                                 NO. 07-03-0076-CV

                            IN THE COURT OF APPEALS

                     FOR THE SEVENTH DISTRICT OF TEXAS

                                    AT AMARILLO

                                       PANEL C

                              DECEMBER 30, 2003
                        ______________________________

           BETTY GAIL KIRKSEY, individually and as independent executrix
       of the estate of HERSHEL ALFORD BOSS, BARBARA LEE PERDIGAN,
        MARY OMEGA ROYS, RONNIE JOE BOSS, DAVID GARREL BOSS,
                             and DOLORES BARBER

                                                            Appellants

                                           v.

                          SAMBASIVA R. MARUPUDI, M.D.,


                                                     Appellee
                       _________________________________

            FROM THE 108TH DISTRICT COURT OF POTTER COUNTY;

                  NO. 84,325-E; HONORABLE ABE LOPEZ, JUDGE
                       _______________________________

Before JOHNSON, C.J., and QUINN and REAVIS, JJ.

      Appellants Betty Gail Kirksey, individually and as independent executrix of the

estate of Hershel Alford Boss, Barbara Lee Perdigan, Mary Omega Roys, Ronnie Joe

Boss, David Garrel Boss, and Dolores Barber (collectively referred to as Kirksey) appeal

from an order dismissing their medical malpractice claim against appellee Dr. Sambasiva

R. Marupudi (Marupudi). Through six issues, she alleges that the trial court erred in
finding that 1) her expert report failed to meet applicable requirements and 2) the

inadequacy was intentional or the result of conscious indifference. We affirm the order

of the trial court.

                                            Background

       On December 3, 1997, the appellants, who are the children of Hershel Alford Boss,

filed a lawsuit alleging medical malpractice on the part of Marupudi. The latter had

performed surgery on Boss for colon cancer. During the patient’s hospital stay, the 81-

year-old fell while getting out of bed and broke his hip. After surgery on his broken hip,

his condition deteriorated, resulting in his death. Kirksey claimed that Marupudi was

negligent in failing to prevent the fall.

          On March 3, 1998, Kirksey filed her expert report as required under article 4590i

of the Texas Revised Civil Statutes. Four years later, on May 14, 2002, Marupudi filed a

motion to dismiss the lawsuit on the basis that the report failed to meet requirements

mandated by statute and case law. In response, Kirksey filed a motion seeking a 30-day

grace period (if the court should find the report deficient) on the basis that the failure to

comply was neither intentional nor the result of conscious indifference. After a hearing,

the trial court granted the motion to dismiss and denied that requesting a 30-day grace

period.               Issues One, Two, Three - Good Faith Expert Report

       In her first three issues, Kirksey disputes the findings of the trial court with respect

to the adequacy of her expert report. We overrule the issues.

       Applicable Law

       One suing another for medical malpractice must


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        [n]ot later than the later of the 180th day after the date on which a health care
        liability claim is filed or the last day of any extended period . . . (1) furnish to
        counsel for each physician . . . one or more expert reports, with a curriculum
        vitae of each expert listed in the report; or (2) voluntarily nonsuit the action
        against the physician. . . .

TEX . REV . CIV . STAT. ANN . art. 4590i, §13.01(d) (Vernon Supp. 2003).1 Should the plaintiff

not do so, then the trial court must

        . . . on the motion of the affected physician . . ., enter an order awarding as
        sanctions against the claimant or the claimant’s attorney: (1) the reasonable
        attorney’s fees and costs of court incurred by that defendant; (2) the
        forfeiture of any cost bond respecting the claimant’s claim against that
        defendant to the extent necessary to pay the award; and (3) the dismissal of
        the action of the claimant against that defendant with prejudice to the claim’s
        refiling.

Id. §13.01(e); Jernigan v. Langley, 111 S.W.3d 153, 156 (Tex. 2003) (stating that the

cause must be dismissed if the trial court determines that the report does not represent a

good faith effort to comply with the definition of an expert report). However, if a report is

timely filed, the opponent may still challenge its adequacy.

        Next, to be adequate, the report must be written by an expert and provide a fair

summary of that expert’s opinions regarding the applicable standards of care, the manner

in which the care rendered deviated from those standards, and the causal relationship

between the deviation and the injury allegedly suffered. Id. at §13.01(r)(6); Chisholm v.

Maron, 63 S.W.3d 903, 906 (Tex. App.--Amarillo 2001, no pet.). In other words, the expert

must do more than merely voice his opinions in the report. He is obligated to also inform



        1
        As of September 1, 2003, the provision is now found at §73.351 of the Civil Practice and Remedies
Code. Furthermore, the claimant no longer has 180 days to serve the report but only 120. TEX. CIV. PRAC.
& REM. CODE ANN. §74.351(a) (Vernon Supp. 2004). However, because the trial court dismissed the suit
before September 1, 2003, we cite to the old statute.

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the defendant of the specific conduct called into question and provide a basis for the trial

court to conclude that the claims have merit. American Transitional Care Ctrs, of Tex. Inc.

v. Palacios, 46 S.W.3d 873, 879 (Tex. 2001); Chisholm v. Maron, 63 S.W.3d at 906. And,

though this does not require the claimant to marshal all his evidence, Rittmer v. Garza,

65 S.W.3d 718, 723 (Tex. App.--Houston [14th Dist.] 2001, no pet.), more than mere

conclusions about the standard of care, its breach, and causation must be uttered.

American Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d at 879. Finally, in

assessing the adequacy of the report, the trial court can look no further than to the four

corners of the report. Bowie Memorial Hospital v. Wright, 79 S.W.3d 48, 52 (Tex. 2002);

American Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d at 878.

