L.M. timely filed a “Revised Chapter 74 Expert Report,” which included a

“Medical Review Report” by Dr. Lola Lumpkins along with her CV. MCA objected

to Dr. Lumpkins’s expert report on the grounds that her causation opinion is

                                         3
conclusory and that she improperly relied on the causation opinions of Benbow,

Thomas, and the ALJ instead of making an independent causation determination.

MCA also again sought dismissal based on Dr. Lumpkins’s allegedly-deficient

expert opinion. MCA alternatively argued in this second motion to dismiss that

the trial court should have granted its first motion to dismiss because the

documents L.M. originally filed constituted no report at all; thus, the trial court

erred by granting L.M. a thirty-day extension. After a hearing, the trial court

overruled MCA’s objections to Dr. Lumpkins’s expert report and denied MCA’s

second motion to dismiss. MCA appealed.

                            II. Complaints On Appeal

      In a single issue, MCA raises the following complaints:

      •   the documents L.M. originally served did not constitute a “‘written

          report’ providing a ‘fair summary’ of an expert’s opinions on the

          standards of care, breach, and causation particular to this lawsuit”;

      •   even if the documents could be considered an expert report, they were

          so deficient that they were no report at all because (a) they did not

          contain a physician’s causation opinion, (b) Benbow, Thomas, and the

          ALJ are not qualified to opine about the standard of care and breach,

          and (c) even if they are qualified, their opinions about the standard of

          care and breach are conclusory;

      •   Dr. Lumpkins’s report is deficient as to L.M.’s vicarious liability claim

          because her causation opinion is conclusory and she improperly relied

                                         4
          on Benbow’s, Thomas’s, and the ALJ’s causation opinions contained in

          the first proffered report; and

      •   because Dr. Lumpkins’s report is deficient as to vicarious liability and

          because neither the original report nor Dr. Lumpkins’s report addressed

          any direct liability claims against MCA, L.M. failed to file an adequate

          expert report on any of her claims.

      Because L.M. has not argued in this court or the trial court that her

allegations against MCA do not fall within chapter 74’s scope, we will review only

whether the trial court abused its discretion by denying MCA’s second motion to

dismiss under section 74.351’s applicable law. See, e.g., Loaisiga v. Cerda, 379

S.W.3d 248, 257 (Tex. 2012) (setting out three-part test for rebutting presumption

that claim against health care provider is a section 74.351 health care liability

claim); Murphy v. Russell, 167 S.W.3d 835, 838–39 (Tex. 2005) (holding that

medical battery claim required expert report under former article 4590i because

expert testimony necessary regarding whether health care provider had any

reasons for performing unconsented-to procedure that did not breach standard of

care); T.C. v. Kayass, No. 02-16-00248-CV, 2017 WL 5180773, at *2, *6 (Tex.

App.––Fort Worth Nov. 9, 2017, no pet.) (holding that claim against doctor for

alleged sexual assault of mother during her children’s appointment was not a

health care liability claim for which an expert report must be filed); Appell v.

Muguerza, 329 S.W.3d 104, 109–13 (Tex. App.––Houston [14th Dist.] 2010, pet.

denied) (concluding that part of claim sounding only in assault was not a health

                                            5
care liability claim for which an expert report is required but also citing cases

holding that alleged sexual assaults of patients during course of medical

examination were inseparable from rendition of medical care), abrogated in part

on other grounds by Tex. W. Oaks Hosp. v. Williams, 371 S.W.3d 171, 184–86

(Tex. 2012); Vanderwerff v. Beathard, 239 S.W.3d 406, 409 (Tex. App.––Dallas

2007, no pet.) (concluding that expert report was required in claim that

chiropractor sexually touched patient during examination when expert testimony

was necessary to establish proper standard of care for examination for patient’s

particular complaint).

      We review a trial court’s denial of a motion to dismiss under section

74.351(b) for an abuse of discretion. Van Ness v. ETMC First Physicians, 461

S.W.3d 140, 142 (Tex. 2015); Am. Transitional Care Ctrs. of Tex., Inc. v.

Palacios, 46 S.W.3d 873, 877 (Tex. 2001). A trial court abuses its discretion if

the court acts without reference to any guiding rules or principles, that is, if the

act is arbitrary or unreasonable.    Low v. Henry, 221 S.W.3d 609, 614 (Tex.

