                                                                                            ACCEPTED
                                                                                        13-15-00170-CV
                                                                        THIRTEENTH COURT OF APPEALS
                                                                               CORPUS CHRISTI, TEXAS
                                                                                   6/23/2015 2:01:03 PM
                                                                                 CECILE FOY GSANGER
                                                                                                 CLERK


                            No. 13-15-00170-CV
______________________________________________________________________________
                                                           FILED IN
                                                 13th COURT OF APPEALS
                                              CORPUS CHRISTI/EDINBURG, TEXAS
                 IN THE   THIRTEENTH COURT OF APPEALS
                                                  6/23/2015 2:01:03 PM
                                                   CECILE FOY GSANGER
                           CORPUS CHRISTI, TEXAS          Clerk
__________________________________________________________________

  DIAGNOSTIC HEALTHCARE SERVICES/ D/B/A ONSITE BALANCE
                    SOLUTIONS, LLC

                                   Appellant

                                      v.

                              DIANE JACKSON

                              Appellee
__________________________________________________________________

                        APPELLEE'S BRIEF
__________________________________________________________________

                   On Appeal from Cause No. 14-E-0190
           In the 23rd District Court of Matagorda County, Texas
__________________________________________________________________


Alexander Forrest
State Bar No. 24065241                         Alan Kolodny
FORREST & KOLODNY, L.L.P.                      State Bar No. 24056882
1011 Augusta Drive, Suite 111              FORREST & KOLODNY, L.L.P.
Houston, Texas 77057-2035                  1011 Augusta Drive, Suite 111
(713) 532-4474                             Houston, Texas 77057-2035
(713) 785-0597 - Facsimile                 (713) 532-4474
aforrest@fko-law.com                       (713) 785-0597 - Facsimile
                                           akolodny@fko-law.com
                    IDENTITY OF PARTIES AND COUNSEL

       In accordance with TEX. R. APP. P. 38.1(a), the following is a complete list

of all parties to this appeal:

Plaintiff / Appellee                           Counsel for Plaintiff/Appellee

Diane Jackson                                 Mr. Alexander Forrest
                                              Mr. Alan Kolodny
                                              FORREST & KOLODNY, L.L.P.
                                              1011 Augusta Drive, Suite 111
                                              Houston, Texas 77057-2035
                                              (713) 532-4474 / (713) 785-0597 - Fax
                                              aforrest@fko-law.com

Defendant / Appellant                          Counsel for Defendant / Appellant

Diagnostic Healthcare Services,               David Luningham
d/b/a/ Onsite Balance Solutions, LLC          Watson, Caraway, Midkiff, & Luningham, LLP
                                              309 W. 7th St., 1600 Oil & Gas Bldng
                                              Forth Worth, TX 76013
                                              (817) 870-1717 / (817) 348-4842 – Fax


                                 OTHER PARTIES

                       Co-Appellant Dr. P Palivela Raju, M.D.

Trial Counsel and Appellate Counsel
Gary Sommer and James R. Boston
State Bar No. 24010415
Boston & Hughes, P.C.
8584 Katy Freeway, Suite 310
Houston, TX 77057
Tel: (713) 961-1122
gsommer@bostonhughes.com
jboston@bostonhughes.com


                                         ii
                          TABLE OF CONTENTS
IDENTITY OF PARTIES AND COUNSEL………………………………………ii
TABLE OF CONTENTS……………………………………………………….iii-iv
INDEX OF AUTHORITIES…………………………………………………….v-vi
STATEMENT OF THE CASE…………………………………………………….1
STATEMENT OF JURISDICTION……………………………………………….2
ISSUES PRESENTED……………………………………………………………..2
 A. Is Appellee’s cause of action against Appellant a Health Care Liability Claim
    (HCLC) subject to Texas Medical Liability Act (TMLA – Chapter 74 of the
    Texas Civil Practice & Remedies Code)?

 B. In the alternative that Appellee’s cause of action against Appellant is a Health
    Care Liability Claim (HCLC), did the trial court abuse its discretion denying
    Appellant’s motion to dismiss pursuant to Tex. Civ. Prac. & Rem. Code
    §74.351(b)?

       a. Does Appellee’s expert report sufficiently “implicate” Appellant by
          addressing the statutory elements of the TMLA?

       b. Does Appellee’s expert report sufficiently set forth the standard of care
          and explain how and why it was breached to satisfy the statutory
          requirements under the TMLA?

       c. Does Appellee’s medical expert report provide a sufficient explanation
          of how different care from Appellee would have prevented Appellant’s
          injuries in order to satisfy the statutory requirements of the TMLA?

ORAL ARGUMENT NOT REQUESTED………………………………………...3

STATEMENT OF THE FACTS…………………………………………………3-6




                                       iii
SUMMARY OF ARGUMENT…………………………………………………6-8
STANDARD OF REVIEW………..……………………………………………8-9
ARGUMENT…………………………………………………………………..9-33
   I.   This Case Does Not Fall Under the Purview of the TMLA………...11-20
  II.   In the Alternative that Appellee’s Claims Against Appellant are Health
        Care Liability Claims, The Trial Court Did Not Abuse Its Discretion
        Denying Appellant’s Motion to Dismiss Pursuant to Tex. Civ. Prac. &
        Rem. Code §74.351(b) of the TMLA……….………….…………...20-33
           A. Dr. Ravdel’s Expert Report implicates Appellant by outlining the
              applicable standard of care, and explaining how Appellant’s breach
              of that standard of care proximately caused injury to
              Appellee……………………………………………………....20-23

           B. Given the “objective good faith” standard for statutory compliance
              under Tex. Civ. Prac. & Rem. Code §74.351(b) of the TMLA,
              Appellee’s expert report sufficiently sets forth the standard of care
              and    explains    how     and      why      that    standard    was
              breached……………………………………………………....23-28

           C. Dr. Ravdel's Expert Report clearly explains that Appellee would not
              have fallen and sustained injuries if the medical chair used for
              balance testing had been properly maintained, a fact so simple that
              the        doctrine       of         res        ipsa       loquitur
              applies………………………………………………………..28-33


CONCLUSION………………………………………………………………..35-36
PRAYER………………………………………………………………………….36
CETFIFICATE OF COMPLIANCE……………………………………………...37
CERTIFICATE OF SERVICE……………………………………………………37




                                       iv
                         INDEX OF AUTHORITIES

Cases

Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873
(Tex.2001)…………………………………………………………………….8, 22

Beckwith v. White, 285 S.W.3d 56, 62 (Tex. App.—Houston [1st Dist.] 2009, no
pet.)………………………………………………………………………………22
Benish v. Grottie, 281 S.W.3d 184 (Tex. App. – Fort Worth 2009, pet
denied)……………………………………………………………………….......30

Doctors Hosp. at Renaissance, Ltd. v. Meja, No. 13-12-00602-CV, 2014
WL 5859592 (Tex.App. – Corpus Christi Aug.1, 2013, pet. filed) (mem.op.)…...13

Good Shepherd Medical Center-Linden, Inc. v. Twilley, 422 S.W.3d 782
(Tex. App. – Texarkana, Mar. 1, 2013, pet. denied)……...11, 12, 13, 14, 16, 17, 33

