Opinion

New Medical Horizons, II, Ltd. D/B/A Cypress Fairbanks Medical Center v. Vickie Milner

575 S.W.3d 53

Court: Texas Court of Appeals, 1st District (Houston)
Filed: Mar 28, 2019
Status: Published
Cited by: 18 cases
Authority: More cited than 65.7%

stating court cannot evaluate data relied on by expert, and thus “does not determine an alleged factual dispute about the underlying medical 23 records,” or consider data expert failed to reference when assessing adequacy of report

How later courts described this case

stating court cannot evaluate data relied on by expert, and thus “does not determine an alleged factual dispute about the underlying medical 23 records,” or consider data expert failed to reference when assessing adequacy of report
stating “court’s role is not to determine the truth or falsity of the expert’s opinion, or the facts upon which the expert bases such opinions, but to act as a gatekeeper in evaluating the sufficiency of the report itself”
concluding that causation opinion provided “how and why” and a “straightforward link” between alleged breach of standard of care and injury
noting that physician who does not specialize in field of medicine at issue may still qualify as an expert if he possesses practical knowledge as to what specialist ordinarily would do under like circumstances

Written by the judges who cited it.

The opinion

Opinion issued March 28, 2019

In The

Court of Appeals

For The

First District of Texas

————————————

NO. 01-17-00827-CV

———————————

NEW MEDICAL HORIZONS, II, LTD. D/B/A CYPRESS FAIRBANKS

MEDICAL CENTER, ANAND BALASUBRAMANIAN, M.D., AND DOAN

K. NGUYEN, M.D., Appellants

VICKIE MILNER, Appellee

On Appeal from the 61st District Court

Harris County, Texas

Trial Court Case No. 2016-79980

OPINION

Appellee Vickie Milner, a diabetic, was admitted to Cypress Fairbanks

Medical Center for a left-foot infection. She alleges that the negligence of appellants

Anand Balasubramanian, M.D., Doan K. Nguyen, M.D., and the nursing staff of

New Medical Horizons, II, LTD D/B/A Cypress Fairbanks Medical Center led to a

gangrenous condition, resulting in amputation of her great toe followed by a

protracted recovery.

The appellants moved to dismiss Milner’s healthcare liability claims, claiming

that her expert’s report was inadequate. In this interlocutory appeal, Dr.

Balasubramanian, Dr. Nguyen, and the Medical Center contend that the trial court

abused its discretion in denying their motions to dismiss. In his three issues, Dr.

Balasubramanian argues that the trial court abused its discretion by denying his

motion to dismiss because: (1) the report of Milner’s expert, Marc E. Mitchell, M.D.,

failed to establish his qualifications to provide an expert report as to Dr.

Balasubramanian; (2) Dr. Mitchell’s report failed to provide a sufficient opinion on

the applicable standard of care and breach as to Dr. Balasubramanian; and (3) Dr.

Mitchell’s report failed to link Milner’s damages to any specific breach by Dr.

Balasubramanian.

In his sole issue, Dr. Nguyen argues that the trial court abused its discretion

by denying his motion to dismiss because Dr. Mitchell’s causation opinions are

conclusory. In its sole issue, the Medical Center argues that the trial court abused its

discretion by finding Dr. Mitchell’s expert report sufficient and denying its motion

to dismiss because Dr. Mitchell’s report failed to provide the necessary fair summary

of the standard of care applicable to the Medical Center’s nursing staff, a breach of

any applicable standard of care, and causation of any injuries by such a breach.

We affirm the trial court’s orders.

Background

The medical records are not before us, and we accept the factual statements in

Dr. Mitchell’s expert report for the limited purpose of this appeal. See Marino v.

Wilkins, 393 S.W.3d 318, 320 n.1 (Tex. App.—Houston [1st Dist.] 2012, pet.

denied).

On March 22, 2015, Milner presented to the Medical Center’s Emergency

Department with an infected left foot. Her diabetic status was known by the

healthcare providers. Her foot was noted to be swollen and “blood red with some

black.” She was admitted to the Medical Center that same day under the care of Dr.

Balasubramanian, an internal medicine physician who was Milner’s attending

physician during her hospitalization. Significant findings included hyperglycemia,

an elevated white blood count, and x-ray evidence of a metallic foreign body in her

left foot. Milner was treated with intravenous antibiotics. Dr. Balasubramanian

ordered an infectious disease consultation (which was performed on March 23,

2015), and he also noted that the pulse in Milner’s left foot was difficult to palpate.

On March 24, 2015, Dr. Balasubramanian ordered a surgical consultation with Dr.

Nguyen, who recommended removal of the foreign body and incision and

debridement of the left distal foot.

On March 25, 2015, Milner underwent incision and drainage of the foot by

Dr. Nguyen. Noted findings by Dr. Nguyen included that Milner was at high risk for

the possibility of eventually losing her toes because of her diabetes and poor

circulation. The dorsal tissue on the plantar aspect of the great toe was found to be

blackish. After the surgery, Dr. Nguyen noted that Milner tolerated the procedure

well and that his plan was for her to undergo wound care and observation.

In the days following the March 25 surgery, there appears to have been little

or no physician follow-up or observation of the condition of Milner’s foot wound.

Dr. Mitchell stated that he saw no evidence in the medical record that Dr.

Balasubramanian ever examined the wound until March 30, after Milner was

scheduled to be discharged home. There was also little or no documented wound

care to indicate whether the wound treatment plan was working. Milner was

scheduled to be discharged home on March 30, but when her daughter arrived to

pick her up from the Medical Center, it was discovered that Milner had a gangrenous

diabetic left-foot infection. Dr. Balasubramanian requested a vascular consult that

day.

A March 31, 2015 CT scan showed occlusion of the distal superficial femoral

artery, and Milner was moved to the ICU. On April 10, 2015, she underwent

amputation of her great toe. On April 5, 2016, Milner had “left above-the-knee

femoral popliteal bypass surgery.” Her preoperative diagnosis was critical limb

ischemia and prior amputation of her great toe. She has continued to require

debridement procedures on her left foot.

Milner filed suit, and within the 120-day deadline of section 74.351(a) of the

Civil Practice and Remedies Code, she provided the defendants with Dr. Mitchell’s

original expert report and then an amended report. The defendants objected that

these reports failed to satisfy section 74.351(r)(6); the trial court agreed but granted

Milner a thirty-day extension to serve a sufficient report under section 74.351(c).

