                         COURT OF APPEALS
                          SECOND DISTRICT OF TEXAS
                               FORT WORTH


                               NO. 2-08-196-CV


STEPHEN C.     WALTERS, D.D.S.;                                     APPELLANTS
ARLINGTON      ORAL SURGERY, P.A.;
AND PARTY      DOING BUSINESS AS
ARLINGTON      ORAL SURGERY

                                        V.

TRINA HUDOBA, INDIVIDUALLY                                              APPELLEE
AND ON BEHALF OF THE ESTATE
OF ELIZABETH TAYLOR, DECEASED

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

           FROM THE 153RD DISTRICT COURT OF TARRANT COUNTY

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

                         MEMORANDUM OPINION 1

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

                                 I. INTRODUCTION

      Stephen C. Walters, D.D.S., and Arlington Oral Surgery, Appellants,

(collectively referred to herein as Dr. Walters) appeal the trial court’s denial of

their motion to dismiss Appellee Trina Hudoba’s dental malpractice claim for the


      1
          … See Tex. R. App. P. 47.4.
alleged failure to file an adequate expert report. Because Appellee timely filed

an adequate expert report, the trial court did not abuse its discretion by refusing

to dismiss the suit. Accordingly, we will affirm the trial court’s order.

                   II. F ACTUAL AND P ROCEDURAL B ACKGROUND

      Appellee’s daughter, Elizabeth Taylor, sought treatment from Dr. Walters

for a tooth extraction. Taylor was five-foot-three-inches tall and weighed 290

pounds; she suffered from a heart murmer, high blood pressure, chest pain,

irregular heart beat, bronchitis, asthma, and sleep apnea. Prior to performing

the tooth extraction procedure, Dr. Walters administered general anesthesia to

Taylor. Following the administration of the anesthesia drugs, Taylor stopped

breathing.     Resuscitation   efforts   commenced;      Dr.   Walters   intubated

Taylor—placing the tube into Taylor’s stomach instead of her lungs—and a call

to 911 was placed. Paramedics arrived and transported Taylor to the hospital

where she was pronounced dead on arrival.

      The State Board of Dental Examiners (the Board) initiated an investigation

into Taylor’s death.    Roger P. Byrne, D.D.S, M.D. examined the Board’s

investigative file and prepared an expert report for the Board. The report is

eighteen pages long and details the records Dr. Byrne reviewed, the statements

Dr. Byrne reviewed, the sequence of events that occurred, the “record keeping”

standard of care violations by Dr. Walters, and the nine “standard of care

                                         2
violations committed by Dr. Walters which led to Ms. Taylor’s death.”         It

contains a report summary concluding that “[i]t is my opinion Dr. Walters’[s]

negligent acts are responsible for the demise of Ms. Elizabeth Taylor.” A copy

of Dr. Byrne’s report is attached to this opinion as Appendix A.

      Appellee attached Dr. Byrne’s report to her October 30, 2007 original

petition to satisfy the statutory expert report requirement. See Tex. Civ. Prac.

& Rem. Code Ann. § 74.351 (Vernon Supp. 2008). Appellants timely filed an

answer that, in two paragraphs, objected to Dr. Byrne’s expert report.

Specifically, Appellants alleged that

      8. Defendants object to the correspondence/report and curriculum
      vitae of Roger P. Byrne, D.D.S., M.D., as attached to Plaintiff’s
      Original Petition. Dr. Byrne’s correspondence, with attached
      curriculum vitae, is confidential communication to the State Board
      of Dental Examiners, and therefore, should not be attached to
      Plaintiff’s Original Petition. Defendants further object to any
      attempt by Plaintiff [sic] utilize Dr. Byrne’s correspondence to
      comply with the expert report requirements of Chapter 74 of the
      Texas Civil Practice & Remedies Code.

      9.   To the extent that Plaintiff is attempting to utilize the
      correspondence and curriculum vitae of Roger P. Byrne, D.D.S.,
      M.D. to comply with the expert report requirements of Chapter 74
      of the Texas Civil Practice & Remedies Code, Defendants object to
      the opinions and qualifications of Dr. Byrne in accordance with
      Chapter 74 of the Texas Civil Practice & Remedies Code.
      Additionally, Defendants object to the sufficiency of the
      report/correspondence and curriculum vitae of Dr. Byrne in
      accordance with Chapter 74 of the Texas Civil Practice & Remedies
      Code.



