CONCUR and DISSENT; and Opinion Filed August 31, 2016.




                                            Court of Appeals
                                                             S      In The


                                     Fifth District of Texas at Dallas
                                                         No. 05-15-01373-CV

      JSC LAKE HIGHLANDS OPERATIONS, LP D/B/A VILLAGES OF LAKE
                              HIGHLANDS,
                METROSTAT DIAGNOSTIC SERVICES, INC.,
   RICHARD M. WILLIAMS, M.D., AND RICHARD M. WILLIAMS, M.D., P.L.L.C.,
                               Appellants
                                  V.
                    KAREN MILLER, INDIVIDUALLY
   AND AS REPRESENTATIVE OF THE ESTATE OF BETTY RUTH HATHCOCK,
             AND BETTY CROCKETT, INDIVIDUALLY, Appellees

                                  On Appeal from the County Court at Law No. 3
                                              Dallas County, Texas
                                      Trial Court Cause No. CC-15-00297-C

                       CONCURRING AND DISSENTING OPINION
                                                    Opinion by Justice O’Neill 1
           The majority reverses the trial court’s order denying chapter 74 motions to dismiss filed

by all appellants. I would conclude the trial court correctly found appellees’ expert reports

sufficient as to appellants Richard M. Williams, M.D. and Richard M. Williams, M.D., P.L.L.C.

(together, Williams) on the issue of causation. Although I respectfully dissent to the majority’s

resolution of the claims against Williams, I join the majority’s opinion in all other respects.




   1
       The Hon. Michael J. O’Neill, Justice, Court of Appeals, Fifth District of Texas at Dallas, Retired, sitting by assignment.
                                              Background Involving Williams

          Appellee Betty Ruth Hathcock was a patient at the nursing home operated by appellant

JSC Lake Highlands Operations, LP d/b/a Villages of Lake Highlands. Over the course of the

day on March 22, 2013, Hathcock developed a raspy voice and a cough. At 8:00 p.m., the

nursing home’s on-call physician ordered a “stat” chest X-ray. A radiology technician from

appellant Metrostat Diagnostic Services, Inc. came to the nursing home and took frontal and

lateral view chest X-rays shortly after 9:30 p.m. 2 The reason given for the procedure was a

“Cough.”

          The films were forwarded to Williams, and his interpretation of the X-rays was

transcribed at 11:51 p.m.:

          Findings: The heart is normal in size and configuration. The aorta and other
          mediastinal structures are in the midline. There is bilateral lower lobe infiltrate.
          Impression: Bilateral lower lobe infiltrate report 3-22-13 at 9:37 p.m.

Williams did not identify the foreign object—a dental implant—lodged in Hathcock’s trachea.

He did not contact Metrostat or JSC Highlands concerning a need for Hathcock to receive urgent

treatment to remove the implant.

          The next morning at approximately 7:00 a.m., more than seven hours after Williams

reviewed her X-rays, Hathcock was discovered unresponsive. She was taken by ambulance to an

emergency room, where the implant was discovered when providers attempted to intubate her.

Hathcock never recovered consciousness and died later that afternoon.




     2
        Reports indicate the X-rays taken by Metrostat are time-stamped 9:51 a.m. The reason for the discrepancy is unclear. All parties agree
the X-rays were taken during the evening of March 22, not the next morning.



                                                                    –2–
                                        Standard of Review

         This court must review a trial court’s ruling concerning the adequacy of an expert report

under an abuse of discretion standard. Am. Transitional Care Ctrs. v. Palacios, 46 S.W.3d 873,

877 (Tex. 2001). A trial court abuses its discretion only if it acts in an arbitrary or unreasonable

manner without reference to guiding rules or principles. See Garcia v. Martinez, 988 S.W.2d

219, 222 (Tex. 1999). When reviewing matters committed to the trial court’s discretion, we may

not substitute our own judgment for that of the trial court. Walker v. Packer, 827 S.W.2d 833,

839 (Tex. 1992). A trial court does not abuse its discretion merely because its discretionary

decision is different from what an appellate court’s disposition would be under similar

circumstances. See Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 241–42 (Tex.

1985).

