                  COURT OF APPEALS
                   SECOND DISTRICT OF TEXAS
                        FORT WORTH

                      NO. 02-10-00313-CV

GERALD ROBERT STEPHENSON,                     APPELLANT
M.D.

                                V.

NATASHA MILLER, INDIVIDUALLY                  APPELLEES
AND AS THE SURVIVING SPOUSE,
HEIR AT LAW, COMMUNITY
SURVIVOR, AND PERSONAL
REPRESENTATIVE OF STEVE
MILLER, DECEASED, AND AS
MOTHER, NEXT FRIEND AND JOINT
MANAGING CONSERVATOR OF
JAYLYNN DENIQUE MILLER,
DEYLIN RAESHAWN MILLER, AND
JACOBE ANTONIO MILLER,
MINORS, AND AS COMMUNITY
SURVIVOR AND BENEFICIARY OF
THE ESTATE OF STEVE MILLER,
DECEASED, AND AS BENEFICIARY,
PURSUANT TO THE TEXAS
WRONGFUL DEATH STATUTE AND
TEXAS SURVIVAL STATUTE; AND
CYNTHIA MILLER, INDIVIDUALLY
AND AS THE SURVIVOR, HEIR AT
LAW, AND BENEFICIARY
PURSUANT TO THE TEXAS
WRONGFUL DEATH STATUTE AND
TEXAS SURVIVAL STATUTE, AND
AS JOINT MANAGING
CONSERVATOR OF JAYLYNN
DENIQUE MILLER, DEYLIN
RAESHAWN MILLER, AND JACOBE
ANTONIO MILLER, MINORS

                                        ----------

          FROM THE 236TH DISTRICT COURT OF TARRANT COUNTY

                                        ----------

                          MEMORANDUM OPINION1
                                        ----------

      Gerald Robert Stephenson, M.D. appeals from the trial court‟s interlocutory

order refusing to dismiss the health care liability claims of appellees Natasha

Miller, in her individual and other capacities, and Cynthia Miller, individually and

in her other capacities. In two issues, appellant challenges the expert reports

proffered by appellees as to standard of care and causation. We affirm.

                             Procedural Background

      Appellees sued appellant, a surgeon who transplanted a kidney into Steve

Miller, alleging that Miller died after appellant failed to recognize signs of

postoperative bleeding, failed to timely order labs that would have purportedly

diagnosed the bleeding at an earlier time, and failed to institute timely and

appropriate therapies that would have prevented Miller‟s death from cardiac

arrest. Appellant filed a motion to dismiss for failure to file an adequate expert

report, which the trial court denied.

                                Standard of Review

      1
       See Tex. R. App. P. 47.4.


                                            2
      A trial court=s decision on a motion to dismiss under section 74.351 is

subject to an abuse of discretion standard. See, e.g., Am. Transitional Care Ctrs.

of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001). To determine whether

a trial court abused its discretion, we must decide whether the trial court acted

without reference to any guiding rules or principles; in other words, we must

decide whether the act was arbitrary or unreasonable. Downer v. Aquamarine

Operators, Inc., 701 S.W.2d 238, 241–42 (Tex. 1985), cert. denied, 476 U.S.

1159 (1986).    Merely because a trial court may decide a matter within its

discretion in a different manner than an appellate court would in a similar

circumstance does not demonstrate that an abuse of discretion has occurred. Id.

at 242. A trial court does not abuse its discretion if it commits a mere error in

judgment. See E.I. du Pont de Nemours & Co. v. Robinson, 923 S.W.2d 549,

558 (Tex. 1995).

                         Expert Report Requirements

      In a health care liability claim, a claimant must serve on each defendant an

expert report that addresses standard of care, liability, and causation no later

than the 120th day after the claim is filed. Tex. Civ. Prac. & Rem. Code Ann. '

74.351(a), (j) (West 2011); Barber v. Mercer, 303 S.W.3d 786, 790 (Tex. App.––

Fort Worth 2009, no pet.).     If an expert report has not been served on a

defendant within the 120-day period, then on the motion of the affected

defendant, the trial court must dismiss the claim with prejudice and award the

defendant reasonable attorney=s fees and costs. Tex. Civ. Prac. & Rem. Code


                                        3
Ann. ' 74.351(b); Barber, 303 S.W.3d at 790. A report Ahas not been served@

under the statute when it has been physically served but it is found deficient by

the trial court.   Lewis v. Funderburk, 253 S.W.3d 204, 207–08 (Tex. 2008);

Barber, 303 S.W.3d at 790B91. When no report has been served because the

report that was served was found to be deficient, the trial court has discretion to

grant one thirty-day extension to allow the claimant the opportunity to cure the

deficiency. Tex. Civ. Prac. & Rem. Code Ann. ' 74.351(c); Barber, 303 S.W.3d

at 791.