                                        3
      The record reflects that Appellee requested a hearing on Dr. Walters’s

objections, set forth above. Dr. Walters filed “Objections to Hearing on Chapter

74 Objections,” claiming that “Chapter 74 does not permit the Court to rule on

Defendants’ objections to Plaintiff’s expert report prior to the 120-day deadline”

and requesting that “the hearing on Defendants’ objections to Plaintiff’s expert

report be reset until after the 120-day deadline.” The trial court conducted a

hearing on January 14, 2008, within 120 days of Appellee’s October 30, 2007

filing of her original petition. The trial court signed a February 5, 2008 order

overruling Dr. Walters’s objection to conducting the hearing prior to the 120-

day deadline and also overruling Dr. Walters’s objections to the expert report

of Dr. Byrne.

      On March 14, 2008, Dr. Walters filed a motion to dismiss Appellee’s

claim for “failure to comply with Chapter 74 expert report requirement.” Dr.

Walters specifically alleged that Dr. Byrne was not qualified and that his report

“fails to establish the causal relationship between defendants’ alleged

negligence and Elizabeth Taylor’s death.”      Appellee filed objections and a

response to Dr. Walters’s motion to dismiss.       Appellee contended that “a

hearing was already held on all of Defendants’ objections to Plaintiff’s expert

report under Chapter 74 and all of Defendants’ objections were overruled.”




                                        4
      The trial court conducted a hearing on Dr. Walters’s motion to dismiss on

April 8, 2008.    The trial court signed an April 21, 2008 order overruling

Appellee’s objection to the motion to dismiss contending that all objections to

Dr. Byrne’s report had been overruled by the trial court’s prior order. The trial

court also denied Dr. Walters’s motion to dismiss. Dr. Walters perfected this

appeal.

                   III. D R. W ALTERS’S A PPELLATE C ONTENTIONS

      In his sole issue, Dr. Walters contends that the trial court abused its

discretion by denying his motion to dismiss. Dr. Walters argues on appeal that

Dr. Byrne’s report “fails to establish the causal relationship between Dr.

Walters’[s] alleged negligence and Ms. Taylor’s death.”           Specifically, Dr.

Walters claims that Dr. Byrne’s report (1) addresses Dr. Walters’s alleged

violation of the State Board’s rules, but it “does not establish the causal

relationship between Dr. Walters’[s] purported negligence and Elizabeth Taylor’s

death;” (2)”is conclusory because he fails to rule out other possible causes of

Ms. Taylor’s death;” (3) “fails to explain how Dr. Walters’[s] failure to

appropriately treat Ms. Taylor’s respiratory depression caused her death;” (4)

“omits any explanation for how Dr. Walters’[s] administration of general

anesthesia proximately caused Ms. Taylor’s death;” (5) “contains a large

analytical gap[] in that he failed to explain how Dr. Walters’[s] administration

                                        5
of Versed, Fentanyl, and Propofal proximately caused Ms. Taylor’s death;” and

(6) “fails to flesh out how Dr. Walters’[s] administration of general anesthesia

and failure to respond to Ms. Taylor’s respiratory depression caused Ms.

Taylor’s death.”

      On appeal, Dr. Walters does not raise any challenge to Dr. Byrne’s

qualifications, but on page 8 of his brief he complains:

              Dr. Byrne was retained by the Texas State Board of Dental
      Examiners (“State Board”) to serve as an expert witness in the
      State Board’s case involving Dr. Walters’[s] treatment of Ms.
      Taylor. Dr. Byrne wrote his report as an expert witness for the
      State Board. . . . Dr. Byrne’s opinions are relevant to the State
      Board’s investigation of Dr. Walters’[s] treatment of Ms. Taylor,
      . . . but Dr. Byrne’s opinions are irrelevant in this malpractice case.
      . . . While Dr. Byrne’s report addresses Dr. Walters’[s] alleged
      violation of the State Board’s Rules, it does not establish the causal
      relationship between Dr. Walters’[s] purported negligence and
      Elizabeth Taylor’s death.”

