                        COURT OF APPEALS
                         SECOND DISTRICT OF TEXAS
                              FORT WORTH


                               NO. 2-09-288-CV


PRESBYTERIAN COMMUNITY HOSPITAL                                     APPELLANTS
OF DENTON D/B/A PRESBYTERIAN
HOSPITAL OF DENTON AND CHAD
HAMMONDS, R.N.

                                        V.

CONNIE SMITH, INDIVIDUALLY AND                                       APPELLEES
AS PERSONAL REPRESENTATIVE OF
THE ESTATE OF THOMAS EDW ARD
SMITH, DECEASED, AND AS NEXT
FRIEND FOR THOMAS ANTHONY
SMITH, A MINOR, AND DOUGLAS
SMITH AND STEPHANIE SMITH

                                    ------------

        FROM THE 393RD DISTRICT COURT OF DENTON COUNTY

                                    ------------

                                  OPINION

                                    ------------

                                I. Introduction

     In this interlocutory appeal, Appellants Presbyterian Hospital of Denton d/b/a

Presbyterian Hospital of Denton and Chad Hammonds, R.N. (collectively, the
Hospital) argue that the trial court abused its discretion by denying the Hospital’s

motion to dismiss. W e affirm the trial court’s order.

                            II. Procedural Background

      Appellees Connie Smith, Individually, and as Personal Representative of the

Estate of Thomas Edward Smith, Deceased, and as Next Friend for Thomas

Anthony Smith, a Minor, and Douglas and Stephanie Smith (collectively, the Smiths)

sued the Hospital on September 2, 2008. The Smiths asserted that the Hospital, by

and through its nurse-employees, acted negligently in its care and treatment of

Thomas Edward Smith. On December 31, 2008, the Smiths served the Hospital with

expert reports by Dr. Michael E. Halkos, a cardiothoracic surgeon, and Dean W .

Hayman, R.N., a registered nurse specializing in cardiac and critical care nursing.

The Hospital filed a motion to dismiss and argued Dr. Halkos’s and Nurse Hayman’s

expert reports do not meet the statutory requirements because they do not constitute

“an objective good faith effort to provide a fair summary of the alleged experts’

opinions on the standard of care, alleged breach thereof, and how any alleged

breach by [the Hospital] caused [the Smiths’] damages.”

      After a hearing, the trial court denied the Hospital’s motion as to Dr. Halkos’s

report. The trial court partially denied and partially granted the Hospital’s motion as

to Nurse Hayman’s report and granted the Smiths an extension to supplement Nurse




                                          2
Hayman’s report if they chose to do so. 1 The Smiths then served the Hospital with

a supplemental report from Nurse Hayman, and the Hospital again objected. After

a hearing, the trial court overruled the Hospital’s objections to the supplemental

report. This interlocutory appeal followed. See Tex. Civ. Prac. & Rem. Code Ann.

§ 51.014(a)(9) (Vernon 2008); Lewis v. Funderburk, 253 S.W .3d 204, 208 (Tex.

2008) (authorizing appeal from trial court order determining that expert report was

adequate and denying motion to dismiss).

                              III. Factual Background

      The Smiths’ fourth amended petition, their live pleading at the time of the

second hearing on the Hospital’s motion to dismiss, contains the following

allegations relevant to their claims against the Hospital.

      On June 21, 2006, Mr. Smith presented to the emergency department at the

Hospital with intermittent headaches, feverishness, increasing malaise and

shortness of breath, minimal cough, shoulder and back pain, and leg swelling. He

was admitted to the Hospital for further evaluation and treatment. Tests revealed

“the presence of bilateral pneumonia and moderate renal compromise” and “severe

tricuspid regurgitation with vegetations present.” Mr. Smith’s blood cultures were



      1
          The trial court stated, “W hile [Nurse Hayman’s report] was deficient in part,
I find that the Halkos report was sufficient to create a basis for asserting a claim that
fairly put the Hospital on notice of the type of claims that are being asserted against
it by and through the nurses.” The trial court also stated that its partial grant of the
Hospital’s objection to Nurse Hayman’s report is “kind of irrelevant because I find
that it’s [otherwise] sufficient.”