      A report is deficient (therefore subjecting a claim to dismissal) when it

Adoes not represent an objective good faith effort to comply with the definition of

an expert report@ in the statute. Tex. Civ. Prac. & Rem. Code Ann. ' 74.351(l);

Barber, 303 S.W.3d at 791. While the expert report Aneed not marshal all the

plaintiff‟s proof,@ Palacios, 46 S.W.3d at 878, it must provide a fair summary of

the expert=s opinions as to the Aapplicable 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); Barber,

303 S.W.3d at 791.

      To qualify as a good faith effort, the report must Adiscuss the standard of

care, breach, and causation with 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.@ Palacios, 46 S.W.3d at 875;


                                        4
Barber, 303 S.W.3d at 791. A report does not fulfill this requirement if it merely

states the expert=s conclusions or if it omits any of the statutory requirements.

Palacios, 46 S.W.3d at 879; Barber, 303 S.W.3d at 791. The information in the

report Adoes not have to meet the same requirements as the evidence offered in

a summary-judgment proceeding or at trial.@ Palacios, 46 S.W.3d at 879; Barber,

303 S.W.3d at 791.       When reviewing the adequacy of a report, the only

information relevant to the inquiry is the information contained within the four

corners of the document alone. Palacios, 46 S.W.3d at 878; Barber, 303 S.W.3d

at 791; see Bowie Mem‟l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002). This

requirement precludes a court from filling gaps in a report by drawing inferences

or guessing as to what the expert likely meant or intended. Barber, 303 S.W.3d

at 791; see Austin Heart, P.A. v. Webb, 228 S.W.3d 276, 279 (Tex. App.––Austin

2007, no pet.) (citing Bowie Mem=l Hosp., 79 S.W.3d at 53).

      “[I]t is not enough that the expert report „provided insight‟ about the

plaintiff‟s claims. Rather, to constitute a good-faith effort to establish the causal-

relationship element, the expert report must fulfill Palacios‟s two-part test.”

Bowie Mem’l Hosp., 79 S.W.3d at 52 (citation omitted); Farishta v. Tenet

Healthsystem Hosps. Dallas, Inc., 224 S.W.3d 448, 453 (Tex. App.––Fort Worth

2007, no pet.). The expert “must explain the bases of the statements [made

regarding causation] and link his or her conclusions to the facts.” Farishta, 224

S.W.3d at 453–54 (quoting Longino v. Crosswhite, 183 S.W.3d 913, 917–18

(Tex. App.––Texarkana 2006, no pet.)).          The report must provide enough


                                          5
information within the document to both inform the defendant of the specific

conduct at issue and to allow the trial court to conclude that the suit has merit.

Bowie Mem’l Hosp., 79 S.W.3d. at 52.

                                     Analysis

      In two issues, appellant challenges the adequacy of the expert reports

provided by appellees because (1) the standard of care and breach opinions

lump all the doctors together collectively and (2) the causation opinions lump all

the doctors together and fail to specify how the breaches caused Miller‟s death or

specifically link those breaches to the cause of death.

      Standard of Care

      Dr. Ronald Ferguson, appellee‟s first expert, had over thirty years‟

experience in the “practice of transplant surgery and the care of kidney transplant

patients.”   He opined that appellant was aware of Miller‟s postoperative

hematocrit drop to 21.72 and elevated potassium of 8.8; a note from appellant the

morning after surgery notes the potassium of 8.8 “and the delayed graft function

(DGF) of the transplanted kidney.” It also notes that Miller “would be scheduled

to be hemodialyzed „today.‟” At 8:03 a.m. the morning after surgery, appellant

made a requisition for 1 gram of calcium gluconate by IV for Miller.




      2
        In some parts of the report, Dr. Ferguson refers to the hematocrit drop as
being to 21.7, and in others, he refers to it as being 22.7. For purposes of this
opinion, the difference is not significant.