                                   Expert Reports on Causation

         Williams raises a single issue on appeal. He argues the trial court abused its discretion by

failing to grant Williams’s motion to dismiss because appellees’ expert reports were deficient on

the issue of causation. The majority agrees with Williams. It concludes the reports of Dr. Ravi

Patel and Dr. David Naeger are insufficient standing alone to satisfy chapter 74’s causation

standard, and it is “unpersuaded” that these reports should be read together to fulfill the statute’s

requirements. I would conclude settled chapter 74 law, applied and evaluated according to our

standard of review, calls for a different result.

                                        Patel’s Expert Report

         Patel was Hathcock’s treating physician in the emergency room. Patel explains in his

expert report that Hathcock’s denture implant was found in the back of her mouth when she

arrived at the hospital. As the majority sets forth, his report contains the following opinions:

                Ms. Hathcock expired on March 24, 2013. Her final diagnosis was
         cardiorespiratory failure second to anoxic brain injury secondary to cardiac arrest.
                                                    –3–
       Had the lodged denture implant been timely discovered, and had she received
       appropriate treatment to remove the denture implant at an earlier stage, it is
       reasonably medically probable that Ms. Hathcock would have survived.

              It is my medical opinion, based upon my care and treatment of
       Ms. Hathcock and in all reasonable medical probability, that the denture implant
       lodged in the throat/trachea area of her airway was the cause of the aspiration,
       which produced the pulmonary edema and pneumothorax which, collectively, was
       a proximate cause of her death.

The majority addresses Patel’s report at the outset of its opinion and concludes that, standing

alone, it is “deficient for causation” because it does not explain what conduct is attributable to

any of the appellants.

       The majority goes on to refuse—for the same reason—to read Patel’s report in

conjunction with any other report in the case. The majority relies on two cases, both of which

involve an expert report that fails to identify a defendant responsible for the conduct charged as

negligence. Neither case, however, supports dismissing Patel’s opinion for all purposes as the

majority has done. First, the majority cites Bogar v. Esparza, 257 S.W.3d 354 (Tex. App.—

Austin 2008, no pet.), and states “because we cannot determine whose conduct Dr. Patel’s

causation opinion implicates, we must conclude the report is insufficient to establish the same.”

In Bogar, however, only one expert report was served for all purposes; that case cannot support a

refusal to read reports together merely because one of them does not identify a defendant at fault.

See id. at 358. The second case is Tenet Hospitals Ltd. v. De La Riva, 351 S.W.3d 398 (Tex.

App.—El Paso 2011, no pet.), which did involve multiple reports. However, the El Paso court

did not refuse to read other reports along with the one that did not identify a particular

defendant’s conduct. Instead, the court addressed each of the remaining reports in an effort to




                                               –4–
remedy the deficiency in the first report, but it found each of the remaining authors to be

unqualified to opine concerning the causation in the case. 3 Id. at 405–07.

           By dismissing Patel’s report in its entirety, the majority ignores the often-repeated

admonition against reading an expert report in isolation. See, e.g., Salais v. Tex. Dep’t of Aging

& Disability Servs., 323 S.W.3d 527, 534 (Tex. App.—Waco 2010, pet. denied) (“A physician’s

report on causation should not be read in isolation.”); see also San Jacinto Methodist Hosp. v.

McCoy, No. 14-12-00682-CV, 2013 WL 3009318, at *3–4 (Tex. App.—Houston [14th Dist.]

June 13, 2013, no pet.) (mem. op.) (“When determining whether expert reports represent a good-

faith effort to satisfy the statutory requirements, we consider them cumulatively rather than in

isolation.”); Martin v. Abilene Reg’l Med. Ctr., No. 11-04-00303-CV, 2006 WL 241509, at *4

(Tex. App.—Eastland Feb. 2, 2006, no pet.) (mem. op.) (“To the extent that the trial court may

have reviewed Dr. Garza’s report in isolation, the trial court abused its discretion because

Section 74.351(i) expressly provides that a claimant may satisfy any requirement of the Act by

providing reports of separate experts.”). This is a critical failing because Patel’s report does not

attempt to resolve the entirety of the causation issue in this case. It does not focus on who caused

the injury that led to Hathcock’s death. Instead, it reports, perhaps better than any retained

expert could, how the injury caused her death. Patel describes finding the dental implant lodged

in Hathcock’s trachea. He opines that if the implant had been timely discovered, and if Hathcock

had earlier received the appropriate treatment to remove the implant, then she would have

survived. Patel traces the damage done by the failure to detect the implant step by step: the

implant became lodged in her trachea; this foreign object in her airway caused her aspiration; the



     3
         The majority also cites Tenet Hospitals as authority for a purported requirement that Patel review other expert reports with which his
would be read. But Patel’s opinions were not derivative of or based on anyone else’s reports; they were based on his own observation and
treatment of Hathcock. On the contrary, in this case, Patel’s records were reviewed by the other experts opining concerning Hathcock’s treatment
in the emergency room and her death.