2007); Cire v. Cummings, 134 S.W.3d 835, 838–39 (Tex. 2004). An appellate

court cannot conclude that a trial court abused its discretion merely because the

appellate court would have ruled differently in the same circumstances. Low,

221 S.W.3d at 620; E.I. du Pont de Nemours & Co. v. Robinson, 923 S.W.2d

549, 558 (Tex. 1995).




                                         6
               III. L.M.’s First Report Was Deficient But Curable

      MCA’s issue on appeal includes several complaints related to its

alternative argument in its second motion to dismiss: that the documents L.M.

filed as her original expert report were so deficient that they constituted no report

at all and that the trial court therefore erred by extending the time for her to file a

report to correct the deficiencies. A complaint that a report is so deficient that it

is tantamount to no report at all is immediately appealable upon the trial court’s

denial of a motion to dismiss raising that ground even if the plaintiff has already

filed an amended report in accordance with an order extending the time to do so.

See Scoresby v. Santillan, 346 S.W.3d 546, 555, 557 (Tex. 2011); In re Watkins,

279 S.W.3d 633, 634 (Tex. 2009) (orig. proceeding); Badiga v. Lopez, 274

S.W.3d 681, 684–85 (Tex. 2009); see also Tex. Civ. Prac. & Rem. Code

Ann. §§ 51.014(a)(9), 74.351(b). Here, the trial court’s October 26, 2016 order

found the documents L.M. served as her first report deficient and granted L.M.

thirty days to file a new report but did not expressly rule on the first motion to

dismiss.3 Thus, we will consider the “no report” alternative argument MCA raised

in its second motion to dismiss, which the trial court expressly ruled on. See

Scoresby, 346 S.W.3d at 557; Badiga, 274 S.W.3d at 682, 685.



      3
        Although MCA argues in its brief that the trial court abused its discretion
by denying both of its motions to dismiss, the trial court’s first order did not
expressly rule on MCA’s first motion to dismiss, and MCA’s notice of appeal
states that it is appealing the denial of the second motion to dismiss.

                                          7
      The supreme court has held that a document filed as an expert report

under section 74.351 need only meet the following standards to be considered a

deficient but curable report: (1) the plaintiff must serve the document purporting

to be a report by the statutory deadline, (2) the report must contain an opinion of

an individual with expertise that the claim has merit, and (3) the report must

implicate the defendant’s conduct. Scoresby, 346 S.W.3d at 557. Although MCA

cites Scoresby in its brief, its arguments are not directed at the Scoresby test;

rather, MCA focuses on whether the documents L.M. filed as her first expert

report meet all of the statutory requirements for an expert report. See Tex. Civ.

Prac. & Rem. Code Ann. § 74.351(r)(5), (6). We will follow Scoresby. 346

S.W.3d at 557–58 (recognizing that three-part test is a “minimal standard” that is

“necessary if multiple interlocutory appeals are to be avoided” and should serve

to “eliminate the first, wasteful appeal”).

A. L.M. Timely Filed Report

      L.M. filed the Nursing Board documents ninety-two days after MCA filed its

original answer; thus, she satisfied the first standard. See Tex. Civ. Prac. &

Rem. Code Ann. § 74.351(a).

B. Benbow Is An Individual With Expertise

      L.M. met the second standard with the CV and testimony of Denise

Benbow, a licensed registered nurse since 1984 with a Master’s degree in

nursing.   At the time Benbow testified in Cagle’s Nursing Board disciplinary

hearing, the Board employed her as a nursing consultant. Over her thirty-two
                                              8
year career, Benbow had worked in medical centers and hospitals as a general-

surgical floor nurse, staff and medication nurse, staff cardiology nurse, nurse

manager of a post-operative and orthopedic unit, and staff nurse on the telemetry

floor. In her work on the telemetry floor, Benbow had “much experience” with in-

and-out catheterizations, and she provided a detailed procedure for how to do

one properly.4 She had also served for two years as an adjunct faculty member

for nursing students at Austin Community College where she “assisted with skills

lab on campus and directed student’s [sic] clinical experiences with pre and post

clinical conferences on 6th floor Seton Medical Center (orthopedic, neurological,

and urological patients).”    As a Nursing Board consultant, she served as an

expert witness at the State Office of Administrative Hearings.      She also (1)

answered questions about the Nursing Practice Act, the Board’s rules, the scope

of nursing practice, and nursing peer review, (2) held webinars on nursing-related

topics, such as medication safety and professional boundaries, and (3) wrote

articles for the Board’s bulletin.