                                           3
also positive for methicillin-sensitive Staphylococcus aureus, and he was treated with

intravenous antibiotics.

      Because of his diagnosis of tricuspid valve endocarditis, Mr. Smith “underwent

a tricuspid valve debridement and excision with tricuspid valve replacement” on June

30, 2006. A transesophageal echocardiogram at the end of the operative procedure

“revealed good seating of the valve with no evidence of perivalvular leak, good

function of the valve leaflets and . . . no evidence of an atrial-ventricular block.” Mr.

Smith then returned to the intensive care unit (the ICU) for further treatment and

recovery.

      On July 4, 2006, Mr. Smith had a Quinton catheter sutured into place in his left

internal jugular vein. He tolerated the procedure well, and all catheters in his body

were “noted to be free of reddness [sic] or edema.” However, Nurse Hammonds

entered Mr. Smith’s room on July 5, 2006, and found that Mr. Smith “was

experiencing agonal respirations,” that “the Quintan [sic] catheter was no longer in

its proper place,” and that Mr. Smith “was and had been experiencing significant

bleeding.” The medical staff successfully resuscitated Mr. Smith, and he remained

in the ICU. Later that day, however, Mr. Smith “was medically assessed that he was

not able to follow simple commands, except to open his eyes when his name was

called.”

      Over the next few days, Mr. Smith continued receiving blood pressure

medications and received a new Quinton catheter. He received dialysis therapy, but


                                           4
by July 8, 2006, his “blood pressure continued to drop despite increasing . . . his

blood pressure medications” and other treatments. Mr. Smith also had “continuous

oozing of blood from his mouth, nose, hemodialysis catheter, and scrotal area.” On

July 9, 2006, Dr. Mario Ruiz informed Mr. Smith’s wife, Connie, that Mr. Smith was

“slowly dying.” On July 10, 2006, “a medical decision was made to withdraw life

support measures from Mr. Smith due to his severely [sic] brain damaged [sic] and

other conditions, such life support measures were withdrawn from Mr. Smith, and he

was pronounced dead” on the evening of July 10, 2006. An autopsy by Dr. Juan

Zamora “revealed pathological findings of a status post recent tricuspid valve

prosthesis implant showing no complications, hypertrophy of the heart (500g) with

organizing fibrinoid percarditis, bilateral granulomata of the lungs, edema of the brain

with acute hepatitis, and other findings.”

                              IV. Standard of Review

      A trial court’s ruling concerning an expert report under section 74.351

(formerly article 4590i, section 13.01) of the Medical Liability and Insurance Act is

reviewable under the abuse of discretion standard. See Tex. Civ. Prac. & Rem.

Code Ann. § 74.351; Bowie Mem’l Hosp. v. Wright, 79 S.W .3d 48, 52 (Tex. 2002);

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. Cire


                                             5
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. Bowie Mem’l, 79 S.W .3d

at 52; E.I. du Pont de Nemours & Co. v. Robinson, 923 S.W .2d 549, 558 (Tex.

1995).

                             V. Statutory Requirements

      A health care liability claimant must serve an expert report on each defendant

no later than the 120th day after the claim is filed. See Tex. Civ. Prac. & Rem. Code

Ann. § 74.351(a). A defendant may challenge the adequacy of a report by filing a

motion to dismiss, and the trial court must grant the motion to dismiss if it finds, after

a hearing, that “the report does not represent an objective good faith effort to comply

with the definition of an expert report” in the statute. Id. § 74.351(l). W hile the

expert report “need not marshal all of the plaintiff’s proof,” it must provide a fair

summary of the expert’s opinions as to the “applicable standard of care, the manner

in which the care rendered by the physician or health care provider failed to meet the

standards, and the causal relationship between that failure and the injury, harm, or

damages claimed.” Id. § 74.351(r)(6); Palacios, 46 S.W .3d at 878 (construing

former article 4590i, § 13.01).