Thus, Dr. Walters’s two main appellate complaints concerning Dr. Byrne’s

report concern causation and Appellee’s reliance on a report prepared for the

Board.

                      IV. W AIVER OF C AUSATION O BJECTION

      Appellee claims that Dr. Walters waived all of his causation objections

because he did not timely assert them in the trial court. Texas Civil Practice

and Remedies Code, section 74.351(a) provides:




                                        6
      In a health care liability claim, a claimant shall, not later than the
      120th day after the date the original petition was filed, serve on
      each party or the party’s attorney one or more expert reports, with
      a curriculum vitae of each expert listed in the report for each
      physician or health care provider against whom a liability claim is
      asserted. . . . Each defendant physician or health care provider
      whose conduct is implicated in a report must file and serve any
      objection to the sufficiency of the report not later than the 21st
      day after the date it was served, failing which all objections are
      waived.

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(a) (emphasis added); see also

Maris v. Hendricks, 262 S.W.3d 379, 385 (Tex. App.—Fort Worth 2008, pet.

denied) (holding objection to sufficiency of chapter 74 expert report was waived

because it was not asserted within the statutory twenty-one-day time period).

      Dr. Walters concedes that he was required to object to Dr. Byrne’s report

within the statutory twenty-one-day time period; Dr. Walters explained at oral

argument that the objection asserted in his answer that “Defendants object to

the sufficiency of the report/correspondence and curriculum vitae of Dr. Byrne

in accordance with Chapter 74 of the Texas Civil Practice & Remedies Code”

impliedly included an objection to every statutory element of an expert report.

Thus, Dr. Walters claims that he did timely assert his causation objection.

      We cannot agree. Dr. Walters’s only timely filed objections to Dr. Byrne’s

report were contained in paragraphs 8 and 9 of his original answer, set forth

previously in this opinion. Dr. Walters objected to Appellee’s use of a report



                                        7
prepared for the Board and to the “opinions and qualifications of Dr. Byrne” and

“the sufficiency of the report.” Neither of these objections raise the objections

to the causation element of Dr. Byrne’s report set forth in his motion to dismiss

or in his brief on appeal. See Tex. R. App. P. 33.1(a) (requiring objection to be

specific); Plemons v. Harris, No. 02-08-00326-CV, 2009 WL 51290, *3 (Tex.

App.—Fort Worth Jan. 8, 2009, no pet. h.) (holding objection to expert report

made in trial court must comport with complaint asserted on appeal). Because

Dr. Walters did not timely assert specific causation objections, he waived those

objections. See Ogletree v. Matthews, 262 S.W.3d 316, 322 (Tex. 2007)

(stating that any objection to report must be made within twenty-one days after

service of report); Williams v. Mora, 264 S.W.3d 888, 891(Tex. App.—Waco

2008, no pet.) (holding that when defendant’s only timely filed objections to

expert report were that two statements were speculative, defendant waived all

other objections); Springer v. Johnson, No. 07-07-00424-CV, 2008 WL

2346385, at *9 (Tex. App.—Amarillo June 4, 2008,              no pet.) (holding

objection to report not raised in trial court was waived). Because the causation

objections asserted in Dr. Walters’s motion to dismiss and in this appeal were

not filed within twenty-one days of the service of Dr. Byrne’s report, we hold

they were waived and overrule the portion of Dr. Walters’s issue arguing that




                                       8
Dr. Byrne’s report is inadequate on the issue of causation. See Tex. Civ. Prac.

& Rem. Code Ann. § 74.351(a).

               V. D R. W ALTERS’S O BJECTION C ONCERNING U SE OF
                       R EPORT P REPARED FOR THE B OARD

      In the second portion of his sole issue, Dr. Walters argues that he did,

however, timely object to Appellee’s use of Dr. Byrne’s report because the

report was prepared for the Texas State Board of Dental Examiners. As set

forth above, at page eight of his brief Dr. Walters attempts to bootstrap, or tie,

his causation arguments to his preserved contention that the trial court abused

its discretion by concluding that a report prepared for the State Board was an

adequate report.     We have held that Dr. Walters waived his causation

objections; but in the interest of justice, alternatively, and because this

causation argument is bootstrapped to an objection that Dr. Walters did timely

make, we address Dr. Walters’s causation arguments below.