      MCA contends that the Nursing Board documents do not contain the

opinion of an individual with expertise because they are not in the form of a


      4
       See Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453,
461 n.37 (Tex. 2017) (concluding that trial court could have properly determined
that registered nurse who had previously worked in labor and delivery unit but
who, at the time of providing an expert report, was working in hematology and
oncology was qualified to opine on the standard of care for a registered nurse in
a labor and delivery unit because section 74.351 “does not require an expert to
have the same specialty as the health care provider she evaluates”).

                                        9
formally authored written report signed by Benbow and because Benbow is not

qualified to give standard of care, breach, and causation opinions. But Scoresby

does not require a formally authored, signed report,5 nor does it require that the

“individual with expertise” be qualified as an expert under chapter 74. Compare

id. § 74.351(r)(5), with Scoresby, 346 S.W.3d at 557 (“The dissent argues that

[the individual] was not qualified to give an opinion about the Physicians’ conduct

. . . . We express no view on the adequacy of [the individual’s] qualifications; the

trial court did not specifically address the matter, and it is premature for us to

consider it.”). Scoresby squarely held that an individual with expertise need not

meet the chapter 74 qualification standards because a lack of qualification is a

deficiency that can be cured. See Scoresby, 346 S.W.3d at 557; Gower v. Univ.

Behavioral Health of Denton, No. 02-16-00245-CV, 2017 WL 3081153, at *9–12

(Tex. App.—Fort Worth July 20, 2017, no pet.) (mem. op.); Koutsoufis v.

Pinnacle Health Facilities GP V, No. 02-16-00150-CV, 2017 WL 370956, at *6

n.4 (Tex. App.––Fort Worth Jan. 26, 2017, no pet.) (mem. op.).

      Unlike the plaintiff in Scoresby, L.M. provided not only Benbow’s testimony

but also her CV detailing her thirty-plus-year career in nursing, which included

      5
       Maxwell v. Seifert, upon which MCA relies, is an intermediate appellate
court opinion issued before the supreme court decided Scoresby. 237 S.W.3d
423, 427 (Tex. App.––Houston [14th Dist.] 2007, pet. denied). Moreover,
Maxwell is inapposite because in that case the plaintiff did not even attempt to
timely serve documents purporting to be an expert report, relying instead on bulk
medical records she produced in discovery that only showed “her physician’s
contemporaneous observations, diagnosis and treatment” and did not include
any attempted statement of a standard of care or probable cause. Id. at 427.

                                        10
testifying as an expert in disciplinary proceedings against other nurses, advising

nurses on compliance with applicable regulatory standards, and teaching

prospective nurses during clinical settings with urological patients.        Thus,

regardless of whether she was qualified as an expert under chapter 74, she is

“an individual with expertise” under the Scoresby test. See Nexion Health at

Garland, Inc. v. Treybig, No. 05-14-00498-CV, 2014 WL 7499373, at *7 (Tex.

App.––Dallas Dec. 31, 2014, no pet.) (mem. op.); HealthSouth of Houston, Inc. v.

Parks, No. 09-12-00213-CV, 2012 WL 4471224, at *2 (Tex. App.––Beaumont

Sept. 27, 2012, pet. denied) (mem. op.); Rosemond v. Al-Lahiq, 362 S.W.3d 830,

833–35, 840 (Tex. App.––Houston [14th Dist.] 2012, pet. denied); see also

Select Specialty Hospital-Houston Ltd. P’ship v. Simmons, No. 01-12-00658-CV,

2013 WL 3877696, at *5 n.2 (Tex. App.––Houston [1st Dist.] July 25, 2013, no

pet.) (mem. op.) (holding that licensed registered nurse consultant––who stated

that she was currently consulting with practicing registered nurses on many

topics, including the prevention and treatment of wounds and pressure ulcers––

was qualified to provide expert report on nurses’ alleged failure to properly treat

pressure ulcers); Certified EMS, Inc. v. Potts, 355 S.W.3d 683, 689–90 (Tex.