Haddock v. Arnspiger, 793 S.W.2d 948 (Tex. 1990)……………………………..31

Harle v. Krchnak, 422 S.W.2d 810, 815 (Tex. App. – Houston 1st 1969). ………31
In re Stacy K. Boone, 223 S.W. 3d 398 (Tex. App. – Amarillo 2006,
orig. proceeding)…………………………………………………………………..27

Marks v. St. Luke's Episcopal Hosp., 319 S.W.3d 658 (Tex. 2010)……………....12
Methodist Health Care Sys. Of San Antonio, Ltd., LLP v. Dewey, 423 S.W.3d 516,
516 (Tex. App – San Antonio 2014, pet. Filed)……………………………....13, 15
Memorial Hermann Hosp. System v. Galvan, 434 S.W.3d 176 (Tex. App. –
Houston [14th Dist.] 2014, no pet. h.)……………………………………………...8
Sinha v. Thurston, 373 S.W.3d 795, 800 (Tex. App—Houston [14th Dist.] 2012. no
pet.)……………………………………………………………………………21, 22
Stockton v. Offenbach, 336 S.W.3d 610 (Tex. 2011)…………………………........8




                                        v
Texas West Oaks Hosp., LP v. Williams, 371 S.W.3d 171
(Tex. 2012)…..…………………………………………………6, 12, 13, 14, 16, 17

Weatherford Tex. Hosp. Co. v. Smart, 423 S.W.3d 462 (Tex. App. –
Fort Worth 2014, pet. filed). ……………………………………………………...14

Whitfield v. Henson, 385 S.W. 3d 708 (Tex. App. – Dallas 2012, no pet.)……….27
Williams v. Riverside Gen. Hosp., Inc., No. 01-13-00335-CV, 2014 WL
4259889 (Tex. App. Aug. 28, 2014)………………………………………………..9

Statutes and Rules
Tex. Civ. Prac. & Rem Code, Chapter 74………..………1,2, 7, 8, 9, 24, 26, 30, 35

TEX. GOV’T CODE 311.021(3)…………………………………………………….26




                                     vi
                          STATEMENT OF THE CASE

Nature of the Case:       This case was initially in the 412th Judicial District Court
                          of Brazoria County, Texas under the Honorable W. Ed
                          Brennan. The case was transferred to the 130th Judicial
                          District Court of Matagorda County and then to the 23rd
                          Judicial District of Matagorda County under the
                          Honorable Ben Hardin.

Trial Court:              The case was initially in the 412th Judicial Disctrict Court
                          of Brazoria County, Texas under the Honorable W. Ed
                          Brennan. The case was transferred to the 130th Judicial
                          District Court of Craig Estlinbaum. Judge Eslinbaum then
                          transferred the case to the 23rd Judicial District Court of
                          Matagorda County under the Honorable Ben Hardin.

Trial Court’s
Disposition:              Appellant failed to timely file his initial objections to
                          Appellee’s expert report. (CR 1-103). After the 120-day
                          period expired, Appellant filed his Motion to dismiss
                          pursuant to Tex. Civ. Prac. & Rem. Code §74.351 (b).
                          (CR 44-48). Judge Hardin denied the motion to dismiss on
                          March 2, 2015 (RR 4).

Court of Appeals:         Appellant filed his Notice of Accelerated Appeal on
                          Monday, March 23, 2015 (CR 90-93).



                       STATEMENT OF JURISDICTION
       The 13th Court of Appeals has jurisdiction over this case under Government
Code §22.201(n) because this case arose in Matagorda County. The Court has
jurisdiction to hear this appeal of the trial court’s order denying Appellant’s motion
to dismiss under Tex. Civ. Prac. & Rem. Code §74.351(b) under Tex. Civ. Prac. &
Rem. Code §51.014(a)(9) (Vernon Supp. 2014).




                                          1
                             ISSUES PRESENTED

A. Is Appellee’s cause of action against Appellant a Health Care Liability Claim
   (HCLC) subject to Texas Medical Liability Act (TMLA – Chapter 74 of the
   Texas Civil Practice & Remedies Code)?

B. In the alternative that Appellee’s cause of action against Appellant is a Health
   Care Liability Claim (HCLC), did the trial court abuse its discretion denying
   Appellant’s motion to dismiss pursuant to Tex. Civ. Prac. & Rem. Code
   §74.351(b)?

      a. Does Appellee’s expert report sufficiently “implicate” Appellant by
         addressing the statutory elements of the TMLA?

      b. Does Appellee’s expert report sufficiently set forth the standard of care
         and explain how and why it was breached to satisfy the statutory
         requirements under the TMLA?

      c. Does Appellee’s medical expert report provide a sufficient explanation of
         how different care from Appellee would have prevented Appellant’s
         injuries in order to satisfy the statutory requirements of the TMLA?



   References to Clerk’s Original Record are shown as (CR _____)

   References to Reporter’s Record are shown as (RR_____)

   References to Co-Appellant’s Clerk’s Supplemental Record are shown as (CR
   Supp. Co-Appellant ___).


                      ORAL ARGUMENT NOT REQUESTED

      Appellee does not request oral argument.



                                        2
                         STATEMENT OF THE FACTS

       The following introductory facts are pertinent to the issues or points

presented. TEX. R. APP. P. 38.1(f).

       On March 28, 2012, Appellee Diane Jackson was at the medical office of Co-

Appellant, P. Palivela Raju, M.D, an otorhinolaryngologist, otherwise known as an

ear, nose and throat doctor (ENT). However, on that date Appellee was not on the

medical practice premises to visit with Dr. Raju. Rather, Appellee was there to

undergo balance testing at the hands of Appellant (Onsite Balance Solutions), a third

party non-physician medical provider. Dr. Raju contracted with Appellant to

perform this medical testing on the premises of his Bay City medical practice. In

anticipation of Appellee’s balance test, Danny Hertzer, a tech employed by on Onsite

Balance Solutions, seated Appellee in a balance chair provided by Dr. Raju’s office

(CR Supp. Co-Appellant 75). After completing the choloic stimulation test, the

Onsite Balance Solutions tech noticed that the “chair was starting to tilt on its back,

so [I] moved to stand on the base to give the base more weight. Despite this the

chair fell slowly on its back and once it had reached the ground Appellee slid out of

it.” Id. A “choloic stimulation” test is defined by the National Institute of Health’s

Medical Encyclopedia as a “test that stimulates your acoustic nerve by delivering

cold    or    warm     water     or    air       into   your   ear   canal.”       See

http://www.nlm.nih.gov/medlineplus/ency/article/003429.htm. Clearly, nothing in


                                             3
the definition of a “choloic stimulation” test implicates the necessary use of a

medical balancing chair. The use of the chair was merely “incidental” to the

performance of the “choloic stimulation” test. It is, therefore, clear from the facts

that no ENT procedure caused the injury (CR Supp. Co-Appellant 75). During the

entire time during which these events transpired, Appellee’s ENT neurologist neither

supervised the testing nor made available any of his nursing or administrative staff

to assist Appellant, further evidence that no ENT procedure was being performed Id.

The only two people in the patient room were Appellant’s tech and Appellee.

Appellee states very clearly in her in affidavit that “neither Dr. Raju nor anyone from

his staff was in the room at the time of the accident.” (CR 64). Furthermore, she

states, “the accident occurred prior to the vertigo test.” Id.