      To constitute a good faith effort, the report must discuss the standards of care,

breach, and causation with sufficient specificity (1) to inform the defendant of the

conduct the plaintiff has called into question and (2) to provide the trial court with a


                                            6
basis to conclude that the claims have merit. See Bowie Mem’l, 79 S.W .3d at 52;

Palacios, 46 S.W .3d at 879. A report does not fulfill this requirement if it merely

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

Mem’l, 79 S.W .3d at 52; Palacios, 46 S.W .3d at 879. But the information in the

report “does 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.

      W hen reviewing the adequacy of a report, the only information relevant to the

inquiry is the information contained within the four corners of the document. Bowie

Mem’l, 79 S.W .3d at 52; Palacios, 46 S.W .3d at 878. 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. See Austin Heart, P.A. v. Webb, 228 S.W .3d 276,

279 (Tex. App.—Austin 2007, no pet.). However, section 74.351 does not prohibit

experts, as opposed to courts, from making inferences based on medical history.

Marvin v. Fithian, No. 14-07-00996-CV, 2008 W L 2579824, at *4 (Tex.

App.—Houston [14th Dist.] July 1, 2008, no pet.) (mem. op.); see also Tex. R. Evid.

703 (providing that an expert may draw inferences from the facts or data in a

particular case); Tex. R. Evid. 705 (providing that expert may testify in terms of

opinions and inferences).

                                    VI. Analysis

      The Hospital argues in its sole issue that the expert reports by Dr. Halkos and

Nurse Hayman are insufficient and that the trial court abused its discretion by


                                          7
denying the Hospital’s motion to dismiss. See Tex. Civ. Prac. & Rem. Code Ann.

§ 74.351(l). Dr. Halkos’s and Nurse Hayman’s expert reports discuss the acts and

omissions of three of the Hospital’s nurse-employees: Donna L. McElravy, R.N.;

Chad Hammonds, R.N.; and Garland Gill, R.N. W e address the allegations against

each of these nurse-employees in turn.

A.    Duty and Alleged Breach by Nurse McElravy

      The Hospital contends Dr. Halkos’s report is insufficient because it does not

adequately describe the standard of care applicable to Nurse McElravy or how Nurse

McElravy allegedly breached the standard of care.

      Relevant portions of Dr. Halkos’s report provide:

      McElravy was responsible for assisting Dr. Bolton in managing the post-
      operative anticoagulation therapy of Mr. Smith to prevent thrombus
      formation as a result of the mechanical valve replacement surgery
      performed on the patient. At that time, the incidence of thrombus
      (blood clot) complications of following mechanical valve replacement
      surgery was or should have been a matter of common knowledge to
      reasonably prudent registered nurses specializing in cardiovascular and
      thoracic surgery.

             McElravy should have properly monitored anticoagulant therapy
      for Mr. Smith in a manner that would maintain an INR (International
      Normalized Ratio) of 2.5 to 3.5; or a PTT (Partial Thromboplastin Time)
      of 1.5 to 2.5 times the control. . . . On the morning of July 4, 2006, at
      about 9:00 a.m., Dr. Bolton noted an INR greater than 3 in Mr. Smith,
      and recorded in the progress notes that Mr. Smith’s INR was greater
      than 3 and noted to hold the administration of coumadin that night.
      [The Hospital] laboratory reported critically abnormal results of Mr.
      Smith’s PT (protime) at about 9:34 a.m., as being greater than 120
      seconds[,] and the laboratory was unable to calculate the INR. The
      protime greater than 120 seconds value reflected an excessive and
      potentially dangerous state of anticoagulation in Mr. Smith’s blood.