Milner then provided Dr. Mitchell’s second amended report, which supersedes his

initial and first amended reports. See Cornejo v. Hilgers, 446 S.W.3d 113, 124 n.11

(Tex. App.—Houston [1st Dist.] 2014, pet. denied). The defendants objected to Dr.

Mitchell’s second supplemental report (referred to in this opinion as Dr. Mitchell’s

report) and moved to dismiss Milner’s claims for her alleged failure to serve a

sufficient expert report under section 74.351. The trial court overruled the objections

and denied the motions to dismiss, and this interlocutory appeal followed.

Chapter 74 Expert Reports

Section 74.351 of the Texas Medical Liability Act (TMLA) provides that no

medical negligence cause of action may proceed until the plaintiff has made a good-

faith effort to demonstrate that a qualified medical expert believes that a defendant’s

conduct breached the applicable standard of care and caused the claimed injury. See

TEX. CIV. PRAC. & REM. CODE § 74.351(l), (r)(6). “[T]he purpose of the expert report

requirement is to weed out frivolous malpractice claims in the early stages of

litigation, not to dispose of potentially meritorious claims.” Abshire v. Christus

Health Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018) (per curiam).

To constitute a good-faith effort, the report must provide enough information

to fulfill two purposes: (1) inform the defendant of the specific conduct that the

plaintiff has called into question; and (2) provide a basis for the trial court to

conclude that the claim has merit. Baty v. Futrell, 543 S.W.3d 689, 693–94 (Tex.

2018); Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 878–

79 (Tex. 2001). A report that merely states the expert’s conclusions about standard

of care, breach, and causation does not fulfill these two purposes. Palacios, 46

S.W.3d at 879. The expert must explain the basis for his statements and link his

conclusions to the facts. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex.

2002). It has been recognized that the supreme court “has construed the TMLA as

setting a relatively low bar as to what comprises an adequate expert report.” Baty,

543 S.W.3d at 698 (Johnson, J., dissenting).

In determining whether the report meets these requirements, the court should

look no further than the report itself because all of the information relevant to the

inquiry must be contained within the report’s four corners. Bowie Mem’l Hosp., 79

S.W.3d at 52. The expert report is not required to marshal all of the plaintiff’s proof

necessary to establish causation at trial. Id. An expert report does not have to meet

the same requirements as the evidence offered in a summary-judgment proceeding

or at trial. Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d 510, 517 (Tex.

2017) (per curiam). The “only question” is whether the report provides “enough

information” for the trial court to conclude that it constitutes a good-faith effort. Id.;

see also Baty, 543 S.W.3d at 696–97. We are also mindful that expert-report

challenges are made at an early, pre-discovery stage in the litigation. See Baty, 543

S.W.3d at 697 & n.10 (rejecting argument that expert report was inadequate,

concluding that expert report sufficed “particularly in light of the purposes the report

is intended to serve” at an early stage in litigation, and stating “additional detail is

simply not required at this stage of the proceeding”).

Standard of Review

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

discretion. Abshire, 563 S.W.3d at 223; Palacios, 46 S.W.3d at 875. “A trial court

abuses its discretion when it acts in an arbitrary or unreasonable manner or without

reference to any guiding rules or principles.” Bowie Mem’l Hosp., 79 S.W.3d at 52.

As a court reviewing matters committed to the trial court’s discretion, we may not

substitute our own judgment for that of the trial court merely because we would have

ruled differently. See id. When reviewing decisions that fall within the trial court’s

discretion, “[c]lose calls must go to the trial court.” Larson v. Downing, 197 S.W.3d

303, 304 (Tex. 2006) (per curiam).

Analysis

Qualifications

In his first issue, Dr. Balasubramanian, an internal medicine physician,

contends that the expert report of Dr. Mitchell, a vascular surgeon, failed to establish

Dr. Mitchell’s qualifications to provide an expert report as to Dr. Balasubramanian.

Dr. Mitchell, a medical doctor who obtained his medical degree from

Georgetown University School of Medicine, is a fellowship-trained and board-

certified vascular surgeon and general surgeon. He has over twenty years of

experience in an academic medical center, where he is actively involved in the

training of medical students, has a busy clinical practice, and routinely cares for

patients with conditions similar to Milner’s. His report states:

Specifically, I have treated, performed surgery, and managed the care

of many patients with diabetic foot wounds. I am very familiar with the

accepted standards of medical care for the treatment of a foreign body

in the foot of a diabetic patient. Caring for such wounds involves a team

approach. I work closely with wound care nursing staff and rely on

wound care nursing staff to document the condition of a wound and

advise me when a wound is deteriorating. In light of my training,

knowledge, experience and qualifications as set forth above, I am

familiar with the standard of care for an admitting hospital, wound care

nurse, attending physician and surgeon with respect to the care and

treatment of Vickie Milner in March, 2015. I am familiar with the

responsibilities and duties these parties provide to a patient with the

signs, symptoms and history Vickie Milner presented with in March,

2015.

Regarding the standards of care applicable to Dr. Balasubramanian and to Dr.

Nguyen, an orthopedic surgeon, Dr. Mitchell’s report states:

These standards of care apply to any physician treating an infected foot

in the presence of a foreign body in a diabetic patient, regardless of the

physician’s specialty. Any attempt to create a superficial difference in

the standards of care between what would have been expected of an

internist and what would have been expected of an orthopedic surgeon,

when faced with the facts and circumstances of this case, is a red

herring. The standards of care and failures to meet the appropriate

standards of care set out in my report, are standards basic to the general

practice of medicine that any general practitioner or resident treating

diabetic patients with foot infections should know. There is nothing

novel about the applicable standards of care for treating a patient with

conditions similar to those of Vickie Milner in March, 2015.

Dr. Balasubramanian specifically argues that Dr. Mitchell provides no

explanation for how he is qualified to render an opinion on the standard of care for

an attending physician who is board certified in internal medicine. Regarding Dr.

Mitchell’s assertions that he is familiar with treating treating injuries like Milner’s

and that he is familiar with the standard of care applicable to all healthcare providers

who would treat those injuries, Dr. Balasubramanian argues that Dr. Mitchell’s

assertions are not supported and are conclusory.