      On January 24, 2014, Appellee filed this lawsuit against Appellant and Dr.

Raju, alleging professional negligence in seating Appellee in a poorly maintained

and malfunctioning patient room balance chair (CR 64). In order to comply with the

expert report requirement for a health care liability claim under the Texas Medical

Liability Act (TMLA – Chapter 74 of the Texas Civil Practice and Remedies Code),

Appellee attached to her original petition a report from orthopedic surgeon Arnold

Ravdel, M.D. (CR 65-67). On July 21, 2014, Appellee filed her Second Amended

Petition and Request for Disclosure to assert general negligence and premises

liability claims in addition to professional negligence, believing that the facts of

                                           4
Appellee’s claims likely do not implicate the TMLA. Although Appellee realizes

that the factual backdrop of Appellee’s case is atypical of health care liability claims,

Appellee nonetheless asserts a health care liability cause of action in order not to

lose the right to sue for professional negligence in the event this Court finds that

Chapter 74 of the TMLA applies to her claims.


      Appellant never objected to the sufficiency of Dr. Ravdel’s report prior to the

expiration of the 120-day period in Section 74.351 (a). Appellant further failed to

make an appearance to join Co-Appellant’s objections at a hearing on April 11, 2014

before the Honorable W. Ed Brennan of the 412th District Court of Brazoria County.

Judge Brennan overruled Co-Appellant’s objections. (RR 4). After the hearing, all

parties agreed to transfer the case to Matagorda County, the county of proper venue.

(RR 4). After the 120-day period expired on June 4, 2014, Appellant filed his motion

to dismiss pursuant to Section 74.351 (b). (CR 44).


      Appellant’s motion to dismiss was first heard by the Honorable Craig

Estlinbaum of the 130th District Court of Matagorda County on June 11, 2014. Judge

Estlinbaum took the matter under advisement and later scheduled a second hearing

for August 11, 2014. By the time of the hearing, the case had been transferred to the

23rd District of Matagorda County. The Honorable Ben Hardin of the 23rd District

Court took the matter under advisement and denied Appellant’s motion to dismiss

on March 2, 2015. Appellee now responds to Appellant’s interlocutory appeal of
                                           5
Judge Ben Hardin’s denial of Appellant’s Motion to Dismiss before this honorable

Texas 13th Court of Appeals.


                       SUMMARY OF THE ARGUMENT

      In responding to Appellant’s Motion to Dismiss in the lower court, Appellee

specifically informed the court that Appellee’s claims are not health care liability

claims, and her filing an expert report under Chapter 74 of the Texas Civil Practice

& Remedies Code was purely done in an abundance of caution, and in

acknowledgement of the split between appellate courts interpreting the Texas West

Oaks Hosp., LP v. Williams precedent. Appellee states as follows:

      The only reason a medical expert opinion is provided in this case is because
      Texas law requires that any Plaintiff injured on the premises of a medical
      establishment open to the public file their claim as a health care liability claim,
      regardless of whether the injury was the result of a doctor performing a
      medical procedure or not. See Texas West Oaks, 371 S.W.3d 171, 178 (Tex.
      2012).
Simply put, different appellate courts are so split in their interpretations of the Texas

West Oaks opinion, that Appellee did not feel comfortable taking the risk of the

statute of limitations expiring in the face of the split in authority between different

appellate courts. Therefore, Appellee timely filed a medical expert report. However,

the substance of the medical expert report does not address standards of care relating

to any particular or specialized area of medicine. Rather, the substance of the report

focuses on the condition of the medical chair, its maintenance or lack thereof, and


                                           6
the duties owed by any medical provider to deliver safe premises and medical

equipment to patients. (CR 65-67).


      In the alternative that this Court finds that Appellee’s claims are health care

liability claims subject to Chapter 74 of the Texas Practice and Remedy Code,

Appellee contends that Dr. Ravdel’s expert report nonetheless satisfies the statutory

requirements. A brief analysis of the facts of the lower court quickly reveals that the

relevant subject area is not any specific area of medical practice, but the general

standard of care any medical physician owes his patients as a premises owner, which

is to ensure that all his medical equipment and chairs are sufficiently maintained and

in working order such that a medical chair used for balance testing does not collapse

when a patient is seated in it. Given the limited discovery rights of Appellee prior

to Judge Hardin’s ruling on Appellant’s Motion to Dismiss Pursuant to the TMLA,

coupled with a factual backdrop where Appellee was injured after merely being

seated in a chair that could not hold her weight, the “objective good faith effort”

standard for determining whether an expert report is statutorily compliant with

Chapter 74 of the Texas Medical Liability Act has clearly been met. Tex. Civ. Prac.

& Rem. Code 74.351(l). The Court should, therefore, find that Appellee submitted

a medical expert report in compliance with Tex. Civ. Prac. & Rem. Code 74.351(b).


                            STANDARD OF REVIEW


                                          7
      The standard of review for judging a trial court's decision with regard to expert

reports is the abuse of discretion. Generally, we review a trial court's order granting

or denying a section 74.351(b) motion under an abuse-of-discretion standard. See

Stockton v. Offenbach, 336 S.W.3d 610, 615 (Tex. 2011); Memorial Hermann Hosp.

System v. Galvan, 434 S.W.3d 176, 178 (Tex. App. – Houston [14th Dist.] 2014, no

pet. h.) But, when the issue presented requires statutory interpretation or a

determination of whether Chapter 74 applies to a claim, the issue is a question of

law to which we apply a de novo standard of review. See Stockton, 336 S.W.3d at

615; Galvan, 434 S.W.3d at 179. CHCA W. Houston, L.P. v. Shelley, 438 S.W.3d

149, 151 (Tex. App. 2014).

      Generally, we review a trial court's decision on a motion to dismiss a health

care liability claim for an abuse of discretion. See Am. Transitional Care Ctrs. of

Tex., Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001); Gray v. CHCA Bayshore

L.P., 189 S.W.3d 855, 858 (Tex. App. – Houston [1st Dist.] 2006, no pet.).

However, because this appeal poses a question of statutory construction (i.e.,

whether Williams' claims are HCLCs), we apply a de novo standard of review.

Loaisiga v. Cerda, 379 S.W.3d 248, 254–55 (Tex.2012); Tex. W. Oaks, 371 S.W.3d

at 177. When determining whether a claim is a health care liability claim, we

consider the entire record, including the pleadings, motions and responses, and

relevant evidence properly admitted. Loaisiga, 379 S.W.3d at 258. Williams v.


                                          8
Riverside Gen. Hosp., Inc., No. 01-13-00335-CV, 2014 WL 4259889, at *2 (Tex.

App. Aug. 28, 2014)


                                  ARGUMENT

      In Appellant’s brief, Appellant presents the main issue as whether the trial

court abused its discretion in denying Appellant's motion to dismiss pursuant to Tex.

Civ. Prac. & Rem. Code §74.351(b). In framing the issue in this manner, Appellant

assumes that the lower court made a finding that Appellee’s claims are health care

liability claims pursuant to Tex. Civ. Prac. & Rem. Code §74.351(b). However,

nothing in the lower court’s record includes any order where the Judge Hardin has

made a ruling on whether Chapter 74 of the TMLA is controlling in this case, or

whether the claims asserted by Appellee are necessarily health care liability claims.