                                         8
             W hen the critically abnormal PT results and lack of a calculable
      INR were reported, McElravy should have become aware of this
      information, and reported such values to Dr. Bolton, Dr. Russell, or PA
      Dizney and cause repeat testing of a new blood specimen from Mr.
      Smith to verify the previously noted and reported critical results. . . .
      Therefore, when McElravy discovered or should have discovered that
      Dr. Bolton improperly recorded Mr. Smith’s INR as greater than 3, she
      failed to meet the applicable standard of reasonable and prudent
      nursing care in that she failed to bring to Dr. Bolton or PA Dizney’s
      attention Dr. Bolton’s improper assessment of Mr. Smith’s INR on the
      morning of July 4, 2006[;] she also failed to meet the standard of
      reasonable nursing care in failing to recognize Mr. Smith’s excessive
      anticoagulation blood condition, report such condition to Dr. Bolton, Dr.
      Russell or PA Dizney and bring about appropriate intervention to
      correct this dangerous condition for Mr. Smith.
      Dr. Halkos’s report adequately describes Nurse McElravy’s duties and alleged

breaches of those duties. The report states that McElravy: (1) had a duty to assist

Dr. Bolton with Mr. Smith’s post-operative anticoagulation therapy; (2) should have

known the incidence of thrombus following mechanical valve replacement surgery;

(3) should have monitored Mr. Smith’s anticoagulant therapy so as to maintain an

INR of 2.5 to 3.5 or a PTT of 1.5 to 2.5 times the control; (4) should have known Dr.

Bolton incorrectly recorded the INR as greater than 3; (5) failed to report Dr. Bolton’s

incorrect assessment of Mr. Smith’s INR; and (6) failed to recognize or report Mr.

Smith’s excessive anticoagulation blood condition to Dr. Bolton, Dr. Russell, or PA

Dizney. These statements, all contained within the four corners of Dr. Halkos’s

report, are sufficient to inform the Hospital of the specific conduct by Nurse McElravy

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




                                           9
conclude that the Smiths’ claim has merit. See Bowie Mem’l Hosp., 79 S.W .3d at

52; Palacios, 46 S.W .3d at 879.

      The Hospital also argues that several individual statements in Dr. Halkos’s

report are insufficient. 2 W e do not address these specific arguments by the Hospital,

however, because Dr. Halkos’s report, as a whole, provides a “fair summary” of his

opinions; it (1) sufficiently informs the Hospital of the conduct the Smiths question

and (2) provides the trial court with a basis to conclude the Smiths’ claim has merit.

See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6); Bowie Mem’l, 79 S.W .3d at

52; Palacios, 46 S.W .3d at 879; Benavides v. Garcia, 278 S.W .3d 794, 799 (Tex.

App.—San Antonio 2009, pet. denied) (stating that opinion in expert report, read in

isolation, appeared conclusory, but holding that opinion was sufficiently described

in context of entire report). The trial court did not abuse its discretion by finding that

Dr. Halkos’s report adequately address Nurse McElravy’s alleged duties and

breaches of those duties.

B.    Duty and Alleged Breach by Nurse Hammonds

      The Hospital also contends Nurse Hayman’s report and supplemental report

are insufficient because they do not adequately describe the standard of care



      2
         For example, the Hospital argues Dr. Halkos’s report states that Nurse
McElravy “should have properly monitored anticoagulant therapy for Mr. Smith” but
does not explain how Nurse McElravy improperly monitored anticoagulant therapy
or how Nurse McElravy should have monitored it and does not state how McElravy
was negligent in not having information about “critically abnormal PT . . . results and
lack of calculable INR” as alleged in the report.

                                           10
applicable to Nurse Hammonds or how Nurse Hammonds allegedly breached the

standard of care.

      Relevant portions of Nurse Hayman’s report provide:

            Nurse Hammonds was responsible for providing reasonable and
      prudent nursing diagnosis, assessment, care and treatment for Mr.
      Smith’s post-operative conditions and well-being in the [Hospital] ICU,
      and this responsibility included careful and frequent monitoring of his
      physical and mental conditions, the plan of care from multiple
      consultants, and the delivery of ongoing intensive nursing care in the
      ICU and interventions as prescribed by attending and consulting
      physicians as well as reasonable nursing practices.