App.––Houston [1st Dist.] 2011) (holding that nurse who served as consultant

and expert witness, and who also worked as quality review nurse for Department

of Aging and Disability Services, was qualified under civil practice and remedies

code section 74.402(b) to provide expert report in case involving nurse’s alleged

sexual assault of hospital patient), aff’d on other grounds, 392 S.W.3d 625, 626,

                                        11
633 (2013). Because the trial court could have properly determined that Benbow

is an individual with expertise, we need not determine whether Thomas or the

ALJ could also be considered individuals with expertise. See Tex. R. App. P.

47.1.

C. Benbow’s Testimony Includes Opinion That L.M.’s Claim Has Merit And
Implicates Cagle’s Conduct

        MCA claims that Benbow did not opine that L.M.’s health care liability claim

has merit because her Nursing Board testimony focused solely on Cagle’s

violation of the Nursing Practice Act and associated administrative rules rather

than the breach of a medical standard of care.6 Additionally, MCA contends that

none of L.M.’s documents addressed any suit or health care liability claim L.M.

had against MCA. But L.M.’s vicarious liability claims against MCA are based on

her claims against Cagle. Thus, we will review L.M.’s allegations against Cagle

individually.

        L.M.’s claims against Cagle included allegations that his negligence and

negligence per se violated the Nursing Practice Act. Specifically, L.M. claimed

that




        6
        MCA also contends that in the absence of an opinion from a person
qualified to opine on causation, the documents are tantamount to “no report.”
But that is not the standard Scoresby articulated. 346 S.W.3d at 557 (“All
deficiencies, whether in the expert’s opinions or qualifications, are subject to
being cured before an appeal may be taken from the trial court’s refusal to
dismiss the case.” (emphasis added)).

                                         12
      •   Cagle was negligent “with respect to the safe, prudent and proper

          administration of nursing procedures for a patient complaining of simple

          chest pains in an ER setting”;

      •   Cagle’s “independent and arbitrary diagnoses and responsive/invasive

          vaginal procedures (in the absence of specific physician orders to

          address said diagnoses) went far beyond the scope of his authority and

          nursing practice”; and

      •   Cagle committed “misconduct in violating professional boundaries and

          in engaging in sexual conduct with a patient/committing a sexual

          assault upon [L.M.] while administering medical care at the hospital.”

L.M. also claimed that Cagle violated subsections (b)(10) and (13) of Texas

Occupations Code section 301.452 and eleven separate sections of the

Standards for Nursing Practice set forth in the Texas Administrative Code. See

Tex. Occ. Code Ann. § 301.452(b)(10), (13) (West Supp. 2017) (providing that

nurse is subject to disciplinary action for unprofessional conduct likely to deceive,

defraud, or injure a patient or the public, for failing to adequately care for a

patient, or for failing to conform to minimum standards of acceptable nursing

practice that in Nursing Board’s opinion exposes a patient or other person

unnecessarily to risk of harm).

      Benbow testified that Cagle violated the Nursing Practice Act because

performing the catheterization without a doctor’s order involved making a medical

diagnosis and prescribing therapeutic or corrective measures, which is beyond

                                           13
the scope of what Texas law permits a nurse to do. See id. §§ 151.002(a)(13),

301.002(2), 301.004(b), (West Supp. 2017); Methodist Hosp. v. German, 369

S.W.3d 333, 341–42 (Tex. App.––Houston [1st Dist.] 2011, pet. denied).            In

addition, Benbow referred to MCA’s departmental notes, which stated that

catheterization to obtain a culture or perform diagnostic tests should be avoided if

the patient can voluntarily void; according to Benbow, nothing in L.M.’s records

indicated she could not voluntarily void.      Benbow opined that those same

departmental notes indicate that an in-and-out catheterization is not appropriate

for chest pain, L.M.’s only complaint that day.      Benbow further testified that

based on L.M.’s testimony at the Board hearing about what Cagle did to her,

Cagle had violated Board rules about unprofessional conduct that endangers a

patient’s safety, concluding that L.M.’s testimony that she had experienced

nightmares showed that Cagle’s actions caused L.M. at least “some harm.”