In a healthcare liability suit, whether an expert witness is qualified to offer an

expert opinion under the relevant statutes and rules lies within the sound discretion

of the trial court. Puppala v. Perry, 564 S.W.3d 190, 202 (Tex. App.—Houston [1st

Dist.] 2018, no pet.). The expert’s qualifications must appear in the four corners of

the expert report or in the expert’s accompanying curriculum vitae. Id. “An expert

report by a person not qualified to testify does not represent a good-faith effort to

comply with the definition of an expert report.” Mettauer v. Noble, 326 S.W.3d 685,

693 (Tex. App.—Houston [1st Dist.] 2010, no pet.).

To qualify as an expert for the purpose of an expert report against a physician,

a person must be a physician who:

(1) is practicing medicine at the time such testimony is given or was

practicing medicine at the time the claim arose;

(2) has knowledge of accepted standards of medical care for the

diagnosis, care, or treatment of the illness, injury, or condition

involved in the claim; and

(3) is qualified on the basis of training or experience to offer an

expert opinion regarding those accepted standards of medical

care.

TEX. CIV. PRAC. & REM. CODE § 74.401(a); see id. § 74.351(r)(5)(A) (defining

“expert” qualified to give opinion on “whether a physician departed from accepted

standards of medical care” as “an expert qualified to testify under the requirements

of Section 74.401”). Section 74.401(c) further provides that in determining whether

an expert witness is qualified based on his training and experience, a trial court shall

consider whether the witness is “board certified or has other substantial training or

experience in an area of medical practice relevant to the claim,” and whether he “is

actively practicing medicine in rendering medical care services relevant to the

claim.” Id. § 74.401(c).

The expert must do more than show that he is a physician, but he “need not

be a specialist in the particular area of the profession for which testimony is offered.”

Owens v. Handyside, 478 S.W.3d 172, 185 (Tex. App.—Houston [1st Dist.] 2015,

pet. denied). The critical inquiry is “whether the expert’s expertise goes to the very

matter on which he or she is to give an opinion.” Broders v. Heise, 924 S.W.2d 148,

153 (Tex. 1996); see Mangin v. Wendt, 480 S.W.3d 701, 707 (Tex. App.—Houston

[1st Dist.] 2015, no pet.).

Also, a physician may be qualified to provide an expert report even if his

specialty differs from that of the defendant if he “has practical knowledge of what is

usually and customarily done by other practitioners under circumstances similar to

those confronting the malpractice defendant,” or “if the subject matter is common to

and equally recognized and developed in all fields of practice.” Keo v. Vu, 76 S.W.3d

725, 732 (Tex. App.—Houston [1st Dist.] 2002, pet. denied). “‘[T]he applicable

‘standard of care’ and an expert’s ability to opine on it are dictated by the medical

condition involved in the claim and by the expert’s familiarity and experience with

that condition.’” Lee v. Le, No. 01-18-00309-CV, 2018 WL 4923938, at *4 (Tex.

App.—Houston [1st Dist.] Oct. 11, 2018, no pet.) (mem. op.) (quoting Barber v.

Dean, 303 S.W.3d 819, 826 (Tex. App.—Fort Worth 2009, no pet.)).

As stated in Dr. Mitchell’s report, he has treated, performed surgery on, and

managed the care of many patients with diabetic foot wounds, and he therefore is

familiar with the accepted standards of medical care for the treatment of patients like

Milner. He further explains that the applicable standards of care “are standards basic

to the general practice of medicine that any general practitioner or resident treating

diabetic patients with foot infections should know.” Based on these statements alone,

the trial court could have reasonably concluded that Dr. Mitchell was qualified to

provide standard-of-care opinions under the explicit provisions of section 74.401.

See Lee, 2018 WL 4923938, at *4; Armenta v. Jones, No. 01-17-00439-CV, 2018

WL 1095388, at *4–5 (Tex. App.—Houston [1st Dist.] Mar. 1, 2018, no pet.) (mem.

op.).

Additionally, this court recently reiterated that the care and treatment of an

open wound and infection are common to and equal in all fields of medicine,1 which

comports with Dr. Mitchell’s opinion:

Here, the subject matter of the claim against Dr. Clavijo involves

the standards of care in the treatment of an open wound and the

prevention of infection. “[T]he care and treatment of open wounds and

the prevention of infection are subjects common to and equally

recognized and developed in all fields of practice, thus any physician

familiar with and experienced in the subject may testify as to the

standard of care.”; . . .

Clavijo v. Fomby, No. 01-17-00120-CV, 2018 WL 2976116, at *7 (Tex. App.—

Houston [1st Dist.] June 14, 2018, pet. denied) (mem. op.) (quoting Legend Oaks—

Dr. Balasubramanian’s reply brief concedes that “the medical issue being

discussed is one of wound management. . . .”

S. San Antonio, L.L.C. v. Molina, No. 04-14-00289-CV, 2015 WL 693225, at *4

(Tex. App.—San Antonio Feb. 18, 2015, no pet.) (mem. op.).2

The trial court did not abuse its discretion in finding that Dr. Mitchell’s report

established his qualifications to opine on the standard of care applicable to Dr.

Balasubramanian. See id. at *6–9 (holding that trial court did not abuse its discretion

in concluding cardiologist was qualified to testify on standard of care applicable to

internist for treatment of open wound and infection prevention). We overrule Dr.

Balasubramanian’s first issue.

Standard of Care and Breach

An expert report must provide a “fair summary” of the expert’s opinions

regarding the (1) applicable standards of care, (2) manner in which the care rendered

by the physician or health care provider failed to meet the standards, and (3) causal

Clavijo also cited as support Khan v. Ramsey, No. 01-12-00169-CV, 2013 WL

1183276, at *6 (Tex. App.—Houston [1st Dist.] Mar. 21, 2013, no pet.) (mem.

op.) (holding that expert with over eighteen years of medical experience,

including ambulatory, urgent, and emergent care, possessed specialized

knowledge on subject matter common to and equally recognized and

developed in all fields of practice, i.e., recognizing importance of patient

history and infection process); Garza v. Keillor, 623 S.W.2d 669, 671 (Tex.

Civ. App.—Houston [1st Dist.] 1981, writ ref’d n.r.e.) (“[T]he standard of

care in the infection process . . . is common to and equal in all fields of

medical practice.”); and Gonzalez v. Padilla, 485 S.W.3d 236, 243–44 (Tex.

App.—El Paso 2016, no pet.) (care and treatment of open wounds and

prevention of infection are common to and equal in all fields of medical

practice). Clavijo, 2018 WL 2976116, at *7.