      Nurse Hammonds administered 4 mg of morphine sulfate by IV and 15
      mg of hydrocodone by mouth at 2000 (8:00 PM) on 7/04/06. Nurse
      Hammonds failed to properly administer the PRN (as necessary) pain
      control orders because he should have known that both medications
      should not have been administered to Mr. Smith in one dose. If Nurse
      Hammonds believed such orders allowed the choice to administer both
      medications at one time, then Hammonds failed to question or clarify
      Dr. Bolton’s orders. It was a violation of the reasonable and prudent
      standards of nursing care for a critical care nurse to administer the
      medications in that manner or not to call Dr. Bolton and question the
      orders.

             Nurse Hammonds failed to perform sufficient surveillance to
      discover the removal of the IJ catheter in time to prevent Mr. Smith’s
      hemorrhagic arrest. A reasonably prudent critical care nurse . . . should
      have known that continuous bleeding for approximately 30–45 minutes
      would lead to hemorrhagic cardiac arrest. Therefore, it is reasonable
      to conclude, in reasonable nursing probability, that Defendant
      Hammonds failed to see and assess Mr. Smith for at least 30 minutes
      prior to his arrest. According to the hospital records, Hammonds
      recorded Mr. Smith’s vital signs at a time prior to his arrest when the
      Quinton catheter must have been out and therefore significant bleeding
      would and should have been obvious to a critical care nurse, including
      Hammonds, performing duties according to the standards for
      reasonable and prudent nurses in ICU settings. The hospital ICU
      records indicate that Hammonds either failed to properly observe Mr.


                                         11
Smith, or he did not accurately and completely record his nursing
actions in the hospital record, and both such failures would be a
violation of the applicable standard of nursing care for Hammonds.

       Nurse Hammonds failed to set alarm limits on the physiologic
monitors that reflected the patient’s baseline vital signs and thereby
failed to discover when various parameters were in alarm condition. .
. . Hammonds either failed to transduce the IJ catheter to the alarm
system or he failed to respond to the alarm condition caused by the
removal of the device. In either situation, Hammonds failed to meet the
applicable standard of nursing care for Mr. Smith. . . . In violation of the
standards for reasonable and prudent critical care nursing, Nurse
Hammonds failed to document alarm conditions, rhythm strips, oxygen
de-saturation or his nursing responses to any of the abnormalities that
occurred before Mr. Smith exsanguinated (bled out) into arrest.

The hospital code record reflects that ECG monitoring and pulse
oximetry were in progress at the time of the arrest event. Defendant
Hammonds either failed to establish that monitoring or he ignored the
alarm conditions that would have occurred in the setting of “agonal
breathing.” Mr. Smith’s agonal breathing would have caused alarm
conditions in the rate of respirations and oxygen saturation on the alarm
system. . . . Defendant Hammonds failed to recognize, intervene in, or
document and report any such alarm conditions for Mr. Smith at that
time. Further, Hammonds had an obligation to be in audible or visual
proximity to promptly and adequately respond to any such clinical or
physiological alarm conditions.

Using the physiologic monitoring system, Nurse Hammonds should
have established and monitored clinical alarms/limits based on [Mr.
Smith’s] condition . . . . All central venous lines or catheters, like the left
internal jugular catheter, should have been transduced to the
physiological monitoring system such that the monitoring system would
alarm when a central line became disconnected.

      Defendant Hammonds failed to perform sufficient surveillance to
discover the removal of the IJ catheter in time to prevent Mr. Smith’s
hemorrhagic arrest. A reasonably prudent critical care nurse, would
have known that continuous bleeding for approximately 30–45 minutes
would lead to hemorrhagic cardiac arrest. Therefore, in reasonable



                                      12
      medical probability, Hammonds failed to observe Mr. Smith for 30–45
      minutes prior to the arrest event.
In addition, Nurse Hayman’s supplemental report provides that the standard of care

applicable to Nurse Hammonds requires him to have basic knowledge of all

medications he administers to a patient, including the potential side effect of the

medications to assess, from a nursing perspective, “decreased levels of

consciousness, disorientation, and/or sedation in patients” similar to Mr. Smith, and

to “utilize wrist restraints in the care of patients, including Mr. Smith, who

demonstrate a decreased level of consciousness, disorientation, and/or sedation in

order to prevent the patient from causing injury to himself.”           Nurse Hayman’s

supplemental report states that Nurse Hammonds failed to appreciate the potential

side effects of simultaneous doses of morphine sulphate and hydrocodone, failed to

assess, from a nursing perspective, Mr. Smith’s resulting neurological impairment

and decreased levels of consciousness, disorientation, and/or sedation, and failed

to utilize wrist restraints to prevent Mr. Smith from causing injury to himself.