Thus, Benbow (1) set forth the standard of care––when an in-and-out

catheterization should and should not be performed and that a nurse should not

sexually assault a patient, (2) opined that Cagle breached that standard of care

by performing the catheterization without a doctor’s order and in the absence of

symptoms indicating it was necessary and by sexually assaulting L.M.,7 and (3)


      7
       See Murphy, 167 S.W.3d at 838–39 (explaining need for expert report in
medical battery case regarding whether adequate reasons exist for performing
procedure without patient’s consent but noting that although expert opinion is
required in report, it will not necessarily be required at trial, depending on facts
learned during discovery).

                                        14
opined that L.M. suffered some harm: nightmares. Benbow therefore opined

that L.M.’s negligence claim has merit and implicated Cagle’s conduct. See, e.g.,

Gower, 2017 WL 3081153, at *4, *11; Alsup v. Hickory Trail Hosp., No. 05-16-

00527-CV, 2017 WL 1046769, at *8 (Tex. App.––Dallas Mar. 20, 2017, no pet.)

(mem. op.); Matagorda Nursing & Rehabilitation Ctr., L.L.C. v. Brooks, No. 13-

16-00266-CV, 2017 WL 127867, at *1, *7 (Tex. App.––Corpus Christi Jan. 12,

2017, no pet.) (mem. op.); RJ Meridian Care of Alice, Ltd. v. Robledo, No. 04-14-

00195-CV, 2014 WL 2917669, at *1–2 (Tex. App.––San Antonio June 25, 2014,

no pet.) (mem. op.); see also Tex. Civ. Prac. & Rem. Code Ann. § 74.001(a)(13)

(West 2017) (“‘Health care liability claim’ means a cause of action against a

health care provider or physician for treatment, lack of treatment, or other

claimed departure from accepted standards of . . . safety or professional or

administrative services directly related to health care.” (emphasis added)).

      We conclude that the documents L.M. first proffered as her expert report

meet the Scoresby standard for a deficient but curable report. Our conclusion

comports with the purpose of section 74.351, which the legislature primarily

designed “to eliminate frivolous healthcare-liability claims, not potentially

meritorious ones.” See Hebner v. Reddy, 498 S.W.3d 37, 39 (Tex. 2016); see

also Scoresby, 346 S.W.3d at 557 (recognizing that three-part test is “a minimal

standard” but also appropriate and “necessary if multiple interlocutory appeals

are to be avoided”).



                                        15
       To the extent that MCA’s briefing includes complaints about statutory

deficiencies in the documents L.M. proffered as her first expert report, we need

not address those complaints because Dr. Lumpkins’s report superseded L.M.’s

first report.   See, e.g., Sison v. Andrew M., No. 02-16-00129-CV, 2017 WL

3974356, at *10 (Tex. App.––Fort Worth Sept. 7, 2017, pet. filed) (mem. op.)

(citing Cornejo v. Hilgers, 446 S.W.3d 113, 124 n.11 (Tex. App.––Houston [1st

Dist.] 2014, pet. denied); HealthSouth Corp. v. Searcy, 228 S.W.3d 907, 909

(Tex. App.––Dallas 2007, no pet.)).

                       IV. Dr. Lumpkins’s Expert Report

       In the remainder of its only issue, MCA contends that Dr. Lumpkins’s

report is deficient because (a) her opinion on causation is conclusory, (b) she

improperly relied on Benbow’s, Thomas’s, and the ALJ’s causation opinions, and

(c) she failed to address any direct liability claims against MCA that would cure

the deficiencies in her report as to vicarious liability based on Cagle’s conduct.

A. Applicable Law

       Section 74.351 requires that an expert report provide a fair summary of the

expert’s opinions regarding the causal relationship between the defendant’s

failure to meet the applicable standards of care and the injury, harm, or damages

claimed by the plaintiff. Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6); see

Gower, 2017 WL 3081153, at *6. Because the purpose of a chapter 74 expert

report is to inform the defendant of the specific conduct that the plaintiff has

called into question and to provide a basis for the trial court to conclude that the

                                         16
plaintiff’s claims have merit, the report must contain sufficiently specific

information to demonstrate causation beyond mere conjecture. See Pedro v.

Lake, No. 02-16-00487-CV, 2017 WL 4296446, at *2 (Tex. App.—Fort Worth

Sept. 28, 2017, no pet.).       The expert report cannot establish the causal

relationship by merely making conclusory statements. Palacios, 46 S.W.3d at

879; Tex. Health Harris Methodist Hosp. Fort Worth v. Biggers, No. 02-12-00486-

CV, 02-13-00040-CV, 2013 WL 5517887, at *7 (Tex. App.—Fort Worth Oct. 3,

2013, no pet.) (mem. op.).      The expert report, however, does not need to

“marshal all the plaintiff’s proof,” nor must it use “magical words like ‘reasonable

probability.’” Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52–53 (Tex. 2002).