                                         6
      Dr. Ferguson noted that appellant was an independent contractor of Harris

Methodist Hospital and that he was bound by their Renal Transplant Program

2006 Protocol guidelines. According to Dr. Ferguson,

             The transplant surgeon is to be available post-operatively for
      the usual post-operative care, [and] for consultation with the Medical
      Director, including the occurrence of possible surgical problems.
      Concurrently, the nephrologists are responsible for the management
      of the transplant patients post-operatively. In the case of Steve
      Miller, nephrologists Linh Le, M.D., Rubina Khan, M.D., Shane
      Kennedy, M.D., and Charles Andrews, M.D., all part of Dialysis
      Associates, were to be responsible for the care of Steve Miller.

             In addition to the above operational guidelines set by the
      Protocol for the Kidney Transplant Program and Unit, the Protocol
      set had established guidelines for the Post Operative Management
      of the Transplant Recipient. The protocol is their standard of care
      for the post-operative care and management of a kidney transplant
      recipient.

             According to the Harris Methodist Hospital – Fort Worth Renal
      Transplant Program 2006 Protocol, applicable to the care of Steve
      Miller on April 2nd and 3rd, 2007, . . . Gerald R. Stephenson, M.D. . . .
      failed to implement this Protocol in the care of Steve Miller by failing
      to assess, monitor, and/or communicate Steve Miller‟s fractional
      urine output that was significantly lower than the 500 cc per four
      hours set as the standard quantitative guideline of the Protocol.

            Steve Miller, whose urine output post-operatively, was less
      than 20cc per hour since surgery, necessitated laboratory monitoring
      every four hours. Accordingly, the Protocol dictated that a complete
      blood count (CBC) and basic metabolic panel (BMP) were to be
      analyzed every four hours until routine labs the following morning.
      This Protocol, had it been implemented as dictated, would have
      provided a CBC, including a hemoglobin and hematocrit, and a
      BMP, which included a potassium level, at 9:30 p.m., 1:30 a.m., and
      5:30 a.m. This pattern of monitoring was critical in the care denied
      Steve Miller.

            ....



                                         7
            . . . Gerald Robert Stephenson, M.D., failed to implement
      Harris Methodist Hospital – Fort Worth – Renal Transplant Program
      2006 Protocol and obtain on Steve Miller a complete blood count
      and basic metabolic panel every four hours post-operatively until
      morning, necessitated by his oliguric status.             The protocol
      recognizes the minimal standard set forth in the community for
      kidney transplant patients. The standard approach recognized for
      laboratory monitoring in the first 24 hours post renal transplant would
      be to obtain testing for hemoglobin, hematocrit, and electrolytes (at
      least) every six hours for the first twenty four hours post
      transplant. . . .

             Had their own Protocol been implemented, or the community
      standard cited above, Steve Miller‟s post-operative bleeding and
      hyperkalemia[3] would have been detected at a much earlier time
      allowing much earlier treatment.

            ....

            ●      Dr. Stephenson is documented in the nursing records to
                   be at Steve Miller‟s bedside at 7:30 a.m. on April 3,
                   2007.

            ....

            ●      Christina Collier, R.N. reports that “Dr. Stephenson was
                   actually in the unit making rounds, so I provided him
                   with a copy of the morning labs.                This was
                   approximately 7:30 a.m. on April 3, 2007. . . .[”]

            ●      Christina Collier, R.N., reports that Dr. Stephenson was
                   at Steve Miller‟s bedside at 7:30 a.m., and documents it
                   in the nurse‟s notes. Further documentation by Nurse
                   Collier notes that “Dr. Kahn and Dr. Stephenson aware”
                   of Steve Miller‟s laboratory values, including his
                   potassium of 8.8 and his hematocrit of 22.7.

            ....


      3
        Hyperkalemia is “[a] greater than normal concentration of potassium ions
in the circulating blood.” Stedman‟s Med. Dictionary 921 (28th ed. 2006).


                                        8
             In addition to having the critical, life threatening potassium
     level, indicating his severe hyperkalemia, Steve Miller was also
     hypovolemic,[4] having critically low hematocrit and hemoglobin
     values that were made known to Drs. Stephenson and Khan at 7:25
     a.m., on 4/3/07. At this time, Steve Miller‟s condition was extremely
     critical and life threatening. Mr. Miller‟s kidney had produced very
     little urine (oliguria) and the hematocrit and hemoglobin values
     indicated an internal hemorrhage. As indicated before, the accepted
     standard for medical care for such a patient in critical condition
     would require urgent therapy with intravenous Calcium Gluconate or
     an insulin and glucose combination. . . .

           ....

