Reversed and Remanded and Memorandum Opinion filed May 17, 2016.




                                     In The

                    Fourteenth Court of Appeals

                             NO. 14-15-00643-CV

    CHRISTUS HEALTH GULF COAST, D/B/A CHRISTUS ST. JOHN
     HOSPITAL, AND CHRISTUS ST. JOHN HOSPITAL, Appellants
                                       V.

       ALISON DAVIDSON, INDIVIDUALLY, AS HEIR, AND AS
 INDEPENDENT ADMINISTRATRIX AND REPRESENTATIVE OF THE
    ESTATE OF PAUL ALAN DAVIDSON, DECEASED, CAROLYN
     DAVIDSON, LANCE DAVIDSON, ALEX DAVIDSON, DEREK
   DAVIDSON, AND STEFANIE DAVIDSON, INDIVIDUALLY AND AS
   HEIRS OF THE ESTATE OF PAUL ALAN DAVIDSON, DECEASED,
                          Appellees

                   On Appeal from the 127th District Court
                           Harris County, Texas
                     Trial Court Cause No. 2014-20812

                 MEMORANDUM OPINION
      In this health-care liability case, a hospital challenges the trial court’s
adverse ruling on the hospital’s objections to an expert medical report and motion
to dismiss health-care liability claims for a plaintiff’s failure to file an expert report
in compliance with section 74.351 of the Texas Civil Practice and Remedies Code.
Because the expert report fails to satisfy the statutory requirements as to causation,
we reverse the trial court’s order and remand for further proceedings consistent
with this opinion.

                     I.    FACTUAL AND PROCEDURAL BACKGROUND

      Dr. Mary Mercado evaluated Paul Alan Davidson in November 2011, for
recurrent and progressive angina. In February 2012, Davidson underwent a “CTA”
for his worsening angina. The CTA revealed heavy calcification of the left main
coronary artery and left circumflex coronary artery with moderate stenosis.
Davidson’s right coronary artery was moderately calcified with stenosis.

      Davidson developed acute coronary syndrome characterized by further
worsening of angina and an elevated Troponin level. Davidson was admitted to
the hospital, where his condition deteriorated. A few days later, Dr. Mercado
performed an emergency cardiac catheterization and coronary arteriogram.
Davidson was in cardiogenic shock at that time, and he died in spite of Dr.
Mercado placing an emergency intra-aortic balloon and performing an angioplasty
with stent implantation.

      Appellees/plaintiffs Alison Davidson, individually, as heir, and as
independent administratrix and representative of the estate of Paul Alan Davidson,
deceased, Carolyn Davidson, Lance Davidson, Alex Davidson, Derek Davidson,
and Stefanie Davidson, individually and as heirs of the estate of Paul Alan
Davidson, deceased (hereinafter the “Davidson Parties”) filed suit against Mary
Mercado, M.D., Mary Mercado M.D., P.A., Christus Health Gulf Coast, d/b/a
Christus St. John Hospital, and Christus St. John Hospital. The Davidson Parties
asserted wrongful death and survival claims and alleged that appellants Christus
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Health Gulf Coast, d/b/a Christus St. John Hospital, and Christus St. John Hospital
(hereinafter the “Hospital Parties”) were negligent in (1) failing to identify signs
and symptoms of Davidson’s impending heart attack, (2) failing to appropriately
respond to and treat the signs and symptoms of Davidson’s impending heart attack,
and (3) failing to inform Dr. Mercado of the signs and symptoms of Davidson’s
impending heart attack.

       In an attempt to comply with section 74.351 of the Texas Civil Practice and
Remedies Code, the Davidson Parties filed expert reports by Dr. Neal Shadoff and
Alexis Williams, RN, BSN. The Hospital Parties moved to dismiss based on the
alleged insufficiency of the expert reports. The trial court signed an agreed order
of the parties stating that the Davidson Parties’ expert reports were deficient as to
causation and granting the Davidson Parties thirty days to cure the deficiency. The
Davidson Parties filed amended expert reports. The Hospital Parties again moved
to dismiss on the ground that the amended expert reports were deficient with
respect to causation. The trial court denied the Hospital Parties’ motion to dismiss,
and the Hospital Parties filed this interlocutory appeal challenging the trial court’s
order denying their motion to dismiss the claims under section 74.351 of the Texas
Civil Practice and Remedies Code.1 See Tex. Civ. Prac. & Rem. Code Ann.
§ 51.014(a)(9) (West, Westlaw through 2015 R.S.) (providing that a trial court’s
order denying a party’s motion to dismiss under section 74.351(b) of the Medical
Liability Act is an appealable interlocutory order).