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

CIV. PRAC. & REM. CODE § 74.351(r)(6); Miller, 536 S.W.3d at 513.

“In a medical malpractice negligence case, the standard of care is what a

doctor of ordinary prudence in that particular field would or would not have done

under the circumstances.” Windrum v. Kareh, No. 17-0328, — S.W.3d —, —, 2019

WL 321925, at *3 (Tex. Jan. 25, 2019); see Palacios, 46 S.W.3d at 880. “To

adequately identify the standard of care, an expert report must set forth ‘specific

information about what the defendant should have done differently.’” Abshire, 563

S.W.3d at 226 (quoting Palacios, 46 S.W.3d at 880).

Dr. Balasubramanian. Dr. Balasubramanian’s second issue asserts that Dr.

Mitchell’s report failed to provide a sufficient opinion on the applicable standard of

care and breach.

Regarding the standard of care applicable to Dr. Balasubramanian (and to Dr.

Nguyen, who does not contest the standard of care and breach in this appeal) and its

breach by Dr. Balasubramanian, Dr. Mitchell’s report states:

An infected foot in the presence of a foreign body in a diabetic patient

is a surgical emergency. Surgical exploration with removal of the

foreign body and surgical debridement should be done as soon as

possible after the diagnosis is made, and within 24 hours at the latest.

This is because the development and progression of the infected wound

is often complicated by diabetic changes, such as neuropathy and

vascular disease. Without early intervention, the wound can rapidly

deteriorate, leading to amputation of the affected limb. Therefore, it is

at this crucial early stage that physicians have the potential to curb what

is often progression from mild infection to a more severe problem, with

necrosis, gangrene and often amputation. If there is any doubt regarding

diagnosis of peripheral vascular disease, the patient should be referred

to a specialist for a full vascular assessment.

After surgical debridement, frequent wound assessment and bacterial

control and moisture balance is required to prevent maceration and

infection. Additionally, infection control and restoring pulsatile blood

flow is critical for healing of the wound. This requires a team approach.

Documentation of the size of the wound is important to determine if the

wound is healing and the treatment plan is working. Debridement may

be a one-off procedure or it may need to be ongoing for maintenance of

the wound bed. The requirement for further debridement should be

determined each day following changing of dressings. [Emphases

added.].

In stating his opinion on the applicable standard of care, Dr. Mitchell’s report

states with sufficient detail what a physician should have done and explains why it

was the standard of care; it provides “enough information” for the trial court to have

concluded that the report constitutes a good-faith effort to set forth the applicable

standard of care as to Dr. Balasubramanian. See Miller, 536 S.W.3d at 517; see also

Baty, 543 S.W.3d at 696–97.

Dr. Balasubramanian’s actual complaint about Dr. Mitchell’s standard-of-care

opinion is that Dr. Mitchell insufficiently explains why his articulated standard of

care applies to Dr. Balasubramanian, an internist. This is a reiteration of Dr.

Balasubramanian’s argument on Dr. Mitchell’s qualifications to provide a standard-

of-care opinion as to Dr. Balasubramanian. We rejected that argument above and

reject this reiteration for the same reason.

Next, we address Dr. Balasubramanian’s assertion that Dr. Mitchell’s report

insufficiently addresses Dr. Balasubramanian’s breach of the standard of care. The

section of Dr. Mitchell’s report concerning Dr. Balasubramanian’s breach of the

standard of care states:

An attending physician, and certainly an internist must be aware that an

infected foot in the presence of a foreign body in a diabetic patient is a

surgical emergency. Ms. Milner should have undergone surgical

exploration with removal of the foreign body and wide surgical

debridement as soon as possible after her March 22nd admission to the

hospital, and within 24 hours at the latest. Dr. Balasubramanian

breached the standard of care by waiting until March 24, 2015 to

request a consult with a surgeon. The delay in getting Ms. Milner to

surgery put her entire leg at risk for amputation and was a proximate

cause of the great toe amputation, as well as, her long and protracted

recovery and hospitalization. This is because diabetic foot wounds are

known to rapidly deteriorate. By the time Dr. Balasubramanian referred

Ms. Milner to surgery, her wound had become more necrotic and

difficult to manage.

After the March 25, 2015 surgery, it does not appear from the medical

records that Dr. Balasubramanian examined the wound until March 30,

2015 when Ms. Milner was scheduled to be discharged. At that point,

it was discovered that Ms. Milner had a gangrenous diabetic left foot

infection. Dr. Balasubramanian breached the standard of care by failing

to follow-up and assess the condition of the wound. The lack of

physician follow-up following surgery put Ms. Milner’s entire leg at

risk for amputation and was a proximate cause of the great toe

amputation, as well as, her long and protracted recovery and

hospitalization. As stated above, diabetic foot wounds can, and do,

rapidly deteriorate and must be managed in a timely and effective way

with tissue debridement, inflammation and infection control, and

moisture balance. A physician cannot simply abandon the patient

following surgery and hope for the best.

On March 23, 2015 it was noted that Ms. Milner’s pulse in the affected

left foot was difficult to palpate. At this time, Dr. Balasubramanian

should have called into question Ms. Milner’s vascular status given her

history of diabetes and ordered a vascular consult. This was critical to

prevent any complications associated with ischemia. Dr.

Balasubramanian breached the standard of care by waiting until March

30, 2015 to order a vascular consult. This too put Ms. Milner’s entire

leg at risk for amputation and was a proximate cause of the great toe

amputation, as well as, her long and protracted recovery and

hospitalization. This is because treating any severe ischemia is critical

to wound healing, regardless of other interventions. Early referral to a

vascular specialist likely would have resulted in earlier arterial

reconstruction to improve blood flow and improve healing of the

wound, which would have substantially reduced the risk of amputation.

Timely and effective wound management in this case, as described

above, likely would have prevented the need for amputation of Vickie

Milner’s great toe.

In summary, Dr. Mitchell opined that Dr. Balasubramanian: (1) failed to

timely consult with a surgeon so that Milner could have undergone surgical

exploration, with removal of the foreign body and wide surgical debridement,

within 24 hours of admission; (2) failed to request a vascular consult when the pulse

in Milner’s affected foot was difficult to palpate; and (3) failed to follow up and

assess the condition of the wound in the five days between surgery and her

scheduled discharge.