The pleadings in the lower court clearly show that Appellee has asserted three claims

against Appellant, only one of which is a health care liability claim. Appellant

provides no argument as to how or why the lower court's denial of his Motion to

Dismiss pursuant to Tex. Civ. Prac. & Rem. Code §74.351(b) makes Appellee’s

claims healthcare in nature, or includes any finding of fact on such an issue. There

is not a an order in the lower court whereby Judge Hardin states that his denial of

Appellant’s Motion to Dismiss was based on a finding that concludes that Chapter

74 of the Texas Civil Practice and Remedies Code necessarily applies to the facts in

this case. Furthermore, Appellant never filed any motion for declaratory judgment
                                         9
asking the trial court to make any such finding. By entirely avoiding the argument

and failing to explain to this Court why Appellant believes Appellee’s claims are

health care liability claims, Appellant improperly asks this Court to assume a fact

not in evidence.

      After impliedly asking this Court to make the unwarranted assumption that

Appellee’s claims are healthcare liability claims, Appellant argues that the trial court

abused its discretion in finding Appellee's expert report provided a fair summary of

the standard of care and causal relationship. Appellant’s brief focuses on the alleged

statutory failures of Appellee’s expert report without providing the necessary factual

analysis as to why Appellee’s expert report should even be subject to a Section

74.351 analysis. Appellee’s pleadings assert general negligence and premises

liability claims, and Appellee relies on the same expert report in asserting those

claims as it would asserting a health care liability claim. To the extent Appellee’s

case against Appellant is not a health care liability claim, Appellant makes no

arguments as to why the expert report would otherwise not be sufficient.


      Appellee’s claims do not fall under the purview of the Texas Medical Liability

Act (TMLA) because the “setting” or “place” of injury is not the controlling question

for determining whether the TMLA applies. “The simple fact that an injury occurred

on a health care providers’ premises is not enough." Good Shepherd Medical Center-

Linden, Inc. v. Twilley, 422 S.W.3d 782, 788 (Tex. App. - Texarkana, Mar. 1, 2013,

                                          10
pet. denied). There simply is no other factual basis for Appellant’s assumption that

Appellee’s claims fall under the purview of Chapter 74 of the Texas Practice and

Remedies Code except the fact that the injury occurred in a medical office.

However, when this fact is weighed against other facts provided hereto and

discussed below, there is good reason to find that Appellant’s case falls outside the

purview of the Texas Medical Liability Act (TMLA).

         I.    THIS CASE DOES NOT FALL UNDER THE PURVIEW OF THE TMLA

       A contentious issue in any litigation involving a health care provider is

whether the Texas Medical Liability Act, Chapter 74 of the TMLA applies to

claimant. Although a contentious issue, it is an issue Appellant entirely avoids in

his brief.

       The three basic elements of a health care liability claim are defined in the

TMLA: (1) a physician or health care provider must be a defendant; (2) the claim or

claims at issue must concern treatment, lack of treatment, or a departure from

accepted standards of medical care, or health care, or safety or professional or

administrative services directly related to health care; and (3) the defendant’s act or

omission complained of must proximately cause injury to the claimant. Texas West

Oaks, 371 S.W.3d at 179-80. The determination of whether a claim is a HCLC

requires an examination of the underlying nature of the claim and the facts related

thereto. See Marks v. St. Luke's Episcopal Hosp., 319 S.W.3d 658, 664 (Tex. 2010).


                                          11
      The facts surrounding Appellee’s case, for example, raise the question of

whether medical treatment was even being provided at the time of her injuries. This

is an important question that should have been addressed in Appellant’s brief. If

Appellant did not provide medical care at the time of Appellee’s injuries, and

Appellee was injured instead by faulty equipment rather than a medical provider’s

hand, Appellee’s claims are safety-related rather than health care-related. In March

2013 the Texarkana court became the first appellate court to address the question of

the nexus between safety-related complaints and health care in light of the Supreme

Court’s decision in Texas West Oaks. Many cases have since expanded on the Texas

West Oaks decision. In the case of Good Shepherd Medical Center–Linden, Inc. v.

Twilley, the hospital’s director of plant operations sued the hospital for negligence

after he fell from a ladder attached to the hospital building and later tripped and fell

over a mound of hardened cement on the hospital’s premises. 422 S.W.3d at 783.

The trial court denied the hospital’s motion to dismiss the employee’s claims for

failure to supply an expert report under the TMLA. Id. at 784. On appeal, the

Texarkana court affirmed the trial court’s ruling and held that, while a safety claim

need not be directly related to health care pursuant to Texas West Oaks v. Williams,

there must be some indirect link between an employee’s safety claim and the

provision of health care in order for the claim to fall under the TMLA. Id. at 785.




                                          12
      Although safety claims do not need to be directly related to health care

pursuant to Texas West Oaks, there must, nevertheless, be some indirect, reasonable

relationship between claims and the provision of health care for such claims to be

health care liability claims. Doctors Hosp. at Renaissance, Ltd. v. Mejia, No. 13–

12–00602–CV, 2013 WL 4859592, at *2 (Tex. App.- Corpus Christi Aug.1, 2013,

pet. filed) (mem.op.) (interpreting Texas West Oaks “narrowly to govern cases that

involve safety claims that are indirectly related to health care”); Twilley, 422 S.W.3d

at 788 (Tex. App. - Texarkana, Mar. 1, 2013, pet. denied) (interpreting Texas West

Oaks narrowly and holding that safety claim must have at least indirect relationship

to health care to be considered HCLC); Methodist Health Care Sys. Of San Antonio,

Ltd., LLP v. Dewey, 423 S.W.3d 516, 519 (Tex. App. – San Antionio, 2014, pet.

filed)(holding that safety claims must have at least indirect relationship to health care

to be considered a health care liability claim). As the Twilley court correctly noted:

      [I]f every safety claim against a health care provider were considered a health
      care liability claim, there would be no need to analyze the nature of the acts
      or omissions which caused the alleged injuries. Twilley, 422 S.W.3d at 788
      (emphasis in original).
See also Texas West Oaks, 371 S.W.3d 171, 176 (Tex. 2012) (directing lower courts

to distinguish ordinary negligence claims from HCLCs by focusing on “nature of the

acts or omissions” causing alleged injuries).


      Most courts weigh facts showing the degree to which the harm resulted from

medical treatment to determine if there is at least an indirect nexus between the
                                           13
medical provider’s act or omission and the injury. For example, in Weatherford Tex.

Hosp. Co. v. Smart, the Fort Worth Court of Appeals held that a visitor falling on a

puddle of water in a hospital was not indirectly related to health care or safety, did

not require an expert report, and was not, therefore, a health care liability claim.

Weatherford Tex. Hosp. Co. v. Smart, 423 S.W.3d 462, 463, 467–68 (Tex.App.-Fort

Worth 2014, pet. filed). In Weatherford Tex. Hosp. the facts made it more obvious

that there was no indirect nexus, since the visitor was not on the medical premises

for treatment.