And nothing in section 74.351 “suggests the preliminary report is required to rule

out every possible cause of the injury, harm, or damages claimed.” Keller SNF v.

Koutsoufis, No. 02-16-00227-CV, 2017 WL 117318, at *8 (Tex. App.—Fort Worth

Jan. 12, 2017, no pet.).

      The sufficiency of the expert report’s causation statement should be

viewed in the context of the entire report. Columbia N. Hills Hosp. Subsidiary,

L.P. v. Gonzales, No. 02-16-00433-CV, 2017 WL 2375770, at *6 (Tex. App.—

Fort Worth June 1, 2017, no pet.) (mem. op.). Furthermore, the detail needed to

establish a causal link generally is proportional to the complexity of the negligent

act giving rise to the claim. See, e.g., Mendez-Martinez v. Carmona, 510 S.W.3d

600, 609 (Tex. App.—El Paso 2016, no pet.) (“While plaintiffs need not drill down

into every possible detail in every case in order to survive dismissal, a report in a

                                         17
case alleging negligence in the context of a complex surgery involving multiple

doctors and nurses, for example, will necessarily require more details than a

report dealing with more straightforward negligence allegations.”).

B. Causation Opinion Not Conclusory

      After detailing the nursing standard of care and breach of that standard,

Dr. Lumpkins ends her report in a section titled “Harm to the Patient”:

             I am also in agreement with the Opinion of Order of the Texas
      Board of Nursing that Nurse Cagle’s conduct and breaches of the
      standard of care as I have discussed above resulted in harm to the
      patient. Nurse Cagle’s actions during his nursing care of [L.M.] in
      patting her buttocks, reaching across her body to massage her back,
      smelling her hair, undressing her, putting his fingers in her vagina
      and/or performing an unnecessary and unordered invasive
      catheterization caused this patient physical pain and distress. [L.M.]
      also suffered actual harm by way of psychological trauma (i.e.,
      nightmares) and lack of trust in medical personnel.

      Looking at Dr. Lumpkins’s causation statement in the context of her entire

report, we conclude that she sufficiently established a causal link between

Cagle’s alleged breach of the standard of care and the harm to L.M.            After

explaining the standard of care––that a nurse should not catheterize a patient

without a physician’s order or unless the patient appears to be unable to

voluntarily void and that a nurse should never make inappropriate sexual contact

with a patient––and describing in detail how Cagle breached that standard of

care by unnecessarily performing an invasive catheterization on L.M. and

touching and digitally penetrating her, Dr. Lumpkins concluded that the physical




                                        18
pain and distress of which L.M. complained, as well as her nightmares and

distrust of medical personnel, were the result of Cagle’s actions.

      Dr. Lumpkins’s causation opinion is not conclusory simply because it is not

complex. See Ranelle v. Beavers, No. 02-08-00437-CV, 2009 WL 1176445, at

*3–6 (Tex. App.––Fort Worth Apr. 30, 2009, no pet.) (mem. op.) (concluding that

expert’s causation opinion was adequate as to claims for medical battery and

negligent performance of unnecessary surgery when expert opined that

surgeon’s breach of standard of care––failing to tell patient the truth about his

condition and need for surgery––caused patient to suffer the pain and other

attendant consequences of surgery).      We hold that Dr. Lumpkins’s causation

opinion is not conclusory. See Gracy Woods I Nursing Home v. Mahan, 520

S.W.3d 171, 190 (Tex. App.––Austin 2017, no pet.) (holding, in direct liability

nursing home sexual assault case, that expert’s opinion that failure to conduct

hallway monitoring or place patient closer to nurses station resulted in a sexual

assault that left patient tearful and afraid was not conclusory); SCC Partners, Inc.

v. Ince, 496 S.W.3d 111, 118 (Tex. App.––Fort Worth 2016, pet. dism’d)

(determining that causation opinion that failure to identify and monitor fixable

pressure sores more likely than not resulted in patient’s greater pain and

suffering was sufficient); Thomas v. Desrochers, No. 04-09-00487-CV, 2009 WL

4981323, at *3 (Tex. App.––San Antonio Dec. 23, 2009, pet. denied) (mem. op.)