                                  II.     STANDARD OF REVIEW

       We apply an abuse-of-discretion standard when reviewing a trial court’s
decision regarding the adequacy of an expert report. See Van Ness v. ETMC First

1
 Unless otherwise noted, all references to a “section” or “subsection” pertain to the Texas Civil
Practice and Remedies Code.

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Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam). The trial court abuses
its discretion if it acts arbitrarily, unreasonably, or without reference to guiding
rules or principles. See Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.
2002). Although this court may not substitute its judgment for that of the trial
court, the trial court has no discretion in determining what the law is or applying
the law to the facts. Id.; Sanjar v. Turner, 252 S.W.3d 460, 463 (Tex. App.—
Houston [14th Dist.] 2008, no pet.).

                                III.           ANALYSIS

      In a single issue, the Hospital Parties assert the trial court abused its
discretion in denying their motion to dismiss because the expert reports are
insufficient. In particular, the Hospital Parties assert that the only statements in the
reports providing an opinion on causation are conclusory.

      Under section 74.351, a claimant, not later than the 120th day after the date a
health-care liability claim is filed, must serve on each party one or more expert
witness reports addressing liability and causation. Tex. Civ. Prac. & Rem. Code
Ann. § 74.351(a), (j) (Vernon 2005); Lewis v. Funderburk, 253 S.W.3d 204, 205
(Tex. 2008). An “expert report” is defined as

      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.

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6) (West, Westlaw through 2015
R.S.). A trial court shall grant a motion challenging the adequacy of the expert
report if the report is not an objective good-faith effort to comply with the
definition of an expert report provided in section 74.351(r)(6). Id. §§ 74.351(l),

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(r)(6). The trial court’s inquiry is limited to the four corners of the report. Jelinek
v. Casas, 328 S.W.3d 526, 539 (Tex. 2010).

      The report must provide sufficient specificity to inform the defendant of the
conduct the plaintiff has called into question and to provide a basis for the trial
court to conclude that the claims have merit. See id. at 539. Omission of any of
the statutory elements prevents the report from being a good-faith effort. See id. A
report that merely states the expert’s conclusions about the standard of care,
breach, and causation does not meet the statutory requirements.            See id.   In
providing the expert’s opinions on these elements, the claimant need not marshal
evidence as if actually litigating the merits at trial or present sufficient evidence to
avoid summary judgment. See id. When a claimant sues more than one defendant
in a health-care liability claim, the report must set forth the standard of care for
each defendant and explain the causal relationship between each defendant’s
individual acts and the injury. Sanjar v. Turner, 252 S.W.3d 460, 465 (Tex.
App.—Houston [14th Dist.] 2008, no pet.).

      The Davidson Parties filed two expert reports, one report authored by
Williams and another report authored by Dr. Shadoff. With regard to Davidson’s
condition while in the care of the Hospital Parties, Dr. Shadoff stated:

       Davidson’s symptoms upon his hospitalization — acute coronary
        syndrome characterized by worsening angina associated with an elevated
        level of Troponin — provided unequivocal objective evidence of
        myocardial ischemia/necrosis.       Davidson’s EKG results were un-
        interpretable for acute ischemia/infarction.
       Acute coronary syndrome with myocardial infarction and an
        uninterpretable EKG is an indication for emergency cardiac
        catheterization within the first twenty-four hours of hospitalization.
       Recurrent and progressive angina with abnormal stress test results
        requires cardiac catheterization.

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 Dr. Mercado breached the standard of care by failing to recommend and
  perform urgent cardiac catheterization within twenty-four hours of
  evaluating Davidson at the hospital.
 Dr. Mercado pursued non-cardiac treatment because of Davidson’s
  elevated “INR” from chronic warfarin therapy, but Dr. Mercado should
  have understood that anticoagulation caused by warfarin could be
  emergently reversed by administering vitamin K.            Based upon
  Davidson’s other symptoms, Dr. Mercado should have recognized that
  Davidson needed cardiac catheterization. Dr. Mercado breached the
  standard of care by failing to reverse the warfarin anticoagulation if it
  contraindicated the necessary cardiac catheterization.
 Based upon a reasonable medical probability, if cardiac catheterization
  had been performed prior to the emergency of the afternoon of February
  13, revascularization would have been feasible, and more likely than not
  successful, and Davidson would have survived at least ten more years if
  optimal medical therapy in combination with coronary revascularization
  had been performed in a reasonable and timely fashion.
 Williams’s analysis is correct:
         [h]er reasoning is sound and her outline of the events as well
         as her opinions are consistent with my own review and
         opinions. It is my opinion that the standard of care for
         hospital nursing staff agents and/or employees who provided
         care to Mr. Davidson as outlined by Nurse Williams in her
         report is accurate and that the breaches of the standard of
         care as listed by Nurse Williams in her report caused or
         contributed to cause the death of Paul Davidson.