       Nurse Hayman’s report and supplemental report provide that Nurse

Hammonds:      (1) had a duty to monitor Mr. Smith’s post-operative mental and

physical conditions; (2) had a duty to either question or clarify Dr. Bolton’s order

before administering both morphine and hydrocodone to Mr. Smith but failed to do

either; (3) failed to assess, from a nursing perspective, or appreciate Mr. Smith’s

altered level of consciousness; (4) failed to use bilateral soft wrist restraints or obtain

orders from Dr. Bolton or Dr. Russell for wrist restraints; (5) failed to provide


                                            13
sufficient observations and surveillance of Mr. Smith; (6) failed to recognize that Mr.

Smith’s Quinton catheter had been removed while recording Mr. Smith’s vital signs;

(7) failed to timely discover the removal of Mr. Smith’s Quinton catheter; and (8)

either failed to establish a physiologic monitoring system and set the appropriate

alarm limits on the monitoring system or failed to monitor and document the alarms

from the monitoring system. These statements, all contained within the four corners

of Nurse Hayman’s report, are sufficient to inform the Hospital of the specific conduct

by Nurse Hammonds that the Smiths have called into question and provide a basis

for the trial court to conclude that the claim has merit. See Bowie Mem’l, 79 S.W .3d

at 52; Palacios, 46 S.W .3d at 879. The trial court did not abuse its discretion in

finding that Nurse Hayman’s report and supplemental report sufficiently address duty

and alleged breach of duty as to Nurse Hammonds.

C.    Duty and Alleged Breach by Nurse Gill

      The Hospital next contends Nurse Hayman’s report and supplemental report

are insufficient because they do not adequately describe the standard of care

applicable to Nurse Gill or how Nurse Gill allegedly breached the standard of care.

      Relevant portions of Nurse Hayman’s report provide:

            Nurse Gill was responsible for providing reasonable and prudent
      nursing diagnosis, assessment, care and treatment for Mr. Smith’s
      post-operative conditions and well-being in the [Hospital] ICU, and this
      responsibility included careful and frequent monitoring of his physical
      and mental conditions, the plan of care from multiple consultants, and
      the delivery of ongoing intensive nursing care in the ICU and



                                          14
      interventions as prescribed by attending and consulting physicians as
      well as reasonable nursing practices.

             Nurse Gill failed to perform sufficient surveillance to discover the
      removal of the IJ catheter in time to prevent Mr. Smith’s hemorrhagic
      arrest. A reasonably prudent critical care nurse, should have known
      that continuous bleeding for approximately 30–45 minutes would lead
      to hemorrhagic cardiac arrest. Therefore, it is reasonable to conclude,
      in reasonable nursing probability, that Defendant Gill failed to see and
      assess Mr. Smith for at least 30 minutes prior to his arrest. The
      hospital ICU records indicate that Gill either failed to properly observe
      Mr. Smith, or he did not accurately and completely record his nursing
      actions in the hospital record, and both such failures would be a
      violation of the applicable standard of nursing care for Gill.

      Defendant Gill failed to recognize, intervene in, or document and report
      any such alarm conditions for Mr. Smith at that time. Further, Gill had
      an obligation to be in audible or visual proximity to promptly and
      adequately respond to any such clinical or physiological alarm
      conditions.

      Using the physiologic monitoring system, Nurse Gill should have
      established and monitored clinical alarms/limits based on [Mr. Smith’s]
      condition . . . . All central venous lines or catheters, like the left internal
      jugular catheter, should have been transduced to the physiological
      monitoring system such that the monitoring system would alarm when
      a central line became disconnected.