(concluding that causation opinion––that unnecessary procedure led to



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improperly placed stent, which caused scarring and led to complaints set forth in

petition––was sufficient).

C. Reference To Benbow’s, Thomas’s, And ALJ’s Determinations Not
Improper

      MCA also contends that Dr. Lumpkins improperly relied on Benbow’s,

Thomas’s, and the ALJ’s unqualified causation opinions in forming her expert

opinion.

      Courts have held that rule of evidence 703 allows a reporting physician to

rely on the opinions of others—including nurses—who have rendered reports or

diagnoses in forming that physician’s own causation opinion so long as the

physician has shown her own qualifications related to her specific experience

with the condition involved. Tex. R. Evid. 703 (“An expert may base an opinion

on facts or data in the case that the expert has been made aware of, reviewed, or

personally observed. If experts in the particular field would reasonably rely on

those kinds of facts or data in forming an opinion on the subject, they need not

be admissible for the opinion to be admitted.”); Sims v. Kemmerling, No. 09-12-

00338-CV, 2013 WL 1189091, at *2 (Tex. App.––Beaumont Mar. 21, 2013, no

pet.) (mem. op.); Kelly v. Rendon, 255 S.W.3d 665, 676 (Tex. App.—Houston

[14th Dist.] 2008, no pet.) (“While a nurse’s report, standing alone, is inadequate

to meet the requirements of the statute as to medical causation, nothing in the

health care liability statute prohibits an otherwise qualified physician from relying

on a nurse’s report in the formation of the physician’s own opinion.”); Cresthaven


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Nursing Residence v. Freeman, 134 S.W.3d 214, 234 (Tex. App.––Amarillo

2003, no pet.); cf. Packard v. Guerra, 252 S.W.3d 511, 532–33 (Tex. App.––

Houston [14th Dist.] 2008, pet. denied) (holding that physician could rely on

expert report of attorney explaining corporate structure of defendants to assist in

addressing the standard of care, breach, and causation applicable to each

defendant).

      Nothing in the record shows that Dr. Lumpkins relied solely on the opinions

expressed by the nurses and ALJ in the Board documents to form her causation

opinion rather than forming her own causation opinion in accordance with her

qualifications, which MCA has not challenged. She stated that her opinion was

“in agreement with” the Board documents, not that she substituted the opinions

expressed in those documents for her own. In addition to the Board documents,

Dr. Lumpkins also relied on MCA’s medical records, L.M.’s sworn testimony, and

L.M.’s original petition. Thus, we hold that the record does not show that Dr.

Lumpkins improperly substituted the opinions expressed in the Board documents

for her own causation opinion.




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D. Direct Liability Claims Against MCA

       MCA finally contends that because Dr. Lumpkins’s report does not address

any direct liability claims against it, the trial court should have dismissed L.M.’s

suit. This argument presumes Dr. Lumpkins’s report is deficient to support L.M.’s

vicarious liability theory.

       Not only have we determined that Dr. Lumpkins’s report in support of

L.M.’s vicarious liability claim is not deficient––and therefore that the trial court

did not abuse its discretion by denying MCA’s motion to dismiss––the supreme

court of Texas has clarified that when a health care liability claim involves either

a purely vicarious claim or a claim raises both vicarious and direct liability

theories, “an expert report that adequately addresses at least one pleaded

liability theory satisfies the statutory requirements.” Certified EMS, 392 S.W.3d

at 632; see also Koutsoufis, 2017 WL 370956, at *5; Ince, 496 S.W.3d at 114–

15. Because Dr. Lumpkins’s report is sufficient to implicate MCA’s liability under

the vicarious liability theory L.M. pleaded, Dr. Lumpkins need not have opined on

any direct liability theory. See Certified EMS, 392 S.W.3d at 632.

                                  V. Conclusion

       We overrule MCA’s sole issue and affirm the trial court’s order denying

MCA’s second motion to dismiss.



                                                    /s/ Charles Bleil
                                                    CHARLES BLEIL
                                                    JUSTICE

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PANEL: WALKER and PITTMAN, JJ.; CHARLES BLEIL (Senior Justice,
Retired, Sitting by Assignment).

DELIVERED: March 1, 2018




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