      Appellee agrees that her claims are rooted in facts that are distinguishable

from the Weatherford Tex. Hosp. opinion. Unlike that Plaintiff, Appellee was on

the Bay City medical practice premises of Co-Appellant for medical treatment at the

time of her injury. She was visiting Co-Appellant’s medical office so that a balance

test could be performed on her to assess her treatment for vertigo. However,

Appellee’s injuries were not the result of any balance test. In fact, at the time of her

injury, no medical treatment was performed on Appellee and no medical doctor was

in her medical exam room. (CR Supp. Co-Appellant 75). In fact neither Appellant

nor his medical staff was present at the time Appellee was seated in the medical chair

by Appellant. (CR Supp. Co-Appellant 75). The only other person present in the

room at the time of Appellee’s injury was Appellant’s employee non-physician tech.

(CR 74). Like the Plaintiff in Dewey who had entered hospital grounds for purposes


                                          14
of medical treatment (i.e., crutches) at the time of injury, Appellee had entered

Appellant’s medical office to undergo medical treatment at the time of her injury.

423 S.W.3d 516, 519–20 (Tex. App.- San Antonio 2014, pet. filed). Yet, even in

Dewey the San Antonio Court of Appeals held that the claim of a hospital visitor on

crutches who fell when the automatic entrance door to the hospital closed on him

was not a health care liability claim. Id. The San Antonio Court of Appeals agreed

“with the Mejia court that the supreme court recognized a new type of health care

liability claim, one involving safety that is indirectly related to health care.” Id.

Nonetheless, the court concluded that even where the Plaintiff is on hospital grounds

for purposes of medical treatment at the time of injury, this fact alone is not

controlling. The Dewey decision stands for the proposition that even if the patient

entered the medical premises for treatment (i.e., on crutches), absent other, specific

and articulable defendant conduct showing the injury was born from negligent

medical treatment, no sufficient nexus exists, even indirectly, to qualify the injury

as a health care liability claim. Id. This is consistent with past precedent in Texas

West Oaks, where the court held that “the heart of these cases lies in the nature of

the acts or omissions causing claimants’ injuries and whether the events are within

the ambit of the legislated scope of the TMLA.” Texas West Oaks, 371 S.W.3d at

178. The decision is also consistent with the Texarcana Court of Appeals decision

in Twilley, which held that "a safety claim must involve a more logical, coherent


                                         15
nexus to health care. The simple fact that an injury occurred on a health care

providers premises is not enough." Twilley, 422 S.W.3d at 788.

      The Texas West Oaks court further observed that expert testimony is a factor

in assessing the nature of a claim against a health care provider. That court found

that where such testimony is necessary to prove or refute the merits of the

employee’s claims, such claims fall under the ambit of the Texas Medical Liability

Act. Texas West Oaks, 371 S.W.3d at 182 (“[W]e now hold that if expert medical

or health care testimony is necessary to prove or refute the merits of the claim against

a physician or health care provider, the claim is a health care liability claim.”). In

the Twilley case, it would be terribly difficult, if not impossible, to find a qualified

expert under the statute who was also competent to opine on the relevant accepted

standards of care—OSHA ladder construction and installation and walking surface

standards. A medical report would not shed any light on whether the ladder violated

OSHA standards or whether the concrete mound constituted an unreasonable risk of

harm. Twilley at 788.

      Similarly, in Appellee’s case, one would be hard pressed to locate a qualified

expert under the statute who was also competent to opine on the relevant accepted

standards of care on the proper installation and maintenance of a medical chair used

for balance testing. A medical expert report would not shed any light on whether




                                          16
the chair was properly maintained and inspected or if it constituted an unreasonable

risk of harm.

      We learn from the Texas West Oaks, Dewy, and Twilley line of cases that the

mere fact of being on the premises of a medical provider, even for the purposes of

medical treatment, is not singularly sufficient to determine whether a plaintiff’s

claim against the medical provider is a health care liability claim. This line of cases

is directing courts to look at the totality of the circumstances, with particular

attention to the underlying nature of the act or omission on the part of the medical

provider. In Diversicare, the Texas Supreme Court used the language “underlying

nature of the claim” to describe the examination required to determine if a cause of

action is a health care liability claim. Diversicare General Partner, Inc. v. Rubio,

185 S.W.3d 842, 848 (Tex. 2005). The court held that one must examine the

underlying nature of the claim when determining whether the claim is in fact a health

care liability claim. Id. When conducting this analysis, the court provided guidance,

finding that a cause of action implicates the departure from acceptable standards of

medical care if the act complained of is an “inseparable part of the rendition of

medical service.” Id.

      Whether Appellee’s injuries are an inseparable part of the rendition of medical

service is best determined by first asking what medical service was provided. The

lower court judge was privy to evidence in this case, such as “Exhibit B” to


                                          17
Appellee’s Response to Appellant’s Motion to Dismiss, where the Onsite Balance

Tech present in the room at the time of Plaintiff’s injury informs Appellant how the

injury occurred (CR Supp. Co-Appellant 75). At no time in the statement does the

tech refer to any medical procedure being conducted at the time Plaintiff’s “chair

was starting to tilt.” Id. In fact, the balance tech reports the injury as occurring

“after the coholic stimulation test” ceased. Id. Furthermore, the record shows very

clearly that everyone in the office heard a loud bang, and a nurse by the name of

“Robyn”

went to check on it, only to find out that Appellee had a “mishap with the chair.”

(CR 74). Assuming that no medical procedure was being performed at the time of

the chair’s tilt, this is the type of medical chair that could tilt anytime a patient or

person is seated in it, regardless of whether medical treatment is being provided or

whether the chair is being used for medical purposes. The Texas Supreme Court has

stated that a claim is not necessarily a health care liability claim merely because a

patient is injured by a physician or health care provider. See Loaisiga v. Cerda, 379

S.W.3d 248, 256–57 (Tex. 2012). “In some instances, the only possible relationship

between the conduct underlying a claim and the rendition of medical services or

health care will be the health care setting (i.e. the physical location of the conduct in

a health care facility), [or] the defendant’s status as a doctor or health care provider,

or both.” Id. In Appellee’s case, the injury occurred when neither her ENT nor his


                                           18
staff was in the medical exam room, and during a time when Appellant’s employee

balance tech had ceased all medical testing.

      Appellee provided an expert physician report not to demonstrate that her

claims are healthcare liability claims, but to show the court that it is precisely the

opposite. The Texas Supreme Court has held “that if expert medical or health care

testimony is necessary to prove or refute the merits of a claim against a physician or

health care provider, the claim is a health care liability claim.” Texas West Oak, 371

S.W.3d at 182. Given that Plaintiff’s expert report adds very little to the factual

analysis of what exactly happened on the day Appellant’s medical chair failed to

hold the weight of Appellee is evidence that medical physician expert testimony adds

nothing to the merits of Appellee’s claim against Appellant. Simply put, the factual

backdrop of this case is so simplistic that with limited discovery rights there is

simply nothing from which any expert can rely to add greater detail or explanation

to the merits of Appellee’s claims against Appellant. Appellee’s medical expert

clearly states in the record that the chair was not properly maintained and that

Appellant’s use of an improperly maintained chair constitutes negligence. To the

extent Appellant argues that an ear, nose, and throat (ENT) specialist would be able

to provide testimony that adds to the merits of Appellee’s claims in the face of an

injury that was not born from any ENT procedure and in the absence of any ENT




                                         19
physician present at the time of the injury flies in the face of the facts and is arguably

an argument made in bad faith.