            Furthermore, [although Dr. Khan ordered 1 gram of calcium
     gluconate “now”] neither Dr. Khan nor Dr. Stephenson took
     responsibility to assure that the Calcium Gluconate was immediately
     processed and administered. In fact, Dr. Stephenson testifies that
     he left the entire clinical emergency management of Steve Miller up
     to Dr. Khan, absent the ordering [of] an advancement of Steve
     Miller‟s diet to „clear liquids‟.

            Drs. Khan and Stephenson, Nurses Laureano, Collier, and
     Dickerson, Harris Methodist Fort Worth Hospital and its health care
     providers, each had a duty, as respective medical doctors,
     registered nurses and health care providers of Harris Methodist
     Hospital – Fort Worth, to Steve Miller, in an emergency situation, to
     see that the „Now‟ order was immediately communicated to the
     pharmacy, [and] processed and administered to Steve Miller within
     one hour. Steve Miller was administered the Calcium Gluconate
     over two hours later. This is below the standard of care for medical
     doctors, specifically Rubina Khan, M.D. and Gerald Stephenson,
     M.D. . . .

           ....

           1.     The standard of care for a post-operative kidney
                  transplant patient is to have a blood assessment, at the
                  very minimum, every six hours, post-operatively, which

     4
        Hypovolemic means having “a decreased amount of blood in the body.”
Id. at 939.


                                       9
       would include a basic metabolic panel. The standard of
       care would require that both the surgeon, in this case,
       Dr. Gerald Stephenson, M.D., and the nephrologist
       group (Dialysis Associates), and the individual
       nephrologist, in this case, Linh Le, M.D., Shane
       Kennedy, M.D. and Rubina Khan, M.D., would be
       responsible for seeing that such order was entered. . . .

....

3.     The medical records do not indicate that either Drs.
       Stephenson or Khan properly diagnosed the fact that
       Steve Miller was hypovolemic as a result of an internal
       hemorrhage, which was causing his low hematocrit and
       hemoglobin levels (as well as the critical potassium
       value of 8.8). The calcium gluconate, together with the
       insulin glucose combination should have been given
       intravenously and immediately. The accepted standard
       of care would require the proper diagnosis be made of
       Steve Miller‟s critical condition that he was bleeding
       internally, and thus, hyperkalemic, and the standard of
       care would require that he be administered the above
       therapy intravenously and that both Drs. Khan and
       Stephenson should have made certain that this order
       was carried out and that therapy was given immediately.
       It was a violation of the standard of care for them not to
       do so. . . .

4.     It was a violation of the standard of care to not order the
       intravenous timely administration of Calcium Gluconate
       or the insulin glucose combination as well as dialysis,
       without ultrafiltration. . . .

       . . . Both Drs. Stephenson and Khan failed to treat the
       primary cause of Steve Miller’s hyperkalemia, the post-
       operative bleeding. The accepted standard of care for a
       post-operative kidney patient, such as Steve Miller,
       would have been not to decrease his fluid volume,
       created quite possibly by surgical post-operative
       bleeding, and to treat medically his hyperkalemia.
       Rubina Khan, M.D. and Gerald Robert Stephenson,
       M.D. failed to perform any of these that were required
       by the accepted standards of care, for a patient of Mr.


                            10
                   Miller‟s condition. Furthermore, it is a violation of the
                   standard of care by both Rubina Khan, M.D. and Gerald
                   Robert Stephenson, M.D., both of whom had the
                   responsibility for Steve Miller upon examining him at
                   7:25 a.m., on 4/03/07, to order and/or permit him to
                   receive ultrafiltration . . . . The standard of care for the
                   nephrologist on duty in the early morning hours of
                   4/03/07, . . . as well as . . . Dr. Stephenson, the kidney
                   transplant surgeon, was to diagnose Steve Miller as
                   suffering from post-operative bleeding which required
                   immediate treatment . . . . Rubina Khan, M.D. and
                   Gerald Robert Stephenson, M.D. failed to take any of
                   the appropriate actions necessary to treat the extremely
                   critical conditions caused by Steve Miller‟s post-
                   operative bleeding. [Emphasis added.]

      Dr. Gallon, appellees‟ second expert, had over ten years‟ experience in the

practice of transplant surgery and the care of transplant patients. He states in his

report that the nephrologists were responsible for postoperative management of

transplant patients and that “[t]he transplant surgeon, Gerald Robert Stephenson,

M.D., was concurrently responsible for Steve Miller‟s post-operative monitoring,

care and intervention as it related to the surgical procedure and potential

complications and/or issues related to the kidney allograft.”