Regarding Dr. Mitchell’s opinion that Dr. Balasubramanian breached the

standard of care by failing to obtain a surgical consultation until two days after

Milner’s admission, Dr. Balasubramanian asserts that the medical records reflect that

he ordered the surgical consultation “within the relevant timeframe.” As stated

above, our review of the adequacy of Dr. Mitchell’s report is limited to the four

corners of his report. Bowie Mem’l Hosp., 79 S.W.3d at 52; Palacios, 46 S.W.3d at

878. The court’s role is not to determine the truth or falsity of the expert’s opinion,

or the facts upon which the expert bases such opinions, but to act as a gatekeeper in

evaluating the sufficiency of the report itself. Mettauer, 326 S.W.3d at 691. Further,

a “court may not consider an expert’s credibility, the data relied upon by the expert,

or the documents that the expert failed to consider at this pre-discovery stage of the

litigation.” Curnel v. Houston Methodist Hosp.-Willowbrook, 562 S.W.3d 553, 562

(Tex. App.—Houston [1st Dist.] 2018, no pet.). Thus, at this preliminary stage, a

court does not determine an alleged factual dispute about the underlying medical

records or the health care at issue. See id.; Holt v. Holt, No. 01-17-00008-CV, 2017

WL 3483211, at *3 (Tex. App.—Houston [1st Dist.] Aug. 15, 2017, pet. denied)

(mem. op.); Mettauer, 326 S.W.3d at 690–92; see also Hood v. Kutcher, No. 01-12-

00363-CV, 2012 WL 4465357, at *4 (Tex. App.—Houston [1st Dist.] Sept. 27,

2012, no pet.) (mem. op.) (“Whether an expert’s factual inferences made in the

expert report are accurate is a question for the fact finder and should not be

considered when ruling on a section 74.351 motion to dismiss.”); Gannon v. Wyche,

321 S.W.3d 881, 885–93 (Tex. App.—Houston [14th Dist.] 2010, pet. denied)

(rejecting argument that expert should not be allowed to rely on plaintiff’s statement

that allegedly was “contrary to actual facts in the medical records”); id. at 892

(“Accepting the premise that an expert’s report may not contradict the medical

records in such a case would preclude a plaintiff from ever being able to satisfy the

expert-report requirement.”).

Dr. Mitchell’s opinion is that Milner’s infected foot was a surgical emergency,

that she needed surgery within 24 hours at the latest, and that Dr. Balasubramanian

breached the standard of care by failing to obtain a surgical consultation until two

days after Milner’s admission. Dr. Mitchell concluded or inferred from the medical

records that Dr. Balasubramanian ordered a surgical consultation with Dr. Nguyen

on March 24, 2015, two days after Milner was admitted to the Medical Center.

Dr. Balasubramanian next contends that Dr. Mitchell does not describe how

Dr. Balasubramanian failed to follow up and assess the condition of Milner’s wound

after the March 25 surgery. We disagree; according to Dr. Mitchell’s report, after

the March 25 surgery, “it does not appear from the medical records that Dr.

Balasubramanian examined the wound until March 30, 2015 when Ms. Milner was

scheduled to be discharged. At that point, it was discovered that Ms. Milner had a

gangrenous diabetic left foot infection.”

Lastly, Dr. Balasubramanian asserts that Dr. Mitchell’s opinion that Dr.

Balasubramanian failed to request a vascular consult is too vague because of Dr.

Mitchell’s statement that if “there is any doubt regarding diagnosis of peripheral

vascular disease, the patient should be referred to a specialist for a full vascular

assessment.” But a court reviews the report “in its entirety,” Baty, 543 S.W.3d at

695, and Dr. Mitchell clarifies later in his report:

On March 23, 2015 it was noted that Ms. Milner’s pulse in the affected

left foot was difficult to palpate. At this time, Dr. Balasubramanian

should have called into question Ms. Milner’s vascular status given her

history of diabetes and ordered a vascular consult. This was critical to

prevent any complications associated with ischemia. Dr.

Balasubramanian breached the standard of care by waiting until March

30, 2015 to order a vascular consult.

“More detail” is not required at this stage. See id. at 696; Lee, 2018 WL

4923938, at *5. Dr. Mitchell’s report sufficiently identifies the “conduct being called

into question.” Baty, 543 S.W.3d at 697; see Palacios, 46 S.W.3d at 875. Dr.

Mitchell’s report on the standard of care and its breaches informs Dr.

Balasubramanian of the specific conduct being called into question and provided the

trial court with a basis to conclude that Milner’s claim has merit; it therefore satisfies

the good-faith effort required by the statute. See id. We overrule Dr.

Balasubramanian’s second issue.

Cypress Fairbanks Medical Center. In its sole issue, the Medical Center

contends in part that Dr. Mitchell’s report failed to provide the necessary fair

summary of the standard of care applicable to its nursing staff and the breach of the

standard of care. Regarding the standard of care applicable to the Medical Center’s

nursing staff and its breach, Dr. Mitchell’s report states:

After surgical debridement frequent wound assessment and bacterial

control and moisture balance is required to prevent maceration.

Additionally, infection control and restoring pulsatile blood flow is

critical for healing of the wound. This requires a team approach. A

physician may only see the patient once or twice per day and relies on

the wound care nursing staff to document the condition of the wound.

Documentation of the size of the wound is important to determine if the

wound is healing and the treatment plan is working. Recording the size,

depth, appearance and location of the wound establishes a baseline for

treatment, and monitoring any response to interventions. The wound

care nursing staff must notify physicians if the wound is deteriorating.

Debridement may be a one-off procedure or it may need to be ongoing

for maintenance of the wound bed. The requirement for further

debridement should be determined after each dressing change. This can

only occur with prompt communication between the wound care

nursing team and the treating physicians. Once the wound progresses

to the state of gangrene, it is often too late to curb life threatening

infection without amputation of the affected limb.

....

In the days following the March 25th surgery there appears to have been

little or no documented wound care or follow-up of the condition of the

wound. The nurses and wound technicians at Cypress Fairbanks

Medical Center breached the standard of care by failing to timely

provide wound care and assessment following the March 25, 2015

surgery, and by failing to timely report the declining condition of Ms.

Milner’s wound to physicians allowing same to become gangrenous by

March 30, 2015. The failure to timely provide wound care and alert

physicians of the declining condition of the wound following the March

25, 2016 surgery put Ms. Milner’s entire leg at risk for amputation and

was a proximate cause of the great toe amputation, as well as, her long

and protracted recovery and hospitalization. This is because diabetic

foot wounds can, and do, rapidly deteriorate in light of diabetic

changes, such as neuropathy and vascular disease. Once the wound

progresses to the state of gangrene, it is often too late to curb life

threatening infection without amputation of the affected limb.