       Application of Law

       The report at bar was provided by Dr. Kalpanba M. Kumar, an individual board

certified in internal medicine. The doctor criticized the failure of Marupudi to use measures

to prevent Boss’ fall. The first measure alluded to was the failure to write a standing order

for anxiolytic medication on an as needed basis. Such medication was purportedly

necessary to treat the patient’s “transient disorientation and anxiety” which “may have led

him to attempt to get out of bed and subsequently fall.” This omission would constitute

negligence, in the expert’s view, “if the patient had attempted to get out of bed and fall, due

to confusion and disorientation.” The second measure involved the failure to order

restraints “[i]f the nurses had . . . discussed Mr. Boss’s confusion and combativeness with

Dr. Marupudi.” Yet, nothing in the report suggests that Boss fell due to disorientation and

anxiety or that the nurses informed Marupudi that his patient was suffering from


                                              4
disorientation or had a history of it. Moreover, Kumar does not opine that the standard of

care required that every patient who slipped and fell once in the hospital should be placed

in restraints and given anti-anxiety medication to prevent subsequent falls. Instead, the

doctor’s opinions are based on the assumption that Boss fell due to disorientation and

confusion even though the circumstances described in the report do not indicate that he

was actually experiencing such a condition when he fell.

       So what we have before us is an opinion accusing Marupudi of negligence. Yet, the

opinion is dependent upon the occurrence of particular circumstances, and the expert does

not suggest, in the report, that those circumstances actually occurred. This is problematic

for the report must give the trial court sufficient information upon which to initially decide

whether the claim is frivolous. American Transitional Care Ctrs. of Texas, Inc. v. Palacios,

46 S.W.3d at 879. In other words, since it must enable the trial court to hold that the claim

has merit, logic dictates that it contain sufficient information to enable the trial court to

make that decision. Given that whether a physician acted negligently depends upon the

circumstances confronting the doctor, see Chambers v. Conaway, 883 S.W.2d 156, 158

(Tex. 1993) (stating that a “physician has a duty to act as would a physician of reasonable

and ordinary prudence under the same or similar circumstance”), it also follows that before

any assessment can be made about the existence of a duty and its breach, the

circumstances confronting the physician must be revealed. And, if the trial court must be

in a position to hold that the claim is meritorious and can look no further than to the report

itself, then the latter must of necessity reiterate the pertinent circumstances. Indeed, this




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is at least one reason why mere conclusions regarding the standard of care, its breach,

and causation do not satisfy the definition of an expert report.


       As previously mentioned, the expert’s opinions here were and are founded upon

hypotheticals. Again, Kumar does not specify the circumstances confronting Marupudi.

Rather, the doctor simply posits the theorum that if X occurred (and assuming Marupudi

knew of it), then Y was the appropriate response. Whether X occurred or whether Kirksey

or Kumar alleged X occurred goes unmentioned in the report. And, because it does, the

trial court lacked sufficient information about the circumstances of the dispute to determine

whether Marupudi had a duty to act, breached that duty, if any, and whether that breach

caused, in any way, Boss’ death. Thus, the trial court did not abuse its discretion in either

concluding that the expert report fell short of that required by Palacios or in dismissing the

suit. See Bowie Memorial Hospital v. Wright, 79 S.W.3d at 52 (stating that whether a trial

court erred in dismissing the suit depends upon whether it abused its discretion).


       Finally, we do not hold that a claimant must marshal his evidence in the expert

report. As previously mentioned, that is not required. Yet, neither are conclusory

statements permissible. Instead, to conform to the dictates of Palacios, the report must

contain a description of the circumstances confronting the doctor and which purportedly

obligated him to respond in a particular manner. Without them, no one can determine how

a reasonable physician would have acted or whether the conduct actually undertaken

caused any injury. Indeed, this is nothing more than requiring a plaintiff to give a

defendant fair notice of his claim.


                       Issues Four, Five, and Six - Grace Period

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       In her last three issues, Kirksey argues that the trial court erred by refusing to grant

a 30-day grace period to provide an adequate expert report. We overrule the issues.


       Article 4590i, §13.01(g) of the Revised Civil Statutes provided:


       Notwithstanding any other provision of this section, if a claimant has failed
       to comply with a deadline established by Subsection (d) of this section and
       after hearing the court finds that the failure of the claimant or claimant’s
       attorney was not intentional or the result of conscious indifference but was
       the result of an accident or mistake, the court shall grant a grace period of
       30 days to permit the claimant to comply with that subsection . . . .

Kirksey believed herself entitled to the aforementioned grace period because her failure

to provide an adequate report purportedly arose from her attorney’s belief that the

document met the applicable requirements. While this would have entitled her to an

extension at one time, see e.g. In re Rodriguez, 99 S.W.3d 825, 828-29 (Tex. App.--

Amarillo 2003, orig. proceeding) (holding that an attorney’s mistaken belief that a report

was sufficient satisfied the prerequisites for obtaining the 30-day grace period), that is no

longer true. After we issued Rodriguez, the Supreme Court held that “a purportedly

mistaken belief that the report complied with the statute does not negate a finding of

‘intentional or conscious indifference.’” Walker v. Gutierrez, 111 S.W.3d 56, 65 (Tex.

2003). Given this, the trial court did not err in rejecting the basis upon which Kirksey

alleged she was entitled to the extension.

       Accordingly, the judgment of the trial court is affirmed.



                                                   Brian Quinn
                                                      Justice


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