       II.      IN THE ALTERNATIVE THAT APPELLEE’S CAUSE OF ACTION AGAINST
                APPELLANT IS A HEALTH CARE LIABILITY CLAIM (HCLC), DID THE
                TRIAL COURT ABUSE ITS DISCRETION DENYING APPELLANT’S MOTION
                TO DISMISS PURSUANT TO TEX. CIV. PRAC. & REM. CODE §74.351(b)?


    A.       Dr. Ravdel’s Expert Report implicates Appellant by outlining the
             applicable standard of care, and explaining how Appellant’s breach of
             that standard of care proximately caused injury to Appellee.

       Dr. Ravdel’s expert report provides that the standard of care under the facts

of this case is to ensure that medical office equipment is properly maintained and in

working order. Dr. Ravdel directly implicates Appellant in the breach of this

standard of care when he writes in his expert report, “Onsite Balance Solutions

administered a vertigo test using a medical chair that was not properly maintained.”

(CR 30).       Dr. Ravdel also explains how this breach of the standard of care

proximately caused Appellee’s injuries, stating that “the chair improperly rolled

after Ms. Jackson was seated in it, causing the patient to fall out of her chair and

sustain an injury to her left knee and left shoulder.” Id. Despite Appellant’s

contention to the contrary, Dr. Ravdel’s expert report clearly outlines the standard

of care, the breach of care, and the proximate causation that led to Appellee’s

injuries.




                                           20
      Appellant cites Sinha v. Thurston in support of its straw-man argument that

an expert report “does not implicate a particular health care provider's conduct

merely because the provider is a defendant in the lawsuit.” Sinha v. Thurston, 373

S.W.3d 795, 800 (Tex. App—Houston [14th Dist.] 2012. no pet.).              However,

Appellee has never argued that Appellant is implicated in Dr. Ravdel’s report simply

because Appellant was named as a defendant. Unlike the appellant in Sinha, who

was never even mentioned by name in the four corners of that expert report,

Appellant in the present case is not only mentioned by name several times within the

four corners of the expert report, but is directly linked to the breach of the standard

of care that caused Appellee’s injuries.

      The trial court in the present case properly limited its assessment of

Appellant’s role in causing Appellee’s injuries within the four corners of the

document without making any inferences, as Sinha requires. The Court found that a

good faith effort had been made to comply with Tex. Civ. Prac. & Rem. Code §

74.351(r)(6). Consequently, applying the Sinha doctrine of implication to the

present facts, which are easily distinguishable from the facts in Sinha, Appellant’s

conduct is clearly implicated in Dr. Ravdel’s report.

      The term “implicate,” as it is used in Tex. Civ. Prac. & Rem. Code §

74.351(a), is not defined anywhere in the statute. Nonetheless, Appellant this has

not prevented Appellant from dreaming up its own meaning for the term. According


                                           21
to Appellant, “to ‘implicate’ Onsite Balance Solutions, Dr. Ravdel should have

‘primarily implicated’ Onsite Balance Solutions.” See page 20 of Appellant’s Brief.

However, Appellant cites no authority that asserts that the word “implicate” in this

statute means to “primarily implicate.”

      While Appellant references Beckwith v. White, which notes that the common-

usage definition of “implicate” is “[t]o show (a person) to be involved in,” Appellant

puts her own deceptive spin on the Beckwith definition. Beckwith v. White, 285

S.W.3d 56, 62 (Tex. App.—Houston [1st Dist.] 2009, no pet.) (citing BLACK’S

LAW DICTIONARY 757 (7th ed. 1999)). The Beckwith court notes:

      a defendant's conduct is implicated when an expert report is ‘directed
      primarily’ to care provided by the defendant, Ogletree v. Matthews, 262
      S.W.3d 316, 318 (Tex.2007), and the report informs the defendant of specific
      conduct called into question and provides a basis for the trial court to
      determine that the claim has merit. Am. Transitional Care Ctrs. of Tex., Inc.
      v. Palacios, 46 S.W.3d 873, 876–80 (Tex.2001).” Id. at 62.

Under the Black’s Law Dictionary definition of “implicate,” which is expanded upon

in Beckwith, Dr. Ravdel’s expert report undoubtedly implicates Appellant. Though

Appellant is not a “person” as defined in Black’s Law Dictionary, Dr. Ravdel’s

expert report explains how Appellant supervised and administered Appellee’s

testing. Multiple times over. (CR 30-32). It also mentions how Appellant placed

Appellee in a chair that was not properly maintained. Id. Indeed, this report (1) is

“directed primarily” to the vertigo testing provided by Appellant, (2) informs

Appellant how it placed Appellee in a malfunctioning chair during this test, and (3)
                                          22
provides the trial court with a basis to determine whether this conduct led to

Appellee’s fall and injuries. The way Dr. Ravdel’s expert report was written fits

perfectly within the Beckwith definition of “implicate” and therefore satisfies the

statutory requirement for an expert report, pursuant to Tex. Civ. Prac. & Rem. Code

§ 74.351.

         B. Given the “objective good faith” standard for statutory compliance
            under Tex. Civ. Prac. & Rem. Code §74.351(b), Appellee’s expert
            report sufficiently sets forth the standard of care and explains how
            and why that standard was breached.

       Dr. Ravdel’s expert report provides that Appellant’s standard of care under

the facts of this case is to ensure that the medical office equipment is properly

maintained and in working order. Appellee’s expert report provided by Dr. Ravdel

meets the “good faith effort” test for satisfying the Section 74.351(b) statutory

requirement for sufficiency of an expert report based on the limited discovery rights

available to Appellee and the factual backdrop where Appellee was injured by a

medical chair that did not hold her weight.

       Appellee provides the standards of care in his expert report with great

specificity. With respect to the physician (Dr. Raju) standard of care, Dr. Ravdel

states in his report:

            Dr. Raju, as the owner and sole physician at [his] medical practice located
            at 1410 Avenue F, Bay City, Texas 77414, is required to ensure that all
            medical equipment is properly maintained, in working order, and that his


                                           23
          patients are supervised by himself or qualified medical staff at all times
          when medical tests are being performed. (CR 66-67)
With respect to Appellant’s (Onsite Balance Solutions) standard of care, Dr. Ravdel

states in his expert report:


          “During the test, conducted by Onsite Balance Solutions, neither Dr. Raju
          nor his office staff were present when Onsite Balance Solutions performed
          the medical testing which led to Ms. Jackson’s fall.” (CR 66-67).


      Appellant contends the above standards of care provided in Dr. Ravdel’s

expert report are so "vague” and “general” that the report fails to provide a fair

summary of the standard of care. Specifically, Appellant claims that a proper

summary as to the standard of care requires that the report provide specific

information about what the defendant could have done differently. He further argues

that because Dr. Ravdel does not state exactly how or what about the medical chair

Appellant could have changed to ensure that the chair would hold Appellee’s weight,

his standard of care opinion is deficient.

      The problem with Appellant’s argument is that it completely ignores the

“good faith effort” standard provided by the Texas Medical Liability Act on whether

an expert report sufficiently satisfies the statutory requirements. Section 74.351 of

the Tex. Civ. Prac. & Rem. Code provides:

      A court shall grant a motion challenging the adequacy of an expert report only
      if it appears to the court, after hearing, that the report does not represent an


                                             24
      objective good faith effort to comply with the definition of an expert report in
      Subsection (r)(6).