Therefore, the wound must be managed in a timely and effective way

with tissue debridement, inflammation and infection control, and

moisture balance. This requires a team approach, including prompt

communication with the treating physicians when the wound is not

healing as desired. Timely and effective wound management, including

communication with physicians when the wound was declining, likely

would have prevented the need for amputation of Ms. Milner’s great

toe. [Emphases added.].

“The standard of care is defined by what an ordinarily prudent healthcare

provider would have done under the same or similar circumstances.” Clavijo, 2018

WL 2976116, at *13 (citing Palacios, 46 S.W.3d at 880); see Peabody v. Manchac,

No. 14-17-00646-CV, — S.W.3d —, —, 2018 WL 6836864, at *3 (Tex. App.—

Houston [14th Dist.] Dec. 27, 2018, no pet. h.).

The Medical Center argues that Dr. Mitchell’s opinion on the applicable

standard of care and its breach lacks the specificity and detail required to satisfy the

fair-summary standard. We disagree. Dr. Mitchell opined that the Medical Center’s

nursing staff should have: (1) performed frequent wound assessment;

(2) documented the condition of the wound; and (3) promptly notified physicians if

the wound was deteriorating. Dr. Mitchell then opined that the Medical Center

nurses and wound technicians breached the standard of care by (1) failing to timely

provide wound care and assessment; (2) failing to document the condition of the

wound; and (3) failing to timely report the declining condition of the wound to

physicians. Dr. Mitchell’s opinions are supported by his statement that, from the

medical records, “there appears to have been little or no documented wound care or

follow-up of the condition of the wound” in the days following the March 25 surgery

and by the fact that Milner’s wound had become gangrenous by March 30, which

was discovered only as she was being discharged and picked up by her daughter.

Dr. Mitchell could infer the standard-of-care breaches from the lack of

documentation in the medical records and the gangrenous condition on March 30.

See Hood, 2012 WL 4465357, at *5–6 (holding expert could infer from lack of

documentation in medical records that thorough wound cleaning did not occur and

breached standard of care); Azle Manor, Inc. v. Vaden, No. 02-08-00115-CV, 2008

WL 4831408, at *6 (Tex. App.—Fort Worth Nov. 6, 2008, no pet.) (mem. op.)

(holding expert could draw inferences from what was not in patient’s medical

records), overruled in part on other grounds by Certified EMS, Inc. v. Potts, 392

S.W.3d 625 (Tex. 2013); see also Bay Oaks SNF, LLC v. Lancaster, 555 S.W.3d

268, 273–74, 280–84 (Tex. App.—Houston [1st Dist.] 2018, pet. filed) (affirming

trial court’s approval of expert report that relied in part on lack of documentation of

required care to prevent pressure ulcers).

The Medical Center further argues that Dr. Mitchell’s report could have

provided more detail:

What is ‘timely’ under the circumstances? What sort of ‘wound’ care

should the nurses have provided? How often should Cypress Fairbank’s

staff have been assessing the wound? Who should have reported the

wound’s condition to the physicians, and when should they have

reported it?

But as Milner also correctly points out, in Hood, a similar wound-care case, this

court rejected similar complaints. See Hood, 2012 WL 4465357, at *3–7. And as the

supreme court stated in Baty, while an expert report can arguably provide “an

additional degree of specificity,” “[a]dditional detail is simply not required at this

stage of the proceedings.” Baty, 543 S.W.3d at 697 & n.10; see Lee, 2018 WL

4923938, at *5.

Dr. Mitchell’s report on the standard of care and its breach gave the trial court

a sufficient basis to reasonably conclude that Milner’s claims against the Medical

Center have merit and advised the Medical Center of the conduct that Milner,

through her expert, has called into question. Baty, 543 S.W.3d at 697; Palacios, 46

S.W.3d at 875. We overrule those portions of the Medical Center’s sole issue.

Causation

Dr. Balasubramanian, Dr. Nguyen, and the Medical Center each contend that

Dr. Mitchell’s report on causation is inadequate.

For causation, the expert report must explain “how and why” the physician’s

or healthcare provider’s breach proximately caused the plaintiff’s injury. Columbia

Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 459–60 (Tex. 2017).

“In satisfying this ‘how and why’ requirement, the expert need not prove the entire

case or account for every known fact; the report is sufficient if it makes ‘a good-faith

effort to explain, factually, how proximate cause is going to be proven.’” Abshire,

563 S.W.3d at 224 (quoting Zamarripa, 526 S.W.3d at 460).

The report need not use the words “proximate cause,” “foreseeability,”

or “cause in fact.” “[A] report’s adequacy does not depend on whether

the expert uses any particular ‘magical words.’”

....

Proximate cause has two components: (1) foreseeability and (2) cause-

in-fact. For a negligent act or omission to have been a cause-in-fact of

the harm, the act or omission must have been a substantial factor in

bringing about the harm, and absent the act or omission—i.e., but for

the act or omission—the harm would not have occurred.

This is the causal relationship between breach and injury that an expert

report must explain to satisfy the Act.

Zamarripa, 526 S.W.3d at 460 (footnoted citations omitted).

A causation opinion must provide a “straightforward link” between the

alleged breach of the standard of care and the claimed injury. See Abshire, 563

S.W.3d 225. The court’s role is to determine whether the expert has explained how

the negligent conduct caused the injury. Id. at 226.

Dr. Balasubramanian. In his third issue, Dr. Balasubramanian contends that

Dr. Mitchell’s report on causation is insufficient because it is “speculative, contains

analytical gaps in its causal links, and relies on assumptions.” He also contends that

Dr. Mitchell’s report only suggests that Milner’s amputation was preventable, that it

impermissibly “works backward” from a bad outcome to establish causation, and

that it fails to exclude other possible causes. In short, Dr. Balasubramanian argues

that Dr. Mitchell does not tie Dr. Balasubramanian’s alleged breaches to the

outcome, resulting in an “impermissible analytical gap” and lack of sufficient

specificity to inform Dr. Balasubramanian of how his alleged breaches caused the

outcome.

The supreme court does not use the term “analytical gap” in the context of

section 74.351 expert reports, but it has noted that some courts of appeals do.3

Abshire, 563 S.W.3d at 225, n.10.