                                                                     –5–
aspiration caused fluid to collect in her lungs (pulmonary edema) and her lung to collapse

(pneumothorax); and those two conditions ultimately caused her death.

                                     Naeger’s Expert Report

       The second report directed toward Williams’s conduct in this case sets forth Naeger’s

opinions on the appropriate standard of care, Williams’s failure to meet that standard, and the

cause of Hathcock’s aspiration. Addressing the Metrostat X-ray films, Naeger states:

       [I]t is my opinion that it is within the standard of radiologic care to detect and
       report the high density foreign body which is visualized in the proximal trachea.
       Further, it is my opinion that such a finding warrants an immediate phone call to
       the ordering provider given the need for an intervention (foreign object removal)
       to prevent possible harm.

Naeger confirms that the death certificate’s finding of “aspiration” is supported by the Metrostat

X-rays, “in which a foreign object is noted in the airway, consistent with a foreign body

aspiration.” In his conclusion, Naeger opines that Williams failed to meet the minimum standard

of radiologic care in:

       Failing to detect and report the high density foreign body which is visualized in
       the proximal trachea and in the frontal and lateral view chest X-rays dated
       3/22/13, 9:51 a.m., [and]

       Failing to contact and alert the ordering provider on an immediate basis of the
       need for an intervention for removal of a foreign object to prevent possible harm.
       By not identifying the object and calling the provider, this delayed a timely
       removal of the foreign body. Not removing the foreign body in a timely manner
       can lead to aspiration, which can be deadly. Aspiration was listed on
       Ms. Hathcock’s death certificate as one of the “significant conditions contributing
       to death.”

As the majority notes, Williams does not challenge Naeger’s standard-of-care opinions. But the

majority does challenge the adequacy of Naeger’s report as to causation, concluding that Naeger

fails to explain how Williams’s failure to detect and report the implant resulted in aspiration and,

ultimately, in Hathcock’s death. The majority concludes Naeger’s report is conclusory, and

therefore deficient, because it fails to explain the basis of his statements linking his conclusions


                                                –6–
to the facts and fails to establish that Williams’s negligent act was a substantial factor in bringing

about the harm that befell Hathcock.

          I disagree, in the first instance, that Naeger’s opinion fails to link Williams’s breach (his

failure to detect and warn of the lodged implant) with Hathcock’s injury (the aspiration).

Indeed, Naeger specifically states that the foreign object in Hathcock’s airway was already

consistent with such an aspiration at the time the X-rays were taken.                                       Moreover, I would

conclude Naeger clearly identifies the causal link between Williams’s breach and Hathcock’s

injury: Williams’s breach “delayed a timely removal of the foreign body.” And then Naeger

links that failure to remove the object with the injury: “Not removing the foreign body in a

timely manner can lead to aspiration, which can be deadly.” 4

                                               Reading the Reports Together

          Regardless of the individual merits of the Patel and Naeger reports, I cannot join the

majority’s refusal to read them together. Chapter 74 has always explicitly allowed expert reports

to be considered together. “[A] claimant may satisfy any requirement of this section for serving

an expert report by serving reports of separate experts . . . regarding different issues arising

from the conduct of a physician.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i) (West Supp.

2015). Thus, a deficiency in one report may be made up in another report. Caviglia v. Tate, 365

S.W.3d 804, 809 (Tex. App.—El Paso 2012, no pet.).