In her expert report, Williams stated:

 The standard of care for the Hospital Parties acting through and by their
  respective nursing staff, agents, or employees required the nurses to
  appropriately communicate their nursing assessments, physical
  examination findings, and critical lab results that evaluate Davidson’s
  risk and identify the signs and symptoms of his declining condition and
  impending myocardial infarction and to timely communicate these
  findings to Dr. Mercado or the attending physician.


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 The nurses caring for Davidson failed to perform adequate assessments
  and physical examinations of Davidson to evaluate his risk for
  myocardial infarction and failed to identify signs and symptoms of
  myocardial infarction.
 The nurses caring for Davidson breached the standard of care by failing
  to identify signs and symptoms indicating a decline in Davidson’s
  medical condition and recognize them as a medical emergency that
  needed to be addressed in a timely manner.
 The nurses caring for Davidson breached the standard of care by failing
  to adequately communicate their nursing assessments, physical
  examination findings and critical lab reports. In addition the nurses
  inadequately used the chain of command to advocate for their patient
  during his hospital stay.
 Nurses breached the standard of care by failing to follow up on telephone
  calls to physicians regarding Davidson’s critical levels of Troponin on
  February 12th at 3:02 a.m., 2:50 p.m., and 7:04 p.m.
 The nurse on duty breached the standard of care by failing to timely
  advise physicians of Davidson’s blood pressure drop to 90/54 on
  February 13th at midnight.
 The nurse advised a physician that Davidson’s chest pain was unrelieved
  by several medications, Davidson was diaphoretic, nauseated, weak, and
  had cool extremities, but the nurse failed to obtain a timely response by
  the physician on February 13th at 8:00 a.m.
 Nurses did not timely notify the rapid-response team, nurse manager or
  nurse director.
 The nurse failed to timely notify a physician that Davidson rated his chest
  pain as a 9-10 on a scale of 1-10 on February 13th at 5:00 a.m.
 Nursing staff failed to advocate for a qualified physician to intervene and
  assess Davidson following his worsening chest pain and failure to
  respond to treatment.
 The nurses breached the standard of care by failing to institute
  appropriate nursing interventions to stabilize Davidson’s condition and
  prevent complications. The appropriate nursing interventions included
  notifying the rapid-response team and communicating changes to a
  physician. No other specific interventions were listed.


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       When a nurse did not receive a return phone call from a physician
        regarding critical results, the nurse should have re-notified the physician
        within twenty minutes and escalated the situation up the chain of
        command to the charge nurse, nurse manager, or medical director if the
        physician did not timely respond to the second phone call. The Hospital
        Parties should have ensured appropriate parameters were in place for
        nurses to communicate imminent changes in a patient’s condition.
      In her report, Williams also stated:

       Nurses called critical Troponin levels to physicians and had the results
        read back by the physician on February 12th at 11:29 a.m. and that a
        physician was on the unit at 11:45 a.m. the same day.
       Critical test results were read back by a physician on February 12th at
        noon.
       Dr. Mercado clarified her orders on February 13th at 10:06 a.m. and
        again at 10:32 a.m.
       Dr. Mercado ordered Amiodarone at 1:45 p.m. on February 13th.
       Laboratory results were read back by a physician at 3:59 p.m. on
        February 13th.
       Dr. Mercado and Dr. Hamer were present at 7:40 p.m. and determined
        Davidson should go to the catheterization laboratory.
      Dr. Shadoff did not indicate any breaches in the standard of care by the
Hospital Parties other than by incorporating Williams’s assessment into his own.
Williams did not state a causation theory. See Aramburo v. Brown, No. 14-12-
00812-CV, 2013 WL 3580640, at *3 (Tex. App.—Houston [14th Dist.] Jul. 11,
2013, no pet.) (mem. op.). The Davidson Parties argue that Williams’s statement –
that a prudent and competent nurse would have assessed Davidson, identified
obvious signs and symptoms and recognized them as a medical emergency that
needed be addressed in a timely manner – constituted a causation theory. Williams
did not identify which signs and symptoms nurses were not tracking or identifying.
Nor did Williams state that recognizing those signs or symptoms would have


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changed Davidson’s care.