It appears that the courts have generally used this term to mean a failure

to link the breach of the standard of care to the injury, which comports

with this Court’s discussion of chapter 74’s expert report requirements

with respect to causation. See Zamarripa, 526 S.W.3d at 460 (holding

that an expert report sufficiently addresses causation where it

“explain[s] the basis of [the expert’s] statements to link [the]

conclusions to the facts”).

Id. We will follow the supreme court and decline to analyze the causation issue with

the term “analytical gap.”

Dr. Balasubramanian’s assertion that Dr. Mitchell’s report has a fatal one-

week gap concerning Milner’s care between March 25 and March 30 is premature.

Cf. Puppula, 564 S.W.3d at 201 (“But the absence of an opinion stating with

specificity at what point in the continuum of disease progression an intervention

The term arose from and is used in the area of expert-opinion reliability. See

Gammill v. Jack Williams Chevrolet, Inc., 972 S.W.2d 713, 726–27 (Tex.

1998) (deeming expert testimony unreliable when “there is simply too great

an analytical gap between the data and the opinion proffered”).

would have proven timely does not cause these experts’ causation opinion to be

conclusory at this early stage of evaluation.”). Further, Dr. Mitchell was not required

to exclude or rule out other possible causes of Milner’s injuries in his expert report.

Curnel, 562 S.W.3d at 562 (quoting Baylor Med. Ctr v. Wallace, 278 S.W.3d 552,

562 (Tex. App.—Dallas 2009, no pet.) (“Nothing in section 74.351 suggests the

preliminary report is required to rule out every possible cause of the injury, harm, or

damages claimed.”)).

Regarding Dr. Balasubramanian’s alleged failure to timely consult with a

surgeon so that Milner could have undergone surgery within 24 hours of admission,

Dr. Mitchell’s report explains “how and why” this failure caused the amputation of

her great toe. It first states that a diabetic patient’s foot infection is a “surgical

emergency” that requires surgical treatment within 24 hours because “diabetic foot

wounds are known to rapidly deteriorate.” “Without early intervention, the wound

can rapidly deteriorate, leading to amputation of the affected limb. Therefore, it is at

this crucial early stage that physicians have the potential to curb what is often

progression from mild infection to a more severe problem, with necrosis, gangrene

and often amputation.”

As a result, Dr. Mitchell then opines, the “delay in getting Ms. Milner to

surgery put her entire leg at risk for amputation and was a proximate cause of the

great toe amputation, as well as, her long and protracted recovery and

hospitalization.”4 To further support his opinion that Dr. Balasubramanian’s delayed

surgical consultation was a cause of the great-toe amputation, Dr. Mitchell notes that

at the time of the allegedly delayed surgery, the “dorsal tissue on the plantar aspect

of the great toe was found to be blackish” by the surgeon, Dr. Nguyen. Dr. Mitchell

concludes that Dr. Balasubramanian’s breach “was a proximate cause of Ms.

Milner’s amputation and long and protracted recovery and hospitalization. I am of

the medical opinion that Ms. Milner more likely than not would not have required

amputation and extended hospitalization with prompt and proper care and

assessment of the wound as described above.”

Dr. Mitchell sufficiently addresses foreseeability. In explaining why a

diabetic’s foot infection with a foreign body is a surgical emergency, he states that

“diabetic foot wounds are known to rapidly deteriorate,” further explaining that this

is “because the development and progression of the infected wound is often

complicated by diabetic changes, such as neuropathy and vascular disease.”

Dr. Mitchell sufficiently describes the causal relationship because he explains

the factual basis for his opinions and he links Dr. Balasubramanian’s alleged

conduct—the delayed surgical consultation—with Milner’s subsequent

development of gangrene and the amputation. See Peabody, — S.W.3d at —, 2018

While not required, see Zamarripa, 526 S.W.3d at 460, Dr. Mitchell’s report

contains and relies on an accurate definition of proximate cause.

WL 6836864, at *7, 14; Clavijo, 2018 WL 2976116, at *11; Holt, 2017 WL

3483211, at *4; Hood, 2012 WL 4465357, at *6. This causation opinion provides

the “how and why” and a “straightforward link” between the alleged breach of the

standard of care and the claimed injury. See Abshire, 563 S.W.3d at 225; Peabody,

— S.W.3d at —, 2018 WL 6836864, at *7, 14.

Regarding Dr. Balasubramanian’s alleged failure to request a vascular

consultation when the pulse in Milner’s affected foot was difficult to palpate on

March 23, Dr. Mitchell’s report explains that this “too put Ms. Milner’s entire leg at

risk for amputation and was a proximate cause of the great toe amputation, as well

as, her long and protracted recovery and hospitalization.” As part of foreseeability,

he explains why: “[T]reating any severe ischemia is critical to wound healing,

regardless of other interventions. Early referral to a vascular specialist likely would

have resulted in earlier arterial reconstruction to improve blood flow and improve

healing of the wound, which would have substantially reduced the risk of

amputation.” And again, his report states elsewhere that “the development and

progression of the infected wound is often complicated by diabetic changes, such as

neuropathy and vascular disease.”

Dr. Mitchell sufficiently describes the causation element pertaining to Dr.

Balasubramanian’s alleged failure to request a vascular consultation. Dr. Mitchell

explains the factual basis for his opinions and links Dr. Balasubramanian’s failure

to request a vascular consultation with Milner’s subsequent development of

gangrene and the amputation. See Peabody, — S.W.3d at —, 2018 WL 6836864, at

*14 (concluding “it is reasonable to anticipate the consulting specialist doctor would

comply with the standard of care”). This causation opinion likewise provides the

“how and why” and a “straightforward link” between the alleged breach of the

standard of care and the claimed injury.5

Because Dr. Mitchell’s expert report adequately links his conclusions with the

underlying facts, the trial court could have reasonably concluded that it constitutes

an objective, good-faith effort to provide a fair summary of his opinions with respect

to the causal relationship between Dr. Balasubramanian’s alleged breaches and

Milner’s injury. See Abshire, 563 S.W.3d at 225–26; Peabody, — S.W.3d at —,

2018 WL 6836864, at *7, 14. We overrule Dr. Balasubramanian’s third issue.

Dr. Nguyen. In his sole issue, Dr. Nguyen asserts that Dr. Mitchell’s

causation opinions are conclusory and contain an “analytical gap” or “missing link.”