Whether a “good faith effort” has been made by Appellee depends on what

information was available to appellee and what information Appellee’s medical

expert relief on in drafting his opinion. In this early stage of the litigation, prior to

the court ruling on a Chapter 74 challenge to Appellee’s expert report, Appellee’s

discovery rights are limited. A plaintiff’s discovery rights are limited where a

defendant challenges a plaintiff’s medical expert report under the Texas Medical

Liability Act. The service of a sufficient expert report is a threshold stage in a Health

Care Liability Claim. The Texas Supreme Court has held that Plaintiffs must pass

that threshold in order to proceed with their claims and conduct full discovery. In

re Alford Chevrolet Geo, 997 S.W.2d 173, 181 (Tex. 1999) (citing Tex. R. Civ. P

190.4(b)(2) and USX Corp v. West, 759 S.W.2d 764, 767 (Tex. App. – Houston [1st

Dist.] 1988, orig. proceeding). Without the right to inspect the medical chair or

conduct depositions prior to the court ruling on Plaintiff’s Motion to Dismiss for

Insufficiency of Appellee’s Expert Report, the only information available to

Appellee’s medical expert was information taken from Appellee’s own medical

records. (CR 110 – 120). However, this information was limited in scope, and did

not include pictures of the medical chair at issue in this case or any items related to

the maintenance of the chair at issue, such as logs or maintenance manuals. To

require Appellee’s medical expert to provide greater specificity when the necessary
                                           25
information is not part of Appellee’s medical records and discovery rights are limited

amounts to a travesty of reason and justice. To state that the TMLA requires greater

specificity from a medical expert report under these facts conflicts with the Texas

Government Code, which provides that when a statute is enacted, there is a

presumption that “a just and reasonable result is intended.” TEX. GOV’T CODE

311.021(3). Given the limited amount of information available to Appellee’s

medical expert, Appellant is being unreasonable in its expectation that Dr. Ravdel

explain exactly what makes the medical chair at issue dysfunctional. To hold

Appellee’s medical expert under such a standard of proof at this early state of the

litigation is in direct conflict with the Texas Supreme Court’s decision in American

Transitional Care Ctrs, Inc. v. Palacios, originally cited by Appellee in Appellee’s

response to Appellant’s Motion to Dismiss (CR 61). In that decision, the Court states

the following:

      “…to avoid dismissal, a plaintiff need not present evidence in the report as if
      it were actually litigating the merits. The report can be informal in that 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.” 46 S.W.3d
      878, 875.

Essentially, with the expectation that Appellant explain exactly how the medical

chair at issue is dysfunctional at this early stage of litigation, Appellant’s brief is

tantamount to asking this Court to hold Appellee’s expert report to the “same




                                          26
requirements as the evidence offered in a summary judgment proceeding or at trial.”

Id.

      To meet the statutory requirements under Chapter 74 of the Texas Practice

and Remedies Code, an expert report must provide a “fair summary of the expert's

opinions” and adequately inform the defendant of the specific conduct called into

question. In re Stacy K. Boone, 223 S.W. 3d 398, 406 (Tex. App. - Amarillo 2006,

orig. proceeding). If a court can determine the basis of a plaintiff's complaint, the

report is adequate. Id. An expert report which "adequately demonstrates the expert's

opinion that the claim has merit, implicates appellant's conduct, and constitutes a fair

summary of his report on causation is adequate." Whitfield v. Henson, 385 S.W. 3d

708 (Tex. App. - Dallas 2012, no pet.). This holds true regardless of whether or not

the report addresses every causation issue that a defendant may raise in a challenge.

Id.

      Plaintiff's expert gives a fair summary of the standard of care given what is

known about Plaintiff's injury and the simplistic facts and circumstances leading to

Plaintiff's injury. The facts of each individual case control the detail required in the

expert report, as the standard is whether the plaintiff has made a "good faith effort"

to meet the statutory requirement. See Tex. Civ. Prac. & Rem. Code §74.351(1).

This analysis necessarily varies depending on the facts of each particular case. The

qualifications of the medical staff supervising Plaintiff and the maintenance history


                                          27
of the chair are not known at this time. Nothing is known about the design or

condition of the chair except for facts and inferences drawn from medical records.

Given Appellee’s limited discovery rights at this early stage in the litigation,

Appellee has limited tools available to acquire greater information. Therefore,

Appellee has used its best efforts and acted in good faith under these facts to comply

with the statutory requirements of the Texas Medical Liability Act.


      C.    Dr. Ravdel's Expert Report clearly explains that Appellee would not
            have fallen and sustained injuries if the medical chair used for
            balance testing had been properly maintained, a fact so simple that
            the doctrine of res ipsa loquitur applies.

      Appellant alleges Dr. Ravdel's causation opinions are lacking explanation of

how different care would have prevented Appellee's injuries. Dr. Ravdel's expert

opinion is simple because of the limited information provided in Appellee’s medical

records, which include no information relating to the maintenance history or

condition of the medical chair at issue in this case.          Furthermore, the facts

surrounding Plaintiff's injuries are simple facts that do not involve matters typical of

medical negligence cases, where the negligence is born from the negligent

application of complex medical procedures and treatments. Appellant’s case is

particularly simplistic given the party admission by the Onsite Balance Solutions

tech, who states that Appellant’s chair failed to hold Appellee’s weight “after”

medical balance testing had ceased. (CR Supp. Co-Appellant 75).

                                          28
        While simplistic, Dr. Ravdel's causation opinion is not conclusory or based

on assumptions. His expert opinion is simple only because the facts surrounding

Plaintiff's injuries are equally simple given Appellee’s limited discovery rights at

this early stage of the litigation. Given the facts available to Appellee, Dr. Ravdel’s

report did the best that any report could do under the circumstances. Dr. Ravel states

very clearly in his report, as follows:

      The chair improperly rolled after Ms. Jackson [Appellee] was seated in it,
      causing the patient to fall out of the chair and sustain injury to her left knee
      and shoulder” and that “in all reasonable medical probability, the torn medial
      and lateral menisci found in the left knee joint, and the partial thickness rotator
      cuff tear, with labral, glenoid tear, is a direct result of the fall on March 28 th,
      2012, when Plaintiff was seated in what appears to be a poorly maintained or
      malfunctioning chair in the control of Dr. Raju and operated by Onsite
      Balance Solutions. (CR 65-67)

Given the common sense facts and inferences underlying Plaintiff's claim, there is

simply no way for Dr. Ravdel to reach any other conclusion except that the medical

chair used for balance testing would not have rolled and fallen over if it had been

properly maintained, and that Appellee was injured as a result of being seated in this

chair. (CR 65-67). With the discovery period uncompleted, and with limited

discovery rights, Appellee should not be expected to explain exactly what part of the

chair was malfunctioning to meet the statutory requirements for sufficiency of the

expert report under the TMLA. Appellee had not even had a chance to inspect the

chair at issue given this early stage of the litigation. Furthermore, Appellant

conveniently failed to include in its record, a copy of Appellee’s motion to inspect
                                           29
the chair in Dr. Raju’s Office, nor Dr. Raju’s Objection to Appellee’s motion to

inspect.