      Dr. Shadoff stated that the “breaches of the standard of care as listed by
Nurse Williams in her report caused or contributed to cause the death of Paul
Davidson.”    This conclusory statement fails to provide a causal link between
Davidson’s death and the failure to identify symptoms or the failure to
communicate nursing assessments and critical lab results.          See Al-Lahiq v.
Rosemond, No. 14-13-00158-CV, 2013 WL 5969720, at *5 (Tex. App.—Houston
[14th Dist.] Nov. 7, 2013, no pet.) (mem. op.). Neither expert explains how more
frequent communication or receiving more physician responses would have
changed the outcome for Davidson. Neither expert explains the causal relationship
between the acts of the Hospital Parties that allegedly breached the standard of care
and Davidson’s injuries. See Baytown Radiology Ass’n v. Carlton, No. 14-09-
00705-CV, 2010 WL 2573880, at *3–4 (Tex. App.—Houston [14th Dist.] Jun. 29,
2010, no pet.) (mem. op.).      This failure to address causation is particularly
problematic in light of Williams’s report, which shows the nursing staff was in
communication with Dr. Mercado and physicians many times throughout the day
on February 12th and February 13th.          Specifically, Williams’s report shows
physicians were aware of Davidson’s critical lab results and condition on both days
and those communications did not result in Davidson receiving emergency
catheterization. Neither Williams nor Dr. Shadoff stated that providing physicians
with additional communications would have resulted in Davidson receiving
emergency catheterization.       There is no explanation of how additional
communications would have affected Davidson’s care.

      In her report, Williams stated that failures to communicate or receive
responses on February 12th and the morning of February 13th were breaches in the
standard of care. The Davidson Parties assert that each breach represented a delay

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in relating Davidson’s deteriorating condition, but there is no statement in either
expert report that any of these breaches delayed Davidson’s care. The Davidson
Parties rely upon Dr. Shadoff’s statement that Davidson needed emergent cardiac
catheterization when he was evaluated February 11th, but this statement does not
explain how further communication with Dr. Mercado, the nurse manager, medical
director, or attending physician would have changed Davidson’s care or led to an
earlier emergency catheterization. Williams’s report shows that nurses were in
touch with Dr. Mercado a few hours after the alleged breaches in the standard of
care. After the alleged breaches, Dr. Mercado clarified her orders on the morning
of February 13th, and Dr. Mercado ordered new medication in the early afternoon.
At neither of those times did Dr. Mercado choose to order an emergency
catheterization. Williams’s report indicates that a physician read back critical
laboratory results at 3:59 p.m. on February 13th, and, even then, the physician did
not conduct an emergency catheterization.

      The Davidson Parties argue on appeal that if something had been addressed
earlier, Davidson would not have died, but neither expert report provides any
evidence that if the nursing staff had received physician read-backs on all of the
critical laboratory results and changes in Davidson’s condition on February 12th or
the morning of February 13th, as opposed to receiving read-backs and
communications from a physician regarding some of Davidson’s critical laboratory
results, Davidson’s care would have been different.

      Considering the four corners of Dr. Shadoff’s expert report, including the
incorporation of Williams’s report, we conclude that the averments and opinions in
the expert report contain conclusory statements concerning causation. See Jelinek,
328 S.W.3d at 539–40; Baytown Radiology Ass’n, 2010 WL 2573880, at *3–4.
Dr. Shadoff’s expert report does not explain the causal relationship between the

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Hospital Parties’ allegedly negligent acts and Davidson’s injuries. See Jelinek, 328
S.W.3d at 539–40; Baytown Radiology Ass’n, 2010 WL 2573880, at *3–4.
Because she is not a physician, Williams is not qualified to be an expert witness on
causation. See Tex. Civ. Prac. & Rem. Code Ann. § 74.403(a) (West, Westlaw
through 2015 R.S.). In any event, even if Williams were qualified to opine as to
causation, her expert report does not explain the causal relationship between the
Hospital Parties’ allegedly negligent acts and Davidson’s injuries. See Jelinek, 328
S.W.3d at 539–40; Baytown Radiology Ass’n, 2010 WL 2573880, at *3–4.
Accordingly, the trial court abused its discretion in denying the Hospital Parties’
motion to dismiss with prejudice the Davidson Parties’ claims against them under
section 74.351. We sustain the Hospital Parties’ issue.

                                    IV.         CONCLUSION

      The trial court abused its discretion in determining that the expert reports
were sufficient and in denying the Hospital Parties’ motion to dismiss. We reverse
the trial court’s order and remand this case with instructions to the trial court (1) to
dismiss the Davidson Parties’ claims with prejudice under section 74.351(b), (2) to
conduct further proceedings to determine the amount of reasonable attorney’s fees
that should be awarded to the Hospital Parties under this statute, and (3) to award
the Hospital Parties reasonable attorney’s fees and court costs incurred by the
Hospital Parties.


                                          /s/     Kem Thompson Frost
                                                  Chief Justice



Panel consists of Chief Justice Frost and Justices Boyce and Wise.



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