          Causation may be shown through explanation of a chain of events that begins with the

defendant health care provider’s negligence and ends in injury to the plaintiff.                                              Nexion

Healthcare Mgmt., Inc. v. Sosa, No. 05-15-01083-CV, 2016 WL 1457069, at *4 (Tex. App.—

Dallas Apr. 12, 2016, no pet.) (mem. op.) (citing McKellar v. Cervantes, 367 S.W.3d 478, 485


     4
       The majority emphasizes the word “can” in each clause of this final sentence and calls the opinion conclusory. The opinion may be
equivocal, but it is hardly conclusory.



                                                                 –7–
(Tex. App.—Texarkana 2012, no pet.)). When the expert reports from Patel and Naeger are read

together, such a chain of events is clear:

           •   At 10:51 p.m., Williams reviews the Metrostat X-rays and fails to detect the

               foreign object lodged in Hathcock’s throat.

           •   Williams fails to warn Hathcock’s providers that immediate intervention is

               necessary to remove the object.

           •   Hathcock goes untreated until she arrives at the emergency room shortly before

               10:30 a.m. and the dental implant is removed from the back of her mouth.

           •   During the time the implant remains lodged in her throat, it causes aspiration.

           •   The aspiration causes fluid to collect in Hathcock’s lungs (pulmonary edema) and

               her lung to collapse (pneumothorax).

           •   The pulmonary edema and pneumothorax ultimately cause Hathcock’s death.

       To establish causation in a personal injury case at trial, a plaintiff has a two-step burden:

she must prove that (1) the conduct of the defendant caused an event, and (2) this event caused

her to suffer compensable injuries. Martin v. Commercial Metals Co., 138 S.W.3d 619, 625

(Tex. App.—Dallas 2004, no pet.). Of course, a chapter 74 expert report does not need to

marshal all of the plaintiff’s proof; the information presented in the report need not meet the

same requirements as evidence offered in a trial. Bakhtari v. Estate of Dumas, 317 S.W.3d 486,

496 (Tex. App.—Dallas 2010, no pet.). Nevertheless, in this case, the Naeger report explains

how Williams’s conduct caused an event: a foreign object remained lodged in Hathcock’s throat

because Williams failed to detect it and to warn her caregivers. Then the Patel report explains

how this same event—the undetected foreign object lodged in Hathcock’s throat—caused the

series of pulmonary issues that eventually caused her death. The two reports are tied together

factually by this identification of the unremedied presence of a foreign object, the dental implant,

                                                 –8–
in the patient’s trachea. And because the reports merge in their understanding of this factual

event, Naeger’s identification of Williams as the negligent actor remedies any deficiency in

Patel’s report, and Patel’s report provides sufficient detail as to the progressive steps leading to

Hathcock’s demise. See Caviglia, 365 S.W.3d at 809.

       I discern no abuse of discretion in the trial court’s refusal to dismiss Hathcock’s claim

against Williams. See Garcia, 988 S.W.2d at 222 (court abuses its discretion only if it acts in

arbitrary or unreasonable manner without reference to guiding rules or principles). Texas law—

beginning with the statute that governs this entire proceeding—permits reading expert reports

together to satisfy any requirement regarding an issue arising from the conduct of a physician.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i). Likewise, we are warned against reading, and

dismissing, any expert report in isolation. See Salais, 323 S.W.3d at 534. Reading Patel’s and

Naeger’s reports together, the trial court could have concluded that Williams’s conduct was a

substantial factor in bringing about Hathcock’s injury, absent which her death would not have

occurred. Nexion Health at Lancaster, Inc. v. Wells, No. 05-16-00018-CV, 2016 WL 4010834,

at *3 (Tex. App.—Dallas July 25, 2016, no pet. h.) (mem. op.). Most importantly, read together,

the Patel and Naeger reports satisfy the fundamental requirement of a good-faith report: they

inform Williams of the specific conduct Hathcock has called into question, and they provide a

basis for the trial court to conclude that her claim against Williams has merit. See Palacios, 46

S.W.3d at 879.




                                                –9–
                                            Conclusion

       I would decide appellants Richard M. Williams, M.D. and Richard M. Williams, M.D.,

P.L.L.C.’s single issue against them and affirm the trial court’s order insofar as it overrules their

motion to dismiss. In all other respects, I concur with the majority’s resolution of this cause.




                                                    /Michael J. O'Neill/
                                                    MICHAEL J. O’NEILL
                                                    JUSTICE, ASSIGNED



151373DF.P05




                                               –10–