Furthermore, Nurse Hayman’s supplemental report states that the standard of care

applicable to Nurse Gill requires him to have basic knowledge of all medications he

administers to a patient, including the potential side effect of the medications to

assess, from a nursing perspective, “decreased levels of consciousness,

disorientation, and/or sedation in patients” similar to Mr. Smith, and to “utilize wrist

restraints in the care of patients, including Mr. Smith, who demonstrate a decreased

level of consciousness, disorientation, and/or sedation in order to prevent the patient


                                            15
from causing injury to him[self].” Nurse Hayman’s supplemental report states that

Nurse Gill failed to appreciate the potential side effects of simultaneous doses of

morphine sulphate and hydrocodone, failed to assess, from a nursing perspective,

Mr.   Smith’s   resulting   neurological    impairment    and    decreased     levels   of

consciousness, disorientation, and/or sedation, and failed to utilize wrist restraints

to prevent Mr. Smith from causing injury to himself.

      Nurse Hayman’s report and supplemental report adequately describe Nurse

Gill’s duties and alleged breaches of those duties. The report and supplemental

report provide that Nurse Gill: (1) had a duty to monitor Mr. Smith’s post-operative

mental and physical conditions; (2) failed to, from a nursing perspective, assess or

appreciate Mr. Smith’s altered level of consciousness; (3) failed to use bilateral soft

wrist restraints or obtain orders from Dr. Bolton or Dr. Russell for wrist restraints; (4)

failed to provide sufficient surveillance of Mr. Smith; (5) failed to timely discover the

removal of Mr. Smith’s Quinton catheter; and (6) failed to establish or monitor and

document a physiologic monitoring system with the appropriate alarm limits. These

statements, all contained within the four corners of Nurse Hayman’s reports, are

sufficient to inform the Hospital of the specific conduct by Nurse Gill that the Smiths

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

Smiths’ claim has merit. See Bowie Mem’l, 79 S.W .3d at 52; Palacios, 46 S.W .3d

at 879. The trial court acted within its discretion in finding that Nurse Hayman’s




                                           16
report and supplemental report sufficiently address duty and alleged breach of duty

as to Nurse Gill.

D.    Causation

      Finally, the Hospital argues the Smiths’ expert reports are insufficient because

they do not sufficiently describe how the alleged breaches of the standard of care

by the Hospital’s three nurse-employees caused any harm to Mr. Smith.

      Relevant portions of Dr. Halkos’s report provide:

      It is my opinion that each of the above-described failures of Dr. Bolton,
      Dr. Russell, Dr. Suominen, PA Dizney, Nurse McElravy, Nurse
      Hammonds, and Nurse Gill to meet the reasonable, prudent, and
      accepted standards of medical, nursing and health care in the
      diagnosis, assessment, care and treatment of [Mr.] Smith’s post-
      operative and clinical conditions, separately and collectively, probably
      caused Mr. Smith to experience a worsening of his physical and mental
      conditions leading to his pulling out the Quinton catheter resulting in
      significant and severe bleeding that led to his hemorrhagic
      cardiopulmonary arrest with pulseless electrical activity, resuscitation,
      additional deterioration, and his death . . . .

      Dr. Bolton and Dr. Russell’s failures to be notified [by Nurse McElravy]
      of Mr. Smith’s severe abnormal anticoagulation condition, as
      demonstrated by his incalculable and undetermined INR as of July 4,
      2006, due to his abnormally high protime (greater than 120 seconds),
      allowed his excessive anticoagulation condition to continue
      unrecognized and uncorrected.