      “Concurrent” is defined as “[o]perating at the same time[,]… covering the

same matters.”     Black‟s Law Dictionary 331 (9th ed. 2009).         A reasonable

construction of Dr. Ferguson‟s and Dr. Gallon‟s use of the word “concurrently” in

their reports is that Dr. Stephenson was to be available for the usual post-

operative care of Miller and that he was to be responsible for the post-operative

management of Miller along with the nephrologists. Thus, any references in the

report to a joint standard of care involving the post-operative management of


                                        11
Miller would be appropriate. See, e.g., Barber v. Dean, 303 S.W.3d 819, 831

(Tex. App.––Fort Worth 2009, no pet.). The excerpts above show that both Dr.

Ferguson and Dr. Gallon concluded and opined that under Harris‟s Protocol, as

well as prevailing standards of care for post-operative care and management of a

patient, the transplant surgeon was responsible for both post-operative care and

management of a patient like Miller. Both reports clearly state that the articulated

standards of care are applicable to both Dr. Stephenson and the nephrologists;

Dr. Ferguson‟s report also states how Dr. Stephenson as well as the

nephrologists breached that standard.         Thus, the expert reports proffered by

appellees fulfill their statutory purpose: to provide enough information within the

document to both inform the defendant of the specific conduct at issue and to

allow the trial court to conclude that the suit has merit. See Bowie Mem’l Hosp.,

79 S.W.3d. at 52.

      We overrule appellant‟s first issue.

      Causation

      Appellant further contends that Dr. Ferguson‟s and Dr. Gallon‟s reports are

deficient because they are conclusory and “also lump all physicians and

defendants together for causation.”

      Appellant contends that appellees‟ experts failed to explain how he is

linked to Miller‟s cardiac arrest, which occurred during ultrafiltration by Dr. Khan,

the nephrologist.    According to appellant, the court must make improper

inferences to “glean precisely how it is that the care of Appellant Dr. Stephenson


                                         12
himself . . . caused the death of the patient.” He contends Dr. Gallon‟s report

fails for the same reason because it is “not surprisingly identical to [that] of Dr.

Ferguson.”

      Dr. Ferguson opined as follows:

             Had their own Protocol been implemented, or the community
      standard cited above, Steve Miller‟s post-operative bleeding and
      hyperkalemia would have been detected at a much earlier time
      allowing much earlier treatment.

      ....

      3.     The critical potassium value indicating the hyperkalemia
      condition that could immediately cause a patient to develop life-
      threatening arrhythmia required aggressive treatment as soon as
      that condition was diagnosed by the blood sample that was drawn at
      3:40 a.m. . . . [A]t 7:25 a.m., on 4/3/07 . . . Steve Miller‟s condition
      was extremely critical and life-threatening. Mr. Miller‟s kidney had
      produced very little urine (oliguria) and the hematocrit and
      hemoglobin values indicated an internal hemorrhage. . . .

      4.    . . . The ultrafiltration removed fluid volume from Steve Miller
      who was already presenting with a compromised hypovolemic
      condition, and was the finishing catalyst in Steve Miller‟s
      hemodynamic[5] collapse and a contributing cause to his death at
      11:27 a.m. on 4/3/07.

      . . . . Due to the cumulative effect of the negligent care, aggressive
      medical management of the hyperkalemia, followed by an operation
      to control bleeding or intraoperative dialysis, with life-support
      measures, accompanied by surgical repair of the postoperative
      bleeding, were at the time, (7:25 a.m.), the only heroic and plausible
      interventions to save the life of this 24 year-old young man.

      ....


      5
        Hemodynamic means “[r]elating to the physical aspects of the blood
circulation.” Id. at 868.


                                        13
      . . . [Miller] died of a cardiac arrest while in dialysis in a state of
      uncontrovertible ventricular tachycardia. . . . He experienced
      postoperative bleeding that caused dangerous hyperkalemia. A
      decision to use dialysis to treat the life threatening hyperkalemia,
      rather than, or in addition to, aggressive medical management, was
      made. While on dialysis, ultrafiltration led to hypotension as it
      frequently does in the early post-transplant dialysis setting and
      definitely does in a compromised hypovolemic post-surgical state.
      This was not recognized, but in fact, more fluid volume was removed
      by ultrafiltration that exacerbated rather than improved the
      hypotension and hypovolemic, thus setting up an environment of
      uncorrected hyperkalemia (repeat potassium in dialysis of 7.9),
      acidosis (arterial pH of 7.166), hypotension, hypovolemic, hypoxia,
      and ventricular tachycardia. Given this setting and environment, it is
      not surprising that the ventricular tachycardia could not be
      successfully reversed and became the ultimate cause of death.

            ....

             Each of the standards of care as I have indicated above was a
      proximate cause of the death of Steve Miller. . . . Earlier, had he
      received the proper treatment, Steve Miller, in all reasonable medical
      probability, would have resulted in his being able to survive the post-
      operative bleeding. . . . The failure to properly treat Steve Miller‟s
      condition by Rubina Khan, M.D., Shane Kennedy, M.D., Gerald
      Robert Stephenson, M.D. and Patricia Fenderson, M.D. [the Director
      of Harris Methodist Hospital – Fort Worth], combined with the failure
      of the nurses and health care providers . . . all of which . . . caused
      Steve Miller to ultimately go into cardiac arrest from which he could
      not be resuscitated, thus, causing his death. Each of the above
      violations of the standard of care was a proximate cause of Steve
      Miller‟s death.

      Earlier in his report, Dr. Ferguson faults Dr. Stephenson for breaching the

following standards of care: failing to ensure the Protocol was implemented as to

timely CBC and BMP laboratory tests, failing to ensure that Dr. Khan‟s “now”

order for calcium gluconate was immediately processed, failing to diagnose and

treat the primary cause of Miller‟s hyperkalemia, which was the postoperative



                                        14
bleeding, and allowing Dr. Khan to order ultrafiltration when it was not indicated.

In his report, he states that had the Protocol been implemented, Miller‟s

hyperkalemic condition would have been evident earlier and would not have

eventually progressed to ventricular tachycardia. According to Dr. Ferguson, Dr.

Stephenson‟s failure to diagnose the underlying cause of Miller‟s hyperkalemia

and his allowing the ultrafiltration exacerbated that continuing hyperkalemic

condition, which eventually led to irreversible ventricular tachycardia.        Dr.

Ferguson‟s report describes a chain of omissions that each had the effect of

further exacerbating Miller‟s condition until it became irreversible.   See, e.g.,

Menefee v. Ohman, 323 S.W.3d 509, 519–20 (Tex. App.––Fort Worth 2010, no

pet.); Presbyterian Cmty. Hosp. of Denton v. Smith, 314 S.W.3d 508, 518–19

(Tex. App.––Fort Worth 2010, no pet.); see also Del Lago Partners, Inc. v. Smith,

307 S.W.3d 762, 774 (Tex. 2010) (holding that there may be more than one

proximate cause of an event).

      Accordingly, we conclude and hold that Dr. Ferguson‟s opinions on

causation are not conclusory, nor do they fail for lack of specificity as to Dr.

Stephenson, with respect to each of the alleged standard of care violations

except for the failure to ensure the timely administration of calcium gluconate or

insulin. Dr. Ferguson does not explain how that failure was a proximate cause of

Miller‟s death. However, Dr. Gallon states in his report that intravenous calcium

gluconate would “stabilize the myocardium” and an insulin/glucose combination

would “treat the hyperkalemia.” Thus, reading both reports together, the alleged


                                        15
failure to ensure the timely administration of the proper medication was another

omission in the chain that led to the exacerbation of Miller‟s hyperkalemia and

ultimate cardiac arrest. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(i);

Davisson v. Nicholson, 310 S.W.3d 543, 558 (Tex. App.––Fort Worth 2010, no

pet.) (op. on reh‟g); Packard v. Guerra, 252 S.W.3d 511, 526–27 (Tex. App.––

Houston [14th Dist.] 2008, pet. denied) (holding that we must review multiple

reports “in the aggregate” to determine if they are adequate as to liability and

causation).

         We conclude and hold that the trial court did not abuse its discretion by

determining that the expert reports proffered by appellees constituted a good

faith effort to comply with the statute. We overrule appellant‟s second issue.

                                    Conclusion

         Having overruled both of appellant‟s issues, we affirm the trial court‟s

order.




                                                   TERRIE LIVINGSTON
                                                   CHIEF JUSTICE

PANEL: LIVINGSTON, C.J.; MEIER, J.; and DIXON W. HOLMAN (Senior
Justice, Retired, Sitting by Assignment).

DELIVERED: July 28, 2011




                                         16