                            A. Standard of Review

      We review a trial court’s denial of a motion to dismiss for an abuse of

discretion. Ctr. for Neurological Disorders, P.A. v. George, 261 S.W.3d 285,

290–91 (Tex. App.—Fort Worth 2008, no pet.); Maris, 262 S.W.3d at 383.

To determine whether a trial court abused its discretion, we must decide

whether the trial court acted without reference to any guiding rules or



                                        9
principles; in other words, we must decide whether the act was arbitrary or

unreasonable.   Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238,

241–42 (Tex. 1985), cert. denied, 476 U.S. 1159 (1986). Merely because a

trial court may decide a matter within its discretion in a different manner than

an appellate court would in a similar circumstance does not demonstrate that

an abuse of discretion has occurred. Id. But a trial court has no discretion in

determining what the law is or in applying the law to the facts, and thus “a

clear failure by the trial court to analyze or apply the law correctly will

constitute an abuse of discretion.” Walker v. Packer, 827 S.W.2d 833, 840

(Tex. 1992); Ehrlich v. Miles, 144 S.W.3d 620, 624 (Tex. App.—Fort Worth

2004, pet. denied).

                          B. No Abuse of Discretion

      A 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. Tex. Civ. Prac. & Rem.

Code Ann. § 74.351(l).     While the expert report “need not marshal all the

plaintiff’s proof,” Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46

S.W.3d 873, 878 (Tex. 2001) (construing former art. 4590i, § 13.01), it must

provide a fair summary of the expert’s opinions as to the “applicable standards

of care, the manner in which the care rendered by the physician or health care

                                       10
provider failed to meet the standards, and the causal relationship between that

failure and the injury, harm, or damages claimed.” Tex. Civ. Prac. & Rem. Code

Ann. § 74.351(r)(6).

      To constitute a good-faith effort, the report must “discuss the standard

of care, breach, and causation with sufficient specificity to inform the

defendant of the conduct the plaintiff has called into question and to provide

a basis for the trial court to conclude that the claims have merit.” Palacios, 46

S.W.3d at 875. A report does not fulfill this requirement if it merely states the

expert’s conclusions or if it omits any of the statutory requirements. Id. 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.” Id. The

claimant’s expert must incorporate enough information to fulfill two purposes:

(1) inform the defendant of the specific conduct the plaintiff has called into

question; and (2) provide a basis for the trial court to conclude the claims are

meritorious. Id.

      When reviewing the adequacy of a report, the only information relevant

to the inquiry is the information contained within the four corners of the

document. Id. 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 id. However, section 74.351 does not prohibit experts, as

                                       11
opposed to courts, from making inferences based on medical history. Marvin

v.   Fithian,   No.   14-07-00996-CV,    2008    WL    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).

       To establish causation, an expert report must provide information linking

the defendant’s purported breach of the standard of care to the plaintiff’s

injury. See Hutchinson v. Montemayor, 144 S.W.3d 614, 617 (Tex. App.—San

Antonio 2004, no pet.); see also Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48,

53 (Tex. 2002). An expert must also explain the basis of his statements to link

his conclusions to the facts. Wright, 79 S.W.3d at 52.

       A review of Dr. Byrne’s report refutes each of Dr. Walters’s claims

concerning its causation sufficiency. Dr. Byrne’s report explains,

       It is my medical opinion, based on the known sequence of events
       and reasonable medical probability, Ms. Taylor’s death on 11/4/05
       resulted from three separate, but obviously connected, findings: 1)
       morbid obesity, reactive airway disease, “difficult airway”, possibly
       contributing obstructive sleep apnea, hypertension and cardiac
       hypertrophy; 2) Dr. Walters[‘s] decision to perform an office-based
       operator-anesthetist general anesthesia on Ms. Taylor; and 3)
       respiratory depression, resultant apnea and hypoxia from the
       administration of Versed, Fentanyl, and Propofol medications with
       a progressive spiral of decline into a life-threatening emergency
       which was not appropriately treated by Dr. Walters.

                                        12
After setting forth Dr. Walters’s standard of care violations in classifying the

pre-operative physical risk status of Ms. Taylor, Dr. Byrne opined, “It is my

opinion Ms. Taylor should have had the tooth removed under a local anesthesia

or possibly a conscious sedation and local anesthesia because of her significant

general anesthesia medical risks.” After setting forth Dr. Walters’s standard of

care violations in failing to consider the increased risk of office-based general

anesthesia in a morbidly obese patient, Dr. Byrne opined, “In my medical

opinion, Dr. Walters had an inadequate fund of knowledge, demonstrated poor

clinical judgment, and possessed extremely low skill levels in his ability to

manage and maintain a difficult airway which caused the death of Ms. Taylor.”

After setting forth Dr. Walters’s standard of care violations in failing to train and

rehearse his office staff in emergency procedures, Dr. Byrne opined, “In my

opinion, the apparent lack of emergency training and performance by Dr.

Walters and his staff caused Ms. Taylor’s death.”          After setting forth Dr.

Walters’s standard of care violations in failing to appropriately treat Ms.

Taylor’s respiratory emergency by failing to immediately administer reversal

agents, failing to establish an intubated airway, and failing to provide adequate

respiratory support, Dr. Byrne opined, “It is my opinion, Dr. Walters had an

inadequate fund of anesthesia knowledge about respiratory depression and

possessed extremely poor judgment and skill levels in his ability to manage and

                                         13
maintain an adequate airway which caused the death of Ms. Taylor.” These

examples do not constitute a complete itemization of the causation opinions in

Dr. Byrne’s report. There are still more, which we do not detail here. Finally,

Dr. Byrne concluded, “It is my opinion that Dr. Walters’[s] negligent acts are

responsible for the demise of Ms. Elizabeth Taylor.”

      Viewing the information set forth within the four corners of Dr. Byrne’s

report, we hold that the trial court did not abuse its discretion by determining

Dr. Byrne’s report provides a fair summary of his expert opinions as to the

“applicable standards of care, the manner in which the care rendered by the

physician or health care provider failed to meet the standards, and the causal

relationship between that failure and the injury, harm, or damages claimed.”

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6); Palacios, 46 S.W.3d at 878.

The trial court did not abuse its discretion by determining that Dr. Byrne’s

report constitutes an objective good faith effort to satisfy the two purposes of

section 74.351. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351.

      The cases cited by Dr. Walters for the contrary position are not applicable

here. See Clark v. HCA, Inc., 210 S.W.3d 1, 11 (Tex. App.—El Paso 2005, no

pet.) (holding expert report did not causally link alleged negligent use of

Lovenox to compartment syndrome alleged as injury from doctor’s negligence);

Barko v. Genzel, 123 S.W.3d 457, 458–59 (Tex. App.—Eastland 2003, no

                                      14
pet.) (holding expert report did not causally link plaintiff’s claims that doctor

negligently failed to diagnose and treat back injury to miscarriage alleged as

injury from doctor’s negligence); Windsor v. Maxwell, 121 S.W.3d 42, 46–50

(Tex. App.—Fort Worth 2003, pet. denied) (holding expert report did not

causally link plaintiff’s pleaded facts to intimal injury to left vertebral artery

alleged as injury from doctor’s negligence); Zavala v. Pinkerton, No. 03-05-

00169-CV, 2007 WL 2010832, at *2 (Tex. App.—Austin July 10, 2007, no

pet.) (mem. op.) (holding expert report did not causally link plaintiff’s claim of

negligent wisdom tooth extraction “to the chronic facial pain, internal

derangement of the right and left temporomandibular joints and other harm”

alleged as injuries from dentist’s negligence); Meyers v. Golden Palms Ret. &

Health Ctrs., Inc., No. 13-06-00289-CV, 2007 W L 1500819, at *3 (Tex.

App.—Corpus Christi May 24, 2007, pet. denied) (mem. op.) (holding expert

report did not show causal link between plaintiff’s claim of nursing home

employees’ negligent performance of a transfer of plaintiff from wheel chair to

the broken femur alleged as injury from negligence).

      Here, unlike the expert reports in Clark, Barko, Windsor, Zavala, and

Meyers, Dr. Byrne’s report does causally link Dr. Walters’s standard of care

violations to the injury—death—alleged to have occurred as a result of Dr.

Walters’s negligence.    As set forth above, and demonstrated in the report

                                       15
attached to this opinion as Appendix A, Dr. Byrne’s report itemizes and then

discusses in detail nine specific standard-of-care violations by Dr. Walters:

failure to appropriately classify the pre-operative physical risk status of Ms.