Dr. Mitchell’s standard-of-care and causation opinions as to Dr. Nguyen are as

follows:

If an expert report adequately addresses at least one liability theory, it satisfies

the statutory requirements. See Certified EMS, Inc. v. Potts, 392 S.W.3d 625,

630–32 (Tex. 2013). Because we have found two of Milner’s negligence

theories in Dr. Mitchell’s expert report against Dr. Balasubramanian to be

adequate, we need not further address the allegation that Dr. Balasubramanian

failed to follow up and assess the condition of the wound in the five days

between surgery and Milner’s scheduled discharge.

Dr. Nguyen noted in his March 25, 2015 operative report that due to

her diabetes, Ms. Milner was at high risk for possibly eventually losing

her toes due to poor circulation. Nevertheless, he breached the standard

of care by failing to refer her to [a] vascular specialist to manage any

ischemia. This put Ms. Milner’s entire leg at risk for amputation and

was a proximate cause of the great toe amputation, as well as, her long

and protracted recovery and hospitalization. This is because treating

any severe ischemia is critical to wound healing, regardless of other

interventions. Early referral to a vascular specialist likely would have

resulted in earlier arterial reconstruction to improve blood flow and

improve healing of the wound, which would have substantially reduced

the risk of amputation.

Between March 25th and March 30th (following the debridement

procedure) it does not appear from the medical records that Dr. Nguyen

ever examined the wound. On March 30, 2015, it was discovered that

Ms. Milner had a gangrenous diabetic left foot infection. Dr. Nguyen

breached the standard of care by failing to follow-up and assess the

condition of the wound. The lack of physician follow-up following

surgery put Ms. Milner’s entire leg at risk for amputation and was a

proximate cause of the great toe amputation, as well as, her long and

protracted recovery and hospitalization. This is because diabetic foot

wounds can, and do, rapidly deteriorate and must be managed in a

timely and effective way with tissue debridement, inflammation and

infection control, and moisture balance. Frequent wound assessment

and bacterial control and moisture balance is required to prevent

maceration. Debridement may need to be repeated for maintenance of

the wound bed. The requirement for further debridement should be

determined after each dressing change. A physician cannot simply

abandon the patient following surgery and hope for the best. Timely

and effective wound management in this case likely would have

prevented the need for amputation of Ms. Milner’s great toe.

Dr. Nguyen relies on Humble Surgical Hospital, LLC v. Davis, 542 S.W.3d

12 (Tex. App.—Houston [14th Dist.] 2017, pet. filed), to support his causation

argument. We find this opinion unpersuasive for several reasons.6 First, it largely

relies on the “analytical gap” argument in the Beaumont Court’s opinion in Abshire,

which has been reversed. Id. at 23–26 (citing HealthSouth Rehabilitation Hosp. of

Beaumont, LLC v. Abshire, 561 S.W.3d 193, 214–17 (Tex. App.—Beaumont 2017),

rev’d, 563 S.W.3d 219 (Tex. 2018)). It is therefore questionable whether the

Fourteenth Court’s opinion in Humble Surgical comports with the supreme court’s

direction in Abshire on the review of causation reports:

Dr. Rushing explained how the nurses’ breach—failing to consistently

document Abshire’s OI, particularly in light of her continued

complaints of back pain—caused a delay in diagnosis and proper

treatment and why that delay caused the issues that led to Abshire’s

paraplegia. Thus, the report adequately explained the links in the causal

chain.

Despite this identified causal link, the court of appeals held that

the report was conclusory because it “fail[ed] to explain how the nurses’

alleged failure to document OI was a substantial factor in causing or

exacerbating Abshire’s injuries . . . or that it would have changed the

outcome.” 562 S.W.3d at 217. Specifically, the court observed that the

physicians did not order tests or provide spinal treatment on either the

November 22 or 23 visits, even though Abshire’s OI was noted during

these visits. See id. at —. Therefore, the court held that Dr. Rushing’s

“opinion that the nurses’ failure to chart Abshire’s history of OI caused

Abshire’s injury rests on an analytic gap that renders his causation

opinion as to the nurses conclusory.” Id. at 201.

We disagree that such an analytic gap exists. As explained above,

Dr. Rushing’s report adequately links his conclusion with the

The plaintiff’s petition for review in Humble Surgical is pending before the

supreme court, and briefing on the merits was requested and has been

completed. See Davis v. Humble Surgical Hosp., LLC, No. 18-0092 (Tex.),

Petition for Review, filed Feb. 2, 2018.

underlying facts (failure to properly document Abshire’s medical

history was a substantial factor in her delayed treatment and subsequent

injury). Rather, it appears the court of appeals simply did not agree with

his conclusions in light of Abshire’s overall course of treatment.

However, the court’s job at this stage is not to weigh the report’s

credibility; that is, the court’s disagreement with the expert's opinion

does not render the expert report conclusory.

....

In the same vein, with respect to causation, the court’s role is to

determine whether the expert has explained how the negligent conduct

caused the injury. Whether this explanation is believable should be

litigated at a later stage of the proceedings.

The ultimate evidentiary value of the opinions proffered by Dr.

Rushing and Nurse Aguirre is a matter to be determined at summary

judgment and beyond. In this regard, the court of appeals improperly

examined the merits of the expert’s claims when it identified what it

deemed an “analytical gap.”

Abshire, 563 S.W.3d at 225–26 (footnote omitted).

Additionally, Peabody, a subsequent Fourteenth Court opinion that applied

the supreme court’s Abshire opinion, is persuasive. See Peabody, — S.W.3d at —,

2018 WL 6836864, at *6, 8–11 (“The Texas Supreme Court recently approved a

causation opinion in a similar expert report . . . . We look to the cases relied on by

St. Luke’s with this more recent test in mind.”) (citing Abshire, 563 S.W.3d at 225–

26). Peabody, which similarly involved alleged delay in treatment, concluded that

the experts’ causation opinions met the test in Abshire. See id., — S.W.3d at —,

2018 WL 6836864, at *8–14.

We have addressed Dr. Mitchell’s causation opinion as to Dr.

Balasubramanian’s alleged failure to request a vascular consultation. For the same

reasons, we conclude that Dr. Mitchell’s causation opinion as to Dr. Nguyen

constitutes an objective, good-faith effort to provide a fair summary of his opinions

with respect to the causal relationship between Dr. Nguyen’s alleged breach and

Milner’s injury.7 We overrule Dr. Nguyen’s sole issue.

Cypress Fairbanks Medical Center. The Medical Center contends in the last

part of its sole issue that Dr. Mitchell’s report failed to explain how its nursing staff

caused Milner’s injury.

Dr. Mitchell’s report states the following on causation as to the Medical

Center: