texas-health-harris-methodist-hospital-fort-worth-harris-methodist ( 2013 )


Menu:
  •                     COURT OF APPEALS
    SECOND DISTRICT OF TEXAS
    FORT WORTH
    NO. 02-12-00486-CV
    TEXAS HEALTH HARRIS                                APPELLANTS
    METHODIST HOSPITAL FORT
    WORTH, HARRIS METHODIST
    HOSPITALS INC., TEXAS HEALTH
    RESOURCES, AND COMMUNITY
    BLOOD CENTER D/B/A
    COMMUNITY TISSUE SERVICES
    V.
    WILLIAM AUSTEN BIGGERS;                             APPELLEES
    WILLIAM ANGUS BIGGERS, III,
    INDIVIDUALLY AND AS GUARDIAN
    OF THE PERSON AND ESTATE OF
    WILLIAM AUSTEN BIGGERS; AND
    LILLIE KAY BIGGERS
    NO. 02-13-00040-CV
    DIANA B. WILSON, M.D.                               APPELLANT
    V.
    WILLIAM AUSTEN BIGGERS;                             APPELLEES
    WILLIAM ANGUS BIGGERS, III,
    INDIVIDUALLY AND AS GUARDIAN
    OF THE PERSON AND ESTATE OF
    WILLIAM AUSTEN BIGGERS; AND
    LILLIE KAY BIGGERS
    ------------
    FROM THE 17TH DISTRICT COURT OF TARRANT COUNTY
    ----------
    MEMORANDUM OPINION 1
    ----------
    Appellants Texas Health Harris Methodist Hospital Fort Worth (Harris
    Methodist),   Harris   Methodist   Hospitals      Inc.,   Texas   Health   Resources
    (collectively, the hospital defendants), Community Blood Center d/b/a Community
    Tissue Services (Community), and Diana B. Wilson, M.D. appeal the trial court’s
    denial of their motions to dismiss appellees William Austen Biggers, William
    Angus Biggers, III, individually and as guardian of the person and estate of
    William Austen Biggers, and Lillie Kay Biggers’s claims against them.            We
    reverse and remand.
    Background Facts
    In March 2010, William Austen was involved in a car crash that resulted in
    severe head injuries. He was taken to Harris Methodist where he was treated by
    neurosurgeon Dr. Diana Wilson among others. William Austen underwent an
    emergency craniectomy during which part of his skull was removed to relieve
    pressure and to allow surgery. Surgeons later determined that they would not be
    able to replace the piece of skull that was removed (the “bone flap”) because it
    had not been properly stored.      Instead, they replaced that part of William
    1
    See Tex. R. App. P. 47.4.
    2
    Austen’s skull with artificial implants. William Austen suffered repeated infections
    from the implants and required additional surgeries on his skull because of them.
    The Biggerses sued the hospital defendants, Community, and Dr. Wilson,
    alleging a number of negligent acts including failure to adequately assess William
    Austen’s injuries, failure to provide adequate information for his family to make
    informed decisions regarding William Austen’s care, allowing inadequately
    trained or qualified doctors to perform surgery on William Austen, and failure to
    properly maintain the portions of William Austen’s skull that were removed in
    surgery. 2
    The Biggerses filed an expert report and curriculum vitae of Dr. Arnold
    Ravdel, an orthopedic surgeon, as required under chapter 74 of the civil
    practices and remedies code.        See Tex. Civ. Prac. & Rem. Code Ann.
    § 74.351(a) (West 2011). The hospital defendants, Community, and Dr. Wilson
    all objected to the sufficiency of Dr. Ravdel’s expert report and moved to dismiss
    the Biggerses’ claims against them. The trial court denied their motions. The
    hospital defendants and Community appealed and, later, so did Dr. Wilson. We
    consolidated the two appeals.
    Standard of Review
    We review a trial court’s denial of a motion to dismiss for an abuse of
    discretion.   Jernigan v. Langley, 
    195 S.W.3d 91
    , 93 (Tex. 2006); Maris v.
    2
    The Biggerses also sued, and later nonsuited, two other doctors, Dr.
    Smith and Dr. Colquitt, neither of whom is a party to this appeal.
    3
    Hendricks, 
    262 S.W.3d 379
    , 383 (Tex. App.—Fort Worth 2008, pet. denied); Ctr.
    for Neurological Disorders, P.A. v. George, 
    261 S.W.3d 285
    , 290–91 (Tex.
    App.—Fort Worth 2008, pet. denied). A trial court abuses its discretion if the
    court acts without reference to any guiding rules or principles, that is, if the act is
    arbitrary or unreasonable. Low v. Henry, 
    221 S.W.3d 609
    , 614 (Tex. 2007); Cire
    v. Cummings, 
    134 S.W.3d 835
    , 838–39 (Tex. 2004). An appellate court cannot
    conclude that a trial court abused its discretion merely because the appellate
    court would have ruled differently in the same circumstances. E.I. du Pont de
    Nemours & Co. v. Robinson, 
    923 S.W.2d 549
    , 558 (Tex. 1995); see also 
    Low, 221 S.W.3d at 620
    .
    The Chapter 74 Expert Report Requirement
    The purpose of the expert report requirement is to inform the defendant of
    the specific conduct the plaintiff has called into question and to provide a basis
    for the trial court to conclude that the claims have merit. Bowie Mem’l Hosp. v.
    Wright, 
    79 S.W.3d 48
    , 52 (Tex. 2002) (citing Am. Transitional Care Ctrs. of Tex.,
    Inc. v. Palacios, 
    46 S.W.3d 873
    , 879 (Tex. 2001)). An expert report “need not
    marshal all the plaintiff’s proof.” 
    Palacios, 46 S.W.3d at 878
    (construing former
    article 4590i, § 13.01). Additionally, 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. at 879.
    However, if a report omits any of the statutory
    elements, it cannot be a good-faith effort. 
    Id. A report
    that merely states the
    4
    expert’s conclusions about the standard of care, breach, and causation is not
    sufficient. 
    Id. A defendant
    may meet the requirements of chapter 74 through multiple
    reports. Tex. Civ. Prac. & Rem. Code Ann. § 74.351(i). A single report need not
    “address all liability and causation issues with respect to all physicians or health
    care providers or with respect to both liability and causation issues for a
    physician or health care provider.”      
    Id. But read
    together, the reports must
    provide a “fair summary” of the experts’ opinions regarding 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.”
    
    Id. § 74.351
    (r)(6).
    If the defendant files a motion challenging the adequacy of the expert
    report, the court shall grant the motion “only if it appears to the court, after
    hearing, that the report does not represent an objective good faith effort to
    comply with the definition of an expert report.” 
    Id. § 74.351
    (l). An expert report is
    defined as a report that “provides a fair summary of the expert’s opinions . . .
    regarding 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.” 
    Id. § 74.351
    (r)(6). The trial court may grant one thirty-day extension to
    cure a deficiency in the expert report. 
    Id. § 74.351
    (c).
    5
    Discussion
    The appellants complain that Dr. Ravdel’s report is deficient for a number
    of reasons.   All the appellants argue that Dr. Ravdel failed to set forth the
    applicable standard of care for each defendant, failed to articulate how each
    defendant breached the standard of care, and failed to explain the causal
    connection between each defendant’s breach and William Austen’s injuries.
    Harris Methodist Hospitals Inc. and Texas Health Resources argue that Dr.
    Ravdel’s report wholly fails to address them and thus constitutes no report at all
    as to them. Harris Methodist and Community also both argue that Dr. Ravdel is
    not qualified to render opinions as to them.
    I. Harris Methodist Hospitals Inc. and Texas Health Resources
    Harris Methodist Hospitals Inc. and Texas Health Resources argue that Dr.
    Ravdel’s report wholly fails to address them and thus the Biggerses failed to
    timely serve an expert report as to them. The Biggerses make no argument in
    response in their brief. In oral argument, they claimed that someone informed
    them that the three hospital defendants “are all the same entity.” Nothing in the
    record supports this contention, and we note that all three hospital defendants
    filed separate answers. In Harris Methodist Hospitals Inc.’s and Texas Health
    Resources’s answers, they both stated that they were not proper parties to the
    suit and were improperly named.        The Biggerses do not claim that Harris
    Methodist Hospitals Inc. or Texas Health Resources are vicariously liable for the
    6
    hospital’s actions. See Certified EMS, Inc. v. Potts, 
    392 S.W.3d 625
    , 632 (Texas
    2013).
    If a report fails to address a defendant health care provider, it constitutes
    no report as to that defendant. See Apodaca v. Russo, 
    228 S.W.3d 252
    , 257
    (Tex. App.—Austin 2007, no pet.).       When no expert report has been timely
    served, a trial court has no authority to grant an extension and must dismiss the
    claims with prejudice.   See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(b);
    Garcia v. Marichalar, 
    185 S.W.3d 70
    , 74 (Tex. App.—San Antonio 2005, no pet.).
    Dr. Ravdel states in the report that its purpose is “to explain how, in reasonable
    medical probability, Texas Health Harris Methodist Hospital . . . [,] Community
    Blood Center . . . , and Diana Wilson, M.D. failed to follow standards of care.” Dr.
    Ravdel’s report makes no mention of either Harris Methodist Hospitals Inc. or
    Texas Health Resources at any point. The Biggerses thus failed to serve an
    expert report as to these two parties. Because the Biggerses did not serve an
    expert report, the trial court was required to dismiss their claims against Harris
    Methodist Hospitals Inc. and Texas Health Resources. It erred by not doing so.
    We therefore sustain the part of the hospital defendants’ first issue addressing
    the report’s deficiency as to Harris Methodist Hospitals Inc. and Texas Health
    Resources.
    7
    II.   Dr. Ravdel’s qualifications as an expert on Harris Methodist and
    Community
    Harris Methodist and Community argue that Dr. Ravdel is not qualified to
    opine on their liability.
    An expert providing a report must have “knowledge of accepted standards
    of care for health care providers for the diagnosis, care, or treatment of the
    illness, injury, or condition involved in the claim” and be “qualified on the basis of
    training or experience to offer an expert opinion regarding those accepted
    standards of health care.” Tex. Civ. Prac. & Rem. Code Ann. § 74.402(b). A
    physician-expert who proffers an opinion on the applicable standard of care of
    another type of healthcare provider must “affirmatively demonstrate experience
    and familiarity with the standard of care for the nonphysician’s field.” Tawa v.
    Gentry, No. 01-12-00407-CV, 
    2013 WL 1694869
    , at *13 (Tex. App.—Houston
    [1st Dist.] Apr. 18, 2013, no pet.) (mem. op.). If a physician states he is familiar
    with the standard of care and responsibilities and requirements for healthcare
    providers, and he has worked with, interacted with, and supervised healthcare
    providers, the physician is qualified on the issue of whether the healthcare
    providers departed from the accepted standards of care for healthcare providers.
    See San Jacinto Methodist Hosp. v. Bennett, 
    256 S.W.3d 806
    , 814 (Tex. App.—
    Houston [14th Dist.] 2008, no pet.).
    Dr. Ravdel’s curriculum vitae states that he completed a general surgery
    residency and an orthopedic surgery residency and then practiced orthopedic
    8
    surgery in South Africa. His curriculum vitae states that he has been in private
    practice in Houston, Texas from 1977 to present. He states in his report,
    All of the opinions expressed in this report are within
    reasonable medical probability and based on my education,
    training[,] and experience as a surgeon and physician having over
    fifty years of experience, and including doing surgeries that involve
    bone grafts and tissue grafts. I am fully familiar with standards of
    care that involve preservation of tissue and storing of tissue by
    surgeons and hospitals.
    Although Dr. Ravdel states that he has peer reviewed cases in which spinal and
    neurosurgery had been done by his colleagues, he does not state that he himself
    has ever performed surgery involving bone flaps removed from a skull.
    Dr. Ravdel’s curriculum vitae and expert report show no indication that he
    is familiar with the standard of care for a tissue bank like Community. He states
    that he is familiar with the standards of care for “preservation of tissue and
    storing of tissue by surgeons and hospitals,” but he does not state that he has
    any knowledge or experience with the cleaning or storage procedures of tissue
    banks and whether they differ from those of a hospital or with the transfer
    procedures from the hospital to the tissue bank.          He therefore has not
    affirmatively demonstrated his experience with tissue banks and he is not
    qualified to opine on Community’s liability. We sustain that part of Community’s
    issue regarding Dr Ravdel’s qualifications.
    Neither has Dr. Ravdel demonstrated that he is qualified to opine on Harris
    Methodist’s liability. He states that he has peer reviewed neurosurgery cases,
    but he does not state that he peer reviewed anything other than the
    9
    neurosurgeon’s performance.        He states that he reviewed “recent medical
    literature” but does not state what that literature was or where it was published.
    Dr. Ravdel does not state whether he has worked or interacted with hospital staff
    to preserve and store tissue or that he has any knowledge of hospital procedures
    beyond a cursory statement that he is “fully familiar with standards of care that
    involve preservation of tissue and storing of tissue by . . . hospitals.” Although
    Dr. Ravdel might indeed have knowledge of these procedures, there is nothing in
    his report from which a trial court could conclude that he is familiar with the
    standards of care for hospitals. See Tawa, 
    2013 WL 1694869
    , at *14 (holding
    that doctor was not qualified to opine on nurse practitioner’s standard of care
    when “[h]e [did] not claim to have experience training or supervising nurse
    practitioners or provide any other basis for the trial court to conclude that he was
    familiar with such standard”); Perry v. Bradley, No. 10-10-00402-CV, 
    2011 WL 6415135
    , at *3 (Tex. App.—Waco Dec. 21, 2011, no pet.) (mem. op.) (holding
    that report that did not state how the pharmacist was knowledgeable about
    standards of care was deficient when such knowledge was not clear from his
    training or experience). We therefore sustain that part of the hospital defendants’
    first issue regarding Dr. Ravdel’s qualifications.
    10
    III. Standards of care and breaches 3
    Harris Methodist, Community, and Dr. Wilson all challenge the adequacy
    of Dr. Ravdel’s report concerning the standards of care applicable to them and
    any breaches they allegedly committed. Standard of care is defined by what an
    ordinarily prudent health care provider or physician would have done under the
    same or similar circumstances.    
    Palacios, 46 S.W.3d at 880
    .    Identifying the
    standard of care is critical: whether a defendant breached his or her duty to a
    patient cannot be determined absent specific information about what the
    defendant should have done differently. 
    Id. While a
    “fair summary” is something
    less than a full statement of the applicable standard of care and how it was
    breached, even a fair summary must set out what care was expected but not
    given. 
    Id. When a
    plaintiff sues more than one defendant, the expert report must
    set forth the standard of care for each defendant and explain the causal
    relationship between each defendant’s individual acts and the injury. Kingwood
    Pines Hosp., LLC v. Gomez, 
    362 S.W.3d 740
    , 748 (Tex. App.—Houston [14th
    Dist.] 2011, no pet.).
    3
    Although we have held that Dr. Ravdel’s report is insufficient as to the
    hospital defendants and Community, because we will remand the case to the trial
    court so that it may consider granting a thirty-day extension to cure the
    deficiencies, we will address the remaining deficiencies alleged by the
    appellants.
    11
    Dr. Ravdel’s report includes five paragraphs on “[s]tandards of care that
    apply to any surgeries involving preservation of bone tissue for use in later
    surgeries or procedures.” He states,
    [T]he part of bone or other tissue needs to be evaluated and
    cleaned, then may be stored in the treating hospital . . . or
    depending on circumstances, may be sent to what we call a “bone
    bank” or “tissue bank” for standard preservation procedures[,] which
    are basically freezing the tissue and labeling it appropriately to the
    patient’s identity as well as identifying what it is. This procedure
    should be documented in the patient’s chart, in accordance with
    standards of care. Specifically, . . . the hospital chart should include
    documentation of what was done with the tissue, when it was
    transmitted to the bone or tissue bank and records of receipt and
    associated activity, including when the material is received by the
    surgeon for restoration.      These standards are well-known to
    surgeons in all specialties where bone or tissue grafts are utilized
    and to hospitals and bone or tissue banks.
    ....
    [S]imple cleaning of the skull material and storage in a simple
    freezer at around -18 degrees Centigrade is effective for lengthy
    periods of time. Accordingly, if standards are followed, the natural
    skull tissue should be viable and not contaminated or deteriorated
    within one year and longer, if proper procedures are undertaken by
    the hospital where the neurosurgery and associated staff are
    planning restorative surgery.
    ....
    Under standards of care applicable to hospitals and to all
    surgeons handling tissue or bone material intended to be utilized
    later in the same patient as in this case, the surgeon or his or her
    staff or associates must document what steps were taken to
    preserve the integrity of the tissue, including such things as
    cleaning, removal of associated traumatized or necrotic tissue, plans
    for packaging (typically in a plastic bag or container and sometimes
    accompanied by prophylactic anti-infection agents)[,] and freezing in
    storage.
    12
    Under the “harm” section of his report, he states,
    Removal of the part of the skull in this type of situation is not
    uncommon, but the material needs to be properly maintained in a
    bone bank. This is mainly the responsibility of the hospital in
    conjunction with the bone bank, but it is up to the neurosurgeon who
    does the craniectomy to see that the removed material is properly
    prepared and that plans for storage and maintenance are
    appropriate.
    Dr. Ravdel’s report implies that the same standard of care applies to Harris
    Methodist, Community, and Dr. Wilson. While it is possible to apply a single
    standard of care to all defendants, there still must be an explanation as to why
    the same standard applies to very different types of providers. See Kettle v.
    Baylor Med. Ctr. at Garland, 
    232 S.W.3d 832
    , 839 (Tex. App.—Dallas 2007, pet.
    denied) (“While it is certainly possible an identical standard of care governs
    different providers, a generalized statement without explanation that a uniform
    standard applies ‘can reasonably be deemed conclusory’ and deficient.”) (quoting
    Gray v. CHCA Bayshore, L.P., 
    189 S.W.3d 855
    , 859–60 (Tex. App.—Houston
    [1st Dist.] 2006, no pet.)). Dr. Ravdel’s report fails to explain how a tissue bank,
    a hospital, and a neurosurgeon would have identical standards of care as to the
    preservation and storage of a bone flap. Because the report does not specify
    what tasks each defendant was responsible for, it does not explain what each
    defendant did to breach the standard of care. See 
    Palacios, 46 S.W.3d at 880
    (stating that whether a defendant breached the standard of care cannot be
    determined without “specific information about what the defendant should have
    13
    done differently”); Taylor v. Christus Spohn Health Sys. Corp., 
    169 S.W.3d 241
    ,
    245–46 (Tex. App.—Corpus Christi 2004, no pet.) (holding expert report deficient
    when it presented only a single standard of care for all defendants and did not
    specify “which party was responsible for undertaking which procedures”).
    Dr. Ravdel states that the patient’s chart does not include documentation
    regarding “what steps were taken to preserve the integrity of the tissue, including
    such things as cleaning, removal of associated traumatized or necrotic tissue,
    plans for packaging . . . [,] and freezing in storage.” He does not specify which of
    the defendants should have documented those steps or if one defendant should
    have documented some steps and another defendant document the others. See
    Jones v. Ark-La-Tex Visiting Nurses, Inc., 
    128 S.W.3d 393
    , 397 (Tex. App.—
    Texarkana 2004, no pet.) (holding that expert’s report was inadequate because it
    “[did] not differentiate between what the hospital did wrong and what the nurses
    did wrong”). Although he does state that “the surgeon or his or her staff or
    associates” are responsible for documenting the preservation of the tissue, it is
    unclear from his report how or why a doctor would be responsible for
    documenting steps that occur after the specimen has left her possession or
    whose responsibility it is to actually clean and store the bone flap. And it was
    critical that the expert report explain this latter duty, because the Biggerses did
    not allege—and Dr. Ravdel did not claim—that the lack of documentation caused
    William Austen’s injuries. Therefore, even if the report did set out a standard of
    14
    care for Dr. Wilson, it was not the standard of care relevant to the Biggerses’
    claims.
    Dr. Ravdel states that either the hospital or the bone bank “improperly
    maintained or stored this patient’s skull material,” but he does not explain what
    either defendant should have done differently. See Kingwood 
    Pines, 362 S.W.3d at 750
    (holding that expert reports were deficient in identifying the breaches of
    the standards of care when they merely stated that the patient should have been
    kept in a secure environment, but failed to articulate how the defendants should
    have accomplished that task). He then suggests that “some other entity” might
    have been responsible for the deterioration, but he fails to explain what that entity
    might have been, how it would have been involved, or how he determined that
    this other entity was not responsible.
    Dr. Ravdel’s statement that the maintenance of the bone flap “is mainly the
    responsibility of the hospital in conjunction with the bone bank, but it is up to the
    neurosurgeon” does not explain which defendant should have communicated
    storage plans or to whom the information should have been directed.             See
    
    Taylor, 169 S.W.3d at 245
    (holding that expert’s report was deficient as to the
    standard of care for defendants when expert did not address the standard for
    each defendant or explain who was responsible for the alleged breaches). He
    does not explain which defendant was responsible for the cleaning of the bone
    flap. He states that procedures “should be documented in the patient’s chart,”
    but he does not explain who was responsible for updating William Austen’s chart.
    15
    See Intra-Op Monitoring Servs., LLC v. Causey, No. 09-12-00050-CV, 
    2012 WL 2849281
    , at *3 (Tex. App.—Beaumont July 12, 2012, no pet.) (mem. op.)
    (holding expert report deficient regarding standard of care when report did not
    explain “which of the several defendants failed to properly interpret the
    monitoring data [and] what monitoring data was not properly interpreted”). Dr.
    Ravdel’s report does not identify the conduct of each defendant that the
    Biggerses have called into question. See 
    Palacios, 46 S.W.3d at 879
    (requiring
    a good-faith effort to inform the defendant of the conduct the plaintiff has called
    into question and provide a basis for the trial court to conclude that the claims
    have merit).
    Because the expert report does not identify what each defendant should
    have done differently, it provided no basis for the trial court to determine whether
    each defendant breached a duty owed to William Austen.           See 
    Palacios, 46 S.W.3d at 880
    . We sustain the hospital defendants’ first issue and Community’s
    and Dr. Wilson’s sole issues as to the elements of standard of care and breach.
    IV. The causal connections
    Harris Methodist, Community, and Dr. Wilson also challenge Dr. Ravdel’s
    report on the ground that it does not explain the causal connection between their
    alleged negligent acts and William Austen’s injuries. While a claimant is not
    required to conclusively prove his case through an expert report, the report may
    not merely state conclusions about any of the elements. 
    Palacios, 46 S.W.3d at 879
    . The expert must explain the basis of his statements linking the facts to his
    16
    conclusions. Bowie Mem’l 
    Hosp., 79 S.W.3d at 52
    (quoting Earle v. Ratliff, 
    998 S.W.2d 882
    , 890 (Tex. 1999)).
    Dr. Ravdel’s report discusses two problems with William Austen’s care.
    First is the lack of documentation in William Austen’s records. Dr. Ravdel states,
    “I have not seen that documentation, but it may not be pertinent, as it may only
    show details of when the material was received, checked out for evaluation if that
    was done, and removed for use in restorative surgery.” He makes no connection
    between the lack of recording of the steps taken to clean and preserve the bone
    flap to any of William Austen’s injuries. See 
    Taylor, 169 S.W.3d at 245
    (holding
    expert report deficient when it “[did] not explain how, if at all, this information
    would have altered the outcome”); Costello v. Christus Santa Rosa Health Care
    Corp., 
    141 S.W.3d 245
    , 249 (Tex. App.—San Antonio 2004, no pet.) (criticizing
    the expert report as insufficient because it did not “explain the causal connection
    between [the hospital’s] claimed omissions . . . and [the patient’s] death”).
    The second issue Dr. Ravdel discusses is the cleaning and preservation of
    the bone flap. His report states that the records he reviewed did not provide the
    details of how the bone flap was maintained and stored, but that a failure to
    properly clean, maintain, and store the bone tissue was “probably what
    happened in this case” because William Austen’s injuries “are the common
    results of improper storage by whatever means.” He also states,
    It is possible that this patient might have had infections even if
    the original cranial material had been usable and used in repairing
    his skull, but infections are much less likely in that situation because
    17
    of the healing and integration of natural bone. The loss of the
    original cranial material definitely caused harm to this patient by
    necessitating additional surgeries, costs of implants, and
    accompanying increased risk of infections and actual infections and
    cost of treatment.
    His later statement that “[t]he failure to maintain adequately the skull
    materials in this case, in reasonable medical probability, caused harm to this
    patient because it led to the necessity of what are described as ‘multiple’
    corrective surgeries” is conclusory and not supported by his previous statements
    that William Austen might still have suffered the infections and multiple surgeries
    if the bone flap had been useable. See Clapp v. Perez, 
    394 S.W.3d 254
    , 261–62
    (Tex. App.—El Paso 2012, no pet.) (“Although broad and sweeping in scope, this
    statement is nothing more than Dr. Herrera’s conclusion that the breach caused
    the injury.”). Moreover, Dr. Ravdel does not state whose failure led to William
    Austen’s harm and as discussed above, even indicated that “some other entity”
    may have been responsible. See 
    id. (“Moreover, Dr.
    Herrera fails to link Perez’s
    death to any specific physician.”); Davisson v. Nicholson, 
    310 S.W.3d 543
    , 559
    (Tex. App.—Fort Worth 2010, no pet.) (holding that reports that failed to fault
    defendant for plaintiff’s injuries were inadequate). Dr. Ravdel’s report thus did
    not adequately explain the causal connection between the alleged breaches of
    the standards of care and William Austen’s injuries. We sustain the remainder of
    the hospital defendants’ first issue and Community’s and Dr. Wilson’s sole issues
    as to this element.
    18
    V. Attorney’s fees
    In their second issue, the hospital defendants argue that they should have
    been awarded attorney’s fees. Chapter 74 allows for the recovery of attorney’s
    fees and costs of court when a plaintiff fails to file an expert report. Tex. Civ.
    Prac. & Rem. Code Ann. § 74.351(b). Chapter 74 also allows the trial court to
    consider a thirty-day extension when a report has been filed but found to be
    deficient. 
    Id. § 74.351
    (c). Because we found Dr. Ravdel’s expert report to be
    deficient regarding Harris Methodist, Community, and Dr. Wilson, the Biggerses
    are entitled to have the trial court consider whether to grant a 30-day extension to
    cure the deficiencies as to those defendants. See 
    id. But because
    the Biggerses
    did not file an expert report as to Harris Methodist Hospitals Inc. and Texas
    Health Resources, they are not entitled to an extension to file a report addressing
    their claims against those providers, and the trial court must dismiss the
    Biggerses claims against them and consider their request for attorney’s fees.
    See Psychiatric Solutions, Inc. v. Palit, No. 12-0388, 
    2013 WL 4493118
    , at *3
    (Tex. Aug. 23, 2013) (remanding case to the trial court with instructions to
    dismiss plaintiff’s claim against provider and to consider provider’s request for
    attorney’s fees and costs). We sustain the hospital defendants’ second issue as
    to Harris Methodist Hospitals Inc. and Texas Health Resources and overrule it as
    to Harris Methodist.
    19
    Conclusion
    Having sustained Dr. Wilson’s and Community’s sole issues and the
    hospital defendants’ first issue as to Harris Methodist, we reverse the trial court’s
    judgment as to those defendants and remand the case to the trial court so that it
    may consider a 30-day extension to cure the deficiencies in the expert report.
    Having sustained the hospital defendants’ first and second issues as to Harris
    Methodist Hospitals Inc. and Texas Health Resources, we reverse the trial
    court’s judgment as to those defendants and remand the case to the trial court
    with instructions to dismiss the Biggerses’ claims against them and to consider
    their request for attorney’s fees and costs.
    LEE GABRIEL
    JUSTICE
    PANEL: MCCOY and GABRIEL, JJ.; and WILLIAM BRIGHAM (Senior Justice,
    Retired, Sitting by Assignment)
    DELIVERED: October 3, 2013
    20