Taylor; failure to consider the increased risks of office-based general anesthesia

in a morbidly obese patient; failure to properly assess the status of Ms. Taylor’s

asthmatic bronchitis prior to administering general anesthesia; failure to train

and rehearse his office staff in emergency procedures; failure to monitor Ms.

Taylor’s vital signs while she was under general anesthesia; failure to properly

treat Ms. Taylor’s respiratory emergency by not immediately administering

reversal agents, not establishing an intubated airway, and not providing

adequate respiratory support; failure to maintain flumazinil (Romazicon)

medication on his “crash cart;” failure to properly perform advanced cardiac life

support on Ms. Taylor; and failure to use prudent medical judgment by choosing

to use general anesthesia on Ms. Taylor for “the simple removal of a tooth.”

After each section of the report discussing each of these nine standard of care

violations, Dr. Byrne’s report links the standard of care violation specifically to

the facts of Ms. Taylor’s death.       Dr. Byrne’s factually specific causation

opinions are not conclusory. See Arkoma Basin Exploration Co. v. FMF Assocs.

1990-A, Ltd., 249 S.W.3d 380, 392 n.32 (Tex. 2008) (defining conclusory as

“[e]xpressing a factual inference without stating the underlying facts on which

                                        16
the inference is based”); see also, e.g., Mosley v. Mundine, 249 S.W.3d 775,

781 (Tex. App.—Dallas 2008, no pet.) (holding expert report sufficient on

causation element); Grindstaff v. Michie, 242 S.W.3d 536, 544 (Tex. App.—El

Paso 2007, no pet.) (same); Patel v. Williams, 237 S.W.3d 901, 906 (Tex.

App.—Houston [14th Dist.] 2007, no pet.) (same); Bidner v. Hill, 231 S.W.3d

471, 474 (Tex. App.—Dallas 2007, pet. denied) (same).

      Moreover, this is not a case like Clark, Barko, Windsor, Zavala, or Meyers,

where the injury alleged by the plaintiff did not necessarily follow from the

negligence alleged by the plaintiff. Here the negligence alleged all relates to Dr.

Walters’s administration of office-based general anesthesia to Ms. Taylor. The

injury alleged, the death of Ms. Taylor from respiratory depression induced by

drugs administered by Dr. Walters, flows—as opined by Dr. Byrne—directly

from Dr. Walters’s negligent administration of those drugs in an office-based

general anesthesia and from Dr. Walters’s negligent care for Ms. Taylor during

general anesthesia and after she suffered respiratory distress.          An “expert

report does not need to marshal all the evidence necessary to establish

causation at trial,” it must only “contain sufficiently specific information to

demonstrate    causation   beyond    mere    conjecture.”     Farishta    v.   Tenet

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




                                        17
Worth 2007, no pet.) (citing Wright, 79 S.W.3d at 52). Dr. Byrne’s report

more than adequately meets this standard.

      Concerning Dr. Walters’s contention that Dr. Byrne’s report is inadequate

because it “fails to rule out other possible causes of Ms. Taylor’s death,” no

such requirement exists, even at trial in a medical negligence case. In a medical

malpractice case, the plaintiff must prove by competent testimony that the

defendant’s negligence proximately caused the plaintiff’s injury. Duff v. Yelin,

751 S.W.2d 175, 176 (Tex. 1988) (citing Hart v. Van Zandt, 399 S.W.2d 791,

792 (Tex. 1965) and Bowles v. Bourdon, 148 Tex. 1, 5, 219 S.W.2d 779, 782

(1949)). The plaintiff must establish a causal connection beyond the point of

conjecture; proof of mere possibilities will not support the submission of an

issue to the jury. Duff, 751 S.W.2d at 176. The plaintiff is required to show

evidence of a “reasonable medical probability” or “reasonable probability” that

his or her injuries were proximately caused by the negligence of one or more of

the defendants. Park Place Hosp. v. Estate of Milo, 909 S.W.2d 508, 511

(Tex. 1995). But a plaintiff is not required to establish causation in terms of

medical certainty, nor is he or she required to exclude every other reasonable

hypothesis. Bradley v. Rogers, 879 S.W.2d 947, 954 (Tex. App.—Houston

[14th Dist.] 1994, writ denied) (citing King v. Flamm, 442 S.W.2d 679, 682

(Tex. 1969)). Dr. Walters has cited no authority, and we have located none,

                                       18
indicating that an expert report must “rule out other possible causes of Ms.