      If Dr. Suominen, PA Dizney or Nurse McElravy had properly evaluated
      Mr. Smith’s conditions and notified Dr. Bolton and Dr. Russell of such
      conditions, then in all probability, Mr. Smith’s state of excessive
      anticoagulation would have been recognized and corrected because
      the applicable standards of medical care for Dr. Bolton and Dr. Russell
      would have required them to take such action under the circumstances.
      Unfortunately, Mr. Smith’s state of excessive anticoagulation continued
      and the administration of large doses of narcotic pain medications


                                         17
administered by Nurse Hammonds to Mr. Smith on the evening of July
4, 2006, in all probability led to disorientation and neurological
impairment in Mr. Smith such that he was able to self-remove the left
internal jugular Quinton catheter causing massive hemorrhage leading
to exsanguinating cardiopulmonary arrest. Although the sequence of
events leading up to Mr. Smith’s hemorrhagic arrest is not accurately
or completely documented in the [Hospital] medical record, it is likely
that Mr. Smith’s neurological impairment, caused by the large doses of
narcotic pain medications for the above-discussed reasons, allowed
him to avoid suffering the significant pain of self-removal of the Quinton
catheter from his neck and not be alarmed by the subsequent massive
hemorrhage he experienced and summon the [Hospital] nursing staff
for help.

Dr. Suominen’s failure to adequately secure the Quinton catheter to Mr.
Smith’s neck and Nurse McElravy’s failure to cause to be ordered[] soft
wrist restraints in the setting of Mr. Smith’s altered level of
consciousness allowed this series of events to occur where Mr. Smith
was able to pull out the Quinton catheter and experience massive
bleeding. If Dr. Suominen had adequately secured the Quinton
catheter in Mr. Smith’s neck and if Nurse McElravy had caused to be
ordered[] soft wrist restraints in the setting of Mr. Smith’s altered level
of consciousness this series of events where Mr. Smith was able to pull
out the Quinton catheter and experience massive bleeding in all
lilklihood [sic] would not have occurred and would not have progressed
to cardiopulmonary arrest.

Nurses Hammonds[‘] and Gill’s failures to properly and adequately
monitor Mr. Smith’s above-described activities and conditions resulted
in their failures to timely and properly recognize his removal of the
Quinton catheter and the bleeding from the catheter site before he
experienced hemorrhagic cardiopulmonary arrest. . . . Nurses
Hammonds and Gill failed to closely monitor Mr. Smith’s conditions for
a period of at least 30 to 45 minutes before Hammonds[’s] discovery of
Mr. Smith’s hemorrhagic arrest. If Nurses Hammonds and Gill had
timely discovered Mr. Smith’s self-removal of the Quinton catheter
within 30 to 45 minutes before arrest, and implemented proper
interventional procedures, it is likely that Mr. Smith’s significant
bleeding condition could have been stopped and would not have
progressed to cardiopulmonary arrest. Although Mr. Smith’s clinical
condition had a mortality of about twenty percent prior to the arrest, the


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       above-discussed failures of Dr. Bolton, Dr. Russell, Dr. Suominen, PA
       Dizney, McElravy, Hammonds, and Gill probably led to the arrest and
       the sequelae that probably ensued and in reasonable probability led to
       his progressive weakness, increasing renal dysfunction, and multi-
       system organ failure and his death.

       These statements, all contained within the four corners of Dr. Halkos’s report,

sufficiently link Dr. Halkos’s causation opinions to the facts and adequately describe

the chain of events allegedly leading to Mr. Smith’s death. See Patel v. Williams,

237 S.W .3d 901, 905–06 (Tex. App.—Houston [14th Dist.] 2007, no pet.) (holding

expert report sufficiently set forth causation when it presented a chain of events

beginning with a contraindicated prescription and ending with the patient’s death).

The trial court acted within its discretion in finding that Dr. Halkos’s report sufficiently

address the element of causation. 3

       W e overrule the Hospital’s sole issue.

                                    VII. Conclusion

       Having overruled the Hospital’s sole issue, we affirm the trial court’s order.



                                                 ANNE GARDNER
                                                 JUSTICE

PANEL: LIVINGSTON, C.J.; GARDNER and W ALKER, JJ.

DELIVERED: May 20, 2010


       3
        The Hospital also argues that Nurse Hayman is not qualified to render
causation opinions. W e need not address this argument, however, because Dr.
Halkos’s report, without reference to Nurse Hayman’s report, sufficiently addresses
the causation element in the Smiths’ claim against the Hospital. See Tex. R. App.
P. 47.1.

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