      Dr. Ravdel’s expert report is sufficient under the TMLA, since he based his

opinion on inferences drawn from Appellee's medical records. In Benish v. Grottie,

appellant argued the trial court abused its discretion in finding appellee's expert

report provided a fair summary of the standard of care and causal relationship when

the expert's opinions were based on unsupported assumptions.          However, the

appellate court found it was clear from the report, that the expert made inferences

based on the medical records, a practice that is accepted by the courts. Benish v.

Grottie, 281 S.W.3d 184, 195 (Tex. App. - Fort Worth 2009, pet denied). Therefore,

the threshold inquiry for whether an expert report is grounded in assumptions or fact

is not the nature of the opinion in a vacuum, but rather, whether or not the opinion

is based on medical records relevant to the claimant’s injuries and based on the

particular facts of the case at hand.




      The nature of Appellee’s injury is so simplistic, the doctrine of res ipsa

loquitur should be applicable in this case. (CR 60). Upon Plaintiff being seated in

the chair, the chair did not hold Plaintiff’s weight. Although courts have generally

recognized that res ipsa loquitur is inapplicable in medical malpractice cases, there

are specific exceptions where it is applicable. See Haddock v. Arnspiger, 793

                                         30
S.W.2d 948, 951 (Tex. 1990), citing Harle v. Krchnak, 422 S.W.2d 810, 815 (Tex.

App. – Houston 1st 1969).

      The court in Haddock held that an exception to the doctrine that res ipsa

loquitur is not applicable in medical malpractice cases is recognized when “the

nature of the alleged malpractice and injuries are plainly within the common

knowledge of laymen, requiring no expert testimony.” Id. The court goes on to cite

examples of the exception, such as “negligence in the use of mechanical instruments,

operating on the wrong portion of the body, or leaving surgical instruments in the

body.” Id. (CR 60).

      The standard for the exception cited by the Haddock Court equally applies in

Plaintiff’s case before this Court. The nature of the alleged malpractice and injuries

in Plaintiff’s case is plainly within the common knowledge of laymen, who would

agree that a chair designed to test for vertigo should not topple to the ground merely

because a patient is seated in it. Id.

      There is no reason to believe medical treatment outside of proper maintenance

to the balancing chair, either direct or indirect, had anything to do with the injuries

sustained by Appellee. At the time of Appellee’s injury, no medical doctor or any

member of Appellant’s staff was present in the patient room. The only person in the

patient room other than Appellee was a non-physician Onsite Balance Solutions tech

(CR Supp. Co-Appellant 75). The tech describes the incident in an email to Dr.


                                          31
Raju, where he clearly implies that whatever caused the chair to fall had nothing to

do with the practice of any medical procedure. Id. He states that after moving his

“cohloic stimulation” testing equipment, he noticed that the “chair was starting to

tilt on its back, so [I] moved to stand on the base to give the base more weight.

Despite this[,] the chair fell slowly on its back” Id. Within this factual backdrop,

Appellee’s medical expert was able to fairly conclude that the chair began to roll,

ultimately falling to the ground and taking Plaintiff down with it. He further

concluded that Appellee fell to the floor with the chair, falling on the left side of her

body when the chair flipped on its side. (CR 65-67). Given the common sense facts

and inferences underlying Appellee's claim, there is simply no way for Dr. Ravdel

to reach any other conclusion except that the medical chair used for balancing testing

would not have rolled and fallen over if it had been properly maintained.


                                   CONCLUSION

      The Texas Supreme Court requires an analysis into the gravamen of the claim

in order to determine if the claim is a health care liability claim subject to the Texas

Medical Liability Act, Chapter 74 of the Texas Civil Practice and Remedies Code.

In this case, the gravamen of the claim is the proper maintenance and repair of a

chair. The simple fact that an injury occurred on a health care providers premises is

not enough to make it subject to the Texas Medical Liability Act.


                                           32
      In this case, the underlying nature or gravamen of the claim is the proper

maintenance and repair of a chair. A safety claim must "involve a more logical

coherent nexus to health care." Twilley at 6-7. The simple fact that the injury

occurred on a health care provider’s premises is not enough to make it subject to the

Texas medical Liability Act. Id. In this case, Appellee does not need expert medical

testimony to prove the merits of her claim, as it is unrelated to health care. One would

be hard pressed to locate a qualified expert under the statute who was also competent

to opine on the relevant accepted standards of care on the proper installation and

maintenance of a balancing chair. A medical expert report would not shed any light

on whether the chair was properly maintained and inspected or if it constituted an

unreasonable risk of harm.

      Appellee maintains that her claim is not a health care liability claim and

therefore not subject to the Chapter 74 expert report requirement. However, in the

alternative, if the claim is found subject to Chapter 74 of the Tex. Civ. Prac. & Rem.

Code, Appellee's expert is qualified to provide expert testimony and has given a fair

summary of the standard of care and causal relationship given what is known about

Plaintiff's injury and the simplistic facts and circumstances leading to said injury,

especially in the factual background of limited discovery rights and medical records

that do not speak to the maintenance history of the balance chair at issue. It should

be sufficient to say that where a medical provider seats a patient in a chair that is not


                                           33
properly maintained, he has breached his duty to ensure that the premises are safe

for his clients. As to whether Dr. Raju or Appellant had greater control of the

condition of the chair is a fact yet to be discovered, as the discovery stage of trial

has only just begun, and is limited for the reasons already discussed. However, no

matter who is more responsible, all medical personal seating their patient in any chair

have a duty to ensure that the medical chair will hold their weight.


                                      PRAYER

      For the above reasons, this Court should affirm the trial court's order denying

Appellant's motion to dismiss. In the event this Court concludes that Appellee’s

claims are governed by the Texas Medical Liability Act (Chapter 74 of the Texas

Civil Practice and Remedies Code) and that Appellee’s expert report is deficient,

Appellee respectfully asks for an additional 30 days to cure the defect on remand.




                                               Respectfully Submitted,

                                               /s/ Alexander Forrest
                                               _______________________
                                               Alexander Forrest
                                               SBOT: 24065241
                                               Forrest & Kolodny, LLP
                                               1011 Augusta Dr., Ste. 111
                                               Houston, TX 77057
                                               Tel: (713) 598-0339
                                               Fax: (713) 785-0507
                                          34
                        CERTIFICATE OF COMPLIANCE

    I certify that this Appellee’s 1st Amended brief was prepared with Microsoft
Word 2010, and that, according to that program’s word-count function, the sections
covered by Texas Rule of Appellate Procedure 9.4(i)(1) contain 9,151 words.


                                                   /s/ Alexander Forrest
                                                   _________________________
                                                   ALEXANDER FORREST


                         CERTIFICATE OF SERVICE

       In accordance with Rule 9.5(e) of the Texas Rules of Appellate Procedure, I
certify that a copy of Appellant’s Original Brief was electronically served on
Appellant through e-filing on this 23rd day of June, 2015.


David Luningham
Watson, Caraway, Midkiff, & Luningham, LLP
309 W. 7th St., 1600 Oil & Gas Bldng
Forth Worth, TX 76013
(817) 870-1717 / (817) 348-4842 – Fax

                                                   /s/ Alexander Forrest
                                                   _________________________
                                                   ALEXANDER FORREST




                                        35