Taylor’s death” in order to be adequate under chapter 74.          Moreover, Dr.

Byrne’s report specifically explains that “the autopsy performed by the Tarrant

[c]ounty Medical Examiner ruled out a catastrophic cause of death such as a

stroke or a myocardial infarction and physical and microscopic findings were

consistent with respiratory and cardiac arrest.”

      Concerning Dr. Walters’s contention that Dr. Byrne’s report is inadequate

because it “fails to explain how Dr. Walters’[s] failure to appropriately treat Ms.

Taylor’s respiratory depression caused her death,” we simply cannot agree; Dr.

Byrne’s report specifically explains that Dr. Walters failed to appropriately treat

Ms. Taylor’s respiratory depression by failing to administer reversal agents,

failing to establish an intubated airway, failing to provide adequate respiratory

support, failing to properly administer advanced cardiac life support, and failing

to train his staff in emergency procedures.       Dr. Byrne’s report specifically

opines that each of these acts caused the death of Ms. Taylor by preventing

adequate ventilation of Ms. Taylor and allowing her oxygen saturation to drop

below an acceptable level.

      Concerning Dr. Walters’s contentions that Dr. Byrne’s report is inadequate

because it “omits any explanation for how Dr. Walters’[s] administration of

general anesthesia proximately caused Ms. Taylor’s death,” “contains a large

                                        19
analytical gap in that he failed to explain how Dr. Walters’[s] administration of

Versed, Fentanyl, and Propofal proximately caused Ms. Taylor’s death,” and

“fails to flesh out how Dr. Walters’[s] administration of general anesthesia and

failure to respond to Ms. Taylor’s respiratory depression caused Ms. Taylor’s

death,” Dr. Byrne’s report speaks for itself. As explained above, Dr. Byrne’s

report details exactly how Dr. Walters’s administration of general anesthesia

caused Ms. Taylor’s death. These contentions are simply variations of the

same challenges to Dr. Byrne’s report that we have rejected.

      Concerning Dr. Walters’s contention that Appellee is somehow prohibited

from using an expert report paid for and prepared for the Texas State Board of

Dental Examiners, we have found no authority for this contention and Dr.

Walters has cited none. And Dr. Byrne’s report expressly states,

      While there are similarities, it is my opinion that a case review for
      a licensing board is different from that of a civil negligence case.
      The licensing board is not only concerned about causal negligent
      acts and damages to a patient as in a civil litigation, I believe they
      are also concerned about other acts which demonstrate a
      practitioner’s fund of knowledge, medical judgment, clinical skill,
      trend of practice, and attitude toward patient care in an effort to
      meet their charge to protect the public.

             Therefore, in my report I will also list all standard of care
      violations I note in this case committed by Dr. Walters, be they
      causal to damage or not . . . .




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Thus, Dr. Byrne’s report does include a “Standard of Care Violations–Section

1,” which addresses Dr. Walters’s violations of standards of care relevant to

the State Board’s rules. We did not utilize these standard of care violations in

our analysis of Dr. Byrne’s report. And Dr. Byrne’s report contains a “Standard

of Care Violations–Section 2” in which Dr. Byrne explains, “In this section I list

and discuss the ‘standard of care’ violations committed by Dr. Walters which

led to Ms. Taylor’s demise.”      These standard of care violations and their

corresponding specific factually based causation opinions form the basis of our

analysis of the adequacy of Dr. Byrne’s report.       Accordingly, although Dr.

Walters may be correct that the section 1 standard of care violations are not

applicable to a health care liability claim, the section 2 standard of care

violations clearly are.

      We overrule the remainder of Dr. Walters’s sole issue.

                                VI. C ONCLUSION

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

denying Dr. Walters’s motion to dismiss.


                                                  SUE WALKER
                                                  JUSTICE

PANEL: GARDNER, WALKER, and MCCOY, JJ.

DELIVERED: January 22, 2009

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